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Adolescent Precursors to Psychiatric Disorders – Learing from Analysis of User-Service Engagement

Final Report Summary - APPLAUSE (Adolescent Precursors to Psychiatric Disorders – Learing from Analysis of User-Service Engagement)

The APPLAUSE study analyses current access models, reports of individual experiences of positive and negative interactions with health care services and the culturally embedded social factors that impact on such access. Addressing this complex problem from a global perspective will advance the development of a more diverse and innovative set of strategies for improving earlier access to care.

We examined patterns of access and engagement and associated outcomes among participants of prospective community cohorts in London, UK, and Sao Paulo and Porto Alegre, Brazil.
Across all sites, there were significant gaps in care with the vast majority of youth, even those who presented with severe and persistent problems, not receiving care--rates of service use among youth with severe and persistent problems were around 30% in the UK and Brazil and this decreased to 24% in the UK and 15% in Brazil for those with less severe, transient conditions.

In both countries, persistence and severity of mental health conditions were associated with greater likelihood of mental health service use and associated costs (reflecting intensity of service use) showing that there is some targeting of services based on need in both Brazil and the UK. However, psychopathology did not explain all of the variation in service use. We identified other significant factors which were also related to service use. In the UK, young people who were socio-economically disadvantaged had a higher likelihood of mental health related service use, compared to those who were not disadvantaged (OR: 2.62; 95%CI: 1.27 to 5.43 p=0.009). We also found that, when their caregivers reported medium/high levels of stigma, young people were less likely to have used services compared to those whose caregivers reported low level of stigma (OR: 0.57; 95% CI: 0.33 to 0.97; p=0.040).

Although we expected youth with lower socio-economic status to have greater barriers to service use, particularly in Brazil where income inequality is greater, we did not find an overall significant association between socio-economic group and service use.

Interestingly, the most robust predictor of service use and associated costs in Brazil was parental stigma. In Brazil, lower parental stigma was associated with greater service use (OR: 1.32 95% CI: 1.07-1.64) and lower costs (OR: 0.38 95% CI: 0.05-0.71). This finding was similar to the UK. ).

This suggests that parents with lower levels of stigma are more likely to seek care and support on behalf of their child in both countries. However, in Brazil (where the sample was also larger) parental stigma was also associated with lower costs (OR: 0.38 95% CI: 0.05-0.71). (Ziebold et al., in preparation). In Brazil, the association with lower costs could be related to the fact that those with lower levels of stigma may avoid more intensive and costly services due to earlier help-seeking. We also found a significant interaction in the UK, whereby, stigma exerted a greater barrier to service use on parents who had never used services themselves (Gronholm et al., 2015).
In addition to parental stigma, we also found that stigma carried by the young person influenced their self-perceptions of their own mental health and their pathways to care and support. Qualitative interviews among a subgroup of the UK cohort showed stigma influenced pathways to care even among early stages of developing a mental health condition and inhibited individuals from disclosing problems because of perceived risks of others’ reactions (Gronholm et al., 2017). This was also further supported by findings from a systematic review on the topic (Gronholm et al., 2017).

These findings can help us to understand how we can improve help-seeking. In particular the robust relationship between stigma and service use provides a clear malleable target where we can focus efforts to improve access to care and support for young people. We know there are evidence-based interventions to reduce stigma and discrimination and these are important to implement to improve access to needed care and support.