Abstract
Background
There are high and increasing levels of psychological distress reported amongst children and adolescents in New Zealand (NZ) and concerning rates of teenage suicide, particularly for Māori youth.
Specialist inpatient mental health (IP-MH) services provide support for children and adolescents who are experiencing severe mental distress and need close observation, intensive investigation, or intervention that cannot be provided safely within a community setting. There is limited information about such services available in the public arena and minimal research conducted in a NZ context.
Aims
In this health services research study, I set out to build on the body of knowledge regarding IP-MH services for children and adolescents in NZ. The aim was to develop understanding of how the system is functioning today and to inform strategic policy inferences for the future.
Methods
A mixed methods research study design was adopted, supported by a conceptual framework informed by theory from complexity and implementation science, blended with an appreciative inquiry approach.
In the first stage of research, to develop the evidence base three complementary studies were completed, each framed against an ecological systems backdrop representing layers of the mental health system. The studies were:
• An umbrella review of systematic reviews – a synthesis and critical appraisal of international evidence on the impacts on mental health outcomes of admission for children and adolescents to IP-MH services.
• Patterns of IP-MH service utilisation by children and adolescents in NZ: a picture of the past decade – a descriptive epidemiological study involving analysis of national mental health services data from 2008/09 to 2017/18 regarding child and adolescent service IP-MH use.
• An exploratory case study of the Regional Rangatahi Adolescent Inpatient Service (RRAIS) in Wellington – in depth qualitative research to identify the characteristics of the IP-MH model of service delivery, to explore how children and adolescents experience inpatient care, and to gather staff perspectives on the strengths and challenges of providing the service.
In the second stage of research, findings from across the three studies were integrated to develop a system-level view of IP-MH services for children and adolescents in NZ. The integrated evidence base was viewed through a ‘CIS-A lens’ (that blended theories from complexity and implementation science, with an appreciative inquiry perspective) to develop understanding of how the system is functioning today and to inform strategic policy inferences for the future.
Results
The umbrella review of systematic reviews found a moderate level of evidence supporting the effectiveness of IP-MH service services for symptom stabilisation, balanced by understanding of potential risks associated with admission for children and adolescents. There were promising results for certain alternative models of service delivery (such as Multi-Systemic Therapy and Assertive Community Treatment). However, models worked in conjunction with IP-MH care, rather than as stand-alone replacements. There was a deficit of NZ-based research in relation to all aspects of services considered.
The descriptive epidemiological study demonstrated significant increased demand pressure on IP-MH services, and high and increasing volumes of bed nights provided by adult services to children and adolescents. There was no evident substitution of other types of secondary mental health services, which all showed decreases over the decade in the mean level of service provided to each person per year. Reductions in the average community residential mental health bed nights per individual each year were substantial. There was variance in access between sub-groups stratified by a range of different socio-demographic characteristics. Rates of service use were highest for Māori and rates of involuntary admission under the Mental Health Act were over three times greater than for other ethnic groups. The predominant trends in service use by children and adolescents reflect growing rates for females and for those from the least deprived areas, alongside increasing presentations of anxiety and depression.
The case study conducted at the RRAIS provided nuanced data regarding how IP-MH services are organised and delivered in a regional service in NZ. Results reflected a balance between significant challenges facing the unit (particularly managing increased demand pressure against a backdrop of chronic staffing shortages), some real strengths in service delivery and evidence of improvement following recent changes in leadership. Rangatahi participants experienced the unit as a place of sanctuary, and valued the support provided by staff to help them manage acute symptoms and get their lives back on track.
Conclusions
Findings from across the three studies were woven together to present an integrated picture from a system-perspective of IP-MH services for children and adolescents in NZ.
Typical properties of complex adaptive systems (CAS) were identified, and the system was conceptualised and mapped as a CAS. The integrated findings were interpreted through the CIS-A theoretical lens to develop a view on current functioning of the IP MH system for children and adolescents and to inform strategic policy inferences. The conclusions highlighted the value provided by such services balanced by the potential risks associated with the inpatient model of care; substantial demand increases have been absorbed without additional investment and the significant stress upon the system is not sustainable. Mental health policy settings need to clarify and secure the future place and purpose of IP-MH services for children and adolescents, within the context of the changing NZ mental health system.
High-level priorities for action to deliver the change required to improve service delivery within this part of the system were suggested as follows:
1. Increase policy focus and investment in the secondary mental health system for children and adolescents
2. Integrate IP-MH services into an acute/sub-acute network of services that improves access to and extends the choice of services available
3. Develop a robust and coherent evidence base within the NZ context
Contribution
This thesis has built substantially on the body of academic knowledge about IP-MH services for children and adolescents in NZ viewed from a systems-perspective, with findings shaped in a way to inform policy development in this field.
Further, the work has extended the practical application of complexity and implementation science theory within a mental health context. The methodology and the CIS-A conceptual framework provide a structured and novel approach to support mixed methods health services and systems research which could be applied in other areas of health systems analysis.