Mental Health in Adolescents

Mental Health Service Use Among Adolescents and Young Adults With Major Depressive Disorder and Suicidality Amy H Cheung, M D Carolyn S Dewa, Objectives: Despite being recognized as a serious public health concern, suicidality among adolescents and young adults is frequently missed, and completed suicide remains the second leading cause of death for young Canadians. With such close links between depression, suicidality, and completed suicide, any intervention must address all 3 of these issues.

However, to develop effective interventions, we must understand the types and rates of mental health service use among adolescents and young adults. This study examines service use rates in young Canadians with depression and suicidality and the influence of sex on the types of service provider chosen. Methods: We used data from the Canadian Community Health Survey: Mental Health and Weil-Being. Our sample included 619 individuals, aged 15 to 24 years, who screened positive for depression and suicidality in the past 12 months. We examined mental health service use rates in general and by provider type.

Results: Among adolescents aged 15 to 18 years with depression, 40% had not used any mental health services. This rate was higher for adolescents with suicidality at 50%. In young adults aged 19 to 24 with depression, 42% had not used any mental health services. Among young adults with suicidality, 48% had not accessed services. Female adolescents and young adults were more likely to receive services from nonspecialty mental health providers. Conclusions: In Canada, many adolescents and young adults with depression and suicidality do not receive mental health services.

Further, there may be a preferential treatment of young men by mental health specialists. Further research is needed to understand the quality of care received by these young Canadians and the factors influencing service use. (Can J Psychiatry 2007;52:228-232) Information on funding and support and author affiliations appears at the end of the article. Clinical Implications • About 50% of adolescents and young adults with depression and suicidality do not use mental health services. • Strategies to increase service use in youth with depression are needed. Strategies to decrease differences between the sexes in service use are needed. Limitations • The quality of care could not be examined from the CCHS 1. 2 data. • The survey results were based on patient recall. • Although this was a national population-based study, the sample size was small. 228 • La Revue canadienne de psychiatrie, vol 52, no 4, avril 2007 Mental Health Service Use Among Adolescents and Young Adults With Major Depressive Disorder and Suicidality Key Words: adolescents, depression, suicidality, service use, young adults D pression and suicidality (ideation and attempts) among adolescents and young adults are frequently unrecognized and untreated by any health professionals. ' Not only are depression and suicidality often linked, but both pose a significant burden on patients and their families. Suicide is the second leading cause of death in youth aged 15 to 18 years, second only to motor vehicle accidents. ^ Further, almost 50% of teens who complete suicide have a diagnosable mood disorder, such as depression, and have expressed suicidality prior to completing suicide. ^^ There are also consistent differences between male and female adolescents, with male adolescents more likely to complete suicide and female adolescents more likely to have depression and suicidality. ^ Policy-makers, families, and providers have struggled to understand how to address this significant public health issue. A first step in addressing the issue is to understand the mental health service use pattems among adolescents and young adults with depression and suicidality.

Given the differences in prevalence rates between young men and women, it is also critical to understand the influence of sex on service use in this age group. have a form of depression. ^ Further, according to a biannual survey of youth in the United States, more than 16% of US teenagers have had thoughts about suicide, and 10% had actually attempted suicide in the previous 12 months. '" We found similar rates in Canada, with almost 20% of teens aged 15 to 18 years reporting suicidality in their lifetime. '' However, it is not known how many of these youth received mental health interventions.

Given that depression and suicidality are so closely linked, it would be a reasonable first step to examine the rates of mental health service use among Canadian adolescents and young adults and, flirther, to look at which type of service provider they are seeing to address these problems. Therefore, this study examines the rates of service use in adolescents aged 15 to 18 and young adults aged 19 to 24 with depression and suicidality. We will also comment on how these service use rates could be used to develop policies targeted at this population. Methods

Subjects The survey sample was drawn from the CCHS 1. 2. We examined a subsample of CCHS 1. 2 respondents aged 15 to 24 years. The total sample size for the CCHS 1. 2 is 36 984, with a sample size of 5646 for individuals between the ages of 15 and 24 years. Our subsample included 619 individuals who screened positive for a diagnosis of depression and (or) suicidality in the past 12 months. We examined the rates of mental health service use in general and according to provider type. Major Depressive Disorder. The diagnosis of MDD was evaluated in the CCHS 1. 2 through the use of structured interviews.

The interview modules were drawn from the CIDI. '^ A diagnosis of MDD was derived from the CIDI. We used the 12-month estimates for MDD. Suicidality. Suicidal attempts and ideation were measured by using the questions on suicide in the depression section ofthe CCHS 1. 2 survey. Subjects were interviewed for suicidality regardless of their screen for depression. Although there are significant risk differences between those with suicidal ideation and those with attempts, we combined these 2 groups in our analyses because of Statistics Canada reporting rules regarding rare events.

Service Use. Service use for MDD and suicidality was measured with mental health service use questions. All service use was measured according to provider and place of contact in the following groups: GPs (nonpsychiatrist medical doctors), psychiatrists, psychologists, social workers or counsellors, and other professionals, including nurses, religious counsellors (such as ministers or rabbis), and naturopaths or other alternative health care practitioners. Service use for each of the groups was defined according to use and nonuse.

Statistical Analyses The CCHS 1. 2 uses a stratified design with differences in sampling fractions across the strata, with some geographical 229 Several studies have examined the rates of mental health service use by adolescents and young adults. However, most of these have been US-based studies. * These studies show that service use is less than 50% among adolescents and young adults aged 15 to 24 years* and that up to 80% of children and adolescents aged 6 to 17 years do not receive needed mental health services. Among adolescents with depression, 50% are not diagnosed prior to adulthood. * In Canada, the rates of depression and service use in Canadians aged 15 to 24 were examined in the Ontario Mental Health Supplement in the early 1990s,' which found the rate of service use in this age group to be less than 50%. However, aside from the supplement, no other Canadian study has examined the rates of service use by young Canadians aged 15 to 24 with depression.

Therefore, even with the increasing recognition by policymakers and service providers that depression poses a significant burden on our youth and their families, there is very little research furthering our understanding of this issue or helping to develop effective strategies to address it. Similarly, we know very little about young individuals with suicidality and their pattern of service use. US surveys have shown that more than 50% of youth who complete suicide Abbreviations used in this article CCHS 1. Cl CIDI GP MDD Canadian Community Health Survey: Mental Heaith and Weli-Being confidence interval Composite International Diagnostic Interview general practicitioner major depressive disorder The Canadian Journal of Psychiatry, Voi 52, No 4, Aprii 2007 Original Research Table 1 Twelve-month service use rates by provider type among youth with major depression and sutcidality Any service % (95%CI) Psychiatrist % (95%CI) GP % (95%CI) Psychologist % (95%CI) Social worker or counsellor % (95%CI) Other provider % (95%CI)

Respondents Adolescents aged 15 to 18 years. suffered from major depression Male Female 56. 3 (34. 4 to 78. 1) 55. 9 (40. 7 to 71. 1) 45. 5 (21. 2 to 69. 9) 21. 4 (11. 2 to 31. 6) 24. 6 (7. 2 to 42. 0) 30. 7 (17. 9 to 43. 6) 25. 2 (0. 5 to 49. 8) 16. 7 (7. 9 to 25. 5) 10. 8 (0. 9 to 20. 7) 39. 9 (24. 7 to 55. 0) 23. 9 (-0. 6 to 48. 3) 16. 4(8. 1 to 24. 8) Adults aged 19 to 24 years, suffered from major depression Men Women 52. 5 (37. 3 to 67. 8) 55. 6 (44. 3 to 66. 9) 28. 9 (15. 3 to 42. 5) 26. 1 (18. 0 to 34. 2) 37. (22. 2 to 51. 9) 45. 9 (35. 3 to 56. 5) 33. 9 (19. 2 to 48. 6) 21. 9 (13. 4 to 30. 5) 17. 6 (7. 8 to 27. 5) 29. 1 (20. 3 to 38. 0) 9. 5 (1. 9 to 17. 1) 21. 1 (12. 7 to 29. 5) Adolescents aged 15 to 18 years. suffered from suicidality Male Female 36. 5 (18. 4 to 54. 5) 49. 0 (38. 5 to 59. 5) 23. 3 (6. 3 to 40. 3) 19. 3 (10. 9 to 27. 7) 14. 7 (4. 4 to 25. 1) 27. 2 (17. 7 to 36. 7) 21. 7 (4. 5 to 38. 8) 21. 0 (12. 3 to 29. 8) 13. 2 (4. 2 to 22. 2) 31. 9(22. 1 to 41. 7) 16. 2 (-1. 1 to 33. 4) 15. 9 (8. 5 to 23. 3)

Adults aged 19 to 24 years, suffered from suicidaiity Men Women 39. 5(27. 1 to 51. 9) 50. 8 (37. 0 to 64. 6) 22. 6 (12. 3 to 33. 0) 17. 5 (9. 6 to 25. 4) 27. 9 (16. 6 to 39. 1) 41. 3 (28. 3 to 54. 3) 24. 1 (10. 9 to 37. 3) 24. 6 (14. 0 to 35. 2) 12. 8 (4. 9 to 20. 7) 20. 8 (11. 6 to 30. 0) 9. 3 (2. 2 to 16. 4) 16. 2 (7. 0 to 25. 3) areas under- or overrepresented in the sample relative to their representation in the population. Therefore, we used the weights recommended by Statistics Canada when conducting analyses.

Rates of service use for mental health reasons were calculated for subjects with MDD and (or) suicidality in the past 12 months. Service use rates were examined according to provider type and the sex ofthe subjects. Chi-square tests were conducted to examine for differences between young men and women with depression and (or) suicidality. Results Among adolescents aged 15 to 18 years with depression, 40% (95%CI, 28% to 53%) had not used any mental health services. The rate was higher for those with suicidality, at 50% (95%CI, 41% to 59%).

Most adolescents and young adults with depression were either not accessing services at all or accessing services for their mental health problems through one provider. Among those aged 15 to 18 years, 22% (95%CI, 11% to 33%) accessed services through one provider, compared with 20% (95%CI, 14% to 27%) of those aged 19 to 24 years. Among young adults aged 19 to 24 years with depression, 42% (95%CI, 33% to 51%) had not used any health services for mental health reasons. For those with suicidality, 48% (95% CI, 39% to 5 8%) had not accessed services in the past 12 months.

As with those with depression, most of our sample with suicidality either did not access services at all or accessed services through one provider. Among those aged 15 to 18 years with suicidality, 21% (95%CI, 14% to 28%) accessed services through one provider, compared with 22. 12% (95%CI, 14% to 30%) of those aged 19 to 24 years. 230 Differences between young men and women were not found in the overall use of mental health services. Service use by type of provider and sex are shown in Table 1.

However, female adolescents aged 15 to 18 years with depression were more likely to use services from social workers and (or) counsellors, compared with male adolescents (female adolescents; 40% [95%CI, 25% to 55%]; male adolescents, 11% [95%CI, 1% to 21%]). Similarly, in young adults aged 19 to 24, a higher percentage of yotmg women saw social workers and (or) counsellors (women, 29% [95%CI, 20% to 38%]; men, 18% [95%CI, 8% to 28%]). For those with suicidality, female subjects in both age groups were more likely to use mental health services from GPs.

Among those aged 15 to 18, 15% (95%CI, 4% to 25%) of male adolescents saw GPs, compared with 27% (95%CI, 18% to 37%) of female adolescents. Among those aged 19 to 24, 27. 9% (95%CI, 17% to 39%) of young men saw GPs, compared with 41% (95%CI, 28% to 54%) of young women. Overall, female adolescents and young adults with depression and (or) suicidality were more likely than male adolescents and young adults to use services from GPs (female subjects aged 15 to 18 years: x^ = 4. 53, dfl,P< 0. 03; aged 19 to 24: X = 14. 88, df 1, P < 0. 001) and from social workers and (or) ^ counsellors (aged 15to 18:^^=15. 54,dfl,P