Inequalities in children's mental health care: analysis of routinely collected data on prescribing and referrals to secondary care

Abstract

Background: One in eight children in the United Kingdom are estimated to have a mental health condition, and many do not receive support or treatment. The COVID-19 pandemic has negatively impacted mental health and disrupted the delivery of care. Prevalence of poor mental health is not evenly distributed across age groups, by sex or socioeconomic groups. Equity in access to mental health care is a policy priority but detailed socio-demographic trends are relatively under-researched.

Methods: We analysed records for all mental health prescriptions and referrals to specialist mental health outpatient care between the years of 2015 and 2021 for children aged 2 to 17 years in a single NHS Scotland health board region. We analysed trends in prescribing, referrals, and acceptance to out-patient treatment over time, and measured differences in treatment and service use rates by age, sex, and area deprivation.

Results: We identified 18,732 children with 178,657 mental health prescriptions and 21,874 referrals to specialist outpatient care. Prescriptions increased by 59% over the study period. Boys received double the prescriptions of girls and the rate of prescribing in the most deprived areas was double that in the least deprived. Mean age at first mental health prescription was almost 1 year younger in the most deprived areas than in the least. Referrals increased 9% overall. Initially, boys and girls both had an annual referral rate of 2.7 per 1000, but this fell 6% for boys and rose 25% for girls. Referral rate for the youngest decreased 67% but increased 21% for the oldest. The proportion of rejected referrals increased steeply since 2020 from 17 to 30%. The proportion of accepted referrals that were for girls rose to 62% and the mean age increased 1.5 years.

Conclusions: The large increase in mental health prescribing and changes in referrals to specialist outpatient care aligns with emerging evidence of increasing poor mental health, particularly since the start of the COVID-19 pandemic. The static size of the population accepted for specialist treatment amid greater demand, and the changing demographics of those accepted, indicate clinical prioritisation and unmet need. Persistent inequities in mental health prescribing and referrals require urgent action.

Keywords: CAMHS; Child & adolescent mental health; Health inequalities; Mental health prescribing.

Fig. 1

Monthly mental health prescription rate per 1000 children aged 2–17. Dashed line indicates the first UK COVID-19 lockdown beginning 2020/03/23. Grey points for melatonin prescriptions only, Red for all prescriptions excluding melatonin

Fig. 2

Monthly mental health prescriptions by BNF Section (January 2015 – May 2021). Dashed line indicates the first UK COVID-19 lockdown beginning 2020/03/23. Note: Y axis scale varies and drugs for treatment of substance dependence are not shown due to low monthly counts

Fig. 3

Monthly mental health prescription rate per 1000 children by school age group. Note: the drop in melatonin prescriptions recorded from mid 2019 to mid 2020 is more pronounced in younger ages. Dashed line represents the start of the 1st UK COVID-19 lockdown

Fig. 4

a) Monthly prescription rate per 1000 children by sex. b) Count of unique individuals with a mental health prescription by age at prescription. Note: includes period of lower melatonin prescribing which is more prominent for boys

Fig. 5

Proportion of total prescriptions by BNF Section and school age group

Fig. 6

a) Slope Index of Inequality and b) Relative Index of Inequality for annual mental health prescriptions per 100 children by area deprivation. Point ranges denote annual SII and RII with confidence intervals. Dashed lines denote mean annual SII and RII over the entire study period and the shaded red area represents the mean annual confidence intervals

Fig. 7

a) Monthly rate of referrals per 1000 children b) Quarterly referral rate per 1000 children by age group (January 2015 to October 2021)

Fig. 8

a) Monthly referral rate per 1000 children by sex. b) Distribution of age at referral for unique individuals by sex

Fig. 9

a) Slope Index of Inequality and b) Relative Index of Inequality for annual specialist CAMHS referrals per 100 children by area deprivation. Point ranges denote annual SII and RII with confidence intervals. Dashed lines denote mean annual SII and RII

Fig. 10

a) Monthly proportion of referrals rejected b) Monthly proportion of referrals rejected by sex c) Quarterly proportion of referrals rejected by age group

Fig. 11

Monthly proportion of accepted referrals which were for girls (2015–2021). Dashed line indicates even referral acceptance for boys and girls