February 2021 marks Place2B’s 7th anniversary of children’s mental health week, building awareness of the importance of children and young people’s mental well-being. Understanding the mental state of children and adolescents is well-timed as we still navigate our way through the COVID-19 pandemic.

Lack of interactions forced by local and national lockdowns and school closures, coupled with families finding themselves in uncertain and rapidly changing situations with home schooling, working from home, and economic pressure. How has this accelerated mental illness?

We’ve seen the increased impact on adult mental health due to pandemic, is this the same for children too? Or has this been under-reported and become a global unmet need?

On 13th January 2021, a landmark reform of the Mental Health Act empower individuals to have more control over their treatment, whilst also addressing disparity and inequalities within BAME communities. Health and Social Care Secretary, Matt Hancock says the reform is central to its manifesto commitments and brings mental health laws into the 21st century.

The Inter-Agency Standing Committee (IASC) have published a book titled, “My Hero is You, How kids can fight COVID-19!” which explains how children cope and manage difficult emotions when faced with a changing environment.

In the last decade, real world data, that is, the study of medicines usages and treatment outcomes in actual clinical practice in non-clinical trial populations, has become progressively more important to healthcare systems, to understand and evaluate the impact of conditions and the therapeutics used to treat them. This is especially true for the UK, which is a leader in both the generation and the systematic use of real world data. At a time when the pandemic is driving rapid changes in unmet needs in mental health, there is an urgent need for timely and objective data to drive effective decision making and the proper allocation of resources.

How big a problem is mental health, particularly amongst children and adolescents?

The Department of Health (DoH) places mental health as the single largest cause of disability in the UK, contributing to 22.8% of total burden. To give some perspective, cancer and cardiovascular disease in comparison are 15.9% and 16.2% respectively. It is estimated that the wider economic impact of mental health in England alone is over £100 billion each year, this includes direct cost for services, incapacity to work and changes to quality of life. A ‘Mental Health of Children and Young People Survey’ conducted by NHS Digital in 2017 showed one in eight of 5-19 years olds has at least one mental disorder, with rates of mental disorders increasing with age. A follow up survey in July 2020 showed one in six of 5-16 years olds having probable mental disorder, an increase of almost half in 3 years.

How is mental health currently diagnosed in children and young people?

Diagnosis of children’s mental health requires careful and complex GP evaluation of symptoms and specialist referral through the ‘Children and young people’s mental health services (CYPMHS)’.

Management of mental health is part of the Quality Outcomes Framework (Key Performance Indicators linked to GP incentives). Mental health is well coded through GP computer systems through Read and SNOMED codes, a number of studies performed in the UK have validated codes by evaluation of prescriptions used to treat mental ill health.

As an example, diagnosing attention deficit hyperactivity disorder (ADHD) in children depends on a set of strict criteria. A child must have six or more symptoms of inattentiveness, or six or more symptoms of hyperactivity and impulsiveness which are usually observed at dual locations such as at home and school.

Timely diagnosis of a mental health condition at a young age will inform younger patients and their parents of available services and treatments that could ensure a better outcome as they mature into adulthood.

What are the treatment pathways?

Population estimates on those entering treatment taken from the ONS, for clinical commissioning group (CCG) in England, suggested that just over 200,000 children received child and adolescent mental health services (CAMHS) treatment in the year 2015 and 2.6% of the age 5-17 years. CAMHS is the NHS service that assesses and treats young people with emotional, behavioural or mental health difficulties. Interestingly, 2015 data showed that, 46% of budget allocated to NHS mental health goes towards CAMHS community services. A longitudinal cohort study in 2017, found that contact with mental health services at age 14 years by adolescents with a mental disorder reduced the likelihood of depression by age 17 years.

As children’s mental health disorders can be of various types, treatment modalities are directed to specific problems. NICE intervention pathways for social anxiety disorder, are well laid out and suggest cognitive behavioural therapy (CBT) as prime management. It was also researched and found, that CBT is helpful in treating anxiety as a comorbid condition, in children with ADHD. A pilot randomised controlled trial examined the acceptability and feasibility of a CBT intervention for children with ADHD and anxiety, and found that it may improve important domains of functioning for children, including ADHD symptom severity.

Depression is another important mental health condition in children and NICE has laid out a pathway for its treatment. The severity (mild, moderate and psychotic high-risk) of depression is considered in this pathway. The stepped-care model in the NICE guideline specifically talks about various pharmacological (fluoxetine, sertraline, etc.) and non-pharmacological (individual / group CBT, etc.) interventions, by age groups and severity. A similar pathway has been created by NICE for obsessive compulsive disorder (OCD) where CBT and use of selective serotonin reuptake inhibitors (SSRIs) were mentioned. In the guidance provided by NICE for ADHD, the detailed pharmacological interventions and non-pharmaco therapeutic treatments are delineated by age.

Harnessing real world data to improve mental health

Real world data can be used to conduct population studies. The use of de-identified patient records would enable researchers to study the clinical effectiveness of mental health interventions, treatment and services by observing outcomes recorded within routine patient care.

IQVIA Medical Research Data incorporating data from THIN, a Cegedim Database, includes non-identified electronic patient health record data from over 18 million patients collected from UK GP Practices using Vision clinical systems. IQVIA implement a wide variety of privacy-enhancing technologies and safeguards to protect individual privacy while maximising the utility of the data for medical research and treatment analysis.

IQVIA Medical Research Data captures coded demographic, administrative data, clinical events, prescriptions, and death information. IQVIA Medical Research Data is approx. 4.5% representative of the UK population, with the UK uniquely positioned with free healthcare through its National Health Service. GP’s essentially act as gatekeepers, unlocking patient care. Current IQVIA Medical Research Data* shows over 1.1 million patients had a prescription to treat mental ill health. Harnessing this data could help provide researchers with deeper understanding of not only mental health but also associated comorbidities that could reduce a patient’s quality of life.

A study published in the British Medical Journal (BMJ) in 2008, using THIN data confirmed that medically attended head injury before the age of 2 did not contribute to being a cause for ADHD, but any medically attended injury before the age of 2 may be a marker for subsequent diagnosis of ADHD. A further study in 2014, compared month of birth and gender of children aged 5-15 in the academic years 2010/11 (Year 1) and 2011/12 (Year 2) and the association with ADHD diagnosis. Results showed younger children in the school year (born Mar-Aug) were 14% more likely in Year 1 and 12% more likely in Year 2 to have ADHD than older children (those born Sep-Feb), with male’s five times more likely to have an ADHD diagnosis in both years.

Furthermore, a 2012 study using THIN data from 610 patients demonstrated that ~40% of patients who initiated treatment for ADHD between the ages of 6-17 years continued to receive prescriptions at 18 years. ADHD guidelines in place at the time suggested that children and adults who respond to pharmacological treatment should continue for as long as remains clinically effective. With published figures suggesting the condition persisted in ~65% of patients, this study suggests more data are needed to understand if guidelines are being adhered to.

In 2018, Public Health England published a report on severe mental illness (SMI) and physical health inequalities using IQVIA Medical Research Data. Analysis from the report demonstrates that SMI patients have a higher prevalence of obesity, asthma, diabetes, COPD, CHD, stroke and HF, with those aged between 15-34 being five times more likely to have three or more physical health conditions. Demographic data also confirms patients living in deprived areas have higher prevalence of SMI with increased susceptibility of physical health conditions.

More recently in 2019, a team at University of Birmingham published work using IQVIA Medical Research Data, in The Lancet which demonstrates those with evidence of childhood maltreatment were twice as likely to be diagnosed mental illness or receive a prescription for mental ill health than those without evidence of maltreatment.

Understand the impact of rapidly changing mental health care and treatment using IMRD

Companies providing mental health care services and treatment will need to continually assess the impact of COVID-19 using up to date Real World Data. IQVIA Medical Research Data is updated frequently, giving the opportunity for healthcare systems and providers to research the impact of the pandemic on children’s mental health, and to support the understanding of how to meet patient’s needs.

For more information, please contact james.philpott@iqvia.com.

Please also take the time to read our latest white paper; A New Dawn: At the Cusp of the CNS Decade

https://www.iqvia.com/library/white-papers/a-new-dawn-at-the-cusp-of-the-cns-decade

Note:

* Data used are preliminary with simple criteria applied and should not be used to draw any conclusions without further analysis.