Mental health conditions refer to a wide range of disorders that affect mood, thinking and behaviour in children and young people (CYP), including acute disorders that require immediate attention and intervention. These conditions can have an adverse effect on a child's emotional, social and environmental development, and can lead to long-term adverse effects on their overall health and well-being. Mental health conditions are experienced by approximately 14% of CYP internationally,1 which have increased exponentially, particularly in light of the COVID-19 pandemic. According to recent reports, the prevalence of mental health disorders among CYP has increased exponentially, with up to 19% reported for suicidal presentations in Australia.Reference Sara, Wu, Uesi, Jong, Perkes and Knight2 Suicide is the leading cause of death among young people, with the global suicide rate of 10.5 per 100 000 individuals.Reference Kim-Cohen, Caspi, Moffitt, Harrington, Milne and Poulton3,Reference Wasserman, Cheng and Jiang4 According to a 2020 report by United Nations International Children's Emergency Fund (UNICEF), mental health issues among CYP are a growing concern globally. Suicide is the second leading cause of death among young people aged 15–19 years.5 The suicide rate has been reported to be 12.0 per 100 000 in the African region, 12.9 per 100 000 in the European region, 13.4 per 100 000 in the South-East Asia region, 11.8 per 100 000 in the USAReference Bould, Mars, Moran, Biddle and Gunnell6 and 10.4 per 100 000 in Canada.Reference Skinner, McFaull, Draca, Frechette, Kaur and Pearson7 The lowest reported suicide rate is 4.3 per 100 000 individuals in the Eastern Mediterranean region.Reference Wasserman, Cheng and Jiang4
A mental health crisis in CYP can arise when they encounter an experience or event that exceeds their and/or their family's capacity to manage their mental health distress, resulting in a significant impairment of their ability to function and requiring urgent medical attention.Reference Hu, Nassar, Shrapnel, Perkes, Hodgins and O'Leary8,Reference John, Synn, Winata, Eapen and Lin9 Validated screening tools are available to identify CYP who require brief interventions to address acute mental health crises. These measurement tools, rigorously validated through scientific scrutiny and empirical evidence, are designed to adhere to stringent psychometric standards. By applying established criteria, these screening tools systematically evaluate the mental health status of CYP, enabling healthcare professionals to discern the severity and urgency of intervention required. The use of validated screening tools ensures the precision and reliability of the assessment process, facilitating the timely and targeted implementation of brief interventions for CYP experiencing acute mental health crises.Reference Deighton, Croudace, Fonagy, Brown, Patalay and Wolpert10
In situations where risks are higher and the criterion is met, in-patient treatment may be necessary, and many CYP who meet the threshold could benefit from brief interventions.Reference Hu, Nassar, Shrapnel, Perkes, Hodgins and O'Leary8,Reference John, Synn, Winata, Eapen and Lin9 However, in-patient hospital admissions can place a significant burden on both CYP and their caregivers because of dislocation from family, friends and support networks, with readmission occurrences heightening this situation. Our recent work in Australia has found a substantial increase in CYP presenting to the emergency departmentReference Hu, Nassar, Shrapnel, Perkes, Hodgins and O'Leary8 and suicide-related ambulance callsReference John, Synn, Winata, Eapen and Lin9 during the COVID-19 pandemic, indicating the need to efficiently respond to an acute mental health condition/presentation/crisis and fill service gaps.Reference Eapen, Stylianakis, Scott, Milroy, Bowden and Haslam11 Therefore, safe and effective brief interventions have been proposed to improve the efficiency and effectiveness of crisis care in a timely, safe and sensitive manner, accounting for the complex, multifaceted needs of consumers.
Aim of the review
The findings of our systematic review are timely and build upon previous reviews reporting outcomes on brief interventions by Otis et al,Reference Otis, Barber, Amet and Nicholls12 Clisu et alReference Clisu, Layther, Dover, Viner, Read and Cheesman13 and Newton et al.Reference Newton, Hartling, Soleimani, Kirkland, Dyson and Cappelli14 These studies collectively suggest that brief interventions have a beneficial impact on reducing readmission rates to the emergency department, which can reduce the burden on emergency departments and improve outcomes for CYP with mental health concerns. In alignment with these previous studies, which highlight the positive impact of brief interventions on reducing readmission rates to emergency departments and enhancing outcomes, our study hypothesises that strategically tailored brief interventions for mental health crises, incorporating established screening procedures and administered in out-patient settings (excluding emergency departments), possess the potential to significantly reduce reliance on emergency department assessments, re-evaluations or in-patient admissions among CYP aged 0–17 years. This hypothesis serves to guide this review, aligning with our aim to contribute essential insights that advance crisis care strategies in the realm of CYP mental health.
Method
For this review, we followed the guidelines outlined in the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement.Reference Page, McKenzie, Bossuyt, Boutron, Hoffmann and Mulrow15 The protocol was registered with the International Prospective Register of Systematic Reviews (PROSPERO; registration number CRD42022323324). Ethical approval was not required as this is a systematic review of published data.
Search strategy and study selection
This systematic literature review utilised five electronic databases (PubMed, PsycINFO via ProQuest, Web of Science via Clarivate, EMBASE and Cochrane Library) to extract studies reporting on the effectiveness of interventions for acute mental health presentations of CYP aged 0–17 years. We also searched cross-references for further articles. Peer-reviewed studies published in the English language were searched over the past 22 years (1 January 2000 to 30 March 2022). We included primary literature evaluating the effectiveness of brief interventions for CYP aged 0–17 years who presented with an acute mental health concern. The full search strategy is included in Supplementary Table 1 available at https://doi.org/10.1192/bjo.2024.25. Search results were de-duplicated in Endnote X9 for Windows (Clarivate Analytics, Berkeley, California, USA; see https://endnote.com/) and again in Rayyan software for Windows for systematic reviews (Rayyan Systems, Cambridge, Massachusetts, USA; see www.rayyan.ai).Reference Ouzzani, Hammady, Fedorowicz and Elmagarmid16 A data collection tool was used to screen each paper for inclusion and exclusion eligibility for the review.
Data extraction and screening
Four reviewers (F.B., B.G., P.H., J.R.J.) performed the initial title and abstract screening with the data collection tool. Two reviewers (F.B., P.H.) independently conducted full-text screening and compared results. At each stage of the selection process, a fifth reviewer (T.W.) was available to resolve or moderate any disagreements on the included articles. Four reviewers (F.B., B.G., P.H., B.O.A.) performed data extraction for the included articles. In parallel, these reviewers extracted data from the full-text reports with Rayyan software, a web-based systematic review application.Reference Ouzzani, Hammady, Fedorowicz and Elmagarmid16 This was used to extract study designs, country, the size of the sample, different characteristics of the study population (including age, ethnicity, gender and diagnoses), type of intervention, characteristics of the control group and the outcomes of interest.
Eligibility criteria
Studies were included if (a) the study reported on the effectiveness of a brief intervention (defined below) targeted at improving mental health outcomes for CYP presenting with an acute mental health condition/presentation/crisis; (b) participants’ age ranged from 0 to 17 years, or where the age range was not reported, the mean age of the participant was <18 years; (c) participants presented with an acute mental health condition/presentation/crisis and (d) studies were published in a peer-reviewed journal in English.
Studies were excluded if (a) participant age criteria were not met (participants >18 years of age), (b) participants were not presenting/attending the intervention for the treatment of an acute mental health condition, (c) the study was a quantitative meta-analysis of published literature and (d) the study was not published in a peer-reviewed journal in English.
Brief intervention services
We defined the term ‘acute mental health crisis’ as a situation in which CYP experience a sudden and severe deterioration in their mental health. This deterioration is often accompanied by significant distress and impairment in their ability to function. In contrast, we will use the term ‘psychiatric emergency’ to refer to situations where there is an immediate risk to the safety or well-being of the CYP or others because of their mental health condition. In this review, we defined ‘brief interventions’ as an intervention that consisted of three or fewer visits to a service or ≤8 weeks of intervention programme duration. The narrative synthesis followed guidance for systematic reviews to assist with evaluating the evidence-based effectiveness of each intervention, such as what interventions (mechanisms) were effective (outcomes) and the type of setting and location (context) where the intervention took place.Reference Popay, Roberts, Sowden, Petticrew, Arai and Rodgers17
Details describing quality assessment, data extraction and risk of bias can be found in Supplementary Appendices 1 and 2.
Statistical analysis
Previously reported data from various studies were synthesised. Given the narrative synthesis nature of our work, we focused on the qualitative integration of findings rather than employing quantitative statistical methods. Our approach involved an examination of the reported outcomes, utilising frequencies and percentages where appropriate, to convey the distribution of data. This facilitated a nuanced exploration of the collective evidence, aligning with the synthesis objectives of this review.
Results
Our initial search yielded 4892 results, of which 3242 were duplicates, resulting in 1650 articles that were eligible for screening. After title and abstract screening, 436 potentially eligible studies were assessed for eligibility, and 30 studies met the eligibility criteria. Figure 1 illustrates the study selection process, using the PRISMA flow diagram.
Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flow diagram of study selection process chart.
Table 1 summarises characteristics of the included studies. Studies were conducted in different geographical regions; 19 studies were from the USA (n = 19),Reference Aupont, Doerfler, Connor, Stille, Tisminetzky and McLaughlin18,Reference Wharff, Ginnis and Ross37 and the rest were from Canada (n = 7),Reference Greenham and Bisnaire38,Reference Carlisle, Mamdani, Schachar and To44 England (n = 2)Reference Adrian and Smith45,Reference Sclare, Michelson, Malpass, Coster and Brown46 and Australia (n = 1).Reference Schley, Yuen, Fletcher and Radovini47 Most of the studies were cohort studies (n = 19),Reference Aupont, Doerfler, Connor, Stille, Tisminetzky and McLaughlin18,Reference Holder, Rogers, Peterson, Shoenleben and Blackhurst21,Reference Cummings, Dubovsky, Ehrlich, Kandefer, Van Cleve and Yin25,Reference Mahajan, Thomas, Rosenberg, Leleszi, Leleszi and Mathur27,Reference Parast, Bardach, Burkhart, Richardson, Murphy and Gidengil28,Reference Uspal, Rutman, Kodish, Moore and Migita31,Reference Morris, Nixon, Keyes and Ashmore39,Reference Gusella, Campbell and Lalji42,Reference Carlisle, Mamdani, Schachar and To44,Reference Chen, Dinyarian, Inglis, Chiasson and Cleverley48 followed by pre and post studies (n = 10) and one non-randomised controlled trial (n = 1).
Characteristics of participants who received brief interventions
Brief intervention was defined as three or fewer visits to a service or ≤8 weeks of intervention programme duration. ATSI, Aboriginal and Torres-Strait Islander.
Methodological quality of the studies
Table 2 provides a comprehensive overview of each of the included studies, with detailed descriptions of the studies, National Health and Medical Research Council (NHMRC) levels of evidence and risk of bias, interventions examined and the results reported. Among the included studies, there was one study that was rated as high quality or provided a high level of evidence based on the NHMRC levels of evidence hierarchy scale (level of evidence I or II),Reference Ishikawa, Chin, Meckler, Hay and Doan40 10 studies were rated as providing moderate evidence (level of evidence III-2: comparative studies with controls such as cohort studies)Reference Hu, Nassar, Shrapnel, Perkes, Hodgins and O'Leary8,Reference Casher, Sutton, Roosevelt and Simpson19,Reference Holder, Rogers, Peterson, Shoenleben and Blackhurst21,Reference Mahajan, Thomas, Rosenberg, Leleszi, Leleszi and Mathur27,Reference Kells, Schubert-Bob, Nagle, Hitchko, O'Neil and Forbes33,Reference Huryk, Casasnovas, Feehan, Paseka, Gazzola and Loeb34,Reference Wharff, Ginnis and Ross37,Reference Gusella, Campbell and Lalji42,Reference Carlisle, Mamdani, Schachar and To44 and 19 studies were of lower-quality evidence (level of evidence III-3: cohort studies without a comparison group; or level of evidence IV: pre and post studies).Reference Aupont, Doerfler, Connor, Stille, Tisminetzky and McLaughlin18,Reference Knapp, Ammen, Arstein-Kerslake, Poulsen and Mastergeorge22,Reference Hasken, Wagers, Sondhi, Miller and Kanis26,Reference Reliford and Adebanjo29–Reference Rogers, Griffin, Masso, Stevens, Mangini and Smith32,Reference McDowell, Valleru, Adams and Fristad35,Reference Gillig36,Reference Greenham and Bisnaire38,Reference Morris, Nixon, Keyes and Ashmore39,Reference Parker, Roberts, Williams, Benjamin, Cripps and Woogh41,Reference Adrian and Smith45,Reference Schley, Yuen, Fletcher and Radovini47 There was considerable variability between study methodologies and 30% (n = 9/30 studies) of studies compared outcomes with a comparison groupReference Casher, Sutton, Roosevelt and Simpson19,Reference Holder, Rogers, Peterson, Shoenleben and Blackhurst21,Reference Mahajan, Thomas, Rosenberg, Leleszi, Leleszi and Mathur27,Reference Parast, Bardach, Burkhart, Richardson, Murphy and Gidengil28,Reference Kells, Schubert-Bob, Nagle, Hitchko, O'Neil and Forbes33,Reference Wharff, Ginnis and Ross37,Reference Gusella, Campbell and Lalji42,Reference Carlisle, Mamdani, Schachar and To44 (see Table 2).
Characteristics of brief intervention studies (N = 30 studies)
NHMRC, National Health and Medical Research Council; HSO, patients who were not admitted to hospital; INT, intervention group; CBT, cognitive–behavioural therapy; AAOT, adolescent assertive outreach team; HoNOSCA, Health of the Nation Outcome Scales; CGAS, Children's Global Assessment Scale; ARC, adolescent resource centre; ADHD, attention-deficit hyperactivity disorder; CYP, children and young people; CNT, control group; LOS, length of stay; YSR, youth self-report; CBCL, Child Behavior Checklist; CAPI, Childhood Acuity of Psychiatric Illness Scale; FBT, family-based treatment; GAF, Global Assessment of Functioning; ICI, intensive crisis intervention; MDT, multidisciplinary team; SCARED, Screen for Child Anxiety Related Emotional Disorders; MFQ, Mood and Feelings Questionnaire; RSES, Rosenberg Self-Esteem Scale; FBCI, family-based crisis intervention.
a. Two interventions incorporated into the same study.
Effect of interventions on mental health symptoms
We narratively synthesised intervention types into the following categories: crisis intervention, integrated services, group therapies, individualised therapy, parent–child dyadic therapy, general services, pharmacotherapy, assessment services, safety and risk planning, and in-hospital treatment (see Table 2).
Assessment services
Five studies (17%) evaluated assessment services, including motivational interviewing, neuropsychology assessment, telepsychiatry and interdisciplinary assessment, targeting CYP (age range: 3–17 years) with psychosis and behavioural disorders.Reference Casher, Sutton, Roosevelt and Simpson19,Reference Hasken, Wagers, Sondhi, Miller and Kanis26,Reference Greenham and Bisnaire38,Reference Morris, Nixon, Keyes and Ashmore39 Although information about mental health disorders for younger children accessing assessment services was not specified, Reliford and Adebanjo's studyReference Reliford and Adebanjo29 demonstrated low-level evidence that on-call telepsychiatry consultations in a non-hospitalised intervention programme significantly reduced the total monthly length of stay (LOS) during a 6-month study period (from 285 to 193 h) compared with prior months. Non-hospitalised patients also experienced a significant reduction in monthly LOS, decreasing from 329 h to 193 h during the study period. Additionally, the telepsychiatry intervention reduced the need for face-to-face evaluations by 75%.
Crisis intervention
Crisis intervention was explored in eight studies (27%) focusing on diverse mental health conditions in CYP, such as anxiety, depression and self-harm.Reference Mahajan, Thomas, Rosenberg, Leleszi, Leleszi and Mathur27,Reference Uspal, Rutman, Kodish, Moore and Migita31,Reference Rogers, Griffin, Masso, Stevens, Mangini and Smith32,Reference Wharff, Ginnis and Ross37,Reference Greenham and Bisnaire38 The average duration for a crisis intervention was 4 days. Among the eight studies that reported outcomes associated with a crisis intervention, there was only one study that showed a reduction in the LOS and the frequency of emergency department return visits. One high-quality studyReference Ishikawa, Chin, Meckler, Hay and Doan40 reported a 15% decrease in 30-day emergency department return visits among the intervention group. Moreover, a moderate-quality cohort studyReference Mahajan, Thomas, Rosenberg, Leleszi, Leleszi and Mathur27 demonstrated significant reductions in emergency department LOS following the ‘Child Guidance’ intervention, with a mean decrease of 43.10 min (P < 0.001). Additional findings can be found in Table 2.Reference Sheridan, Sheridan, Johnson, Laurie, Knapper and Fu30,Reference Parker, Roberts, Williams, Benjamin, Cripps and Woogh41
General services
General services for CYP mental health included psychiatric evaluations, treatment plan reviews, psychosocial treatments, psychoeducation for families and behavioural health treatments. In the reviewed studies (23%), these services, examined through cohort and pre–post intervention studies, benefited CYP aged 3–17 years with various mental health diagnoses (anxiety, autism spectrum disorder, attention-deficit hyperactivity disorder, conduct disorders, depression, eating disorders, psychotic disorders, self-harm/suicidal ideation) (Table 2).
One study indicated an 8% reduction in emergency department presentations (32.8–24.5%) after receiving intervention services.Reference Parast, Bardach, Burkhart, Richardson, Murphy and Gidengil28 Another study focusing on psychosis intervention found significant improvements in CYP behaviour disorders and psychosis, evidenced by improved Children's Global Assessment Scale (CGAS) scores at assessment and discharge.Reference Greenham and Bisnaire38 Interventions, lasting from 3 h to <3 months, demonstrated overall benefits, improving outcomes in behaviour disorders and reducing emergency department presentations.Reference Aupont, Doerfler, Connor, Stille, Tisminetzky and McLaughlin18,Reference Grimes, Creedon, Webster, Coffey, Hagan and Chow20,Reference Hasken, Wagers, Sondhi, Miller and Kanis26,Reference Parast, Bardach, Burkhart, Richardson, Murphy and Gidengil28,Reference Morris, Nixon, Keyes and Ashmore39,Reference Adrian and Smith45,Reference Schley, Yuen, Fletcher and Radovini47
Group therapy
Group therapy, including family therapy, psychotherapy, wellness and substance misuse counselling, demonstrated effectiveness, notably in reducing hospital readmission rates for CYP in family-based interventions.Reference Huryk, Casasnovas, Feehan, Paseka, Gazzola and Loeb34 Older adolescents in these therapies exhibited diverse mental health symptoms (anxiety, autism spectrum, behavioural disorders, depression, eating disorders, psychosis, self-harm/suicidal ideation)Reference Martin, McConville, Williamson, Feldman and Boekamp23,Reference Cummings, Dubovsky, Ehrlich, Kandefer, Van Cleve and Yin25,Reference McDowell, Valleru, Adams and Fristad35,Reference Gusella, Campbell and Lalji42,Reference Adrian and Smith45
Cognitive–behavioural therapy (CBT) was evaluated in four low-level evidence studies (14%)Reference McBee-Strayer, Thomas, Bruns, Heck, Alexy and Bridge24,Reference Morris, Nixon, Keyes and Ashmore39,Reference Adrian and Smith45,Reference Sclare, Michelson, Malpass, Coster and Brown46 of CBT programmes for CYP (age range: 8–16 years).Reference McBee-Strayer, Thomas, Bruns, Heck, Alexy and Bridge24,Reference Carlisle, Mamdani, Schachar and To44,Reference Asarnow, Jaycox, Tang, Duan, LaBorde and Zeledon49,Reference Rickwood, Mazzer, Telford, Parker, Tanti and McGorry51 A group-based CBT programme effectively reduced suicidal ideation at 30 days and 3 months post-intervention for adolescents aged 12–17 years.Reference McBee-Strayer, Thomas, Bruns, Heck, Alexy and Bridge24 Additionally, CBT interventions for older adolescents (mean age 16 years) resulted in significant improvements in anxiety and mood, without cases of deterioration.Reference Sclare, Michelson, Malpass, Coster and Brown46
In-hospital treatment
In five studies (17%) centred on in-hospital interventions for CYP aged 8–21 years, two were pre-and post-studiesReference Hasken, Wagers, Sondhi, Miller and Kanis26,Reference Adrian and Smith45 and three were cohort studies,Reference Uspal, Rutman, Kodish, Moore and Migita31,Reference Huryk, Casasnovas, Feehan, Paseka, Gazzola and Loeb34,Reference Greenham and Bisnaire38 with risks of bias ranging from moderate to high. Diagnoses included adjustment disorders, anxiety, autism spectrum disorder, behavioural disorders, depression, eating disorders, psychosis and self-harm/suicidal ideation. In-hospital stays, lasting from 1 to 3 months, tailored interventions to mental health conditions. One study reported multimodal in-hospital interventions for CYP showed positive outcomes, with emergency evaluation interviews and brief therapeutic interventions effectively treating CYP within 24 h of their emergency department presentation. Hospital admission rates decreased significantly after the intervention, and no control group was provided for comparison.Reference Uspal, Rutman, Kodish, Moore and Migita31,Reference Gillig36
Individualised therapy
Two studiesReference Mahajan, Thomas, Rosenberg, Leleszi, Leleszi and Mathur27,Reference Parker, Roberts, Williams, Benjamin, Cripps and Woogh41 with a moderate risk of bias (7%) investigated individualised therapy for CYP.Reference Grimes, Creedon, Webster, Coffey, Hagan and Chow20,Reference Huryk, Casasnovas, Feehan, Paseka, Gazzola and Loeb34 In one study,Reference Grimes, Creedon, Webster, Coffey, Hagan and Chow20 a collaborative practice model intervention was associated with increased access to psychiatric evaluations (adjusted odds ratio 4.16, P < 0.01) and greater engagement in follow-up sessions (adjusted odds ratio 7.54, P < 0.01) for CYP with behaviour, anxiety and mood disorders. The other study found that young people with eating disorders who received weekly individual therapy in a partial hospital programme had significantly lower LOS (29.37 days, s.d. = 18.85 days) compared with the control group (32.96 days, s.d. = 14.59 days), along with lower hospital readmission rates (P < 0.04).Reference Huryk, Casasnovas, Feehan, Paseka, Gazzola and Loeb34
Integrated services
Integrated services, comprising various components such as integration with primary care, linkage to specialty and community mental health services, and paediatric behavioural interventions, were explored in eight studies.Reference Casher, Sutton, Roosevelt and Simpson19,Reference Holder, Rogers, Peterson, Shoenleben and Blackhurst21,Reference McBee-Strayer, Thomas, Bruns, Heck, Alexy and Bridge24,Reference Greenham and Bisnaire38,Reference Adrian and Smith45,Reference Schley, Yuen, Fletcher and Radovini47 These services had a duration of <3 months and were accessed by CYP aged 0–17 years with conditions like adjustment disorder,Reference Greenham and Bisnaire38 aggression and anxiety,Reference Schley, Yuen, Fletcher and Radovini47 autism spectrum disorder,Reference Cummings, Dubovsky, Ehrlich, Kandefer, Van Cleve and Yin25,Reference Adrian and Smith45,Reference Jensen-Doss and Hawley52 behaviour disorders,Reference Greenham and Bisnaire38 depression and mood disorders,Reference Greenham and Bisnaire38,Reference Adrian and Smith45 eating disorders,Reference Greenham and Bisnaire38,Reference Adrian and Smith45 psychotic disorders,Reference Greenham and Bisnaire38,Reference Adrian and Smith45 self-harm/suicidal ideationReference McBee-Strayer, Thomas, Bruns, Heck, Alexy and Bridge24,Reference Greenham and Bisnaire38,Reference Adrian and Smith45,Reference Schley, Yuen, Fletcher and Radovini47 and substance misuse.Reference Schley, Yuen, Fletcher and Radovini47 Two Canadian studies provided moderate-level evidence on out-patient aftercare services, showing mixed results in terms of emergency department readmissions.Reference Cheng, Chan, Gula and Parker43,Reference Carlisle, Mamdani, Schachar and To44 Another study highlighted the positive impact of a multidisciplinary mobile youth outreach service on consumer engagement and hostility risk in CYP with psychotic disorders.Reference Schley, Yuen, Fletcher and Radovini47
Parent–child dyadic therapy
Parent–child dyadic therapy was the focus of one study with a moderate level of bias and low-quality evidence.Reference Knapp, Ammen, Arstein-Kerslake, Poulsen and Mastergeorge22 The study evaluated an infant preschool family mental health initiative for young children (mean age 3 years, range 0–5 years) with anxiety, behavioural disorders, adjustment disorder and affective or reactive disorders. The intervention employed relationship-based dyadic techniques with parents and their children, resulting in high parental satisfaction and significant improvements in the Mental Health Screening Tool and Moderate Risk Assessment scores, as well as higher scores on the Parent–Infant Relationship Global Assessment Scale and Global Assessment of Functioning Scale at post-test.Reference Knapp, Ammen, Arstein-Kerslake, Poulsen and Mastergeorge22
Pharmacotherapy
Five studies (16%) evaluated pharmacotherapy efficacy for CYP aged 4–16 years.Reference Aupont, Doerfler, Connor, Stille, Tisminetzky and McLaughlin18,Reference Martin, McConville, Williamson, Feldman and Boekamp23,Reference Cummings, Dubovsky, Ehrlich, Kandefer, Van Cleve and Yin25,Reference Morris, Nixon, Keyes and Ashmore39,Reference Adrian and Smith45 Medication, combined with other therapies, showed significant improvements in mental health symptoms, particularly for externalising symptoms (Cohen's d = 0.99) and total problems (Cohen's d = 0.86).Reference Martin, McConville, Williamson, Feldman and Boekamp23 Older adolescents received pharmacotherapy for a range of mental health conditions, such as attention-deficient hyperactivity disorder, autism and depression.Reference Aupont, Doerfler, Connor, Stille, Tisminetzky and McLaughlin18,Reference Cummings, Dubovsky, Ehrlich, Kandefer, Van Cleve and Yin25,Reference Morris, Nixon, Keyes and Ashmore39 However, some studies lacked specific medication details (type and dose) and effects.Reference Aupont, Doerfler, Connor, Stille, Tisminetzky and McLaughlin18,Reference Adrian and Smith45 An early psychosis intervention service employing medication management and multimodal therapies, including psychiatric evaluations, psychoeducation (i.e. healthy lifestyle choices, symptom awareness, medication management), individual and family therapy sessions showed improved CGAS scores.Reference Morris, Nixon, Keyes and Ashmore39 Additional details associated with the outcomes for each study can be found in Table 1, where a summary of the results from each research study are provided.
Safety and risk assessment planning
Three studies (10%) examined safety and risk assessment planning services, all with a moderate risk of bias. Safety and risk assessments for younger children (age 2–5 years) primarily focused on those with behavioural disorders,Reference Martin, McConville, Williamson, Feldman and Boekamp23 whereas for adolescents (age 12–17 years), the services targeted individuals with self-harm/suicidal ideationReference McBee-Strayer, Thomas, Bruns, Heck, Alexy and Bridge24 and behavioural disorders.Reference Sheridan, Sheridan, Johnson, Laurie, Knapper and Fu30 In a study with moderate evidence, safety planning was integrated into a care service for young people with self-harm/suicidal ideation,Reference Casher, Sutton, Roosevelt and Simpson19 and outcomes were compared with a control group. Among the participants, 26% received behavioural safety planning as part of the intervention, and the results showed no significant difference in 30- or 90-day emergency department return rates compared with the control group.Reference Casher, Sutton, Roosevelt and Simpson19
Discussion
The aim of this study was to investigate whether brief interventions, incorporating established screening procedures and delivered in out-patient settings (excluding emergency departments), effectively decreased the reliance on emergency department assessments, re-evaluations or in-patient admissions among CYP experiencing mental health crises. This systematic review included studies exploring a wide range of brief interventions in different settings for CYP presenting with a mental health crisis. To translate these findings into practical strategies, several key considerations need to be considered.
In the context of the emergency department, the use of measurement-based care (MBC) for screening purposes can help identify CYP who require brief interventions and improve their treatment outcomes.Reference Jensen-Doss and Hawley52,Reference Chorpita, Daleiden and Weisz54 MBC can be used by trained health professionals to track treatment progress and outcomes, and has been shown to improve treatment outcomes for CYP with mental health conditions. A study by Parikh et alReference Parikh, Fristad, Axelson and Krishna55 found that the use of standardised screening tools in the emergency department improved the identification of mental health disorders and increased the provision of appropriate referrals and interventions. Another study by Chun et alReference Chun, Duffy and Linakis56 found that the use of screening tools in the emergency department improved the identification of mental health conditions among CYP. Further, Bickman et alReference Bickman, Kelley, Breda, de Andrade and Riemer57 found that the use of MBC led to significant improvements in mental health outcomes for youths in community mental health clinics, including a reduction in symptoms and improvement in overall functioning.
Integrated services are core strategies to be employed in brief interventions in mental health programmes. Drake et alReference Drake, Goldman, Leff, Lehman, Dixon and Mueser58 found that the use of a care coordination model was a key component of successful implementation of evidence-based practices in routine mental health service settings. The authors emphasised the importance of considering regional disparities between urban and rural healthcare systems in the implementation of programmes. A study by Probst et alReference Probst, Laditka, Wang and Johnson59 found that rural areas face unique challenges in implementing integrated service programmes, because of limited resources and access to care. Hoffman et alReference Hoffmann, Krass, Rodean, Bardach, Cafferty and Coker60 examined the association between follow-up care visits and return mental health acute care encounters among CYP who had received mental health emergency care, and showed that CYP who received follow-up care visits within 7 and 30 days after an initial mental health emergency visit were less likely to have return mental health acute care encounters. These findings suggest that follow-up care is crucial in reducing the risk of subsequent acute care encounters among CYP with mental health conditions. Further, Lyon and BrunsReference Lyon and Bruns61 also found that factors such as a reduction in symptom severity and family engagement were associated with the likelihood of follow-up care after brief interventions for CYP with behavioural health needs.
Crisis interventions also play key role in emergency department LOS. For example, the ‘Child Guidance’ intervention contributed to significant reductions in emergency department LOS. The Child Guidance intervention is a collaborative model that involves a full-time psychiatric social worker and a full-time child psychiatrist.Reference McBee-Strayer, Thomas, Bruns, Heck, Alexy and Bridge24 It is specifically designed to provide efficient mental healthcare to children with volatile mood disorders in the emergency department. This innovative approach ensures that CYP with acute mental health needs receive timely and specialised care, resulting in notable reductions in emergency department LOS. The success of the Child Guidance intervention highlights its potential as an effective and efficient strategy for optimising the care and outcomes of CYP in crisis situations.Reference McBee-Strayer, Thomas, Bruns, Heck, Alexy and Bridge24
The implementation of brief interventions may require additional funding and resources. Therefore, it is important to consider the cost-effectiveness surrounding them when developing and implementing these programmes. For example, a study by Grist et alReference Grist, Croker, Denne and Stallard62 found that a brief intervention for CYP with anxiety disorders was cost-effective compared with usual care.Reference Grist, Croker, Denne and Stallard62,Reference Morrissey-Kane and Prinz63
Screening CYP to determine the appropriate intervention can be challenging. However, validated screening tools are available to identify CYP who require brief interventions. For example, the Pediatric Symptom Checklist is a widely used screening tool to identify CYP with mental health conditions in primary care settings,Reference Jellinek, Murphy, Little, Pagano, Comer and Kelleher64 whereas the ‘Home, Education, Activities/peers, Drugs/alcohol, Suicidality, Emotions/behavior, Discharge resources' tool has been shown to be effective in identifying CYP who require emergency department-based interventions.Reference Cappelli, Gray, Zemek, Cloutier, Kennedy and Glennie65 Moreover, the Suicide Assessment Five-Step Evaluation and Triage is also a widely used tool for assessing suicide risk in individuals, including CYP who present with suicidal ideation.66 Additionally screening tools, such as the CGASReference Shaffer, Gould, Brasic, Ambrosini, Fisher and Bird67 and the Screen for Child Anxiety Related Emotional Disorders,Reference Birmaher, Khetarpal, Brent, Cully, Balach and Kaufman68 may also be useful in identifying CYP who require brief interventions.Reference Ringeisen, Henderson and Hoagwood69,Reference Birmaher, Brent, Chiappetta, Bridge, Monga and Baugher70
Addressing the barriers to follow-up care is important for improving treatment outcomes for CYP who receive brief interventions. Recent studies have highlighted the importance of follow-up care for CYP with mental health conditions. For example, a study by Katon et alReference Katon, Richardson, Russo, McCarty, Rockhill and McCauley71 found that regular follow-up care was associated with improved mental health outcomes for CYP with depression. A study by Zima et alReference Zima, Murphy, Scholle, Hoagwood, Sachdeva and Mangione-Smith72 found that many CYP with mental health conditions face barriers in accessing mental health services, such as a lack of available services in their area or difficulty accessing care because of transportation issues. In addition, stigma and shame surrounding mental health issues can also be a barrier to care for some CYP.Reference Purtle, Peters and Brownson73 Interventions that address these barriers, such as providing culturally sensitive care and enhancing communication between healthcare providers and families, have been shown to improve follow-up rates among CYP with mental health conditions.Reference Betancourt, Green, Carrillo and Ananeh-Firempong74
Long-term data collection is also an important aspect in evaluating the effectiveness of mental health for CYP, and recent studies have emphasised the significance of conducting follow-up assessments to assess treatment outcomes over extended periods. Weisz et alReference Weisz, Kuppens, Ng, Eckshtain, Ugueto and Vaughn-Coaxum75 observed that CBT demonstrated sustained benefits for anxiety and depression in CYP, evident even at a 5-year follow-up assessment. Moreover, a meta-analysis conducted by Bickman et alReference Bickman, Kelley, Breda, de Andrade and Riemer57 indicated that mental health treatments for CYP generally maintained their effects over time, with potential implications that longer treatment durations could yield more lasting results. Although our systematic review did not explicitly incorporate long-term data supporting the findings, we recognise the importance of considering such data to enhance our understanding of mental health treatment effectiveness. Future research efforts should identify factors contributing to sustained treatment effects and develop interventions promoting enduring mental health outcomes for CYP.
Limitations
Given the escalating number of CYP who present to the emergency department in crisis, it is plausible that brief interventions may enhance mental health outcomes for this population. Consequently, it is imperative to systematically assess the outcomes of brief interventions against a comparison group (including pre-intervention controls), utilising consistent measurement tools to investigate their effectiveness in lowering emergency department presentations, in-patient admissions, LOS, as well as the psychological impact on CYP and their families. Further research is needed to identify impediments to the effective implementation of these interventions, as well as high-quality studies that can compare different interventions in terms of consumer outcomes and perspectives, with appropriate control groups. Moreover, it is crucial to assess the impact of offering brief interventions on other parts of the mental health treatment services sector, such as private services, primary healthcare and community-based public mental health services.
In conclusion, this systematic review examined the impact of brief interventions, incorporating established screening procedures and delivered in out-patient settings, on the utilisation of emergency department assessments, re-evaluations and in-patient admissions among CYP experiencing mental health crises. Findings provide useful insights to guide and support the development of new and existing brief interventions for consumers with mental health concerns and their families/caregivers. The findings indicate that brief interventions can be successfully delivered in various out-patient settings, such as linking clients to community or out-patient services or in-home care, leading to a reduction in hospital readmission rates and LOS in hospital. This review provided moderate evidence to indicate that incorporating family-based therapies into hospital programmes improves mental health outcomes for CYP in the short term, whereas other lower-quality evidence supports multimodal treatments, including parent–child dyadic therapy and CBT.
However, the feasibility and acceptability of lower-quality evidenced brief interventions for CYP and their families/caregivers requires further research, with a pre-intervention comparison group, in assessing their effectiveness in reducing symptoms and improving mental health function and quality of life across a wide spectrum of mental health symptoms, severity and age groups. As a rationale for improving mental health outcomes for CYP, brief interventions should consider patient safety, care integration and quality of care, as well as rigorous and consistent evaluation of new brief interventions and therapies. Finally, given that these interventions were typically delivered over a short period (often 8 weeks), long-term follow-up is necessary to determine their sustained effectiveness and success.
Supplementary material
Supplementary material is available online at https://doi.org/10.1192/bjo.2024.25
Data availability
Data availability is not applicable to this article as no new data were created or analysed in this study.
Acknowledgements
We would like to acknowledge the following individuals who have contributed to this study, Ms Rutu Trivedi and Ms Catherine Ouyang.
Author contributions
The study was designed by V.E., with input from M.B., B.G., P.H. and B.O.A., and B.G., B.O.A, P.H. and V.E. developed the search strategy. B.G. and B.O.A. assessed the quality and bias of each of the studies. F.B., B.G., P.H., J.R.J., R.T. and B.O.A. screened and analysed the data. V.E and B.G. drafted the manuscript. M.B., P.H., B.O.A., J.R.J., T.W. and T.P.N. made substantial contributions in revising the manuscript and interpretation of results. All authors read and approved the final manuscript.
Funding
This research study was funded by the New South Wales Ministry of Health, Australia, awarded to V.E. (grant number RG213712). The funder was involved in the protocol development.
Declaration of interest
None.
Open access
eLetters
No eLetters have been published for this article.