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

IntroductionOne in eight children in the United Kingdom are estimated to have a mental health condition, and many do not receive support or treatment. Childhood is a key period for long-term mental health trajectories and the prevalence of poor mental health is not evenly distributed across age-groups, by sex or socioeconomic groups. Equity in access to health care is a policy priority but relatively under-researched. This work aims to inform service planning and provision by linking previously unlinked individual-level data from community and specialist outpatient settings. We describe the trends in treatment and service use among children and adolescents in NHS Grampian to understand the socio-demographic characteristics and inequalities in access to mental health services and care. Methods We linked records for all mental health prescriptions and all referrals to specialist CAMHS between the years of 2015 and 2021 for children aged 2 to 17 in the NHS Grampian health board (North East of Scotland). 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 individuals across the two datasets and a total of 178,657 mental health prescriptions and 21,874 referrals to specialist CAMHS. Monthly prescriptions of mental health medications increased by 59% over the study period. Boys received almost double the number of prescriptions than girls. Primary school aged boys were more likely to receive medications to treat attention deficit hyperactivity disorder (ADHD) and high-school aged girls were more likely to receive anti-depressant medications. The rate of prescribing in the most deprived 10% of areas was double that of the 10% least deprived. The monthly referral rate for specialist CAMHS was roughly static between 2015 & the end of 2019 but increased by 9% since the start of 2020. The rate of rejected referrals increased over time and the number of accepted referrals has remained static. However, there have been demographic changes in who is accepted for treatment. The proportion of accepted referrals who are girls has increased from 48% in 2015 to 62% in 2021. Discussion The large and consistent increase in mental health prescribing for children and young people since 2015 and the increase in referrals to specialist CAMHS since 2020 aligns with emerging evidence of increasing prevalence of poor mental health over time and particularly since the start of the COVID-19 pandemic. The static size of referrals accepted by specialist CAMHS amid greater demand and changing demographics may represent unmet need. Data for alternative sources of treatment such as community based CAMHS is not currently available and future analysis should explore treatment trajectories of those not accepted for specialist CAMHS treatment.