Screening for psychological and mental health difficulties in young people who offend: a systematic review and decision model

Abstract

BackgroundThere is policy interest in the screening and treatment of mental health problems in young people who offend, but the value of such screening is not yet known.ObjectivesTo assess the diagnostic test accuracy of screening measures for mental health problems in young people who offend; to evaluate the clinical effectiveness and cost-effectiveness of screening and treatment; to model estimates of cost; to assess the evidence base for screening against UK National Screening Committee criteria; and to identify future research priorities.Data sourcesIn total, 25 electronic databases including MEDLINE, PsycINFO, EMBASE and The Cochrane Library were searched from inception until April 2011. Reverse citation searches of included studies were undertaken and reference list of included studies were examined.Review methodsTwo reviewers independently examined titles and abstracts and extracted data from included studies using a standardised form. The inclusion criteria for the review were (1) population – young offenders (aged 10–21 years); (2) intervention/instrument – screening instruments for mental health problems, implementation of a screening programme or a psychological or pharmacological intervention as part of a clinical trial; (3) comparator – for diagnostic test accuracy studies, any standardised diagnostic interview; for trials, any comparator; (4) outcomes – details of diagnostic test accuracy, mental health outcomes over the short or longer term or measurement of cost data; and (5) study design – for diagnostic test accuracy studies, any design; for screening programmes, randomised controlled trials or controlled trials; for clinical effectiveness studies, randomised controlled trials; for economic studies, economic evaluations of screening strategies or interventions.ResultsOf 13,580 studies identified, nine, including eight independent samples, met the inclusion criteria for the diagnostic test accuracy and validity of screening measures review. Screening accuracy was typically modest. No studies examined the clinical effectiveness of screening, although 10 studies were identified that examined the clinical effectiveness of interventions for mental health problems. There were too few studies to make firm conclusions about the clinical effectiveness of treatments in this population. No studies met the inclusion criteria for the assessment of the cost-effectiveness of screening or treatment. An exemplar decision model was developed for depression, which identified a number of the likely key drivers of uncertainty, including the prevalence of unidentified mental health problems, the severity of mental health problems and their relationship to generic measures of outcome and the impact of treatment on recidivism. The information evaluated as part of the review was relevant to five of the UK National Screening Committee criteria. On the basis of the above results, none of the five criteria was met.LimitationsThe conclusions of the review are based on limited evidence. Conclusions are tentative and the decision model should be treated as an exemplar.ConclusionsEvidence on the clinical effectiveness and cost-effectiveness of screening for mental health problems in young people who offend is currently lacking. Future research should consider feasibility trials of clinical interventions to establish important parameters ahead of conducting definitive trials. Future diagnostic studies should compare the diagnostic test accuracy of a range of screening instruments, including those recommended for use in the UK in this population. These studies should be designed to reduce the decision uncertainty identified by the exemplar decision model.RegistrationThis study is registered as PROSPERO CRD42011001466.FundingThe National Institute for Health Research Health Technology Assessment programme.

Identifying Risk and Protective Factors in Recidivist Juvenile Offenders: A Decision Tree Approach

“…In this study, the variables that show a relationship to repeated S-ASB, in order of the strength of their association, are as follows: antisocial peers [ 17 , 18 , 20 , 25 – 27 ]; age’s at the baseline S-ASB [ 18 , 33 ]; criminality in family members [ 31 – 32 ], school problems [ 17 , 18 , 20 – 24 ], father’s lack of parental supervision [ 27 , 30 ], the juvenile’s mental health [ 56 – 57 ] and being accompanied when committing the S-ASB.…”

Identifying attributes of care that may improve cost‐effectiveness in the youth mental health service system

“…Timely assessment strategies, including screening, were att ributes of interventions for a range of mental health problems examined in 10 of the included studies (Box 4). 47,[49][50][51][52][53][54][55][56][57] The economic evidence for such approaches was generally favourable, although there were exceptions. 52,55 Schools-based screening and prevention interventions were examined for anxiety, 58 depression, 47,53,62,63 eating disorders 52,59 and substance use disorders.…”

“…47,[49][50][51][52][53][54][55][56][57] The economic evidence for such approaches was generally favourable, although there were exceptions. 52,55 Schools-based screening and prevention interventions were examined for anxiety, 58 depression, 47,53,62,63 eating disorders 52,59 and substance use disorders. 60 A UK RCT 61,62 and Australian modelling studies 47,53,63 came to diff erent conclusions about the potential cost-eff ectiveness of schoolsbased prevention strategies for depression, although challenges relating to acceptability and implementation of such strategies were highlighted in both contexts.…”

What Is “High Risk” and What Are We Actually Supposed to Do About It?

“…Finally, we cannot ethically mandate screening when the average child who screens positive will then have very limited access to appropriate treatment. [15][16][17][18] We have a small number of treatments that have demonstrated efficacy in reducing suicide risk, but nevertheless a larger number of treatments that effectively address the risk factors that underlie suicide risk, such as depression, anxiety, impulsivity, family conflict, and substance use disorders. Investment in broader access to individual-and family-based psychotherapies, psychopharmacologic treatments, and wraparound services that directly mitigate these risk factors, along with investment in research to determine with more granularity the efficacy of these treatments for different populations of youth, is needed before we can tie risk assessment to intervention in a meaningful way.…”