Centre for Women's Mental Health, University of Manchester, Manchester, UK; Faculty of Biology, Medicine and Health Sciences, University of Manchester, Manchester, UK.
Centre for Women's Mental Health, University of Manchester, Manchester, UK; Faculty of Biology, Medicine and Health Sciences, University of Manchester, Manchester, UK.
Lancet Psychiatry. 2024 Apr;11(4):274-284. doi: 10.1016/S2215-0366(24)00038-5.
Little information is available on the clinical trajectories of children and adolescents who attend general practice (GP) with psychiatric symptoms. We aimed to examine 5-year service use in English primary care for children and adolescents with neurodevelopmental or mental health symptoms or diagnoses.
In this retrospective cohort study, we used anonymised primary care health records from the Clinical Practice Research Datalink Aurum database (CPRD-Aurum). We identified children and adolescents (aged 3-18 years) presenting to primary care in England between Jan 1, 2000, and May 9, 2016, with a symptom or diagnosis of a mental health, behavioural, or neurodevelopmental condition. Participants were excluded if they had less than 1 year of follow-up. We followed up participants from their index date until either death, transfer out of the practice, or the end of data collection on May 5, 2021, and for trajectory analysis we limited follow-up to 5 years. We used group-based multi-trajectory models to identify clusters with similar trajectories over 5 years of follow-up for three primary outcomes: mental health-related GP contacts, psychotropic medication prescriptions, and specialist mental health-care contact. We did survival analysis to examine the associations between trajectory-group membership and hospital admission for self-harm or death by suicide, as indicators of severe psychiatric distress.
We included 369 340 children and adolescents, of whom 180 863 (49·0%) were girls, 188 438 (51·0%) were boys, 39 (<0·1%) were of indeterminate gender, 290 125 (78·6%) were White, 9161 (2·5%) were South Asian, 10 418 (2·8%) were Black, 8115 (2·2%) were of mixed ethnicity, and 8587 (2·3%) were other ethnicities, and the median age at index presentation was 13·6 years (IQR 8·4-16·7). In the best-fitting, seven-group, group-based multi-trajectory model, over a 5-year period, the largest group (low contact; 207 985 [51·2%]) had low rates of additional service contact or psychotropic prescriptions. The other trajectory groups were moderate, non-pharmacological contact (43 836 [13·0%]); declining contact (25 469 [8·7%]); year-4 escalating contact (18 277 [6·9%]); year-5 escalating contact (18 139; 5·2%); prolonged GP contact (32 147 [8·6%]); and prolonged specialist contact (23 487 [6·5%]). Non-White ethnicity and presentation in earlier study years (eg, 2000-2004) were associated with low-contact group membership. The prolonged specialist-contact group had the highest risk of hospital admission for self-harm (hazard ratio vs low-contact group 2·19 [95% CI 2·03-2·36]) and suicide (2·67 [1·72-4·14]).
Most children and adolescents presenting to primary care with psychiatric symptoms or diagnoses have low or declining rates of ongoing contact. If these trajectories reflect symptomatic improvement, these findings provide reassurance for children and adolescents and their caregivers. However, these trajectories might reflect an unmet need for some children and adolescents.
National Institute for Health and Care Research and the Wellcome Trust.
针对在普通科就诊时出现精神科症状的儿童和青少年，目前有关其临床病程的信息较少。本研究旨在研究在英格兰，接受神经发育或精神健康症状或诊断的儿童和青少年在初级保健机构中，5 年内的服务使用情况。
在这项回顾性队列研究中，我们使用了来自临床实践研究数据链接 Aurum 数据库（CPRD-Aurum）的匿名初级保健健康记录。我们在英格兰确定了 2000 年 1 月 1 日至 2016 年 5 月 9 日期间因心理健康、行为或神经发育状况出现症状或诊断而到初级保健机构就诊的儿童和青少年（年龄 3-18 岁）。如果参与者的随访时间少于 1 年，则将其排除在外。我们从参与者的索引日期开始随访，直到死亡、转出实践或 2021 年 5 月 5 日数据收集结束，对于轨迹分析，我们将随访时间限制在 5 年以内。我们使用基于群组的多轨迹模型来识别在 5 年随访期间具有相似轨迹的群组，主要结局包括：与心理健康相关的全科医生就诊次数、精神科药物处方数量和专科心理健康护理就诊次数。我们进行了生存分析，以检查轨迹组别的成员资格与自残或自杀导致的住院治疗之间的关联，这些指标是严重精神困扰的标志。
我们纳入了 369340 名儿童和青少年，其中 180863 名（49.0%）为女孩，188438 名（51.0%）为男孩，39 名（<0.1%）为不确定性别，290125 名（78.6%）为白人，9161 名（2.5%）为南亚人，10418 名（2.8%）为黑人，8115 名（2.2%）为混血儿，8587 名（2.3%）为其他种族，中位数年龄为 13.6 岁（IQR 8.4-16.7）。在拟合度最佳的七组基于群组的多轨迹模型中，在 5 年内，最大的群组（低接触组；207985 名[51.2%]）出现额外服务接触或精神科药物处方的几率较低。其他轨迹群组为中等程度的非药物接触（43836 名[13.0%]）；接触下降（25469 名[8.7%]）；第 4 年接触增加（18277 名[6.9%]）；第 5 年接触增加（18139 名[5.2%]）；持续全科医生接触（32147 名[8.6%]）；持续专科接触（23487 名[6.5%]）。非白种人种族和较早年份（如 2000-2004 年）就诊与低接触组的成员资格相关。持续专科接触组的自残住院治疗风险最高（与低接触组相比，风险比为 2.19[95%CI 2.03-2.36]）和自杀（2.67[1.72-4.14]）。
大多数因精神科症状或诊断而到普通科就诊的儿童和青少年的持续接触率较低或呈下降趋势。如果这些轨迹反映了症状的改善，这为儿童和青少年及其照顾者提供了一些安慰。然而，这些轨迹可能反映了一些儿童和青少年存在未满足的需求。
英国国家卫生与保健研究所和惠康基金会。
