A Comparative Case Control Study between Innovations Team Malta and Innovations Project UK Working with Hard to Reach Young People with Complex Mental Disorders

This case control study compared the outcomes from two HTRYP services, Innovations Team Malta (IT Malta) and Innovations Project UK (IP UK) and a matched control from a UK based Community Mental Health Team (CMHT) over a 12 month period. IT Malta included HTRYP 13-25 years and IP UK 15-25 years. An in-depth MDT assessment was carried out together with the Health of the Nation Outcome Scales for Child and Adolescent Mental Health (HoNOSCA) and Children’s Global Assessment Scale (CGAS) at assessment and discharge. HTRYP meeting criteria were offered intensive individual tailored therapy.

A Key Practitioner Message 1. There are a number of young people who are suffering from complex mental disorders and despite this, are refusing to access services or are slipping through the healthcare system.
2. Both Innovations Project UK and Innovations Team Malta were able to identify a similar cohort of hard to reach young people suffering from complex mental disorders when compared to community mental health team. 3. Following access to individualised tailored therapy, a signi cant improvement in mental state and social function was observed in both hard to reach services. 4. Investment in time and therapeutic engagement has shown to improve attendance rate and yield better treatment outcomes.
5. Hard to reach young people would bene t from a speci c dedicated service with an outreach component which has a high staff to patient ratio. 6. We propose a possible ceiling effect that is reached with the improvement in hard to reach young people's mental state and social functioning as these remained clinically worse than young people attending CMHT.

Background
As part of normal development, adolescents negotiate multiple transitions in many aspects of their life, these include; furthering education or employment and becoming independent so as to individualise into unique adults. Often the adolescent period has been described as being one of high-risk. Many YP tend to be "unprepared for transitions" or ill-equipped for the multiple challenges of adolescence and consequently, their mental disorders may worsen (p < 0.05) (Camilleri et al., 2017). These transitions compounded with other psychosocial stressors make young people (YP) more vulnerable to particular risks such as mental disorders (Camilleri et al., 2017).
5-10% of YP are de ned as 'hard to reach' (HTRYP). These HTRYP are particularly vulnerable individuals who are at risk of coming from disadvantaged backgrounds, ending up being marginalised, sometimes homeless and who often slip through the health care system or are unwilling to engage in services (Camilleri et al., 2017). For the purpose of this study the term HTRYP will be used to describe such a person.
In order to access specialised services, a referral by a GP is required, which to a YP with complex needs may be a barrier to access services. Furthermore, most mental health services are associated with high levels of stigma. Another barrier to accessing mental health services is age. Singh  team was to offer an intensive and exible service, which focused on using an in-depth multimodal developmental assessment, followed by individualised community-based outreach care plans.
The aim of this study was to compare the service offered, demographics, mental disorders and social functioning of the IT Malta to a similar UK service (IP UK) and with a matched sample from a community mental health team (CMHT). The latter; was a CMHT also based in the North East England. The alternative hypothesis was that there were no signi cant clinical differences found between IT Malta and IP UK, however a statistically signi cant change would be found in the mental state and social functioning of IT Malta and IP UK from TP1 (baseline) to TP2 (discharge) when compared to CMHT cohort of YP over a maximum period of twelve months.

Methods
This case control study compared the outcomes from two service evaluations (IT Malta and IP UK) and a matched group from a UK based CMHT. The organisational setup of the IT Malta service was mapped onto IP UK, meaning the team consisted of a multidisciplinary team (MDT) having different child and adolescent mental health training backgrounds. The same protocol used in IP UK was amended and adapted for use in IT Malta (Camilleri et al., 2017).
In order to decrease barriers to access, both IT Malta and IP UK accepted referrals from; GPs, social services, schools, self-referrals or walk-ins. Following the completion of the described assessment every YP would be discussed at an MDT formulation meeting, only those who met the criteria described within the service protocol for HTRYP (Camilleri et al., 2017) and deemed to be suffering from complex mental disorders would be taken on for treatment. Those YP who did not meet criteria would be discharged from IP UK or IT Malta and referred to other appropriate services. HTRYP taken on for intervention would be allocated a key worker who would be responsible for coordinating the intervention plan and ensuring appropriate liaison with external agencies. All interventions would be tailored to meet the needs of the YP (therefore were not manualised).
Initially the mainstay of intervention would focus on engagement. This was followed by providing the appropriate time needed (at times more than once weekly) to apply evidence based interventions. This consisted of psychopharmacology, home visits, outreach meetings held in the community, supportive psychotherapy, cognitive behaviour therapy, dialectical behaviour therapy skills (DBT), family therapy, social worker involvement and if required admissions to in-patient units. The majority of referrals to CMHT were received from GPs (71.4%) whereas CYPS (24.4%), looked after children (26.8%) and GPs (17.1%) mainly referred to the IP UK. There were no direct referrals from GPs to IT Malta and YP were mainly referred from CYPS (33.3%), walk-in (25%), adult services (20.8%) or directly from the in-patient psychiatry hospital upon discharge (16.7%), X 2 (20) = 109.38, p < 0.001. The majority of YP referred to both HTRYP services had previous service involvement when compared to CMHT (X 2 (2) = 23.596, p < 0.001). The HoNOSCA scores at baseline and discharge for both the IT Malta and IP UK services were similar. Both had higher HoNOSCA scores which inferred a greater severity of mental disorder when compared with the CMHT group (p < 0.001), Fig. 1. The CGAS at baseline for IT Malta (mean 46.0, SD ± 9.4) elucidates more impairment when compared to IP UK (mean 51.1, SD ± 14.0) and CMHT (mean 58.9, SD ± 5.1). Using Tukey Post-Hoc Test there was a signi cant difference between baseline CGAS of IT Malta and CMHT (p = 0.006, SE 4.1) however there was no signi cant difference found between the three groups for CGAS on discharge (p = 0.18), Fig. 2.
The mean number of diagnosis per YP were similar for both the IT Malta and IP UK but differed signi cantly from the CMHT X 2 (36) = 95.89, p < 0.001. The most common diagnosis in the CMHT was depression (56.3%) and anxiety disorder (23.9%), whereas in IP UK, 52.5% were diagnosed with substance misuse, 37.5% had anxiety and depression and 32.5% had antisocial personality disorder (ASPD), conduct disorder (CD) or oppositional de ant disorder (ODD). The commonest disorder diagnosed in IT Malta was anxiety (30.4%), followed by attention de cit hyperactivity disorder and attachment disorder (26.1%) and post-traumatic stress disorder and ASPD/CD/ODD (21.7%). The most commonly prescribed medication for IP UK was Atomoxetine (60.0%) whereas only 18.3% YP in CMHT and 0% in IT Malta where prescribed this medication. Hypnotics were more commonly prescribed in the CMHT (36.6%) when compared to both the IP UK (8.6%) and IT Malta (0%). The most common medication prescribed in IT Malta were selective serotonin reuptake inhibitors (SSRI) (50%), Table 4. The main modality of therapy for the IT Malta was supportive, motivational and DBT (58%) whereas home treatment was the main focus for IP UK (20%) and CMHT (14.1%) as shown in Table 5.

Conclusions
Both the IT Malta and IP UK were able to identify, engage and treat a number of YP with multiple complex mental disorders whose needs were not being met by other mental health services. There was no statistical difference between the baseline HoNOSCA and CGAS for both IT Malta and IP UK, indicating that both services were able to identify YP who although not registered within mental health services, were living in the community and suffering from a greater severity of degree of mental disorder than those YP attending the CMHT. Both innovation services had statistically and clinically worse baseline scores than the CMHT. Both IT Malta and IP UK identi ed YP who were suffering from more than one mental disorder which is greater than is reported in the literature (Jenkins et al., 2009). The HTRYP identi ed were suffering from complex mental disorders, to the extent that this was affecting their social functioning as evidenced by the demographics, worse HoNOSCA and CGAS scores, higher number of diagnoses and more treatments prescribed.
The lower mean age in Malta could be the result of accepting younger (ages 13 and 14 vs IP UK age 15) YP into the service. It could also be that since IT Malta was based within the CYPS, the HTRYP were identi ed early from CYPS and referred to IT Malta. The gender difference may be explained as depression was more commonly diagnosed in IP UK and CMHT when compared to Malta and postpuberty depression would be more prevalent in females (Cohen et al., 1993).
IT Malta dedicated triple and IP UK double the amount of time per YP when compared to the CMHT. This study postulates the importance of 'time' being a key factor to successful engagement with a HTRYP and offering a clinically effective treatment. A dedicated outreach team with a high staff to patient ratio working speci cally on engaging YP with complex mental disorders and offering them an individualised tailored management plan, was clinically effective.
The signi cant proportion (frequency 22.1%) of HTRYP with neurodevelopmental disorders supports the concept that a developmental approach is relevant and should be used in assessments by psychiatric services into early adult life (Camilleri et al., 2017). A number of HTRYP may have had previously unsatisfactory contact with mental health services (Camilleri et al., 2017). However, through the availability of a more exible service which facilitated access of referrals into the service, provided a focus on engagement through the use of home and community reviews, the variety of mental health professionals with different training backgrounds, the repeated attempts at contacting the YP via a nurse or psychology assistant rather than receiving cold calls through a letter or clerk and having a MDT with a different set of psychotherapeutic skills increased the possibility of offering a clinically effective intervention to these HTRYP. This intervention helped to reduce their morbidity and mortality through mental disorders (McGorry, Purcell, Hickie, & Jorm, 2007).
The longer waiting times record by IT Malta could be a result of the stigma associated with the location (CYPS) of this service opposed to being located within a GP surgery like IP UK or, perhaps because IT Malta staff, although were better staffed in terms of numbers than IP UK, were not working within this service full time. Therefore, a recommendation from this study is for such future services to be based outside of mental health facilities and within the community or GP surgeries.
Generalisability of these ndings needs to be done with care since to date no Maltese control group has been identi ed and compared. However, both IP UK and CMHT groups were matched on a number of demographic factors and severity of mental disorder. Another limitation of this study was the small sample sizes of both the HTRYP services. This was expected considering the nature of the characteristics of the targeted cohort. No formal reliability testing for the data collection process was undertaken, although to minimise any bias a trained clinical researcher carried out the double data checking.
The next steps would be to carry out a qualitative and quantitative follow up study and compare the results of these services and a control CMHT in Malta. This would help elucidate whether the positive clinical change following intervention had a lasting effect on the trajectory of the lives of these YP.
Although there was an improvement in the mental state and social function of both IT Malta and IP UK over time, the mental state and social function of these HTRYP remained clinically worse than those of the control group. A recommended study would be to identify moderators and mediators that could help identify which HTRYP suffering from which disorders would bene t from which speci c psychotherapeutic interventions.

Declarations
Ethics approval and consent to participate

Consent for publication
Andrea Saliba and Nigel Camilleri give their consent for this study to be published in Child and Adolescent Psychiatry and Mental Health Journal.
Availability of data and materials Authors con rm that they have full access to all the data in the study and take responsibility for the integrity of the data in the study and the accuracy of the data analysis.