Interventions to improve children's access to mental health care: a systematic review and meta-analysis
Open accessAbstract
Aims: Mental disorders in children are a significant and growing cause of morbidity worldwide. Although interventions to help overcome barriers along the pathway to accessing health care for children with mental disorders exist, there is no overview of randomised controlled trials (RCTs) on these interventions as yet. This study aimed to systematically identify RCTs of interventions to improve access to mental health care for children and synthesise them using a conceptual framework of access to health care. Methods: This systematic review was performed following a predefined protocol registered with PROSPERO (ID: CRD42018081714). We searched the databases MEDLINE, EMBASE, PsycINFO and CENTRAL for RCTs up to 15 May 2019 using terms related to the concepts ‘young people,’ ‘mental disorders’ and ‘help-seeking interventions’ and scanned reference lists from relevant studies. Two reviewers independently screened all identified articles in a two-stage process, extracted results on outcomes of interest (knowledge, attitudes, intentions, help-seeking, accessing care, mental health outcomes and satisfaction), assessed the risk of bias and conducted meta-analyses where deemed appropriate. Results: After screening 5641 identified articles, 34 RCTs were eligible for inclusion. Eighty per cent of universal school-based interventions measuring knowledge (n= 5) and 67% measuring attitudes (n= 6) reported significantly better results compared with controls on those outcomes, whereas 20% measuring access to care (n= 5) and none measuring mental health outcomes (n= 7) did. In contrast, 71% of interventions targeting at-risk individuals (n= 21) reported better access to care compared with controls, while just 33% (n= 6) did for mental health outcomes. For satisfaction with care, this proportion was 80% (n= 5). Meta-analyses of interventions measuring initial appointment attendance yielded combined odds ratios of 3.11 (2.07–4.67) for appointment reminder interventions and 3.51 (2.02–6.11) for treatment engagement interventions. The outcomes for universal school-based interventions were heterogeneous and could not be summarised quantitatively through meta-analysis. Conclusions: To have a population-level effect on improving children's access to mental health care, two-stage interventions that identify those in need and then engage them in the health-care system may be necessary. We need more evidence on interventions to target contextual factors such as affordability and infrastructural barriers.
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Written from the paper’s full text.
TL;DR
This systematic review and meta-analysis of 34 RCTs found that universal school-based interventions improved knowledge and attitudes about mental health care but rarely improved actual access or mental health outcomes, whereas interventions targeting at-risk children already identified by the health-care system improved access to care and satisfaction. Meta-analyses showed appointment reminder and treatment engagement interventions increased first appointment attendance, with combined odds ratios of 3.11 and 3.51, respectively.
Key findings
- Among 34 included RCTs, universal school-based interventions had significant effects in 80% (4/5) of studies measuring knowledge and 67% (4/6) measuring attitudes, but only 20% (1/5) measuring access to care and 0% (0/7) measuring mental health outcomes.
- Interventions targeting at-risk individuals already identified by the health-care system improved access to care in 71% (15/21) of studies, mental health outcomes in 33% (2/6), and satisfaction with care in 80% (4/5).
- Meta-analyses of first appointment attendance yielded combined odds ratios of 3.11 (95% CI 2.07–4.67; I² = 0%) for appointment reminder interventions and 3.51 (95% CI 2.02–6.11; I² = 70%) for treatment engagement interventions.
- No included studies targeted acceptability, affordability, or individuals’ ability to reach or pay for care; only one infrastructural intervention was identified, involving onsite mental health services for primary care patients.
Methods
- Systematic review following PRISMA and a PROSPERO-registered protocol (CRD42018081714); searched MEDLINE, EMBASE, PsycINFO, and CENTRAL up to 15 May 2019, plus reference-list hand searching; two reviewers independently screened, extracted data, and assessed risk of bias.
- Included RCTs of interventions for children/adolescents <19 years old (or >50% under 19) designed to improve access to mental health care along Levesque et al.’s conceptual framework; outcomes included knowledge, attitudes, intentions, help-seeking, accessing care, mental health outcomes, and satisfaction.
- Results were mapped to the framework; dichotomous outcomes were expressed as odds ratios and continuous outcomes as standardized mean differences; meta-analyses used the inverse variance method, with fixed-effects models if I² <30% and both fixed and random-effects models if I² >30%.
Limitations
- The paper states that the broad search required restricting to the title field and English-language publications, and that hand searching reference lists and key articles was used to mitigate this; retention in treatment was not included as an outcome.
- The paper states that no included studies took place in low- or middle-income countries, that universal school-based outcomes were heterogeneous and could not be summarized quantitatively through meta-analysis, and that evidence is lacking on acceptability, affordability, and ability to reach or pay for care.
- Evident from the risk-of-bias reporting: randomisation procedure was not described in half of studies, allocation concealment was reported in only 21%, and some studies had high or unclear risk (e.g., consent obtained after randomisation, schools switching groups, different outcome assessment procedures); GRADE was not used to grade overall quality of evidence.
Model-written summary. Check it against the paper before relying on it.
Integrity signals
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Cites
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Claims the paper makes
0 of 35 cited sources checked · 0 supported · 0 flagged
- Findingown data
None of the universal school-based interventions measuring mental health outcomes (n = 7) reported significantly better results compared with controls on mental health outcomes.
“whereas 20% measuring access to care (n = 5) and none measuring mental health outcomes (n = 7) did.”
Quote in the paperNot a substantial claim - Findingown data
All but one study had a low risk of bias for incomplete outcome data.
“All but one study had a low risk of bias for incomplete outcome data.”
Quote in the paperNot a substantial claim - Findingown data
Meta-analysis of appointment reminder interventions measuring initial appointment attendance yielded a combined odds ratio of 3.11 (2.07-4.67).
“Meta-analyses of interventions measuring initial appointment attendance yielded combined odds ratios of 3.11 (2.07–4.67) for appointment reminder interventions and 3.51 (2.02–6.11) for treatment engagement interventions.”
Quote in the paperSubstantial claim - Findingown data
80% (8/10) of studies on treatment engagement interventions had a significant effect on accessing care.
“Eighty per cent (8/10) of studies on treatment engagement interventions (e.g., a family-based session to increase motivation during an emergency room or motivational telephone calls with trained staff) and 80% (4/5) of studies on appointment reminder interventions had a significant effect on accessing care.”
Quote in the paperNot a substantial claim - Findingown data
24% (5/21) of engagement interventions involved appointment reminder interventions.
“while 24% (5/21) involved using a telephone or letter reminder mechanism to improve first appointment attendance (henceforth called appointment reminder interventions).”
Quote in the paperNot a substantial claim
- Findingown data
48% (10/21) of engagement interventions consisted of treatment engagement interventions.
“Forty-eight per cent (10/21) of these interventions consisted of programs to engage and motivate patients or to improve service providers' communication skills (henceforth called treatment engagement interventions)”
Quote in the paperNot a substantial claim - Findingown data
71% of interventions targeting at-risk individuals (n = 21) reported better access to care compared with controls.
“In contrast, 71% of interventions targeting at-risk individuals (n = 21) reported better access to care compared with controls”
Quote in the paperSubstantial claim - Findingown data
Effect sizes for knowledge about seeking health care ranged from −0.06 to 0.96.
“The effect sizes ranged from −0.06 to 0.96 for knowledge about seeking health care, −0.02 to 2.56 for attitudes about seeking health care and −0.15 to 0.30 for intensions to seek health care or help others seek health care.”
Quote in the paperNot a substantial claim - Findingown data
20% of universal school-based interventions measuring access to care (n = 5) reported significantly better results compared with controls on access to care.
“whereas 20% measuring access to care (n = 5) and none measuring mental health outcomes (n = 7) did.”
Quote in the paperNot a substantial claim - Findingown data
In all studies except one, it was unclear whether a lack of blinding of participants and personnel would influence the outcome.
“In all studies except for one, it was unclear whether a lack of blinding of participants and personnel would influence the outcome.”
Quote in the paperNot a substantial claim - Findingown data
Odds ratios for health outcomes ranged from 0.62 to 1.12.
“The odds ratios ranged from 0.96 to 21.64 for help-seeking, 0.99 to 11.34 for accessing care and 0.62 to 1.12 for health outcomes.”
Quote in the paperNot a substantial claim - Findingown data
33% (n = 6) of interventions targeting at-risk individuals reported better mental health outcomes compared with controls.
“while just 33% (n = 6) did for mental health outcomes.”
Quote in the paperSubstantial claim - Findingown data
80% of universal school-based interventions measuring knowledge (n = 5) reported significantly better results compared with controls on knowledge.
“Eighty per cent of universal school-based interventions measuring knowledge (n = 5) and 67% measuring attitudes (n = 6) reported significantly better results compared with controls on those outcomes”
Quote in the paperNot a substantial claim - Findingown data
Effect sizes for attitudes about seeking health care ranged from −0.02 to 2.56.
“The effect sizes ranged from −0.06 to 0.96 for knowledge about seeking health care, −0.02 to 2.56 for attitudes about seeking health care and −0.15 to 0.30 for intensions to seek health care or help others seek health care.”
Quote in the paperNot a substantial claim - Findingown data
Details on allocation concealment were only provided in 21% of the studies.
“Details on allocation concealment were only provided in 21% of the studies.”
Quote in the paperNot a substantial claim - Findingown data
All studies on interventions targeting at-risk individuals assessed accessing care as an outcome.
“Among studies on these interventions, all assessed accessing care (e.g., the proportion of study subjects who attended the first appointment or number of appointments attended) as an outcome, and 71% (15/21) of these interventions had a significant impact on that outcome.”
Quote in the paperNot a substantial claim - Findingown data
Meta-analysis of treatment engagement interventions measuring initial appointment attendance yielded a combined odds ratio of 3.51 (2.02-6.11).
“Meta-analyses of interventions measuring initial appointment attendance yielded combined odds ratios of 3.11 (2.07–4.67) for appointment reminder interventions and 3.51 (2.02–6.11) for treatment engagement interventions.”
Quote in the paperSubstantial claim - Findingown data
71% (15/21) of interventions targeting at-risk individuals had a significant impact on accessing care.
“Among studies on these interventions, all assessed accessing care (e.g., the proportion of study subjects who attended the first appointment or number of appointments attended) as an outcome, and 71% (15/21) of these interventions had a significant impact on that outcome.”
Quote in the paperSubstantial claim - Findingown data
Odds ratios for accessing care ranged from 0.99 to 11.34.
“The odds ratios ranged from 0.96 to 21.64 for help-seeking, 0.99 to 11.34 for accessing care and 0.62 to 1.12 for health outcomes.”
Quote in the paperNot a substantial claim - Findingown data
Just one intervention was infrastructural in nature and involved providing onsite mental health services for primary care patients.
“Just one intervention was infrastructural in nature and involved providing onsite mental health services for primary care patients.”
Quote in the paperNot a substantial claim - Findingown data
None of the identified studies targeted the acceptability of service providers, affordability of care, or individuals' personal ability to reach or pay for care.
“None of the identified studies targeted the acceptability (cultural and social factors that make it possible for individuals to accept services) of service providers, affordability of care, or individuals' personal ability to reach (e.g., their personal mobility or support from their social network) or pay for care.”
Quote in the paperNot a substantial claim - Findingown data
The vast majority of engagement interventions from the second category mostly targeted service providers' appropriateness or individuals' ability to engage.
“The vast majority of engagement interventions from the second category mostly targeted service providers' appropriateness or individuals' ability to engage.”
Quote in the paperNot a substantial claim - Findingown data
Effect sizes for intentions to seek health care or help others seek health care ranged from −0.15 to 0.30.
“The effect sizes ranged from −0.06 to 0.96 for knowledge about seeking health care, −0.02 to 2.56 for attitudes about seeking health care and −0.15 to 0.30 for intensions to seek health care or help others seek health care.”
Quote in the paperNot a substantial claim - Findingown data
Odds ratios for help-seeking ranged from 0.96 to 21.64.
“The odds ratios ranged from 0.96 to 21.64 for help-seeking, 0.99 to 11.34 for accessing care and 0.62 to 1.12 for health outcomes.”
Quote in the paperNot a substantial claim - Findingown data
67% of universal school-based interventions measuring attitudes (n = 6) reported significantly better results compared with controls on attitudes.
“Eighty per cent of universal school-based interventions measuring knowledge (n = 5) and 67% measuring attitudes (n = 6) reported significantly better results compared with controls on those outcomes”
Quote in the paperNot a substantial claim - Findingown data
Interventions within the first category exclusively targeted service providers' approachability and individuals' abilities to perceive a need for and to seek care.
“Interventions within the first category exclusively targeted service providers' approachability (i.e., service providers making their existence known to individuals) and the abilities of individuals to perceive a need for and to seek care.”
Quote in the paperNot a substantial claim - Findingcitation
In this systematic review, the only study that targeted the general population yet had a significant impact on accessing care was Husky et al. (2011), which tested systematic referral to mental health services using a brief mental health screening in a school setting.
“In this systematic review, the only study in that targeted the general population, yet had a significant impact on accessing care was Husky et al. (2011), which tested systematic referral to mental health services using a brief mental health screening in a school setting (Husky et al., 2011).”
Quote in the paperSubstantial claim0 of 1 sources checked- cites Husky et al., 2011
Not checked in the free run.
- Findingown data
Only two of these five studies had a significant effect on access to care as compared with controls.
“Additionally, five of the six studies targeting at-risk children that took place in a primary care setting used a screening procedure to identify these at-risk children; however, only two of these five studies had a significant effect on access to care as compared with controls.”
Quote in the paperSubstantial claim - Findingown data
None of the studies identified in this systematic review took place in low- or middle-income countries.
“Finally, none of the studies identified in this systematic review took place in low- or middle-income countries.”
Quote in the paperSubstantial claim - Findingown data
Heterogeneity for appointment reminder interventions was low (I2 = 0%).
“For the appointment reminder interventions, we only calculated a fixed-effects model since heterogeneity was low (I2 = 0%).”
Quote in the paperNot a substantial claim - Findingown data
The combined odds ratio of the appointment reminder interventions was 3.11 (2.07-4.67).
“The combined odds ratio of the appointment reminder interventions was 3.11 (2.07–4.67), and the combined odds ratio calculated using the random-effects model for the treatment engagement interventions was 3.51 (2.02–6.11).”
Quote in the paperSubstantial claim - Findingown data
80% (4/5) of studies on appointment reminder interventions had a significant effect on accessing care.
“Eighty per cent (8/10) of studies on treatment engagement interventions (e.g., a family-based session to increase motivation during an emergency room or motivational telephone calls with trained staff) and 80% (4/5) of studies on appointment reminder interventions had a significant effect on accessing care.”
Quote in the paperNot a substantial claim - Findingown data
33% (2/6) of interventions assessing mental health outcomes were significantly better than controls on that outcome.
“Of the seven interventions that assessed the remaining two outcomes along the pathway to accessing care, 33% (2/6) of those that assessed mental health outcomes and 80% (4/5) of those that assessed satisfaction with care were significantly better as compared with controls on the respective outcome.”
Quote in the paperNot a substantial claim - Findingcitation
We identified just one infrastructural intervention that involved providing onsite mental health services for primary care patients.
“however, we identified just one infrastructural intervention that involved providing onsite mental health services for primary care patients (Lieberman et al., 2006).”
Quote in the paperSubstantial claim0 of 1 sources checked- cites Lieberman et al., 2006 source
Not checked in the free run.
- Findingown data
Our systematic review revealed gaps in the research on interventions to improve acceptability, affordability and individuals' ability to reach and pay.
“In light of this and the fact that our systematic review revealed gaps in the research on interventions to improve acceptability, affordability and individuals' ability to reach and pay,”
Quote in the paperSubstantial claim - Findingown data
The combined odds ratio calculated using the random-effects model for the treatment engagement interventions was 3.51 (2.02-6.11).
“The combined odds ratio of the appointment reminder interventions was 3.11 (2.07–4.67), and the combined odds ratio calculated using the random-effects model for the treatment engagement interventions was 3.51 (2.02–6.11).”
Quote in the paperSubstantial claim - Findingown data
We did not identify studies that targeted the domains of acceptability and affordability or individuals' ability to reach or pay for care.
“We did not identify studies that targeted the domains of acceptability and affordability or individuals' ability to reach or pay for care.”
Quote in the paperSubstantial claim - Findingown data
80% (4/5) of interventions assessing satisfaction with care were significantly better than controls on that outcome.
“Of the seven interventions that assessed the remaining two outcomes along the pathway to accessing care, 33% (2/6) of those that assessed mental health outcomes and 80% (4/5) of those that assessed satisfaction with care were significantly better as compared with controls on the respective outcome.”
Quote in the paperNot a substantial claim - Findingown data
Five of the six studies targeting at-risk children that took place in a primary care setting used a screening procedure to identify these at-risk children.
“Additionally, five of the six studies targeting at-risk children that took place in a primary care setting used a screening procedure to identify these at-risk children; however, only two of these five studies had a significant effect on access to care as compared with controls.”
Quote in the paperSubstantial claim - Findingown data
Just three interventions targeting at-risk individuals assessed outcomes that preceded accessing care.
“Just three interventions targeting at-risk individuals assessed outcomes that preceded accessing care.”
Quote in the paperSubstantial claim - Findingown data
Heterogeneity for treatment engagement interventions was substantial (I2 = 70%).
“For the treatment engagement interventions, heterogeneity was substantial (I2 = 70%), so we calculated fixed effects and random-effects models.”
Quote in the paperNot a substantial claim - Study design and conductreasoning
The review decided against using the GRADE approach because heterogeneity, imprecision and indirectness could rarely be assessed beyond a single or a few studies.
“Because our review included a large variety of interventions and outcomes, we could rarely assess the heterogeneity, imprecision and indirectness beyond a single or a few studies and therefore decided against using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach (Guyatt et al., 2011) to judge the overall quality of evidence.”
Quote in the paperSubstantial claim0 of 1 sources checked- cites Guyatt et al., 2011
Not checked in the free run.
- Premisecitation
There is little high-quality evidence on interventions targeting dimensions of accessibility or abilities to address barriers along the pathway to accessing care.
“To close the treatment gap, interventions targeting one or more dimensions of accessibility of services and/or abilities of persons have been designed to address the barriers along the pathway to accessing care (e.g., screenings, health literacy promotion); however, there is little high-quality evidence on these interventions (National Institute for Health and Clinical Excellence, 2011).”
Quote in the paperSubstantial claim0 of 1 sources checked- cites National Institute for Health and Clinical Excellence, 2011
Not checked in the free run.
- Interpretationown data
The pattern of significant outcomes found for universal interventions differed from that observed for interventions targeting at-risk individuals who had already been identified by the health-care system.
“The pattern of significant outcomes found for universal interventions differed from that observed for interventions targeting at-risk individuals who had already been identified by the health-care system.”
Quote in the paperSubstantial claim - Premisecitation
International studies have consistently revealed a treatment gap: estimates of the gap between those in need of mental health care and those who access it exceed 50%.
“Despite the magnitude and importance of mental health problems in childhood and adolescence, international studies have consistently revealed a treatment gap: estimates of the gap between those in need of mental health care and those who access it exceed 50% (Saxena et al., 2007).”
Quote in the paperSubstantial claim0 of 1 sources checked- cites Saxena et al., 2007
Not checked in the free run.
- Interpretationown data
To have a population-level effect on improving children's access to mental health care, two-stage interventions that identify those in need and then engage them in the health-care system may be necessary.
“To have a population-level effect on improving children's access to mental health care, two-stage interventions that identify those in need and then engage them in the health-care system may be necessary.”
Quote in the paperSubstantial claim - Study design and conductown data
The risk of bias for studies on universal school-based interventions ranged from low to high.
“The risk of bias for studies on these interventions ranged from low to high (see Table 1).”
Quote in the paperNot a substantial claim - Premisecitation
Systematic reviews conducted in the past on interventions to improve access to mental health care for children and adolescents have limited searches to specific types of interventions and disorders.
“Moreover, systematic reviews conducted in the past on interventions to improve access to mental health care for children and adolescents have limited searches to specific types of interventions and disorders (Ingoldsby, 2010; Gulliver et al., 2012; Lindsey et al., 2014; Anderson et al., 2017; Dunne et al., 2017; Richardson et al., 2017).”
Quote in the paperSubstantial claim0 of 3 sources checked- cites Ingoldsby, 2010
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- cites Gulliver et al., 2012
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- cites Lindsey et al., 2014
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- Study design and conductown data
The risk of bias found for appointment reminder and treatment engagement interventions ranged from low to high.
“The risk of bias found for appointment reminder and treatment engagement interventions ranged from low to high (see Table 1).”
Quote in the paperNot a substantial claim - Interpretationown data
The odds of attending an initial appointment were 3.11 times higher for those who received an appointment reminder as compared with controls.
“In other words, the odds of attending an initial appointment were 3.11 times higher for those who received an appointment reminder as compared with controls and 3.51 higher for those who participated in a treatment engagement intervention as compared with controls, indicating that overall, both types of interventions yielded significantly higher first appointment attendance in the target”
Quote in the paperSubstantial claim - Premisecitation
Targeting individual barriers in isolation, such as cost or insurance coverage, without addressing other barriers like accessibility, acceptability and availability may not improve service utilisation.
“In addition, targeting individual barriers in isolation, such as cost or insurance coverage, without addressing other barriers like accessibility, acceptability and availability may not improve service utilisation (So et al., 2019).”
Quote in the paperSubstantial claim0 of 1 sources checked- cites So et al., 2019
Not checked in the free run.
- Interpretationreasoning
The effects on knowledge about accessing mental health care, attitudes or beliefs about seeking care and help-seeking for at-risk individuals were unclear due to the limited number of studies measuring these outcomes.
“The effects on knowledge about accessing mental health care, attitudes or beliefs about seeking care and help-seeking were thus unclear due to the limited number of studies measuring these outcomes.”
Quote in the paperSubstantial claim - Interpretationown data
The odds of attending an initial appointment were 3.51 times higher for those who participated in a treatment engagement intervention as compared with controls.
“In other words, the odds of attending an initial appointment were 3.11 times higher for those who received an appointment reminder as compared with controls and 3.51 higher for those who participated in a treatment engagement intervention as compared with controls, indicating that overall, both types of interventions yielded significantly higher first appointment attendance in the target”
Quote in the paperSubstantial claim - Interpretationcitation
Interventions can improve knowledge and attitudes about mental disorders and their treatment.
“Both the results of this systematic review and previous research have shown that interventions can improve knowledge and attitudes about mental disorders and their treatment (Lo et al., 2017);”
Quote in the paperSubstantial claim0 of 1 sources checked- cites Lo et al., 2017
Not checked in the free run.
- Premisecitation
The evidence to recommend screening the general population of children for mental disorders is currently insufficient.
“Since the evidence to recommend screening the general population of children for mental disorders is currently insufficient (Lenzer, 2017),”
Quote in the paperSubstantial claim0 of 1 sources checked- cites Lenzer, 2017
Not checked in the free run.
- Premisecitation
Interventions that improve knowledge and attitudes do not necessarily have an impact on health behaviours, such as help-seeking.
“however, there is evidence that such interventions do not necessarily have an impact on health behaviours, such as help-seeking (Kelly and Barker, 2016; Laverack, 2017).”
Quote in the paperSubstantial claim0 of 2 sources checked- cites Kelly and Barker, 2016
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- cites Laverack, 2017
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- Premisecitation
There is growing evidence that changing environmental factors, including policies, infrastructure and health-care financing, can have a larger impact on health behaviours such as help-seeking than health literacy education.
“There is growing evidence that changing environmental factors, including policies, infrastructure and health-care financing (Hodgkinson et al., 2017; So et al., 2019), can have a larger impact on health behaviours such as help-seeking than health literacy education (Kelly and Barker, 2016).”
Quote in the paperSubstantial claim0 of 3 sources checked- cites Hodgkinson et al., 2017
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- cites So et al., 2019
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- cites Kelly and Barker, 2016
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- Interpretationcitation
This is the same pattern that we found for the outcome of accessing care.
“This is the same pattern that we found for the outcome of accessing care.”
Quote in the paperSubstantial claim - Interpretationown data
Interventions that aim to improve knowledge and attitudes about mental health care in the general population are not sufficient to bridge the existing treatment gap in mental health care for children.
“In order to bridge the existing treatment gap in mental health care for children, interventions that aim to improve knowledge and attitudes about mental health care in the general population are not sufficient.”
Quote in the paperSubstantial claim- Rests on an assumption: There is an existing treatment gap in mental health care for children.
- Premisecitation
Interventions to engage and motivate an at-risk population have been shown to significantly change health behaviours.
“Interventions to engage and motivate an at-risk population, on the other hand, have been shown to significantly change health behaviours (Ingoldsby, 2010).”
Quote in the paperSubstantial claim0 of 1 sources checked- cites Ingoldsby, 2010
Not checked in the free run.
- May combine two claims. 18
- The quote only partly states this claim. 1
- Classified as probably not a substantial claim. 16
May combine two claims.
Findingown dataThree studies did not report all outcomes and three studies had other sources of potential bias.
“Three studies did not report all outcomes and three studies had other sources of potential bias.”
Quote in the paperNot a substantial claimThe quote only partly states this claim.
Findingown data80% (n = 5) of interventions targeting at-risk individuals measuring satisfaction with care reported better satisfaction compared with controls.
“For satisfaction with care, this proportion was 80% (n = 5).”
Quote in the paperNot a substantial claimMay combine two claims.
Findingown dataThe included studies fell into two main categories: universal school-based interventions targeting the general population (13 studies) and interventions to engage at-risk individuals already identified by the health-care system (21 studies).
“These studies fell into two main categories: (1) universal school-based interventions targeting the general population (13 studies) and (2) interventions to engage at-risk individuals who had already been identified by the health-care system (21 studies).”
Quote in the paperNot a substantial claimMay combine two claims.
Findingown dataThe outcomes for universal school-based interventions were heterogeneous and could not be summarised quantitatively through meta-analysis.
“The outcomes for universal school-based interventions were heterogeneous and could not be summarised quantitatively through meta-analysis.”
Quote in the paperNot a substantial claimMay combine two claims.
Findingown dataAfter screening 5641 unique records, 34 RCTs were eligible for inclusion in the systematic review.
“After screening 5641 identified articles, 34 RCTs were eligible for inclusion.”
- Also stated in: § Results of the search and excluded studies · plain
“The remaining 34 articles were included in the systematic review.”
Quote in the paperNot a substantial claim- Also stated in: § Results of the search and excluded studies · plain
May combine two claims.
Findingown dataThe randomisation procedure was not described in half of the studies, and two studies described a non-random sequence generation procedure.
“The randomisation procedure was not described in half of the studies, and two studies described a non-random sequence generation procedure.”
Quote in the paperNot a substantial claimMay combine two claims.
Findingown dataThis systematic review identified 34 RCTs of interventions that fell into two main categories: universal school-based interventions targeting the general population and interventions to engage at-risk individuals who had already been identified by the health-care system.
“This systematic review identified 34 RCTs of interventions that fell into two main categories: universal school-based interventions targeting the general population and interventions to engage at-risk individuals who had already been identified by the health-care system.”
Quote in the paperSubstantial claimMay combine two claims.
InterpretationreasoningA lack of blinding of outcome assessment would not have an impact on the outcome because most outcomes were evaluated either by questionnaire or service use records.
“However, we judged that a lack of blinding of outcome assessment would not have an impact on the outcome since most outcomes were evaluated either by questionnaire or service use records.”
Quote in the paperNot a substantial claimProbably not a substantial claim: may not pass S3 (load-bearing).
Study design and conductown dataTwo reviewers independently extracted data on study characteristics.
“The two reviewers independently extracted data on the following study characteristics: title, first author, year, country, study design, age range, intervention setting, condition in focus, sample size, response rate, intervention condition, control condition, length of intervention, evaluation time points, method of outcome assessment and results.”
Quote in the paperNot a substantial claimClassified as probably not a substantial claim.
PremisecitationAt each stage of the access pathway, supply-side dimensions of accessibility of services interact with demand-side abilities of persons to determine access to health care.
“At each stage, supply-side dimensions of accessibility of services (e.g., approachability, availability or affordability) interact with demand-side abilities of persons (e.g., abilities to perceive, pay or engage) to determine access to health care (see Appendix 1) (Levesque et al., 2013).”
Quote in the paperSubstantial claim0 of 1 sources checked- cites Levesque et al., 2013
Not checked in the free run.
Classified as probably not a substantial claim.
Study design and conductcitationTwo reviewers independently assessed the risk of bias of each article using the Cochrane Collaboration's tool for assessing risk of bias in randomised trials.
“Two reviewers (LW, DG) assessed the risk of bias of each article using the Cochrane Collaboration's tool for assessing risk of bias in randomised trials (Higgins et al., 2011) and discussed discrepant evaluations until they reached a consensus.”
Quote in the paperSubstantial claim0 of 1 sources checked- cites Higgins et al., 2011
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May combine two claims.
PremisecitationBarriers to mental health help-seeking in young people include lack of knowledge about services and stigma about mental health problems.
“Barriers to mental health help-seeking in young people include lack of knowledge about services and stigma about mental health problems (Gulliver et al., 2010).”
Quote in the paperNot a substantial claim0 of 1 sources checked- cites Gulliver et al., 2010
Not checked in the free run.
Probably not a substantial claim: may not pass S3 (load-bearing).
Study design and conductcitationThe review's reporting follows the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA).
“our reporting follows the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) (Moher et al., 2009).”
Quote in the paperNot a substantial claim0 of 1 sources checked- cites Moher et al., 2009
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Classified as probably not a substantial claim.
PremisecitationLevesque et al. (2013) proposed a comprehensive conceptual framework describing accessing health care as a series of steps beginning with the opportunity to perceive health-care needs, leading to opportunities to seek health care, reach health-care services, utilise health-care services and ultimately have health-care needs fulfilled.
“They have proposed a comprehensive conceptual framework describing accessing health care as a series of steps beginning with the opportunity to perceive health-care needs that can lead to opportunities to seek health care, reach health-care services, utilise health-care services and ultimately have health-care needs fulfilled (Levesque et al., 2013).”
Quote in the paperSubstantial claim0 of 1 sources checked- cites Levesque et al., 2013
Not checked in the free run.
Probably not a substantial claim: may not pass S3 (load-bearing).
Study design and conductnone givenThe systematic review was performed following a predefined protocol registered with PROSPERO (ID: CRD42018081714).
“This systematic review was performed following a predefined protocol registered with PROSPERO (ID: CRD42018081714).”
- Also stated in: § Methods · plain
“We registered our systematic review protocol with the International Prospective Register of Systematic Reviews (PROSPERO, ID: CRD42018081714).”
Quote in the paperNot a substantial claim- Also stated in: § Methods · plain
Classified as probably not a substantial claim.
Study design and conductreasoningThe risk of bias assessment was used as an indicator of the quality of evidence.
“Instead, we used the risk of bias assessment as an indicator of the quality of evidence.”
Quote in the paperSubstantial claimProbably not a substantial claim: may not pass S3 (load-bearing).
Study design and conductown dataThe review considered heterogeneity, risk of bias and precision where appropriate when reporting the effects of interventions.
“Although we did not formally grade the quality of evidence using the GRADE approach (Guyatt et al., 2011), we considered the criteria heterogeneity, risk of bias and precision where appropriate when reporting the effects of interventions below.”
Quote in the paperNot a substantial claim0 of 1 sources checked- cites Guyatt et al., 2011
Not checked in the free run.
Probably not a substantial claim: may not pass S3 (load-bearing).
Study design and conductcitationThe methods used for this systematic review are based on the Centre for Reviews and Dissemination's guidance for undertaking reviews in health care.
“The methods used for this systematic review are based on the Centre for Reviews and Dissemination's guidance for undertaking reviews in health care (Centre for Reviews and Dissemination, 2009)”
Quote in the paperNot a substantial claim0 of 1 sources checked- cites Centre for Reviews and Dissemination, 2009
Not checked in the free run.
May combine two claims.
Interpretationown dataUniversal school-based interventions targeting individuals from the general population tended to have a significant impact on steps earlier on the pathway to accessing care, especially knowledge and attitudes, but not on later steps, such as actually accessing care or mental health outcomes.
“Thus, universal school-based interventions targeting individuals from the general population tended to have a significant impact on steps earlier on the pathway to accessing care, especially knowledge and attitudes, but not on later steps, such as actually accessing care or mental health outcomes.”
- Also stated in: § Summary of main results · plain
“Interventions in the first category generally yielded significantly better knowledge and attitudes about accessing care as compared with controls, but did not have an impact on actually accessing care or on mental health outcomes.”
Quote in the paperSubstantial claim- Also stated in: § Summary of main results · plain
May combine two claims.
PremisecitationPaediatricians perceive a wide variety of organizational hindrances, including inadequate reimbursement and lack of time and space, and many feel they lack the training and confidence to treat mental disorders.
“As an example of barriers on the supply side, paediatricians perceive a wide variety of organizational hindrances, including inadequate reimbursement and lack of time and space, and many feel they lack the training and confidence to treat mental disorders (Horwitz et al., 2007).”
Quote in the paperNot a substantial claim0 of 1 sources checked- cites Horwitz et al., 2007
Not checked in the free run.
May combine two claims.
PremisecitationYoung patients with a mental disorder have a lower probability of receiving treatment and a longer delay between disease onset and first treatment compared with adults.
“In addition, young patients with a mental disorder have a lower probability of receiving treatment and a longer delay between disease onset and first treatment compared with adults (Christiana et al., 2000; Wang et al., 2005; Iza et al., 2013).”
Quote in the paperSubstantial claim0 of 3 sources checked- cites Christiana et al., 2000
Not checked in the free run.
- cites Wang et al., 2005
Not checked in the free run.
- cites Iza et al., 2013
Not checked in the free run.
Probably not a substantial claim: may not pass S3 (load-bearing).
Study design and conductown dataTwo reviewers independently screened all identified articles in a two-stage process.
“Two reviewers independently screened all identified articles in a two-stage process, extracted results on outcomes of interest (knowledge, attitudes, intentions, help-seeking, accessing care, mental health outcomes and satisfaction), assessed the risk of bias and conducted meta-analyses where deemed appropriate.”
- Also stated in: § Selection of studies and data extraction · plain
“Two reviewers (LW, DG) independently assessed the title and abstract of all identified papers, recorded their decision about whether the paper should be included for full-text assessment and discussed discrepant decisions until a consensus was reached.”
Quote in the paperNot a substantial claim- Also stated in: § Selection of studies and data extraction · plain
Classified as probably not a substantial claim.
PremisecitationPotential barriers that could explain the treatment gap can be found at each transition from step to step along the pathway to accessing care.
“Potential barriers that could explain the treatment gap can be found at each transition from step to step along this pathway to accessing care (Levesque et al., 2013).”
Quote in the paperSubstantial claim0 of 1 sources checked- cites Levesque et al., 2013
Not checked in the free run.
May combine two claims.
PremisecitationAnother systematic review on interventions to promote help-seeking for mental health problems found that interventions increased formal help-seeking behaviours when targeting affected or at-risk people with mental disorders, but not the general population.
“Another systematic review on interventions to promote help-seeking for mental health problems found that interventions increased formal help-seeking behaviours when targeting affected or at-risk people with mental disorders, but not the general population (Xu et al., 2018).”
Quote in the paperNot a substantial claim0 of 1 sources checked- cites Xu et al., 2018
Not checked in the free run.
May combine two claims.
Interpretationown dataBoth appointment reminder and treatment engagement interventions yielded significantly higher first appointment attendance in the target population as compared with controls.
“In other words, the odds of attending an initial appointment were 3.11 times higher for those who received an appointment reminder as compared with controls and 3.51 higher for those who participated in a treatment engagement intervention as compared with controls, indicating that overall, both types of interventions yielded significantly higher first appointment attendance in the target”
- Also stated in: § Summary of main results · plain
“Meta-analyses of appointment reminder interventions and treatment engagement interventions measuring the outcome accessing care using the binary measure first appointment attendance found that both types of interventions yielded significantly more access to care as compared with controls.”
Quote in the paperSubstantial claim- Also stated in: § Summary of main results · plain
Probably not a substantial claim: may not pass S3 (load-bearing).
PremisecitationIntegrating mental health services into existing service settings is considered a promising means of improving access to care.
“Integrating mental health services into existing service settings is considered a promising means of improving access to care (Anderson et al., 2017; Hodgkinson et al., 2017; Richardson et al., 2017);”
Quote in the paperNot a substantial claim0 of 3 sources checked- cites Anderson et al., 2017
Not checked in the free run.
- cites Hodgkinson et al., 2017
Not checked in the free run.
- cites Richardson et al., 2017
Not checked in the free run.
May combine two claims.
PremisecitationIn low- and middle-income countries, there is a shortage of mental health professionals, lower detection rates of mental disorders, less developed infrastructure, and potentially more stigma surrounding mental health disorders.
“Due to a shortage of mental health professionals, the fact that detection rates of mental disorders are much lower in many of these countries, less developed infrastructure and potentially more stigma surrounding mental health disorders, different interventions than those that are effective in high-income countries may be required (Patel et al., 2013).”
Quote in the paperSubstantial claim0 of 1 sources checked- cites Patel et al., 2013
Not checked in the free run.
Classified as probably not a substantial claim.
Study design and conductreasoningWe did not include retention in treatment as an outcome in this review since we were interested in gaining access to treatment.
“In addition, we did not include retention in treatment as an outcome in this review since we were interested in gaining access to treatment.”
Quote in the paperSubstantial claimMay combine two claims.
InterpretationreasoningExisting interventions do not improve access to care for people in need from the general population, leaving a large treatment gap.
“From a public health perspective, the problem with this finding is that existing interventions do not improve access to care for people in need from the general population, leaving a large treatment gap.”
Quote in the paperSubstantial claim- Rests on an assumption: There is an existing treatment gap in mental health care for children.
May combine two claims.
Interpretationown dataInterventions targeting at-risk children who had already been identified by the health-care system generally yielded more access to care and satisfaction with care as compared with controls, but not necessarily improved mental health outcomes.
“Interventions targeting at-risk children who had already been identified by the health-care system therefore generally yielded more access to care and satisfaction with care as compared with controls, but not necessarily improved mental health outcomes.”
- Also stated in: § Summary of main results · hedged
“Most interventions targeting at-risk children who had already been identified by the health-care system yielded significantly better access to care and satisfaction with care as compared with controls, but did not seem to have a significant impact on mental health outcomes.”
Quote in the paperSubstantial claim- Also stated in: § Summary of main results · hedged
Classified as probably not a substantial claim. May combine two claims.
Study design and conductnone givenThis systematic review provided an overview of interventions to improve access to mental health care along the entire pathway to accessing care using a conceptual framework, which allowed us to assess where evidence for effective interventions lies and where evidence is missing.
“This systematic review provided an overview of interventions to improve access to mental health care along the entire pathway to accessing care using a conceptual framework, which allowed us to assess where evidence for effective interventions lies and where evidence is missing.”
Quote in the paperSubstantial claimProbably not a substantial claim: may not pass S3 (load-bearing).
Study design and conductreasoningTaking a broad approach to the search necessitated restricting the search to the title field and English language only.
“However, taking a broad approach to the search necessitated restricting the search to the title field and English language only.”
Quote in the paperNot a substantial claimMay combine two claims.
InterpretationcitationOur results on the effects of universal interventions targeting individuals from the general population were similar to those from a previous systematic review on help-seeking interventions for depression, anxiety and general psychological distress in adults that found that mental health literacy content significantly improved help-seeking attitudes, but did not have an effect on help-seeking
“Our results on the effects of universal interventions targeting individuals from the general population were similar to those from a previous systematic review on help-seeking interventions for depression, anxiety and general psychological distress in adults that found that mental health literacy content significantly improved help-seeking attitudes, but did not have an effect on help-seeking”
Quote in the paperNot a substantial claim0 of 1 sources checked- cites Gulliver et al., 2012
Not checked in the free run.
Probably not a substantial claim: may not pass S3 (load-bearing).
Study design and conductreasoningWe attempted to address the search restriction by hand searching reference lists and key articles.
“We attempted to address this by hand searching reference lists and key articles.”
Quote in the paperNot a substantial claim
The paper relies on this without support.
There is an existing treatment gap in mental health care for children.
“In order to bridge the existing treatment gap in mental health care for children, interventions that aim to improve knowledge and attitudes about mental health care in the general population are not sufficient.”
Claims other papers make about this one
Each is checked against this paper’s own text: does it say what the citing paper says it does?
Eight (80%) of ten studies on treatment engagement for individuals at risk showed improved access to care with interventions.
“Eight (80%) of ten studies on treatment engagement for individuals at risk (eg, a family-based session to increase motivation during an emergency room visit) showed improved access to care with interventions.”
From The Lancet Commission on ending stigma and discrimination in mental health (2022) · cites this paper as [103]
Two-stage interventions that first identify people in need and then engage them in the health-care system are necessary to achieve a population-level effect on improving children's access to mental health care.
“The authors concluded that two-stage interventions that first identify people in need and then engage them in the health-care system are necessary to achieve a populationlevel effect on improving children's access to mental health care.”
From The Lancet Commission on ending stigma and discrimination in mental health (2022) · cites this paper as [103]
Formal quality assessment of constituent studies was done in four reviews, and two studies included meta-analyses.
“Formal quality assessment of constituent studies was done in four reviews.[102][103][104][105] Two studies included meta-analyses.102,104”
From The Lancet Commission on ending stigma and discrimination in mental health (2022) · cites this paper as [103]
A review focusing on children and adolescents identified 13 studies on universal school-based interventions and 21 studies to engage at-risk individuals.
“A review focusing on children and adolescents, 103 identified 13 studies on universal school-based interventions and 21 studies to engage at-risk individuals.”
From The Lancet Commission on ending stigma and discrimination in mental health (2022) · cites this paper as [103]
Help-seeking intentions improved in two of nine studies (effect size -0.15 to 0.30), and accessing care improved in one of five studies.
“At the same time, help-seeking intentions improved in two of nine studies (effect size -0•15 to 0•30) as did accessing care in one of five studies.”
From The Lancet Commission on ending stigma and discrimination in mental health (2022) · cites this paper as [103]
In a meta-analysis, significant improvements in attitudes or beliefs about seeking care were seen in four of six studies (effect size -0.02 to 2.56).
“In a meta-analysis, they found significant improvements in attitudes or beliefs about seeking care could be seen in four of six studies (effect size -0•02 to 2•56).”
From The Lancet Commission on ending stigma and discrimination in mental health (2022) · cites this paper as [103]
Self-check
Percentages, sums and reported differences re-computed from the paper’s own numbers.
Each contradiction between two passages listed here was confirmed by an independent check.
Attitudes odds ratio reported as an effect size
MinorThe stated upper end of the attitudes effect-size range, 2.56, is labelled an odds ratio in Table 2, not a standardised effect size. The text combines two different measures in one effect-size range.
“The effect sizes ranged from −0.06 to 0.96 for knowledge about seeking health care, −0.02 to 2.56 for attitudes about seeking health care”
“OR: 2.56 (1.44–4.57)a”
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Flagged first, then by citations
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Child and adolescent psychiatry: challenges, solutions, opportunities, and future directions
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- Authors
- Werlen, L., Gjukaj, D., Mohler-Kuo, M., & Puhan, M. A.
- Affiliations
- HES-SO University of Applied Sciences and Arts Western Switzerland (CH)
- University of Zurich (CH)
- Corresponding author
- Werlen, L.
- Venue
- Epidemiology and Psychiatric Sciences
- Publisher
- Cambridge University Press (CUP)
- Published
- 2019-10-17
- Volume
- 29
- Pages
- e58-e58
- ISSN
- 2045-7960 (ISSN-L)
- 2045-7979
- PMC
- PMC8061244
- OpenAlex
- W2980863930
- Semantic Scholar
- cd3cbb6d3c53e467bae1bdf92ee7f9c53ebd12df
- Cited by
- 45
- References
- 70
- Citations by year
- 2026: 9 · 2025: 11 · 2024: 7 · 2023: 5 · 2022: 4 · 2021: 6 · 2020: 3
- FWCI
- 0.50
- Type
- journal article
- Language
- en
- Open access
- hybrid
- doi.org
- Locations
- Epidemiology and Psychiatric Sciences (publishedVersion, cc-by)
- PubMed Central (publishedVersion, cc-by)
- PubMed (publishedVersion)
- Zurich Open Repository and Archive (University of Zurich) (acceptedVersion, cc-by)
- ArODES (HES-SO (https://www.hes-so.ch/)) (submittedVersion)
- Zurich Open Repository and Archive (University of Zurich) (submittedVersion, cc-by)
- Zurich Open Repository and Archive (University of Zurich)
- Topics
- Social Sciences › Psychology › Social Psychology › Mental Health Treatment and Access
- Social Sciences › Psychology › Clinical Psychology › Child and Adolescent Psychosocial and Emotional Development
- Health Sciences › Health Professions › Speech and Hearing › School Health and Nursing Education
- Keywords
- access to mental health care, help-seeking interventions, school-based intervention, appointment reminders, treatment engagement, help-seeking intentions, at-risk youth, help-seeking barriers, satisfaction with care, mental health service utilization, appointment attendance, infrastructure barriers, child mental health services, help-seeking
- MeSH terms
- Help-Seeking Behavior, Internet-Based Intervention, Adolescent, Mental Disorders, Child, Health Education, Health Services Accessibility, Humans, Health Knowledge, Attitudes, Practice, Mental Health Services, School Health Services, Intention
About these checks
Registry, retraction, Cites and statistics results are computed, not judged, with one exception: a printed reference that no index lists is read once by a model before it counts as a citation error. Claims are extracted by a model and kept only when their quote appears verbatim in the text; each cited source is then checked, with a model’s help, for whether it says what the claim relies on. Those verdicts can be wrong — read the claim’s quote and the cited source before relying on one.
Claims read by deepseek-v4.1-flash under definition version 3 (extract-v3) on 2026-10-07.
Classified by jev-1.13-20260917 (gold-guideline-v0.2) on 2026-10-07.
Statistics and arithmetic are recomputed, not judged.
Confidence bands are shown only for fields calibrated on our annotated test set. None is calibrated yet, so no band is shown.
What counts as a claim ›How we measure confidence ›How we check this ›
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