Disparities in adolescent mental health-related National Health Service presentations in England: secondary school cohort study

IntroductionEvidence on demographic and socioeconomic differences in adolescent mental health service use is vital for developing equitable health policy and service responses. We quantified inequalities in referrals to National Health Service (NHS)-funded mental health services and NHS-hospital use for mental health concerns by social strata for secondary school pupils in England. MethodsWe used linked records from state-funded schools and national health services (ECHILD) in England to create a secondary school cohort of pupils (age 11 years/Year 7 at entry) from 2012/13 to 2021/22. We measured rates of service use by gender, racial-ethnic group, region of residence, free school meal eligibility, and area-level deprivation defined by the index of multiple deprivation. Service contacts were captured by records in the Mental Health Services Data Set and Hospital Episode Statistics. Pupils were followed up until the first chronological event of: service contact, age 21 years, death or end of study (31st August 2022). ResultsOf 5,629,719 pupils, 980,648 (17.4%) were referred to NHS-funded mental health services; a rate of 45.2 per 1000 person-years (95% confidence interval 45.1-45.2). Within stratum, rates of referrals were higher in females (55.5, 55.4-55.7) than males (35.7, 35.6-35.8), highest in White Irish Traveller (70.8, 66.2-75.8) and lowest in Pakistani racial-ethnic groups (20.8, 20.5-21.1), highest in the North East (58.2, 57.7-58.7) and lowest in London (37.7, 37.5-37.9). Adolescents who were eligible for free school meals had particularly high referral rates (75.3, 75.0-75.6) and there was a gradient in rates by quintiles of area-level deprivation. There was consistency in the sociodemographic patterns across mental health-related referrals, emergency department attendances, and hospital admissions. ConclusionsWe find marked variation in mental health service use across social strata, but with consistency across different service types, indicating significant inequalities in the underlying prevalence of mental ill-health and access to services. Key Messages What is already known on this topicO_ST_ABSsummarise the state of scientific knowledge on this subject before you did your study and why this study needed to be doneC_ST_ABSO_LIImproving access to mental health services for young people is a priority for the English National Health Service, but there is limited population-level information about rates of contacts across multiple health care services and with comprehensive coverage of England. C_LI What this study addsO_ST_ABSsummarise what we now know as a result of this study that we did not know beforeC_ST_ABSO_LIAlmost one fifth of pupils were referred to mental health services, with stark variation by gender, racial-ethnic group, free school meal eligibility, neighbourhood deprivation and region of residence C_LIO_LIRelative patterns of contacts by social strata were similar across emergency department attendances and hospital admissions C_LI How this study might affect research, practice or policyO_ST_ABSSummarise the implications of this studyC_ST_ABSO_LIClear differences in services contacts across social strata indicate significant inequalities, likely reflecting differential barriers to access, the acceptability of NHS services to specific population strata, as well as differences in the underlying prevalence of mental ill-health C_LIO_LIWe find no evidence of disproportionate use of a single service type, suggesting that policies addressing inequalities should span across all services and must seek to address social determinants of health, including differential barriers to service use. C_LI