Impact case study database

In 2017, around one in eight 5–19-year-olds in England were estimated to have at least one mental health disorder (NHS Digital, 2018). By 2020, prevalence had increased further, with more than 25% of older female adolescents having a probable mental health disorder (NHS Digital, 2020). Despite such high levels of need, child and young people (CYP) mental health services have been significantly under-resourced. In 2015 there were fewer than 1 whole time equivalent (WTE) mental health practitioners per 1,000 young people under 18, in services receiving over 270,000 annual referrals. Reynolds and colleagues’ research findings on adolescent depression characteristics and treatment factors has had wide influence, though the development of Brief BA, by identifying and exploring young people’s experiences of anhedonia and isolating values to engage and motivate them. This has led to significant improvements in depressed adolescents being able to access and engage in treatment in a timely manner, making a difference to thousands of young people’s lives.

Influence on child and adolescent mental health policy and practice

The findings of the IMPACT trial, conducted across 15 CAMHs, were highly generalisable to clinical practice, and resulted in an update to the 2019 NICE Guidelines for the identification and management of child and adolescent depression [E1]. CBT is still the primary recommended treatment, but both STPP and BPI have been added as recommended if CBT is not suitable.

The research has also influenced NHS England decisions on the provision and training of CYP mental health practitioners. As a result of confirmation from the IMPACT trial that CBT was effective, NHS England and HEE sought to expand the CYP IAPT workforce by funding training for 1,000 new CBT therapists in Child and Adolescent Mental Health services (CAMHs) within the CYP IAPT Programme. Notably, the Reading team’s research also influenced the development, training and introduction (in 2017) of a ‘low intensity’ workforce stream within CYP mental health services. Reynolds was a member of the National CYP IAPT programme board and the CYP IAPT curriculum group that steered the development of this new workstream. Two distinct roles have been developed:

1. Child Well-Being Practitioners (CWPs), who work largely in NHS CAMHs. Health Education England and the Department of Health in England have provided funding for 1,700 new CWPs and 800 supervisors to be trained by 2021.

2. Educational Mental Health Practitioners (EMHPs) work in schools/colleges in newly established Mental Health Support Teams (MHSTs). In 2017 England’s Department of Health and Department for Education announced funding to train 8,000 new MHST staff by 2025.

These low intensity therapists deliver brief, focused, evidence-based psychological interventions for clients with mild-to- moderate symptoms of anxiety and depression as part of a stepped care service. Brief BA is one of four core interventions for these therapists and is part of national curricula for this workstream [E2, E3, E4].

To put this expansion in context, the total workforce for NHS CAMHs in England in 2016 was 7,900 WTE – therefore 10,500 additional CYP practitioners represents a very significant increase in the workforce and change in practice.

Building capacity within CYP mental health services through training

Reynolds and Pass have been actively involved in training cohorts of CWP and EMHP students and their supervisors. Since 2015, the pair have trained approximately 850 students and their supervisors to deliver Brief BA, as part of CYP-IAPT programme training in London, South East, South West, Midlands, and the North West [E5]. To meet ongoing and future demand, they also developed a ‘train the trainer’ programme and wrote Brief Behavioural Activation for adolescent depression: A Clinician’s manual and Session-by-Session guide, which was published in September 2020 [E6]. Between April and December 2020, they have delivered the ‘train the trainer’ model in collaboration with NHS Education Scotland (NES). As a result, Brief BA for adolescent depression has been introduced into every CAMHs in Scotland (Scottish CAMHs receive over 25,000 referrals each year). Training materials developed by Reynolds and Pass are hosted on the NES website to support future cascade of training into education settings [E7]. In response to the COVID-19 pandemic, Reynolds and Pass adapted materials to train and deliver Brief BA remotely. For example, they have disseminated resources to support the use of Brief BA in the context of COVID-19 via publicly available podcasts and webinars, including a series of role play videos for clinician training and client psycho-education, published in June 2020 [E8].

Increased provision of evidence-based psychological therapy for adolescent depression

Reynolds and Pass's treatment manual, training, 'train the trainer' model, and the introduction of new low intensity clinicians have greatly increased the availability of treatment for depressed young people. For example, evidence from the University of Reading's AnDY clinic, which works in partnership with the local CAMHs service, has directly treated over 160 young people with depression symptoms in clinic or at school. This group of young people engaged well, showed evidence of significant improvements in depression symptoms and functioning, and the vast majority did not require any further input for depression symptoms after receiving Brief BA.

Between January 2015 and September 2020 well over 2,000 clinical trainees across all NHS funded CWP and EMHP training programmes in England as well as all CAMHs teams in Scotland will have been trained in Brief BA. Therefore, Reynolds et al. estimate that by December 2020 at least 12,000 young people will have received Brief BA for depression in schools and clinics in the UK.

The work of Reynolds et al. has also been disseminated internationally via clinical training programmes and workshops, to over 1,500 individuals in over 10 countries. Reynolds et al. have consulted with clinical teams in Canada, Sweden, Australia, Hong Kong and Iceland and collaborated with them to develop culturally specific Brief BA resources that can be integrated into their services for adolescents with depression [E5].

Increasing public understanding of adolescent depression and raising the profile of evidence-based support

Since November 2017, over 70,000 people from more than 50 countries have taken part in two free Massive Open Online Courses (MOOCs) about adolescent depression, which were developed by the Reading team. The first, a five-week course, highlights University of Reading research on adolescent depression and provides parents, teachers and primary care professionals with practical evidence-based information to support young people who have symptoms of depression [E9]. The course includes specific content on Brief BA, tailored for accessible, online learning for a diverse audience of adolescents, their parents, teachers and therapists. Brief BA was also central to a second MOOC on supporting young people with low mood during COVID-19 [E9].

The University of Reading team have also disseminated their work, including specific guidance on Brief BA techniques, via blogs, podcasts, public lectures, self-help books for young people and parents. Reynolds’ self-help book for young people ‘Am I Depressed and what can I do about it? ’ (ISBN 9781472114532, published by Hachette UK in 2015) was selected by Reading Well for its Books on Prescription list and is therefore available in all public and school libraries in the UK as part of the Universal Public Library Health Offer [E10].

Summary

University of Reading research has advanced both the understanding and treatment of adolescent depression. Reynolds and colleagues’ findings have steered NICE guidelines, broadening the number of treatments now recommended for adolescent depression, and they have supported the delivery of a new workforce of CYP mental health workers, with thousands of new low intensity clinicians trained to deliver the Reading team’s treatment for adolescent depression: Brief BA. The University of Reading ‘train the trainer’ model, treatment manual, supporting materials and online resources makes this a sustainable programme. The Reading researchers have provided evidenced-based information to tens of thousands of young people and their parents, which has enabled them to understand and manage their symptoms better. Together, this work is enabling more young people with depression to access safe and effective help, faster.