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Prospective cohort study.
2316 Finnish 18 year old boys attending military call-up. Participants were part of a 10 year follow up study of a representative sample of Finnish children born in 1981 (the Epidemiological Multicentre Child Psychiatric Study in Finland).
Participants were first assessed at age 8 using self-report (the Children’s Depression Inventory), parent reports (Rutter A2 Scale) and teacher reports (Rutter B2 Scale). Children with a score of 13 or above on the Rutter A2 scale, or 9 or above on the Rutter B2 scale were classified as having behavioural problems. At military call-up, participants completed a questionnaire assessing mental health service use in the previous year. Univariate and multivariate logistic regression were used to analyse associations.
Self-reported use of mental health services in the previous year.
Follow up period:
In the previous year, 2.1% of participants (48/2316) had used mental health services; seven respondents (0.3%) had received psychiatric inpatient care. Boys who were considered by their teachers to have behavioural problems at age 8 were significantly more likely to have utilised mental health services at age 18 (OR 2.6, CI 95% 1.3 to 5.1; multivariate analysis). Parental or self-report of behavioural problems at age 8 did not significantly predict service use (figures not presented).
The rate of use of mental health services in 18 year old Finnish boys is considerably lower than the estimated prevalence of psychopathology in adolescents. Education services have a crucial role in identifying children at risk of future mental health problems.
Sourander et al replicate findings from other epidemiological studies that report mental health service utilisation by adolescent males is very low (approximately 2%). Further analysis identified a range of psychopathological symptoms (anxious–depressive and withdrawn symptoms) and other variables (health problems; not living with parents; illicit drug, alcohol, and cigarette use) that were independently associated with mental health service use in a multivariate model. These findings concur with identification of comorbidity and multidomain impairment in clinical child and adolescent mental health samples1 and highlight the need for an inclusive service response, such as the multisystemic therapy model,2 rather than fragmentation across different providers.
Sourander et al should be commended for a design that utilises an existing cohort, enabling a predictive model of mental health service use to be tested. In analyses of age 8 variables, teacher perceptions of the need to refer to mental health services or low school performance (univariate regression model) and teacher determination of emotional and behavioural symptom levels (multivariate model) independently predicted mental health service use when aged 18.
The results emphasise the importance of the school experience in the development of children and adolescents and underline the need for referral links with schools and teachers as key informants of psychopathology and impairment. The authors conclude that the school setting should be considered as the logical site for universal and targeted mental health preventive interventions. As clinic based care is not accessible to the majority of adolescent males, alternative models including home based and outreach services should be evaluated. Further research that aims to understand why male adolescents do not use mental health services is essential. Given evidence that adolescent psychopathology has increased over the past 25 years3 and the lack of capacity of mental health services to respond to large increases in adolescent presentations, the need for effective preventative interventions is urgent.
For correspondence: Dr A Sourander, Department of Child Psychiatry, Turku University Hospital, 20520 Turku, Finland;
Sources of funding: the Sigrid Juselius Foundation, and the Signe and Arne Gyllenberg Foundation.