Inside UK youth mental health services: mapping treatment as usual for depression

Treatment as usual in UK Child and Adolescent Mental Health Services (CAMHS) is far messier than trial designers often assume, according to a mixed methods study published in Discover Health Systems. Researchers from the ATTEND feasibility programme combined clinician interviews, treatment recording sheets and an audit of electronic health records to describe, in unprecedented detail, what young people with depression actually receive after they enter specialist services. Their central conclusion is stark: care pathways share a common skeleton, but the support flowing through that skeleton varies enormously from site to site, clinician to clinician and young person to young person.

The work was motivated by a practical problem in clinical trials. When researchers test a new intervention against treatment as usual, they need to know what the comparator actually consists of. Yet systematic reviews of treatments for depression in children and young people reveal a bewildering array of control conditions, including wait-lists, minimum attention controls, pill or psychological placebos and loosely defined usual care. Where treatment as usual is the comparator, protocolising care across study sites is uncommon, and participants can be offered different types of care with different durations and intensities. In one recent network meta-analysis of adolescent depression treatments, the sheer variety of control conditions reduced network connectivity and analytical power, weakening the conclusions.

The study focused on second-line treatment, the support offered to young people who have already completed one evidence-based first-line intervention for depression but have not recovered sufficiently for discharge. This population matters because epidemiological data indicate that 20 to 40 percent of young people do not benefit from first-line interventions, and relapse is common. The researchers argue that mindfulness-based cognitive therapy, which is established in adults as relapse prevention for depression but remains in its infancy for young people, could serve as a second-line option. Evaluating it properly requires understanding what it would be compared against.

To build that picture, the team drew on the ATTEND feasibility pilot trial, which ran from October 2020 to January 2022 across two CAMHS sites in England, one urban and one semi-rural. Twenty-eight young people aged 14 to 17 were recruited and randomised in a 2:1 ratio to Mindfulness for Adolescents and Carers, a nine-session adapted mindfulness-based cognitive therapy programme delivered to young people and their carers in parallel, plus treatment as usual, or to treatment as usual alone. Because of the Covid-19 pandemic, the mindfulness sessions moved online. The researchers triangulated three data sources: interviews with ten senior managers and eleven case-managing clinicians, Treatment Recording Sheets completed by clinicians for 21 of the 28 participants, and an audit of 1,507 patient records at one site covering referrals accepted between January 2018 and December 2019.

Despite site-level differences in geography, service organisation and assessment models, the synthesis identified a broadly shared pathway structure. Young people enter through referral and screening, typically from general practice, which accounted for 39.7 percent of audit referrals, or accident and emergency departments, which accounted for 15.4 percent. Those meeting the threshold for specialist care undergo assessment, often using standard measures such as the Revised Child Anxiety and Depression Scale and the Strengths and Difficulties Questionnaire. They then enter a waiting and supportive phase, followed by first-line treatment, second-line treatment where needed, discharge and possible re-referral, with crisis support running alongside. Waiting times varied dramatically: in the audit, the median time from referral acceptance to a first attended appointment was 32 days, but the range stretched from less than one day to over two years.

First-line treatments were wide-ranging, including cognitive behavioural therapy, interpersonal psychotherapy, family therapy, brief psychosocial intervention, compassion-focused therapy, short-term psychodynamic psychotherapy, acceptance and commitment therapy, art therapy and medication. In the audit, at least one identifiable talking therapy episode occurred during the index referral for 22.1 percent of patients, with a median of eight sessions in the first episode. Interviews suggested first-line treatment typically ran six to eight sessions fortnightly over 12 to 14 weeks. Clinicians also reported widespread use of supportive listening and generic partnership work, and the recording sheets showed moderate to frequent use of supportive listening across both trial arms.

The most striking finding concerned care coordination, the oversight of a young person’s care by a designated clinician. This emerged as the most common second-line provision and was received by participants in both trial arms. It typically involved regular review contacts, monitoring of mental state and risk, liaison with families and agencies, and help navigating services, but it was not delivered as a structured therapeutic intervention. Clinicians were candid about its limits. One described referring a young person to a second-line intervention in April and, a year later, still carrying the full burden of weekly check-ins herself, calling it a massive gap between what services say they can offer and what they actually offer. Others admitted that young people were sometimes matched with whichever clinician had space, regardless of skillset.

Medication featured prominently in routine care. Treatment recording sheets showed antidepressant use by 7 of 21 participants, and the audit’s natural language processing tool detected antidepressant mentions in 48.8 percent of records, sleeping medications or tranquilisers in 31.1 percent, antipsychotics in 15.9 percent and mood stabilisers in 3.6 percent. Discharge patterns were also revealing: among audit patients, 95.5 percent had been discharged by data extraction, two-thirds of them back to their general practitioner, with a median of 421 days in the service. Nearly 44 percent of discharged patients had a subsequent referral to the trust’s mental health services, and 62.7 percent of index referrals were still active when the patient turned 18, raising questions about transitions to adult care.

An unexpected observation carries important implications for trial design. Young people allocated to the mindfulness intervention generally had fewer contacts with CAMHS and did not receive additional interventions compared with those allocated to treatment as usual alone. Participation in a trial intervention, in other words, appeared to alter the quantity and nature of routine support received, blurring the conceptual line between testing an intervention against treatment as usual and testing it alongside it. The authors suggest this may be a false dichotomy and argue that trials must carefully document care received across all arms, because variation in routine provision may influence both intervention delivery and the interpretation of outcomes.

The researchers are careful about the limits of their findings. Clinician participation in interviews was voluntary, with lower response rates among clinicians supporting the treatment-as-usual arm, so the interview data may not capture the full breadth of care received. The recording sheets covered only a four-week window at a single time point, potentially underestimating the complexity and sequencing of support. The feasibility trial ran during the pandemic, which likely affected both the mindfulness programme and routine provision, although the audit used pre-pandemic 2018 to 2019 data and produced consistent findings. With only two sites, the identified pathway should be explored more widely before claims of generalisability. Even so, the study’s contribution is not a definitive portrait of current services but a demonstration of how complex, variable and context-dependent treatment as usual is, even within a small number of sites. The authors recommend that future studies compare treatment plus care coordination with treatment as usual, and that structured reporting frameworks such as the TIDieR checklist and its new extension for child and youth health interventions be used to specify comparator conditions, improving transparency and reproducibility in trials for this vulnerable group.

Subject of Research: Treatment as usual and care pathways for young people with depression in UK Child and Adolescent Mental Health Services

Article Title: A mixed methods exploration of mental health pathways and treatment as usual for young people experiencing depression in the United Kingdom

Article References: Mitchell, S. B., Berry, V., Westbrook, J., Carey, E. G., Wickersham, A., Garrood, A., Hayes, R., Galante, J., Basri, H. H., Liabo, K., & Ford, T. (2026). A mixed methods exploration of mental health pathways and treatment as usual for young people experiencing depression in the United Kingdom. Discover Health Systems, 5(1), Article 75. https://doi.org/10.1007/s44250-026-00412-0

Image Credits: AI Generated

DOI: 10.1007/s44250-026-00412-0

Keywords: CAMHS, adolescent depression, treatment as usual, care pathways, care coordination, mindfulness-based cognitive therapy, ATTEND feasibility trial, mental health services, clinical trials, United Kingdom, waiting times, second-line treatment