Schools key to reaching the one in ten children with mental health problems

Schools are a vital way of reaching the 10-20 percent of children and young people across the globe who would benefit from some sort of mental health intervention, according to a new Series on mental health interventions in schools published in The Lancet Psychiatry.

The Series highlights that is an important window for intervention because around 75% of adults who access have had a diagnosable disorder before the age of 18. What is more, estimates from high-income countries (HICs) indicate that only 25% of children with a problem get identified or treated.

Speaking to The Lancet Psychiatry in a podcast, Series lead author Dr Mina Fazel, a child psychiatrist at the University of Oxford in the UK explains, "Mental illness often starts in adolescence but doesn't end in adolescence: it is a life-long disorder. It is therefore essential to find innovative ways to approach treatment and to reach to maximise their academic, emotional, and social development, and schools are where children spend much of their time."

The most common disorders in school children are behavioural disorders and anxiety, with depression becoming common in the later years of secondary school. Untreated depression and other affect many different aspects of a young person's development and can lead to school failure and non-attendance as well as affecting long-term career choices and relationships.

Routine mental health screening in schools is controversial. Concerns have been raised about the labelling and stigmatising of young people. However, Dr Fazel disagrees, "If 10% of children had diabetes, we wouldn't be saying that screening was a bad thing. Schools provide a platform to access large proportions of young people, and the vast majority of children picked up by screening would not need complex interventions."

So what needs to be done? (see panel, paper 1, page 381). Large numbers of interventions have already been trialled and proven to work in whole schools, classrooms, and among selected individuals. The primary barrier to meeting the mental health needs of young people is the gap between research and practice, says Dr Fazel. "We know what works, but where we fall down is implementing this on a large scale in schools. We also need national policies to help education and mental health services work more closely together."

"The evidence shows that children prefer to be seen in school rather than outside school. But right now, health and education are very different systems", adds Dr Fazel. "The reality is that we are not maximising on the opportunities to work in these environments. We need to have an approach that is child focused and to do this health and education must become more closely aligned."

The Series highlights that the mental health gap (unmet mental health needs) is far more extreme in low-and middle-income countries, where more than 80% of the global population of children and adolescents live. In the second Series paper, Fazel and colleagues discuss ways to bridge this gap in countries without the professionals and resources of HICs. The SHAPE programme (see panel 1, paper 2, page 389) in India shows that this is feasible, acceptable, and has an impact. SHAPE uses trained lay school health counsellors to look at both physical and mental health promotion (eg, screening for visual and weight problems as well as violence and bullying). They work with schools to conduct whole- interventions, and where necessary, one-on-one counselling for .

The Lancet Psychiatry Editor Dr Niall Boyce says, "The promotion of good mental health needs to come out of the clinic and into the wider world. We hope that The Lancet Psychiatry papers by Mina Fazel and colleagues will be a valuable resource for teaching and mental health professionals around the world as they strive to improve the education and wellbeing of young people."

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