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

Introduction Evidence 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. Methods We 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). Results Of 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. Conclusions We 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.