The right place at the right time

Abstract

Being in “the right place at the right time” is often said to have influenced everything around us—from an individual finding the perfect partner or job, to which politicians came to power and the direction taken by world history. In medicine, from serendipity in drug discoveries, to how we interact with individual patients to intervene in illness, time and place have been key. Variations in prognoses of the same illness in different individuals often owe much to being in the right place at the right time. From odds of survival after serious road traffic accidents varying according to distance to a major trauma centre, to the course and outcomes of a psychotic illness varying according to access to early intervention services, many outcomes depend on a mixture of existence and physical proximity of care, and acceptability to service users influencing whether they take up the resources offered. Finding the right time and the right place to help people with mental health problems is notoriously difficult. This is seen in the many, often short-lived, new ideas of settings in which to interact with patients, from dedicated hospitals, to community centres, to cafes and parks. Whatever the newest model of intervention is, they are inevitably designed to help improve access to services and be as inclusive as possible, but sadly many new innovations fail as uptake and effect are lower than was hoped. Across all cultures, people with mental health problems are more likely to experience greater financial difficulties, social isolation, and discrimination than others, all of which make getting to the right place at the right time that much harder. The inverse care law (first described by Julian Tudor Hart, 1971) states that the availability of good medical care tends to vary inversely with the need for it in the population, and this is also thought to apply to mental health-care usage, with people who need it the most using services the least. Deliverance of effective care to people with mental health problems is an ongoing challenge and one that requires huge collaborative efforts of health services with other agencies to even begin to remove some of these practical barriers. Much of this infrastructure is already in place for children and young people in a school setting. In The Lancet Psychiatry, Mina Fazel and colleagues review mental health services and interventions in schools, focusing on high-income countries in one paper, and countries with middle and low income in another. They explain how, because almost all young people in high-income countries attend school and the numbers attending in the rest of the world is increasing, this setting provides the ideal opportunity to offer both universal education about mental health issues and specialised help for those who need it. Implementation of mental health services in schools can provide timely input to children, thereby improving their present wellbeing—sometimes overlooked in child mental health in favour of longer-term outcomes only. Also, as the authors point out, by children receiving care in a place they are already attending and during the school day, this democratises access to services, as being able to receive care is not determined by parental income or work patterns, and might overcome initial willingness to engage with health professionals. There are still many challenges to overcome with mental health services in schools, including on the one hand the risks of overdiagnosis when universal interventions are offered, and on the other, insufficient uptake of services if students perceive that they might be stigmatised or bullied or the services might not be of help. Professionals delivering new care stategies might not ‘buy-in’ to them either as shown by Thornicroft and colleagues in The Lancet in 2013. Their work showed that some staff were not adequately prepared to deliver a new intervention and had little sense of ownership of it. These will be particularly important barriers to overcome towards mental health services in schools, in which buy-in from teachers, who might not view these services as part of their role, will be as important as that from health-care staff. However, provision of mental health services in schools has a unique opportunity to reach out to people who might otherwise be in the substantial proportion for whom barriers to seeking care are insurmountable. Bach claimed, “It's easy to play any musical instrument: all you have to do is touch the right key at the right time”, and although many might not agree, most of us would concede that although providing mental health care is never easy and always comes with individual challenges, touching on the right issues at the right time is important. It seems that school mental health provisions are improving and increasingly hitting the right notes, in providing time and space to allow all young people access to mental health education and care. Mental health interventions in schools in high-income countriesMental health services embedded within school systems can create a continuum of integrative care that improves both mental health and educational attainment for children. To strengthen this continuum, and for optimum child development, a reconfiguration of education and mental health systems to aid implementation of evidence-based practice might be needed. Integrative strategies that combine classroom-level and student-level interventions have much potential. A robust research agenda is needed that focuses on system-level implementation and maintenance of interventions over time. Full-Text PDF Mental health interventions in schools in low-income and middle-income countriesIncreasing enrolment rates could place schools in a crucial position to support mental health in low-income and middle-income countries. In this Review, we provide evidence for mental health interventions in schools in accordance with a public mental health approach spanning promotion, prevention, and treatment. We identified a systematic review for mental health promotion, and identified further prevention and treatment studies. Present evidence supports schools as places for promotion of positive aspects of mental health using a whole-school approach. Full-Text PDF