Discussion
UC
RECRUITMENT, BLIND
This is the first-ever RCT of a scalable intervention for improving mental health outcomes for YP at the child–adult SB. We met our original recruitment target and retention of participants was better than expected: 15-month primary outcome was assessed in 76% (602/793) of the cohort across eight countries. Overall, the trial covered 38 child/adolescent services in eight European countries making the study findings generalisable to a range of settings.We developed and tested a new intervention, MT, in eight European countries (Singh et al., Our MT model ensures that the process of transition is planned and purposeful, and addresses the needs of YP as they reach the upper age SB and move towards independence (Paul et al., Previous attempts at improving service transition in mental health are few, and no RCT has ever been conducted (Appleton et al., Our MT model provides a solution that can be applied within existing service structures. For more robust transitional health care for YP, the MT model could be implemented as part of a comprehensive package of service alignment. The MT model is far less resource intensive than large-scale service reorganisation such as the 0–25 model, multi-component transition-specific programmes, or youth-friendly service models (Hetrick et al., The modest clinical gains of our trial need to be interpreted in the context of the need for a single quantitative primary outcome measure for a process-related study. Finding a suitable measure for the primary outcome was difficult, owing to the nature of the intervention and clinical diversity of the participants. We decided on HoNOSCA because it was developed for child/adolescent mental health care settings and is used widely in Europe (Garralda et al., We were surprised at the relatively large proportion of YP still in CAMHS or without a transition decision at 15 months, but similar findings have been confirmed in a recent systematic review (Appleton et al., There are, as in any trial, limitations of this study. The most unwell may be underrepresented; so we may have missed some for whom transition is essential but particularly challenging. We could not blind the CAMHS clinicians or assessors; the former was unavoidable given the nature of the intervention, but the latter was imposed due to resourcing issues. Blinding of assessors would have required two research assistants per recruitment site: one to deal with training, recruitment and the administrative aspects of the trial and another to undertake HoNOSCA interviews and assessments. This may also have made it more difficult for our research assistants to bond with participants, as each participant would now have two contacts within the research team to develop a relationship with rather than one. For clinicians in the UC arm, knowledge of the trial may have enhanced their focus on transition options. Furthermore, although, clinicians in the UC arm did not receive the TRAM summary report they did complete the clinician version of the TRAM, which may also have influenced their decision making.