Over-medication is a symptom of our failing children's mental health service
Children's mental health services are falling short.
A new report from the NI Commissioner for Children and Young People (NICCY), released in the past week, details many areas where services are inadequate.
Children's Commissioner Koulla Yiasouma said she "found the system wanting in areas such as lengthy waiting times, the high proportion of children not being accepted to specialist services, problems with access to services for children with learning difficulties, or drug and alcohol issues, unacceptable failings in the care of children in mental health crises."
The problems in these areas, all necessary parts of comprehensive provision, comes alongside an over reliance on the use of medication as treatment.
NICCY's report, Still Waiting, was launched in June 2017 and involved extensive engagement with children and young people about their experiences of accessing, or trying to access, mental health support, as well as hearing from parents, carers, and professionals within the system.
The paper is a rights-based review of services and, as such, pays significant attention to the United Nations Conventions on the Rights of the Child (UNCRC).
States who have ratified the UNCRC (which includes NI) are required to submit periodic reports on how they are delivering on commitments within the convention.
In the other direction, the UN Committee on the Rights of the Child (CRC) makes appraisals every few years of how states are fulfilling their obligations. The latest of these about NI was in 2016 and NICCY's report includes excerpts from a number of "strongly worded recommendations" from the CRC, including "that prescription of drugs is used as a measure of last resort and only after an individualized assessment of the best interests of that child, and that children and their parents are properly informed about the possible side effects of this medical treatment and about non-medical alternatives."
Unfortunately, that is not the way things are.
One young person, speaking to NICCY about their own experiences, raised huge concerns about the health professionals' reliance on medication:
“If I’m in desperate need and I’m a young person, and if I’m saying I’m suicidal and all, instead of getting handed depressants cos that’s happened before – I said I’m suicidal, they handed me anti-depressants – I went home and hung myself twice. The wires just broke(..)“
Medication as a treatment option
When it comes to medication, the report speaks for itself:
"In the information provided through the Review survey and interviews, a theme arising was young people being offered medication when they did not want it, and young people disagreeing that they had been given a choice of alternatives. This feedback raises concerns about a reliance on medication for treating mental ill-health in young people and the extent to which alternative choices are available to young people.
"Medication was a very common form of treatment offered to young people with mental health and alcohol and drug problems. Many of young people interviewed were reluctant to take medication because of the problems they had with substances, including misuse of prescription drugs…
"Information on the types of drug based treatment options provided to young people are not regularly published or monitored. However, we know from government statistics that large numbers of prescriptions of anti-depressants are being made to young people in Northern Ireland. In 2017, 12,765 were given to 2,706 under 18 year olds, a proportion of whom were under 12 years of age…
"In Northern Ireland, young people aged under 18 years old are being prescribed additional anti-depressant drugs that have not been clinically trialed with that age group…
"The anti-depressant prescribing figures for under 18 year olds raises questions about the extent to which psychological therapies are being offered to children and young people, rather than, or in addition to medication. There are no publically available statistics on the therapies provided to children and young people as part of their treatment…
"We understand from figures provided by the HSCB that regional recurrent funding of £50,000 was invested in training in psychological therapies for children and young people in 2015/16. This is compared to millions of pounds spent on prescription medication. It represents a grossly higher and disproportionate spend on medication, compared to non-drug based treatment. There would also appear to be much less focus on under 18 year olds, than 18+ year olds, with regards to initiatives such as the primary talking therapy hubs."
Of course, psychological therapies are not the only other type of treatment when compared with medication. However, £50,000 seems like a drop in the ocean, whereas millions spent on prescriptions does not.
Looking at the detail of the NICCY report, it is hard not to think this is an assessment of a system stretched to the limit, and which is configured in such a way so as not to snap in the short-term, rather than a model with long-term goals in mind.
In her statement accompanying publication of the report, Ms Yiasouma said: “The system is under pressure and must reform urgently to respond to the scale of need and complexity of issues our children and young people have, to support their families and to allow the professionals working within the system to care for our children effectively.
“Even though many young people told us about the challenges they faced in accessing the right support, 8 out of 10 said they would encourage others to seek help for their mental health and we have certainly found professionals going ‘above and beyond’ to support young people within extremely stretched resources.
“I welcome the recent announcement that the Department of Health will fund Northern Ireland’s first study to assess the mental health needs of our children and young people. However, I would question how we have been planning and commissioning services when we are not yet fully aware of the exact needs of our children.
“My Review found alarming gaps in how the system collects operational data including but certainly not limited to, reasons why young people are not being accepted to specialist mental health services, if or to where they are referred on, or how long they have to wait for that alternative support."
Overuse of medication seems symptomatic of a vastly under-resourced system.
Of course, it would be overly reductive to fail to recognise that anti-depressants and other drugs can be extremely useful, or that mental health provision is an extremely complicated area.
The range of provision is large, and there is nothing close to an effective one-size-fits-all treatment. For instance, while counselling can have huge value, some young people who responded to NICCY said "that the traditional face-to-face counselling sessions can be very difficult, and that they do not always find it helpful to talk directly about their problems in this way."
Nevertheless, in Northern Ireland pills are not the last resort they should be, according to the UNCRC. Or, if they are, perhaps that is because some clinicians feel, given the massive waiting times and other points of pressure, prescriptions are an alternative to effectively doing nothing at all.
The fault is systemic. Not enough resources - not nearly enough - are devoted to children's mental health services.
Better provision would be better now and much better in the future. Good mental health support for young people, such as building resilience, can reduce instances of ill health later in life.
If the solution was as simple as throwing more support at the children and young people's mental health sector, presumably that would have happened already.
Northern Ireland is not a land of infinite plenty. Resources - be that money, expertise, even the bricks and mortar of clinical settings - are all limited.
Nevertheless, there has to be some combination of systemic restructuring and increased budgets (and other support) that leads to something better than what we have.
Change is needed. The current model is about using paltry resources to get through today, without thinking about tomorrow - indeed, the use of anti-depressants might be short-termist in manifold ways, according to new findings in the news this week that they cause potentially serious withdrawal symptoms in most of the people who use them.
Ms Yiasouma said: “It is widely understood that spend on mental health is inadequate, particularly when considering the impact the legacy of the conflict continues to have on mental health, including those generations seemingly not directly affected.
“My Review found that approximately £31 Million is spent here on children’s emotional wellbeing and mental health services which represents 0.8% of our overall health budget, equating to less than 1 penny in every pound. This lack of investment is very short sighted.
“We know that half of all adult mental health issues begin by age 14 and 75% by age 18. We spend only £45 per young person on statutory mental health services in Northern Ireland, compared with £163 per adult. If we invest earlier and get young people the help and support they need, we will not only save money, but have a huge impact on the mental health of our people throughout their lives.”
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