CARING FOR YOUNG MINDS IN IRELAND
Sinead McGilloway, Michael Donnelly
Ireland Psychology Medical Journal, 2000, pages 114-116
"Society...has a choice whether or not to acknowledge the importance of the mental health of its children [and young people] and invest in it appropriately or not...if we are to change things, action is needed now."
Recent years have seen an upsurge of interest among policymakers, researchers and practitioners -throughout the UK and elsewhere - in the growing number of young people aged under 25 who are developing mental health problems. The research evidence indicates that approximately one in five children and adolescents have mental ill health, a figure all the more disturbing in view of further evidence suggesting that the majority rarely reach special services.
Recently, the Mental Health Foundation reported that approximately two million young people under 20 in the UK have a mental health problem, the range and severity of which tends to increase dramatically with age. The kinds of problems typically reported include emotional and conduct disorders, substance abuse, self harm, eating disorders and psychotic illnesses. For example, anxiety and disruptive disorders account for approximately 12% and 10% respectively of all those aged four to 20 years. While some of these problems are likely to be relatively mild and self-limiting, others such as the psychotic and pervasive developmental disorders will, if left untreated, pose continuing and potentially more serious problems into adulthood.
Furthermore, one in 100 teenagers in the UK attempt suicide and it is now the most common reason for admission to hospital in this age group. Previous research has shown a correlation between attempted suicide and adult-type depressive illness in young people. More recent research in Norway has also shown the suicide risk among male adolescent psychiatric inpatients to be almost seven times higher than in the general population.
Even more worrying, therefore, in the context of these finding, is the potentially significant contribution of mental ill health and possible subsequent hospitalisation to the increase in suicidal behaviour and growing suicide rate particularly (but not exclusively) among young men, about which there has been considerable and growing concern in recent years.
According to local practitioners in Northern Ireland, mental health services are under-resourced when compared to the rest of the UK and youth mental health services, in particular, are in urgent need of funding and/or re-organisation. This is perhaps most apparent in the acute shortage of specialist provision for vulnerable young people over 14 which, at present, comprises a single, regional, six-bed inpatient and outpatient unit located in Belfast (the Young People's Centre [YPC]). Reports from local practitioners indicate an over-subscription of places to the YPC and a waiting list for admission. Last year, the Department of Health in London allocated #20 million to improve services for young people, a sizeable chunk of which is likely to be secured for mental health service provision,
particularly following recent reports by prestigious bodies such as the Health Advisory Service (HAS) and the Mental Health Foundation.
Unfortunately, the kind of ring-fenced funding which may be required to meet the mental health needs of young people in Ireland is less forthcoming despite a rapidly developing policy agenda. Each of the four Health and Social Services Boards in Northern Ireland has undertaken a review of, or is in the process of reviewing, youth mental health services.
Completed review acknowledge the need for rapid change in service organisation and delivery particularly for those young people moving into their teens. The reports highlight, above all, the importance of adopting the four-tier model of care advocated by the Health Advisory Service and, in turn, by other key bodies and committees including the Mental Health Foundation and Audit Commission.
Briefly, this 'template' of mental health service provision for young people describes a strategic approach to commissioning and delivering a comprehensive and fully integrated child and adolescent mental health service which straddles four pivotal levels or "tiers' of provision. Tier One services comprise, in large part, primary care professionals, amongst whom the GP is probably best placed to recognise the early symptoms of mental illness. Tier Two services refer to direct mental health interventions by individual professionals. Services at Tier Three, on the other hand, are more specialised and provided by multi-disciplinary teams to assess and treat at-risk groups such as those with eating and developmental disorders. These teams, in turn, act as gatekeepers to Tier Four services
which include specialist inpatient and secure provision for young people with highly specific and complex needs. Tier Four professionals are tasked with providing advice and support to professionals in the other three tiers of provision while links between and within Tiers One and Two may be developed and strengthened by the work of designated primary mental health workers. According to the HAS, the implementation of the model should be guided by the values and principles (e.g.. comprehensiveness, integration and development/change) which underpin any high quality service development.
This model, or parts thereof, have been implemented in Great Britain through, for example, the appointment of primary mental health workers. Following its policy statement on the way forward for child and adolescent mental health services in Northern Ireland, the Department of Health and Social Services has recently indicated that it is planning to undertake a review of psychiatric hospital provision for adolescents (personal communication). The Irish government has gone further by stating its intention to provide 'approved centres' for the care and treatment of children with mental disorders.
The most recent figures show that 130 children and young people aged under 16 (ie 0.5% of all admissions) were admitted to psychiatric inpatient care in Ireland during 1998, although this represents a substantial reduction from the 203 admissions during the previous year. It is notable that under the Mental Health Act (1995) in the south of Ireland (unlike Northern Ireland), anyone under the age of 16 should not be 'detained' in adult psychiatric inpatient units. (emphasis added)
There is a strong focus on Tier Four services in both jurisdictions. Youth mental health care is an area where an all-Ireland or cross-border approach has the potential to generate important lessons for policy and service provision. Our research has shown an increasing trend in admissions of young Northern Irish teenagers (under 18) to adult psychiatric inpatient care between 1989 and 1995. In addition, we found that almost one in five of under 18 admissions (86/443, 19%) were aged under 16 when first admitted to adult wards during this six-year period. Moreover, recent census-based research undertaken in Northern Ireland has shown an increase of 33% - between the years 1981 and 1991 - in psychiatric bed occupancy among young men aged 15-24 years. (emphasis added)
Importantly, the recent draft policy statement by the DHSS (NI) states, among other things, that "...children and adolescents should not be accommodated together with adults. Undoubtedly, the full implementation for well-integrated Tier One and Tier Two services - with their emphasis on early detection and treatment - would go a long way toward preventing and/or reducing admissions to hospital (particularly an adult psychiatric ward) for young people with more serious mental health needs. Therefore, strategic efforts to improve the highly specialised Tier Four services in both the north and south of Ireland ought to be accompanied by simultaneous attempts to address services at the other three levels particularly with respect to early detection and prevention.
Most important of all, perhaps, is the need to develop: successful intra- and inter-agency working between specialist mental health services and primary and community care-based professionals; closer co-operation between adult and youth mental health services; and effective partnerships between individual mental health (and other) professionals and parents/carers and young people. For example, the direct and active collaboration of GP's with local child and adolescent service providers might help to improve the generally low level of detection and recognition of child and adolescent psychiatric disorder in primary care settings. The severity of symptoms in a young teenager may be underestimated and/or less well recognised by healthcare professionals than in adults with mental ill health because
"things are not always as they seem". Thus distress in a young teenager may present as a normal reaction to exam pressures or may be due to a complex psychosocial and clinical problem. Community mental health teams and, in particular, adult psychiatrists may - as suggested by Fitzgerald, - play an important preventive role by adopting a more holistic and 'user-friendly' approach encompassing the treatment of both parents and their children.
In addition, those involved in the lives of young people (e.g. parents, carers) act as an initial 'filter' to Tier One services and their role, therefore, in recognising early symptoms of mental ill health and possible suicidal behaviour cannot be under-estimated. Consequently, the implementation of parental training and awareness packages through the health or education sector (or both) ought to receive serious consideration.
Arguably, the resource implications of changes in youth mental health service provision may be significant and any potentially innovative service responses might well be stymied by the considerable uncertainty surrounding the extent to which it might be possible to implement the four-tier model within available resources. However, it should be possible to carry forward at least some of the HAS recommendations (e.g. those related to information, awareness and training) within existing funds and staffing arrangements.
Recent political cross-border developments provide an important and timely opportunity to explore the possibilities for comparative ad collaborative work on youth (and adult) mental health within the two jurisdictions. For example, the establishment of a national forum or several regional fora would, in the first instance, facilitate shared learning between health boards, Trusts and primary care and specialist mental heath professionals with respect to the planning, development and delivery of the full range of youth mental health services.
Collaborative research is required to examine the prevalence, nature, detection and treatment of psychiatric disorder in young Irish people. The benefits or otherwise of hospitalisation both in specialised and adult psychiatric settings also merit investigation. More specifically, further audit and research ought to be conducted in order to:
- translate a locally suited version of the four-tier model taking account of factors such as rurality, available resources and the economic consequences of service configuration;
- help identify 'at-risk' populations and gaps in service provision;
- elicit the experiences and views of young people with mental health and their parents/carers (despite the well known difficulties in recruiting young research participants)
- evaluate and disseminate preventive and other models of good practice in youth mental health.
Local commissioners and service providers ought to be willing to take on board the results emanating from this kind of research. However, "...the root of the difficulty in applying research finding to improve services is that the services are mostly not conceived of as a system of care. Thus, if mental health is the desired outcome, we can only hope to achieve it if services are planned and enabled to work together as a system with this common aim.
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