‘How is it possible to be in a mental health service that makes your mental health worse?’

A year on from the publication of Dr Sean Maskey’s report on child and adolescent mental health services (Camhs) in south Kerry – which found 240 mentally unwell children had been exposed to “a risk of harm” and that “significant harm” had been caused to at least 46 – the service is bracing itself for more anguish.

On Monday, the Mental Health Commission (MHC) will publish what is expected to be a damning interim report on the national service. The publication had been due in last week but was delayed twice to allow the Health Service Executive (HSE) to put in place a national helpline for worried families from Monday.

Undertaken in the wake of Dr Maskey’s report, the commission’s interim report covers Camhs in five of the HSE’s nine community health organisations.

Dr Susan Finnerty, the commission’s chief mental health inspector, is said to have been so concerned by what her team has found so far that this interim report is being published up to a year before her work is completed.

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While Dr Maskey’s primary focus was on an effectively unsupervised, junior doctor who inappropriately prescribed medicines to hundreds of children. Beyond that he detailed an understaffed and exhausted team; poor monitoring of medications and prescribing practices; inaction by management when risks were flagged; chaotic paper-based record-keeping; reporting systems break downs – a system at breaking point.

Shocking as it was, it catalogued a cluster-crisis that was “waiting to happen” and surprised few, says Dr Maeve Doyle, consultant child psychiatrist, formerly with Camhs and a spokeswoman for the Irish College of Psychiatrists.

“I wasn’t surprised by it at all,” she says.

Dr Finnerty’s report is expected to confirm Dr Doyle’s view – that the mentally unwell children and young people of south Kerry are not alone in having been at risk of harm when seeking treatment through Camhs.

While some parents who spoke to The Irish Times in the past week said their children had benefited from their engagement with Camhs, the majority were disappointed, frustrated and felt their children had been badly failed.

In south Kerry, the care of mentally unwell children is being overseen for 23 hours a week by a psychiatrist working online from the Middle East

One woman believed her daughter – now aged 19 – would have died by suicide had she and her former partner not been able to access private care, having given up on Camhs after five years of trying.

Another woman fears her daughter (12) could die. She was initially told the girl’s self-cutting and alcohol consumption was “a trend” and did not merit admission for treatment. She now has a Camhs care-plan following intervention by gardaí, Tusla and her local TD.

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The mother of a 14-year-old boy in north Co Dublin says her son has hardly left the house in almost two years due to autism, severe anxiety and the eating disorder arfid (avoidant/restrictive food intake disorder). He refuses to go to school or to Camhs appointments. She cannot persuade her local Camhs to visit him at home.

“So they see me in their office and we discuss his medication,” she says. “When you tell people he is in Camhs people think it’s great, things will be sorted ... I thought he’d be golden when we were referred to Camhs. How is it possible to be in a mental health service that makes your mental health worse?”

GPs referring children into the service describe frustrations with “obstacles” accessing Camhs for ill and distressed children, while those recently working within the service describe it as being “in massive crisis”.

“There has been a significant increase in mental health presentations among children and adolescents ... in the past few years.,” says Galway-based GP Dr Brian Osborne.

While children and teenagers are “generally well-managed” once they get into CAMHS, he says “there are huge numbers of children waiting for their first appointment” and that there can be “restrictive criteria for referrals”.

His referrals are frequently kicked back to him, with a recommendation he refer the child instead to a community psychologist or the National Educational Psychological Service (NEPS). But with waiting lists for primary care psychology at “more than 18 months” and “long wait times” for NEPS, the system can be “obviously very distressing for children and their families and very frustrating for GPs,” says Dr Osborne.

He is seeing young children “unable to articulate their feelings” but presenting with “pains in their tummy, headaches or pains in their chest”.

“They might have altered sleep, be tearful, acting out or have temper tantrums,” he continues. “Older children and teenagers are presenting with lack of motivation, social withdrawal, poor sleep and we are seeing increased rates of anxiety, self-harm and eating disorders.”

[ Mentally ill Irish children more ‘likely to be underprescribed’ than overprescribed medication ]

Figures supplied to Sinn Féin spokesman on mental health Mark Ward TD show that 579 children are waiting more than a year for a first appointment with Camhs, and waiting lists have almost doubled over the past 2½ years – from 2,112 in July 2020 to 3,937 last November.

The longest waiting list was in Cork/south Kerry, where 276 children were waiting a year or more. The shortest was in Galway/Mayo/Roscommon, with eight children waiting more than a year.

“There has been an increase in demand for Camhs and an increase in complexity of cases referred since Covid,” said a HSE spokeswoman. “Waiting lists are also impacted by capacity in other services – where young people do not have access to assessment and early intervention, their needs can become more complex over time necessitating referral to Camhs.”

Increased mental distress was well-flagged from the start of the pandemic but yet the crisis in Camhs has got worse.

Even since the Maskey report, 11 of the 24 in-patient Camhs beds at Linn Dara in Cherry Orchard, Dublin were closed and are unlikely to open in the near future. Six of the 20 Camhs beds at Merlin Park, Galway are closed, as are four of the 12 in St Vincent’s hospital, Fairview, Dublin – all due to staff shortages. In Eist Linn, Cork, all 16 beds are open.

We need a real overhaul of clinical governance.

In south Kerry, the care of mentally unwell children is being overseen for 23 hours a week by a psychiatrist working online from the Middle East. The permanent consultant post has been vacant since 2016 and a HSE spokeswoman said it had “not yet been able to recruit into that vacancy; not because of a lack of resources or effort, but because there is a worldwide shortage of Camhs consultants”.

It’s all a long way from what was envisioned in the landmark A Vison for Change strategy 17 years ago. The HSE still describes it as “a national policy that sets out the direction for Mental Health Services in Ireland”.

For the then population of 3.6 million, it said there should be two multidisciplinary child mental health teams (CMHTs) per 100,000 population (72 teams). Now, with a population of more than 5 million there are just 73.

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On each of the teams, the policy says there should be one consultant psychiatrist, one doctor in training, two psychiatric nurses, two clinical psychologists, two social workers, one occupational therapist, one speech and language therapist, one childcare worker, and two administrative staff. None of the teams has a full complement, with many trying to cope with about 50 per cent.

The policy says there should be 100 in-patient Camhs beds in five units. In four units now there are 72 beds, of which 21 are closed.

Camhs, nonetheless, sees about 20,000 young people, providing in the region of 225,000 appointments a year. What is noted, however, is where it is failing and at the root of that, observers say, is the HSE’s failure to recruit and retain staff.

Dr Kieran Moore, a child psychiatrist, left his position with Camhs in Wexford in 2018 after 16 years there. “Camhs was impossible in terms of resources but also in lack of understanding by management of what we do,” he says.

He is now employed by Children’s Health Ireland in Crumlin hospital, Dublin. “Here, if I want to go to management, I go to their office and say, ‘Oi’. In the HSE, not a hope. I had five managers over those years. None of them ever came to see the service even though I asked them. There was a total disconnect between management and Camhs on the ground.”

He adds: “I love working with young people, the families and doing some good, but it is phenomenally frustrating when you don’t have the resources, the basics and you spend so much time doing political stuff.”

Echoing his view, Dr Doyle says the recruitment and retention crisis “is about funding, yes, but also governance. We need a real overhaul of clinical governance.” She says governance should be decentralised more to local Camhs teams, which should be empowered to recruit as needed and respond locally with transparent, service-specific budgets.

“That is vital if we are to attract quality candidates,” she says. “I cannot emphasise enough how much we all love what we do. If you know what you need to run a really good service, which most of us do, but you have no influence, are underfunded, overworked and not supported, that’s really demoralising and frustrating.”