To paraphrase Einstein, the definition of madness is doing the same thing again and again and expecting a different outcome. Our Child and Adolescent Mental Health Services (Camhs) are a tragic demonstration of just that. The outcomes the Maskey Report highlight show the medicalisation of difficulties that many young people experience.
Dr Seán Maskey found “unreliable diagnoses, inappropriate prescriptions and poor monitoring of treatment and potential adverse effects” exposed many children unnecessarily to the risk of significant harm in South Kerry Child and Adolescent Mental Health services between July 2016 and April 2021.
The over-prescription of medication reflects not just a system that offers insufficient alternatives to drugging young people, but trenchant resistance from the psychiatry profession to adopting more collaborative and better decision-making approaches within the teams in which they work.
Let’s consider the difference between what we know from research and what we do in practice.
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[ Immediate regulation of Camhs must be a priority, warns mental health inspectorOpens in new window ]
We know that the “diagnosis” of mental health conditions – practised primarily in Ireland by general practitioners, psychiatrists and psychologists – is inaccurate and unreliable; and that it is not a good basis for understanding mental health problems or deciding how to help people.
We know that mental health conditions are on a continuum of the absent/mild/moderate/severe type and not a categorical “you have it or you don’t have it” dichotomy.
We know that drugs create - they do not ‘fix’ - a chemical imbalance in the brain; but for some people this can be helpful
We know that there are no “biological markers” or identified biological causes for mental health problems. There is no blood test, scan, metabolic or electrical brain pattern which maps neatly on to mental health conditions. We know that psychosocial factors such as the experience of social disadvantage, trauma or bullying creates mental health conditions. We know that drugs create – they do not fix– a chemical imbalance in the brain; but for some people this can be helpful in suppressing their distress (“symptoms”) and allowing them to develop more effective coping. We know that drugs should never be the only intervention provided and that there should always be a drug-withdrawal plan.
We also know that most people with mental health conditions can be effectively helped without drugs; with environmental, family, school, occupational and individual supports and therapy.
Finally, the research is also very clear that the less hierarchical the working of clinical teams like Camhs, the better the decisions made – and the less risk of the dreadful outcomes we have seen in Kerry and are likely to see elsewhere.
Given all that we know, how do we design our Child and Adolescent Mental Health Services?
No law in Ireland or directive from our Department of Health requires community mental health services to be led by any particular profession. In community disability services, the team leadership is appointed through a competency-based open competition; where the most competent clinician in terms of the required skills is appointed, regardless of their professional background. This is not so in mental health services, where the Health Service Executive has chosen to restrict the leadership of Camhs teams only to psychiatrists.
We should not have to wish for exceptional individuals, we should design the system the way we want it to work
This means that in a team where most people don’t support a “medical model” approach to mental health, the team lead must be someone who is trained in that model, who often thinks along the line of “mental illness-diagnosis-drug treatment plus other things”, and who may feel that their authority as team leader is undermined by resistance to prescribing drugs – that is, to understanding people’s difficulties in line with the research evidence, and in seeking to make decisions collaboratively. Of course, we have some brilliant, open, participative and progressive psychiatrists who willingly background both themselves and “medical-model” thinking and promote psychosocial interventions. But we should not have to wish for exceptional individuals; we should design the system the way we want it to work.
In mental health only one profession holds the keys to design. Some excellent psychiatrists also feel locked-out by this domineering design.
It doesn’t have to be like this. I recently spoke with a professor of psychiatry at University College London who told me she worked in a team where the clinical lead was a consultant nurse; and another senior psychiatrist in King’s College London worked in a specialist community team led by a consultant clinical psychologist. What is the fear of appointing the most competent person to lead a team?
[ Camhs case study: ‘Every appointment was rushed. Staff were stressed’Opens in new window ]
[ Mentally ill children not receiving timely care is ‘unacceptable’, Tánaiste saysOpens in new window ]
What are the consequences if the medical model continues to dominate? Developmental difficulties will be medicalised and medicated and – as we have seen – sometimes overmedicated. It also means that insufficient resources go to the training of other professions who can provide psychological, social and environmental support to children in difficulties. Caring for and supporting children with difficulties should not be about any profession seeking to dominate another.
The crisis in Camhs is not unexpected. Mental health is a multidisciplinary field where the medical model approach is now very much a minority view, and where other professions and many patient/client representative groups – and indeed an increasing number of psychiatrists – advocate for a very different one. Our mental health services have not evolved to reflect what we know about mental health. They have maintained the vice-grip of a medical model and are designed to protect the privilege and interests of one profession at the expense of people’s mental health. There are better ways, and we all know it.
It is time for clinicians – especially psychiatrists – to respond to the Kerry Camhs controversy by using it as a compelling basis to propel both Camhs and adult mental health services into an evidence-based service, whose leaders are appointed based on competency with parity of esteem between professions and with service users. This also requires other health and social care professions to follow the lead of many service-user representative groups: to stand up, speak out, seek and assume leadership roles – something which these other professions have not done sufficiently or collectively.
Mac MacLachlan is professor of psychology and social inclusion at Maynooth University