Impact of a national audit on child and adolescent psychiatrists' prescribing practices

BACKGROUND

A look back review of South Kerry Child and Adolescent Mental Health Services (CAMHS) in Ireland, known as the 'Maskey report' (MR), highlighted substandard prescribing practices. The aim of this 'Maskey Impact Study' (MIS) was to explore changes to child and adolescent psychiatrists' prescribing practices following the MR.

METHOD

The study was cross-sectional and mixed method. A study specific questionnaire was distributed electronically to psychiatrists working in CAMHS (n = 160).

RESULTS

102 psychiatrists participated in the study (response rate 63.8%). Perceived improvement in prescribing practices included improved medical record keeping (63.7%), consent documentation (53.9%), medication information provision (41.2%) and physical health monitoring (60.8%). However, 43.1% of psychiatrists reported a reluctance to prescribe medication even when clinically indicated and 50% were more likely to avoid off-label use. Most respondents reported increased stress levels (80.4%) with higher stress being significantly associated with reticence in prescribing (χ2 = 11.746, p < .001) and avoiding off-label use (χ2 = 15.392, p < 0.001). Thematic analysis highlighted increased medication hesitancy, enforced 'meaningless' bureaucracy and medication mistrust among families.

DISCUSSION

Although improvements reported are welcomed, the increased hesitancy of medication use, avoidance of prescribing more than one medication, and avoidance of off-label use, is of concern with potential unintended adverse consequences. Reluctance in prescribing may deprive youth of access to evidence-based treatments and limit exposure of NCHDs to the safe practice of consultant-initiated psychopharmacology. Further research will be important to determine if this impacts clinical care. Continued education in psychopharmacology is essential along with increased public awareness of the evidence for medication, to help restore public confidence and trust in psychopharmacology.

Systematic review of effectiveness and satisfaction evaluation in child and adolescent mental health services in Ireland

OBJECTIVES

Increasing numbers of youth experience mental illness, and also require and benefit from specialist child and adolescent mental health services (CAMHS). Worldwide, such services are underfunded and under-resourced, and services in Ireland are no different. It is vital that existing services are regularly reviewed for both efficacy and acceptability. Our objective was to review published studies evaluating service user satisfaction with CAMHS in Ireland and CAMHS therapeutic efficacy.

METHODS

MEDLINE, PsycINFO and CINAHL databases were systematically searched. Studies were included if they reported on service user satisfaction or an evaluation of CAMHS in Ireland.

RESULTS

From an initial 125 articles identified, 15 studies meet the inclusion criteria: four reporting on overall CAMHS satisfaction, three on satisfaction where a specific diagnosis was present, while eight evaluated various interventions offered. Whilst most service users perceived services to be satisfactory, important issues relating to accessibility were present. Evidence of efficacy was present for a small number of interventions, but studies were limited by methodological issues.

CONCLUSIONS

There is a dearth of studies evaluating CAMHS in Ireland. The extant literature suggests a positive experience once accessed, but long waiting times and poor collaboration are seen to limit services users' experience. More robust methodologically sound studies are urgently required. Given the expected increased demand linked to the current COVID-19 pandemic, coupled with the resultant compromised financial position, it is essential that scant resources are appropriately directed.

Occupational stress in clinical and non-clinical staff in Child and Adolescent Mental Health Services (CAMHS): a cross-sectional study

BACKGROUND

Previous literature has highlighted high rates of burnout among doctors and nurses in healthcare settings. Non-clinical and support staff such as administrative, housekeeping and managerial staff are also exposed to the stressors of a health care setting, but fewer studies report on their experiences. Therefore, the aim of this research is to examine occupational stress in all staff working in Child and Adolescent Mental Health Services (CAMHS) in Ireland and identify risk and protective factors.

METHOD

Fifty-nine clinical and non-clinical staff (44% response rate) were surveyed. Participants completed the Copenhagen Burnout Inventory (CBI) and the Effort Reward Imbalance scale, as well as survey-specific questions.

RESULTS

Both clinical and non-clinical staff were found to experience moderate or high rates of work-related, personal and patient-related burnout (57.6%, 52.2% and 50.8%, respectively). Univariate general linear modelling showed an association between total CBI scores and effort reward index (B = 64 306, t = 3.430, p = 0.001); overcommitment (B = 1.963, t = 3.061, p = 0.003); and an unwillingness to work in CAMHS (B = 28.429, t = 3.247, p = 0.002).

CONCLUSION

Pre-pandemic levels of stress were high among clinical and non-clinical staff surveyed. Given the anticipated increased demand on CAMHS post COVID-19, urgent action is needed to protect all staff from intolerable levels of occupational stress and burnout.

Anorexia Nervosa in vivo cytokine production: a systematic review

INTRODUCTION

The underlying psychobiology that contributes to Anorexia Nervosa (AN) onset and disease progression remains unclear. New research is emerging suggesting a possible link between inflammation and a variety of mental illnesses. Alterations of cytokines may play a role in the pathogenesis of AN. Some studies have found differences in the cytokine profile of those with AN compared to healthy controls, but results are heterogeneous. The aim of this work was to systematically review existing studies investigating in-vivo cytokine production in those with AN before and after weight restoration compared to controls.

METHODS

A comprehensive literature search of four electronic databases (PubMed, PsychInfo, EMBASE and CINAH) was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines to identify human in-vivo studies investigating the relationship between AN and cytokine production. Data extracted from included studies related to population characteristics (e.g. age, gender, mean mBMI/%IBW), cytokine measurement and relevant findings. Confounding factors (e.g. smoking status, co-morbid mental illness, menstruation status) were also collected.

RESULTS

36 studies were eligible for this systematic review of which the majority were conducted in Europe (77.8%) and involved female subjects (97.2%). Those with AN ranged in age from 13 to 47 years and had an illness duration of 3 months to 24 years. 15 candidate cytokines and 3 receptors were identified (TNF-alpha, IL-6, IL-1B, CRP, IL-2, IL-7, IL-10, IFN-γ, TNF-R2, IL-1 α, IL-15, TNF-R1, IL-17, IL-18, TGF-B1, IL-12, IL-6R and TGF-B2) exploring in-vivo levels in patients with AN and comparing to controls. TNF-alpha and IL-6 were the most extensively studied with IL-6 being significantly elevated in 4 out of 8 (50%) of longitudinal studies when comparing AN patients at baseline compared to post weight restoration. Following weight restoration, there was no difference in IL-6 levels when comparing to HC in 7 of 8 (87.5%) longitudinal studies examined.

CONCLUSIONS

The most promising cytokine potentially involved in the pathogenesis of AN appears to be IL-6, and possibly TNF-alpha pathways. The heterogeneity of clinical and methodology factors impedes the generalizability of results. Future studies may wish to address these methodological shortcomings as alterations in cytokine levels in AN could act as therapeutic targets assisting with weight restoration and psychopathology and may offer diagnostic potential.

General Practitioner referrals to Child and Adolescent Mental Health Services: Did they differ during Covid-19?

OBJECTIVES

The COVID pandemic has been associated with poorer mental health in youth. This study aimed to evaluate any change in General Practitioner (GP) referral pattern to Child and Adolescent Mental Health (CAMH) services during the first 10 months of Covid-19 and compare with a similar time frame in 2019.

METHODS

All accepted referrals to a CAMH Service in Dublin during the study time frame were reviewed. Referral letters were batch anonymised and clinical data extracted using a study specific proforma for analysis.

RESULTS

Referral numbers between the two time periods did not statistically differ. Proportionally more females were referred during the pandemic, increasing to 56.9%, n = 99, compared to 43.1%, n = 75 in 2019 (p = 0.01). Referrals were more often designated by the clinician as urgent during the pandemic (61.3%, n = 98) than before (39%, n = 62, p < 0.001). Referrals outlining self-harm or suicidal ideation increased significantly, from 42.1% (n = 67) to 55.9% (n = 90) (p = 0.014). Referrals for externalising problems fell from 2019 rates; ADHD (21.4%, n = 34 vs 11.1%, n = 18; p = 0.013), ASD (26.4%, n = 42 vs 16.1%, n = 26; p = 0.038) and conduct problems (23.3%, n = 37 vs 7.4%, n = 12; p < 0.001). Although numbers for psychosis in 2019 were low (10.7%, n = 17), these also fell significantly in 2020 (2.5%, n = 4; p < 0.001).

DISCUSSION

The finding of reduced referrals for ADHD and ASD has not previously been reported. With concerns regarding educational loss linked to online learning, it is crucial that these youth are not doubly disadvantaged by delayed referral and education decline.

Psychological distress among healthcare workers post COVID-19 pandemic: from the resilience of individuals to healthcare systems

Since the emergence of the COVID-19 pandemic, there has been increased interest in identifying ways of protecting the mental well-being of healthcare workers (HCWs). Much of this has been directed towards promoting and enhancing the resilience of those deemed as frontline workers. Based on a review of the extant literature, this paper seeks to problematise aspects of how 'frontline work' and 'resilience' are currently conceptualised. Firstly, frontline work is arbitrarily defined and often narrowly focused on acute, hospital-based settings, leading to the needs of HCWs in other sectors of the healthcare system being overlooked. Secondly, dominant narratives are often underpinned by a reductionist understanding of the concept of resilience, whereby solutions are built around addressing the perceived deficiencies of (frontline) HCWs rather than the structural antecedents of distress. The paper concludes by considering what interventions are appropriate to minimise the risk of burnout across all sectors of the healthcare system in a post-pandemic environment.

Neuroimaging findings in adolescent gaming disorder: a systematic review

OBJECTIVES

Gaming disorder is a growing concern affecting adolescents, exacerbated by the impact of recent COVID-19 restrictions. The World Health Organization has recently included gaming disorder in the 11th International Classification of Diseases (ICD-11). However, there is still an ongoing debate about the validity and reliability of the proposed clinical criteria, despite growing neurobiological evidence in this cohort. Systematic reviews in this area have focused mainly on adults or mixed adult/adolescent populations. Therefore, this systematic review explored the neuroimaging literature in adolescents (under 18 years old) with gaming disorder.

METHODS

Using PRISMA 2020 guidelines, 3288 primary studies were identified from PubMed, CINAHL Plus, PsycINFO and Web of Science. After applying inclusion and exclusion criteria (appropriate title, abstract, comparison group used within study, English-language, neuroimaging and mean age under 18), 24 studies were included in this review.

RESULTS

Functional and structural brain alterations in adolescent gaming disorder were noted across several imaging modalities, including electroencephalogram (EEG), functional magnetic resonance imaging (fMRI) and structural magnetic resonance imaging (MRI). Compared with healthy controls, adolescents with gaming disorder demonstrated neurological changes comparable to substance addiction, namely impairments in emotional regulation, reward-seeking, inhibition and increased risky decision-making. Positive brain adaptations in the areas of visuospatial processing and memory were observed.

CONCLUSIONS

A number of key brain regions are affected in adolescent gaming disorder. These findings can help clinicians understand adolescent presentations with gaming disorder from a neurobiological perspective. Future studies should focus on forming a robust neurobiological and clinical framework for adolescent gaming disorder.

Effect of managed transition on mental health outcomes for young people at the child-adult mental health service boundary: a randomised clinical trial

BACKGROUND

Poor transition planning contributes to discontinuity of care at the child-adult mental health service boundary (SB), adversely affecting mental health outcomes in young people (YP). The aim of the study was to determine whether managed transition (MT) improves mental health outcomes of YP reaching the child/adolescent mental health service (CAMHS) boundary compared with usual care (UC).

METHODS

A two-arm cluster-randomised trial (ISRCTN83240263 and NCT03013595) with clusters allocated 1:2 between MT and UC. Recruitment took place in 40 CAMHS (eight European countries) between October 2015 and December 2016. Eligible participants were CAMHS service users who were receiving treatment or had a diagnosed mental disorder, had an IQ ⩾ 70 and were within 1 year of reaching the SB. MT was a multi-component intervention that included CAMHS training, systematic identification of YP approaching SB, a structured assessment (Transition Readiness and Appropriateness Measure) and sharing of information between CAMHS and adult mental health services. The primary outcome was HoNOSCA (Health of the Nation Outcome Scale for Children and Adolescents) score 15-months post-entry to the trial.

RESULTS

The mean difference in HoNOSCA scores between the MT and UC arms at 15 months was -1.11 points (95% confidence interval -2.07 to -0.14, p = 0.03). The cost of delivering the intervention was relatively modest (€17-€65 per service user).

CONCLUSIONS

MT led to improved mental health of YP after the SB but the magnitude of the effect was small. The intervention can be implemented at low cost and form part of planned and purposeful transitional care.

Prevalence of mental health disorders in children and adolescents in the Republic of Ireland: a systematic review

Referrals to Child and Adolescent Mental Health Services (CAMHS) have increased in recent years. Services are already under-resourced and the adverse psychological impact of Covid-19 is likely to increase demand. Accordingly, an understanding of prevalence of mental health (MH) disorders among youth is imperative to help inform and plan services.

AIM

To establish prevalence of MH disorders among youth (under 18) in Ireland.

METHOD

A systematic review using pre-defined search terms in PubMed, PsycInfo, Embase and CINAHL was conducted. Empirical studies conducted in Ireland, in youth and focusing on MH disorders were included.

RESULTS

From a total of 830 papers identified, 38 papers met inclusion criteria. Significant variation in rates of MH disorders was evident based on study methodology. Screening questionnaires for general psychopathology reported rates of 4.8-17.8% scoring above clinical cut-offs, with higher rates for ADHD (7.3%). Studies examining depression ranged from 4% to 20.8%, while rates for 'current' MH disorder, determined by semi-structured interview, were 15.5%, while 'lifetime' rates varied from 19.9% to 31.2%. Fewer than half (44%) of those identified as 'in need' of specialist MH services were accessing CAMHS.

CONCLUSION

Data on MH disorders among Irish youth is limited, and studies showed significant variance in rates, making service planning difficult. There is an urgent need for serial epidemiological surveys, with clear operational criteria for clinically impairing MH difficulties. Such studies are essential to understand potential demand and service planning. This is most urgent given the expected increased demand post Covid-19.

Consultant psychiatrists' experience of the impact of the COVID-19 pandemic on mental health services

OBJECTIVES

The novel coronavirus 2019 (COVID-19) has spread worldwide threatening human health. To reduce transmission, a 'lockdown' was introduced in Ireland between March and May 2020. The aim of this study is to capture the experiences of consultant psychiatrists during lockdown and their perception of it's impact on mental health services.

METHODS

A questionnaire designed by the Royal College of Psychiatrists was adapted and circulated to consultant members of the College of Psychiatrists of Ireland following the easing of restrictions. The questionnaire assessed the perceived impact on referral rates, mental health act provision, availability of information technology (IT), consultant well-being and availability of personal protective equipment (PPE). Thematic analysis was employed to analyse free-text sections.

RESULTS

Response rate was 32% (n = 197/623). Consultants reported an initial decrease/significant decrease in referrals in the first month of lockdown (68%, n = 95/140) followed by an increase/significant increase in the second month for both new (83%, n = 100/137) and previously attending patients (65%, n = 88/136). Social isolation and reduced face-to-face mental health supports were among the main reasons identified. The needs of children and older adults were highlighted. Most consultants (76%, n = 98/129) felt their working day was affected and their well-being reduced (52%, n = 61/119). The majority felt IT equipment availability was inadequate (67%, n = 88/132). Main themes identified from free-text sections were service management, relationship between patients and healthcare service and effects on consultants' lives.

CONCLUSIONS

The COVID-19 pandemic has placed increased pressure on service provision and consultant wellness. This further supports the longstanding need to increase mental health service investment.

The Long-Term Impact of COVID-19 on Presentations to a Specialist Child and Adolescent Eating Disorder Program

Aim Explore the impact of COVID-19 on numbers and clinical profile of Eating Disorder (ED) presentations to a specialist ED program pre- and during COVID-19. Methods Retrospective chart review of referrals pre- COVID-19 (January 2018 - February 2020) and during COVID-19 (March 2020 - August 2021) were compared. Results 128 youth were assessed with significantly higher rates of referrals each month during COVID-19 compared to pre- COVID-19 (3.78 vs. 2.31, p = 0.02). Youth referred during COVID-19 showed a higher rate of % Ideal Body Weight (IBW) loss (4.8% = vs. 2.6%, p = &lt; 0.001) and had a shorter duration of illness pre-referral (4.8 months vs. 7.4 months, p = 0.001). Fewer youth during COVID- 19 (19% vs. 43%, p = 0.011) were prescribed psychotropic medication. Many youth (80%), self-declared COVID-19 as a contributory factor in the development of their ED. Conclusion This study supports the growing consensus of a COVID-19 specific impact on ED services with higher rates of referrals, youth presenting with a faster pace of weight loss and earlier referral to specialist services. Whether this represents a true increase in EDs or an overall increase in CAMHS referrals with a faster transfer to ED services requires further exploration.

Paediatric hospital admissions for psychiatric and psychosocial reasons during the first year of the COVID-19 pandemic

Increases in youth psychiatric presentations to out-patient and emergency department settings during COVID-19 have been reported. This study, using data from five hospitals in Ireland, examines changes in the number and type of paediatric admissions during COVID-19 (March 2020 - February 2021) compared to the previous two years. ICD-10 classification was used to establish admissions with mental, behavioural, neuro-developmental disorders and psychosocial reasons (MBN-PS). Overall hospital admissions fell by 25.3%, while MBN-PS fell by only 2.6%, mostly during an initial lockdown. Admissions for MBN-PS increased in July-August (9.2%), increased further in September-December (28.3%), returning to pre-COVID-19 levels in January-February 2021. Significant increases were observed among youths with anorexia nervosa (47.8%), other eating disorders (42.9%), and admissions for anxiety (29.6%), with these effects relating to females only. Although admissions for self-harm increased (3%) and rates of ASD admissions reduced (17%), these were not statistically significant. The disproportionate increase in admissions for MBN-PS compared to medical admissions suggests an adverse effect of COVID-19 on youth mental health, for females in particular, and supports previous reports of a pandemic specific increase in eating psychopathology. Combined community and acute service delivery and capacity planning are urgently needed given the prior underfunding of services pre-pandemic.

Covid-19, Child & Adolescent Mental Health Services (CAMHS) and Crises

Despite low rates of Covid-19 infection and mortality, children and adolescents have experienced disproportionate restrictions on their personal, social and academic life. Among youth in Ireland, reports of increased attendances by primary care counselling services have been mirrored by increased presentations to emergency departments and specialist mental health services, most notably self-harm and eating disorders. Following an immediate post lock down reduction, emergency department presentations by children for acute mental health care and referrals to child and adolescent mental health services (CAMHS) showed a sustained increase throughout 2020. Urgent action is needed to invest in CAMHS post pandemic to prevent any further increase in psychiatric illness among youth. We all share this collective responsibility to insist of government commitment to our youth.

Demographic, clinical, and service-use characteristics related to the clinician's recommendation to transition from child to adult mental health services

PURPOSE

The service configuration with distinct child and adolescent mental health services (CAMHS) and adult mental health services (AMHS) may be a barrier to continuity of care. Because of a lack of transition policy, CAMHS clinicians have to decide whether and when a young person should transition to AMHS. This study describes which characteristics are associated with the clinicians' advice to continue treatment at AMHS.

METHODS

Demographic, family, clinical, treatment, and service-use characteristics of the MILESTONE cohort of 763 young people from 39 CAMHS in Europe were assessed using multi-informant and standardized assessment tools. Logistic mixed models were fitted to assess the relationship between these characteristics and clinicians' transition recommendations.

RESULTS

Young people with higher clinician-rated severity of psychopathology scores, with self- and parent-reported need for ongoing treatment, with lower everyday functional skills and without self-reported psychotic experiences were more likely to be recommended to continue treatment. Among those who had been recommended to continue treatment, young people who used psychotropic medication, who had been in CAMHS for more than a year, and for whom appropriate AMHS were available were more likely to be recommended to continue treatment at AMHS. Young people whose parents indicated a need for ongoing treatment were more likely to be recommended to stay in CAMHS.

CONCLUSION

Although the decision regarding continuity of treatment was mostly determined by a small set of clinical characteristics, the recommendation to continue treatment at AMHS was mostly affected by service-use related characteristics, such as the availability of appropriate services.

An Exploration of Sleep and Family Factors in Young Children at Familial Risk for ADHD

Objective: The aim of the current study was to examine relations between sleep problems and family factors and early markers of ADHD in young children with and without a familial risk for ADHD.Methods: Differences in sleep behavior and family functioning in children under 6 years with (n = 72) and without (n = 139) a familial risk for ADHD were investigated. The influence of family and sleep factors on the development of early temperament markers of ADHD (effortful control and negative affect) was explored. Parents/caregivers completed questionnaires on family functioning, child sleep behavior, and general regulatory behaviors.Results: A significant difference was observed between high-risk and low-risk groups for family functioning in the infant/toddler (<3 years) and preschool (>3 years) cohorts. Parents of infants/toddlers in the high-risk group reported poorer infant sleep. However, there were no sleep differences reported for the preschool cohort. Family functioning was found to predict effortful control, while sleep quality predicted negative affect.Conclusion: The results of this study highlight potential family and sleep issues for young children with a familial history of ADHD and the potential influence of these factors on early temperament markers of ADHD. Future research should explore these relations further in order to better establish whether early sleep and family interventions could mitigate later ADHD symptomatology.

Childhood onset exercise addiction or atypical anorexia nervosa during Covid-19: case report

BACKGROUND

Childhood-onset Anorexia Nervosa (AN) is recognised to be atypical in presentation, both in terms of extent and nature of eating pathology, exercise and compensatory behaviours with many falling short of full diagnostic criteria. Failure to consider an eating disorder diagnosis in youth who present with extreme weight loss may have serious immediate and long term implications. However, failure to consider other non-organic causes of weight loss may be equally detrimental to the child's health.

CASE PRESENTATION

This case reports on the acute presentation of a 12-year old boy, who presented to hospital in a severely malnourished state eight weeks into lockdown. To compensate for Covid-19 induced restrictions on sporting activity, this boy had followed a self-imposed daily schedule of arduous exercise, without increasing his nutritional intake. This report examines the clinical features suggestive of AN and other differential diagnosis. A discussion on the specific diagnostic differential of exercise addiction and challenges faced by youth during Covid-19 restrictions are presented.

CONCLUSION

Accepting that AN may present atypically in pre-pubertal youth, it is important that clinicians maintain an open mind in youth presenting without goal directed weight loss. Although weight loss was significant in this case, it was due to an excessive exercise regime. This may have commenced as a coping strategy in response to Covid-19 restrictions but subsequently became excessive and impairing in nature. The collateral damage of Covid-19 mandated restrictions, aimed at containing the spread of the virus, are evident in this case. Clinicians need to be alert to potentially maladaptive coping strategies and unusual or altered pathways of presentation, especially in younger children during these challenging times.

COVID-19, mental health and psychological first aid

Crises such as the global pandemic of COVID-19 (coronavirus) elicit a range of responses from individuals and societies adversely affecting physical and emotional well-being. This article provides an overview of factors elicited in response to COVID-19 and their impact on immunity, physical health, mental health and well-being. Certain groups, such as individuals with mental illness, are especially vulnerable, so it is important to maximise the supports available to this population and their families during the pandemic. More broadly, the World Health Organization recommends 'Psychological First Aid' as a useful technique that can help many people in a time of crisis.

'Policing' a pandemic: Garda wellbeing and COVID-19

In response to the global pandemic COVID-19, the Irish government has called upon the Garda Síochána to implement an unparalleled mode of policing to mitigate and contain the spread of the Coronavirus. Studies investigating smaller scale epidemics, such as Severe Acute Respiratory Syndrome (SARS), indicate that staff at the frontlines of an outbreak are exposed to an insuperable amount of stress and experience increased psychological morbidities as a result. Furthermore, research not only indicates that heighted levels of psychological distress are an occupational hazard associated with the law enforcement profession, but that members of the Garda Síochána feel their mental health needs are largely unmet by their organisation. Given the pandemic's propensity to expose officers to indeterminate echelons of physical and psychological threat; there has never been a more appropriate time to explore the potential burdens associated with 'policing' a pandemic, question the governments capacity to address the psychological support needs of frontline professionals, and plan future research for best practice.

'Policing' a pandemic: Garda wellbeing and COVID-19

In response to the global pandemic COVID-19, the Irish government has called upon the Garda Síochána to implement an unparalleled mode of policing to mitigate and contain the spread of the Coronavirus. Studies investigating smaller scale epidemics, such as Severe Acute Respiratory Syndrome (SARS), indicate that staff at the frontlines of an outbreak are exposed to an insuperable amount of stress and experience increased psychological morbidities as a result. Furthermore, research not only indicates that heighted levels of psychological distress are an occupational hazard associated with the law enforcement profession, but that members of the Garda Síochána feel their mental health needs are largely unmet by their organisation. Given the pandemic's propensity to expose officers to indeterminate echelons of physical and psychological threat; there has never been a more appropriate time to explore the potential burdens associated with 'policing' a pandemic, question the governments capacity to address the psychological support needs of frontline professionals, and plan future research for best practice.

Mental health and the COVID-19 pandemic

With the advent of the COVID-19 pandemic, we have witnessed the greatest global challenge in a generation. The full extent of the mental health impact is, as yet, unknown, but is anticipated to be severe and enduring. In this Special Issue dedicated to mental health and the COVID-19 pandemic, we aim to lay the foundation for an improved understanding of how COVID-19 is affecting mental health services both in Ireland and globally. This Special Issue highlights how the mental health effects of COVID-19 stretch to almost every element of society. The issue includes perspectives from several countries across multiple disciplines and healthcare settings. The drive for rapid innovation and service development is clearly evident throughout and provides hope that by working collaboratively we can positively impact population mental health in the months and years ahead.

Impact and Mechanism of Covid-19 on Mental Health and Wellbeing

The Covid-19 pandemic has brought unprecedented pressure to healthcare systems worldwide, resulting in significant and precipitous changes in demand, burden and method of delivery. The psychosocial impact of this crisis is likely to increase over the course of the pandemic, peak later than medical cases and endure for longer thereby significantly exceeding medical morbidity. It will have far reaching impact on the individual, their family and their care providers. Frontline healthcare workers and those with pre-existing mental health difficulties are recognised at increased risk. Now that the initial surge has been expertly curtailed, it is essential that urgent consideration is now directed towards the mental health implications of the current outbreak and ensure that we are as ready for the increased MH needs of the community as we were for the intensive medical care.

Protocol for the development and validation procedure of the managing the link and strengthening transition from child to adult mental health care (MILESTONE) suite of measures

Background

Mental health disorders in the child and adolescent population are a pressing public health concern. Despite the high prevalence of psychopathology in this vulnerable population, the transition from Child and Adolescent Mental Health Services (CAMHS) to Adult Mental Health Services (AMHS) has many obstacles such as deficiencies in planning, organisational readiness and policy gaps. All these factors contribute to an inadequate and suboptimal transition process. A suite of measures is required that would allow young people to be assessed in a structured and standardised way to determine the on-going need for care and to improve communication across clinicians at CAMHS and AMHS. This will have the potential to reduce the overall health economic burden and could also improve the quality of life for patients travelling across the transition boundary. The MILESTONE (Managing the Link and Strengthening Transition from Child to Adult Mental Health Care) project aims to address the significant socioeconomic and societal challenge related to the transition process. This protocol paper describes the development of two MILESTONE transition-related measures: The Transition Readiness and Appropriateness Measure (TRAM), designed to be a decision-making aide for clinicians, and the Transition Related Outcome Measure (TROM), for examining the outcome of transition.

Methods

The TRAM and TROM have been developed and were validated following the US FDA Guidance for Patient-reported Outcome Measures which follows an incremental stepwise framework. The study gathers information from service users, parents, families and mental health care professionals who have experience working with young people undergoing the transition process from eight European countries.

Discussion

There is an urgent need for comprehensive measures that can assess transition across the CAMHS/AMHS boundary. This study protocol describes the process of development of two new transition measures: the TRAM and TROM. The TRAM has the potential to nurture better transitions as the findings can be summarised and provided to clinicians as a clinician-decision making support tool for identifying cases who need to transition and the TROM can be used to examine the outcomes of the transition process.

Trial registration

MILESTONE study registration: ISRCTN83240263 Registered 23-July-2015 - ClinicalTrials.gov NCT03013595 Registered 6 January 2017.

A One Year Cost Analysis of Acute Paediatric Mental Health Presentations

Aim Examine costs associated with acute mental health presentations (AMHP) to a paediatric emergency department (ED) in 2016 and 2018. Methods Case identification and bed costs were calculated. Results In 2018, 163 youths attended the ED with AMHP, 122 (75%) were admitted (average 8 days), representing a yearly cost to the hospital of €1,028,020, average cost per patient €8,426. This marks an increase of €425,320 or €2,686 per patient compared to 2016. Arriving out of hours, presence of self-harm (SH) and discharge to an inpatient psychiatry bed were all associated with greater costs. Conclusion Despite increasing hospital costs associated with out of hours psychiatric emergencies, dedicated funding is not yet in place. All children should have access to urgent MH assessment. Work force planning and creation of pathways of care for young people with MH needs, including dedicated funding from HSE mental health division must be a priority.

Adolescents Presenting with Mental Health Crises

Aims The aim of the study is to examine emergency mental health (MH) presentations and assessments of adolescents (16-18) presenting to a Dublin adult emergency department (ED). Methods Clinical data was collected on all patients over a 12 month period. Results Seventy seven adolescents presented, the majority out of hours (n=58, 75%) and with either self-harm (n=34, 44%) or suicidal ideation (n=28, 36%), where females significantly outnumbered males (89% vs 66%; p=.028). Other presentations included low mood, anxiety and behavioural problems, and following assessment from an adult mental health service team member, 55% (n=39) were given an Axis I psychiatric diagnosis. Almost all adolescents were discharged following assessment (n=68, 96%), the majority being referred on to Child and Adolescent Mental Health Service (CAMHS) (55, 78%). Conclusion Crisis presentations to EDs often occur in adolescents with co-existing psychiatric disorders, and require skilled and therapeutic assessment. Knowledge of appropriate services for onward referral is essential, and highlight the importance of a close collaborative between adult EDs and CAMHS.

Child & Adolescent Emergency Mental Health Crisis: A Neglected Cohort

Aims To highlight the ongoing concern regarding the mental health well-being of children and adolescents in Ireland and access to appropriate and timely MH services. Methods With reference to existing literature and policy planning documents, this paper presents an over view of child and adolescent MH services (CAMHS) and paediatric liaison psychiatry services (PLPs) along with their respective roles in the management of children presenting with acute MH crisis. Results Despite longstanding and growing public and professional awareness of unequal and inadequate MH services for youth, progress has been slow. The long-standing lack of parity between mental and physical health remains, most prominent in the area of access to urgent MH assessment. Conclusion Urgent action is needed given ongoing concerns about the rising prevalence of MH distress and disorders in youth, and the lack of access to MH services in Ireland.

Managing the link and strengthening transition from child to adult mental health Care in Europe (MILESTONE): background, rationale and methodology

BACKGROUND

Transition from distinct Child and Adolescent Mental Health (CAMHS) to Adult Mental Health Services (AMHS) is beset with multitude of problems affecting continuity of care for young people with mental health needs. Transition-related discontinuity of care is a major health, socioeconomic and societal challenge globally. The overall aim of the Managing the Link and Strengthening Transition from Child to Adult Mental Health Care in Europe (MILESTONE) project (2014-19) is to improve transition from CAMHS to AMHS in diverse healthcare settings across Europe. MILESTONE focuses on current service provision in Europe, new transition-related measures, long term outcomes of young people leaving CAMHS, improving transitional care through 'managed transition', ethics of transitioning and the training of health care professionals.

METHODS

Data will be collected via systematic literature reviews, pan-European surveys, and focus groups with service providers, users and carers, and members of youth advocacy and mental health advocacy groups. A prospective cohort study will be conducted with a nested cluster randomised controlled trial in eight European Union (EU) countries (Belgium, Croatia, France, Germany, Ireland, Italy, Netherlands, UK) involving over 1000 CAMHS users, their carers, and clinicians.

DISCUSSION

Improving transitional care can facilitate not only recovery but also mental health promotion and mental illness prevention for young people. MILESTONE will provide evidence of the organisational structures and processes influencing transition at the service interface across differing healthcare models in Europe and longitudinal outcomes for young people leaving CAMHS, solutions for improving transitional care in a cost-effective manner, training modules for clinicians, and commissioning and policy guidelines for service providers and policy makers.

TRIAL REGISTRATION

"MILESTONE study" registration: ISRCTN ISRCTN83240263 Registered 23 July 2015; ClinicalTrials.gov NCT03013595 Registered 6 January 2017.

Hidden Costs in Paediatric Psychiatry Consultation Liaison Services

AIM

Children with acute mental health (MH) concerns increasingly present to Emergency Departments, and in the absence of an accessible MH bed, are admitted. This study estimated the hidden associated costs.

METHODS

All Emergency MH admissions over a 12-month period (2016) were identified (N=105). Costs associated with length of stay (LOS) and one-to-one nursing were calculated.

RESULTS

The average Length of Stay for acute MH presentations was 6 days, there were 615 bed day associated with this cohort, totalling costs of €1,216,470, with an average cost/patient of €12,684. Sixty-eight patients (65%) required an average of 5 days of one-to-one nursing, totalling 335 days. Estimating that 40% of this was provided by agency staff, the hospital cost was €115,374. Taken together, the costs associated with primary Emergency Mental Health presentations is €1,331,844. Costs associated with patients who were previously known to MH services were €843,417.

DISCUSSION

Despite an increasing number of dedicated MH beds, demand outweighs availability, and immediate access remains problematic, the default often being a paediatric admission. Adequate funding and appropriate use of these scare and costly resources must be part of national MH policy planning, especially with ongoing planning for the National Children's Hospital.

Paediatric Consultation Liaison Psychiatry Services (PCLPS) -what are they actually doing?

Introduction Paediatric Consultation Liaison Psychiatry Services (PCLPS) are specialised services treating mental health difficulties co-morbid with medical problems. Methods Standardised clinical data was retrieved from all case notes (N=108) during the study timeframe (Jan-June 2016). Results The majority of children were female 59 (55%) with a mean age of 13. Presentation was typically via the Emergency Department (ED) (85, 79%), and of those, the majority (53, 62%) were 'out of hours' and for Deliberate Self-harm (44, 52%) Almost half of all cases seen (50, 46%) were previously known, and discharged back (84, 78%), to CAMHS. Discussion The majority of work conducted by the PCLPS involved children with acute or deteriorating psychiatry disorders, previously known to CAMHS, with a much smaller focus on typical liaison presentations. Adequate resourcing of hospital based PCLPS and 'out of hours' CAMHS are necessary to allow PCLPS provide a specialist service to children with combined medical and MH problems. Given the development of the National Children's Hospital, addressing these resourcing deficits is of vital importance.

Development of a 22q11DS psycho-educational programme: exploration of the views, concerns and educational needs of parents caring for children or adolescents with 22q11DS in relation to mental health issues

BACKGROUND

22q11.2 deletion syndrome (22q11DS) is a multisystem genetic condition with a broad phenotype. It is associated with a high prevalence of depression and anxiety during childhood and increased risk of schizophrenia in adulthood. Despite this, studies report that families may receive inadequate information of mental health (MH) risks at diagnosis. Therefore, this study investigated parents' experiences of caring for a child with 22q11DS, investigated their knowledge regarding the risk of MH problems and assessed the need for a psycho-educational programme.

METHODS

A qualitative design and purposeful sampling was utilized. Parents registered with the '22q11 Ireland' support group, and parents listed on the cleft palate database in a children's hospital in Ireland were invited to participate. Focus groups were held with 22 parents. Data were thematically analysed using Burnard's method of analysis.

RESULTS

Most parents had some knowledge of the relationship between 22q11DS and an increased risk of MH issues. Parents reported that MH information relating to 22q11DS was mainly obtained from 22q11DS conferences, the '22q11 Ireland' support group and the Internet. Parents expressed a need for information to prevent or cope with their child's MH issues. Parents suggested that the following topics would be quite useful in a psycho-educational programme. These included information on the early warning signs of MH issues and guidance on when and how to tell the child about the condition and how to manage the child or young person's anxiety, obsessive behaviour or hearing voices.

CONCLUSIONS

The findings indicated parental support for a psycho-educational programme that would provide relevant, accurate and timely information on how to effectively care for a child with 22q11DS MH needs.

A systematic review of service transitions in people with ADHD

Background

Young people (YP) with attention deficit hyperactivity disorder (ADHD) are recognized to be a group who are particularly vulnerable to falling through the gap regarding transitioning from Child and Adolescent Mental health Services (CAMHS) to Adult Mental Health Services (AMHS). This presentation will combine a systematic review of the literature with some clinical examples of the pathway for a number of YP with ADHD who reach the transition boundary (TB).

Method

(1) Databases (e.g., PubMed, PsycINFO, AMED, CINAHL, EMBASE, Web of Knowledge), and grey literature, were searched systematically with database-specific key words, variants and truncations, to cover six subject areas: ADHD; transition or transfer; age; experiences or views; service development; and policies or protocols. Hand searching of key journals, ancestry and forward searches of references, and expert consultation were conducted. Two reviewers critically evaluated studies using a validated appraisal tool for mixed methodologies and findings were synthesized. (2) Following ethical approval, CAMHS clinicians from 9 clinics in Republic of Ireland identified all cases where a YP with ADHD had reached the TB, and identified referral/service outcomes (n = 20).

Results

The search yielded 27 studies, covering areas of service review and recommendations (7), guidelines (3), medication (5), case note audit (3), professional's views (5), pilot transition clinics (2). A further set of papers covered the perspective of the young person (4) and parent (2). Overall these highlighted the less than optimum experience by both clinicians and service users of the experience with suggestions for future developments. These findings were mirrored in the review of clinical notes and individual interviews of YP identified through their CAMHS. Of the 20 young people identified, only 1 was directly transferred to AMHS. Eight were retained in CAMHS, on average for over a year. A significant number (7) refused onward referral. A perception from CAMHS clinicians, that AMHS did not accept such cases or lacked relevant service/expertise, may have contributed to the low rate of referral.

Conclusion

Both the extant literature and the specific study presented highlight the lack of clear cut consensus about the appropriate management of young people with ADHD have who reach the transition boundary. Low rates of AMHS transfer may come from CAMHS clinicians’ perceptions of AMHS, and preferences of young people and families. Before assuming the very low rate of referral by CAMHS clinicians is poor practice, clinical outcomes need to be identified, young people's reasons for refusing transfer explored and service options identified.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

Adolescents' and parents' views of Child and Adolescent Mental Health Services (CAMHS) in Ireland

Service user involvement is essential for quality care in the Child and Adolescent Mental Health Services (CAMHS). This study was conducted to explore adolescents' and parents' experiences of CAMHS in relation to accessibility, approachability and appropriateness. This study used a descriptive qualitative design, and focus groups and single interviews were conducted with adolescents (n = 15) and parents (n = 32) from three mental health clinics. Data were analysed using thematic analysis. Accessing mental health services was a challenging experience for many parents and adolescents due to knowledge deficit, lack of information and limited availability of specialist services. Some parents and adolescents reported positive experiences while others reported negative experiences. They expressed a need for more information, involvement in decision making, flexible scheduling of appointments, school support and parent support groups. The nature and quality of the relationship with staff was critical to positive experience with the service; therefore, frequent changes of medical staff was disruptive. Mental health nurses can play a vital role in ensuring continuity, assessing adolescents' participation preferences and advocating for their information needs with other members of the interdisciplinary team.

Safe and judicious paediatric psychotropic prescribing

Psychotropic medications are now a well-established and evidenced based treatment for increasing number of child mental health disorders prescribed at increasing frequencies and by increasing number of professional groups. Clinicians' perceived levels of competence and standardised monitoring lag behind prescribing practice and should be addressed by regular continuous professional development. A study specific questionnaire on psychotropic prescribing practice in children was mailed to all child psychiatrists and paediatricians working in Ireland and GPs from a selected Dublin CAMHS catchment area. Of the 116 who replied, (39% response rate), antidepressants (58.7%), antipsychotics (57.1%) and ADHD medications (36.5%) were most commonly prescribed. Results suggest increasing trends of monitoring amongst Irish clinicians over time, but with some lack of specificity. Commensurate with the wish of clinicians, ongoing training in paediatric psychopharmacology is considered essential in order to benefit from the increasing advances in pharmacology.

To adhere or not, and what we can do to help

Two factors predict treatment outcome, how effective the treatment is and whether the patient takes or follows the treatment plan. As clinicians or scientists, we strive to develop newer and more effective treatments, both pharmacological and non-pharmacological to improve treatment outcome in our patient population. Adherence is the single most modifiable factor associated with treatment outcome, yet how often is the issue of adherence addressed in clinical consultations? The best treatment is rendered useless if not adhered to. Initial adherence rates are low and get worse with time, but methodological difficulties in studies make it difficult to determine both the clinical implication of suboptimal adherence and successful strategies. Further research should apply more rigour to the area of definition and measurement, be sufficiently powered and long term, and measure possible confounders, to allow for an understanding on the link and impact between adherence and clinical outcome. This article reviews some of the main issues with regard to adherence and cost implications of suboptimal adherence and suggests future directions.

Cyclical vomiting syndrome in children: a prospective study

BACKGROUND

Cyclical vomiting syndrome (CVS) is a disorder that affects all ages and is characterized by episodes of severe nausea and vomiting with symptom-free intervals between episodes. The incidence in children is 3.15/100 000 children per year. Our objective was to evaluate the natural history of CVS and examine factors that predict symptom resolution.

METHODS

Thirty newly diagnosed children (mean 9.15 years, SD 3.31 range 3.5-15.7) were enrolled. All children had a follow-up interview at 3 months, 27/30 at 6 months, and 22/30 at 9 months.

KEY RESULTS

Following diagnosis of CVS, only 5/22(22.7%) children had no further episodes of vomiting at 9 months, whereas 17/22 (77.3%) continued to vomit. In the year prior to diagnosis, 15/30 (50%) children were admitted to hospital. Of the 22 children with follow-up for 9 months, only one child required hospital admission. Children who continued to vomit had higher internalizing scores on CBCL compared with those who stopped vomiting (P = NS). The Pediatric Quality-of-Life Score suggested those who continued to vomit had a poorer quality of life at diagnosis compared with those who stopped vomiting (P < 0.05).

CONCLUSIONS & INFERENCES

Making a positive diagnosis of CVS and providing families with information is very important in the management of CVS. Although 75% of children reported regular episodes of vomiting 9 months after diagnosis, there was a significant reduction in the frequency and severity of symptoms in addition to a marked reduction in the use of medical services.

Can general practice help address youth mental health? A retrospective cross-sectional study in Dublin's south inner city

AIMS

With general practice potentially having an important role in early intervention of mental and substance use disorders among young people, we aim to explore this issue by determining the prevalence of psychological problems and general practice/health service utilization among young people attending general practice.

METHODS

A retrospective cross-sectional study of patients attending three general practices in Dublin city.

RESULTS

Among a sample of young people (mostly women, 44% general medical services (GMS) eligible), we observed considerable contact with general practice, both lifetime and for the 2 years of the study. The mean consultation rate was 3.9 consultations in 2 years and psychosocial issues (most commonly stress/anxiety and depression) were documented in 35% of cases. Identification of psychosocial issues was associated with GMS eligibility, three or more doctor consultations, and documentation of smoking and drinking status.

CONCLUSIONS

Psychosocial issues are common among young people attending general practice and more work on their epidemiology and further identification in general practice are advocated.

Suicide in children over two decades: 1993-2008

Suicide rates have increased in Ireland's youth over the past two decades. However, no research report has focussed on suicide rates in those aged under 18--the children of Ireland. We retrieved national disaggregated age and sex-specific suicide mortality data from 1993-1998 and compared it with similar suicide mortality data from 2003-2008. Significant age (older vs younger) and sex effects (boys greater risk than girls) are apparent in both decades Suicide rates in both males and females have increased (males: 9.3-13.5/100,000), (females: 2.4-5.1/100,000. Suicide rates in under 15 year olds boys and girls is extremely rare for both time periods studied (1.6/100,000). Results are discussed in light of the rights of children and the obligation of the nation in this regard, as well as more child-specific and transition to adulthood-specific suicide prevention policy implications.

Paediatricians' views on their role in the assessment and management of ADHD and autism

ADHD and Autistic Spectrum Disorders (ASD) are a core component of paediatricians case work in the U.K. and U.S., but the situation in Ireland is less clear. Due to significant underdevelopment of Child and Adolescent Mental Health Services in Ireland, long waiting lists may delay identification and treatment. The aim of our study was to explore the views of a group of paediatricians in relation to their current and future practice of assessing and managing ADHD and ASD. The outcome of our study indicated that more than half of the paediatricians surveyed are directly involved in the assessment or treatment of ADHD and ASD. Eighty five per cent (85%) of paediatricians believed that they should have a role in the assessment of ADHD and ASD and over half had thought that they should be involved in managing ADHD and ASD. These results suggest that there is potential to develop alternative specialist services in Ireland for the identification and treatment of children with ADHD and ASD. The development of a well coordinated integrated care pathway may reduce waiting times for families and lead to easier access to services.