Mind the gap

Getting appropriate services can be difficult even for people with
severe mental illnesses. But for people in their late teens and
early 20s, the difficulties are compounded by a chronic shortage of
in-patient or community-based services, and by a tendency for those
older than 16 to disappear into the gap between children’s and
adults’ services.

It can also be difficult for mental health professionals to engage
with young people who suffer mental illness, partly because
adolescents shy away from the stigma of receiving services. At this
age many young people are also going through major life changes,
such as starting university or leaving home.

Yet the importance of appropriate adolescent services is underlined
by the fact that the occurrence of severe mental illness increases
20 times as 13 to 15-year-olds move into the 16-19 age group. The
onset of schizophrenia often occurs between the ages of 16 and 25,
when psychotic episodes tend to take place for the first
time.

Even though about 10 per cent of children and adolescents have a
mental disorder that leaves them disturbed and agitated, only 5 per
cent of the mental health budget goes on this group, according to
the charity YoungMinds.

The scale of the problem is revealed in research¹ by the
Royal College of Psychiatrists (RCP) on behalf of the Department of
Health. This found that a lack of adolescent in-patient beds meant
that about one-third of adolescents referred to in-patient services
had been placed in adult or paediatric wards.

A mental health charity official, who asked not to be named, says:
“There are about 800 adolescent beds but that’s nowhere near
enough, so we have several hundred inappropriately sent to adult or
children’s wards.”

Sue Bailey, RCP spokesperson on adolescent and child mental health,
says the in-patient issue has become so worrying that the college
has drawn up guidance to psychiatrists on what to do when an
adolescent is put on an adult ward.

“When this occurs it must be flagged to the hospital authorities as
a ‘critical incident’, which means the authorities must investigate
why the young person was sent there,” says Bailey.

Specialists are clear that putting older adolescents on child or
adult wards can be damaging. This is because adult and child
psychiatrists are not properly trained to deal with older
adolescents, who often experience their mental illness in a
different way from, say, a 30-year-old or a young child.

“There’s a problem across all mental health services that
professionals are not developmentally trained to engage with
adolescents,” says Bailey.

Part of the problem facing older adolescents is the transition
between children’s and adult services. In many parts of the country
there are inadequate protocols governing the transfer of young
people between the two services, and 16 to 18 year-olds can slip
through the net.

YoungMinds director Peter Wilson says: “It’s an awkward age and
quite a lot of services lose interest when someone becomes 16, even
though they’re not yet an adult and are still going through a
delicate phase of development.”

For those young people experiencing mental illness who also have a
drug or alcohol dependency, the situation is likely to be much
worse, with the adolescent shunted between mental health and
addiction treatment services.

One reason given why many young people with mental illness do not
seek help is that they are more likely to perceive a stigma
attached to mental health services than other age groups.

But Bailey plays down this argument: “Our research suggests that,
where services are offered flexibly, such as in school, young
people are happy to come forward. The problem is among adult
professionals, such as teachers, who are sometimes reluctant to
allow us into the school.”

A big problem, she says, is the attitude of some social care
professionals: “The behaviour of some professionals perpetuates
this idea of stigma. I still often turn up at a residential
placement to see an adolescent and the staff haven’t told the young
person who I am, only that I’m a doctor.”

Chronic under-funding of services is the main reason for inadequate
provision for adolescents. There are hopes that this may begin to
change with the children’s national service framework, which is
expected next year. And the government has also announced plans for
50 early intervention teams to deal with the onset of psychosis in
the 14-35 age group.

Although welcoming this initiative, campaigners point out that
psychosis, such as schizophrenia and manic depression, is only one
small facet of the mental health issues faced by adolescents.

“We need young people to be referred to mental health services more
quickly and more co-operation between children’s and adults’
services,” says Wilson.

It is probably too much to expect a separate adolescent mental
health service, he says, but perhaps every locality could put in
place a strategy on adolescent mental health involving the local
authority, health service and voluntary sector.

“I’d like to see teams in every area, drawn from the different
agencies and including youth counselling services who do a lot of
important mental health work but are sometimes undervalued by the
medical profession.”

Bailey argues strongly in favour of more community-based provision
for adolescents. But she insists that such services must be
designed with the involvement of young people. “Both social and
health care professionals need to come together and get young
people’s views on how services can best be offered. For too long
adolescents’ views have not been given enough importance.”

¹ The National In-patient Child
and Adolescent Project study will be published by the DoH at the
end of September, at
www.doh.gov.uk/mentalhealth/nimhe.htm