Referrals

Overall, referrals to CAMHS fell during 2020 and were 11% lower than 2019 and 4.2% lower than 2018. This difference was most evident in phase 1 (1 March–31 May), which signalled the closure of non-essential businesses, schools and colleges. A stay-at-home order was put in place, exercise was limited to 5 km from home and social gatherings forbidden. Referrals in this period dropped by 53% compared with 2019 and 51% compared with 2018 (Figure 1). Referral rates during the summer months 2020 (1 June–31 August), when restrictions had been lifted, remained lower than previous years. There were 10% fewer referrals received during phase 2 compared with 2019, and 15% fewer than 2018.

This drop in presentation to mental health services immediately post restrictions has also been reported in community mental health^{Reference Tromans, Chester, Harrison, Pankhania, Booth and Chakraborty8} and hospital settings.^{Reference McAndrew, O'Leary, Cotter, Cannon, MacHale and Murphy9} Tromans and colleagues, examining UK mental health referral data, in the 8-week period before (27 January–22 March 2020) and after (23 March–17 May 2020) the first UK lockdown, reported a significant reduction in referrals to all services (37%), with rates in CAMHS falling by 51%.^{Reference Tromans, Chester, Harrison, Pankhania, Booth and Chakraborty8} Examining psychiatry referrals to the emergency department during the initial 8-week COVID-19 restrictions in Ireland (16 March 2020 to 10 May 2020), McAndrew and colleagues also reported a significant reduction in weekly referrals by 21%, compared with previous years.^{Reference McAndrew, O'Leary, Cotter, Cannon, MacHale and Murphy9} In studies where the time period was extended, a rebound in attendances has been noted. Presentations with self-harm dropped by 35% from March to April but rose by 104% for adults from April to May.^{Reference McIntyre, Tong, McMahon and Doherty10} Rates of children attending emergency departments for either medical or mental health presentations also fell during this initial 3-month period (March–May).^{Reference McDonnell, Nicholson, Conlon, Barrett, Cummins and Hensey11}

Reasons for reduced referrals during phase 1 and phase 2 (March–August 2020)

There are a number of possible explanations for reduced referrals to CAMHS in early 2020. For one, it could reflect a reluctance of the patient or the family to seek help during lockdown, including low attendance at general practitioner services, the gate-keepers to CAMHS referral. Research in the UK suggests that nearly 1 in 12 parents (8.3%) of children with a ‘probable mental disorder’ decided not to seek help and more than 1 in 5 of 17- to 22-year-old young people themselves with a probable mental disorder chose not to seek help.^{Reference McDonnell, Nicholson, Conlon, Barrett, Cummins and Hensey11} It could also reflect difficulty accessing general practitioner services because of prioritisation of COVID-19-related activity. It is also possible that reduced referrals could reflect a genuine reduction in mental health problems, arising, for example as a result of school closures.

Schools represent a major source of stress for many young people, including from academic, social and behavioural perspectives. What is more, for many young people, parents may have been more available to them during this period given workplace closures and home working. In the Mental Health of Children and Young People in England study, a significant minority of youth reported that lockdown had made their life better.^{Reference McDonnell, Nicholson, Conlon, Barrett, Cummins and Hensey11}

Although these factors might account for the initial decrease, they do not persist. Research indicates that as COVID-19 progressed, presentations of youth to emergency departments increased.^{Reference Leeb, Bitsko, Radhakrishnan, Martinez, Njai and Holland12} Leeb and colleagues reported that whereas mental health-related emergency department attendances decreased sharply from mid-March through early April, they increased steadily through to October 2020.^{Reference Leeb, Bitsko, Radhakrishnan, Martinez, Njai and Holland12}

Attendances at non-specialist services also increased. For example, domestic violence helplines saw an increase in calls,^{Reference Vindegaard and Benros2} the Irish youth mental health charity Jigsaw reported a 400% increase in traffic to its e-mental health platform^{Reference Ní Aodha5} and Bodywhys, the eating disorder organisation, reported a 110% increase in online supportive engagement.^{Reference Ryan13}

A series of surveys conducted by Young Minds UK, reported that youth with prior mental health difficulties (n > 2000) had decreasing levels of mental health well-being as the pandemic progressed and experienced increased difficulty accessing services.^{Reference Young Minds14} They found that 32% of respondents believed that COVID-19 had made their mental health ‘much worse’ in March 2020, increasing to 41% by June 2020. Feelings of loneliness and isolation were reported by 87%, despite the majority (71%) staying in touch with friends. A total of 68% of students reported that returning to school in September 2020 after a period of absence lead to deterioration in their mental health, with 40% reporting there was no school counsellor available, and 23% experiencing that mental health school supports were fewer than pre-COVID-19.^{Reference Young Minds14} Immediately post-lockdown, 31% of youth surveyed reported being no longer able to access previously attended mental health services despite their ongoing need.^{Reference Young Minds14} Follow-up data from England's Mental Health of Children and Young People survey suggest an increase in rates of ‘probable mental health conditions’ from 10.8% in 2017 to 16% in July 2020.^{Reference Vizard, Sadler and Ford15} The ongoing and increasing need for CAMHS services as COVID-19 progresses has been evident in this study by the large increase in referrals in phase 3.

Clinical complexity

A higher proportion of patients referred to CAMHS during COVID-19 were deemed urgent, and increased numbers were in need of onward referral from CAMHS to other specialist services, which included in-patient and hospital-based paediatric liaison psychiatry services. In 2020, 7.5% of all patients seen were transferred on to other CAMHS, which is double the rate seen in 2019 (3.4%) within the Lucena service and higher than prior national averages (4.5%).¹⁶ Although data is not publicly available on the clinical profile of referrals, anecdotal reports by clinicians indicate an increase in referral complexity, with a higher proportion with suicidal ideation and with eating disorders.

Internal referrals to the eating disorder family-based treatment team within Lucena saw a jump from 19 referrals in 2019 to 42 in 2020.^{Reference Walsh and McNicholas17} This increase in maladaptive and disordered eating has also been reported in the UK.^{Reference Robertson, Duffy, Newman, Bravo, Ates and Sharpe18} Among youth in the UK, new referrals have increased by 46% during the pandemic^{Reference Jayanetti19} and there has been a 20% increase in emergency admissions to acute hospitals among adults with eating disorders.^{Reference Ayton, Viljoen, Ryan, Ibrahim and Ford20} Increased clinical complexity has been highlighted in studies examining presentations to paediatric emergency departments.^{Reference Ougrin, Wong, Vaezinejad, Plener, Mehdi and Romaniuk21}

Data collected from March to May 2020 from 23 emergency departments internationally, corresponding with phase 1 of this study, showed that despite a decrease in overall referrals, clinical complexity increased and the proportion of youth presenting with self-harm increased.^{Reference Ougrin, Wong, Vaezinejad, Plener, Mehdi and Romaniuk21} The increased awareness of rising rates of self-harm among youth was already a cause for concern pre- COVID-19 in the UK^{Reference Hawton, Saunders and O'Connor22} and the ROI,^{Reference Griffin, McMahon, McNicholas, Corcoran, Perry and Arensman23} but had been in parallel with improvements in evidence-based treatments.^{Reference Iyengar, Snowden, Asarnow, Moran, Tranah and Ougrin24} Increased presentation and lethality of self-harm among adults during COVID-19 has also been reported.^{Reference McDonnell, Nicholson, Conlon, Barrett, Cummins and Hensey11}

Activity

Relative to January–February 2020, clinic activity declined during the immediate lockdown period (March–May) and over the summer months. However, appointments increased sharply from September to November, with a 71.8% increase in appointments offered per month with respect to the summer months, and 35.6% higher than the equivalent period in 2019. Non-attendance rates were also higher during the earlier COVID-19 period such that 32.6% of all patients from phase 1 did not attend, 19% did not attend from phase 2, and 25% did not attend from phase 0. By phase 3 (1 September to 30 November) the overwhelming majority of appointments offered were attended (84.9%) and the non-attendance rate without prior cancellation was 6.6%, which is below previous national averages (8.5%).^{Reference Ryan25} Taking both advanced cancellations (n = 1723) and ‘no-shows’ or did not attend (n = 1351), overall non-attendance during this period was 15.1%.

Capacity

The ongoing demand on already overstretched services is a cause for concern. Fewer patients who were deemed in urgent need of an appointment were able to be seen within a 3-day period, in 2020 compared with 2019, suggesting capacity overload in 2020. This poses a risk of not only leading to prolonged stress in families, but also contributing to moral injury among clinicians, unable to provide a necessary and timely service, and exposing them to additional risk of burnout. It has long been recognised that CAMHS in the ROI are underfunded and underresourced, but as yet urgent and targeted investment has not occurred. Prior to the COVID-19 pandemic, CAMHS were already experiencing an increased volume of referrals, with the HSE reporting a 24% increase in accepted referrals between 2012 and 2018.^{Reference Ryan25} In that same period, national staffing levels were just 58% of the clinical staffing levels recommended in the Irish mental health policy document, A Vision for Change.¹⁶ Given that 25% of the ROI population is under 18 years of age this chronic underresourcing continues to be a public health crisis. To add the recognised increased demand, consequent to COVID-19, on an already depleted service provides the perfect storm for staff burnout. High rates of staff burnout have already been reported by consultants working in CAMHS.^{Reference McNicholas, Sharma, OConnor and Barrett26} The increased referral rates to CAMHS, increased activity and recognised adverse psychological impact of COVID-19 on clinicians expose a vulnerable service.

Limitations

The referral data presented is from a group of five CAMHS from one organisation (St John of God Lucena Service) and although it covers a large youth catchment area, it may not be generalisable to other regions in Ireland. Furthermore, as an urban group, it may not accurately reflect rural services with reduced access to community-based mental health supports or paediatric emergency departments.

Data available is limited to referral numbers and out-patient activity level, with no supporting clinical or demographic information to allow an examination of any differential increases imposed by COVID-19 or the restrictions by clinical type or sociodemographic factors. The available reporting data to the HSE is based on monthly returns, and allowed the authors present data over the timeframes outlined (Appendix). The time periods are close approximations to the level of COVID-19 restrictions imposed, rather than an exact fit, as restrictions introduced in Ireland did not commence on the first day of each month. However, they closely align with periods in which schools were closed as part of COVID-19 restrictions (phase 1), schools were on vacation (phase 2) or schools were open despite other COVID-19 restrictions (phase 3). The time periods chosen also mirror those chosen by other Irish studies.^{Reference Tromans, Chester, Harrison, Pankhania, Booth and Chakraborty8,Reference McAndrew, O'Leary, Cotter, Cannon, MacHale and Murphy9}

Implications

Data presented in this study show an initial 6-month decline in CAMHS referrals in 2020 followed by a sharp increase from September, peaking in November. The immediate decline in referrals post-lockdown might erroneously have suggested a reduced need for mental health youth services. However, subsequent months saw increased referrals and an increased demand for CAMHS.

The lower rate of infection, lower morbidity and mortality in youth from COVID-19 has not been met with modified restrictions, and concerns have correctly been raised about the ‘wider collateral damage to children’ of restrictions on education, socialisation, development and psychological well-being.^{Reference Crawley, Loades, Feder, Logan, Redwood and Macleod27} The adverse impact on clinicians within CAMHS is also a concern. Careful planning, including data-collection systems that allow more in-depth examination of clinical information, and resourcing of CAMHS is urgently needed in the ROI to cope with the expected ongoing demand for services.