The Royal College of Psychiatrists, UK, is the professional body responsible for education and training, and setting and raising standards in psychiatry. It is an increasingly international organisation with approximately a fifth of members living outside the UK. In partnership with the UK-charity Medical Aid for Palestinians (MAP), the college was invited to develop a national strategy for child and adolescent mental health in Palestine for the Ministry of Health. Children are at higher risk of developing mental illness when living in overcrowded areas with ongoing shelling, siege, and other acts of violence as is the case in Gaza. A significant proportion of Palestinian children experience serious psychological distress especially anxiety and post-traumatic stress disorder (PTSD), with children reporting not wanting to be apart from their parents. The aim of the strategy is to set key priorities for child and adolescent mental health so that funders, institutions, organizations and community members align their activities in a coordinated and efficient way.

Information was gathered from an extensive literature review and three in-person missions to visit the West Bank to meet key stakeholders from governmental and non-governemental organizations including the Ministries of Health, Education and Social Development and the only Child and Adolescent Mental Health Services in Halhoul, north of Hebron. A thematic meeting was held in August 2022 and a feedback meeting in December 2022. All comments and feedback were reviewed and incorporated into the final document for submission to the Ministry of Health for official approval.

Today's child in Palestine bears the burden of decades of violence, conflict and hardships that have accumulated during their lives and those of their parents and grandparents. In total, 2242 Palestinian children have been killed by Israeli military forces between the years 2000 and 2022. Childhood is not a given for Palestinian children, but instead something that must be determined, retrieved, and understood within a complex web of implications mandated by the dynamics of power that are in play. As a testament to the Palestinian people's ability to adapt, endure and demonstrate sumud (steadfastness), through strong family and community relations, many children show remarkable resilience. However, there are children and families who require additional support and expert care.

Demand for child and adolescent mental health services is not being met by current clinical services which are fragmented and under-funded. Clinical pathways to refer vulnerable young people suffering from mental illness do not exist; nor do day or inpatient facilities for young people who require specialist interventions or admission, be it for severe mental illnesses or high risk behaviours. The lack of clear child protection protocols and limited availability of supportive family counselling and therapy compounds the pressure on caregivers. Vulnerable children are left exposed.

Every child deserves a childhood and a future. This national strategy takes a holistic view of childhood and adolescence, using the multi-level framework for child and adolescent well-being developed by the United Nations Children's Fund (UNICEF).

The strategy's vision is for every Palestinian child's mental health and well-being to be promoted and protected throughout their developmental journey into adulthood by strong multi-sectorial support networks and for mental illnesses to be detected and treated by collaborative, effective systems of care, free from stigmatization, discrimination and marginalization so they can live fulfilling lives as integrated members of society. This vision is build on four pillars of‘'Rights and Regulation’'‘'Prevention and Promotion’'‘'Capacity Buildling and Clinical Service’' and‘'Community Integration and Contribution’' The vision can be realised through the implementation of ten initiatives, each with their own action plan and outcome measure, with the critical enablers of funding and stakeholder participation and collaboration.

To examine the impact of using Communty Treatment Orders (CTO) of the Mental Health Act on use of inpatient care in Assertive Outreach team.

Currently there is little evidence of the efficacy of community treatment orders (CTOs), and in particular with patients who use the Assertive Outreach service. One large randomised controlled study found no impact on use of inpatient care while a naturalistc study found significant impact.

Our primary outcome was the number of admissions with and without a CTO comparing each patient with themselves before CTO and under CTO(“mirror-image”). Our secondary outcomes were the number of bed days, and the percentage of missed community visits post-discharge. We also looked at the potential cost savings of a reduction in inpatient bed usage.

All the 63 patients studied over period of 6 years had a severe and enduring mental illness. The use of a CTO was linked to a significant reduction in the number of admissions (mean difference = 0.89, 95% CI = 0.53–1.25, P < 0.0001) and bed days (mean difference = 158.65, 95% CI = 102.21–215.09, P < 0.0001) There was no significant difference in the percentage of missed community visits post-discharge. Looking at the costs, an average cost for an inpatient Assertive Outreach bed per day in the local Trust was £250, and there were 8145 bed days saved in total, making a potential saving of just over £2million, during the study period.

This study suggests that the implementation of CTOs using clinical judgment and knowledge of patients can significantly reduce the bed usage of Assertive Outreach patients. The financial implications of CTOs need to be reviewed further, but this study does suggest that the implementation of CTOs is a cost-effective intervention and is economically advantageous to the local Trust.