According to recent research, 10 per cent of 10–15 year olds and 17 per cent of 16–19 year olds display symptoms consistent with a mental health disorder.1 Moreover, four per cent of children and young people have ‘a clinically diagnosable... emotional disorder’, and anxiety is more likely to affect young people than any other age group.2 Mental health has, therefore, necessarily been placed high on the agenda of all services working with children and young people.
However, in reality, children and young people may not always receive the support that they need for their mental wellbeing. This article considers the provision of psychological therapies and medication for children and young people suffering from mental ill health. It explores how GPs’ perceptions of children, young people and mental health may impact upon the services that are provided.
Access to psychological therapies
NICE guidelines 20133 stipulate that psychological therapies should be the first option when dealing with anxiety and depression in children and young people. Medication should not be routinely offered to treat social anxiety disorder, and antidepressants should only be prescribed for moderate to severe depression, and only then in conjunction with psychological treatments. When treating depression in children and young people, NICE recommends that health professionals should ‘build a trusting relationship’ and ‘explore treatment options with hope and optimism, explaining the different courses of treatment for depression and that recovery is possible’,4 and the patient should be involved in planning and reviewing their care pathway. There are no guidelines on how to deal specifically with anxiety in children and young people, but NICE guidelines are clear that anxiolytics should not be prescribed to under 18 year olds,3 with Fluoxetine being the only acceptable SSRI.
However, while the NICE guidelines are reassuring, research shows that what is actually happening is often very different. In 2003, the Committee on Safety of Medicines (CSM) advised against the use of SSRIs (other than Fluoxetine) for children and young people, recommending cognitive behavioural therapy instead.5 Data show that, while there was a significant reduction in the number of prescribed SSRIs (as recommended), symptoms were still being recorded at the same level, and yet recorded diagnoses of depression decreased dramatically.6 It appears that, while GPs acted on the advice from the CSM not to prescribe SSRIs, they did not offer alternatives. The rate of prescription of Fluoxetine did not increase and, without diagnoses, neither did referrals to primary mental healthcare. In fact, since 2003, the rate of recorded anxiety symptoms in children and young people has increased threefold, while recorded numbers of diagnoses have remained stable.2 Further data collation and research into rates of anxiety and depression in children and young people will be greatly hindered by these unrecorded statistics.
Most recent data from 2009 show an increase in the number of antidepressants being prescribed across all age groups,2 with Citalopram being most widely prescribed for children and young people as an ‘initial medication’, rather than Fluoxetine. On the one hand, there are concerns with the ‘medicalisation of unhappiness and normal human experience, resulting in over-diagnosis and over-treatment’7 while, on the other, research shows that many mental health disorders are not recognised, diagnosed and/or treated.1,6 The most glaring conflict within the collated data is that, although the numbers of recorded diagnoses for anxiety and depression have decreased, the number of prescriptions has increased.2,7 This begs the question, why are GPs not able or willing to give a diagnosis, yet are happy to prescribe the medication?
The role of the GP
Hinrichs et al,8 studying GPs’ experience and perception of CAMHS, suggest that GPs resort to prescription without diagnosis partly due to a lack of confidence in their ability to diagnose mental health issues. Added to this is a very real concern that a diagnosis should initiate a referral to mental health services (usually CAMHS), but that this referral may well be rejected. In fact, referrals to CAMHS by GPs are three times more likely to be rejected than those by other referrers.8 Interviews with GPs indicate that ‘detecting the signs and symptoms of mental illness in young people is a challenge’8 due to a lack of specialist training and knowledge. In England, on average only 46 per cent of GPs undertook a training placement in a mental health setting,9 and only 28 per cent undertook further training in mental health.10 While highly desirable, the idea of building a relationship, exploring and discussing with each patient seems somewhat unlikely, given that GPs have on average only nine minutes to spend with them.11 It is therefore likely that the referrals that are being made to CAMHS are inappropriate, causing their rejection, thus perpetuating the GPs’ lack of confidence in their ability to diagnose and refer to appropriate services.
Research by Biddle et al12,13 into how willing young people are to seek help from their GP for mental health issues, also indicates a worrying trend: less than one-third of young people questioned felt that their GP was an appropriate source of support and guidance. In their view, the GP’s role was to deal with physical health, GPs did not have the necessary training to deal with mental health, would not be able to offer talking therapies and were therefore likely to simply prescribe antidepressants (which the majority of children and young people interviewed did not want to take). The report concludes that these views ‘are discordant with the key role assigned to GPs in the delivery of mental health services’ and that ‘Young people require a better understanding of GPs’ role’.12 However, the concerns that they are voicing are, in fact, almost identical to those raised by GPs in a paper by Roberts et al,1 suggesting that young people in fact have a very good grasp of the situation. Roberts et al found that GPs are anxious about dealing with mental health – particularly when it comes to young people. They do not feel they have the necessary skills to diagnose depression and anxiety, are unclear about pathways for referrals, but are concerned that if they do not act in some way and ‘something goes wrong’, they will be accountable. GPs claimed that older patients are clearer in describing their symptoms (making for an easier diagnosis), whereas young people often come with a range of problems and issues which ‘mask’ an underlying mental health problem; they talk of young people bringing issues that are ‘in the extreme realms of the undefined’1 and, as a result of limited training, GPs ‘feel poorly equipped to manage young people’s emotional distress’.7 There is also a concern, highlighted in the London School of Economics’ report on how mental health is losing out within the NHS, that GPs themselves are dismissive of mental health and psychiatric services – viewing them as ‘less scientific’.14
What is apparent is that the majority of children and young people presenting with mental health issues are not being referred for or accessing talking therapies. GPs – the first point of contact for many young people – are not able to fulfil the role which has been allocated to them. With training and expertise in mental health falling desperately short of what is needed, GPs are either missing or dismissing presenting mental health issues and/or relying too heavily on medication. Over-reliance on medication encourages the belief that there is something ‘wrong’ that can (or cannot) be ‘fixed’, but that it is outside the control of the young person. GPs have been asked to take on responsibilities for which they are ill equipped, not only in terms of experience and time, but perhaps most importantly, willingness. Failure to engage with and explore the issues that a young person brings to the GP undermines their resiliance because it amounts to a failure to find out, and then offer, what is needed.
The picture that is emerging is one of a worrying lack of cohesion. GPs are being told that they should play a key role in the delivery of mental health services,12 through policies which ‘have emphasised the role of GPs in the promotion of psychological well-being and early indication of difficulties’.14 However, they feel ill equipped to deal with the issues that are being presented to them, lacking the additional time and training they so desperately need. Young people, experiencing ever-increasing mental health issues, are being told to consult their GPs, but are quite rightly reluctant to do so, concerned that they will be met with a lack of willingness to engage and an over-enthusiasm for the ‘quick fix’ of medication.
For those young people who visit their GP with depression or anxiety and come away with nothing more than medication, the message they are being given is that they have an illness, which can only be ‘cured’ by a pill. Rather than embarking on a journey of exploration of their emotions, understanding their strengths and weaknesses, learning to adapt, seek support, make changes and find solutions, they are told that something ‘is wrong’ with them and only medication can fix it.15 According to Frances, ‘Prematurely resorting to medication short-circuits the traditional pathways of restorative natural healing’.15 If a young person, visiting the GP because they feel that they cannot cope with their feelings of anxiety, is given medication as the only solution, the implication is that the GP agrees that they cannot cope, potentially reinforcing their anxiety and feelings of helplessness.16 Even if the medication works, the young person cannot say that they have learnt how to manage their anxiety, that they know what to do with overwhelming emotions, or that they are more resilient and able to cope in future. As Assareh et al17 state, ‘one of the most powerful buffers against anxiety and depression disorders is the individual’s belief in their personal control of how they will cope with adverse circumstances’. Frances15 talks of the importance of time in our struggle to achieve our ‘homeostasis’, that while we are designed to experience a wide range of emotions, our minds and bodies desire to achieve and maintain equilibrium, but in order to do this, we need time to learn to understand and regulate our emotions, where possible without medication. Time, belief and personal agency are all missing from the scenarios young people and GPs describe.
Many young people are not seeking help and advice because they do not trust, or do not know how to access, what is on offer. They are not only losing out on the possibility of early intervention, which is considered to be of key importance in promoting recovery,2 but are also not being given any hope. Maholmes emphasises the importance of hope, claiming that it is ‘an important psychological resource’.18 We need to believe, she says, that we can find solutions, that things will improve, that we will cope – that we have agency. Could it perhaps be argued that medication provides hope, in the form of a remedy? Not, I would argue, if personal agency is unsupported. Medication masks emotions and reduces agency, whereas talking therapies offer a young person the opportunity to engage with personal agency, and develop their resilience. For some time now, we have been advocating the consideration of mental health as equal in importance to physical health; perhaps it is time that action is taken against the over-prescribing of anti-anxiety and antidepressant medication, in the same way that action has been taken against over-use of antibiotics. Both have the potential to undermine our natural immune systems.
Elen Thomas is currently completing a postgraduate qualification in psychotherapy at the University of Wales Trinity Saint David. For many years, she has worked in education and the third sector, supporting young people with their mental health and wellbeing.
1 Roberts J, Crosland A, Fulton J. ‘I think this is may be our Achilles heel...’ exploring GPs’ responses to young people presenting with emotional distress in general practice: a qualitative study. BMJ Open 2013; 3(9): e002927 (accessed 15 January 2019).
2 John A, Marchant AL, McGregor JI, Tan JO, Hutchings HA, Kovess V, Choppin S, Dennis MS, Lloyd K. Recent trends in the incidence of anxiety and prescription of anxiolytics and hypnotics in children and young people: an e-cohort study. Journal of Affective Disorders 2015; 183(C): 134–141.
3 National Institute for Health and Care Excellence. Social anxiety disorder: recognition, assessment and treatment. [Online.] NICE; 2013. https://www.nice.org.uk/guidance/cg159 (accessed 21 January 2019).
4 National Institute for Health and Care Excellence. Depression in adults: recognition and management. [Online.] NICE; 2018. https://www.nice.org. uk/guidance/cg90 (accessed 21 January 2019).
5 Committee on Safety of Medicines. Selective serotonin reuptake inhibitors (SSRIs) – overview of regulatory status and CSM advice relating to major depressive disorder (MDD) in children and adolescents: summary of clinical trials. London: Medicines and Healthcare Products Regulatory Agency (MHRA); 2003.
6 Wijlaars L, Nazareth I, Petersen I, Hashimoto K. Trends in depression and antidepressant prescribing in children and adolescents: a cohort study in The Health Improvement Network (THIN) (trends in depression in children and adolescents). PLoS ONE 2012; 7(3): e33181 (accessed 15 January 2019).
7 John A, Marchant AL, Fone DL, McGregor JI, Dennis MS, Tan JO, Lloyd. Recent trends in primary-care antidepressant prescribing to children and young people: an e-cohort study. Psychological Medicine 2016; 46(16): 3315–3327.
8 Hinrichs S, Owens M, Dunn V, Goodyer I. General practitioner experience and perception of Child and Adolescent Mental Health Services (CAMHS) care pathways: a multimethod research study. BMJ Open 2012; 2(6): e001573 (accessed 15 January 2019).
9 Mind. GPs and practice nurses aren’t getting enough mental health training. [Online.] Mind; 2016. https://www.mind.org.uk/news-campaigns/ news/gps-and-practice-nurses-aren-t-getting-enough-mental-healthtraining/ (accessed 21 January 2019).
10 Mental Health Workforce Action Team. The Primary Care Key Group report to the Workforce Action Team. London: Department of Health; 2001.
11 Royal Pharmaceutical Society. UK has shortest GP consultations in Europe, study finds. [Online.] The Pharmaceutical Journal; 2017. https:// www.pharmaceutical-journal.com/news-and-analysis/news/uk-hasshortest-gp-consultations-in-europe-study-finds/20203923. article?firstPass=false (accessed 21 January 2019).
12 Biddle L, Donovan JL, Gunnell D. Young adults’ perceptions of GPs as a help source for mental distress: a qualitative study. British Journal of General Practice 2006; 56(533): 924–931.
13 Biddle L, Gunnell D, Donovan J, Sharp D. Young adults’ reluctance to seek help and use medications for mental distress. Journal of Epidemiology and Community Health 2006; 60(5): 426.
14 Layard R. How mental illness loses out in the NHS. A report by The Centre for Economic Performance’s Mental Health Policy Group. CEP Special Papers 26. London: LSE Centre for Economic Performance; 2012.
15 Frances A. Saving normal. New York: Harper Collins; 2013.
16 Breggin P. Toxic psychiatry. London: Harper Collins; 1993.
17 Assareh A, Sharpley C, Mcfarlane J, Sachdev P. Biological determinants of depression following bereavement. Neuroscience and Biobehavioral Reviews 2015; 49(C): 171–181.
18 Maholmes V. Fostering resilience and well-being in children and families in poverty. Why hope still matters. New York: Oxford University Press; 2014.