Mental healthcare for young people has been under pressure for years. Then the pandemic struck…
Clarissa Jeffery was half way through a programme of mental health therapy at Springfield Hospital in south London, in January, when Boris Johnson announced that the country would go into a third national lockdown. The professionals responsible for Clarissa’s treatment were suddenly redirected to Covid-related work. She was discharged from hospital within days, unsure how her brain would react.
“I was really scared,” she said. “It set off my anxiety, it was a really unnerving time.”
For Clarissa, the hospital’s programme of electroconvulsive therapy, or ECT, where small electrical currents are sent to your brain, causing a brief seizure, was a last resort. It was the only treatment available on the NHS that had some success against her treatment-resistant depression, and she had only been able to access it when she was a severe enough suicide risk to meet the threshold for a course. The journey there had been long.
Clarissa was first diagnosed with an eating disorder at 13 years old, an age when, for the first of many times, she self-harmed. She has been in and out of hospital since then with diagnoses of OCD, eating disorders and complex post-traumatic stress disorder, triggered by various traumatic experiences throughout her life. Now 26, she has spent years trying unsuccessfully to get therapy on the NHS that would deal specifically with the underlying trauma.
Intermittent episodes of treatment-resistant depression came and went throughout her youth, which left her unable to get out of bed or eat solid food. Clarissa hasn’t been able to complete any sustained period of study or develop skills for more than a few months, without the recurrent depressive episodes, since her GCSEs.
Last year, when the ECT was having some success, Clarissa was trying to become a florist and start her own business. She was living partially in her own flat, and partially with her parents down the road. They were important steps forward on her path to recovery, which came to end with the third national lockdown.
Clarissa asked her local community mental health team to be put on a waiting list for therapy, to do preventative work against falling into future depressive episodes where she could become a critical risk to herself. The psychologist for NHS Richmond had also left for other reasons, she was told, so there was no point going on a waiting list.
“There’s a deep reason where my eating disorder stems from,” she said. “I know I just need to do some specific trauma work; it just doesn’t seem like it will be available to me.”
Clarissa is one of tens – if not hundreds – of thousands of children and young people who have suffered mental health struggles in the last year, but have been left without treatment or put on waiting lists for mental health services that may never arrive. Data is starting to emerge on the scale of what clinicians are calling a secondary pandemic, the effects of which are likely to shape the horizons of young people in the UK for years to come.
One in six school-aged children had a mental health problem of some sort in the middle of 2020, according to NHS Digital. This was an increase from one in seven only three years ago, and one in ten in 2004. There were 61,000 referrals in November 2020 to children and adolescent mental health services, shortened to CAMHS, the local NHS service for under-18s that, increasingly, only has resources to offer treatment to the most severe of cases.
That figure was a record high, and a 66 per cent increase on the year before. Since then, the third lockdown closed schools for a second time, from December to March 2021, disrupting the education of roughly eight million pupils, and prolonging the year of isolation and remote learning for university students. Upon reopening in March of this year, a large-scale rise in mental health disorders – most notably, anxiety and eating disorders – has been reported by clinicians, school counsellors and teachers in conversations with Tortoise. And that rise cuts across geography, education level and class.
As schools and universities went online in January for the second time in the previous 12 months, many of the usual benefits – being around friends and mentors; physical activity and cultural enrichment – were stripped away, leaving just the bare bones of lessons and seminars, delivered through screens. For those who have graduated, a third of under-25s have lost their job due to Covid-19, compared to a sixth of working adults generally. The collective isolation brought on by lockdown is unmatched by probably any other event in modern history.
“We don’t know what’s going to happen next, because we’ve never done this before,” said Stephanie Satariano, a child psychologist.
There is clear science behind the disproportionate effect that lockdown has on young people. A report in The Lancet Child & Adolescent Health in June 2020 described how animal research suggests that isolation has unique effects on brain and behaviour in adolescence; teenagers are markedly more sensitive to peer acceptance or social rejection than adults.
As well as their own isolation, the rapid changes in young people’s social environment have played their own role. “We’ve seen Covid-19 bring on a rise in families separating, domestic violence and job losses,” said Laura Ayling, the designated safeguarding lead at Ark Victoria Academy, a school in Birmingham. “When schools were closed, the kids had no escape from those things.”
When schools reopened in March, the relief of return to social life meant a subdued level of reports of disorders from within schools at first. A few weeks in, the floodgates opened.
“There’s also been a massive increase in self-harming and suicidal ideation in our secondary school population,” said James Emmett, the regional clinical lead for the Midlands and the North at Place2Be, a charity that works in hundreds of schools. Thousands have come forward with a mental struggle for the first time, while conditions for many of those who were treading water before have become overwhelming.
Teachers noticed behavioural changes that might be subtle, but spoke to a difficulty processing rapid change. Pupils’ habits like silently withdrawing, or developing an eating disorder, rose, giving them a way to gain control over an overwhelming world that they felt they had no control over.
A quarter of young people’s clinical treatment was, like Clarissa’s, stopped due to Covid disruption, according to a report by the charity Young Minds; a majority received reduced support or had their treatment go remote, to phone calls or Zoom. A successful referral to see a clinician in person through CAMHS for under-18s, or the local community mental health team (CMHT) for over-18s, is typically inaccessible to all but the most extreme cases.
“I don’t know any families that are getting face to face support [for their child] right now,” said Satariano. “It’s all over the phone, but for people in crisis, this just doesn’t work.”
The threshold for a successful referral for one CAMHS service, in southern England, is that the child must have attempted suicide three times. Anything less than this and there is no capacity for help. Just as a mental health crisis has accelerated over the last year, the capacity for services to deal with it has been whittled away.
“I get five requests a day from parents who just find me online, saying ‘my child is self-harming’, or ‘my child has thoughts about suicide’,” said Satariano. “And I can’t do anything but say ‘I’m sorry’ and refer them to A&E.”
The pressure on mental health services has been building for years, before the pandemic. From 2015 to 2019, referrals to CAMHS had risen 35 per cent. There is no agreed-upon explanation for why Generation Z are suffering the highest rates of mental health issues on record, though consensus coalesces around a few common themes: social media addiction and cyber-bullying; greater exposure to influential content online; the complexity of issues of identity; and the greater ability and willingness to present with disorders and have them diagnosed. But some portion of the problem seems to remain unexplained.
While the Department of Health talks of a “record investment” in mental health services since 2015, the £1.4 billion invested only delivered an increase of four per cent of treatments accessed, despite the 35 per cent referral rise. An under-supply of the relevant clinically trained professionals at the local level, across the range of disorders, has been clear for years.
The government has long relied on charities to fill the gap, many of which do life-saving work; but some, like Lancaster Lodge, which Clarissa entered when she was 19 and left during a mismanagement crisis that resulted in Sophie Bennett’s death, operate with little oversight or accountability.
Indefinite waiting lists for NHS services were common pre-March 2020. In 2019, a survey of GPs labelled CAMHS “grossly inadequate,” and in some areas “non-existent,” in research conducted by teenage mental health charity Stem4. “CAMHS are different in every single borough,” said Emmett of Place2Be. “In Greater Manchester there are seven different CAMHS centres, funded differently, run differently, by different CCGs. For one area it might be a two week waiting list, another it’s eight months.”
An escalation of disorders is the upshot of endless waiting. For the mental health service in Birmingham, the wait for what might just be a telephone conversation is around three months. “In that 12-15 weeks you get worse and then when you finally do get [support],” said Laura Ayling at Ark Victoria, “what you needed before is not what you need now. It’s a vicious cycle. That’s why we try to deal with it in school as quickly as possible.”
For those under 18, schools are the best place to do both preventative work to nip issues in the bud and, as Ayling puts it, “build emotional resilience”. Teachers and counsellors can best pick up small changes in the behaviour and demeanour of pupils, who are often comfortable sharing things with teachers they have close relationships with, when mental health may not be talked about at home.
But thousands of schools do not have their own clinically trained professional to deal with disorders, either sharing one that travels between multiple schools, or more likely having a teacher with counsellor responsibilities to offer pastoral support. “The weight of responsibility currently on teachers to respond to children who are severely ill is enormous,” said Ela McSorley, the principal at Ark Victoria working alongside Ayling. Just under half of all schools had no counsellor or mental health support team at all in their schools, according to a recent Young Minds report.
The government is piloting a programme of placing a clinically trained professional directly within schools to be able to treat pupils on campus. McSorley lights up when discussing this possibility. “The difference that would make would just be….enormous,” she said. “We [the teachers] are not medically trained. We just need the experts within the school.”
Emmett agrees. “Having someone inside a school is absolutely essential,” he said. “It means it’s really accessible, the biggest barrier [to treatment] often is geographical.” The children’s commissioner has repeatedly called on an NHS-funded counsellor to be installed in every school as quickly as possible; the Department for Health plans to roll out the programme by 2023, but only with capacity to reach a quarter of schools by then.
Meanwhile, the emphasis in government and television campaigns on “speaking up” about mental health, or “starting a conversation”, receives its fair share of criticism given the months-long waiting lists for a phone call. However, conversations with those who work in schools suggest the work of de-stigmatisation still left to do should not be underestimated.
“We asked parents in 2015 how you would feel if your child wanted counselling, and 29 per cent said they would feel embarrassed,” said James Emmett of Place2Be. “We asked the same question last year, and it was the same figure.” Generation Z are increasingly comfortable talking about it, but a culture shift in parents appears a longer game to win.
“We would struggle to get parental consent, the issue is hidden, [parents think] ‘this isn’t a problem’,” said McSorley, whose predominantly Muslim pupils live in the Birmingham suburb of Small Heath which has this clear generational divide in attitudes. “Strangely, the pandemic has helped us in making it more acceptable to talk about. We need to continue doing that in a community-friendly language that families understand.”
The mental health impact seen in the last year is likely to only be the beginning. The impact of seismic changes in people’s lives can be held in for a long time. “It impacts our immune system, our energy levels, our stress response,” said Emmett. The full effects are likely to last for years, depending on the support that young people can access. Many won’t stabilise; some might.
Clarissa managed to set up her floristry business. She has friends who live nearby that she treasures going on walks with. “Doing stuff like this is scary,” she said, “because I don’t want to lose it.”
“I’m just trying to make the most of how much I’m able to do right now. And not focus on the fear that this won’t last.”
Photographs for Tortoise by Tom Pilston