PMHA at the party conferences

Max Davie, PMHA convenor, reflects on the party conferences:

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For the past few weeks, I’ve been roaming the country with the RCPCH public affairs team. We’ve been talking about children and young people’s mental health at fringe meetings at the three major party conferences, along with colleagues from the RC Psych and the charity Young Minds. I’ve been able to talk to people from around the country about the problems with CAMHS, and discuss some possible solutions. For the benefit of PMHA members, here are some thematic reflections on the problems:

  • There isn’t enough money in the system

While there had been no concerted attempt to cut CAMHS, the brute reality of NHS and local authority funding has led to unprecedented reductions in budgets, by up to 40% in 4 years. This is in part due a lack of clear tariffs and targets, because in the NHS “money follows targets”. An understandable retreat by local authorities into their ‘core business’ has compounded matters.

  • We think of CAMHS services, when we should be thinking about a local CAMHS system.

Services have, in response to cuts, raised the drawbridge to referrals, and shrunk their scope. Paradoxically, once children are in services, there are perverse incentives to pass then to ever more expensive echelons of the system. Meanwhile, other children and young people are lost between services as they don’t ‘fit’ anywhere. Only by re-imagining CAMHS as a comprehensive system, supported by specialists and incorporating education, health, social care and the charitable sector, can we maximise our resources.

  • Early intervention needs more priority

More lucrative specialist services have been prioritised by cash-strapped mental health trusts, but parenting programmes and universal mental health education for children are low cost, effective interventions which need political priority.

  •  Professional cultures need to be more collaborative and inclusive

There is a pervasive myth that mental health can only be done by specialist CAMHS. This is encouraged by lack of engagement by many CAMHS services with the wider system. This leads not only to poor integration, but also another lost opportunity for early intervention outside of specialist CAMHS.

  •  Parity of esteem needs to be more than just a phrase

Many of my first points can be encapsulated in this: parity was enshrined in the health and social care act, and yet mental health continues to be a poor relation of physical health. Recent policy announcements, especially by the liberal democrats, are welcome, but a robust plan is required to embed parity across the NHS.

  •  No CAMHS system will serve children and young people unless it listens to these young people

The best speech I heard at our meetings was by Lisa Murphy, from the RCPCH youth panel, who talked passionately about the need for a responsive system which listened and respected young people as individuals. How we achieve this while embedding robust commissioning and manage a continuing squeeze on finances is the challenge of the next five years.

 It was fascinating to visit the conferences, with their bustle, intrigue and hubbub of chat and speeches. Mental health had never been higher up the political agenda, and we hope that we have played a small part in keeping this vital issue somewhat at the forefront of politicians’ minds.

 

Sluggish Cognitive Tempo: the next big thing in diagnosis?

This blog ://www.slate.com/articles/health_and_science/medical_examiner/2014/09/sluggish_cognitive_tempo_is_it_a_disease_independent_of_adhd_and_can_drugs.single.html is very good, and recommended.
Briefly, sluggish cognitive tempo is a terribly-named new conception of children who have poor concentration, not due to the ‘fizziness’ of the ADHD brain, but due to slow processing in the absence of other learning disabilities. The slate article rejects SCT partly on the basis that it’s just an exaggeration of normality, but PMHA members will know that this argument could apply to whole swathes of the diagnostic textbook, from ADHD to hypertension.
So should we be looking at diagnosing this condition in our clinics? At present, it’s very hard to be clear, as the evidence base is tiny for usefulness of this concept, and it is likely to be mainly treated with educational intervention.
But we would be interested in your thoughts…

neurocognitive deficits in ADHD and conduct disorder. Same same

Really interesting work reported here http://www.sciencedaily.com/releases/2014/08/140812121542.htm?
Essentially, the basis of young people with ADHD, conduct disorder and substance misuse show very similar neurocognitive patterns. This might suggest some shared causation, and possible intervention targets which cut across all conditions. We shall see, but if the cognitive deficits can be targeted specifically, that would be a revolution in conical and diagnostic practice.

Autism and substance misuse: assume nothing

This excellent blog post http://blogs.psychcentral.com/science-addiction/2014/07/people-on-autism-spectrum-at-increased-risk-for-substance-abuse/ tangles with the complexity of the relationship between ASD and substance misuse. Essentially, able people with ASD seem quite prone to addictive behaviour. This may not be a surprise, but because people with ASD are often socially isolated it might be assumed that they don’t get exposed to substances socially. This work is another reminder to see the person, and not the diagnosis.
Of course the next question is how this relates to mental health problems in this population….

Can you diagnose ADHD without childhood symptoms?

http://www.medicalnewstoday.com/releases/279619.php?tw

US researchers have found that the move in Dsm 5 to increase the age of onset criteria from 7 to 12 did not significantly alter the profile of the population diagnosed, although did increase the proportion of predominantly inattentive diagnoses.
Many UK clinicians are alarmed at the explosion of ADHD diagnosis in the US, and may view this with some suspicion. Increasingly, as prevalence rates across the Atlantic exceed 10%, we are diagnosing quite distinct populations, as European clinicians diagnose a fat Mir select group. This limits the applicability of this finding to a UK context.

Is parity of esteem just an empty phrase?

In 2012 the government pledged to achieve parity of esteem between physical and mental health. Since then there have been working parties, reports and briefings, but also scandals like NHS England mandating a 20% greater cut for mental health, CAMHS services losing up to 40% of capacity in 4 years, and most recently and viscerally, people dying in scores while awaiting treatment for mental health problems.
So is parity just rhetoric, to keep a deeply disenfranchised group quiet till the next government? It doesn’t have to be…

To grasp the importance of parity, imagine if it was achieved. Not in the way we want, but by down-grading physical health services to the status of mental health in the NHS. People with the most serious problems, like heart disease, would have no guaranteed access times for treatment and hundreds would die unnecessarily. Young people presenting with sporting injuries would be made to feel they are a wasting staff time in A&E, while those suffering from leukaemia would be shunted across the country in search of a dwindling number of beds. Children with long term conditions like cystic fibrosis wouldn’t be able to get any treatment at all until they had complications, by which time outcomes would already be compromised. And health education and support in schools? We don’t talk about that sort of thing, thanks, we’ve got exams to pass.

There would be a national scandal, people marching through on the streets, resignations, the works. And yet we have all allowed people with mental health problems, some of our most vulnerable citizens, to be treated in this shoddy way. This has to stop. And the way to give this vague, arm-waving term ‘parity of esteem’ some guts, and enlist it for the fight, is to think not of equal esteem for ‘mental health’ as an abstract, but about equality of esteem for the people, mothers, fathers, workers, sons, daughters, friends, lovers, and colleagues, who suffer in this way.

So what now? Well, I’m on my way to the Labour party conference in Manchester, to the first of three events run jointly by the RCPCH, RCPSYCH and Young Minds, asking the three major parties to commit to a tangible action plan to achieve parity of esteem for people with mental health problems. We hope you can help by tweeting about our campaign #thinkagain, by visiting the young minds website and signing the petition calling for an end to CAMHS cuts, but above all by taking to colleagues, friends, and family about mental health, and making it a political issue.

Because it damn well ought to be.

Suicidal thoughts common in people with autism

Another sfari.org blog http://sfari.org/news-and-opinion/news/2014/suicidal-thoughts-alarmingly-common-in-people-with-autism discusses recent work on suicidality in ASD, especially aspergers. It’s an excellent piece, and I just wanted to add a few points:

1) as professionals we should be asking young people with ASD about thoughts of self harm and suicide whenever possible. Conventional depression scales won’t cut it.

2) this should put to bed once and for all the myth of autistic people as emotionally ‘frozen’. Their emotional life is qualitatively different to typicals, but no less intense.

3) the data suggesting an increase in suicide attempts is unpublished,  so should be treated with caution, but there are good reasons given to think there might be a greater risk. How much can be accounted for by conventional depression is unclear

4) if people with autism can be suicidal but not depressed, how on earth do we treat/ protect them? This I suspect will be a puzzler

5) this is a good example of a problem that would reward particular attention on people with aspergers.  It seems a shame to have dispensed with the term,  doesn’t it?