Mental health reform requires concerted action on many fronts. Photo / NZME file
For the past eight months, the Herald has run an editorial campaign called Great Minds. An important focus of the series has been the alarming rise in mental health problems among children and teenagers, and the lack of services and support available for them.
Over the past week, a series of articles has set out the serious challenges families and public services are facing in responding to this rising tide of distress, including the lack of options for teens in acute distress and the difficulty that some families have in getting effective treatment when their children need it.
The worsening mental health of our young people is a vast and complicated problem that began long before the Covid-19 pandemic (although it has been aggravated by it). It predates this current government. It is not isolated to New Zealand. It is not a problem with easy answers or that can be resolved soon. But it is an urgent problem, and it has received too little attention for too long.
In the process of reporting this series, we have also spoken to numerous parents, clinicians, researchers, and officials about ways that the government, our public institutions, communities – all of us – could help to improve the situation. There were many suggestions, some broad, some highly specific.
Today we are highlighting some of those solutions. None is a silver bullet. Nor is it a definitive list. It is intended to be the starting point for an ongoing national discussion.
Resolving the crisis will take years, probably decades, of sustained commitment and investment from successive governments, and it needs to start now, with urgency, led from the top. Jacinda Ardern has rallied the country together in moments of crisis before, most recently in the Covid-19 outbreak, and she should now front a broad national recovery plan. It needs to be a cross-government effort and politically bipartisan. National has said it will appoint a dedicated minister for mental health. It's not just the government that needs to step up; all our public leaders and institutions need to do more. For too long the impetus for change in this area has come from passionate outsiders like Mike King and Sir John Kirwan.
There's vastly more public awareness of the importance of mental health than there was in previous decades. People are far more likely to talk about it and reach out for help if they are having difficulties than they once were. That is important progress, but now it's time for a more sophisticated national discussion, one that doesn't just acknowledge the existence of mental health difficulties, but which raises awareness of the diversity and complexity of conditions and empowers people to take control of their wellbeing and support others who are suffering distress. This must include an honest discussion of the limitations of our knowledge of mental illness, the effectiveness of treatments, and the pressures on services. In interviews, young people and parents complained repeatedly about being told constantly to reach out for help only to find that help can be hard to access. "We need to be transparent about what we can and cannot offer," clinicians at a beleaguered child service in Wellington implored their managers in one memo.
The alarming decline in young people's mental health has been happening for more than a decade now but we still don't really have a deep understanding of what is happening. There are many strongly-held theories — including the emergence of social media — but there are many complicated, intersecting factors at play. We need more research into the pressures on young people, how the pandemic has added to those, and potential interventions to reduce their impact. Health bodies need better data for monitoring mental health needs and services, and to make it widely available; the current publicly available data is patchy and outdated. A national survey of the prevalence of mental health conditions has not been held in New Zealand since 2006 and this should be a priority.
One of the main recommendations in the He Ara Oranga report was to put consumers and families at the centre of the system, supporting them to be active participants in their care and treatment. But although the government has embraced this approach in principle, interviews with dozens of service users and their parents reveal that this is still very far from the reality on the ground. Too many people who seek help experience condescension, resistance, and discrimination. "I was treated as a nuisance and made to feel like I was just looking for attention," says one teenager of the treatment she received in an emergency department after a suicide attempt. Distressed teenagers shouldn't be treated as "attention seeking". Services must be designed so that young people will engage with them.
"This is hugely traumatising for us as well," says a mother in Christchurch whose son has suffered serious depression. In recent months, the Herald spoke to dozens of parents who say they were left feeling exhausted, hopeless, and isolated by their experiences in the system. Many said they were nearly broken by the stress of trying to navigate a difficult system and left traumatised by seeing their children hurting themselves being feeling powerless to protect them. It has impacted careers and destroyed marriages. Parents say they need better communication from professionals, more education on how to cope with unwell children, and more support to help them get through it.
Teachers say they're being overwhelmed by increasing numbers of children with mental health problems, particularly anxiety-related conditions. "Nearly half my class are currently seeing a school counsellor," says one intermediate teacher. In the long-term, researchers say, building emotional resilience in our children needs to start early and be sustained as they develop, taking a holistic approach to wellbeing. Efforts to reduce stressors such as bullying are vital. For those who develop problems, there needs to be more access to effective therapies. The government should roll out its Mana Ake initiative to all schools nationally, not just the five regions it has committed to so far.
"We can't medicate or treat our way out of the epidemic of mental distress and addiction affecting all layers of society," said the He Ara Oranga report. An abundance of research has demonstrated the importance of good sleep, a healthy diet, exercise, social connections, meaningful relationships, and other lifestyle factors for maintaining and improving mental wellbeing. Over time, it's essential that we invest in and promote these behaviours if we are to reduce the stress on our young people, give them better emotional resources to manage their own wellbeing, and reduce the incidence of mental health problems. The Mental Health Foundation has called for a ringfenced budget to be allocated to mental health promotion.
One key aspect of mental health promotion is addressing the unhealthy relationship that many of us have with alcohol. In numerous reports and studies over the years, including He Ara Oranga, experts have pointed out the enormous toll that unhealthy drinking has on mental health, yet successive governments have resisted calls to address it. "There is a lot more we could be doing to reduce the harm of alcohol," says Barbara Disley, who sat on the He Ara Oranga inquiry panel, "and we've not done it."
Also essential to reducing the incidence of mental ill-health in the future is addressing the social and economic factors that cause so many people to be distressed. While mental illness isn't always a response to live events, research also shows clearly that people from vulnerable groups — those on low incomes, marginalised ethnic groups, people with disabilities, Rainbow youth — are disproportionately likely to experience mental ill-health and have poorer outcomes when they do. With the cost of living rising, housing unaffordable, growing inequality, and worsening social divisions, any improvements to mental health treatment will be inconsequential if society doesn't adequately support people who need it most.
Pregnant women and new mothers experience alarmingly high rates of mental distress, depression, and suicidal thinking, which can have huge consequences for their children later on in life. Researchers say stress in pregnancy and infancy can strongly influence a child's emotional and cognitive development, putting them at higher risk of later having problems with learning, behaviour, relationships, and mental health. New mothers, particularly those from groups at higher risk of distress (those on low incomes, those with disabilities, Māori, Pacific, Asian ethnicities) need good maternal care, a range of financial and social supports to reduce stress, and rapid access to mental health treatment if they develop problems.
Resources for parents of children with mental health problems
A host of apps, websites, and other digital services designed to improve young people's emotional wellbeing have emerged in recent years. Research has shown that the best of these services are clinically effective and experts in the field say there is vast potential for technology to reach new people and fill some of the service gaps in the overtaxed health system. However, the digital landscape is currently "poorly defined and lacks the cohesiveness and strategic support it needs to flourish", according to the Digital Health Association. Uptake of potentially useful tools by health providers is low. The group urged the government to urgently formulate a strategic plan to expand the industry.
At all levels and in all regions, our mental health workforce is desperately short of the people it needs to provide timely and effective care to those who need it. It is the biggest obstacle to improving the system. For years, New Zealand relied too much on bringing in clinicians from overseas and did not train enough skilled professionals to meet growing demand. We have a workforce that does not reflect the diversity of the patients it serves, and is desperately short of psychiatrists, psychologists, nurses, social workers, and other experienced staff. It is a problem that can't easily be fixed. The government is working on measures to address the gaps, but critics say they will hardly make a dent. A bold long-term vision is required to develop a diverse, capable workforce that includes clinical expertise and people with lived experience. In the meantime, more urgently needs to be done to retain staff who are already in the sector, who are overloaded, burnt out, and leaving in large numbers.
We can't treat our way out of a mental health crisis. We need more prevention and early intervention. Yet we also can't overlook the growing numbers of children and teenagers experiencing life-changing distress and mental illness, who need more support right now. Child and adolescent services (CAMHS), which treat around 50,000 young people with the most serious conditions every year, have been overwhelmed by the increasing numbers of patients they're being asked to see and their growing urgency and complexity, but have been neglected for far too long. Officials calculate CAMHS receive funding of $3600 per patient, compared to $5800 per patient in adult services, even though their work is just as intense and important. Two groups that urgently need more and better services are children with neurodiverse conditions, such as autism and ADHD, and teenagers with eating disorders.
According to the latest and best thinking, the optimal treatment of young people with significant conditions such as depression and anxiety is evidence-based talk therapy delivered by experienced professionals, with medication used only cautiously and with close monitoring by a psychiatrist. In reality, prescriptions of antidepressant drugs have soared in recent years while people struggle to get timely and effective therapy. We need better treatments that are consistently available and easy to access, delivered by skilled practitioners, with close monitoring of outcomes. The government should also look at funding disparities that can be a barrier to accessing therapy, including ending discrimination by health insurers against psychological conditions.
Thousands of teenagers are being rushed to emergency departments or being attended by police officers because mental health crisis teams are too stretched to support them. We urgently need a national plan to create a consistent, comprehensive service for those who develop such severe distress that they become a danger to themselves. At minimum, that means embedding mental health staff around-the-clock in EDs and creating safe, comforting spaces in those A&E departments so that young people don't have to wait hours for assessments in conditions that make them more stressed. We need better-resourced crisis helplines that don't turn people away; responsive mobile crisis teams that work closely with police and paramedics to tend to people urgently and empathetically; and safe havens for young people to go when they can't be protected in their own homes, that are staffed by a mix of clinicians and people with experience of mental illness. There should be more residential facilities for those who need intensive support.
In April, the Herald and NZME launched a major editorial project, Great Minds, to examine the state of New Zealand's mental health and solutions for improving wellbeing in the aftermath of the Covid-19 pandemic. As part of this, Investigations editor Alex Spence examined the state of services for people with the most urgent and severe problems.
In the past eight months, we spoke to dozens of people at all levels of the system, including service users, their families, clinicians, researchers, and officials; obtained data from more than 25 public bodies; and examined thousands of pages of government and health authority documents, many of which have not previously been made public.
This week, the Herald has published several stories examining the worsening mental health of our children and young people, the government's policies in this area, and potential actions that could help to resolve the crisis.
If it is an emergency and you or someone else is at risk, call 111.
For counselling and support
Lifeline: Call 0800 543 354 or text 4357 (HELP)
Suicide Crisis Helpline: Call 0508 828 865 (0508 TAUTOKO)
Need to talk? Call or text 1737
Depression helpline: Call 0800 111 757 or text 4202
For children and young people
Youthline: Call 0800 376 633 or text 234
What's Up: Call 0800 942 8787 (11am to 11pm) or webchat (11am to 10.30pm)
For help with specific issues
Alcohol and Drug Helpline: Call 0800 787 797
Anxiety Helpline: Call 0800 269 4389 (0800 ANXIETY)
OutLine: Call 0800 688 5463 (0800 OUTLINE) (6pm-9pm)
Safe to talk (sexual harm): Call 0800 044 334 or text 4334
All services are free and available 24/7 unless otherwise specified.
For more information and support, talk to your local doctor, hauora, community mental health team, or counselling service. The Mental Health Foundation has more helplines and service contacts on its website.
Enrolments surged due to increased immigration and local relocations.