At a time when more children and teenagers are suffering mental health problems, the specialist services that treat the severest conditions are more stretched than ever, and some are reaching "crisis point", a Weekend Herald investigation has found.
Health officials, clinicians, and parents say the child and adolescent mental health services run by district health boards across New Zealand – which collectively saw about 51,000 patients last year, including some of the country's most vulnerable young people – have been overwhelmed by unprecedented demand and a workforce crunch years in the making.
Interviews with people across the sector and documents obtained from numerous health authorities reveal the problems in these services are more extensive and urgent than have previously been reported. They show while demand surged in the past few years, services across the country have struggled to provide an adequate level of care, putting patients at risk and causing staff to burn out.
Child and adolescent services, known in the sector as "CAMHS" or "ICAMHS", were already facing a rising tide of young people with depression, anxiety, self-harm, eating disorders and other serious conditions before the pandemic, and Covid-19 amplified the trend, clinicians, researchers, and officials say. But after decades of underfunding and understaffing, the specialist services are poorly equipped to respond to the growing need.
DHBs have been scrambling to recruit psychiatrists, psychologists, nurses and other skilled staff – often with little success. In some places, clinicians' caseloads reached twice the level considered safe. Inexperienced workers have been thrust into highly stressful and risky positions because there were no other staff available. Many have left the sector because they got so frustrated and exhausted.
Struggling to cope with the demand, services have increased their thresholds for admission, meaning some young people with significant mental health problems have been turned away. Those who are accepted face growing waits for assessments and therapy.
At the Capital & Coast DHB, based in Wellington, the clinical leader of the young persons' mental health services sent a memo to her bosses in January setting out "grave concerns" about the psychiatrist workforce across the region.
"There is currently absolutely no 'fat' in our CAMHS [senior medical officer] staffing," she wrote. "None at all."
Resignations and retirements had left the service so short of psychiatrists that if one took a holiday there would be nobody to cover them. "This situation puts the services and the doctors at risk," the clinical leader wrote.
Vacancies for nurses and allied health professionals across CAMHS were at "historic highs, at the same time that referrals have increased massively in the past year", she added. "Experienced clinicians have been resigning at alarming rates." The DHB would recruit replacements, but "it is very likely that many of these will have little CAMHS experience."
In April, Capital & Coast developed a business case to outsource therapy for patients with "moderate" mental health conditions to a charity, in an attempt to "blitz" its waitlist.
"It is well known that there has been a national surge in demand for CAMHS in response to the Covid-19 pandemic," the business case stated. "This has coincided with a shortage of suitably qualified and experienced clinicians with additional challenges recruiting with closed borders."
At the time, the Wellington CAMHS service was missing half of its staff, the business case said, and around a quarter of the 129 young people waiting for a face-to-face contact had been waiting for more than six months.
A specialist team for young Māori was in an even worse state, the document said.
"The service has had a significant number of resignations over the last 12 months," it said, and "this coupled with the surge in referrals during the Covid pandemic has meant we have been unable to meet the needs of young people referred to the service… Many young people and whānau have protracted wait times with no intervention unless they present in crisis. The increased wait has at times culminated in a deterioration of the mental health of these young people."
In an eight-page memo to their leadership just before Christmas, employees in the Māori team warned that the division was in a "crisis state" because of the staffing problems. They had "significant concerns" about the safety of patients who were not being seen.
"There is no transparency with the public on the challenges faced by our (and other) services they are going on referral lists for," the staff said, "thus we are not enabling them to make informed choices on their health care."
Karla Bergquist, executive director of mental health services at Capital & Coast, told the Herald the Wellington team had hired several new staff and reduced its waiting list to 94 in June, although "we accept that the waitlist remains high and acknowledge the distress this could cause to young people and their families". The Māori team is actively recruiting for several permanent roles.
"The service works continually to ensure current models, resource, and capacity are aligned with the needs of the rangitahi we provide care for," Bergquist said.
At Lakes DHB, in Rotorua, the manager of the mental health service told executives in a memo in September: "The ICAMHS workforce gap has reached a crisis point and with an increase in demand and complexity this is now a significant clinical risk."
Lakes is funded to provide mental health care to 3 per cent of young people in the region, but at the time it was seeing twice that, the memo said. Staffing pressures had "now reached a tipping point where the demand can no longer be met".
In April, the same manager gave a presentation to a public oversight committee which said Lakes' ICAMHS service was on the DHB's register of major risks listed as "critical" and was "currently unable to fully deliver the contracted service due to critical staff shortages and there is a risk of further staff leaving due to burnout and less stressful opportunities".
In a statement, Lakes said it has since recruited a senior nurse to the service and is bringing on other staff. "All ICAMHS across the country are under pressure, some of which is due to isolation and social changes due to Covid," a spokesperson said. "We have made changes to how the service is delivered to try and manage the increasing demand."
At MidCentral, in Palmerston North, a manager said in a memo in September that clinicians were "working at or above capacity".
At Whanganui DHB, a manager warned in November young people were waiting an average of three months to see a psychiatrist, "the longest it has ever been, although not exceptional nationally". The DHB said in a statement the average wait is now down to two months.
In Canterbury, the DHB's young persons' service is listed as a "major" concern on its risk register, because of capacity constraints causing "unacceptably high" waiting times for assessments and treatments and increasing the likelihood of young people suffering harm and staff burning out.
And in Hawke's Bay, concerns about the regional service there prompted the DHB to commission an external review last year. DHB officials refused to release the audit to the Herald, citing privacy concerns, and instead provided a statement saying the review had led to "significant improvements".
Several DHBs provided comments to the Herald acknowledging the pressures facing their ICAMHS divisions. Measures they are taking to mitigate them include "targeted recruitment", changing the care models they follow, reducing wait times for first contact, and improving the condition of facilities.
At a national level, the Government has commenced several initiatives for young people as part of its wider investments in mental health, although these are mainly aimed at early intervention in primary care and community settings in the hope of reducing demand over time rather than providing immediate relief to specialist services.
Last month, the Herald revealed the existence of a briefing by health officials to Andrew Little, the Minister of Health, which acknowledged serious problems in ICAMHS across the country. Despite the importance of intervening early to address mental health problems, the services were not funded or staffed to keep up with the demand, the briefing said.
ICAMHS receive funding of $3600 per patient while adult services get $5800 per patient, the document said, a longstanding disparity that "does not reflect current needs". The workforce is under "significant and increasing pressures", with staff leaving frontline positions for jobs elsewhere that are less stressful and better paid.
At the same time, the briefing acknowledged, the number of children and teens needing help has increased significantly. The number of young people seen in hospital emergency departments in crisis jumped by 177 per cent in a decade, "including a peak after the Covid-19 lockdowns", it said.
In May, at the latest budget, Labour allocated an extra $18.7 million for child and adolescent services, spread over four years, which it said would allow them to see another 1300 children annually by 2026.
Clinicians say the pressures on ICAMHS are likely to grow, with more young people needing care and no easy solutions to the staffing crisis.
"I worry about what we're going to see next," says Dr Tanya Wright, a child psychiatrist speaking on behalf of the Royal Australian and New Zealand College of Psychiatrists.
Help us investigate
This story is part of a series examining the state of mental health services and how to improve them. We need your help to continue our reporting.
If you have experience of child and adolescent mental health services, as a patient, caregiver or staff, and have information that would help us understand the pressures on services, please contact Investigations Editor Alex Spence at firstname.lastname@example.org. We will not publish your name or identify you as a source unless you want us to.
Where to get help
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.