The waiting game: How CAMHS waiting times are adding to young people's mental ill-health

When members of the Scottish Youth Parliament consulted their constituents about what they should campaign on in the year ahead the results were overwhelming: mental health training and education should be top of the list. With a sharp increase in the number of young people presenting in acute mental distress in the years since the pandemic, 89 per cent of the 4,100 people consulted agreed there should be mandatory training for those working in education and healthcare settings on how to identify mental health problems and provide support for all young people, especially those most at risk. The aim is to have a uniform system in place that helps identify mental health issues before they escalate into serious mental illness.

“We want to have a protocol in place that’s not being reactive but is proactive,” says Mollie McGoran, chair of the Scottish Youth Parliament board. It’s important that that protocol is the same throughout Scotland, says McGoran’s vice-chair Ellie Craig, because the inconsistency that exists at the moment means “young people across the country are getting different levels of support”. Though the members of the youth parliament are still working on how the campaign will shape up, ultimately they are looking for a commitment from the Scottish Government to ensure all schools, universities, colleges and youth groups have action plans in place and that youngsters know exactly where they can go to access information and support. Prevention, they believe, is better than cure.

“Youth work really does save lives,” Craig says. “We appreciate that the funding landscape is really difficult, but we still have to invest in young people.”

It is perhaps unsurprising that mental health is such a key concern for the younger generation given that the evidence shows that mental ill health among that cohort is on the rise while the way it manifests itself is changing. 

It is widely accepted that the enforced isolation caused by the coronavirus pandemic had a huge detrimental impact on young people’s wellbeing, but a recent paper co-authored by University of Glasgow professor David Blanchflower suggests that the mental health of young people had been deteriorating long before any lockdowns were imposed. The paper – The Declining Mental Health of the Young and the Global Disappearance of the Hump Shape in Age in Unhappiness – notes that while wellbeing used to follow a U-shaped trend, with happiness declining as young people entered middle age before rising again as they got older, it now appears to be monotonic. The evidence, the researchers found, suggests that the younger a person is, the worse their mental health is, with improvements following a linear, not U-shaped, trajectory as they age.

We are seeing more acute presentations than ever before – things like psychosis and self-harm

“There is a growing body of evidence suggesting that the rise in ill-being of the young is associated with the rise in the use of the internet and smartphones,” the paper states. “The timing fits almost exactly – both the use of the internet and the declining mental health of the young, and especially for young females, both started climbing from around 2011. Covid simply extended pre-existing trends.”

For Billy Burke, a former secondary school teacher who since last year has been head of development and innovation at the charity Scottish Action for Mental Health (SAMH), this chimes with what he has observed in the workplace.

“What SAMH has seen is that the increases in challenges in young people’s mental health started before the pandemic – we’re pretty clear on that,” he says. “There are a number of factors involved. Some of the most common research will point to global challenges like climate anxiety and we know from the work partners like Young Scot have done that there’s anxiety about the future around housing in particular. Also, young people are growing up in a digital world, a 24/7 world, where social media in particular is more prevalent than ever […] The impact on the young people we work with is increased anxiety, low mood, isolation, a lack of confidence and a whole range of other mental health issues – in the pandemic in particular eating disorders became a concern.” 

For some people that feeling of isolation or low mood can be dealt with via community support, with organisations like SAMH providing training for teachers and young peer support workers on how best to provide it. At the other end of the spectrum, though, the rise in mental ill health more generally is being reflected in a rise in the number of youngsters being referred to the NHS’s Child and Adolescent Mental Health Services (CAMHS). CAMHS, whose offering is focused on children and young people up to the age of 18, gives clinical treatments to youngsters with mental health problems that are, the Scottish Government says, “causing significant impairments in their day-to-day lives” and where community-based support has either not been effective or is deemed to be inappropriate. 

It is, in other words, for youngsters experiencing acute mental distress. In the final quarter of 2023 there were 9,527 young people facing such a situation for the first time, according to the number of new patients referred into the service in that three-month period. While that represents a drop of seven per cent from 10,241 during the same period in the previous year, the total number of referrals across the year stood at 37,812 – less than one per cent lower than the 38,081 seen in 2022. For Dr Kandarp Joshi, vice-chair of the CAMHS faculty at the Royal College of Psychiatrists in Scotland, the numbers show that “the problem is very real” but what they do not fully elucidate is that the situation has actually got worse.

“We are seeing more acute presentations than ever before – things like psychosis and self-harm,” he says. “We used to see that but not very often and we have patients who presented during the pandemic that are still with us.”

The reasons, he says, are manifold, with social-media use definitely playing a part, particularly among girls, and particularly around the stage of puberty. But one glaring problem, which was exacerbated by the pandemic and has now become deep seated, is that issues that should have been identified and addressed were left to fester.

“What has happened is that some young people have been left without assessments or without the support they need in schools and that has had a backlog effect,” Joshi says. “Children in primary schools might have been told that their dyslexia assessment was about to happen then the pandemic hit. By the time they got to secondary school it had got worse – they might have been bullied or decided to stay out of school. That’s not really mental health but they might have got anxiety or depression because of it and that’s when they present to us. There’s a link.”

The problem now is that CAMHS itself is adding to the delays. Prior to the pandemic there was a huge backlog of patients waiting to be seen, with 10,820 on the waiting list at the end of 2019. Things have improved – in the final quarter of 2023 there were 5,517 people waiting to be seen, down from 7,606 during the same period the previous year, while 84 per cent of children were being seen within 18 weeks of referral. That is a significantly better performance than the end of 2019, when just two-thirds of youngsters were seen within 18 weeks of referral, but still falls short of the Scottish Government’s pledge that 90 per cent of those referred will be on treatment within 18 weeks. And, while 50 per cent of youngsters were being treated within six weeks at the end of 2023, down from 10 weeks in the previous quarter and nine weeks in the same quarter the previous year, for those presenting in acute distress even short waits can be devastating. “For a small group, waiting longer makes it worse,” Joshi says. 

Joshi is clear that on the one hand the best way to remedy the situation is for the Scottish Government to better fund CAMHS so waiting times can be eliminated and all those referred can be seen at the point of immediate need, not just those in extreme distress. “It comes down to investment in CAMHS,” he says. “What we lack is workforce – how can the government incentivise recruitment in Scotland?”

On the other hand, he says early intervention is the key to ensuring youngsters are not presenting at CAMHS for unscheduled emergency care – something he says is “consistently very responsive” because it has to be – which itself is the key to ensuring that routine care can be better provided. 

We appreciate that the funding landscape is really difficult but we still have to invest in young people

Burke agrees. “CAMHS have increased capacity but demand has increased too and there’s also an increased need among young people who are accessing CAMHS for a neurodivergent diagnosis – the system is doing a lot of things and carrying a heavy burden,” Burke says. “The government is committed to addressing the mental health crisis in children and young people but we want to see more progress. The work that SAMH does is around early intervention and prevention.”

Some of that is exactly what the youth parliament wants to see more of, providing training to young people on how to talk about their mental health, helping address stigma, and providing signposting to the kind of services that could help before the stage of needing to access CAMHS is reached. One project goes further, ensuring that those who access CAMHS get the most out of the treatment that is offered, something that both enhances their recovery and frees up the service to treat other patients.

“CAMHS has a specific clinical role and our view is that there’s a wider support system that needs to sit under that if we’re going to reduce the number of people that are referred in the first place,” Burke says. “When they are accepted, a number of young people struggle with what CAMHS offers – it’s a clinical setting but they might be struggling to leave the house. Through the community link worker service we build relationships with the young people, whether in a community setting, in a café, in their home, and we walk with them through their journey. The young person might be totally disengaged from school and isolated, they might need a mentoring approach to get them out and active at a gym or a club. It adds a level of relationship and a level of humanity outwith the clinical setting.”

For now, the link worker service is only available in Glasgow, but Burke says SAMH would like to see it rolled out across the country. It all links in with what the youth parliament, whose members have already met with new First Minister John Swinney, is trying to do. CAMHS waiting times are a problem, but education, signposting, early intervention and targeted support are all designed to take away some of the strain and, crucially, ensure young people get help before a mental health issue becomes a matter of mental ill-health. 

“The youth parliament has had a lot of success in the past – equal marriage, the incorporation of the UNCRC, free bus travel, they all started as youth parliament campaigns,” Craig says. “We’re excited to see what change this campaign brings about.”