Nuts of Normalcy for Winter
A medical colleague in Cambridge recently reported “I want to find normalcy for Christmas, my health needs this to carry on, it is urgent”. Many share his wishes. Concerns relating to serious medical problems, not related to COVID-19, have increased markedly for many (many relating to the immune system or chronic ‘stress’). Referrals for serious mental health concerns have also increased markedly, 500% or more, based on reports, including relating to professionals with no predisposing factors. Co-morbid concerns include increase in aggression and violence, often at home (at least 300%, many report 10x this figure), child abuse (nearly 100%, many report at least 20x this figure), drug and alcohol use (400%, many report 10-20x this figure). Many report “I used to have a few glasses of wine on a Saturday (1-4), now I drink every day, starting in the morning, and I mostly drink vodka (up to 9 units per day)”, 50 year old professional. We have not liaised with one person who have not reported a marked increase in alcohol consumption “due to rules, not fear of the virus”, as reported by most.
Colleagues including medical doctors are asking where they can travel during Christmas to find;
• autonomy (“where I am allowed to educate myself and follow good clinical evidence”, GP)
• a focus on good clinical evidence (eg no mandatory face masks in the general public indoors or outdoors or in flights, no mandatory tests when no clinical indication, no mandatory vaccines and boosters, and “no showing the dreaded sign on your phone that proves you have been vaccinated, so that you can enter or eat or shop or buy food i.e. live”, medical specialist).
“Crossing the Eurotunnel I am usually asked – has your dog been vaccinated – this time I was asked only one question – have you been vaccinated. It is time to follow clinical thinking for this infectious disease and this virus – it is not hard.” GP
Many are concerned that no flights offer the above 4 protective factors, “which means we are all stuck in dark prisons, because many doctors want to avoid rules not based on good evidence”, GP. Hong Kong’s Cathay Pacific has an option, however, very expensive.
Good clinical evidence is recognised not only by professionals in the field, by medical doctors with extensive clinical training and clinical experience, but also by the general public and children.
We have never been approached by more individuals in Cambridge sharing thoughts or concerns – all congruent with this summary. Various fields are represented including International Travel leads for County Councils, Criminal Justice, Health, Law, Social Care, Education, Optometrists, Dentists, Driving Instructors, Hair Stylists, Bakers and Business leaders.
Children report “I want normal to come back for Christmas, I don’t want to show a sign to be allowed to go into a shop or restaurant, and I don’t want to be forced to wear masks, I am tired of being forced every day, a mask is a symbol of submission, control and being a prisoner without a voice, I am tired of it, my friends all say it will never end”, 14 year old planning to study Law.
Referrals of CAMHS have increased by at least 1000% as reported. Waiting lists were usually 100 children, sometimes 300 for certain teams, however, teams are now reporting waiting lists of at least 1200 children.
Children are informed that they have to wait 3-5 years for an assessment (no longer 2 years).
Children are also informed that they will likely not be assessed by a Child Psychiatrist (the only medical specialist with specialist training in child mental health and neurodevelopmental problems such as ADHD or ASD). Child Psychiatrists are now informed that CAMHS (Child and Adolescent Mental Health Services) prefer to use psychologists or other doctors without specialist training such as paediatricians or adult psychiatrists, because they see “up to 10x more children per day”. Child Psychiatrists have raised concerns regarding inaccurate diagnoses, prescribing and over prescribing in this context. More at the end of this posting.
Paediatricians, nurses, social workers, psychologists, therapists, adult psychiatrists or doctors without specialist training (staff grades) and other mental health professionals, such as occupational therapist or speech therapists, are exceptionally valuable team members with valuable and unique skills required for CAMHS teams to provide families with a multi-disciplinary treatment plan to improve prognosis (short term and long term outcomes). Children cannot function well if their parents present with serious and untreated mental health problems. A systemic approach is required.
Every professional has a different perspective based on training and experience (and sometimes interest). We learn from these professionals on a daily basis and they continue to expire us. For example – We have a family therapist colleague in Cambridge, always insightful and measured, able to assist families and change a poor prognosis into a good prognosis with a few sessions. We have psychology colleagues with exceptional skills in CBT to assist children with severe OCD (Obsessional Compulsive Disorder) and various phobias, where most therapists or doctors will struggle to change a poor prognosis into a good prognosis. Psychology colleagues also provide excellent insights in terms of children’s learning profiles (different learning strengths and weaknesses); treatment plans usually require insight into learning profiles.
Paediatric colleagues offer helpful insights in relation to children presenting with head injuries, Migraine or Epilepsy, or general health concern such as cardiac problems. Medical nursing colleagues are incredibly valuable during medical emergencies due to their consistent level heads and medical or nursing contributions. Psychiatric nurses are incredibly valuable during psycho-social emergencies, many have backgrounds working as Police Officers, which makes for incredibly valuable team members due to their ability to think systemically and manage risk successfully (deescalate rather than escalate).
Benefits of working with colleagues in multi-disciplinary areas such as nurses, psychologists, different therapists, paediatricians are too numerous to describe.
Most Child Psychiatrists have extensive training and experience in assessing and managing high risk and complex presentations relating to neurodevelopment (eg ADHD or ASD) and children’s mental health, and training and experience in at least 5-6 psychotherapies, along with social interventions (knowing which child and which presentation will likely benefit from which psycho-social approach), which means medication can often be avoided or kept to a minimum, and children’s needs can be identified and met without delay.
Differential diagnoses (different diagnoses that present as similar) and comorbidities (eg children with ADHD often present with many comorbidities such as difficulties relating to depression and anxiety) are frequent in CAMHS. The word ‘CAMHS’ usually refers to Tier 3 CAMHS – children’s specialist services, and most children, at least 90%, are usually referred with complex (possibly more than one difficulty, challenge or diagnosis) and high risk presentations. This varies from team to team for example children in Cambridge often present with a lower risk compared to children in Chester. CAMHS also should have a Tier 1 (before referral is made to the GP – focussed on prevention) and a Tier 2 (Primary Care or GP level input required), also often aimed at prevention. Serious mental health problems in children such as relating to possible depression or anxiety disorders are usually referred to Tier 3. Tier 4 refers to inpatient care, which is usually avoided where possible with children (only in high risk contexts are children admitted where clinically indicated – many high risk children are not admitted). Problems such as school refusal (without concerns relating to mental health) or night terrors can often be managed within Tier 1 or Tier 2 and no specialist mental health care is usually needed.
Child Psychiatrists are now (2021) informed by medical directors or IT departments of some NHS Trusts that they continue to prefer that they work remotely, which most are happy with (many CAMHS teams have limited office space, some specialists are asked to work in kitchens or storage rooms and often no admin or computers available), however, that they need to remain in the UK during this time at all times, which means many teams are now without any Child Psychiatrist or doctor with AC status to support children under the Mental Health Act. Many, including professionals in leadership positions in the NHS for 30 years, report “this is personal and due to Brexit”, which makes little sense. Specialist children’s mental health teams are now losing specialists or have no specialists/consultants in Child Psychiatry due to these decisions, not based on national or international policies or laws. Most medical doctors or specialists are happy to be in the UK within 24-48 hours if clinically indicated for any patient including for NHS work, however, in at least 10 years, this has never been clinically indicated, required or asked of us (we have provided online assessments and consultation, remote work, including attendance of Court and Tribunals for charity and private organisations, as well as for the NHS, since 2009).
Child psychiatrists usually work in a context where social workers, emergency department doctors, nurses and other professionals work with them (with the ongoing support and consultation from child psychiatrists). In person attendance is not often required, even in emergencies. Exceptions relate to for instance hard to reach children who initially refuse to engage. In person assessments are then essential, however, in the last 10 years we know of no NHS Trusts who have offered services to hard to reach children, children who refuse to engage. Many children and families or carers report that they prefer it if child psychiatrists work remotely, because then “we can stay at home, it is easier and more practical” and many report “it is less scary”. We, as an organisation, complete regular surveys and audits in this context.
We have offered NHS Trusts remote work, online work, and we have engaged in online consultation to assess and treat children in the UK since 2009 with good clinical outcomes. Our work will not be continue with this new change in place. No national or international policy supports this change. This timing, during this pandemic, could not be worse, or more curious. There are 1500 Child Psychiatrists in the UK, 0.4% of the medical workforce. Child Psychiatrists are now on long term sick leave stating “the system is broken, children’s care is not prioritised, I can’t work like this”, taking early retirement or are leaving the UK. Many of our colleagues now work abroad.
Please see more information relating to increased risk and harm for children during the pandemic at the end of the page.
We liaised with groups of American tourists in Italy, all reported that they prioritised the above 4 items and that “this is the best time to travel”, as reported by medical doctors. None wore face masks (this was allowed in this context – being outside).
We must add that this was in October/November, before the dramatic change in the EU recently which now means no freedom of movement in the EU.
We liaised with a group of American tourists in London recently (November/beginning December), most were aged 75 to 85. Most presented with more than one serious chronic medical problem including various malignancies (many were high risk for severe COVID). Many showed their wheelchairs, prostheses, wigs and reported hair loss due to various treatments, “but nothing will stop us to live our lives, I have had two different cancers, do you think I have time to waste and I can’t think for myself”, as reported by a 75 year old. Many reported “life is for living, no day must be wasted, I have no days to waste for agendas that are not mine, when someone tries to scare you – always be suspicious, that is how wars are started, good evidence should be in charge, always, we’ve been through war in our life times, we recognise human problems when we see it, and we are doctors – we know what is virus and what is not virus.” None wore face masks (this was allowed in this context – in a hotel, pub, restaurant or outside).
Most report that they aim to avoid contexts where masks are mandatory. In the UK at the time face masks were not mandatory in any indoor establishments such as hotels or restaurants, however masks were mandatory for shops and public transport (not all taxis). Masks were not mandatory in any context in the general public, except for health settings (however masks were handed to patients with unwashed hands in hospitals) until a few days prior to our meeting.
More or less 50% of the general public wore a sign around their necks stating that ‘I am exempt’ and that they do not need to wear a face mask in any context, based on our observation in London and Cambridge, as well as surrounding areas such as Milton Keynes. Tests were required before engaging in general life such as watching a show in London, which many were unhappy with, and many in the general public reported that their friends now insist on a negative test before they visit, which is unfortunate. More or less 50% of individuals we liaised with reported that close friendships had “broken up because of imposed rules”. “Great dramas about boosters and timing and why Astra Zeneca is not available are very sad and not clinically sensible, it is clear this is political not clinical”, GP. “The little test centres set up saying ‘so you tested negative today, have another test’ is also very far from clinically reasonable or appropriate, and motives are apparent”, GP.
“Most people, at least 90%, from observation, wear masks in ways that will increase biological risk (relating to infectious diseases). There is no good evidence to support masks in the public, but if you do want to wear a mask, wear a mask safely, otherwise you increase biological risk for infection, different infections, significantly. I see people put them open on tables in restaurants, others walk by and cough on them. I see people in hospitals hand patients masks with their dirty hands, masks that have been open all day, as people walked next to them coughing and sneezing. You make a mask a little petri dish for infections and then you breathe into it all day.” GP. The WHO provides information on safe mask wearing. We have previously provided links.
Many now report “I am keeping a good eye to see which countries make their rules more strict or cruel before Christmas, because it says everything, especially when not based on good evidence, because almost all good doctors and professionals said in the Summer that this virus has no where left to go to become more dangerous (following the pattern of previous viral outbreaks in this context), now presenting with much more mild symptoms like hay fever sniffles mostly – political patterns during these days are predictable, we knew people would turn off more lights before Christmas, and I will plan where my family moves to next year by what a country prioritises – my vote is good evidence, freedom, equality, autonomy, the right to have a normal life and be educated and make your own decisions, with other words, to live in the light, not the dark ages – my vote is Florida” (medical specialist, 20 years experience). Many colleagues report that they plan to move to Florida. https://www.flgov.com/2021/11/18/governor-ron-desantis-signs-legislation-to-protect-florida-jobs/
We certainly recommend sharing concerns with authorities, however, in curious and respectful ways with the aim to learn, to educate yourself and your loved ones along with the general public, to protect and work together with all parties and all nations. Education is the first step to liberty, autonomy and collaboration.
Liberty, autonomy, education, normalcy, following good clinical (medical or scientific) evidence are very significant protective factors for general health (strong immune system), mental health and social well-being (eg peace, safety); this is based on consistent and longstanding good clinical evidence. Most medical doctors always adhere to these principles starting with first do no harm.
Many is concerned that risk is increased and harm is caused by initiatives not based on good clinical evidence, that continue and escalate, now, 2 years after the onset of this viral outbreak.
“They force you to have 3 vaccines, which is not clinically necessary or recommended for most, then they force you to still wear a face mask, never good evidence and harms many or most, then they force you to still be tested like a guinea pig for no clinical reason, and be quarantined, also no clinical reason – there is no clinical evidence for any of this, and if medical doctors did any of this, even one thing, without good clinical evidence and patient consent, it would be considered assault, this we all know”, medical specialist with law degree.
Many colleagues report that they have cancelled their holidays to countries such as South Africa, not due to the traffic light system, which most agree is not based on clinical evidence and not appropriate during this pandemic in most contexts, but due to mandatory face masks and “rules depriving liberty, autonomy and normal”, GP.
Countries offering the above protective factors at the moment (this often varies from time to time):
• States in the USA such as Florida
These countries present with much better statistics compared to many others. Countries who followed good clinical evidence from the start, such as Singapore or South Korea, continue to present with good statistics, however, many report “pressure from the old world” to follow their lead.
We want to thank the countries and leaders who follow good clinical evidence and prioritise protective factors, especially when a consistent approach is applied. You are saving lives, especially lives of children.
More nuts for the winter – more information to assist with education: Quotes, definition and helpful information (Oct and early Nov)
WHO “At present there is only limited and inconsistent scientific evidence to support the effectiveness of masking healthy people in the community to prevent infection with respiratory viruses, including SARS-CoV-2” More details at https://apps.who.int/iris/rest/bitstreams/1319378/retrieve and https://www.who.int/news-room/q-a-detail/coronavirus-disease-covid-19-masks and https://www.who.int/publications/i/item/advice-on-the-use-of-masks-in-the-community-during-home-care-and-in-healthcare-settings-in-the-context-of-the-novel-coronavirus-(2019-ncov)-outbreak
Dr A Tegnell noted that Sweden had seen fewer extra deaths in 2020 than most other European countries which imposed lockdowns (or face masks). Reuters reported in March that preliminary data from EU statistics agency Eurostat suggested that Sweden had excess mortality of 7.7% for 2020, compared to 18.1% and 16.2% for Spain and Belgium. https://www.businessinsider.com/sweden-anders-tegnell-mask-lockdown-vaccine-covid-strategy-2021-9?r=US&IR=T
Indiscriminate mandatory face mask policies have been discontinued in several countries such as Denmark, Finland, Norway and the UK. Statistics relating to serious cases identified or mortality do not increase further to discontinued face mask wearing, the opposite is often observed. https://coronavirus.data.gov.uk/details/cases
Aggressive and violent behaviour due to face mask wearing policies has increased markedly on airplanes. “The overall number of incidents (unruly behaviour) this year is already more than all flight disruptions for the last 15 years together, according to FAA data.” https://www.faa.gov/newsroom/faa-fines-against-unruly-passengers-reach-1m?newsId=26440
Statistics and Definitions: Many agree that it is important to consider statistics relating to serious cases and mortalities, and are concerned that medical data is not accurately recorded.
Many families and medical colleagues report ongoing concerns regarding ’cause of death’ reported as COVID-19 when patients presented with longstanding health problems such as malignancies or recent trauma such as motor vehicle accidents. One major leading hospital in the UK recently reported to a family that they get a “financial grant” for every COVID-19 death. The hospital did however agree to change the ’cause of death’ for the family member.
Many professionals agree that COVID-19 deaths are recorded in such a way, due to definitions or guidelines, that mortalities due to COVID-19 is likely much lower than recorded in many countries; “people who die with positive tests a month ago, who never had symptoms of covid, but died in a car crash, are marked as covid deaths …” and “many countries mark the same person as ‘new case’ in their country, because they don’t bother to take a history or to record medical information at all or accurately, whatever happened to accountability and good medical practice”, Medical specialist.
Some nations, committed to accurate medical reporting, have audited statistics, as per good medical or clinical practice guidelines. “On re-evaluation by the National Institute of Health, only 12% of death certificates have shown a direct causality from coronavirus, while 88% of patients who have died have at least one pre-morbidity, many had two or three.” Prof W Ricciardi, Italy
The WHO international guidelines define deaths due to COVID-19 as “a death resulting from a clinically compatible illness, in a probable or confirmed COVID-19 case, unless there is a clear alternative cause of death that cannot be related to COVID disease (e.g. trauma). There should be no period of complete recovery from COVID-19 between illness and death.”
Public Health England defines a covid-related death as “a death in a person with a laboratory-confirmed positive COVID-19 test and died within (equal to or less than) 28 days of the first positive specimen date”. Many agree that this definition will result in “an enormous amount of false positives”.
Most professionals agree that these marked variations in definitions and guidelines will also help to explain the different mortality rates due to COVID-19 in different countries.
We have been asked to comment on COVID-19 in the context of other relatively common infectious diseases and mortality or infection or case fatality rates. We have, but will share details on this forum in later posts. However, in 2020, before vaccines were available, the following statements were published:
• “80% of the time COVID-19 is a mild disease that feels like a minor cold or cough.” Prof P Piot, Director for The London School of Hygiene and Tropical Medicine
• “95.5% of the general population will likely not require hospitalisation, only 4.5% of the global population will likely require hospitalisation if infected with SARS-CoV-2.” The London School of Hygiene and Tropical Medicine
• “Only 4% of those younger than 20 years could be at increased risk for severe COVID-19.” This is an important and relevant statistic to consider when making ethical and lawful decisions regarding children in the context of the pandemic. “About 1 in 5 individuals worldwide could be at increased risk of severe COVID-19, should they become infected, due to underlying health conditions, but this risk varies considerably by age, for instance, the risk is 4% for those younger than 20 years and >66% for those 70 years and older.” https://www.thelancet.com/journals/langlo/article/PIIS2214-109X(20)30264-3/fulltext
• Most medical doctors agreed in early 2020, “earlier estimates that 80% of infections are asymptomatic were too high and have since been revised down to between 17% and 20% of people with infections.” https://www.bmj.com/content/371/bmj.m4851
• Organisations including the WHO have reported on previous flu (influenza and coronavirus) outbreaks and related mortality rates before the pandemic: The WHO reports “650 000 people worldwide die of respiratory diseases linked to seasonal influenza each year, up to 72 000 of these occur in the WHO European region”.
• A case fatality or mortality rate is estimated to be more or less 2% for COVID-19, some report 1-2%.
• The Imperial College, London, estimated an infection mortality rate for COVID-19 of more or less 1.15% in the UK and high income countries in October 2020.
Mortality and morbidity rates can vary depending on a multitude of risk and protective factors, and over time, as is often observed in various infectious diseases or outbreaks. These mortality rates are similar to, and sometimes lower than many other infectious diseases for many. Many medical doctors continue to manage biological risks, with a risk much higher than COVID-19, on a daily basis without face masks, but by following good clinical evidence.
We have expressed our concern regarding lack of education in the context of relatively common infectious diseases in the UK. Prevention cannot be achieved without education, especially in healthcare. Helpful information often available at https://travelhealthpro.org.uk.
Vaccines and Boosters:
Prof S Gilbert, lead scientist for the Oxford vaccine, Astra-Zeneca, reported, Sept 2021, that “immunity from the vaccine was holding up well, even against the delta variant. While the elderly and those who are immune-compromised may need boosters, the standard two-dose regimen is providing lasting protection for most people … I don’t think we need to boost everybody. Immunity is lasting well in the majority of people” and there is “nowhere left for Covid to go to mutate into a deadly or much deadlier variant … there is no reason to think we will have a more virulent version of Sars-CoV-2 …viruses tend to become less virulent over time as they spread through a population becoming more immune.” https://apple.news/AtJ4KMvbsSda6Od1APWlXtA and https://apple.news/Aqd2ODvgdRbKOdrAbWewudQ
WHO “Vaccines are effective for protecting people from COVID-19. Governments and/or institutional policy-makers should use arguments to encourage voluntary vaccination against COVID-19 before contemplating mandatory vaccination. Introducing booster doses should be firmly evidence-driven and targeted to the population groups in greatest need. The rationale for implementing booster doses should be guided by evidence on waning vaccine effectiveness, in particular a decline in protection against severe disease in the general population or in high risk populations, or due to a circulating VOC. To date, the evidence remains limited and inconclusive on any widespread need for booster doses following a primary vaccination series. More evidence is needed on the use of the different COVID-19 vaccines in children to be able to make general recommendations on vaccinating children against COVID-19. Vaccine trials for children are ongoing.” https://www.who.int/emergencies/diseases/novel-coronavirus-2019/covid-19-vaccines/advice and https://www.who.int/news/item/10-08-2021-interim-statement-on-covid-19-vaccine-booster-doses
CDC “COVID-19 vaccines are not mandated under Emergency Use Authorizations (EUAs). The Food and Drug Administration (FDA) does not mandate vaccination. People who are fully vaccinated can resume activities that they did prior to the pandemic.” The CDC recommends Pfizer-BioNTech’s boosters for individuals at high risk such as relating to age or underlying medical conditions. “More data on the effectiveness and safety of Moderna and J&J/Janssen booster shots are expected soon.” https://www.cdc.gov/coronavirus/2019-ncov/vaccines/recommendations/essentialworker/workplace-vaccination-program.html and https://www.cdc.gov/coronavirus/2019-ncov/vaccines/recommendations/adolescents.html and https://www.cdc.gov/media/releases/2021/p0924-booster-recommendations-.html and https://www.cdc.gov/coronavirus/2019-ncov/vaccines/booster-shot.html
ECDC “The majority of countries do not have mandatory vaccination in place for any population groups …The available evidence at this time regarding ‘real world’ vaccine effectiveness and the duration of protection shows that all vaccines authorised in the EU/EEA are currently highly protective against COVID-19-related hospitalisation, severe disease and death, suggesting there is no urgent need for the administration of booster doses of vaccines to fully vaccinated individuals in the general population.” https://www.ecdc.europa.eu/sites/default/files/documents/Interim-public-health-considerations-for-COVID-19-vaccination-of-adolescents.pdf and https://www.ecdc.europa.eu/sites/default/files/documents/Interim-public-health-considerations-for-the-provision-of-additional-COVID-19-vaccine-doses.pdf and https://www.ecdc.europa.eu/en/publications-data/overview-implementation-covid-19-vaccination-strategies-and-deployment-plans
Recommendations to safeguard children – most colleagues recommend ending indiscriminate mandatory initiatives, not based on good clinical evidence, where evidence exists that harm is caused and risk is increased without delay.
Most colleagues agree that face masks and vaccines should not be mandatory for children, unless specific indications, such as children presenting as high risk for severe COVID-19, then vaccines should be recommended, but still not mandatory.
Most children report significant distress and impairment secondary to mandatory mask wearing policies. Physical health, mental health and social risk is increased by initiatives not based on good evidence. Children with learning disabilities, ADHD, ASD or serious mental health problems have particular difficulties, however some children with significant anxiety report that “I will never stop wearing a mask, I can hide from the world and be safe from the world’s germs”, 16 year old. “It seems people with a premorbid personality of severe anxiety or insecurity are more comfortable with mask wearing”, GP.
Many children have not engaged in school for nearly 2 years due to school refusing to see children who had not been seen by CAMHS yet, and due to CAMHS long waiting lists. Children are harmed in many ways, considering a systemic view.
“The benefits of wearing masks in children for COVID-19 control should be weighed against potential harm associated with wearing masks, including feasibility and discomfort, as well as social and communication concerns.” WHO https://apps.who.int/iris/rest/bitstreams/1296520/retrieve.
The WHO report that “More evidence is needed on the use of the different COVID-19 vaccines in children to be able to make general recommendations on vaccinating children against COVID-19. Vaccine trials for children are ongoing.” https://www.who.int/emergencies/diseases/novel-coronavirus-2019/covid-19-vaccines/advice and https://www.who.int/news/item/10-08-2021-interim-statement-on-covid-19-vaccine-booster-doses
Please consider full guidance of every organisation on every topic.
Social risk has increased up to 4x (400%), some say more, for children due to indiscriminate mandatory initiatives not based on good clinical evidence, but with evidence that bio-psycho-social risk is increased and harm is caused. Initiatives include mandatory face mask wearing indoors/outdoors, routine testing without clinical indications, stay at home messages, curfews, lockdown, self-isolation or quarantine (including hotel quarantine). Statistics relating to increased risk published in 2020:
• 80-400% for children living with domestic abuse, parental drug/alcohol dependence and severe parental mental illness, England’s Children’s Commissioner. 18.6% of children in England (2.2 million) lived with domestic abuse, parental drug or alcohol dependency and/or severe parental mental illness before the pandemic. WHO. Ms Bhatia, deputy executive director, UN Women, reports “it provided institutional cover for people not being able to leave the house. And so it just was, if you will, the perfect set of circumstances for a perpetrator of abuse”.
• 300% in general violence. 80% in domestic violence, National Domestic Abuse Helpline. In the UK, calls, emails and website visits to Respect, national domestic violence charity, increased 97%, 185% and 581% respectively. “In the UK 14 women and 2 children were murdered in the first 3 weeks of lockdown, the highest figures in 11 years.” WHO
• 400% in alcohol abuse, Alcohol Change UK. The Royal College of Psychiatrists reported, Sept 2020, “8.5 million adults drinking at high risk (versus 4.8 million Feb 2020), while number of people addicted to opiates seeking help in April at highest level since 2015”. Bans on alcohol sales often increase use of illicit drugs.
• 30-65% in child abuse, 60% in online sexual abuse, NSPCC, 90% in child sexual exploitation, NCMEC. Baseline before pandemic: “50% of children aged 2-17 suffered violence and 75% of children aged 2-4 years regularly suffered physical or psychological violence. Globally it is estimated that nearly 50%, 1 billion out of 2.2 billion children worldwide, aged 2-17, experienced child abuse in the past year”. WHO
Mental health risk has increased up to 4-10x (400-1000%), some say more, for children due to indiscriminate mandatory initiatives not based on good clinical evidence, but with evidence that bio-psycho-social risk is increased and harm is caused. Initiatives include mandatory face mask wearing indoors or outdoors, testing without clinical indications, stay at home messages, curfews, lockdown, self-isolation or quarantine. Countries continue to report concerns such as “suicide rates soar”. We were informed of the following pattern in one example: >500 calls per day from individuals with suicidal ideation before the pandemic, 2x more during lockdown and 4x more currently (October 2021). Concerns appear to have doubled in CAMHS for children between October 2021 and December 2021, as per reports.
Children waiting for appointments at NHS CAMHS (Child and Adolescent Mental Health Services) in the UK has been described as record high (October 2021). One Child Psychiatry consultant usually sees 50 children per year, significantly less if complex or high risk cases. Many children are routinely informed that they have to wait at least 2 years for an assessment (more recently 3-5 years), which can relate to a significant increase in morbidity or complications and which can result in significantly poor prognoses.
A 33% year-on-year increase in CAMHS referrals has been reported in the UK (between 2020 and 2021). Public Health Scotland has reported that the number of children and young people waiting a year or more for specialist mental health care has increased by almost 115% in the last 12 months.
Many CAMHS teams don’t accept referrals of children who externalise, rather than internalise, or who refuse or are unable to attend clinic (due to eg social phobias, germ phobias, agoraphobias etc) which means statistics are much worse than presented.
Private organisations or doctors, often with little appropriate training or experience, are now contracted to manage CAMHS waiting lists. CAMHS teams are reporting “we are told we cannot ask questions about their training or experience, we have to work with them”. Families report that they have written to CEOs of NHS Trusts due to concerns regarding these matters, but that “CEOs often change, so by the time I wait for a response, it is a new person”, mother of 15 year old child, October 2021.
We have previously raised serious concerns regarding professionals with no training in Child Psychiatry (training or experience in identifying serious mental illness or neurodevelopmental problems such as ADHD or ASD) or Medicine (to rule our medical problems that can often present similar to mental health or neurodevelopmental problems) offering children assessments in CAMHS. It is not usual that some children wait 5 years before assessment by a child psychiatrist, referred due to treatment resistance when diagnosis was never accurate. In our experience, it is not unusual that 30-50% (sometimes 60%) of children in ADHD teams are not correctly diagnosed. It is also not unusual to identify 5 year olds on 3 different psychotropic medications (nearly always inappropriate) with serious side-effects (unacceptable).
Medical and legal colleagues, as well as senior government officials and business colleagues always insist that their children are seen by a Child Psychiatrist if presenting with concerns relating to neurodevelopment eg ADHD, ASD or mental health, why should the general public not get a specialist in a specialist service?
Comprehensive initial assessments in CAMHS, screening for serious mental illness, neurodevelopmental problems and medical problems, without delay, further to referral, providing a bio-psycho-social impression and recommendations, will improve short term and long term prognosis markedly, as well as outcomes in adult life and for the patient’s children and children’s children.
A comprehensive assessment, by an appropriate specialist, with appropriate training and experience, can often be achieved in one 90 minute session, however, sometimes 2-3 sessions are required (if complex or high risk). Let’s get this right from the start. Children often present to CAMHS with 10 lifetimes of losses, trauma and challenge, let’s not perpetuate the harm. Let’s be honest, let’s offer children services associated with integrity and honour. We teach by doing.
We are sometimes asked to allow doctors specialising in Paediatrics to attend our clinics as part of their training; it is not unusual that these doctors report that their 3 year specialist training in Paediatrics only includes 1 day of training relating to ADHD or ASD or mental health, which is the day they spend with us observing 1-3 cases (and often all 3 appointments cancel or do not arrive).
This must be compared to Child Psychiatry training (CCTs in Child Psychiatry) where doctors specialising offer direct assessment and treatment to at least 100 children per year (including ADHD and ASD) under supervision; this includes therapeutic training in at least behavioural therapies, CBT (cognitive behavioural therapy), CAT (cognitive analytical therapy), psychodynamic therapy and systemic family therapy, as well as (sometimes) creative therapies such as play, drama or art therapy. It is essential that these therapies are available at all CAMHS clinics; children presenting with a significant history of trauma or loss (most children in CAMHS in most cases) often require CAT or psychodynamic therapy to move forward and achieve clinical goals.
Children with mental health problems often present very differently to adults with mental health problems. Mental health problems, neurodevelopmental problems (eg ADHD or ASD), medical problems and social risk (eg abuse or anxiety due to threat) can often present very similar in children (differential diagnosis), it is therefore essential that professionals who offer initial assessments, offer comprehensive assessments based on adequate training and experience to ensure diagnoses are accurate. “Child psychiatrists usually screen for everything including health problems during assessments, so assessments are very comprehensive usually”, GP.
The WHO reports that medical problems are often missed in mental health patients, leading to increased morbidity and mortality (life expectancy reduced by up to 20 years). Clinical goals should include accurate diagnoses for children.
Recently, the focus in Health is on financial or political matters, however, the focus needs to be on clinical matters if reduced morbidity, reduced mortality and good clinical outcomes are the goals.
Most child psychiatrists agree that the “NHS could have a good capacity to meet the children’s needs if there were fewer managers (routinely 5 per doctor or therapist in some clinics), especially with zero child psychiatry or medical experience, more or some admin support, more private offices with desks as well as general support for the professionals in the team, especially listening to the professionals when they identify problems, such as I need someone to post my clinic letters on time”, as reported by a child psychiatry consultant colleague.
Statistics relating to increased risk published by MIND, Young Minds and Samaritans in the UK, 2020:
• 75-80% in mental health concerns for individuals with a relevant mental health history
• 55% increase in mental health concerns for individuals without a relevant mental health history
• marked increase relating to self-harm and suicidal ideation or attempts
Baseline statistics prior to the pandemic indicate that in England more or less;
• “1 in 4 people will experience a mental health problem of some kind each year,
• 1 in 6 people report experiencing a common mental health problem in any week;
• 1 in 5 people have suicidal thoughts,
• 1 in 14 people self-harm,
• 1 in 15 people attempt suicide,
• 1 in 8 adults with a mental health problem are currently getting any kind of treatment.”
Many believe statistics are “better for children compared to adults”, however, this is not the case in most domains, and most children with social risk or serious mental health concerns are not identified. Many believe “mental health problems get better when you get older so longer term consequences will not be severe”, however, considering a global perspective, prior to this outbreak, in developed and developing countries, as reported by the WHO, “depression is one of the leading causes of disability. Suicide is the second leading cause of death among 15-29-year-olds. People with severe mental health conditions die prematurely – as much as two decades early – due to preventable physical conditions.” The WHO commented 20 plus years ago that “around 450 million people currently suffer from such conditions, placing mental disorders among the leading causes of ill-health and disability worldwide.”
Mental health problems can occur as once off presentations, as recurrent presentations or chronic presentations, much like many medical problems. Individuals who have presented with a mental health disorder once, such as depression or an anxiety disorder, are usually at risk for recurrence; prevention (or preventing escalation or deterioration) is therefore the key to effectively managing most mental health disorders. Prevention starts with evidence-based protective factors.
Evidence-based protective factors for general health, mental health and reducing social risk include, but is not limited to, normalcy, education, autonomy, liberty and maintaining a calm and positive mental state / environment. Confidentiality and consent are also important items to protect the general public in the context of Health.
Respecting Consent: Most agree that the gathering of genetic, biometric or personal data through COVID testing, or when sharing evidence of vaccines, should not be allowed, this includes personal photographs, personal videos, date of birth and personal addresses (date of birth and personal address can be shared as part of medical information on medical documents to be kept secure and confidential as medical records by medical/health services), considering that some governments have collected human DNA samples (not only viral genetic data) without patient consent during COVID tests (many doctors are concerned that this has prevented the public from getting tested if symptoms or concerns) https://www.gov.uk/government/publications/coronavirus-covid-19-testing-privacy-information/testing-for-coronavirus-privacy-information-quick-read–2 and considering some individuals work in high risk fields such as Police or individuals working in child protection contexts.
It is relevant to consider data relating to violence at work, March 2019, https://www.hse.gov.uk/statistics/causinj/violence/work-related-violence-report-19.pdf, and to consider that this research was not focused on individuals working in high risk fields, where stalking behaviour, threats, aggression and violence can be common. It is relevant to consider the recent increase in violent behaviour, as reported earlier. Violence (or threats) at work in CAMHS or Social Care settings has increased markedly, as reported by colleagues.
We thank you for your time.
Many of these observations and concerns have been shared with appropriate authorities in the UK, the EU and abroad. Many authorities, government officials and professionals including medical doctors share these concerns, and confirm this to us in writing. Most agree that a systemic bio-psycho-social approach, always considering bio-psycho-social risk and protective factors, and following only good clinical evidence are essential to achieve good clinical outcomes. National and international health organisations as well as organisations safeguarding children have requested to remain on our mailing list since March 2020.
A congruent and consistent approach is required and urgent – between government, health professionals and the general public, and also between nations – to achieve clinical goals. Clinical goals have to be defined as reducing general health, mental health and social risk (and harm) for children and adults, high and low risk, equally.
A global health plan is essential to move forward and to protect nations.
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