‘Not licensed for use in children, but I prescribe them anyway’
Dr David Turner argues that failures in children’s mental health services are forcing GPs to break the rules
The patient in front of me is a child, and is very ill. There is a not insignificant risk that they could die. In most situations I would refer them urgently to the paediatricians, but unfortunately for them their illness is of the mind – not the body – and I cannot get them seen by a specialist for weeks or months.
My professional duty is to do my best for the child, I prescribe a treatment for them, the medication states:
‘Unlicensed use. Not licensed for use in children.’
This is what the BNF says about SSRI use in children. These medications are unlicensed and hence should only be initiated in people under the age of 18 by a psychiatrist. Yet GPs do this every day, as highlighted last month.
Access to NHS mental health services is generally terrible for all parties involved, but it is particularly bad for under 18s. For full disclosure, I should state that I regularly break the rules and prescribe antidepressants in children; and I have never received anything other than gratitude from the children and their parents for helping them.
The number of children presenting with mental health problems has spiked in recent years – particularly since Covid. The mental health service for young people, CAMHS, which was already on its knees pre-pandemic, is now just unable to meet the demand for its services in anything like a reasonable time scale. In 2023/24, just shy of 80,000 young people who were referred to CAMHS had to wait over 12 months for treatment; an increase of 52% on the previous year. The average wait to be seen in 2023/24 was 392 days.
As GPs we are regularly left with a serious problem: a seriously depressed and/or suicidal young person and only two tools in the box to treat them; antidepressants and/or talking therapy; both of which could take months or years to access through the NHS. This is a moral dilemma that many of us face each week.
The situation is appalling and unimaginable in any speciality other than mental health. Imagine the outcry if haematology or cardiology said they had over a 12 month wait to treat children with life threatening blood or heart conditions?
For some reason psychiatry has always been seen as ‘different’ to other parts of medicine. To the extent that many mental health trusts are geographically and administratively separate from the rest of the secondary care trust. A fact which further emphasises how the speciality is not always seen as ‘important’ as other areas of medicine. Politicians love to have their photo taken standing in front of shiny new cancer and cardiac centres, but when did you last see an MP at a photo shoot in front of a new mental health unit?
The biggest problem is that mental health service capacity is nowhere close to matching demand. As a frontline GP, the other problem I see is the number of referrals for neurodiversity we are making has shot up. By and large, neurodiversity issues are not usually life threatening but depression and severe eating disorders can be. A sinking secondary care mental health service is being pushed under further by the sheer volume of referrals for neurodiversity being made to it in this current ‘epidemic’ of requests from those who suspect (or whose parents suspect) they are not neurotypical.
Long term, there is no other solution than huge investment in secondary care mental health support services for children. In the short term, I feel we have no choice but to ration care. In the same way we might expect a child with anaemia to wait longer to see a haematologist then a child with suspected leukaemia, maybe it should be made clear a diagnosis of suicidal depression takes priority over suspected ADHD.
I know, I probably shouldn’t have said all that, but I did. And I stand by it.
Dr David Turner is a GP in Hertfordshire
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READERS' COMMENTS [11]
Please note, only GPs are permitted to add comments to articles
Good highlighting of a troubling dilemma for many GPs. Some would say that we’re not investing enough in mental health services, and others that there is over-medicalisation of some mental health, MH, disorders (eg ADHD, ASD, eating disorders etc).
But my view is that the rot started when bored Rene Descartes erred by splitting the human into a mind-body dualism. Enlightenment successors then rushed to build on his error, eager to place Reason at the centre of life, and to secularise society, turning it away from (whole-person, or holistic) religion.
It’s known to all that work in the caring professions that MH disorders aren’t detached from the body, and are subject to factors such as nourishment, the house one lives in, the family, and society (whether it’s a caring one, or not). So the solution must surely be located, not only in a MH referral, but also in improving those causes that impact such as the person’s financial security, housing, family support, education etc.
Politicians imagine their responsibility discharged by foisting these patients onto underfunded GPs to refer to underfunded MH services! This is the opposite of the Age of Reason.
We’re in the Cul-de-sac of Joined-Up Stupidity.
Where the service doesn’t make suicidal kids in the same queue as those awaiting adhd assessment but the waits are still not great. I don’t see how they can justify using no triage system though. I’d also point out that there are probably a higher number of children awaiting neurodiversity assessment who also have mental health problems particularly as it seems school in this era does not suit so many of these kids.
A depressed and suicidal child is always going to be more urgent than a child with ADHD (only).
If the child was immediate high risk and no CAHMS/ crisis team to see then you should send to ED.
Mental health has been hollowed out and under funded for years. It’s the canary in the coal mine where the experiment of flattened hierarchy and allied health professionals triaging and undertaking initial secondary assessment is well and truly failing.
Dear Dr David Turner
I recognise your personal need to help, but the inadequacies of the standard service are not your responsibility to put a sticking plaster on. You may avoid an individual catastrophe but you delay the urgency of the correction of dangerous service
Whenever I criticised the response times in CAMHS, I was denounced as exagerating and spreading falsehooods. The service has always been available in timely fashion to all children needing help at any time.
I also remember once being approached on a Friday afternoon, I think shortly after school finishing time, by the children’s counsellor working from a room in the surgery, who was “concerned” about one of the young people he had just seen.
He was asking what could be done, implying that same day, as ‘safeguarding’ support.
I replied to the effect of “we can make a cup of tea. Is she still here?”.
He rephrased that he meant ‘to whom could we refer’.
And I reiterated the point about the tea and chat – as it was after lunch in Friday, this was a problem the GP was expected to deal with to the best of their ability until after the weekend, and that I was prepared to do that.
He was quite shocked.
I would not refer that child to A&E, since our local A&E only had a GP trainee for the patient to see, and I was a qualified GP, on call for the whole weekend, with, in theory, a lesser workload than the A&E trainee. Plus the A&E is not in our town, but up to an hour away by car, longer if you have to wait for the train (which don’t run overnight).
Before I recently retired, it was a known ‘fix’ to start children on prozac then refer to psychiatry.
They would be given a urgent appointment to stop the prozac! ‘We stopped knowing who our psychiatrists were about 10 years ago as the turnover was so fast. We used to have dynamic pragmatic consultants in post for decades and we could speak to them to discuss problem patients. How this country gets away with such a failing service beggars belief.
Vicky Cleak, great comment. They’re now doing the same in other areas of medicine because it has worked so well in psychiatry
In seemingly high acute risk circumstances in the piece above , theres only so many times (zero in my case) you’d want the headline to be:
“Child takes own life after GP prescribes unlicensed medication known to increase risk of suicide”
Good luck with the GMC and MDO on that.
The evidence has only grown in recent years that in any form recognizable to a GP or useful to a patient, CAMHS does not in fact exist.
But to step in and take on their functions is not a fix, and should not in my view be countenanced. We work bloody hard within our generalist role, with an increasingly unreasonable demand that we go ever broader and ever deeper. And while we expend untold appointments on this placeholding for secondary and specialist care waitlists and service voids, patients who can’t access us for our core generalist role present to ED instead and complain anon.
I prescribe to under 18 year olds as well. I’ve dealt with nearly 17 year olds who have been discharged from CAHMS with the advice to see your GP to start medication and contact the adult Talking Therapies. It’s time adolescent MH services look after young people until they’re 25. You’re certainly not an adult at 16, or when you’re at school. We need to invest in the mental health of these young people and ensure they’re settled into jobs and adulthood.
Like @JustaGP, I too will not prescribe antidepressants in children, for reasons of self-protection.
Possibly some wriggle room if young person is, say, 17years and 11 months old, but even then I may say “start it in 3 weeks time”.
When a child commits suicide and it is blamed on you for prescribing an antidepressant where will you stand?. Will you be indemnified for prescribing out with your expertise. Will the GMC take kindly to your dilemma? NO!. You are not responsible for the failings of the government to fund the health service . Refer on as you would expect to do for other emergencies.