As a young Emergency Department doctor, I developed a spiel for the kids who came in with mental health problems. ‘I do the easy bit,’ I told them. ‘I deal with the physical. Let’s get that sorted first and then I’ll put you in touch with the people who’ll do the hard bit, the important bit, and who’ll help make life brighter for you.’
Often I told them this as I stitched up gashes they’d made in their arms or legs or chests. Frequently the gaping skin, parted to reveal glistening fat or muscle beneath, lay beside rows of older scars. Sometimes there’d be no scars save their despair, and I’d be taking blood to check on their overdose. Other times, more rarely, there’d really be nothing physical at all, and my only job was to confirm that before referring them on.
That was over 20 years ago, and somehow mental illness in children has grown worse. A Welsh study tracked children through their whole childhoods: of those turning 18 in 2009, one in 17 had used Child and Adolescent Mental Health Services (CAMHS); of those turning 18 in 2023, one in five. NHS England data suggest this is not merely increased help-seeking: mental disorders themselves have become more common.
The Royal College of Paediatrics and Child Health (RCPCH) has now released the results of a freedom of information request to NHS England. Between 2019 and 2025, there was a 36 per cent rise in 6-to-17-year-olds attending A&E with mental health problems; among six-to-nine-year-olds, 62 per cent. The number spending over 12 hours in A&E rose 217 per cent, and 338 children spent more than three days there. I spend much of my professional life in these places, and after three days I’d lose sanity as well as hope. The College wants a strategy, but I’m not sure that’s enough.
Kids, even the first-timers, knew as well as I did that I was swanning in and doing the easy bit. There’s an immediate horror to the sight of an arm gashed open down to the muscle. A few stitches and it looks human again. ‘Bones heal and chicks dig scars,’ said Evel Knievel, and I used to quote him to boys. Girls feared scars far more, and I’d refer them to Plastics if I thought it would help. You could make most of them feel they were in a system that was going to help. And for those who weren’t reassured you could refuse to give in to their conviction that the world was mad or hellish and that hope was lost. Sometimes all one has to offer, in the face of calamity, is adamantine optimism that life is worth living. Optimism, not certainty, because certainty is a lie.
Tell all the truth, said Emily Dickinson, but tell it slant. What I never told the kids was how bad the mental health services were. In every hospital I’ve worked in, the CAMHS teams were those we looked to with least hope. Painfully slow, quick to find reasons why children were someone else’s responsibility, they were endlessly tolerant of leaving kids distressed and suffering in the ED. I generalise, but even the most miserable generalisations don’t cease to be true for having noble exceptions.
I never told the kids that and I never really did anything to try and help. To do that would have been difficult. CAMHS is a Cinderella service without a fairy godmother: low prestige and poor at attracting and motivating staff. Mental health interventions for children are often bitterly disappointing for children and parents. They are no less dispiriting for clinicians. Anorexia and self-harm are desperately hard to fix. Why dedicate your life to work where success is so uncertain, so difficult to see? Why should healthcare services fund what works poorly when disciplines that work well are crying out for the same money?
In children antidepressants have weak evidence of weak benefit
Behind all of this is a sickness at the heart of modern psychiatry, the temptation to mimic internal medicine, replacing the flawed, difficult and honest business of talking and listening with labels and drugs. Neither depression nor psychosis is as simple as bacterial infection. Psychiatric drugs are named as though they’re targeted cures but they aren’t. In children antidepressants have weak evidence of weak benefit. Antipsychotics suppress psychosis and suppress life. They are shut-you-up and damp-you-down drugs. They can be life-saving, but they are not biochemical solutions to biochemical problems.
And behind psychiatry there is society’s similar failure, where attempts to think about the unsolvable problems of life get replaced by labels and diagnoses that terminate thought. Diagnosis becomes a ticked box, not the starting point for asking about parents, friendships, hopes, loneliness.
Juniors stitch the wounds. Now I babysit the admitted patients afterwards, including the overdoses, while waiting interminably for CAMHS to show up and offer them a leaflet. I have never really tried to help. Had I done so, had I poured my soul into trying to make things better for those for whom life is at its utter worst, I suspect I’d have had a miserable career, that I’d have helped very few, and that I’d be filled with despair. Instead I’ve had rather a fun job, curing infection and treating heart attacks and strokes and cancers, and even when things go wrong people thank you for trying. Doing the easy bit.
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