Warning: This article discusses self-harm and mental health problems and could be distressing for some people.
In April last year, Erin*, an Auckland businesswoman in her 50s, got a text message from her husband that stopped her cold. James* had been tidying their 14-year-old daughter's bedroom when he found evidence that she'd been self-harming.
"It was hard to believe," Erin says. As a child Lucy* had shown signs of anxiety at times, but mostly she was happy. It had never occurred to Erin that Lucy would become so distressed that she would hurt herself.
A few years earlier, the family had moved to Auckland from the US, where Erin and James had successful professional careers; Erin, who was born and raised in New Zealand, wanted Lucy and her sibling to get a taste of the Kiwi upbringing she had enjoyed.
Erin thought Lucy had adjusted well to the change, even in the early stages of the Covid-19 pandemic, when so many young people struggled with the disruption to school and social routines. Lucy was popular, involved in sport, and seemed to be doing well at school.
When Erin and her husband confronted Lucy about self-harming, Lucy admitted it right away.
They took her to their family doctor, who referred Lucy to a private psychiatrist and psychologist. The waiting list for the psychologist was five weeks. The wait to see the psychiatrist was five months.
"Her mental state rapidly deteriorated from that point," Erin says.
While Lucy waited for private treatment, she withdrew from her social life, stopped playing sports, and found it hard to go to school. She self-harmed every day, Erin says.
One night Lucy injured herself so badly that her parents phoned Lifeline and a counsellor told them to take Lucy to hospital.
They waited five hours in an emergency department to see a psychiatrist, who arranged an assessment the next week at one of the Auckland child and adolescent mental health services that treat young people with serious psychiatric conditions.
When Lucy saw a psychiatrist at the service, she was diagnosed with depression and generalised anxiety disorder and prescribed antidepressant medication.
"They told us that she would take them for a year and then probably be fine," Erin says. "We were so relieved to finally get some acknowledgement and help."
But the family's ordeal had only started.
Over the next several months, Lucy's mental health fell apart.
The antidepressants had disruptive side effects and didn't improve her mood. She saw another psychiatrist who put her on a different drug, but the side effects of that were worse. By the end of 2021, Lucy had developed such severe social anxiety that she couldn't leave the house without having a panic attack.
Her moods were increasingly volatile. She spent more than a dozen hours a day online. Erin and James argued about whether they should try to remove her devices and access to the internet, or if that would just take away the last thing distracting her from her anguish; the advice they found from professionals on what to do seemed ambiguous.
Erin says they struggled to find a treatment that worked.
Erin and James are driven, resourceful people who made a good living grappling with hard problems, and they approached Lucy's situation with tenacity and purpose. But they kept running into dead ends, Erin says.
They bounced between an understaffed public system that is overburdened with children even more acutely unwell than Lucy, and a private market that is also desperately short of the expertise needed to help young people with complex conditions.
They believed Lucy needed medication but say they were offered nothing after the first two drugs didn't work. Lucy says, "I felt like after the antidepressants didn't work that my psychiatrist almost gave up on me."
They believed Lucy needed specialised therapy but couldn't find a psychologist with the expertise to help her. Erin says they reached a "complete dead-end on what to do next".
James left his job to care full-time for Lucy. They tried easing Lucy back to school, but she couldn't cope with it. "She never made it back," Erin says.
Stuck in limbo
Erin and James are among more than 50 parents of young people with mental illness who spoke to the Herald as part of a major investigation into the state of mental health in New Zealand.
In the past eight months, we spoke to dozens of people across the system, including service users, frontline staff, researchers, and health officials; reviewed data from numerous public bodies; and obtained hundreds of documents that have not previously been made public.
One of the major themes that emerged in our investigation was the worrying decline in the mental health of young people and the gaps in support available for them. Even before Covid, rates of psychological problems among children and adolescents were steadily increasing, for reasons that researchers and medical professionals say are complicated and not yet well understood. The pandemic accelerated that trend.
Government documents and data obtained by the Herald reveal there have been significant increases in the past two years in the numbers of young people presenting to EDs after self-harm or suicide attempts and experiencing acute, complex conditions such as anxiety and eating disorders.
It is a development that families, schools, primary health providers, and specialist mental health services — depleted by years of underfunding, bad planning, and shortages of psychiatrists, psychologists, nurses, and skilled staff — are struggling to respond to.
According to medical experts, the best treatment for a teenager experiencing significant anxiety and depression, like Lucy, is evidence-based talk therapy delivered by experienced health professionals who work collaboratively and supportively with the young person, their family, school, and so on. Medication should be prescribed cautiously, not on its own without psychological therapy, and carefully and regularly monitored.
But parents say it is increasingly difficult to access or sustain that bundle of effective care in a system that is more stretched than ever.
Medication use has substantially increased, according to data obtained from Pharmac.
Last year, 218,312 prescriptions for antidepressants were given to people aged 15-24 (up 147 per cent in a decade); and 19,015 to people aged 5-14 (an increase of 205 per cent), according to the medicines agency's figures.
There were 82,741 prescriptions for antipsychotic medications given to people aged 15-24 (an increase of 143 per cent in a decade); and 9,917 to people aged 5-14 (a 140 per cent jump).
These stark increases have generated surprisingly little public discussion but are a source of growing unease in the sector. In May last year, two prominent researchers at the University of Auckland said that although some people improve markedly on antidepressants, the benefits in children and adolescents are usually modest. The drawbacks can be major, including increases in suicidal thinking and self-harm in some users.
When antidepressants are prescribed, Professor Sally Merry and Associate Professor Sarah Hetrick said, "they should be used in combination with evidenced-based talking therapy, the most common being cognitive behavioural therapy (CBT), and there must be a commitment to ensure close monitoring of their impact".
Many of the parents who spoke to the Herald said they had problems with medications — the drugs were wrongly prescribed, they didn't work, they caused harmful side effects, they weren't reviewed properly — but finding good therapy for their children was even more challenging.
In theory, there should be a range of competent therapists across the private and public sectors able to cater to a spectrum of needs, with primary care providers, schools, NGOs, private counsellors, online platforms such as Mike King's Gumboot Friday, and other community services to help those with moderate problems, and specialist mental health services for the most urgent and serious cases.
In reality, all parts of the system are strained by severe funding and staffing pressures.
Specialist child and adolescent mental health services — which are known as "CAMHS" or "ICAMHS" and operated by Te Whatu Ora/Health New Zealand — are the sector's "ambulance at the bottom of the cliff", seeing around 50,000 people with severe conditions every year, but they are poorly equipped to cope with the rising tide of distress after years of underinvestment and poor planning by successive governments.
A series of articles by the Herald has revealed how CAMHS across the country have been pushed into crisis by soaring demand, greater complexity and acuity of the patients they're seeing, and a severe shortage of psychiatrists, psychologists, nurses, and other staff.
After one of the stories, Health Minister Andrew Little said, "It's under huge pressure. There are areas where I know young people in particular are struggling to get the specialist attention that they need, waiting a long time to get it. That is in crisis. Child and adolescent mental health services are in crisis."
With demand growing, services have raised thresholds for admission, making it harder for GPs, school guidance counsellors, NGOs and others to refer even acutely unwell children for specialist treatment. For those patients who are accepted for treatment, there are lengthening delays for assessments and therapy, constant changes in the staff they interact with, and care that can be of inconsistent or inadequate quality.
Staff turnover in the services is high. Vacancies are hard to fill. Those who remain are carrying growing caseloads. Inexperienced staff have been thrust into stressful and risky situations. Morale is low and burnout is high.
In March, a departing senior psychologist in the Capital & Coast district health board (now part of Te Whatu Ora) wrote to their managers raising concerns about the wellbeing of their colleagues. "Many (if not all) [of] my colleagues carry high caseloads, to the extent that they are likely unable to offer consistent and high-quality service to all their clients," the psychologist wrote.
"My colleagues at CAMHS are diligent, exceptional clinicians, hard-working and deeply care about the clients and families they provide a service for," said the letter, which was obtained by the Herald under the Official Information Act. "I have observed many members of the team, particularly in the last few months of my employment, exhibit signs of increased stress, tiredness, and exhaustion."
Eight of the psychologists' colleagues had completed a burnout survey using a standard measurement tool and all but one of them scored highly. "I have heard several psychologists comment that a full-time CAMHS role is unsustainable," the psychologist said.
Out of options
The capacity constraints leave young people like Lucy stuck in limbo: Too unwell and complex to be properly supported by a GP or school counsellor, but not acutely distressed enough to be a priority for specialist services.
Erin says the family cobbled together what support they could for Lucy, including regular talk therapy sessions with a private psychologist who didn't have the expertise to deal with Lucy's specific anxiety problems but did at least establish a rapport with her.
"He didn't really help me very much, but he did listen," Lucy says.
Erin spent a lot of time researching treatments and therapies available in other countries, but says she was frustrated that when she raised these with psychiatrists, they seemed powerless to offer more than the interventions they had already given them.
"The providers delivering services are not bad people," Erin says. "They do their best with the resources available. Some of them seem to care deeply, but others seem burned out and no longer able to empathise with seriously ill patients and their families."
Erin says she felt that Lucy's self-harm wasn't approached seriously enough. She says one doctor told her it was "normal teenage behaviour" that the service saw in a lot of its teenage patients.
"I told him I did not think it was normal for a child to not be attending school and for her parents to worry about whether she was alive or not every time we went into the room," she says.
A few months ago, the family went back to the US for a visit. While they were there, the family spent time looking at mental health providers and facilities that might be able to help Lucy.
For all the flaws in American healthcare — not least the exorbitant cost — Erin says they found vastly more options there than they could in New Zealand, at different levels of intensity, including outpatient and residential programmes. They also looked at special schools that would help Lucy reintegrate into mainstream education.
They decided to move back to the US when their other child finishes this school year, so Lucy can enter an intensive outpatient programme to treat her anxiety disorder.
"It's not the dream I had for my family when we moved back to New Zealand," Erin says. It means giving up her job in Auckland, selling their house here, and the upheaval of another international move at a time of immense economic uncertainty. But they feel there's no choice — that Lucy will keep getting worse, and her life will be in danger, if they don't get effective treatment soon.
"We think we need to do something to help Lucy and cannot see any further options here," Erin says.
Erin knows the family's financial position and roots in the US gives them an alternative that most Kiwi families grappling with this problem don't have. People sometimes tell her they're lucky. "Somehow I don't feel lucky," she says. "I just feel worried and distraught about my child."
*names changed to protect privacy.
About this series
In April, the Herald and NZME launched a major editorial project, Great Minds, to examine the state of New Zealand's mental health and solutions for improving wellbeing in the aftermath of the Covid-19 pandemic. As part of this, Investigations editor Alex Spence examined the state of services for people with the most urgent and severe problems.
In the past eight months, we spoke to dozens of people at all levels of the system, including service users, their families, clinicians, researchers, and officials; obtained data from more than 25 public bodies; and examined thousands of pages of government and health authority documents, many of which have not previously been made public.
This week, the Herald is publishing several stories examining the worsening mental health of our children and young people, the government's policies in this area, and potential actions that could help to resolve the crisis.
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.