| Abstract |
Introduction: The provision of adequate and timely psychiatric care for children and adolescents is a key factor in the promotion of public health. The existing psychiatric services for children and adolescents in Crete are, by and large, unconnected and patchy, unable to meet the psychiatric needs of the population, which, incidentally, have never been properly estimated.
Purpose: The purpose of this research is firstly to identify the psychiatric needs of children and adolescents in the 7th Health Region of Crete based on international data and, secondly, the juxtaposition of these needs with existing services in the 7th Health Region of Crete, in order to arrive at a series of rational conclusions, for a streamlined development of Child and Adolescent Mental Health Services (CAMHS) in Crete.
Material and Method: The psychiatric needs of children and adolescents in Crete were determined in the absence of national and local epidemiological data, as «expected rates of major psychiatric disorders» based on international standards of prevalence of mental illness in this age group and the absolute number of children / adolescents in Crete as evidenced by the 2011 census. Then, we determined the number of those who are expected to seek help, based again on international data. Finally, we recorded and analyzed using the statistical package SPSS 20 (statistical package for social sciences) the intake data (first examination) from the CAMHS,
Δημόσια Υγεία & Διοίκηση Υπηρεσιών Υγείας
Τμήμα Ιατρικής – Πανεπιστήμιο Κρήτης
6
operating in the General University Hospital of Heraklion (a.k.a Pa.G.N.I.) for the last 17 years (since 1996). This way, we were able to compare the expected with the actual data of the major CAMHS in Crete.
Results: Among the 623,065 on record residents of Crete in 2011, the 61.139 are children / adolescents up to 19 years old. We estimated that 367 individuals fall within the autistic spectrum disorders (any severity) in Crete. For the 4-16 years age group (40,000 in Crete), we estimated based on published international data, that 5,320 individuals (half with a significant decline in functionality) have one or more psychiatric diagnoses (excluding speech and learning disorders or disabilities) at any 3-month point in time. Of those we estimated, based on published international data, that an average of 212 individuals per year, were expected to seek the help of the CAMHS outpatient services in P.A.G.N.I. The analysis of new cases from the P.A.G.N.I. CAMHS outpatients, showed that in the 17 years of its operation, an average of 154 individuals per year was seeking help, but this dropped to 112 individuals per year, with a slight predominance of males, when we removed referrals for speech and learning disorders and disabilities. 61.5% of new referrals arrived from the community with a clear rising trend since 2010, and 38.5% of new referrals arrived from P.A.G.N.I. wards (mainly pediatric and medical wards). 72% of new referrals arrived from the Heraklion prefecture. When these were excluded, the rate of new cases coming from rural areas rose from 29% to 40% compared to the urban centers of Crete (thus decreased from 67 % to 60 %). The most surprising finding was that new cases referred mainly to children up to 13-14 years old with declining numbers of adolescents 14 years and older, despite the expected increase in psychopathology in this age group. This finding remained even after the exclusion of cases of dyslexia / learning / language disorders, which as expected concerned the early childhood. Those adolescents (> 13 years old) who attended the CAMHS services were not referred so much from the community (parents - teachers), as from P.A.G.N.I. wards, especially inpatient females hospitalized after serious emotional (anxiety/depressive) disorders and suicide attempts. In contrast, males were referred mainly for behavioral disorders from the community (parents - teachers) in childhood rather than in adolescence.
Conclusions -Suggestions:
I. The average rate of new psychiatric referrals to P.G.N.I. CAMHS outpatients clinic per year is almost half of the expected according to international data A greater effort to increase public awareness , along with more adequate staffing of CAMHS outpatient services for timely and efficient detection of psychiatric cases. It also seems prudent to develop a separate service for children and adolescents with learning disabilities and speech disorders.
Δημόσια Υγεία & Διοίκηση Υπηρεσιών Υγείας
Τμήμα Ιατρικής – Πανεπιστήμιο Κρήτης
7
II. The pediatric and medical wards of Pa.G.N.I. constitute an important source of referrals to the hospital’s CAMHS outpatient service, and therefore, they require more support with the development of a dedicated Consultation-Liaison CAMHS service.
III. The rise of referrals from the community (parents - teachers) after 2010, may reflect the effects of the economic crisis and especially the inability of parents to turn to the private health sector. It also may reflect, without excluding the prior possibility, the fact that as of 2010 the CAMHS outpatients, were served by a second child psychiatrist. In any case, it seems that there is a tendency for an increasing public demand in child psychiatric services and therefore, the long overdue coverage and manning of the outpatient as well as inpatient CAMHS services can no longer wait. .
IV. The geographical pattern of new referrals shows the need to improve access to CAMHS services from rural and remote areas. The most economical, direct and effective way would be to establish a remote CAMHS outpatient service, using new tele-psychiatry technologies.
V. Females suffer more frequently from emotional (anxiety - depression), while males more frequently exhibit behavioral disorders, as expected. Male and female adolescent were dramatically underrepresented in the new referrals of PAGNI CAMHS services, and as a result, male adolescents with behavioral problems were almost absent, while female adolescents were referred after hospitalization in medical wards for serious anxiety/depressive syndromes and suicide attempts. It seems urgent to establish a Community Mental Health Center for Adolescents aiming to sensitize and increase public awareness (parents, students, High School, teachers, welfare, judiciary services), to detect high-risk adolescents in the general population, to practice early diagnosis and intervention in high-risk adolescent groups, in a non-medical environment. The detection and early diagnosis / intervention in adolescents is essential to prevent the negative or often catastrophic outcomes in mental health of our future adult population and therefore, it is a main determinant of public health
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