Professor Brendan Kelly:

The point about anti-depressants is an interesting one. Generally speaking, Ireland is a low-medication society. We are on the EU average for anti-depressants in adults. In children, the rate of prescribing anti-depressants was 4.7 per 1,000 in 2002. That fell over subsequent years to 2.6 per 1,000. It is important that medication is only used when appropriate and, when indicated, always as part of a broader treatment plan.

With regard to Senator Ó Céidigh's comment, I support the idea of the pyramid very strongly, and our comments focused on the top of that pyramid. That is the part that one is involved in professionally, and as a citizen and as a parent one is aware of the need for intervention in schools and of the sociological awareness that deprivation is a huge driver of distress at population level.

With regard to a Friday night in an emergency department in a hospital, as a general adult psychiatrist on call, I have been in all the major hospitals. One would commonly see a 16 year old or 17 year old child who presents with a very distressed family, possibly following self-harm or an overdose. His or her medical needs are attended to by the emergency department staff but then comes the difficult part, which is dealing with the underpinnings of what brought that child to this point. The emergency departments in our hospitals are busy and noisy places. I have always been impressed by the way the staff try their best to accommodate the emotional and psychological needs of children and families, but they can only do so much. I see the person, or the junior doctor might see the person, and if the child or young adult requires inpatient care, we embark on the search for a bed. It is not always the case that they need inpatient care as the vast majority do not. We seek a bed in a child and adolescent unit. When a child might need to be admitted to an adult unit, we need to fill out a statutory Mental Health Commission form detailing the efforts we made to find a bed in an adolescent unit. We try to phone every single one in the country during the middle of the night. I might be in at 2 a.m. and spend three or four hours on the telephone trying to see if there is a bed but knowing in my heart that if I am in Dublin and I do identify a bed in Cork, it is very unlikely that it is the right move for the patient or the family. It can be very difficult at night to do that anyway, and it is under that kind of circumstance where there is no other alternative that a child is admitted to an adult unit.

I share the experience of my colleague, Dr. Begley, in that I have been impressed by the adult psychiatry staff's efforts to make special bespoke arrangements for any admitted child, but it is a fact that most of the admissions do not meet the requirements in terms of educational provision for children or separate occupational therapy for children. We do it in the circumstances described and it has always been with the support, as it were, of parents or guardians who appreciate that this bad option is the best of the bad options.