Dr. John Hillery:

I thank the Deputy. I again make the point that we are not entitled to do any annual review of CAMHS except its inpatient services. The staffing issues come into the assessments. I will ask Professor Lucey to talk a little more about that, if the Deputy likes and if we have time.

On the monitoring of medications, it is well known internationally that, unfortunately, people with intellectual disabilities are much more likely to be on major psychiatric drugs, often without any psychiatric diagnosis. Some of that is because it is difficult to make a diagnosis but a lot of it is due to trying to manage behavioural issues by using medication rather than by dealing with the environments that are causing those issues. We have made a lot of strides in that regard in that we have services that are now trying to give people individualised community-based environments. People are being taken off medications they have been on for ages and it is to be hoped younger people are not being put on them. However, it is an issue about having resources, having people in environments they can deal with and realising that medication is not the answer.

Unfortunately, my experience is that it is often not psychiatrists who are trying to push medication. We are often trying to reduce it but many people feel that if we do that there will be problems. It is an ongoing issue. There is a programme in the UK, stopping overmedication of people with a learning disability, autism or both with psychotropic medicines, STOMP - I am a psychiatrist who works with people with intellectual disabilities so that is why I am speaking from experience - that many of us in Ireland adhere to and try to take people off medication.

There is something else which I referenced, namely, situations where somebody is at home and very disturbed because the home does not meet his or her needs, whatever the nature of the disability is. Such people are often put on medication first by the GP and sometimes by people like me to try to make the situation safer for those around them. It is not good but it is because we are trying to do our best in situations where we cannot get anything else done. The main way of stopping people being put on medication is, first, the awareness that a lot of behaviours are not due to mental illness but to the environment, and that we need to give people environments that will help them not have to show behaviours that are difficult. That is an ongoing battle but people are now aware of it. It also means that we need people who are trained, like me, to review people and take them off medication. If people are not reviewed, they can just be left on medication for years.

As regards the waiting list, that depends on where people are in the country. Dr. Finnerty referred to that. There is a list in the full report of areas of the country that are worse than others. I cannot give any more information in that regard.

On dual diagnosis and nobody filling the gap, there is definitely an issue regarding people with autism, when they have a mental health problem, having it dealt with properly. There is a lack of access. To my mind, there is not a gap. We do not need a new service or new system. We need to give people access to the services that are there. The dual diagnosis is similar to me having two diagnoses, for example, arthritis and gastrointestinal problems because of the medication I am on for that arthritis or for other reasons, where I would get access to two different specialties, depending on the waiting list. We do not seem to have met that so well in psychiatry, some of which is due to culture and some to resourcing. Once again, I will go back to the message I keep giving. If we had a national set of standards and a body charged with monitoring and implementing them, that would be less likely to happen.

One of the issues with children and adult facilities is that we do not have enough out-of-hours places for children under stress. Not all of them have mental illness. A child may be threatening to harm themselves and not have a mental illness. They need a place of safety or someone to support them. A child may have a mental illness and we do not have an inpatient bed for them to go into because we do not have enough of them. There are a few different reasons people turn up in accident and emergency. A colleague of mine is an adult psychiatrist, who says she has seen more children and adolescents than any of the other child psychiatrists in her area, because she is seeing them out of hours. They turn up in accident and emergency. People feel they have to respond in some way, and it can happen that the children end up in adult units. It should not happen. It is not just about resourcing psychiatry but the other things needed by children under stress. The Deputy will know from his constituency work that a lot of that is not to do with mental illness. It is mental health, but not mental illness. They need access to other facilities. That goes back to what we spoke about earlier, which was having a joined-up system with a central triage where if someone presents with something, there is somebody who can make a decision as to where that person needs to go.