Warning: This article discusses suspected suicide and mental health problems and could be distressing for some people.
On a Friday in late 2020, Lisa* tried to kill herself.
A softly spoken Auckland teenager with a talent for making TikToks, Lisa had been depressed for months. She was at home from school on a teacher-only day when she was suddenly overwhelmed by despair. "I couldn't take it anymore," she says.
Lisa's mother rushed her to the emergency department at a major hospital. It was busy and the triage nurses on duty seemed frantic. When one of the nurses came to assess her, Lisa was taken aback by her curtness. The nurse asked Lisa if she planned to hurt herself again but hardly waited for her to answer before flinging a hospital gown at her. "Put this on," the nurse said, pulled the curtain across, and left. Soon, a doctor arrived whose manner didn't make Lisa feel much better.
"I was treated as a nuisance and made to feel like I was just looking for attention," she says.
For nearly two days Lisa stayed in the ED, under constant watch by a healthcare assistant, before mental health staff came to do a psychiatric assessment. They seemed to be in a rush. They recommended that Lisa be admitted to the psychiatric unit at Starship children's hospital. Two other staff transported Lisa there, spending most of the drive chatting to each other and ignoring Lisa. "It was awful," Lisa says, still angry about the experience two years later.
Lisa says the way she was treated was invalidating, added to her distress, and made her reluctant to ask for help the next time she was feeling suicidal.
Lisa's account echoes that of dozens of other young people who shared their experiences with the Herald as part of an eight-month investigation into the state of mental health care in New Zealand.
Dozens of interviews with service users, parents, frontline staff, officials, researchers and others, along with a review of hundreds of documents that have not previously been made public, in the past eight months have exposed how a disjointed, underfunded, and understaffed mental health system is struggling to cope with a significant increase in young people experiencing mental health difficulties.
Even before the coronavirus pandemic, rates of children and teenagers displaying symptoms of major psychological problems such as depression and anxiety were rising steadily, for reasons that are complicated and not well understood. Covid-19 has amplified this trend, aggravating problems for people who were already vulnerable and triggering new episodes of mental illness and distress.
For some of these young people, the distress becomes so overwhelming that they experience a mental health "crisis", which could lead to them to violently injure themselves or become suicidal. Last year, mental health services saw 8,919 children and adolescents in crisis, according to figures from the Ministry of Health, up 20 per cent on five years ago.
Depleted by years of underinvestment and poor planning, mental health services have been unable to keep up with the growing need. There are major gaps across the system, but in interviews people with first-hand experience of mental health services repeatedly stressed the lack of adequate support for people in crisis as an important and urgent challenge.
Across the country, mental health services around the country are so stretched that desperate parents say they often have no choice when their children experience a mental health crisis but to take them to Accident & Emergency or to call 111 and have police attend to them.
"I've called the [local health authority's mental health] crisis line many, many times and every time their solution is to call the police," says an Auckland mother of a teenage girl with an eating disorder who has tried to kill herself several times.
The number of children and teens seen in crisis in emergency departments rose by more than 410 per cent in a decade, reaching 3,178 last year, according to a recent Ministry of Health briefing to Prime Minister Jacinda Ardern.
Police data shows the number of mental health or suicide-related calls handled by police rose by 60 per cent in the past five years, and analysts are predicting this to rise by another 44 per cent by 2025.
For people in serious mental distress, neither police nor emergency medicine staff are ideal first responders.
Police have only minimal training in dealing with people with mental illness. And emergency departments — busy, brightly-lit, and noisy — can be unsettling for young people who are already in an elevated state and may have sensory processing problems in addition to mental health difficulties. Mental health patients tend to wait longer to be seen in EDs and are more likely to leave before they are assessed, researchers have found.
"The emergency department isn't the right environment for somebody who is in acute mental distress," says Dr Kate Allan, of the Australasian College for Emergency Medicine.
In interviews, parents said it is common to wait several hours in ED for mental health staff to arrive. Sometimes it can take days if the child has physical injuries that need to be medically cleared first. In many cases, their children were kept under watch by police, nurses, healthcare assistants, or security guards because they were deemed a suicide risk, which can be intensely humiliating. Some kids, the parents said, were so wound up by the overstimulating surroundings that they had to be sedated or restrained, while others tried to run away.
Although the staff in emergency departments mostly do a stellar job in trying circumstances, it is not uncommon to hear complaints like Lisa's about some doctors and nurses being dismissive towards mental health patients.
One 19-year-old woman recalled being made to feel on numerous occasions that she was letting her mother down and taking up a bed that other people needed more than her.
At her worst point, she said, she spent a night in A&E at an Auckland hospital after a suicide attempt. Her mother went home to sleep having been told that she would be admitted to a respite facility the next morning. But when the girl woke up, she found discharge papers and a prescription for antidepressants on the bed next to her.
"I just thought, 'Wow, they really do not care what happens to my life,'" she said.
Parents described a gruelling cycle of calls to mental health crisis lines and 111, police callouts, ED visits, and short psychiatric admissions that always seems to end in the same way: with children being sent home to be looked after by families that are by that point exhausted, despairing, and traumatised. Often there is no follow-up care by community mental health services after they are sent home.
"You take them to ED and they're sent home a few hours later," says one mother whose teenage daughter has tried to kill herself more than a dozen times. "And then you just watch, and you wait for the next crisis, and the next crisis."
Some parents say they sought out long-term hospital or residential facilities that would keep their children safe while treating their conditions but found no good options. There are only three inpatient units in the country that specialise in children or adolescents — the Child & Family Unit (CFU) at Starship covers the top half of the North Island — and those beds are often occupied. Psychiatrists say these units aren't suitable for most children.
If parents are exasperated with the lack of crisis support, so too are emergency medicine staff who are also simultaneously dealing with the fallout of multiple other failures of the healthcare system.
"It's an additional workload that is really difficult to deal with," Allan says. "You feel like you're not delivering the best care you can for those patients."
Police are also fed up with handling so many mental health incidents, at a time when they are under pressure to stop shootings, ram raids, and other types of crime.
A complex mental health incident could take a couple of officers off the beat for five or more hours if they must accompany someone to an ED, police say.
Police leadership's frustration was captured in briefings to Commissioner Andrew Coster before meetings with senior mental health officials last year. In one briefing obtained by the Herald, police officials said Labour's commitment of around $2 billion to mental health in the past four years has so far had "little to no effect" on demand for police to attend mental health calls.
More money is essential to make mental health services "adequately funded and resourced to progress the effective transformation of the mental health system", the police officials said.
Labour made mental health a top policy priority in its 2019 Wellbeing Budget, but has so far focused on establishing early interventions in primary care for people with milder conditions. New investments in specialist care for young people and crisis services have so far been modest. District health boards were mostly left to respond to the growing need out of existing resources.
One promising initiative was a pilot in Wellington of a "co-response team", based on an Australian model, that combines mental health nurses, police, and paramedics into a mobile rapid-response unit to handle mental health calls that otherwise might be attended solely by police.
According to an evaluation by the University of Otago, this multi-agency team received "resoundingly positive responses" from stakeholders across the board and significantly reduced the number of ED visits on the days it operated. "We strongly recommend the service be continued and that other districts across New Zealand look to adopting similar models," the researchers who evaluated the programme said.
Police are keen to expand the model. National has been looking at setting up co-response teams in Auckland, Hamilton, Tauranga, Rotorua, Wellington, Christchurch, and Dunedin if it gets back into government, which would be funded by redirecting money from Labour's flagship early intervention initiatives.
But officials at the Ministry of Health were lukewarm about the Wellington co-response pilot, according to documents obtained by the Herald.
In a recent briefing to Health Minister Andrew Little, health officials cautioned that the Otago University evaluation "did not consider value for money". Officials worry that expanding the pilot would draw away resources and staff from overtaxed mental health services without significantly reducing the need for crisis support.
In Whanganui, a similar joint crisis response service is being funded through the Ministry of Justice's Proceeds of Crime Fund.
In Auckland, North Shore hospital is embedding mental health staff 24/7 in its ED to cut down on waiting times for assessments, after a 60 per cent increase in the number of people seen with acute problems in five years.
In Hamilton, the Waikato health authority is planning to develop a round-the-clock crisis haven staffed by people with experience of mental illness that would provide a soothing alternative to ED.
However, these plans are still in the early stages, would only available in certain places, and are not necessarily designed for children and teenagers.
In interviews, parents and clinicians expressed frustration that there is not a consistent, timely, effective crisis-response service around the country.
In August, Philip Grady, the senior mental health official at Te Whatu Ora/Health New Zealand, told the Herald that formulating such a plan is a top priority in the new national health body.
Te Whatu Ora is developing seven or eight new crisis-response initiatives around the country that will be funded through a $27 million allocation in the latest Budget in May.
For the teens, parents, counsellors, psychiatrists, police, and others on the front lines of our mental health crisis, those can't come soon enough.
In the long run, experts say, the crisis in young people's mental health is not something that can be resolved by medical treatment alone. A lot of hard and sustained work will be required across government and society to better understand the pressures that are causing our young people to experience such difficulties, to build resilience, and prevent them from developing into life-changing conditions.
But there is also an urgent need, they say, for more support for those in severe distress, including better-staffed helplines and mobile crisis teams, better follow-up care by community mental health teams, closer cooperation between mental health services and other agencies, embedded mental health staff in EDs, dedicated spaces adjacent to EDs for psychiatric patients, residential facilities for teens in crisis who are not safe in their own homes, and better training and support for whanau and communities struggling to cope with distressed teens.
In Lisa's view, change needs to start with a fundamental shift in our understanding of what young people like her are going through.
After her experience in hospital in late 2020, Lisa tried to kill herself several more times.
One suicide attempt last year caused catastrophic physical injuries that required hospitalisation for months. Lisa says she will be living with the consequences for many years to come.
Lisa was struck by how differently she was treated by medical staff who attended to her physical injuries than she was as a mental health patient. She says too many professionals dismissed her mental suffering as "attention seeking", as a teenage phase she would grow out of, an inconvenience, and that only made it worse.
"I feel like you have to be on the brink of death for mental health professionals to actually believe you and take your pleas for help seriously," she says.
*name 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 will publish 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.