Abstract
Sri Lanka is an island in South Asia with 0.52 general adult psychiatrists (GAP) and 0.03 child and adolescent psychiatrists (CAP) per 100,000 population (World Health Organization, 2017). Only 12 CAP have been board-certified in Sri Lanka to date. CAMHS in the country are provided by both CAP and GAP.
To assess the state of CAMHS in the country, the email addresses of the 136 psychiatrists currently practising in Sri Lanka was obtained from the Sri Lanka College of Psychiatrists. A Google form was emailed, collecting information on the human resources, infrastructure and suggestions for improvement. A total of 61 psychiatrists (44.8%), covering all provinces completed the survey. CAP were available only in four of the nine provinces and 50% were located in the Colombo district, which highlighted their unequal distribution.
Majority of the GAP (81.1%) provided outpatient CAMHS, 75% provided inpatient services for adolescents and 41% provided inpatient services to children (<12 years). Majority (63.1%) of the children needing inpatient care were admitted to paediatric wards and 46% of the adolescents needing inpatient care was managed in adult psychiatry inpatient units, followed by general medical wards (32%).
More than half (57.4%) of the mental health services had an occupational therapist and a psychiatric social worker (54.1%), whereas only 4.9% had a psychologist. Few (9.8%) had no allied health specialists. Fluoxetine, sertraline, risperidone and olanzapine were available in all services. Methylphenidate was available in 96.7%, while atomoxetine was available in only 14.8% and clonidine only in 9.8%. Melatonin was available in less than 5% of the services.
A substantial proportion of CAMHS in the country is still provided by GAP, who have only had a 3-month rotation in child and adolescent psychiatry. Therefore, CME programmes to improve the knowledge of GAP was suggested as important by majority (82%).
Child and adolescent psychiatry was introduced as a subspecialty in Sri Lanka in 2011. From 2016 to 2020, only one training post was made available for sub-specialisation per year, which is insufficient to meet the demands. Thus, 67.2% of the participants highlighted the need of increasing the number of training slots for subspecialisation.
Only half of the participants believed that telepsychiatry would be useful in improving CAMHS, probably due to limited feasibility in the local context, due to lack of high-speed broadband connections, exclusive phone connections and lack of hardware and appropriate software (Ali et al., 2020).
Low public awareness of child and adolescent mental health was also rated as an obstacle to providing services by 54.1%, which highlights the need for public awareness programmes.
Unavailability of validated screening tools was reported as a barrier to providing services by 42%. As direct translation of instruments may produce misleading conclusions, rigorous cultural adaptation is needed to ensure assessment tools are locally appropriate (Atilola, 2015), to ensure effective service provision.
We found that the majority of adolescents receive inpatient treatment in adult psychiatry wards. Adolescents experience less satisfaction, less confidence in staff and feel out of place when managed in adult wards, where their developmental needs are not met (Smith, 2004; Viner, 2007). Thus, providing separate inpatient facilities for children and adolescents should be a priority when developing infrastructure for CAMHS in Sri Lanka.
Lack of allied health specialists to deliver psychological therapies was also evident, which highlights the need to train and recruit allied health specialist urgently. Limited pharmacological options further exacerbate the management difficulties, as pharmacological treatment often constitute the mainstay of management of child psychiatric disorders in Sri Lanka, owing to the limited availability of psychotherapy.
As suggested by the majority of GAP’s, CME programmes are essential to ensure that treatment practices within the CAMHS are based on the latest evidence, in order to improve the quality of CAMHS (White et al., 2007).
Although telepsychiatry was not considered as useful by the participants, studies done in Sri Lanka during the pandemic indicate that telepsychiatry through social media apps like WhatsApp and viber are accepted among patients (Nanayakkara et al., 2021), and this should be explored an alternative method of expanding the CAMHS.
