CAMH services, integrative methods, and quality improvement

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For this podcast, we are joined by Dr. Sundar Gnanavel, Specialty Doctor CAMHS at Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust, and winner of ACAMH’s 2021 Postgraduate Clinical Trainee of the Year Award.

Sundar sets the scene by providing insight into how he came to be interested in child and adolescent mental health, and what it meant to him to have received recognition for his work by winning ACAMH’s 2021 Postgraduate Clinical Trainee of the Year award.

Passionate about teaching clinical psychiatry and using integrative methods, Sundar shares some of the methods that have proved successful, as well as what improvements he would like to see in the delivery of child and adolescent mental health services, and what changes are needed to enable this to happen.

Sundar details insights he has gained from exposure to different health care systems and different child and adolescent populations, having worked both in developing and developed countries, before talking about his co-authored paper exploring the challenges that COVID has presented to child and adolescent mental health researchers and, in particular, early careerists.

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Dr. Sundar Gnanavel
Dr. Sundar Gnanavel

Dr Sundar Gnanavel, is a consultant with neurodevelopmental services, child and adolescent psychiatry (CAP) in Sunderland, North East England. He recently completed his higher training in CAP through the Northern scheme and completed his basic psychiatry training previously from the All India Institute of medical sciences (AIIMS), New Delhi, India. He holds a postgraduate certificate in medical education from Newcastle University and Edward Jenner certificate from NHS leadership academy. His areas of special interest include biological psychiatry (genetics, neuroimaging and psychoneuroimmunology); curriculum development in child psychiatry for both specialists and non- specialists; neurodevelopmental psychiatry and cultural determinants and neurosciences as applied to child and adolescent psychiatry.

His other interests include developing models of service delivery for neurodevelopmental disorders and collaborative with service users and primary care physicians for the same. He is the Royal college of Psychiatry, neuroscience champion for the North East England region under the Gatsby-Welcome trust neuroscience project and a taskforce member of EPA (European psychiatric association)- ECPC (Early career psychiatrists committee). He has won a number of international awards (including from WPA, IACAPAP, IBRO and RCPsych, UK) and has a number of publications in reputed international journals.


[00:00:30.350] Jo Carlowe: Hello. Welcome to In Conversation podcast series for the Association for Child and Adolescent Mental Health or ACAMH for short. I’m Jo Carlowe, a freelance journalist with a specialism in psychology. Today, I’m interviewing Dr. Sundar Gnanavel, Specialty Doctor CAMHS at Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust. Sundar recently won ACAMH’s 2021 Postgraduate Clinical Trainee of the Year Award.

[00:00:57.260] If you’re a fan of our In Conversation series, please subscribe on your preferred streaming platform. Let us know how we did with a rating or review. And do share with friends and colleagues. Sundar, thank you for joining me. Can you start with a brief introduction about who you are and what you do?

[00:01:12.750] Dr. Sundar Gnanavel: Hi, everyone. Thanks to ACAMH for welcoming me for this podcast and for this opportunity. So I am Sundar Gnanavel, so I am an SD6. That is a higher trainee doctor in child and adolescent mental health within the northern [inaudible] working currently with the Cumbria, Northumberland, Tyne and Wear NHS Trust. I’m currently placed in a forensic adolescent unit based in Newcastle, and I am shortly completing my training in a couple of months time before I move over to my next consultant role.

[00:01:43.910] Jo Carlowe: Sundar, how did you come to be interested in child and adolescent mental health?

[00:01:48.667] Dr. Sundar Gnanavel: Oh, that’s a very interesting question. I think I’ll have to go back a few years to answer this question. So I completed my primary training in psychiatry from India from the All India Institute of Medical Sciences at New Delhi. So there, we do not have a specialized separate training system in CAMHS, though CAMHS is assumed under the broader rubric of psychiatry, so we do have some exclusive child guidance clinics that we are trained in.

[00:02:14.660] So what I found quite interesting back home when I was working in India was how much of a change you could produce in the life trajectory of an individual if you intervene early, which means when you offer services for child and adolescent with mental health difficulties. So you could produce drastic transformations, and you could produce quality work that will be lasting for life for individuals. So that’s what sparked off my interest.

[00:02:40.910] And then when they moved over to the UK, I was initially placed within the CAMH services within the autism and the ADHD clinics. And there, the spark sort of took off. I started to develop a keen interest and a passion for child and adolescent mental health because I started to appreciate how clinicians who work within child and adolescent mental health take a very holistic systemic approach towards helping those children and adolescents with mental health difficulties.

[00:03:07.580] That was quite inspiring for me. And then I decided that I would be pursuing my career further in this subspecialty of psychiatry. And that’s how it all began and continued.

[00:03:17.313] Jo Carlowe: Fantastic. Thank you. Sundar, I want to congratulate you on becoming the winner of ACAMH’s 2021 Postgraduate Clinical Trainee of the Year. What did it mean to you to have received that recognition?

[00:03:29.665] Dr. Sundar Gnanavel: Thanks for this, and thanks to ACAMH for the award. It does definitely mean a lot to me. When I came to the UK, I did mention that I was initially working with the CAMH services. And there, I was introduced to ACAMH as an organization by my colleagues, who highly commended the seminars, and the courses, and conferences, and the masterclasses that they run. And then I started to attend quite a few of those.

[00:03:54.500] Initially, some of those were physically at the headquarters in London, and some of it was in other places. It was all top quality. It was awe inspiring. And this was an organization I started to adore right from the time I landed in the UK around five years ago. And for me, it’s a dream come true to be awarded as the Trainee of the Year by the very same organization that I started to adore and then became a member of around four to five years ago.

[00:04:21.380] It’s been quite inspiring for me here.

[00:04:23.870] Jo Carlowe: You list as a professional aspiration quality improvement in delivery of child and adolescent mental health service. What improvements would you like to see? And what changes are needed to enable this to happen?

[00:04:38.025] Dr. Sundar Gnanavel: Yes, so I think this is a very pertinent and quite an important question to answer. So I have been having a keen interest in quality improvement within child and adolescent mental health services because, on one side, we talk about improving the accessibility to children and adolescents with mental health difficulties, which means more children and adolescents are going to be referred into the services. But then there is always a shortage of clinicians who work in child and adolescent mental health.

[00:05:05.100] So how do we offer quality services for a large clientele? And that’s where, I think, quality improvement methodologies come into play because we need to ensure that we offer high-quality services, but we also need to offer high-quality services to a large population and not a selected subset of the population too. As far as I am concerned personally, I have been involved in a few of projects relating to quality improvement in child and adolescent mental health.

[00:05:31.400] For example, improving physical health monitoring of those children and adolescents with ADHD who are on ADHD medication and those who are on antipsychotic medication. And so I completed audit cycles on these as part of a quality improvement project and went on to present and share these findings with other organizations. This resulted in quite a few of the ideas which we could implement and also translate into improved outcomes for our patients.

[00:05:57.210] So this is one example of something that I have been personally involved in. But there have been quite a few other projects which I have found quite inspiring to observe and see– say, for example, training other child and adolescent mental health professionals, training prescribers in psychiatry who are nurses and training them to be prescribers for child and adolescent mental health service users, and other quality improvement projects, like improving the diagnostic processes, particularly after the onset of COVID and the tele-mental health.

[00:06:28.440] How do you ensure quality mental health services for children and adolescents? So these are other areas and avenues which are emerging and quite of interest. And I think quality improvement and quality improvement methodologies are going to underpin all of this work, and everyone should inculcate it into their routine service delivery practices.

[00:06:48.237] Jo Carlowe: You just mentioned, there, the importance of training. And I know you’re passionate about teaching clinical psychiatry and using integrative methods. Can you share some of the methods that have proved successful?

[00:07:02.210] Dr. Sundar Gnanavel: So apart from child and adolescent mental health, something else that’s equally dear to me is medical education. And I just completed my postgraduate certificate in medical education from the Newcastle University. And that provided me plenty of fertile fodder for my thoughts as with regards to teaching and training. So I actively involve myself in teaching and training of not just my colleague trainee psychiatrist, but also medical students in universities and other colleagues, including nurse practitioners, occupational therapists, and the rest of my multidisciplinary team colleagues.

[00:07:35.540] So one thing that I possibly would like to highlight is I have been actively engaged in teaching what is called as integrative day sessions within the Newcastle University. So this is quite unique in the sense that we teach to medical students what is at the interface of women’s mental health, child mental health, and the infant mental health. So there are certain things that lay on the fringes and common to all these three groups.

[00:07:59.880] So we as child psychiatrists along with obstetricians, and gynecologists, and pediatricians from the general hospitals together deliver these sessions. So this brings in perspectives from different angles. And we do it together in the form of interactive workshops, role plays, case discussions, and didactic lectures delivered to medical students in Newcastle University. So they have been quite appreciative of this.

[00:08:23.660] And this is something that I thought I would highlight as a good model for the future. That and you’re bringing colleagues from all disciplines together and teach in an integrated manner to your students, rather than trying to compartmentalize things into different aspects. We found it quite effective with excellent student feedback.

[00:08:40.934] Jo Carlowe: It sounds really effective. Is that being rolled out elsewhere?

[00:08:44.468] Dr. Sundar Gnanavel: Yeah, it’s gradually being rolled off across the Northeast of England with other universities like Sunderland University, et cetera. But I don’t think it’s being rolled out outside of the region at the moment. But I think this is something that the other regions could consider as well because it’s been hugely successful, to say the least.

[00:09:03.800] Jo Carlowe: Sundar, you have worked both in developing and developed countries. I’m just wondering what insights you’ve gained from this exposure to different health care systems and different child and adolescent populations.

[00:09:16.915] Dr. Sundar Gnanavel: Oh, I think this is an extremely interesting question because this is something that I routinely reflect upon, having trained for 5 and 1/2 years in India and then, now, having worked around five years in child psychiatry in the United Kingdom. So the differences can be quite stark. Back home in India, you do not have a community outreach service. The patients would have to approach you.

[00:09:40.190] The primary care system is really not that great, so you do not have a referral system like what the GPs here have over in the United Kingdom. So this means accessibility to mental health services, referral to child mental health services can be a problem. And generally, not just in India, in many of the developing nations, what we generally find is child mental health is low on the list of policy makers and governmental priorities.

[00:10:06.120] So it can be quite challenging and taxing. From a training perspective, yes, it did give me unique opportunities and plentiful opportunities to train in child and adolescent mental health. But from a service user perspective, I think there were huge challenges and barriers in care. After I came here, I was really happy to find the multidisciplinary teams functioning across the country efficiently– robust referral system from primary care.

[00:10:32.130] There are challenges in developed countries like United Kingdom as well, considering the number of referrals that come in– the challenge in admitting patients, the challenge with manpower, et cetera. But then when you compare the two systems, I would have to say that the system is much more robust here because of the resources that are on offer. And that’s why I always think it should be a priority for developing countries and the developed country systems to work together, collaborate, and develop initiatives to help each other.

[00:11:00.330] So I think that would be the way forward.

[00:11:02.570] Jo Carlowe: I want to turn now to COVID. Of course, we’ve all been impacted by it. You wrote a really interesting paper, or you co-wrote a paper about the challenges that COVID has presented to child and adolescent mental health researchers and, in particular, to early careerists. Can you talk about this? What has the impact of COVID been for you and also for some of your peers?

[00:11:26.148] Dr. Sundar Gnanavel: Well, I think this is an extremely important question in the current COVID era. So there were quite a few unanswered questions in my mind as to how was COVID actually affecting training of psychiatrists early in their career, and service provision, and research in child psychiatry? And that’s where I embarked on these projects with the help of my colleagues in child and adolescent mental health spread across the globe in both developed countries and developing countries.

[00:11:53.820] So there were quite a few challenges that were shared and common across the countries. We did realize that training in child and adolescent mental health was being compromised quite a lot, particularly in the early stages of COVID because patients were unable to access the community care. And child and adolescent mental health was slowly being delegated lower down the list of priorities, considering the acuteness of the COVID pandemic that was going around.

[00:12:19.340] And similarly, with regards to research, gaining supervision for research, getting grants– actually carrying out research was all becoming a problem with COVID restrictions. From a personal point of view, I think I found it quite challenging during the early stages as well because of lack of access and tele-mental health, which was rolled out all of a sudden. And this was not something that I was used to before the COVID pandemic.

[00:12:45.570] So it was a challenge for myself as well as the service users, our patients, and parents and carers to sit in front of the computer. And then we had to complete our assessments, and then you make decisions on diagnosis and prescribe, and so on. So it was quite a bit of a challenge early on. But gradually, as people became used to working virtually and the online systems, particularly, the tech savvy ones, the adolescent patients who start off with were much more comfortable with the virtual forum.

[00:13:13.760] And it did bring about quite a bit of potential that virtual platforms could have in delivering child and adolescent mental health services. So it was quite a bit of a revelation for me.

[00:13:23.990] Jo Carlowe: Do you have any tips for having negotiated this yourself for researchers?

[00:13:29.600] Dr. Sundar Gnanavel: Yes, so I think having the priorities quite clear, having an early discussion with the supervisor as to how to clearly go about things, for researchers to choose those topics of research that does not actually involve hands on with the patient– for example, doing literature reviews, et cetera might be helpful to start off with. And with regards to service provision, I think there is a need for training professionals in tele-mental health as to how to go about doing quality assessments virtually and how to assure the quality of those assessments and, similarly, preparing and familiarizing our patients and parents or carers as to how the virtual platforms work might improve the quality of the services that we offer and might improve the service outcomes as well.

[00:14:13.770] So I think many of the places have now gone onto a hybrid mode of doing some interviews and assessments face-to-face and where it is possible to do it virtually and remotely. So this model has quite a bit of a promise as well and might be helpful in the future.

[00:14:30.270] Jo Carlowe: Sundar, what other recent research or clinical projects have you been involved with that you’d like to mention?

[00:14:35.870] Dr. Sundar Gnanavel: Mm-hmm, so I think one project that I would like to mention was the recent project that I completed with my research supervisor, Dr. Sharma, on inpatient admissions in child and adolescent psychiatry across England. So this was quite an interesting project which we started off from the pre-COVID times, from 2016 switching on to 2019, wherein we pulled in data from NHS Digital, which is available in public domain, as to how many children and adolescents were admitted across the country and for what diagnosis, and what was their age, and what came out of it?

[00:15:09.180] So we did the analysis of the admissions inpatient admissions over this seven-year period over the last decade. And we did come up with some interesting results. For example, there was a definite increase in admissions with depression in adolescents during this period. This was quite interesting, and we are in the process of writing up this paper and having it published in a journal. And the findings from this study will definitely have quite a bit of implications in planning, prioritizing, and delivering CAMH services in England.

[00:15:40.725] Jo Carlowe: Can you say anything or reveal anything about some of the reasons for the increased admissions?

[00:15:46.180] Dr. Sundar Gnanavel: OK, so this was a descriptive study. So all that we could do was to hypothesize what could be the possible reasons. There is no way to infer as to what, exactly, resulted in this increase with depression. So we possibly zeroed in on a number of possibilities. Possibly, there isn’t enough of early intervention services for mood disorders in the country. And secondly, there is a dearth or scarcity of inpatient beds for children and adolescents.

[00:16:14.050] This means their turnover is quite fast. You discharge the patients fast. And then they come back to you, get readmitted. So this increase might possibly explain an increase in admission rate. And possibly, there are quite a few psychosocial issues which have come about over the last decade, ranging from an increase in cyberbullying to school-related stressors, other interpersonal stressors that have increased over the last decade related too, for example, social media, et cetera.

[00:16:40.150] So those could be other possible reasons that explain the strain. But of course, these are simply assumptions because we do not have the way to zero in on what, exactly, caused this based on the current study. But that would be a good study for the future.

[00:16:53.560] Jo Carlowe: Sounds really interesting. Are there any other recent research or other clinical projects that you want to mention?

[00:16:59.740] Dr. Sundar Gnanavel: In addition to the other recent projects that I would possibly like to mention, I’m doing a review on the ecological changes and what effect that has on children and adolescent mental health– the ecological crisis, and the global warming, and the changes in the environment, and what effect does it have on the psychological well-being on children and adolescents. So I have embarked on a review on this particular subject. And secondly, I’m also involved currently in a project on finding out the patterns in referral to the tertiary mood disorders service that we have in Newcastle, where we receive referrals from across the country with regards to mood disorders, particularly bipolar disorder.

[00:17:39.920] So we are trying to unravel what are the trends and patterns in this referral over the last five years. So these are a couple of other projects that I’m currently involved in.

[00:17:48.677] Jo Carlowe: And is there anything else in the pipeline for you?

[00:17:51.730] Dr. Sundar Gnanavel: So I am looking forward, as say started off telling, so I am due to complete my training in child and adolescent mental health by the end of this month and transition to a consultant job from next month. So I’m starting off as a consultant to neurodevelopmental disorders, autism, and ADHD at Northumberland from next month. So I’m keenly looking forward to that job. That fits into quite a few of my interests, so I have a particular passion an interest in autism and ADHD and helping improve the quality of services for children and adolescents with autism and ADHD.

[00:18:24.220] So that is something that I’m looking forward keenly.

[00:18:26.530] Jo Carlowe: Brilliant. And finally, Sundar, what is your takeaway message for those listening to our conversation?

[00:18:31.785] Dr. Sundar Gnanavel: There are a couple of key messages that I would like to probably mention now. One, the child and adolescent mental health is a great discipline. It’s an excellent subspecialty of psychiatry which I would encourage both medical students and co-trainees in psychiatry and also psychology trainees to think about specializing in because I believe you can have a fulfilling and rewarding career to change the life trajectories of children and adolescents by intervening quite early and producing dramatic and remarkable transformations, which might not be the case in adult or old-age psychiatry.

[00:19:07.850] So I would encourage everybody, both psychiatrists and psychologists, to consider specializing in child and adolescent mental health. And ACAMH is a great organization that you can seek support from, that you can seek resources from to develop your professional career in this regard. Secondly, it’s a fascinating career, but it’s not something that’s without its own challenges.

[00:19:28.130] So as I already mentioned, quality improvement is going to be the key thing for this because, considering the increase in the rate of referrals and the need for ensuring quality mental health services for this population, it’s going to be a challenge. And it will be quite important for practitioners in this discipline to be quite well-versed with quality improvement methodologies and also try and see how best to implement it within their local services.

[00:19:52.250] So these would be a couple of key messages that I would like to mention now.

[00:19:56.333] Jo Carlowe: Brilliant. Sundar, thank you ever so much, and good luck with the completion of your training. For more details on Dr. Sundar Gnanavel, please visit the ACAMH website, and Twitter @acamh. ACAMH is spelled A-C-A-M-H. And don’t forget to follow us on your preferred streaming platform. Let us know if you enjoy the podcast with a rating or review, and do share with friends and colleagues.

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