Mental health difficulties are common during adolescence, with approximately one in seven (14.3%) young people aged 10-19 years experiencing a mental health condition.¹ Anxiety, depression and behavioural disorders are among the leading causes of illness and distress in this age group. Recent Irish research continues to highlight significant mental health difficulties among adolescents.² Recent Irish research examining GP referrals to CAMHS found increased referrals for anxiety, self-harm and eating disorders in the post-pandemic period, highlighting the changing complexity of presentations reaching specialist services.³
In the GP practice, recognising mental health difficulties can be challenging because adolescents do not always present with an explicit mental health concern. Psychological distress may instead manifest through headaches, abdominal pain, fatigue, sleep disturbance, changes in appetite, school avoidance or behavioural change. Recurrent physical symptoms can therefore provide an opportunity to explore mental health. International primary care research has demonstrated associations between consultations for symptoms such as headache and abdominal pain and subsequent presentations involving internalising difficulties such as anxiety and depression.⁴ School avoidance/refusal can also be an indicator of underlying mental health issues. Morning nausea, headache or abdominal pain may occur alongside anxiety about school, bullying, academic pressure or social difficulties. The World Health Organization (WHO) highlights that anxiety and depressive disorders can significantly affect school attendance, schoolwork and social functioning.¹ Other presentations may include irritability, anger, withdrawal, loss of interest, reduced motivation, deterioration in self-care, changes in eating or sleeping, or declining academic performance. This highlights the important role general practice plays in early recognition, initial support and identification of young people who may require specialist assessment.
Assessment and initial management in primary care
Factors to consider when assessing should explore family relationships, school, friendships, bullying and cyberbullying, social media use, alcohol or substance use, sleep, eating patterns and recent stressful life events. Where possible, adolescents should have an opportunity to speak privately during the consultation, with confidentiality and its limits, clearly explained. This is particularly important when discussing self-harm, suicidal thoughts, substance use, eating difficulties, relationships and safeguarding. Young people under 18 years should be made aware at the start of consultation regarding the limits of confidentiality. In cases of concerns regarding risk to self or others, those concerns would need to be discussed with parents and/or relevant agencies.
The relationship with the GP matters. A systematic review of young people's experiences of mental health support in primary care identified trust, empathy, being taken seriously and having sufficient time to talk as central to a positive consultation.⁵ A more recent systematic review similarly found that adolescents value privacy, confidentiality, good communication and healthcare professionals who understand their needs.⁶
The consultation appointment is an opportunity to understand not only what symptoms are present, but how they are affecting the young person's life. Asking about school attendance, friendships, family relationships, sleep, appetite, self-care and usual activities can provide a clearer picture of severity and whether functioning is being impaired. Many young people with mild anxiety, adjustment difficulties or low mood can initially be supported within general practice with psychoeducation, support with sleep, physical activity, routine and signposting to appropriate community resources when clinically appropriate. Suicide and self-harm should be assessed directly where clinically indicated. Assessment should explore suicidal thoughts, intent, planning, previous attempts or self-harm, access to means, protective factors and the availability of supportive adults. NICE guidance provides recommendations for assessment and management of self-harm in children and young people.⁷
A single consultation appointment represents only a snapshot of an adolescent's mental health. Monitoring symptoms, functioning and risk over time can help determine if difficulties are improving, persisting or deteriorating.
When should a GP refer to specialist care?
Not every adolescent experiencing anxiety, low mood or emotional distress requires specialist mental healthcare and can be supported in general practice or by community services.
Referral to CAMHS should be considered when the severity, complexity, risk or functional impact of the presentation exceeds what can safely be managed in primary care. This may include:
- moderate to severe or persistent depression or anxiety with significant functional impairment
• significant or escalating self-harm or suicidal ideation
• eating disorders or significant concerns about dietary intake and weight
• emerging psychosis or significant disturbance in reality testing
• marked deterioration in school attendance, relationships, self-care or everyday functioning
• symptoms that are worsening despite appropriate support in primary care
• complex presentations requiring multidisciplinary specialist assessment.
The current HSE CAMHS Operational Guideline (2025) defines CAMHS as providing specialist mental health services for young people up to 18 years with moderate to severe mental disorders requiring multidisciplinary input. The guideline covers both community and inpatient CAMHS and aims to provide greater consistency in service delivery nationally.⁸
What is a mental health crisis?
A mental health crisis differs from a routine referral. It occurs when a young person's mental state has deteriorated to a point where their safety, or the safety of others, cannot be maintained with routine community support.
Urgent assessment should be considered where there is:
- imminent or escalating risk of suicide or serious self-harm
- significant inability to maintain safety at home
- first-episode psychosis or significant loss of contact with reality
- severe behavioural or emotional deterioration
- severe eating disorder symptoms, with significant medical or psychiatric risk
- an immediate safeguarding concern.
Not every crisis involves suicidal thoughts. Severe deterioration from baseline, psychosis, extreme distress or an inability of the young person or family to maintain safety may also indicate the need for urgent assessment. In these circumstances, the priority is immediate safety rather than waiting for a routine CAMHS appointment. Depending on the clinical presentation and local pathway, urgent specialist assessment or Emergency Department assessment may be required. In the event of significant concerns regarding physical health due to eating-disordered behaviour, assessment using the Medical Emergencies in Eating Disorders (MEED) checklist should be used.⁹
CAMHS or inpatient care?
It is important to distinguish between a referral to CAMHS and an inpatient admission. Most young people referred to CAMHS will receive community-based assessment and treatment and GPs can refer directly to CAMHS services. Specialist inpatient care is indicated for young people whose level of illness or risk means that they cannot be safely managed in the community.⁸ HSE CAMHS can refer to HSE inpatient units if needed. GPs can refer directly to hospitals in the independent sector but not HSE units.
This distinction is particularly useful for GPs: CAMHS referral does not mean the young person needs hospital admission, and a crisis does not necessarily mean inpatient admission is needed. The decision is based on risk, severity, functional impairment and the ability to maintain safety in the community. When deciding whether a young person requires specialist assessment, consider three areas:
- Risk: Is there a current or escalating risk of suicide, self-harm, harm to others, psychosis or significant safeguarding concerns?
- Function: How significantly is the young person's mental health difficulty affecting school attendance, relationships, self-care, sleep, eating or everyday activities?
- Change over time: Are symptoms improving, stable or deteriorating? Has there been a significant change from the young person's usual level of functioning despite appropriate support?
This provides a useful framework because severity is not determined by symptoms alone. A young person with apparently moderate symptoms but significant functional deterioration or escalating risk may require specialist assessment, while another with similar symptoms but preserved functioning may be appropriately managed initially in primary care. A formal diagnosis is not always necessary before seeking specialist advice. Significant risk, functional impairment or deterioration over time may be sufficient to prompt referral.
Conclusion
General practice remains central to adolescent mental healthcare in Ireland. Mental health difficulties may initially present through physical symptoms, behavioural change or problems with school attendance, making the GP consultation an important opportunity for early recognition. The challenge is not simply identifying a diagnosis, but recognising when a young person’s risk, functional impairment or change over time indicates that specialist input is needed.
As the GP, the key questions are: What has changed; how is the young person functioning; what is the level of risk; and can they be safely supported in primary care?
Onward referral to CAMHS or urgent assessment where necessary combined with continued GP involvement, monitoring and safety planning provides an important bridge between primary and specialist care.
Key messages for GPs
- Adolescents may present with physical symptoms rather than an explicit mental health complaint.
- Recurrent headaches, abdominal pain, nausea, fatigue and sleep disturbance may accompany psychological distress, but physical causes should always be appropriately considered.
- Changes in school attendance, relationships, behaviour, self-care and functioning can be important indicators of deteriorating mental health.
- Give adolescents an opportunity to speak privately and explain confidentiality and its limits.
- Always assess and document suicide and self-harm risk.
- Consider risk, function and changes over time when deciding whether specialist assessment is required.
- Most young people requiring specialist mental healthcare can be managed through community CAMHS; inpatient care is indicated for those whose illness or level of risk cannot be safely managed in the community.
- A mental health crisis is defined by immediate safety and level of deterioration, not solely by the presence of suicidal thoughts.
- While awaiting specialist assessment, GPs remain central to continuity of care, monitoring, safety planning and family support.
References available on request.