Mental health services have been neglected and underfunded for decades. Aontú seeks to change that.
A Vision for Change was published in 2006 as a guide for the direction of mental health services in Ireland (DoHC, 2006). It set out the standard of care across mental health services, but in most areas of Ireland, the Government has not resourced services to the level recommended by this document (CPI, 2012). This is not surprising when funding allocation is considered: despite consistent evidence that mental health problems account for 13% of the burden of disease internationally (WHO, 2008), in Ireland only 4.3% of the total health budget is assigned to the treatment of mental illness.
Our health services are staffed by highly qualified clinicians, many with training/experience from international centres of excellence. Unfortunately they cannot perform to their optimal level as a result of the constraints under which services attempt to operate. This is one reason why many Irish psychiatrists, mental health nurses, psychologists and other health care professionals employed overseas have little interest in returning to a stretched service where they cannot properly use their skills. There are currently 101 unfilled consultant psychiatrist posts in Ireland.
A bed crisis
In 1985, there were over 12,000 acute psychiatric beds in Ireland, by 2010 the Mental Health Commission recorded 1,138, and since 2010 there have been further reductions in numbers (HRB, 2006; MHC, 2010). This reduction was part of the much-needed shift of focus of care from institutions to the community. Unfortunately, this community-based side of this care has not been provided at the level that is required, and furthermore we have too few beds. In recent years, mental health services around Ireland have had to buy beds in the private system due to persistent bed crises in their local services. This means that some patients are being treated over 100miles from their families and supports.
A knock-on effect of the lack of bed availability is a higher threshold for admission, i.e. people need to be more severely unwell before their admission can be justified, which results in patients with mental disorders waiting longer, and some of the most vulnerable ending up homeless or even in the criminal justice system. A shocking 8.3% of remand prisoners have active severe mental disorders, with a lifetime rate of 17.9% (Curtin et al 2009). A Dublin study found that 70% of the homeless population have a formal diagnosis of a mental disorder (Keogh et al, 2015).
Community services – secondary care
Despite the recommendations of A Vision for Change (HSE, 2006) and commitments given in HSE Mental Health Operational Plan 2017, the provision of 24/7 community mental health services remains aspirational. In the main, out of hours services are accessed in Emergency Departments (EDs). Given that the policy set out in the National Emergency Medicine Programme states that the ED should not be “the pathway of access to mental health care for patients with mental ill-health who have no acute medical need” (HSE, 2012), there is an urgent need for a more appropriate pathway: community based 24/7 services. Community mental health teams need to be adequately resourced, adequately staffed and need to have a maximum wait list time of 4 weeks.
Primary care mental health services
People with mild mental disorders or distress are most appropriately managed in Primary Care than in specialist psychiatric settings, and research suggests this is in line with patient preference (Doherty, 2007). There is a need for urgent expansion of the Counselling in Primary Care programme, which in many areas has a waiting list of many months (in which time the problem has either resolved or deteriorated to the point where secondary care services are required).
Child and adolescent mental health services (CAMHS)
The under-resourcing of CAMHS has become a national scandal, with over 3600 on waiting lists and 386 children waiting over 1 year for assessment (RTÉ, 2018). This is particularly concerning as delay in treatment of mental illness is associated with poorer long-term outcomes (Kissley et al, 2018). The Taoiseach has stated this is “not acceptable”, but the government he has led has not taken action: waiting lists have grown since he first took office as minister for health (RTÉ, 2008b).
Suicide prevention by means reduction
The international experience tells us that when access to lethal means is reduced, suicide levels fall. This was first observed in the UK with the changeover from lethal coal gas to the less toxic natural gas during the 1960s. Not alone did the numbers of people dying by suicide by gas drop, the overall suicide rates dropped by one-third (Kreitman, 1976). Similarly, the reduction of paracetamol pack sizes resulted in reduction in death by paracetamol poisoning by 43%: 68 lives are saved per annum in the UK alone.
In Ireland there have been a number of very progressive initiatives to address self-harm in hospitals via the excellent National Clinical Programme in Self Harm (self-harm is one of the risk factors for death by suicide), and to address suicide via a number of public health initiatives. However, means reduction is another facet of prevention which needs to be implemented in areas where there are patterns of intentional deaths. For example, in areas where there are high numbers of drownings, tracts of water from which rescue is difficult need to be made inaccessible to the public.
Acute or General Medical Hospital Settings
There is growing evidence which demonstrates that the integration of mental and physical healthcare results in improved outcomes across both domains. The speciality of Liaison Psychiatry is central to such developments, both in terms of services development and the underlying research. In Birmingham the RAID study demonstrated that for every £1 invested in a liaison psychiatry service, £4 were saved across medical bed days. These savings arose from reduced admissions, reduced length of stay and avoidance of repeat admissions (Parsonage 2011). This should be a no-brainer.
Other specialist services and settings
The publication of the Specialist Perinatal Mental Health Model of Care is welcome, but many maternity units in Ireland remain without specialist perinatal mental health teams (HSE, 2017). International best practice for mothers with postnatal mental disorders who require inpatient treatment is specialist Mother and Baby units, where a mother can be admitted with her baby. In Ireland we have no such units, meaning that new mothers who require inpatient treatment are separated from their babies. This is a scandal from a government that has claimed to care about pregnant women and mothers.
Eating disorders are common in Ireland – and are serious, life threatening conditions (standardised mortality rate of 5.86, Arcelus et al, 2011) , but services remain non-existent in Ireland with only public 3 beds for South Dublin. Inpatient beds may be bought in the private hospitals if local non-specialist treatment fails, but they cannot accept the most severe patients who remain in general units. This is a serious gap in the service and needs to be addressed as a priority.
Ethnic minority groups
Although ethnic minorities internationally have similar rates of major mental illness to the general population, certain groups are at increased risk of mental health problems, for example refugees have higher rates (10-fold) of PTSD (Fazel et al, 2005). In the UK, white people have been found to be more likely to receive treatment following self-harm. Minority groups report barriers in accessing services, including a lack of understanding of the socio-economic context, paucity of information and communication and language barriers (MHC, 2016).
In addition, our own indigenous ethnic minority group, Irish Travellers, suffer higher rates of mental ill-health and a significantly elevated suicide rate compared to the rest of the population: Traveller men are 7 times more likely to die by suicide than non-Traveller men (Quirke, 2010). The All Ireland Traveller Health Study found that Travellers were less likely to use mental health and counselling services, and more likely to report they found them to be inadequate (Quirke et al, 2010). Given the significant disadvantage that such groups are at, it is essential that are services designed to optimise engagement of high-risk groups, and that they are culturally appropriate and accessible.
In devising the SláinteCare programme, which sets out Government policy for healthcare in Ireland over the next 10 years, the Government established an Advisory Council, which did not include any psychiatric expertise, or indeed any input from secondary care mental health services. It also fails to make any provision for the integration of mental and physical health treatments for comorbid conditions, despite this being a priority in international health. This suggests that mental healthcare is not a priority for this government.
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