Mental Health for All - Greater Investment, Greater Access. Everyone, Everywhere.
The area of mental health is one requiring urgent attention. Mental health is critical to individual well-being, as well as for social and economic participation and yet it is estimated that more than one in six people across EU countries had a mental health issue (in 2016), equivalent to about 84 million people (OECD, 2018). The connection between disadvantage and ill health when the social determinants of health (such as housing, income, childcare support, education and so on) are not met is well documented. This is also true in respect of mental health issues. So, for example, people in the lowest income group are more than two times more likely to report chronic depression than those in the highest income group across the EU (OECD 2018).
The estimated prevalence of mental health disorders is relatively high in Ireland compared with other European countries yet spending on mental health is relatively low (OECD, 2018).
The policy blue-print, A Vision for Change – Report of the Expert Group on Mental Health Policy (2006), offered many worthwhile pathways to address mental health issues. By December 2018 there was a total of 1,687 staff in the General Adult Community Mental Health Service which (according to the HSE) represents 74.8 per cent of the clinical staffing levels recommended in A Vision for Change (HSE 2018). Thus, unfortunately, the pace of implementation has been extremely slow. This is confirmed recently by the Mental Health Commission which highlights how ‘the level of change in our mental health service provision is uncoordinated, ad hoc and slow’ (2019: 2). Issues highlighted include the need for best practice to be applied consistently across the country, for specialist in-patient approved centres to be up to standard, and the need to continue moving the treatment and recovery model to specialist professional community care. That report also highlights the situation of vulnerable people living in unregulated ‘community residences’.
In 2019, the Inspector of Mental Health also highlighted the continued lack of development of mental health rehabilitation services (rehabilitation in this context meaning an approach to recovery from mental illness that maximizes quality of life and social inclusion). One example from this report relates to recommendations from A Vision for Change (2006) to develop 48 rehabilitation teams, whereas there are now only 23 poorly staffed teams (Finnerty 2019). That report also considers it to be ‘imperative’ that funding is made available to implement a Model of Care for the provision of rehabilitation mental health services, rather than simply providing highly supported residential care.
Funding has been allocated in recent budgets for mental health services. Social Justice Ireland welcomed these allocations. However, progress in implementation has continued to be slow related partly to recruitment difficulties.
Areas of concern in mental health: There is a need for effective community services including effective outreach and follow-up programmes for people who have been in-patients in institutions upon their discharge into the wider community. These should provide:
- sheltered housing (high, medium and low supported housing);
- monitoring of medication;
- retraining and rehabilitation; and
- assistance with integration into community.
In the development of mental health teams there should be a particular focus on people with an intellectual disability and other potentially vulnerable groups, including children, homeless people, prisoners, Travellers, asylum seekers, refugees and other minority groups. People in these and related categories have a right to a specialist service to provide for their often complex needs. A great deal remains to be done before this right could be acknowledged as having been recognised and honoured in the healthcare system.
Research and development in all areas of mental health are needed to ensure a quality service is delivered. Providing good mental health services is a necessary investment in the future wellbeing of the country. Public awareness-raising should continue, to ensure a clearer understanding of mental illness so that the rights of those with mental illness are recognised.
Older people and Mental Health
Mental health issues affect all groups in society and people of all ages. Dementia is not the only mental health issue to affect older people. It is not an inevitable part of ageing nor is it solely a disease of older age, but older people with dementia are a particularly vulnerable group. Numbers of people with dementia in Ireland are estimated at between 39,000 and 55,000 (depending on the international prevalence rates used) and the incidence has increased as the population has aged to at least 7,752 new cases per year (Pierse, O’Shea and Carney 2019). At least 11,175 people are estimated to be living at home in Ireland with dementia who have a serious functional impairment (Pierse, O’Shea and Carney 2019). However, by December 2018, there were 355 staff (clinical 314) working in 31 Psychiatry of Later Life Service teams, which represents (according to the HSE) only 60 per cent of the clinical staffing level as recommended in A Vision for Change (HSE, 2018).
A co-ordinated service needs to be provided to meet the demand occasioned by population growth and population ageing. The uncoordinated and fragmented provision of specialist care units for people with dementia represents an example of a lack of planning and coherence. It is generally agreed that the needs of people with dementia are unmet within long-term care and that many symptoms are caused, not by dementia itself, but from the quality of care people with dementia receive in inappropriate settings (Cahill et al, 2015). As a consequence, specialist care units are required, but where they exist in Ireland, they account for only 11 per cent of the long-term care facilities (54 units), and accommodate only 7 per cent of long-term care residents despite the fact that more than 60 per cent of residents living in long-term care facilities are estimated to have dementia (Cahill et al, 2015). A high proportion of specialist units that do exist care for people in groups larger than the recommended small-group living arrangements, and there are significant inequities regarding access to them and their geographic location (over 50 per cent were in only four counties).
A National Dementia Strategy was published in 2014 and funding has been promised for three priority areas– intensive home care supports, GP education, and training and dementia awareness. This is welcome and implementation is required. However, there are many other areas that also require investment, including day centres, respite services and other supports for carers, quality long-term care (at home and in care settings) and specialist care units, as well as evaluation and monitoring of all services.
Suicide – a Mental Health Issue
Suicide is the ultimate, and most deadly, manifestation of mental health issues. Over time Ireland’s suicide rate rose significantly from 6.4 suicides per 100,000 people in 1980 to a peak of 13.9 in 1998 (National Office of Suicide Prevention, 2011). A downward trend from 2003 stopped in 2007, something attributed by the National Office of Suicide Prevention in part to the change in the economy.
Statistics for 2017 and 2018, which are still provisional, suggest that the downward trend has largely continued since 2012 (with a slight increase in 2014). The overall rate was 12.6 per 100,000 people in 2012 and it had dropped to 7.2 per 100,000 in 2018 (National Office of Suicide Prevention, 2019). The numbers affected were 352 in 2018 (down from 392 in 2017). Most suicides were amongst males – 282 males, 70 females in 2018 (again, based on provisional statistics) (National Office of Suicide Prevention, 2019).
While it is not easy to compare suicide rates among European countries (because of variations in registration and reporting systems), at 9.37 suicides per 100,000 people in 2016, Ireland ranked 11th lowest among 34 countries (comparison by Eurostat) (National Office of Suicide Prevention, 2019a). However, comparing rates of suicide of young people (aged 15-19) suggests, alarmingly, that Ireland had the 2nd highest rate amongst 33 countries (in 2016), second only to Iceland (National Office of Suicide Prevention, 2019a).
The Implementation Plan for Connecting for Life (Ireland’s National Suicide Prevention Strategy 2015-2020) was published in January 2018 setting out actions from 2017-2020.
The issue of suicide is a significant healthcare and societal problem and the rates amongst young people raise particular concerns. Of course, the statistics only tell one part of the story. Behind each of these statistics are families and communities devastated by these tragedies as well as a unique personal story which leads to people taking their own lives. Social Justice Ireland believes that further attention and resources need to be devoted to researching and addressing Ireland’s suicide problem.
Cahill, S., O’Nolan, C., O’Caheny, D., Bobersky, A. (2015) An Irish National Survey of Dementia in Long-term Residential Care. Dublin: Dementia Services Information and Development Centre
Finnerty, S. (2019) Rehabilitation and Recovery Mental Health Services in Ireland 2018/2019. Dublin: Mental Health Commission
Health Service Executive (2018). HSE Mental Health Service: Delivering Specialist Mental Health Services, 2018.
Mental Health Commission (2019) Mental Health Commission Annual Report 2018 including the Report of the Inspector of Mental Health Services. Dublin: Mental Health Commission
National Office for Suicide Prevention (2019). Annual Report, 2018. Dublin: HSE
National Office for Suicide Prevention (2019a). Briefing on Eurostat Suicide Data. Dublin: HSE. Updated 4.11.2019
National Office for Suicide Prevention (2011). Annual Report 2010. Dublin.
OECD/EU (2018), Health at a Glance: Europe 2018: State of Health in the EU Cycle, OECD Publishing, Paris. https://doi.org/10.1787/health_glance_eur-2018-en
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