I welcome Ms Sandra Hogan, public relations officer, and Ms Julie Healy, national support group co-ordinator of AWARE to the joint committee to commence the presentation on mental health issues.
I remind Members of the long-standing parliamentary practice to the effect that they should not comment on, criticise or make charges against any person outside the House, or any official by name, or in such a way as to make him or her identifiable.
I thank the joint committee for inviting us to discuss our concerns on mental health issues. I will start by providing some background on the organisation AWARE as some of the committee may not be as familiar with it as others. AWARE is a national organisation founded in 1985 and celebrating its 20th anniversary this year. Its central aims are to provide emotional support and information for those who experience depressive illness and their families. It also seeks to create awareness of depression, a common illness of which many people are unaware. More than 300,000 people here suffer from depressive illness. We also promote research into the illness.
Our central services include a LoCall helpline, a network of support groups in more than 60 locations throughout the country and a second level education programme called Beat the Blues which seeks to inform adolescents of the link between depression and suicide and of the services available to them if they find themselves in emotional distress. We also have a public lecture series, a free information service and a mail order book service.
Our most important main concern with regard to mental health issues is the lack of knowledge, recognition and understanding that surrounds mental illness, particularly depression. The lack of knowledge in Ireland has a number of impacts. Many people at risk of depressive illness are not aware of the illness, the signs and symptoms of depression and do not know where to go for help if they experience some of those symptoms. This is a significant problem because it means people do not seek help for the illness or cannot find ways of support which would give them an opportunity to recover from the illness. There is an important link between depression and suicide. International experts have estimated that approximately 80% of suicides can be traced back to depression. I am sure the committee is familiar with the latest statistics on suicide in Ireland. In 2003, 444 Irish people chose to end their own lives.
Depressive illness can be fatal in severe under-recognised and under-treated cases. However, there has not been a national public information campaign on mental health and suicide prevention. If somebody came to any of us and said he or she had a bad pain in his or her left arm and had difficulty breathing, we would be worried and probably call an ambulance because we would think a heart attack was in the offing. However, if somebody comes to us talking about the symptoms of depressive illness, for example disturbed sleep patterns, poor concentration at work, lack of interest in hobbies and family life and perhaps a feeling that life is not worth living, how many of us would know these are signs of a depressive illness? Many people would not realise this, yet these symptoms could prove fatal because if somebody with depressive illness reaches out to another human being and is not taken seriously or given guidance on what to do next, they may have lost their only opportunity to get help. Therefore it is important that we increase the level of recognition of the symptoms here.
The stigma surrounding mental illness is another devastating result of lack of education about mental health. Stigma results from ignorance, lack of information and fear. It is something that contributes to the isolating nature of depressive illness. We need to work at changing this and must chip away at the stigma surrounding mental illness.
There are a number of wide-ranging consequences of mental ill health. A report published by the European Commission in 2004 suggested that the overall economic cost of depression is at least 1% of GDP across countries, with the principal economic costs of depression incurred outside of the health system. This is something of a surprise because we would all think the major cost of depression would be incurred within the health system. However, there is an enormous impact in terms of working days lost and in other areas such as housing, education, justice and social welfare.
In 1997 the budget spend on funding for the mental health sector was 11% but in 2003 this was reduced to 6.6%. Since 1998 the Government has provided approximately €17 million for suicide prevention and research. A similar amount is spent on road safety campaigns every year, yet more people here die by suicide each year than are killed on the roads. In 2003, 336 people were killed on Irish roads while 444 people died by suicide. Clearly, there is a lack of judgment in the amount of money contributed to mental health.
AWARE also has a number of concerns relating to the health service. The need for patients to have continuity of care is important and is a concern for many members of our organisation and those who come to us for support. Junior doctors change on a six-monthly basis in the health system and this causes severe distress to people who suffer from depressive illness and their families. The nature of depressive illness means that patients and sufferers establish emotional bonds with the treating doctor. If every six months they need to start from scratch to establish a rapport with a new doctor, this has a negative impact on them as they have shared issues relating to their emotional experiences, thoughts and feelings. The system is training focused whereas it should be patient focused, particularly with regard to mental health.
Another area of concern in the mental health sector is the lack of choice of consultant. There is also little opportunity in consultation for family involvement and input, which is important in depressive illness. There is insufficient opportunity for psychological or cognitive treatments and those who opt for private in-patient treatment find that on discharge they are unable to avail of day hospital services or support from the community psychiatric services. There is an ideal opportunity now for the Government to go some way towards increasing funding for services. We suggest that financial gains from the sale of land and buildings previously used by the psychiatric services should be ring-fenced for use in mental health services.
Child and adolescent mental health is another cause of concern for AWARE. The services for child and adolescent psychiatry here are, to say the least, haphazard. The Irish College of Psychiatrists has stated that in some areas a waiting period of more than one year for assessment is the norm. This is abhorrent. What can this wait do for a 16 or 17 year old who is engaging in suicidal behaviour or actions? What can it do for his or her family, particularly parents concerned about their child?
AWARE runs a secondary schools education programme entitled Beat the Blues. This is aimed in particular at transition year students and seeks to create awareness of the illness of depression and its link with suicide. We get very good feedback from teachers, students and, sometimes, parents on Beat the Blues. There is definitely a need for information to be introduced to schools even earlier. We recommend that through the schools' social and personal health education programme more effective coping mechanisms could be developed. The importance of self-esteem, positive life values, inclusiveness and mutual respect in society could be promoted. This would contribute to the overall health and mental well-being of people.
The 1998 national task force on suicide recommended that youth mental health should be recognised at an early stage and interpreted correctly. It recommended that children and young people at a time of crisis should have access to appropriate support services and a comprehensive range of psychological and counselling services. As this is clearly not the case in Ireland, something needs to be done about it.
On the issue of social exclusion, a study being conducted in the Mater Hospital has found that one third of all referrals from its accident and emergency department for psychiatric assessment were homeless. That is just one hospital in one city. Those who are homeless are also at risk of being excluded from health board areas. They might not be considered to reside within the functional area of the health board. This issue should be examined, particularly with regard to the Disability Bill.
Within the prison system, 20% of all prisoners are considered to be mentally ill. There is a need to improve and augment the existing psychiatric services in prisons. AWARE has previously suggested that the Inspector of Mental Hospitals should be given the remit to report on the level of psychiatric care in prisons.
The final point relates to discrimination. Those with psychiatric illness are discriminated against on a number of levels and I will refer to two of those. First, there is considerable discrimination in regulations pertaining to private medical insurance. Second, the drugs scheme also discriminates against those with depressive illness. Because depression is not classified as a long-term illness under the drugs scheme, sufferers must contribute towards the cost of medications whereas this is not the case with similar illnesses of a long-term nature.
These are the main concerns of AWARE in relation to mental health issues. I thank the committee.
I thank Ms Hogan for a very wide-ranging and comprehensive presentation. I strongly believe anything that can be done to heighten the awareness of depression in society is to be welcomed and obviously AWARE is doing great work in that regard. I apologise for Deputy Gormley who had to leave for a prior engagement but he will return.
I welcome the delegation and congratulate them on their work. It is important this issue is highlighted. The Labour Party recently produced a document on the area of mental health. When preparing this document I was very struck by the decline in the percentage of the health budget given to mental health which is very much the poor relation. There has been a rapid dip from 11% in 1997 to approximately 6.8% now. Does the delegation think it would be helpful to have a ring-fencing of a budget for mental health within the health budget? On the point about the lack of counsellors, I was very struck by the fact that in 12 counties there is no counsellor employed by the health board for those with anxiety or depression. Does the delegation regard this as a key issue?
The idea regarding junior hospital doctors is something I had not thought of but I think it is difficult to find a way through that unless one perhaps considers the role of a nurse practitioner as some other person to have a central role in the care of a person with depression. Does the delegation see possibilities there or must it be the medical practitioner because the turnover of junior hospital doctors is something that will not be changed quickly?
On the question of the prevention of suicide, it seems very difficult to find ways of preventing suicide but clearly alcohol is a key issue and I invite the delegation to comment.
Before the delegation answers those questions I invite two more questions and they can all be answered together.
Like Deputy McManus I welcome the delegation and thank them for the presentation. It is to be welcomed that such organisations meet the committee and have the opportunity of coming to the Houses of the Oireachtas. All Departments are finding that it is becoming very competitive as far as their budgets are concerned and this is very much the case for health. It is important to point out that when people talk about health they refer to accident and emergency and issues relating to hospitals and sometimes it is a struggle to remember that there are other issues.
I do not wish to be emotive but the point about suicide and suicide prevention is well made. Those of us who unfortunately have known families who have suffered in that regard come to understand and appreciate how important an issue this is. Like other colleagues I try to support the various agencies who look after mental health in my constituency of Dublin South-West, particularly in the Tallaght area. Without being patronising, it is important that this is done.
I wish to underline the point about the competitive nature of the business and how the delegation is coping with that. This is not meant as a criticism but I often wonder what co-operation there is among all the various agencies which represent different views on health, disability and mental health. What are the delegation's current definite needs in the sense of future funding? Despite being a Government backbencher — for which I do not apologise — I certainly do not disagree with the point made by Deputy McManus that it is important that mental health be given proper recognition in the health budget. As a Fianna Fáil member of health boards over the years, including the Eastern Health Board from 1994, and as founder chairman of the South Western Area Health Board, I had an opportunity to visit various institutions in the Dublin region. We should all put our hands up and acknowledge the need to modernise those facilities. Much progress has been made in respect of services and in some facilities. A fine unit exists in St. Loman's in Tallaght which is as it should be. However, in other parts of the Dublin region, other facilities clearly need to be dealt with. I was interested in the point made in respect of the available resources and the facilities such as land banks which could be used for other purposes with the benefits accruing to the mental health services. I welcome the opportunity to support AWARE and I look forward to doing so in the future.
I welcome members of the delegation and I thank them for their presentation. I agree with almost everything Ms Hogan has said. I have some questions and observations. I worked in the psychiatric service and I have some understanding of the points made. While great strides have been made in the area of psychiatry and the psychiatric services — this must be recognised — there is nevertheless still a long way to go. There have been marvellous policy innovations in planning for the future in the psychiatric services but as well as developing the community service it is imperative to ensure that a good hospital service is retained and this may have been overlooked sometimes.
The Government is developing the concept of units in general hospitals and this is to be commended and supported. An identified and established need exists for a step-down service because there will always be people who by reason of the nature of their illness will require ongoing care, either provided by the established hospital unit or residences in the community. What is the view of the delegation on the operation and workings of the community residences? Is it satisfied with the level and service available in the hospital context?
Ms Hogan referred to depression as being closely correlated with suicide which is indeed the case. I do not think there are too many families in this country who have not experienced the icy touch of suicide in one way or another. What is the delegation's experience of the support structures available from family and friends when a person is diagnosed as suffering from a psychiatric illness? I have not worked in the service for the past seven years but in my experience, such support left a lot to be desired. Sufferers of psychiatric illness are often overlooked. If one asks a patient how they are by saying, "You are looking great", the response will often be, "Ask me how I feel". That is the big question. I am a Fianna Fáil Member of the Oireachtas and the Government spokesperson on Health and Children in the Seanad along with my colleague, Senator Feeney. This has been the Cinderella service for many years under successive administrations. Nevertheless many advances have been made. I particularly take note of the point AWARE made on the costs of drugs, where I fully recognise there is a clear anomaly. This matter has been raised at the Midland Health Board, of which I was a member for many years.
A one-year wait for child and adolescence psychiatry is unacceptable. However, this is not true across the board. In the Midland Health Board area that service is operational and I do not believe this is the case. However, if it exists in one case in one area, it is one case too many. Such a delay is much too long. The Cathaoirleach, as a practitioner, knows it is very important that children who develop any illness, psychiatric or otherwise, are attended to at the early stages.
I agree with Deputy McManus on the matter of alcohol and drugs. Drug use causes terrible problems for the psychiatric services. I noticed in my latter days working in the psychiatric services that problems associated with drugs were increasing. I remember statistics from our annual report indicating the most common reasons given for admission to St. Loman's Hospital in Mullingar were drink-related issues. Now these are drink and-or drug related issues.
The support from families, including spouses and siblings, and close friends is not what it should be. This causes the isolation. Representatives from AWARE are correct in pointing out the stigma that existed in the old days regarding those admitted to psychiatric hospitals. Regrettably in many cases people just wanted to see the back of those in psychiatric hospitals. While it is terrible to have to admit this, it has been my experience.
I will talk about suicide prevention programmes to which Deputy McManus referred while Ms Healy will talk about doctors and the health system. We need a suicide prevention campaign. There is no point in looking at suicide prevention and including only people who are at high risk of suicide. We need to look at suicide prevention in terms of educating the public to maintain the mental health as opposed to trying to recover them from mental ill health in order that we do not get to the stage of having people who are at high risk of suicide. This will be a big factor in reducing the number of suicides in Ireland. This should be worked at and we need to take a step back along the path before people become so mentally unwell that suicide is actually an option for them. We should consider suicide prevention as one huge step we need to take; it can be done.
Deputy McManus mentioned the lack of people to provide counselling, which is of real concern. Many posts within the health boards are not filled resulting in the treating team missing key people. Previous thinking might have identified treatment for depression as being either medication or psychotherapy, counselling, cognitive therapy or something in that area, whereas in the ideal world people would be able to avail of both. In terms of medications it is important to note that in treatment of some depressions anti-depressant medication has been shown scientifically to work. However, this does not mean that people who experience depression should just be given a prescription. People need the sort of cognitive support and help that can be provided by counsellors. Deputy McManus raised a very important point. Part of the teamwork involves medical people involved in nursing and occupational therapy, and certainly involves people in the cognitive therapy area and counselling.
The issue of junior doctors ties in with this matter and the point we made about continuity of care. It is important to note that junior doctors are doctors who have qualified medically, but are in training, moving every six months, working up hours of experience in the psychiatric service. Although they are meeting and treating the patients, junior doctors are not the consultants who are treating the people. While if the Hanly report is implemented we will have more consultants, that is a long way down the road. In the meantime people receiving ongoing treatment absolutely dread January and June when the junior doctors move on. For any of us visiting our GPs it is nice to see the same person and this continuity is what is seriously missing in the mental health service.
There is also a need for an alcohol education focus. AWARE commissioned a report last September on the link between depression, suicide and alcohol, and found a very real correlation. For instance, in the decade to 2000 alcohol consumption here increased by 41% and the suicide rate increased by 40%, which indicates a pretty definite correlation. As I said earlier in terms of a suicide prevention programme, educating young people particularly about alcohol, its dangers and how it can affect one's mood is very important.
Alcohol is a depressant. We are all familiar with having a drink and feeling great. Some people will feel absolutely awful the day after and their mood decreases significantly. Alcohol is also a disinhibitor which means normal inhibitions towards, for instance, self-aggression and self-harm are significantly reduced, which is where the danger comes in because we are disinhibited and we are depressed if we have a mood disorder and we are taking alcohol. Something needs to be done about this and we need to educate the public more about these dangers.
I apologise for stepping out earlier. However, I caught most of the presentation. Other members have touched on some of the topics I wanted to raise, including the question of alcohol. This brings me to an important topic. We are continually told of what is important for our physical health, in terms of diet, exercise etc. However, does a programme informing people about good mental health exist? This particularly relates to alcohol. If such a correlation between mental health and alcohol consumption exists, would AWARE agree with having warnings on alcohol bottles advising of the link in the same way that we have warnings about the dangers of smoking in cigarette packets?
As Members of the Oireachtas, we have all come across the devastation caused through having a mentally ill person in a family. The counselling available to families seems to be non-existent. They are left more or less on their own and cannot cope. Has AWARE made recommendations to Government on the assistance required for relatives? I do not doubt the existence of the link, which I have seen this year in particular. I know of people who have committed suicide and I do not doubt that depression was a factor in such cases. How does one know that, however? It is a real problem. When one meets people who seem to be in great form and on top of the world, how can one know they are suffering from depression? How can the families of such people know they are going through mental torture and are going to commit suicide? How can one see the signs?
The delegation mentioned that 20% of prisoners are affected by psychiatric difficulties. What can the Prison Service do to address such problems? I am aware of a young man in my home county who was involved in difficulties with the law and was given a short prison sentence. He committed suicide after he was released from jail. His father and the rest of his family were upset because they felt his imprisonment was the catalyst for his decision to take his life. One could not blame the prison sentence for that decision, but it certainly spurred him on in some respects. His term in prison affected him very badly. How can we ensure that those who go to prison are not affected adversely by their prison sentences? What services are in place for such people? What services should be put in place to ensure that we do not encounter cases of this kind again?
Like my colleagues, I welcome the representatives of AWARE and congratulate them on their excellent work. I am familiar with the Beat the Blues programme in secondary schools. I am delighted that the delegation discussed the subject of child and adolescent mental health, an issue I raised in the Seanad before Christmas. I became aware at that time of the tragic case of a 15 year old whose psychiatrist could not find a bed for him in any of the Dublin hospitals, simply because there are no paediatric or adolescent beds in that area. The psychiatrist secured a bed for the boy in question in a mental hospital for adults. He vanished while he was being checked in, however, and was found dead several hours later, unfortunately. I have been told in recent days that eight paediatric or adolescent beds will become available.
I agree with Deputy McManus's request for the Government to consider ring-fencing part of the health budget for mental health. It is fine to come in here this morning. Senator Glynn is right to state that we have all been affected by suicide, or know somebody who has been affected by it. We have often gone to a church or stood at a grave and thought "if only we could have done something about it". I would like some part of the health budget to be ring-fenced for adolescents with mental health problems.
I do not know whether we can break down the stigma related to mental health problems as time goes by. Perhaps there is a need for better public relations or better public education. I was not aware that the budget of €17 million spent on road safety is equal to that spent on mental health services. There are 108 more deaths as a result of suicide each year than there are on the road. All of us think of the terrible advertisements we see on television when we are driving. I turn off the television advertisements that refer to drink driving because they are so vicious that I get upset. If there were better public relations campaigns, people might start to understand that there should not be a stigma with regard to mental illness. Given that our mental and emotional health is an important part of our physical health, why should it be considered differently?
Ms Hogan said that she thinks there is a greater focus on training than on patients and I suppose that is true. That is what has come from our medical schools since we started to train and educate doctors. Patients do not fall under the direct responsibility of junior doctors. The consultant who is in charge of the relevant junior doctor is responsible for the care of the patient. I appreciate that it must be daunting and terrifying when rotas change in January and June, after six months of training have been completed. It may be possible to examine that, however, in the context of trainers and consultants. Perhaps the registrar, who has been in place for longer than the junior doctor, can start to play more of a role just before the changeover in January and June in order that the transfer does not have the significant impact that has been suggested by Ms Hogan.
I have probably covered many of the matters which were covered by other speakers. I thank the delegation for its worthwhile presentation.
Does the delegation wish to respond to the points Senator Glynn and I made earlier?
I will ask our guests to answer that question at the end of the session, if any points are outstanding.
I think our questions may have fallen out of the loop.
They have not fallen out of the loop. We would never allow that to happen.
I thank the delegation for its presentation. When groups like AWARE address the committee, they can give a interesting perspective on the service that is different to the committee's understanding of it. As a GP, I was interested to hear the delegation's take on mental health services and, in particular, junior doctors. Having once worked as a junior doctor in psychiatry, I agree with the witnesses' comments. One might be moved to a completely different department just after one has succeeded in building up a relationship with a person to whom one is providing marriage guidance counselling or a patient with a long-term illness. That can result in a decrease in the level of continuity of care. It was interesting that this process was cited as a major factor in the AWARE presentation.
The committee does not need to engage in a debate with the delegation about the deficiencies of the health service because, to be quite honest, they are pretty extensive. As Senator Feeney pointed out when she spoke about child adolescent care, a Government report which was published a year and a half ago recommended that 50 beds be provided, but just 12 beds have been provided for the whole country so far. Psychological and counselling services are extremely weak throughout the country, regardless of where one deals with them.
I wish to focus on the work of AWARE, which has organised a series of public lectures — I have given some of them — and runs support groups. Such activities engage those who recognise that they have an illness and have an interest in it. What does AWARE consider would be the best programmes to address prevention and to reach those who are unaware that they have such an illness? How long has the Beat the Blues programme been running? Has it been running for five or six years, or just two or three years?
It has been running since 1995.
Can AWARE provide information on the programme's success? What do young people in areas where it has been implemented think of it? Has the programme been successful? Educating the public is often a great way to prevent things from happening.
While many people do not associate alcohol with the risk of committing suicide, I know of two cases in the past six months of people trying to hang themselves having come home after a night spent drinking. Both cases having been lucky in that someone found them, they each felt total self-revulsion the following day. They could easily have become further suicide statistics, even though I do not think they initially intended to kill themselves. Their pre-morbid personalities before going out drinking were not so depressive as to drive them to attempt to commit suicide. The two suicide attempts were related purely to the amount of alcohol they had taken on board and its disinhibiting effect on the mental states of the persons involved when they arrived home from the pub. In both cases it was lucky that a family member woke up, heard what was happening and investigated it. The people in question were actually hanging, rather than about to do it. I would like to hear AWARE's views on preventative programmes to get through to the entire population. I would like to get Ms Healy's views on that. Does she believe we should focus more on that, taking the public lecture series into the schools? Should we get it to the population that will not come out to hotels at night, perhaps? Should we target groups which might contain one or two people who might be affected? I would like her to focus on that more, rather than on what is basically a Government issue and share the experience of AWARE with the committee. Perhaps members could then pick up from that, which would be interesting.
There have been a number of questions and comments about the effects of depression on the greater family. These are important points because depression obviously does not affect just the person experiencing it. Because the victim relates emotionally to people around him or her, they too can be seriously affected. What AWARE can do and what needs to happen on a much wider scale is to make families aware that a person's behaviour when he or she is depressed is illness-related and not necessarily about the individual. Often family members observe what they see as behaviour about relationships when that is not the case, but rather behaviour about illness. If people can learn to identify illness-related behaviour and in a sense isolate it — but not the person — from normal day-to-day family relationships, that can be of enormous help. To be able to do that family members need information and support. AWARE provides support groups, particularly for family members. However, information must be directed on a much wider scale at family members who are with the victim of depression from the time it is first diagnosed. Treatment, whether by a general practitioner or psychiatrist, must involve members of the family from that point onwards and keep them involved. The general pattern is that family members are very concerned at first and want to do everything they can for the person affected. When the depression does not lift immediately they move on to a mode of being angry, annoyed and upset because of the way their own lives are being affected. When nothing significant arises from that they tend to move into the third mode of ignoring the person concerned and moving back emotionally from a situation they cannot handle. Therefore family members need support and information and AWARE provides that. We also have a publication called Keeping Hope Alive, which is specifically for family members. That is extremely important.
There was a question about how one knows if someone is depressed. That is a difficult one because sometimes the depressed person, as we said in our introduction, is not always capable of acknowledging that fact. If one has a pain in the arm or chest, one knows that this could indicate a problem. There is not the same degree of knowledge as regards depression and its effects and therefore a much greater national campaign, as regards symptoms, is required. AWARE is constantly limited in its impact because of funding. Deputy O'Connor raised the question of our funding needs. We get 13% of funding from statutory grants and the balance must be met through fund raising. Much of the energy within the organisation is being devoted to fund raising which could be targeting public campaigns about depression. Fund raising can of course be two-pronged in that it too is concerned with raising public awareness. However, much more money needs to be allocated specifically for public information programmes.
Deputy Twomey mentioned that people who come to AWARE want to learn. They are sufficiently affected by the illness to be motivated to come out at night to a group meeting or whatever. However, vast numbers of the public, perhaps, are not accessing our services, for whatever reasons. Either they do not know about them or they are not aware that they need them.
In terms of prison, there are enormous concerns. AWARE has suggested in previous submissions that the inspector of mental hospitals should be given the remit to go into prisons and report on services available there within the psychiatry area. On a personal level I visit prisons from time to time to provide information about depression to inmates, mainly through the library service. In general, inmates who identify themselves as being depressed fear they might be moved to a hospital setting rather than being left to cope within the prison. A simple initiative is the availability of mobile phones with a dedicated number that provides contact with theSamaritans. Prisoners fear, however, that if they ask for a mobile phone they might be indicating they are suicidal to the authorities and so run the risk of being moved.
I will attempt to answer a few questions in one fell swoop. There is a need for a public information campaign on mental health and mental well-being. Deputy Gormley asked whether there was such a programme. It has been attempted in other countries through public information campaigns. However, we need to develop one for Ireland and to get it into the public domain as part of a wider information campaign. The public needs to be educated about factors such as alcohol abuse and the effect this can have on mental health. People need to know about the signs and symptoms of depression to look out for in family members in order to be more confident about their own mental health and that of their loved ones. Members of the public need to be educated to such a degree that fear is eradicated and stigma is not allowed to continue. Stigma prevents people from learning. Many Irish people are afraid of mental health and of people who are mentally unwell or display such symptoms. They fear them because they do not understand the reality of these conditions or how to help people so affected. The Government, ideally, could make an effort to devise a public information campaign in conjunction with organisations such as AWARE or Schizophrenia Ireland, representatives of which are here today. It is important, too, to get oral advice on mental health and this can and must be done sooner rather than later. A situation whereby 15 year old children are taking their own lives just cannot be allowed to continue. I do not believe anyone in this room sees that as acceptable.
Deputy O'Connor asked how we co-operate with other voluntary organisations. An umbrella group, Alliance for Mental Health, operates in Dublin and in various health board areas around the country, where all of the voluntary groups come together including our colleagues, Schizophrenia Ireland, Grow, Recovery, Bodywhys and AA, and together give presentations and work very much as a team, despite being autonomous bodies.
I asked one or two questions, to which I would like a response about the maintenance of the hospital service and the need for step-down facilities between the community and the hospital.
The Senator mentioned psychiatric units in general hospitals, which are to be welcomed. In an earlier submission AWARE suggested that such units should cater for occupational therapy and provide opportunities for people to avail of programmes for recovery. Often the psychiatry units in general hospitals are small and self-contained. I have in mind a city hospital where the psychiatric unit is located in the bowels of the earth and access to a garden or any type of occupational therapy is missing, within a tight unit that is dealing with acute cases. This means the extra motivation patients need to encourage them to leave the bed and walk around is missing. Psychiatric units in general hospitals are welcome but they need to be opened up. Some people who go into hospital from time to time are concerned that a bed will not be available should they need it. Many family members are concerned that the provision of community care services is not sufficient for the needs of someone who is acutely ill. Early discharge from hospital is welcome but that should not mean the person is discharged before he or she has recovered. If readmission rates were published, it might show that those who were discharged after a few days following an acute episode of depression were back in hospital after a short period.
People find the residential step down facilities very useful. Considerable improvements have been carried out in those units in the past few years, however there is always room for further improvement.
I am aware that there are normally one or two intervention beds in community residences. Because of the nature of some psychiatric illness, people will need ongoing care and it is important that there are appropriate facilities for that group. The need for such a service may fall between two stools, that is, between community care and the acute unit at the general hospital.
The answer to that is the high support residential unit which is staffed on a 24 hour basis by professionals in psychiatric care. Many more such units are needed.
I am referring to people with challenging behaviour, and the high support unit does not cater for them.
They would need care in a specialist unit.
I thank Ms Hogan and Ms Healy for an excellent presentation, for answering all our questions so well and for outlining to us the fundamental issues which surround some problems in mental health today. I welcome Mr. John Saunders, director, Mr. Patrick Annesley, chairperson, and Ms Kahlil Thompson, projects officer of Schizophrenia Ireland.
Before the witnesses make their presentation I remind them of the long-standing parliamentary practice that members should not comment on, criticise or make charges against a person outside the House or an official by name or in such a way that makes him or her identifiable.
On behalf of Schizophrenia Ireland, I thank the committee for the opportunity to make a presentation to it. Schizophrenia Ireland is a national voluntary organisation founded in 1975 which supports people with severe mental illness and their family members. We have 52 support groups, which provide mutual support either for relatives of people with mental illness or for people who are experiencing mental illness and these groups operate nationally throughout the Twenty-six Counties.
We provide a range of services specifically for people with severe mental illness and their families to include a national helpline service, counselling in four locations and a comprehensive information service for people who have experience of the illness or have family members with it. We provide a range of direct services for people in areas of employment support, information, education and other projects that aim to assist people in recovery.
Our document Recovery in Practice was circulated to the committee. We see service delivery in Ireland having moved fundamentally from institutional care towards care in the community. However, many key elements of treatment are still provided in centralised treatment facilities. The provision of co-ordinated and extensive community service still remains in our opinion incomplete. There is also a continuing reliance on the maintenance model of care for people with a psychiatric illness. This devalues the ability of people to participate actively in the management of their own care or to recover from this experience.
In setting out our mental health strategy, it is vital that services and research are reoriented towards partnership and recovery and that recovery is viewed as an overarching objective for mental health policy. This may seem to be a novel approach in the sense that we assume recovery is the objective but we would advocate that in many of our services, the objective is not recovery but the maintenance of people in the status quo. Reports from the inspector of mental hospitals have continuously stated that 70% of all admissions to psychiatric care services are frequent readmissions. We ask why that is the case.
The role and importance of peer groups and supports need to be recognised by medical and other professionals and included as equal partners in the process of recovery. We believe fundamentally that the Irish mental health care services are focused directly on the person as patient and often do not realise that the person is part of a family and much can be done to assist the family in achieving recovery for that person. The committee should remember that 90% of the care for people with severe mental illness is provided by family members, in other words, they spend most of their time outside the formal residential care services and are at home receiving informal care. Much of this care is unsupported by the State and is given by local and voluntary effort. We believe that interventions for people in the statutory health care service should be person centred and include a wide range of complementary and alternative therapies and supports. There have been many publications in the recent past which suggest that the only form of intervention for many people with severe mental illness is medication based. There is an absence of so-called talking therapies based on psychological interventions. There is an absence of counselling services. There is an absence of information and support with income maintenance, housing, re-employment and regeneration of one's lifestyle after the initial illness. The result is that many people are maintained in a state of stability which is controlled by medication, but they do not achieve a full and sustained recovery.
Schizophrenia Ireland believes that the policy drivers, which should be embedded in the overall mental health service, should include the concept of recovery. Recovery must be recognised as a goal for mental health care. We also believe that holistic participation is an important concept. Mental health care must be conceptualised beyond the medical model. People with self-experience of mental illness and their families need to be partners in service treatment planning and policy development at all levels. Talking to people who have made a sustained recovery, many of them report that the secret to recovery has been their own ability to participate in the recovery process. They first have to realise that there exists a serious problem, then they have to seek assistance with re-orientating their lifestyle in order that they can achieve the required recovery. Integration of services is an important issue. Services need to be integrated across all Departments which need to foster social integration. The provision of health and recovery services is not the remit of one Department. Many Departments have a role in recovery from mental illness. For example, the Department of Enterprise, Trade and Employment provides FÁS based and other employment support services which are very important to people with mental illness. Through the local authorities, the Department of the Environment, Heritage and Local Government is responsible for social housing. The Department of Social and Family Affairs and the Department of Community, Rural and Gaeltacht Affairs both have a role in income maintenance.
Access to services, information, education and support must be fostered actively for both service users and their relatives at all stages. This is an important role for Schizophrenia Ireland, where we are constantly told that patients and family members do not receive adequate or timely information about their condition or about their treatment at the point of service delivery. In spite of our information age, there is still a paucity of appropriate and timely information for people in that situation. We need to foster the development of effective partnerships with other providers including non-governmental organisations and statutory agencies. We work in alliance with a number of other voluntary agencies and we promote this partnership approach in order to provide a nationwide response to the needs of people with severe mental illness. We believe that choice must be given to people with self-experience and to their relatives. Many people who become ill and their families report that they have not had choice in many situations. They have had to accept the particular medical approach offered by one service or one clinician. They have often had to accept one particular day intervention or employment intervention which may not be the most appropriate for that person at that time.
Access to a full range of advocacy services and training in self-advocacy should be available at all points of service delivery. We are part of the advocacy movement, but there are also many developments in the area of individual and peer advocacy, whereby people with mental illness are taking charge of their own lives and are making demands on the services to meet their own particular requirements. To achieve quality of services, increased funding for mental health care is imperative. Mental health care, as a proportion of the overall health care budget, has dropped from 10.6% in 1990 to around 6.8% in 2003. This fact has been repeated in many different fora. The real cost of mental health must be reflected in an appropriate allocation of financial and human resources. It is now time to invest in recovery. I thank the Chairman and the committee members for their attention.
I thank Mr. Saunders for a clear and concise presentation. I am shocked that the percentage of funding for mental health services has dropped. We must take that on board.
I welcome the witnesses. They are doing excellent work with individuals and in policy development. It is important that people who are closely involved articulate the policy changes that are needed.
The idea of recovery is very interesting. Can we now think of the recovery model because medical treatments have improved? To integrate services, the obvious thing to do is to set up an interdepartmental committee or have a Minister of State with responsibility in the different Departments. Have the witnesses thought out how we can ensure integration occurs across the different Departments? Would it be a good idea to have ring-fenced funding from the Department?
It seems extraordinary that information is still lacking. Why is that the case? Is it because professionals are overstretched and do not have the time? Is it that people do not believe that those suffering from schizophrenia need information? What is the organisation's experience of professionals and statutory bodies in trying to adopt the recovery model? Is there a good response, or do people just want to work in the old mode without changing, but want more money and more beds to keep the old system going?
I thank Mr. Saunders for his presentation. I thought recognition of recovery as a goal for mental health was a given and that it would be the role of anyone suffering an illness. Like the Chairman, I am amazed at the funding and how much it has dropped. It dropped to 6.8% in 2003 according to the presentation slide, but the source is the Mental Health Commission annual report for 2002. Is that statistic for 2003 or should it be for 2001?
That is a misprint. It is last year's report.
Thank you.
When funding drops that much, although in real terms it has gone up, where have the mental health services lost out? Is the service that was available in 1990 the same as that provided today? Has there been no improvement in 14 years that we might have expected in other parts of the health service? I am talking here about holistic things such as access to information, counselling and other non-medical interventions. In the course of that 14 year period, during which the mental health budget dropped as a percentage of the overall health budget, what was the effect on services? Has the situation worsened in the mental health sector? Does Mr. Saunders have a view as to why the mental health sector, which managed to get 10% of the health budget in 1990 during much tighter financial times, suffered a reduction when the country became wealthier? I presume the difficulties in the mental health sector have not gone away and, if anything, are more prevalent. Will Mr. Saunders comment to allow us to formulate ideas on the mental health sector?
To answer that and related questions on funding from Senator Feeney, if the members look behind the statistics we have quoted, it is obvious that over the past 20 years the number of people living in large mental hospitals has reduced. It is well documented that the number in long-term residential care has reduced to approximately 3,000 as opposed to 24,000 in the 1980s. This is for three main reasons. First, as the large centres have closed or reduced in size, there appears to have been some leakage out of the system of funding which is no longer required to run those services. Second, the ratio of expenditure in non-mental health services has changed with the result that the ratio of expenditure in the so-called high-tech general health services has increased and this has served to reduce the percentage in mental health care. Third, the allocation of real expenditure year on year has continued to increase but it has been absorbed in higher wage costs and higher non-pay costs for existing services. The reality is that we have similar services or sometimes fewer services, which cost more than they did 15 or 20 years ago for obvious inflationary reasons.
In response to Deputy McManus, if one considers the programme expenditures of the Department of Health and Children and the former health boards, it is clear mental health care funding is ring-fenced. However, it is worrying that because of the leakages, funding is lost to other areas because it is perceived to be no longer required in a particular area. We would argue, for example, that when one reduces the population of a large hospital, its funding should be reinvested in more appropriate community based models of care within the same location so that the funding is not lost through leakage. However, this has not happened to date. Funding has been taken from Peter to pay Paul in all of the former health board regions over the past 15 or 20 years.
Another matter raised by members was that of recovery. We cited the fact that of all mental health, hospital admissions 70% are readmissions, sometimes frequent readmissions. There is a view abroad that many patients are taken into hospital when a crisis appears in their lives. In other words, they live in the community for long periods but do not receive sufficient primary care or advanced community care. Nothing happens until a crisis develops and they and their families are then faced with the choice of admission to a residential hospital. Hospitals take the patients for a period of time but, as many psychiatrists agree, they must often discharge patients before they are completely well because of the pressure to admit someone else in an equally difficult position. There is a revolving door syndrome because of the pressure on beds and patients may be discharged when they are well enough to be discharged despite not having made a complete recovery. In other words, they are vulnerable. This earlier than desirable discharge is one reason for the cyclical pattern of readmission in similar circumstances.
We fundamentally believe the maintenance model is supported by the idea of admitting people to residential care. The recovery model is based on the idea of keeping people in the community, providing the necessary interventions for them at a timely and early stage and therefore minimising the likelihood of admission. We do not deny that admission is necessary but it should be a last rather than first resort in many cases.
The information issue is interesting. Our research and that of other organisations shows that at the point where a crisis is developing, the mental health care services do not focus sufficiently on providing timely and appropriate information. They may give information but it is often too technical or detailed, and may not be required at a particular time. In hindsight, one realises that the staff and services have not given information to the families and to the patients. While this is not always true, it is in many cases.
In the most recent research we undertook, we found that of the sample surveyed, which was more than 500, two thirds reported that they did not receive sufficient information about the treatment they were receiving, usually from their psychiatrists but sometimes from their general practitioner. An information issue arises. As families become more aware and more familiar with the situation, we find that they rely on voluntary organisations like ours to provide the information required to support them.
Could I develop the concept of cost in regard to patients who were in long-term care in a hospital before moving out into community houses? My understanding was that it was more expensive to maintain the patient in the community rather than in a long-term psychiatric hospital. Does Mr. Saunders believe that, because of the cutbacks in the funding to which he referred, patients who have moved into the community are more at risk than they should be?
Research in Ireland and abroad shows that the initial set-up costs of, for example, a group home or hostel in the community are more expensive because one must take into account the site and capital purchase cost of setting up a building. However, thereafter the costs are the same or less than would be the case with institutional care because one is not providing for the significant overheads or staff ratio which would be the case with a large building. Initially, the costs are higher but over the long term we believe they are the same or less, which has been demonstrated by research in countries and cities where the transition has been made from care in large institutions to care in smaller group homes.
On the second part of your question, Chairman, we have developed a number of group home and hostel services in Ireland which, by and large, have done a good job in providing care. However, many of those hostels and group homes have become mini-institutions that have not provided the most appropriate type of care for the person in that environment. To quote from the section on community residences of the report of the Inspector of Mental Hospitals published last year, which was laid before the Houses of the Oireachtas:
The Inspectorate had been struck by how little rehabilitation took place in community residences and how their management was oriented towards continuing, rather than decreasing dependency. Many were over-staffed, patients were not encouraged to take on the management of these, their homes, did not take charge of domestic matters such as paying their own expenses for light, telephone, heating accounts and so on. Many were staffed at a level of skill far beyond that required, such as having nurses sleeping over . . .
We now have a situation where patients have been taken out of large hospitals, which was correct, but we have created for them what the inspector calls mini-institutions in the community. These are not cost-efficient or productive in terms of providing recovery for patients who badly need it.
That is pretty shocking because all the thinking for the past 20 years has been to move patients out to the community. If we are now discovering that what is in the community is perhaps worse than what existed before, it is a severe indictment of the system.
I do not know whether it is worse but it is interesting and Mr. Saunders has explained something that was a mystery to me. We have all met people who are living in such units on an ongoing basis and are keen to leave. Although it may seem like the ideal arrangement on the surface, it is not good for people to feel powerless, dependent and unhappy. It has explained something that I could never understand. Furthermore, it seems to represent bad value at a time when we are trying to put more investment into the area of mental health.
I am equally shocked to hear this. I believed it was wonderful that all these people were getting out of long-term mental hospitals and returning to the community. We are all aware that there has been displeasure in some communities when houses have been used to accommodate such patients. We all support the hospital staff looking after mentally ill persons in these situations. However, if it is the case that there is no independent living, I am surprised we did not see that when we were debating the report in the Oireachtas recently.
Is this the delegation's view of the issue? Where I live in Sligo, I am surrounded by such houses because I live close to the local mental hospital. My impression does not seem to tally with the information Mr. Saunders has conveyed. I observe the mental health patients who occupy these houses coming and going as they go shopping or to their jobs. I greet these people on the street on a daily basis. Is what Mr. Saunders has described the norm or is the situation I have described in Sligo more usual?
Both situations are prevalent. We must bear in mind that these are supported community residences for which there are two functions. First, they serve to accommodate the relocation of institutionalised long-term patients. Second, they function as a potential stepping stone back into the community for people who are discharged from acute units. Some of these houses are functioning well in the latter capacity. A significant problem with the revolving door syndrome of readmission is that in many areas, especially inner city locations, there are simply not enough of these halfway houses which offer interim, supported accommodation.
As with many areas of the health service, if there is a system for monitoring the best example of certain facilities and practices and trying to apply the lessons of good practice throughout the service, there will be significant improvement and some of the deficiencies highlighted by the inspector will disappear. The question arose as to whether such facilities are more expensive. Where they succeed in reintegrating people into the community, they involve a saving of all the costs of mental ill health which were referred to in the presentation by the delegation from AWARE. Members of the delegation made the point that the greater part of the cost of mental ill health is not incurred within the health service but is a cost to the community at large and the budget in general.
I thank Mr. Saunders, Mr. Annesley and Ms Thompson for attending and enlightening members as to the fundamental issues regarding mental health. It has been a worthwhile and informative session and I assure the delegation that the committee will regard mental health as a priority issue during the coming year.
The joint committee adjourned at 11.25 a.m. until 9.30 a.m. on Thursday, 3 February 2005.
