I welcome everyone to the sub-committee. The members present are Deputies Neville and O'Connor and Senator Glynn. Deputy Neville has been involved in the area of suicide prevention for many years. The presentation today on the high levels of suicide in Irish society is by the mental health division of the Department of Health and Children, from which I welcome Ms Bairbre Nic Aongusa, with Mr. Geoff Day, head of the National Office for Suicide Prevention in the Health Service Executive; Dr. Ella Arensman, director of research at the National Suicide Research Foundation, and Mr. Derek Chambers, a researcher. I ask Ms Nic Aongusa to make her presentation. We will take questions later.
High Levels of Suicide: Presentation.
Ms Bairbre Nic Aongusa
I thank the sub-committee for giving me and my colleagues from the HSE the opportunity to speak to it today about this topic and to outline some of the measures being taken by the Department of Health and Children in conjunction with the HSE and the many community and voluntary organisations to address the issue of suicide in Irish society. I will briefly outline what we know about suicide. I will also talk about the cost and outline the strategy we launched recently to tackle the issue. As members have received a copy of my presentation, I will only discuss the main issues.
As regards the data available, on average, there were 494 deaths by suicide in Ireland annually between 2000 and 2002. The figure peaked at 519 in 2001. More recent provisional figures show that there were 444 and 457 deaths in 2003 and 2004, respectively. These data represent a rate of approximately 12.9 per 100,000 of the population. The chart in Appendix 1 of my presentation shows where Ireland stands in relation to other EU member states. We rank 17th among the 25 EU member states for total population suicide rates. According to the CSO data, the Irish suicide rate has doubled since the early 1980s and suicide is at least four times more common in men than women. We are concerned about the youth suicide rate which is currently the fifth highest in the European Union. If one looks at the table in Appendix 2 of my presentation, one will see where Ireland ranks compared to the other 24 EU member states. The rate is higher in Ireland among people in their 20s and 30s. We are particularly concerned about the fact that men under 35 years of age now account for approximately 40% of all Irish suicides.
Another aspect of suicidal behaviour is deliberate self-harm which used to be referred to as parasuicide. The National Parasuicide Registry has registered more than 11,000 cases of deliberate self-harm presenting in Irish hospitals. This is highest among younger age groups, particularly young girls.
Suicide has a wide impact and does not affect only those concerned. A community survey of young men aged 13 to 34 years showed that 78% of young men knew at least one person who had committed suicide. The impact on society is, therefore, significant.
The cost to society of suicide is also worth considering. As mentioned by the Tánaiste and Minister for Health and Children at the launch of the strategy, the cost in terms of lives lost and the potential contribution of the young people concerned is immeasurable. As suicide occurs mainly among young people, society is deprived of their potential and the contribution they could have made. Also, the personal cost is immense.
It is worth noting the economic cost of suicide. In the course of work in preparation for the strategy the cost was estimated at €871.5 million, equivalent to a little under 1% of GNP for 2001. Much of this relates to human cost, the economic methodology which puts a value on society's willingness to pay for suicide, a concept which is difficult to grasp. Another figure worth bearing in mind is that for the direct and indirect cost, as illustrated in the first row of the slide, of €247 million in terms of lost productivity in the economy.
How are we to respond to suicide? It is important to note the causes are complex and are likely to involve an inter-play of psychological, biological, social and environmental factors in the context of a person's negative experience over a lifetime and often aggravated by a recent personal difficulty. Given its complexity, there is no single intervention or approach that will of itself adequately address the problem. What is required is a strategic framework which will assist us in identifying actions that can be taken in a co-ordinated way through partnership between statutory, voluntary and community groups and individuals supported by the Government. The message is that everyone has a role to play in suicide prevention or, as the Minister said, suicide prevention is everybody's business, including schools, the community and the corporate and business world.
Reach Out, the national strategy for action on suicide prevention contains the strategic framework to allow us move forward. Members have received a copy of the strategy which was launched by the Tánaiste and Minister for Health and Children on 8 September. It is a ten year strategy prepared by the project management unit of the HSE and the national suicide review group with the active support of the mental health division of the Department of Health and Children. It builds on the report of the national task force on suicide published in 1998 and takes account of all the efforts and initiatives developed and put in place by the former health boards and voluntary sector in recent years. As members will be aware, there has been a great deal of activity in these areas in recent years.
It took two years to develop the strategy. One of the key measures was a wide-ranging consultation process to draw on the experiences, perspectives and ideas of the key stakeholders and interested parties. It is not a strategy concocted by a group of people in a room who thought they knew best. It involved a whole range of individuals discussing with various sectors of society how they felt and what they wanted done to build a programme which would effect real change during the next five to ten years.
The strategy takes a combined public health and high risk approach to suicide prevention and proposes four levels of action: a general population approach which targets the whole population; a targeted approach which includes a range of actions aimed at particular groups, particularly vulnerable groups in society; a section on responding to suicide and caring for those bereaved by it and, information and research. Each of the four levels is divided into action areas. The strategy includes 26 such areas, each of which has been planned, measured and set out in detail.
The combined public health and high risk approach to suicide prevention taken in the strategy is in line with international best practice as advocated by the International Association for Suicide Prevention and in keeping with the European action plan on mental health signed by the 52 member states of the European region of the WHO at a ministerial conference held in Helsinki earlier this year. The Health Service Executive will take a lead role in implementation of the strategy. The National Office for Suicide Prevention, a new office announced by the Tánaiste and Minister for Health and Children on the day the strategy was launched, will drive it. Mr. Geoff Day heads the office and will provide the sub-committee with further information on its role and functions.
As the Tánaiste and Minister for Health and Children announced on 8 September, a further €500,000 has been allocated to the HSE for the remainder of 2005 to commence implementation of the strategy immediately. We are considering the funding required for 2006 in the context of the Estimates process. The Tánaiste and Minister for Health and Children is on record as saying additional funding allocations will be made available in the coming years to support the strategy and complement efforts at local and national level. The cost of implementing all the actions identified in the first phase is estimated at €3 million per year.
The strategy is practical and achievable. It is founded on extensive consultation with all key stakeholders, sound evidence and national and international best practice. It is evidence of our determination to take whatever steps we can to reduce the levels of suicide and will be subject to regular monitoring and evaluation over its lifetime to ensure its outcomes are achieved. Following Mr. Day's presentation, my colleagues and I will be happy to answer any questions.
Mr. Geoff Day
I thank the sub-committee for giving me the opportunity to speak about the present and future work of the new National Office for Suicide Prevention. The HSE established the office as recommended in Reach Out: A National Strategy for Action on Suicide Prevention, launched by the Tánaiste and Minister for Health and Children on 8 September. The office forms part of the HSE's population health directorate and I have been appointed as its head. It currently comprises four staff and is based in the HSE in the north east. All of the staff currently employed in the office are existing health service employees and all future moneys for the development of services will be earmarked for achieving the objectives in the strategy document.
The functions of the office are fourfold. They are to oversee implementation of Reach Out: A National Strategy for Action on Suicide Prevention. The office will not be responsible for implementing the actions identified in the strategy but will ensure those from whom we commission work will achieve the objectives set out. The office will commission appropriate research into suicide and disseminate research and best practice throughout Ireland. As mentioned by a number of commentators and the President of Ireland at a forum earlier this year on suicide prevention, the office will co-ordinate our various suicide prevention efforts. Many hard working people put a lot of effort into tackling the issue. The office will consult widely and regularly with organisations and interested parties on current evidence, good practice and new initiatives in the area.
The office will also encompass the role previously held by the national suicide review group, including the production of an annual report on suicide prevention initiatives as required by the Health (Miscellaneous Provisions) Act 2001. The final report on the national suicide review group's activities for 2004 was laid before the Houses of the Oireachtas on 30 September, a copy of which is available to committee members.
I stated the office has an important role in seeking advice from experts and a range of organisations. We will establish an advisory group comprising those with expertise in the area of suicide prevention, drawing together important contributions from Irish experts in this field. A national forum of organisations involved in suicide prevention will meet at least annually to hear a report on progress on implementation of Reach Out: A National Strategy for Action on Suicide Prevention, with regard to new research and evidence on the subject. The forum will, importantly, listen to organisations about future developments.
Additional development moneys of €500,000 have been allocated in 2005. This funding will be focused on the following four areas. A major national anti-stigma media campaign relating to mental health will be initiated with health promotion colleagues and voluntary agencies. Young men, in particular, will be encouraged to seek help. This is itemised as area 10.1 in the strategy for action document. I hope this campaign which will take up considerable resources will facilitate the awareness of young men especially.
A national skills training programme will be initiated, using, among others, the assist model. This is the applied suicide skills training model which was created last year and has already trained over 1,700 people in various communities. This takes in areas 7.3 and 13.2 in the Reach Out document.
The health service response to self-harm presentations in accident and emergency departments will be improved by establishing new services to increase coverage, from 50% to 90%, in accident and emergency departments. This is categorised as area 12.3 in the strategy document.
The co-ordination between bereavement support services provided by a number of voluntary organisations will reviewed and improved. This is an extremely important issue that should be focused on.
A comprehensive work plan has been agreed for 2006 based on the actions and priorities set out in the strategy for action document. The extent of implementation will clearly be dependent on additional resources to be made available by the Health Service Executive in 2006. I have listed the areas proposed to be focused on. The national anti-stigma campaign should be implemented and sustained over a period of time, as we know from the experience of colleagues in other parts of Europe, particularly Scotland.
Deliberate self-harm services should be put in place in the remaining 10% of accident and emergency departments in order that complete and comprehensive coverage is achieved. Regional training officers should be appointed to implement the extensive training programme outlined in the strategy document, while the actions arising from the review of bereavement services should be completed and implemented. Specifically, we would look to fill in gaps in bereavement services.
Discussions should take place with stakeholders on the establishment and structure of a national confidential inquiry into deaths from unnatural causes with a view to implementation in 2007. Research should be conducted on the link between institutional abuse and suicide, a source of strong concern. We have already heard from survivor groups. A pilot primary care fast-track response programme should be put in place for identified suicide risks in the area of general practice. This would examine the value of a primary care approach to suicide prevention.
Work should be done with the media to improve the reporting of suicide and instances of deliberate self-harm, while a research programme should be agreed upon that reflects suicide prevention in an Irish context, looking specifically at Irish research to address issues faced within the country. An approach should be agreed with key stakeholders to reach out to young people using e-mail and text messaging formats. This would be an ambitious programme that would, if properly resourced, build on valued work already undertaken by statutory services, voluntary organisations and local communities. I will now answer questions from members of the joint committee.
I welcome the delegates and thank them for their presentation. I know three of them very well for many years and I am sure I will get to know Ms Nic Aongusa also.
The report is both comprehensive and welcome. It is similar to that of the national task force on suicide but could not be otherwise. The situation would not have changed much in seven years. What was right then is right now. This does not take from the national task force on suicide. The report reiterates the previous one, brings the subject to the fore again, creates a discussion around the issues raised and looked at the matter in different ways. For that reason, it is welcome.
I have several questions. I understand a detailed costing of the full report has been done. That would be of enormous benefit to the sub-committee which is to engage consultants and would have asked them immediately to do a detailed costing of the full report. It would be very helpful if the information was made available to the sub-committee. Without detailed costings over the ten year period, one cannot evaluate progress. It is crucial information. I was surprised it did not form part of the report; if the sub-committee receives it, it will be included in its report.
Five years ago the World Health Organisation was in favour of having targets of success on suicide prevention. The United Kingdom set a target that by a certain time suicide rates would be reduced by approximately 5%. Ireland set no target. In the past few weeks we have learned that without targets and clear objectives, one cannot evaluate the success of a programme. I would expect the mental health division of the Department of Health and Children to set five or ten year targets for the reduction of suicide and attempted suicide or self-harm rates. I will not suggest a figure. Was this discussed by the mental health division? It obviously decided not to set targets. It puts a lot of pressure on the Department, or the Health Service Executive; we never know whether we are talking to the Department or the executive, it depends on which question the Minister wants to answer.
On the National Office for Suicide Prevention, the Tánaiste and Minister for Health and Children has mentioned a figure of €500,000 on several occasions and it was mentioned again today. According to the reply to a parliamentary question I obtained approximately two years ago, €22 million was spent on road safety, excluding the cost of the Garda. The figure is probably higher now. Spending on suicide prevention measures this year will come to €500,000, although more die by suicide than in road accidents. This out of proportion.
I want to clarify something. I recently received a reply to a parliamentary question from the HSE informing me that this year €4.5 million would be spent on suicide prevention measures. I was told a similar figure, approximately €6 million, was spent last year. Will a reply from the Health Service Executive to a parliamentary question state X amount has been spent on suicide prevention? Will the National Office for Suicide Prevention have control over how this money is spent? Will it be able to outline in its report where the money went? It is important that this information is known because, if not, there will be little difference between the national suicide review group and the National Office for Suicide Prevention.
The national suicide review group's terms of reference, included in its first report in 1999, stated its responsibility to oversee implementation of the recommendations of the task force. However, the group was never properly resourced. Good people were involved in it and they are now moving to the National Office for Suicide Prevention. They have much experience and many skills in this area. However, if the office is not resourced, it will be like the national suicide review group. It will be another reason for the Minister for Health and Children to answer parliamentary questions and claim that this is the way it is done. Until it is properly resourced and accounted for, we will not be able to evaluate its work.
Recently I noted in a survey that 87.5% of those who had taken their lives had been suffering from a psychiatric condition. The funding and development of psychiatric services are vital to any suicide prevention programme. Will the delegation touch on this issue? What three crucial issues would the delegation put at the top of a list of suicide prevention measures?
When reading the report, I noted that in his paper Mr. Geoff Day had referred to the comprehensive plan for 2006 based on the actions set out in the strategy for reaction. While this reads very well and I understand the delegation's position, the paper continues to state that the extent of implementation will be dependent on the initial resources made available by the Health Service Executive for 2006. This underlines what Deputy Neville said. On the one hand, we are discussing the large costs, €22 million, involved in rolling out road safety programmes. On the other, we feel much more can be done in suicide prevention but are in doubt as to what funding will be available.
Some months ago members of the sub-committee attended a conference, arranged in County Leitrim and hosted by mothers of young people who had taken their own lives. I came away from it fully understanding the concerns of those involved, that the political process had not latched onto or did not understand the issue of suicide. If we are to move on this issue, a line suggesting funding may not be available simply sets the process back. I am not taking it out on the delegation. However, if we are to have any impact on suicide prevention, the sub-committee will have to tell the Tánaiste and Minister for Health and Children that there should be a belief that the issue will be tackled. However, that is immediately taken away by the suggestion funding cannot be guaranteed. This makes a nonsense of the work of the sub-committee.
Some 400 families were represented at the two-day conference in County Leitrim. Although we suggested the representatives of the families concerned could become involved in advising the sub-committee on how to proceed, they were concerned we were not tuned into their concerns. I understand things move slowly, but to mention ten years and then to suggest funding is not guaranteed does not seem like progress. We are not meeting as a committee for the sake of it. This is a huge issue. There must be a firm commitment to fund each year of that ten year programme rather than relying on something good turning up. The point was made that 40% of people under 35 have taken their own lives. I hope we have the resources to find out why that is the case. It was stated during the presentations last week that perhaps the time has come for us to research the career or social background of certain categories of people, although that will require funding. I thought we were getting a clear direction last week about how to research the background to what is called aspecific suicide and then how to make proposals to ensure there is not a recurrence due to certain issues. However, we will not get to that point if funding is a problem. I suggest, on behalf of the committee, that we support this strategy. We must start to put together specific funding to allow you and the experts to give us a clear direction.
Ms Nic Aongusa
Deputy Neville raised a number of points. I will deal with some of them, while the other people here will deal with the rest. As regards the issue of costings, detailed costings were carried out on the actions in phase one of the report. The Deputy will notice the tables in the report with a range of actions and three different phases. We costed in detail the first three years, which is phase one of the ten year plan. The reason is that it is difficult to get accurate costings for phases two and three at this time because many of the actions in phases two and three depend on the outcome of phase one. We have detailed costings for phase one only, namely, €3 million in a full year.
Only one out of ten is costed.
Ms Nic Aongusa
The first three years are costed at a total of €3 million in a full year.
As regards the issue of funding, members will be aware that we are currently in discussions with the Department of Finance about the Estimates for 2006. At this stage in the discussions all the items are on the table, but final decisions have not been taken. We are not in a position to say with any guarantee that funding will be available for certain things. Everything is on the table for discussion. The Minister for Health and Children is on record as saying that funding will be provided for the implementation of this strategy. That is the basis on which we are in discussions.
This committee has been conducting its business for approximately one month and now is the time when the Estimates are being prepared. We are trying to take a firm position. If we dovetail with the report, now is the time to provide adequate finance so that we can at least begin the programme for year one. One of the cornerstones of the success of the ten year implementation plan and of this committee is the involvement of the families of the bereaved. That extra step will not be taken if it is hampered by lack of funding or commitment. Commitment and funding are important in this regard. If one does not have funding, one will not have commitment and vice versa. We will say to the Minister that the committee wants a direct response and that we want to see results. Specific funding has been allocated for road safety. We want a similarly funded strategy in order that we can get results. That is our main plea today.
Ms Nic Aongusa
Deputy Neville raised another issue I would like to address, namely, funding for the development of mental health services in general. I agree such matters as the provision for mental health services are relevant to the issue of suicide prevention. Members will be aware an expert group is putting together a comprehensive policy framework for such services.
That is what the Minister has been telling me for the past two years.
Ms Nic Aongusa
The report which is due to be finalised by the end of the year will provide us with another strategy for the development of mental health services with a broad brush.
Reference was made to a presentation to the joint committee last week. It is true mental illness has a huge bearing on suicide and suicide prevention. However, the key point is that suicide is a complex issue. There is no one measure or project that can of itself address the problem. What is required is a multi-faceted strategy, which is what the Reach Out document provides. A range of measures require to be taken at the same time. What is most needed is co-ordination and leadership, both of which are addressed in the strategy.
Mr. Day
To be frank, I would not have taken on the job of head of the national office if I did not believe I could make a difference. This is a serious issue which requires all of us to commit personally to it. Also, I do not believe it will be possible to make a difference unless the resources to implement the actions outlined in the Reach Out document are made available. The funding provided for the first three years is reasonable. Were more to become available we could bring forth some of the other phases of the strategy. However, what we are seeking to do is achievable and will make a difference.
I accept Deputy Neville's point regarding the spend on road safety measures to reduce the number of traffic accidents. Were that kind of money invested in suicide prevention measures we might be able to make a significant difference. However, that is a matter for the Government. I believe the first three phases are achievable and that the figure of €3 million in that regard will deliver significant results.
It is worth bearing in mind that we are speaking about public resources. However, there are significant additional resources which we will be seeking to utilise effectively. The corporate sector is keen and has funded initiatives related to suicide prevention. I welcome the ESB's initiative, Electric Aid, which will provide up to €500,000 over the next three years to support local groups in their efforts on suicide prevention. The use of moneys from the dormant accounts fund to address this issue is also of critical importance.
It is important that the national office links with corporate sector organisations in trying to reach young people through e-mail, texting and messaging. In other words, we must use the technology with which young people are most familiar when trying to offer them services which they may require. We will be looking to the corporate sector to assist us in that process. I have not yet approached it in that regard but the indications are that it may be supportive.
My colleague, Mr. Chambers, will respond to Deputy Neville's question on the setting of targets, while Dr. Arensman will address the question relating to research.
Mr. Derek Chambers
As well as being a researcher with the Health Service Executive, I worked as project manager on the development of the strategy and will be working with Mr. Day in the national office.
Deputy Neville raised some concerns relating to targets, an important issue when developing a national strategy for suicide prevention. We considered targets in the project team and writing group. The document identifies two reasons for not setting a target at this stage for a reduction in the national suicide rate. First, we have concerns about the accuracy of the mortality data. For example, when the national task force on suicide reported in 1998, suicide rates were underestimated by 5%. The figure was based on the number of undetermined deaths returned each year by the CSO as a percentage of suicide deaths. Since then, as we moved to publication this year, the number of undetermined deaths as a percentage of suicide deaths has risen to 18%. We did not wish to set a target in such a false environment. Our priority is to establish the accuracy of data, perhaps by means of a national confidential inquiry.
The second reason is that a range of factors can influence the national suicide rate. Other countries have set targets for the overall rate in their strategies. For example, in 2002 the United Kingdom targeted a 20% reduction over ten years but as rates were going down for a couple of years before it launched its strategy, it conformed to an overall trend. While it acknowledged that there was a range of factors, it decided to set a target because doing so focused the attention of those working in suicide prevention and mental health services, as well as that of the general public, thus providing an important impetus, irrespective of whether cause and effect were proven. It is also important to broaden the perception of what we are trying to achieve in order that there is a range of outcome measures for each action identified in the strategy. These include measuring rates in respect of the repetition of deliberate self-harm as well as measures for the implementation of mental health promotion programmes in schools.
The WHO recommends the setting of targets, does it not?
Mr. Chambers
The strategy document states that when the Minister for Health and Children is satisfied as to the accuracy of the data, we will set a target, bearing in mind the aforementioned caveats.
When will that happen?
Mr. Chambers
It will depend on the work started by the national suicide review group on Form 104 and recording practices in the CSO. There will be a report this year in the form of a scoping paper on the accuracy of data from Form 104 and on data collection systems in the CSO.
Dr. Ella Arensman
This sub-committee is important and its establishment timely in the light of the launch of the new strategy. I have been director of research with the National Suicide Research Foundation since 2003. In the previous 15 years I worked in the same field, mostly in the Netherlands but also in the United Kingdom for one year.
As mentioned last week by Professor Malone, it is important to prioritise research into the backgrounds of those who have died by suicide. We only have statistics about risk groups and gender and age specifics but no specific systematic information on risk factors. In the current strategy we have prioritised important research on the national confidential inquiry into deaths by suicide. In detail, this means to establish a routine system of data collection on all cases of suicide or deaths where there was a request for an inquest by a coroner. We wish to propose a system that has been implemented in the UK since 1996 in which researchers throughout the country can obtain specific information, such as whether psychiatric disorders were present or the number of treatment sessions or psychiatric treatments prior to suicide. We would encourage the implementation of this system in Ireland also.
Another important point from the past few years is that different statistics have been obtained. For example, through the National Parasuicide Registry we know the prevalence of deliberate self-harm among people who attend accident and emergency departments over the State, and we have specific information coming from the CSO. However, we are not able to link the information and we are often confronted with the question of whether young people, especially men, who frequently harm themselves are the same people who eventually die by suicide five or ten years later. A confidential inquiry system could have the answers to this.
A limitation of the confidential inquiry is that only systematic information that has been recorded in the mental health service or general health care services can be obtained. These are patients for whom a medical file exists. We propose an additional step in cases of suicide where no information is available by going back to the next of kin, or the family of those who committed suicide, and performing an extensive interview that would give us the opportunity to provide required support and treatment for those left behind. This is a research priority in the current action strategy, and effective examples can be referred to in the UK and other countries.
I thank the witnesses for their submissions and responses thus far. Statistics in the submission by Ms Nic Aongusa state that there were 494 deaths by suicide in Ireland annually between 2000 and 2002, peaking at 519 in 2001. It is axiomatic that if a national office on suicide prevention is established, it must be resourced. Deaths by suicide are preventable if the proper strategy is employed. If the statistics are to be improved, a national office must be resourced and it is not a point for debate.
Despite all the efforts up to now in Ireland and abroad, which have been substantial, enough is clearly not being done on this issue. I have some knowledge of the psychiatric services as I worked with them for a number of years, and it is time to review the policy of planning for the future of the psychiatric services. In that particular policy document, much emphasis was placed on the community. Although community service is a better service, the hospital service forms an integral part of it.
A fully-fledged community service is a far more expensive service, and recent statistics have shown that input into psychiatric services, relative to other services, has fallen. The argument has been articulated that some people commit suicide who have never used psychiatric services, but a number of people have committed suicide who have used such services. We must re-examine the concept of mental health and psychiatric services, see what is available and improve on them. Additional services must be provided. Representatives of the Royal College of Psychiatry made this point to the committee and I support it. The Government is not putting enough into the psychiatric services, which have a pivotal role in suicide prevention. Of course targets are required. Without them one does not know where one has come from or where one is going. If a target is not achieved, one must change strategy.
What helplines have been established? There was a very useful one established by the then Midland Health Board with the slogan "Don't get down, get help". That was a very successful line. The speaker referred to sporting organisations. They have a major role to play. We know that church attendance in all denominations has diminished but the churches have a role to play. What is the mental health division's view? Society is part of the suicide prevention team. What are the mental health division's views on pulling all the strands together — the mental health services, society in general, the bereavement groups, sports organisations and the church?
Will a website be developed? That would be an easy way of communicating. People could go on-line, get information and advice. I understand there are some websites offering advice on how to commit suicide. Has the mental division a role in closing those sites down, whether in Ireland or worldwide? People use the Internet more than ever before and this has benefits and downsides.
I see in the report that hanging is the most common way of committing suicide for men and women. From an early age we look at cartoons showing cats being blown up or having a heavy object dropped on them. They pick themselves up, dust themselves down and carry on. As we get older we see films showing people being blown away and other violent scenes. Is there a certain amount of naïveté in some people? While they intend to take their lives, is there something in the back of their minds that suggests that this might not actually happen? Maybe they do not fully intend to take their lives, but because of the bombardment of violent images throughout their lives, they feel they can recover from their actions. We are becoming immune to violence through the television and other media. Even PlayStation games are incredibly violent now. Are people able to differentiate that from reality? I privately question whether people fully intended to commit suicide. They may have had the equipment for it and unfortunately they pull it off, perhaps not intending to. I do not know what the solution to that is. We are bombarded from an early age with images that perhaps can prove confusing later.
Ms Nic Aongusa
On Senator Glynn's point about psychiatric services, the Government, and specifically the Minister of State at the Department of Health and Children with special responsibility for mental health services, has decided it is time to review planning for the future. The terms of reference of the expert group I referred to earlier——
I am delighted to hear this.
Ms Nic Aongusa
——include a review of planning for the future, an examination of how it is being implemented and what lessons can be learned. The expert group must also come up with a comprehensive framework for a new mental health policy and the modernisation of services.
In the course of its work, it undertook an extensive public consultation process in 2004. The outcome of the process is available in two reports, What We Heard and Speaking Your Mind, copies of which we can make available to the sub-committee. This was the first occasion to my knowledge that users of the mental health services were asked what they thought of the services they were receiving and what they wanted from them.
Among the key messages heard in the process was that service users wanted more services based in the community but they also wanted services available when needed. Several issues discussed were having services available 24/7, good relationships with the community-based team and people available to listen. A strong message from the consultation process was the demand for alternatives to medication, such as complementary treatments and talking therapies. The messages from the process have been fed into the work of the expert group which is finalising its report. I hope it will be completed by the end of the year and recommendations will be made for a new mental health policy for the next ten years, building on those messages received from services users.
Mr. Day
I wish to pick up on a comment made by Senators Glynn and Browne on helplines, IT systems and the worldwide web. These are the media young people use to communicate with each other. As head of the National Office for Suicide Prevention, one important issue for me is to be able to reach out to that 40% of young people, particularly young men, who take their own lives or are engaged in deliberate self-harm. I do not believe we have yet found a successful way of reaching out to them. We must do so in the way they normally engage with each other, such as texting and other similar media. Further work needs to be done in this area. I am keen in setting up a national arrangement for text messaging and the like for young people. However, I am reluctant to do that at this stage because the expert group on mental health is looking at global evidence on helplines. I prefer to wait for this work to be completed before I make a decision.
It would be in our thinking that we should talk to young people about the medium by which they wish to communicate when seeking help and advice. We must look at putting in place a system that allows us to provide several responses, not just in terms of their passive interaction with the worldwide web, but a more interactive method of communication so we can offer young people, if they so wish, counselling, one-to-one interviews, on-line information or information through the post. I want to expand the notion of communicating with young people on websites to a system that meets their needs.
We are supportive of the approach taken by one youth website, www.spunout.ie, operating in the north west. This site is keen to expand to the rest of the country. We would be happy to have those discussions with the website organisers, as it engages and communicates with young people, giving them useful information and responses.
Senator Browne mentioned websites which offer people the method and the means to take their own lives. As we all know, it is difficult to close down many of these websites. If we had the opportunity and if any of them emanated from Ireland, we would seek to close them down. I am not too familiar with the technology for closing down websites. However, we should constantly consider ways to challenge the subversive approach taken by some websites which seek to offer people the means to take their own lives.
Before we continue, I want to welcome some people in the Visitors Gallery. I am sure members of the sub-committee join me in welcoming the Honourable Dan Hays, Speaker of the Canadian Senate. On my own behalf and that of my colleagues, I hope he and his colleagues have a successful visit.
I also welcome our visitors. I find these sessions difficult. As a public representative, I have dealt with this issue on many occasions. Mr. Day knows about the teenage telephone line in Tallaght where I live which was set up in memory of a young man from Kilnamanagh. How does the delegation feel about such initiatives and how they might be supported?
Much of the discussion has been about how suicide affects young people. That is important. I attended a meeting some time ago in relation to the educational project, An Cosan, in Tallaght. The men's group organised a meeting on suicide through Sr. Kathleen, the chaplain in Tallaght Hospital. In addition to emphasising the point about young people, the meeting also threw up some surprising statistics about elderly people, with which I was fascinated. Although I do not accept it, I understand why the rate is so high among young people. However, I am confused about why it is a problem among people who are settled and have lived their lives. That point was made strongly at the meeting. I am not saying it is not a huge problem among other age groups also. Does the delegation have any views on this?
The Chairman made an accurate contribution, which I support. We must be careful in terms of our expectations and how we will deal with this issue. If the delegation was sitting on this side of the table, what would it say? Does it wish to pursue something specific?
Dr. Arensman
It is an important issue to raise. Given the fast increasing rate of suicide among young men, in particular, and deliberate self-harm among young females and male and female adolescents, we tend to forget about older people. It is possible to conclude from the suicide statistics in Ireland from the beginning of the 1990s and the first available statistics on deliberate self-harm from the middle of the 1990s that the rates are increasing. I support initiatives in that regard, as is outlined in the strategy. Although great emphasis is placed on young people, we must not forget about older people. The regional variation in suicides indicates suicide rates are generally higher in rural areas and relate in the main to older people living in remote areas. We must prioritise the development of proactive reach out strategies for older people. Also, the media do not help when they focus, as during the past two years, on incidents of suicide among young people and exclude reporting on suicide among older people, an issue which we have tried to address in the strategy.
Mr. Day
Deputy O'Connor asked about Teenline. We support that approach which stems from a commitment on behalf of an individual family who identified a need for action, a commitment which has been repeated by individuals and communities throughout the country. Part of what the national office needs to do is to link together those people. Although we would like to do so, it will be impossible for the national office to visit every community. I hope to be in a position to speak to the organisers of Teenline in the next week or so.
If we are to bring people together in order that they can feel part of a concerted effort on suicide prevention, it may be necessary to take the route chosen by President McAleese earlier this year, namely, holding a meeting of all interested parties involved in suicide prevention. I believe we should recognise the efforts of Teenline and all those committed to addressing this problem by bringing them together from time to time and offering them our support in their work. Also, we could, if they requested it, offer them advice on whether the concept of a helpline is one which can produce a positive response. If research is available on helplines in terms of how they could be organised and so on, we should offer that to them.
The Deputy also asked what I would do were I seated on his side of the room. Deputy Neville asked us to identify the three areas on which we believe it is important to focus. Apart from the obvious, lobbying for funding and raising awareness through holding committee meetings like this in public, the three areas on which I believe we should focus are, first, a much more organised response to those who inflict deliberate self-harm, and not only through accident and emergency departments. Second is a national initiative on the stigma of mental health, encouraging those with psychiatric problems to come forward and seek help. A study of the Scottish experience illustrated that society's view of mental health improved as a result of its national campaign. The third was referred to by the Chairman at the beginning of the meeting when he spoke of those bereaved through suicide. We must increase the already significant efforts of groups like Console and Living Links who provide bereavement services for such people, though not extensively throughout the country. I would like to see the availability of local bereavement services which could be accessed by those needing to discuss the real issues surrounding suicide.
I am anxious to get a response to my question relating to the €6 million provided last year to address suicide prevention. While we do not yet know how much will be provided for such measures next year, I presume the figure will not be less than that provided last year, although it did drop to €655,000 some three or four years ago. Will Mr. Day control spending? I hope the figure of €4.5 million will rise to something like the road accident budget of between €22 million and €25 million. Is €500,000 adequate to run the office? It will become €1 million next year.
From the figures I have seen during the years and discussions I have had with persons involved in the health service and on the ground, the money has not been well spent. Rather than being spent on suicide prevention measures, it has been absorbed into the health service budget. It should be ring-fenced and increased. If that is not the case and Mr. Day is not fully responsible for it, this sub-committee will recommend that the money be spent on the development of psychiatric services.
The association in Cork does excellent work but 11,200 people have attempted to take their lives in recent years. Are there any plans to engage in research into how many attempt suicide but do not present at accident and emergency services, choosing instead to present to their general practitioner or a counsellor or not to tell anybody because of the stigma involved? We need to know the full extent of the problem, over and above the figures given by accident and emergency departments. Does Mr. Day or Dr. Arensman know from experience or records compiled in other countries?
Mr. Day
Deputy Neville's question about funding is valid. I need to be sure that the money will be ring-fenced for suicide prevention measures as originally intended. Most of it went to health boards. Some was used to fund the appointment of resource officers for suicide prevention. One of the first tasks of my office is to track down the money and make sure it has been spent on suicide prevention measures. If not, I will try to arrange that it is spent on such initiatives.
Will that information be made available?
Mr. Day
I can make it available. Some of the money has been used to fund organisations such as the NSRF and the National Parasuicide Registry.
A sum of €75,000 was allocated to the Irish Association of Suicidology. The Minister for Communications, Marine and Natural Resources, Deputy Dempsey, called it small money.
Mr. Day
Ireland can be rightly proud of the National Parasuicide Registry. We were the first to implement a reporting system for parasuicide through accident and emergency departments and many other countries are now following suit. While it is only the tip of the iceberg, it has given us to analyse important data over a two to three year period. Every single cent of the €500,000 available this year will be used to develop services or actions to implement the strategy. The National Office for Suicide Prevention is already funded from within the HSE. My office and the three people who work with me are already funded by the Health Service Executive. Whatever funding is received in future will be focused on implementing the actions set out in the strategy document rather than creating some huge bureaucracy. That is not my intention. I wish to see the funding go to developing services.
Dr. Arensman
I thank Deputy Neville for his important comment on the recorded cases being the tip of the iceberg. A large study was done in the HSE southern area a short time ago, and I distributed reports of this before the meeting. This was the first large school-based study carried out in Ireland among nearly 4,000 students aged between 15 and 17 years. We found a prevalence of deliberate self-harm much higher than what was expected based on anecdotal evidence. The prevalence was over 9%, although this is a conservative estimate as restrictive measures were used with regard to determining cases of deliberate self-harm. If students had reported self-harm without giving a detailed description, it was not included in the survey. The figure is probably even higher because of this.
Another important finding coming from the study is that 85% of the young people who had harmed themselves did not come to the attention of any health care service either before or after their acts of deliberate self-harm. That information made it possible for us to state that we are dealing with an iceberg where an important and large group remains hidden from the register, society and many health care services. A priority, leading from the recommendations of the study and incorporated in the strategy document, is the urgent need for evidence-based mental health promotion programmes, particularly in schools. Some of the joint committee may argue that many initiatives, such as SPHE and others, have been run for many years. What is not known is if such initiatives address the real issues that come from this study, and the overall effectiveness of these interventions in reducing mental health problems and eventual deliberate self-harm.
The last important point from this study is that we were surprised to see that of the young people who had harmed themselves, almost 50% had harmed themselves more than once previously. We know from studies in other countries and some first research projects in Ireland that having engaged previously in deliberate self-harm is the strongest predictor for future self-harm and eventual suicide. This may take longer for women and the risk may be higher at an earlier stage for men. This information is valuable in determining services and the promotion of evidence-based mental health programmes.
Does a recent figure exist for the incidence of self-harm?
Dr. Arensman
No.
I know Dr. Arensman is a researcher but sometimes an indication has to be given. Where would the figure roughly lie?
Dr. Arensman
Based on this study, the figure for total numbers in the State could easily be another 10,000 cases. This may seem a lot, but it would be in line with findings from other studies in countries such as the Netherlands or the UK. The problem is far bigger than what we had known previously.
The figure is probably 20,000 cases.
Dr. Arensman
Yes, exactly.
With regard to the two graphs in the submission, and our suicide figure per 100,000 of population, Ireland is 12.4 and Britain is almost five points below us. Italy is even further below us. On youth suicide, the UK rate is 6.7 while the rate in Ireland is 16.1. What are they doing right that we are not?
That is the question.
It is.
The sub-committee acknowledges and shares the speakers' commitment to resolving the issue but this commitment must be matched by the level of funding secured by the Minister. I emphasise the point made by Deputy Neville. If we see a specific fund allocated to road safety measures and recognise suicide as equally problematic, it is up to us to strive to make sure funding is provided. We can talk all we want in this committee room. The real evidence will be presented when we come to deal with the Estimates and the budget. We see no reason to pursue a committee dealing with the issue of suicide if the required funding is not provided immediately. We can talk, define and research as much as we want but without the wherewithal, we will not achieve much. I thank the speakers for their valuable presentation.
Sitting suspended at 3.30 p.m. and resumed at 3.50 p.m.
I welcome Mr. Gerry Hickey, addiction counsellor. Accompanying him are Ms Dorothy Peelo, Mr. Pat Bowe and Dr. Patrick Andrews.
Mr. Gerry Hickey
I thank the sub-committee for the invitation to appear before it. I am a counsellor and psychotherapist. The sub-committee has been presented with evidence by Alcohol Action Ireland of a possible link between alcohol consumption and suicide. I am more familiar with problem drinking in our society and will concentrate on proposals to reduce this, thus expecting a knock-on effect in suicide reduction.
For 20 years I have worked with problem drinkers and their concerned persons. I am not anti-alcohol but I am against the human devastation it can cause. Most of my clients were referred by their GPs, many presenting with signs of serious stress, anxiety or depression. In over 68% of the presenting cases the client either grew up in a home seriously affected by alcohol, was involved in a relationship with someone damaged by alcohol or was himself or herself using alcohol in an unhealthy manner. Concerned persons live with the denial, mood swings, irrational behaviour, outbursts of anger and other emotional methods used by problem drinkers to protect their drug usage. Concerned persons question their own actions and frequently doubt themselves, leading to self-esteem issues and fatalistic thoughts.
As a society, we appear to have a relaxed and tolerant attitude towards alcohol, sometimes selective about our condemnation of its negative side effects. Perhaps this revolves around our own personal consumption of the product. This belief system needs to be challenged. I propose the establishment of an independent authority to be proactive and specific in educational and informational activities. Its remit would initially be charged with clarity of definition. We are faced with a range of problem drinking sub-definitions such as hazardous, harmful, dependent and binge drinking. I suggest in most cases it is simply problem drinking. However, sometimes the broad range of these terms gives the problem drinker opt-out options to what is really serious problem drinking, needing drastic action to resolve.
Problem drinking is a pattern of drinking in which a person has lost control over her or his drinking, with the result that it is interfering with a vital area of her or his life such as family, friends, job, school or health. This is a solid template for a simple definition and will curtail psychological escape routes used by problem drinkers to justify abuse. The independent authority would ensure widespread familiarity with any agreed definition.
Some choose not to take alcohol. While their reasons vary, they are under enormous societal and peer pressure to partake. Some are made to feel less of a person and socialite for their choice. A major promotional campaign for positive, inclusive social attitudes to those in society who do not take alcohol through choice or for health reasons must be introduced. Alcohol embeds itself in our culture in an insidious manner, subtly endorsed in celebrations on public occasions and at major sports events. However, concerned persons continue to suffer in silence enabling shame, embarrassment, secrets and lies, the four major constituents of dysfunctional living, to flourish.
It is estimated that each problem drinker affects approximately eight to 12 people. Parents, siblings, partners and children are particularly vulnerable in this immediate group. It is a breeding ground for depression and suicidal tendencies, not only in the user but also in those close to him or her. As there are an estimated 200,000 problem drinkers in the country, according to the Irish Nurses' Organisation website, this means that approximately 2 million people are negatively affected by problem drinking. That is a staggering figure. The ripple effects of this chronic situation on children can last a lifetime. I frequently see people in their 30s and 40s paralysed by emotional insecurity and uncertainty, whose origins are firmly rooted in the subtle state of high anxiety experienced in an alcoholic household.
We need a structured nationwide survey to establish the true extent of the problem. We should not fear the result of honest assessments, as once accurately established, we will have a great opportunity to confront any denial and adopt a structured, multifaceted and intolerant approach to deal with it. The current widely accepted option of telling people to drink sensibly and responsibly is of little use to problem drinkers. It is the equivalent of telling a dog not to bark. I have not once heard it said in all the advertising campaigns that some should not take alcohol at all. For many, that would be the most sensible and responsible advice alcohol providers could offer.
My suggestion in the submission about brief intervention at Garda stations and accident and emergency wards would go some way towards at least naming the problem directly with the abuser and giving him or her the opportunity to take positive action. Educational intervention would assist concerned persons to evaluate their position and review any enabling, entrapment and silence. Some 25% of accident and emergency attendances are alcohol-fuelled. Garda figures show that 87% of public order offences relate to alcohol. There is limited research available to measure the effectiveness of intervention. However, a recent London Underground five year study showed success rates of 55%. That is encouraging. I suggest that every educational intervention is successful and that there is an army of suitable persons who could be trained to do this. Since I made my submission, I have become aware of a number of hospitals with intervention procedures. It is encouraging to hear this.
As regards synchronicity of recovery and facilitation options, many may look for further help following intervention. A truly successful programme must be able to guide those seeking help to the appropriate assistance. The authority could devise best practice in that regard, including all agencies from the public, private and voluntary sectors.
There are contrasting opinions on the participation of alcohol providers in providing financial assistance. Two issues need attention in this regard. Alcohol plays an integral part in our society and will not leave it. Many profit from its existence and, whether we like it, it plays a vital part in the Government's fund-raising activities. Those of us who deal with alcohol's negative side-effects witness the physical and emotional wreckage its use can cause. We also see a lack of effective support and facilities for victims and concerned persons. Financial issues play a major part in preventing concerned persons taking action, which leads to a quandary. If the authority was sufficiently protected from commercial interference, we should seriously consider discussing a substantial, unconditional financial input by those who profit from alcohol.
I am convinced that my suggestion, if adopted, will bring about substantial change in a five year period. By intervention and education I would expect people to open up more which would lessen the risks of depression and suicidal thoughts. Those affected would be offered a prospect of hope backed by practical support.
In researching this submission I have encountered many views on effective actions to deal with this chronic problem. As a society, we suffer from a chronic alcohol problem. We are a race known for innovation and applying ourselves in a focused manner. I am suggesting we now become leaders in tackling this problem, establishing our own programme, progressing it to become a world leader, evidenced-based and incorporating best practice. We must be open to new ideas and challenge our own base beliefs no matter which side we stand on. I thank the sub-committee for its time and attention.
Before inviting members to ask questions, will Mr. Hickey elaborate on how such an authority would be rolled out?
Mr. Hickey
A substantial sum of money is already provided by the providers and producers of alcohol to advertise their products. As stated in my submission, there is nothing to suggest people should not take a drink, although it is a known fact that certain people should not drink. If the authority was Government-sponsored with an unconditional input from the drinks companies by way of a levy or contribution——
Not voluntarily.
Mr. Hickey
No, this would require to be managed on an independent basis. Alcohol is here to stay. It is very much part of the problem and I am suggesting we make its providers, producers and promoters part of the solution.
Nobody could disagree with Mr. Hickey's comments and I support what he had to say. However, his proposals on funding would mean increases in tax. He will be aware that the supplier would merely add any extra cost to the product. I am not suggesting this is right or wrong, it may be okay. We are oceans apart in terms of from where Mr. Hickey is coming and where we are going in regard to alcohol advertising and promotion in terms of sports and youth organisations. Alcohol manufactures are aware of their market and target it accordingly. There is a growing recognition in that regard. I come from a constituency in Limerick long associated with hurling which is identified with Guinness and which, some 25 years ago, was identified with cigarette smoking. Does Mr. Hickey's foresee a day when the advertising and promotion of alcohol will be seen in a similar way to that for tobacco products?
Mr. Hickey
I take the Deputy's point. My motivation for the submission is based on the following: a 25 year old man who when he was eight years of age tried to drag his drunk, nude mother from the bathroom to her bed before his father came home; a lady who when six years old had to comfort her mother and younger siblings following a beating by their drunken father; and two children thrown out of their home at Christmas who became clients of mine in their late 20s. The list goes on and on. A thought that regularly goes through my mind when meeting new clients is, "God, not another one". I do not see anybody taking much notice of the people concerned. I am not an expert in advertising. I am merely seeking the resources to provide for a healthy intervention that will provide results. I cannot guarantee results——
I apologise but I must leave to attend Leaders' Questions.
I am sure the Deputy will monitor the sub-committee's proceedings. The sub-committee is faced with a difficulty in terms of research, support or the finance which can be provided by the Department to roll-out a proper ten year programme on suicide prevention. We have tried to address in advertising campaigns the example used by Mr. Hickey, namely, that there are some persons who should never drink alcohol. Vintners' groups or others in the industry, however, say they are not trying to tempt everyone to drink. They realise that some people should never drink alcohol. I am a vintner and have experience of family run pubs throughout the country. In that context, I am aware that it is not in the interest of publicans to have people intoxicated on their premises. Publicans have been involved in safe home campaigns, the designated driver scheme and the campaign against under age drinking and would be prepared to fund research into why this country has such a tendency toward under age and binge drinking. When the suggestion is made, however, groups totally opposed to alcohol do not want to touch the industry because they are of the view that allowing it to participate will tarnish their entire campaigns. If members of the trade are responsible, as the vast majority are, their funding should be welcomed. The idea of a specific tax, ring-fenced for research or ideas to reduce consumption, should be welcomed but there seems to be no clear path for the committee to follow.
Mr. Hickey
I agree with most of what the Chairman says. We should be more proactive and sit down with the relevant drinks companies to agree an agenda. I insist that there be no commercial agenda but that it should be seen as a responsibility rather than a promotional opportunity. If we held a vox pop in the street, every person would know what a problem drinker is because many are living with serious problem drinkers and are in denial, believing that these individuals only have a few pints every couple of weeks. In that period, family members tread on eggshells wondering when it will happen again. They might not be drinkers themselves but they suffer the negative side effects.
It is important to agree an agenda but it is difficult. I have asked representative interest groups in the drinks trade their reaction to Mr. Hickey's suggestion. People might expect me to say this but the vast majority of publicans want the name of running responsible houses. The days of having intoxicated people on their premises are long gone. Allowing such people on the premises does no good for the image of a pub at a time when there is serious competition. When they suggest becoming part of a solution, the next step is difficult because people of Mr. Hickey's persuasion, although he expresses his views with moderation despite having seen all the problems at first hand, are suspicious of the traders' motives. The trade does not need alcohol abusers but it does need those who can handle alcohol. Until a consensus is achieved, why can the various groups not sit down without the suspicion that there is an agenda? There is an agenda but it is to be seen as participating in a market, selling goods and services in a respectable and responsible manner. They feel that by not participating, the problem is exacerbated. I hope, taking into account the sub-committee meetings today and in the next few months, that when the sub-committee produces its report, all those who feel they are responsible in finding a solution will have been invited to participate. There should not be a notion that discussions with the drinks industry cannot be held because it is sullied in some way. It is not tainted.
Mr. Hickey
I agree with the Chairman that the drinks industry must be represented at the table. The issue must be ironed out. What concerns people is that there is a potential hidden agenda, where somewhere down the line a drinks maker will state that by participating it may have benefitted those negatively affected by alcohol. That is a token gesture. The drinks industry already has an organisation which is helping. However, when I hear comments by its spokespersons, I sometimes find there is a hidden agenda.
Surely we are mature enough to elicit from the industry its real agenda. There is a stand-off and nobody knows the real agenda. Perhaps Mr. Hickey is advocating the establishment of an independent authority that would deal with the level of funding required and how it was spent.
Mr. Hickey
We must bring this issue into the open and stop acting behind the scenes.
I am glad to hear that.
Mr. Hickey
I do not agree with those who argue the drinks industry should be ignored. It is part of our society. A television set cannot be switched on or, as Deputy Neville stated, a football match or other sports event cannot be viewed without being exposed to its influence. The position is similar in going to a christening, a wedding or a funeral. An accurate assessment of what constitutes a drink problem must be the first priority. People are being told that if they have more than six drinks, they could be binge drinkers. That is not healthy. What is the limit and what do people do when they return home? Whose money is being drunk and what are the other knock-on effects within society? The figure that every problem drinker affects eight to 12 people is staggering. We are talking about roughly 2 million people suffering in some way from drinking in society. If we were dealing with any other issue, there would be marches on the street day and night.
I agree with many of the sentiments of Mr. Hickey. There is a need for a balanced advertising and information campaign. Instead we are bombarded with a sexy and glamorous image of drinking; we do not see the physical or mental disadvantages.
I am sceptical about the use of shock tactics. I was a member of the Joint Committee on Transport before I became a member of this committee. The number of road fatalities is increasing every year, despite the introduction of an aggressive media campaign. When people see something on a screen, they do not appear to relate to it. Therefore, it is not just a question of advertising, but of clever advertising. The public should also be informed, as if it is bombarded with images that alcohol is bad, the argument will be lost immediately. If sensible information is distributed and sensible drinking promoted, we may succeed. There is a massive need for such a campaign, as there is currently an imbalance.
Mr. Hickey's opinions on accident and emergency departments are interesting. I have advocated the possibility of breathalysing people as they enter accident and emergency departments. If a person is involved in a car crash, he or she is breathalysed automatically if there is a suspicion he or she has been drinking. This makes sense. I have no sympathy for somebody who deliberately spends €100 on drink and then engages in an action as a direct result of consuming huge quantities of alcohol. By contrast, an elderly lady or man who has fallen down the stairs by accident could be waiting to be treated. He or she could be stuck beside the heavy drinker who is taking a bed in the department as a result of self-inflicted damage. Moreover, heavy drinkers may cause disruption within the accident and emergency department. We should not be tolerant of such actions. If people were breathalysed in accident and emergency departments and found to be two or three times over the legal limit, the imposition of a large fine the next day might sober them up quickly. The money raised could be ring-fenced for counselling services.
It is time we faced up to the facts as there is a cute hoor syndrome in Ireland when people talk about alcohol. We talk about people having a few pints and say a person is a great laugh and sings after having a few pints. Our approach is hypocritical. It is time we got real and exposed the horrible downside of alcohol abuse and the huge impact it has on the innocent victims who are surrounded by alcoholics and have that burden in their lives. It is time we faced up to our problems. Consider a person who attends an accident and emergency department purely because of drinking a huge amount of alcohol. If he or she is prepared to spend €100 on alcohol, why should he or she not receive a fine of €200 the next day in the post? It could be a wake-up call. We need to have balanced and more informed advertising. I do not envy the difficult job of accident and emergency nurses and doctors. It is shocking to think people attend accident and emergency departments mainly due to alcohol abuse.
Mr. Hickey
I agree 100% with Senator Browne. I spoke recently with two accident and emergency doctors who said a number of their patients attended once a month or more as a result of alcohol abuse. These are foreign doctors with names that are difficult to pronounce and they have regular patients who know them by name. This is a waste of resources. It is despicable that the people concerned are allowed to continue without some intervention. Their families or concerned persons should receive information on what a drink problem is, how they should deal with it, what enabling a drink problem is and how to withdraw it. We need financial support and adequate facilities to help such persons. An enormous number of victims do nothing because they are terrified. In most cases the abuser controls the finances of the home, is bigger than the others or there is another reason he or she is in control. Fear is a major issue. If we can confront this, we will begin, slowly but surely, to confront the myth of "hail fellow well met". It is no longer acceptable.
Has Mr. Hickey seen a significant increase in the number of female clients, in particular younger female clients, since he began practising?
Mr. Hickey
Yes, I have seen a big increase. Many of them will do something about their drinking when they are confronted and there is intervention. They are easier to deal with than men in that regard. Many of them say that if they go out for a drink, for example, at the end of the office week, the pressure to take a drink is phenomenal. That is why I am talking about a proactive promotional campaign indicating it is okay not to drink. I find these "drink sensibly" advertisements funny at a psychological level, or perhaps not so funny. The first word in the sentence is "drink", but do it "sensibly". However, if a person has a problem and has that first or second drink, caution goes out the window because the alcohol takes effect, his or her metabolism changes completely and he or she becomes a different person. Therefore, telling someone who is prone to having an alcohol problem to drink sensibly or responsibly is not acceptable. Often the first condition in my dealing with a patient in my private practice is that he or she should go off alcohol for three months before I will deal with his or her problem, for example, depression or stress management. Many of them do not have an serious drink problem; it may just have got out of hand. They do not have to give up drink for life, but we get a three month break to talk about what is going on. During this time the societal pressure they will be under is phenomenal, as recent newspaper articles confirm.
There was a person on the Gerry Ryan show during the week who said he used to drink 35 pints a day but cannot now go to a pub because if he did, he would be back on the drink straightaway.
We must bring all players on board. It may be a difficult question to answer because of the level of research available but do we know the number of people who drink? If we can obtain this figure, could we determine the percentage of problem drinkers? If we are to secure the support of all players, we must target those who have a problem with alcohol, not those who do not. The drinks trade should not be worried if this campaign is successful because we are talking about people who cause a problem for it.
Mr. Hickey
I have talked to many people to try to get those figures. There is an enormous variation, which is why I have asked for a national survey, for which I have specific questions in mind and they are not the same as some of those suggested. In the USA, the United Kingdom and here some 6% to 10% are thought to be problem drinkers. My own experience suggests the true figure is at the upper end. I often make an assessment of a client only to find later he or she suffers from a terrible hangover after a night out from which he or she does not recover until the Tuesday or Wednesday. He or she may be in financial or other trouble. Alternatively, he or she may hold down a job, pay his or her bills and maintain a respectable lifestyle but he or she is not happy and his or her drinking makes his or her family unhappy. The number of people involved is not particularly large but tackling the problem would be of enormous benefit. I agree it is not threatening to the promoters and providers of alcohol.
The sub-committee has heard that one person in 50 is affected by suicide and that 6% to 10% have problems associated with drink. At a conference in County Leitrim we heard from counsellors that at least 150,000 people presented themselves with a depressive illness and that the actual number might be twice that figure because not everybody presented to an medical expert. If we collate the figures for those conditions, we have a huge problem that should have been tackled years ago. It is important to continue with our hearings and make recommendations. I ask Mr. Hickey to read the sub-committee reports on an ongoing basis. If he discovers anything of interest between now and the end of the hearings, he is welcome to come back.
Last week Professor Malone made a comment which shocked me. Two or three days after a bout of binge drinking a sudden mood swing kicks in. Does Mr. Hickey concur?
Mr. Hickey
I agree. However, I question the term "binge drinking". While it is an internationally accepted term, it should be called "periodic problem drinking". Those who have a problem with alcohol can abstain from Monday to Friday but going into work on Monday morning their minds are on the drinks waiting for them on Friday evening. That is what keeps them going throughout the week. It is an insidious, devious and manipulative internal illness. Society's failure to understand is one of the reasons many of the actions taken to rectify it are not working. On one side is the industry; on the other are the health professionals and somewhere in the middle are those who do not drink alcohol. I reiterate the last statement made in my submission, that we must be open to new ideas and challenge our own base beliefs, no matter on which side we stand. From where we stand, we have achieved some progress but we are still not achieving the desired result. Only last weekend at my clinic I dealt with a patient who was 43 years old, could not keep relationships and showed some signs of depression, although the person concerned did not drink. On investigation, we discovered a history of drinking in the family, which caused much harm to the person concerned. In my mind I silently admitted it was the same old story. If something along the lines of what is being suggested is not done, we will have to sift through these issues again in 30 or 40 years time. That is not to say, however, that today's suggestions are the be all and end all.
What Mr. Hickey is suggesting is the be all and end all. The problem will be to get such thinking across. The consistent view from those attempting to find a solution is that it cannot be achieved without the people who have a direct financial interest being at the table also. I have heard separately from the drinks trade that it wants to show its sense of responsibility. Mr. Hickey's presentation suggests there is a need for consultation. This must be funded properly and be independent.
In the previous submission the point was made that corporate bodies were putting themselves forward on these issues, although they were not directly involved. For example, the point was made that the ESB was funding research into suicide, although clearly there is no connection between it and suicide. There would be no difficulty in accepting this funding. There is a direct connection between the alcohol trade and the effects of drinking, and this is where the problem lies. I hope Mr. Hickey can, by way of his professional experience, get the message across that it is surely worth the effort to bring everybody to the table without preconditions. I hope to do the same by the end of these hearings. Each group's intentions could then be tested to see how real they are.
I consistently hear that binge drinking, under-age drinking, etc., could be connected to climate change or attitudes to drink, or the point is made that Iceland, Scandinavian nations and other countries with dark climates share this country's alcohol problems. Perhaps they do. If the problem is that simple, research will surely confirm this and direct us on how to solve the problem. The challenge for us as a sub-committee and the delegates is to ensure some discussions take place with persons representing all aspects of the issue, including counsellors, the Pioneer Total Abstinence Association, Alcohol Action Ireland and consultants in accident and emergency departments. Every group must become involved or else we will just be talking to ourselves. The problem will then remain until next year and beyond. The challenge for those who wish to be seen as responsible is to act in such a fashion if given the chance.
Mr. Hickey
I suggest the Chairman's idea of joint discussion be taken up with the proviso that people can walk from the table if they so wish. I do not see any problem with talking. I agree strongly with the Chairman.
Having attended a conference on the issue in County Leitrim, it is clear the problem should at least be put out into the open. This notion has been well received. If any meaningful action is to be taken before the sub-committee presents its report, we must get all relevant groups together.
Mr. Hickey
I wish to respond to a comment by Senator Browne on the number caught drink-driving, to which I did not have a chance to reply earlier. I do not know the figures on how many are repeatedly caught for this offence, although I did attempt to get them. With regard to drink-driving or public order offences, if a person is taken into a Garda station and released, there is no intervention, as I understand it, to challenge him or her on his or her problem. The chances are that the person concerned will exhibit the same behaviour the following night or weekend, and although he or she may not get caught, he or she may take another person's life.
I am emphasising the need for such intervention. If it takes place, family members, partners or others living with such a person will also have an opportunity to educate themselves and perhaps withdraw from the enabling, as every problem drinker has an enabler of some type.
When the Chairman mentioned the industry, was he referring to companies such as Diageo?
Yes.
I would differentiate between the vintners and the industry.
I agree and it is important to clarify that. Everyone considers that the distributors constitute the drinks industry. However, the main players are the people who dispense alcohol. I know many of them and I accept their bona fides. It does not do their image any good if they are irresponsible and serve drink to those who are under age or who have already had more than enough to drink. They have said that to me on numerous occasions. That was acceptable some years ago but things have moved on since then. The image is now of well run pubs. We cannot separate that from the producer who is the main player in terms of advertising. Many publicans have made the point that huge advertising campaigns do not benefit their premises. If that is the case, why do we need such campaigns? They are targeted at people who have not yet begun to consume alcohol. If that point was accepted, it would be a watershed. It should be the beginning of our efforts to reduce the cases of under age drinking. We must have a better understanding of the issue. I do not understand how that could have a detrimental effect on the responsible publican. Every part of the trade must participate. Trade members have suggested to me that they are interested in putting together a bursary in one of our national colleges to fund a study of our thoughts on alcohol and our attitude to under age and binge drinking. I do not know if that will focus goodwill on the trade. It is participating by responding to how things should be done.
Mr. Hickey
Some of it is being done at present. I spoke to Dr. Patrick Wall in UCD last week and he said that. There is little I can do when dealing with the victims, their families and concerned persons. A young man rang me yesterday from London because his mother is ill here as a result of alcohol. He does not know what to do. The hospitals are full and there is a waiting list. She says she wants help now but they cannot afford the medical treatment. I feel that sense of powerlessness when I see some of the most awful situations caused by alcohol. I try to educate the people who are concerned, such as daughters, mothers and fathers. Parents are often terrified before football matches, for example, because they do not know what their son or daughter will be like when he or she comes home from the pub. I know a number of persons who locked themselves in their bedrooms and put wardrobes against the doors to protect themselves from the violence. I remember meeting four mothers and fathers during a World Cup tournament who were terrified about the effect the binge drinking would have on them. They were not the type of people one would expect to be afraid. I am not sure we realise the seriousness of the situation. We have some type of collective denial.
I have done much research and talking and I have a great deal of clinical experience. My friends have been extraordinarily supportive, which is why I wanted them with me today. Dr. Andrews is here from London, Ms Peelo has done much research in this field and Mr. Bowe is a project worker in this area and in that of homelessness. We know what is happening. There is a certain amount of help in the public sector when we cry for it but it is not what it should be.
We do not want Mr. Hickey's colleagues to have wasted their journey. We will give this issue as much attention as possible for the next two months. That is not a cliché. We want to take on board our Mr. Hickey's suggestions in our report. We want him to keep a watchful eye on our proceedings. Perhaps he could inform us if we have the right picture before we publish our report. We have told all the groups which have appeared before us that we do not have any difficulty being advised about certain issues or about directions we should take. We do not have a difficulty with people telling us we are losing the plot. We want to produce a meaningful and beneficial report that will bring about change. We are not doing this to establish an Oireachtas committee. I know the report, when published, will be well scrutinised by the professionals who will be the judges of whether our time has been wasted during the past three months.
Mr. Hickey
I wish to make a final statement in respect of something which came to mind when driving home late last night. We will only begin to address this problem when we express a revulsion similar to that expressed in terms of incidents of sexual abuse in respect of incidents of family alcohol abuse.
I thank Mr. Hickey for his professional presentation.
The joint committee adjourned at 4.40 p.m. until 2 p.m. on Tuesday, 18 October 2005.