We welcome the opportunity to address the sub-committee. I will put our presentation into context. I am a consultant child and adolescent psychiatrist in the Mater and Temple Street hospitals. My colleague, Nollaig Byrne, is clinical director of the Mater Hospital child and adolescent mental health service. The Mater service provides a mental health service for young people up to the age of 16 living in north Dublin. We serve a population of 350,000, of whom 78,000 are under the age of 16. There are two accident and emergency departments for which we provide psychiatric cover, one in the Mater Hospital and one in Temple Street Hospital. We deal with suicidal behaviour on a weekly, if not on a daily, basis.
Approximately 50 young people who present with suicidal behaviour are seen each year in the accident and emergency department at Temple Street Hospital. These individuals, aged up to 14, present with varying levels of suicidality, from thoughts of self-harm to serious suicide attempts. They are all seen for psychiatric and psychosocial assessment. In the Mater Hospital accident and emergency department, we see approximately 20 to 30 young people, aged 14 or 15 and with similar suicidal behaviour, each year. Once young people reach the age of 16, they are seen by the adult psychiatry services. However, we understand this will change in the near future.
The suicide statistics in Ireland will be familiar to members of the sub-committee. The overall rate across all ages is 12.2 per 100,000 of population. In young men in the 15 to 24 age range the rate is 24 per 100,000. In young women in the same age range the rate is 4.4 per 100,000. The rate of suicide in young men in Ireland has more than doubled in the past 20 years. Suicide is the leading cause of death in young men in this age group. It is important not to forget that children also die by suicide. Some 34 children aged less than 15 have died by suicide in Ireland in the past ten years.
How much do we know about these young men who die by suicide? We actually know very little. Anecdotally, we feel we all know some of them, certainly if we have adolescent or young adult children we know some of them because they are the friends and colleagues of those young people. However, little systematic study has been carried out in respect of these young people and no published psychological autopsy studies have been carried out in Ireland. A psychological autopsy study is an in-depth interview study with the people closest to the young person who has died by suicide and attempts to clarify the issues which, in the final months of their lives, may have contributed to them dying by suicide. Such studies have been carried out with this age group in the United Kingdom and the United States and details of the references are contained in the documentation provided. From those psychological autopsy studies, we know something about these young people. I stress that we do not know whether the same applies to these young people in Ireland.
When we look at young people, we realise that they exist within families, communities and social networks. Factors at each of these levels impact on young people, just as young people impact on the systems which surround them. Being male is one of the factors associated with young people who are more likely to commit suicide. Males tend to use dangerous methods, or methods from which there is no coming back, to commit suicide. I refer, for example, to hanging. Young people from the lower socio-economic groups are over-represented in the suicide figures in the United Kingdom. That is not the case in the United States, where suicide in young men occurs equally throughout all socio-economic groups. We do not have details of the socio-economic patterns in this country.
Young men who commit suicide tend to be out of school, college or work. Some 40% of them have a history of previous self-harm and some 60% have unrecognised depressive disorders prior to their deaths. Alcohol is involved in the final act of suicide in more than 50% of cases involving young men. It is important to note that just 20% of young men who commit suicide were attending, or had previously attended, mental health services. The services with which the Mater Hospital's guidance clinic works tend not, by and large, to be in contact with the young men to whom I refer.
Psychological autopsy studies have taught us that the nature of young people's families can have an impact on their propensity for suicide. The risk of young people committing suicide is increased if they come from families that are not intact, families with a history of suicide or depressive disorders and families in which there is conflict between children and parents. There are also some risk factors in the community. Suicide involving young people sometimes occurs in clusters in communities. On many occasions during the past ten years, the death of a young person by suicide has been closely followed by a number of other deaths by suicide in the same community.
As already stated, alcohol plays a part in suicide. Ireland has one of the highest rates of alcohol use by young people in Europe. I do not think we can examine the role of alcohol in the life of young people without looking at the role of alcohol in Irish life and society in general. It has been suggested that the change in the role of men and the rapid development of Irish society during the past 20 years have contributed to suicide among young men. This may be a further factor. Research has indicated that certain factors protect young people against suicide. Young people who come from a cohesive family or who have a religious conviction are less likely to commit suicide. That the roles of the family and the Catholic church in society have changed radically and quickly in the past ten years may be a further factor in the increase in suicide rates in young men.
I had hoped to highlight a particular project, called Working Things Out, which has been developed by 11 young people who have attended the Mater Hospital's guidance clinic over recent years. The young people in question, who presented to the hospital with depressive disorders, suicidal behaviour and other mental health problems, have told their stories on CD and DVD. In particular, they have spoken about what helped them to get through their difficulties. It is a pity that the sound is not working on the CD in this room because I would have liked to have played an extract for the committee. I will give a copy of the CD to members so they can listen to it later. The comments of the young people on the CD bring their stories to life and would have made this presentation much more interesting.
The importance to young people of being able to talk to somebody about how they are feeling is one of the main things to have come from the Working Things Out project. Many young men have said the turning point for them in their attempts to cope with their difficulties was when they became able to talk to somebody about their feelings. Much of our work in dealing with young people with suicidal behaviours involves supporting them to be able to tell somebody about how they feel.
What can mental health services do? We can certainly help parents, carers and teachers to recognise young people at risk by means of education and making people more aware that depressive disorders and risk factors for suicide can be detected if one knows for what one is looking. We can develop mental health promotion programmes for schools and the Mater Hospital is doing this, working with the social, personal and health education programme — SPHE programme — which is part of the curriculum in first, second and third years in post-primary schools. We are carrying out a pilot study which aims to significantly increase the mental health promotion component of the SPHE programme by incorporating into it some of the stories from Working Things Out and by providing teacher training and undertaking activities with young people.
These are some of the things we can do but there are number of things we currently cannot do. As mental health professionals, we are not able to provide accessible mental health services which are user friendly for adolescents. Currently, only one community based specific adolescent service operates in the Dublin area. Adolescents up to the age of 16 years are referred, if at all, to the routine child and adolescent mental health services, which mostly have long waiting lists and are physically unsuitable for adolescents because they are strongly geared towards younger children.
We, as mental health professionals, cannot provide safe care for young people presenting to accident and emergency departments with suicidal behaviour. We can provide care for those young people for whom it is safe to return home following their assessments, once they are linked in with follow-up services. This group accounts for the majority of those young people presenting to us. However, we are not able to provide safe care for a significant minority of the young people who present to our accident and emergency departments with serious suicidal behaviour. We are unable to provide inpatient psychiatric treatment to these young people because it is not available. Warrenstown House is the only public inpatient psychiatric treatment facility for children under the age of 16 years. It does not provide an emergency service, the service is available only from Monday to Friday and it is always full. We are in the difficult position of being asked to assess these young people, which includes carrying out a risk assessment, yet we are not in a position to provide them with the service they need.
In our professional opinion it is only a matter of time before a suicidal young person for whom an appropriate care placement or inpatient psychiatric treatment bed cannot be provided leaves or is discharged from hospital and subsequently dies by suicide. If this happens, it will undoubtedly lead to an inquiry which results in recommendations being made that appropriate care be provided for these young people. This will be too late for the young person in question. As professionals, we have done everything we can to advise the hospitals in which we work, the Health Service Executive and the Ombudsman for Children of the danger to these young people. So far, however, this has been to no avail.
The young people in question often do not have families who are in a position to advocate for them. They are some of the most vulnerable young people in our society. We ask the sub-committee to do all in its power to ensure the needs of this vulnerable group of young people are addressed by ensuring appropriate care places are made available for those young people who cannot be cared for within their families. Many of these most vulnerable young people are in need of safe care in the community. Some of them are homeless and others are cared for within the out-of-hours service, whereby, if they are lucky, they will have a hostel place for the night and, if they are not so lucky, they will not obtain such a place. They tend to be on the streets during the day. We also ask the sub-committee to do what it can to ensure that inpatient adolescent psychiatric treatment facilities are made available for the small group of adolescents for whom this is necessary.
