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JOINT COMMITTEE ON HEALTH AND CHILDREN (Sub-Committee on High Levels of Suicide in Irish Society) díospóireacht -
Tuesday, 4 Oct 2005

High Levels of Suicide: Presentations.

I welcome people to this meeting of the sub-committee dealing with the high level of suicide in Irish society. The sub-committee comprises Deputies Neville and O'Connor and Senators Browne and Glynn. We have also been joined by Deputy Cooper-Flynn. Our brief is to deal with the issue of suicide and see what we can achieve through listening to expert opinion.

The sub-committee will not run for long as we intend to appoint a consultant to prepare a report to be ready in early December. During the coming weeks we intend to invite a number of experts to come before the sub-committee. The sub-committee will be active and will report back to the Joint Oireachtas Committee on Health and Children. The establishment of this sub-committee ties in with the suicide prevention strategy which was announced by the Tánaiste some time ago and which was recently launched.

Rather than going through all of the figures presented publicly during the past few years and months, it is worth remembering a few key facts and figures before we begin. The average number of suicide deaths in Ireland each year is 494. The highest number of deaths, 519, occurred in 2001. As they listen to expert opinions, members of this sub-committee should bear in mind that suicide is at least four times more common among men than women. Men under 35 years of age account for approximately 40% of all suicide deaths. The Irish suicide rate has doubled since the early 1980s. More than 11,000 cases of deliberate self-harm are seen in Irish hospitals every year. I also advise all people presenting to the committee to raise matters that they believe to impinge on suicide levels.

I welcome our first presentation from Professor Kevin Malone of the Department of Psychiatry, St. Vincent's Hospital, UCD, and scientific director of Turning the Tide of Suicide in Ireland. I invite him to make his presentation.

Professor Kevin Malone

Go raibh maith agaibh. Is cúis uafásach é seo agus cúis dhóchasach ag an am gcéanna.

I offer my congratulations to this sub-committee for putting in front of the people the darkest topic in the modern Irish landscape and for debating it in this manner. I am honoured to be invited here today.

My day job involves clinical work with patients suffering from mental illness. I also teach medical students in UCD and lead a research programme in the area of suicidal behaviour, including suicide. In my spare time, I am involved in a charity which I co-founded, Turning the Tide of Suicide, with a group of individuals who expressed concern about the problem and who wanted to learn whether those dedicated to this issue could advance a resolution. It is a pleasure to present to this informed sub-committee, which is cognisant of the statistics described by the Chairman.

Suicide is a global mental health issue. The top right part of the map before members demonstrates the distribution of suicide rates across communities internationally. Unfortunately, Ireland is one of the few countries in the developed world with suicide rates above 13 per 100,000. Ireland is fourth in Europe with regard to youth suicide and suicide is the leading cause of death among young males in Ireland. The figure on the bottom left is the EU total suicide rate, in which Ireland ranks 18th. The figure on the right, youth suicide, is disturbing because Ireland is fourth behind Lithuania, Finland and Latvia. The graph does not show that Finland used to have almost double its current youth suicide rate. For the past ten years, the Finnish Government and population have been dedicated to reducing suicide rates and are beginning to succeed. That is an important point.

The rise in youth suicide is depicted on the left of the next image and the national strategy for action on suicide prevention, which was launched this year with a completion deadline of 2014, is represented on the right. Those who read the document will be aware that it contains a desirable wish list. It is difficult to avoid the fact that, if one examines other countries, resourcing and supporting mental illness services will be a key pillar of this programme if it is to be successful.

I will not talk about statistics. I suspect everyone in this room has been touched by suicide in one way or another. The true devastation caused by suicide in Ireland goes far beyond the statistics. It includes the human costs, which are the lives lost, the shattered families, the fractured communities and the reflection on modern Irish society. The questions are who cares and whether we can galvanise all of them.

President Mary McAleese definitely cares. She attended a conference — Suicide in Modern Ireland: New Dimensions, New Responses — convened by Turning the Tide of Suicide in November 2004, where she stated: "It must remain an absolute imperative of society to do all that we can to reduce the incidence of suicide, to end the unconscionable suffering for everyone touched by it."

At this point, I will move away from my day job and show the committee a three minute DVD that the Turning the Tide of Suicide charity put together to help the launch of the "Be Not Afraid" bracelet campaign, which was launched by Daniel Philbin Bowman, who decided to donate the proceeds to two tragedies: Darfur and the problem of suicide in modern Ireland. The script of the DVD is as follows:

The word "suicide" in modern Ireland is just as bad as the word "cancer" was 30 years ago. It has the same effect on people. The number one killer of the young men of Ireland is not road traffic accidents or cancer; it is suicide and it is tearing communities apart across the island of Ireland.

Ireland has a very serious knowledge gap in its understanding of suicide. We know some of the frightening statistics: over 444 deaths from suicide in 2003, over 92 of which were young men. However, we know very little about the people behind these statistics. This is vital information if we are to advance the development of proper prevention and intervention programmes across the life cycle and communities.

The three Ts stand for Turning the Tide of Suicide, an umbrella charity that aims to help other charities in their work and to drive forward the awareness, education, intervention and prevention of suicide across life cycles and communities.

The current most pressing objective of the three Ts is to complete the suicide in Ireland survey. We must go to communities and talk to bereaved families as, in many instances, they are the experts. They have that knowledge that could be critical. They will be contributing to a national archive of information and understanding and, in a way, giving a meaning to the lives lost to suicide.

People do not conveniently become suicidal between 9 a.m. and 5 p.m., Monday to Friday. We must have a service right across the country that people can access at all hours in their times of suicidal crisis. The goal of the three Ts is that Ireland should be an international leader in the fight against suicide, not play second or third fiddle. We must lead on this issue so the legacy we leave to the next generation is that suicide was a problem but Ireland tackled it effectively.

"Be Not Afraid" is a message filled with hope, togetherness and solidarity, all of which we will need in great measure if we are to succeed, which we will. Let us face this issue together. This is our call to you and we thank you for supporting the three Ts.

I apologise there is not a copy of the DVD for everyone in the audience but we will leave a copy with the committee.

People care about this problem. We must tap into the resources around the country, there are many people who care about suicide in Ireland. Pádraig Harrington, who has been one of the spokespeople for Turning the Tide of Suicide, has said that it is an undercurrent of our society that people do not like to talk about but I am sure there is not a family in Ireland that has not been touched in one way or another by suicide, either directly or indirectly. Over 11,500 people took part in the three Ts golf tournament in golf clubs all over the country this year to raise awareness of suicide.

A component of the national suicide strategy is to develop research in Ireland to inform us about the problem. I will give the joint committee a brief overview of the top ten projects that are currently being run or are about to begin in University College Dublin. The university has sent a clear message that it cares about suicide and wants to develop a sustained programme of research, both with regard to understanding suicide and intervention strategies that can make a difference.

I am involved in several North-South projects and I currently have research fellows in Dublin, Ballinasloe, Letterkenny, Omagh and Belfast. Until recently, I had a research fellow in the midlands and Limerick. To date, we have gathered face-to-face information on over 500 new referrals to the psychiatric services and over 500 suicidal crises presenting to accident and emergency departments over the last three years. The DVD I presented to the joint committee contained information about an upcoming suicide in Ireland survey, entitled "A Thousand Lives Lost Behind the Statistics".

We are also well under way with a national study of rail and waterways deaths encompassing all deaths on railways, including suicides, of which there are quite a number. We have just completed a study which has been published in The American Journal of Psychiatry on suicide in the Defence Forces and we are at an advanced stage with regard to a study of suicide in the Garda Síochána and among physicians. These are groups of people who have occupation-specific risk factors for suicide that we need to understand more about in our community. Obviously, we want to follow up all the patients we recruited in studies one and two.

Project eight is a very novel international one that looks at brain imaging studies of patients with suicidal depression. We are at the forefront of international research with regard to brain imaging projects at University College Dublin and we recently received a distinguished investigator award from the American Foundation for Suicide Prevention to develop this project at University College Dublin. We are also looking at the immune system and how it functions in suicidal depression.

On intervention, I am collaborating with Professor Carol Fitzpatrick on a project — Working Things Out — which involves sitting down with young people who have been through suicidal depression to get their views on how they worked things out during their times of crisis.

The title of the suicide in Ireland survey, which is not currently funded by Government sources, is "From Awareness to Knowledge". We raised funding for the survey through private sources but the reality, to which the Chairman alluded, is that there have been more than 1,600 deaths by suicide in the Republic of Ireland and 2,200 deaths by suicide on the island of Ireland between 2003 and 2005. There is an enormous knowledge gap. The Chairman provided some statistics but there is a considerable amount that we do not know. Who are the people behind these statistics? The suicide in Ireland survey aims to discover this. In the course of the survey, we will talk to family members and relatives who have lost someone to suicide. We have already received expressions of interest from more than 400 families who wish to donate their stories in the hope that they will help other people understand more about suicide. If it helps prevent one suicide in Ireland, the families believe it is worth it. The message is "help us to help Ireland".

University College Dublin is committed to a programme of research, education, prevention and intervention. I have been assigned the leadership role in this programme and I am willing to step up to the plate on it. We should be an international leader on this issue and develop and share transferable knowledge for a global society.

We already have been involved in a number of projects we believe can impact on the community. Members can see information on the top left hand side of the screen about a research project where we have begun to explore what happens in the brain when people think negative as opposed to positive thoughts about the future. Very different brain areas are activated during these two states. Our next project is to conduct this research on patients with suicidal depression. We hosted a "three Ts" candlelit vigil on world suicide prevention day, 10 September 2004 and 2005. This was attended by more than 300 people. It was a moment of great sadness and grief but also of great hope.

I have mentioned the Be Not Afraid campaign. In light of the recent television programmes about lost asylums in Ireland, focusing on St. Ita's Hospital, it is important to say there is a future. There is a new inpatient psychiatric unit in St. Vincent's University Hospital, a purpose-built, state-of-the-art unit that should be the model for such units. This kind of service for patients with mental illness is long overdue.

Bricks and mortar are not enough to cure anybody but when I brought Professor Herbert Hendon, a director of the American Foundation for Suicide Prevention, to the hospital last Friday he exclaimed that the light in the building would cure people. Light is used extremely well in the building and there are no dark corners. He said it was the nicest psychiatric inpatient unit he had seen in 40 years of clinical experience.

In summary, the focus should be on going forward but giving back. My goal is to lead the way to reducing suicide rates by helping all the organisations involved in this process. The need is great, the timing is urgent, the yield is to individuals, communities, society and the economy. What is the cost of suffering if we do nothing? What is the value of saving one life if we do something? This problem does not belong to someone else it belongs to everybody.

I thank Professor Malone for his presentation. We commit ourselves to his work. We intend to be an active committee and will take on board what the Professor and our other visitors say. I am glad the Professor referred to involving the families of the bereaved by, we hope, inviting them to meet this committee. This is a new idea to me and we might discuss it with Professor Malone later.

Professor Malone outlined the real stories behind these statistics, which are important. I am not an expert in the field but as a funeral director from the midlands I am aware of these tragedies, having seen them over the years. I have seen the grief of the bereaved families and know there is little support for them to pick up the pieces afterwards. We need to recognise that great burden of grief and set about better understanding the associated issues and involve the families in the process.

I am delighted to invite Deputy Neville to speak. He is known throughout the State for his interest in suicide and his leading papers on the subject.

I too welcome and thank Professor Malone for making his most informative presentation to the committee. I wish to touch on three points. In the 1960s an average of 60 people died by suicide each year. That number is now 450, although the Chairman put the figure higher than that. Although psychiatric illness is a significant factor in suicide, its level has not increased at that rate. There must be other factors contributing to the increase.

Will the Professor deal with the societal factors that have caused the massive increase in suicide and particularly why so many young people despair so much that they take their lives or harm themselves? The figure for self-harm is 11,200 but that represents only those who presented at accident and emergency units. Does Professor Malone have an estimate of the total figure for those who may have presented at their general practitioners or has there been any research into those who may not have presented? The true figure for self-harm is much higher than 11,200. That is statistically correct, being based on the work of the national suicide review group. There are societal differences, and one of the key themes in Australia, where suicide has been reduced by 24%, was investment in the psychiatric services. Perhaps the professor might touch on his views regarding the financing of the psychiatric services and what should happen to deal with the problem. I am attending a conference this evening on the spiritual and ethical aspects of suicide. Some of us feel very strongly that changes in the status and practice of religion, and changing beliefs, have affected matters. There is no simple answer to why suicide happens, since it is a multifaceted issue. Perhaps the professor might address those three questions. There is a great deal of fear among young people regarding their peers and among parents regarding young people in distress or crisis. Now there is the possibility that people will become suicidal, something that would not generally have happened previously in Irish society.

Professor Malone

I certainly do not want to wait ten years for the answers to some of the Deputy's questions, which he has raised with welcome urgency. He is right about young people's fears. They are very concerned about this and particularly disappointed at the lack of response from society in general. There is an underground network of support among young people, and some of the more successful programmes, for example, in UK or US colleges, are driven by or harness them. The committee must hear the voice of young people. However it does so and whomever it consults, we must harness young people, since they are dealing with the new currency of suicidal behaviour as an expression of pain and suffering, whereas previously, however we expressed pain and suffering, it was not through such behaviour or through suicide itself. I am coming at the problem from the point of view of young people, particularly young men.

Deputy Neville also asked about society's response, and he is absolutely right. There is a balance of risk and protective factors. Unfortunately, the latter are not what they once were, while the former have probably increased. Those include increased wealth and opportunity to spend money on alcohol, and an increased likelihood of some people being left behind. The protective factors that have gone are religion, as opposed to spirituality, to which I will return presently. Even the familial protective factors have eroded significantly.

We are about to conduct a study of suicide in Ireland. We are fairly sure that we will succeed in our aim of interviewing at least 80% of families who have lost a member to suicide in the last two years. If one secures a representative sample of that population, one can superimpose all our knowledge of society, local and national economics, political decisions, and North-South issues. Since we have researchers in the BMW region, we can examine that area too. This study will give us a unique opportunity. We believe that it will give a voice and meaning to the void that has been left behind by suicide and a chance to inform society in a unique way. This has been done in only one other country, Finland. The Finns successfully learned from that research and were able to reduce the incidence of suicide.

Deputy Neville raised the issue of psychiatric services, and statistics regarding the infrastructure of financial support for the psychiatric services have frequently been articulated. We know there is reduced spending in the health budget compared with ten years ago. That is not coincidental. Having worked as a consultant psychiatrist in both the north inner city and on the south side, I am aware that there are large areas of deprivation. We have a threadbare mental health service compared with those in, for example, the United Kingdom, United States and Australia.

There are some countries in which the problem is taken seriously and we should learn from them. Deputy Neville mentioned Australia as an example in this regard. Another is Scotland. The authorities there have, independent of improvements to mental health services, ring-fenced £30 million in respect of suicide prevention. We must take the lead from those who are serious about tackling the problem. Irish people are proud that our country can lead and be successful in so many domains and there is no reason we cannot lead the way and be to the forefront in five years' time in tackling this issue.

Deputy Neville raised the question of spirituality, a matter about which I am not qualified to speak. At our conference last November, Professor Enda McDonagh, retired professor of moral theology at St. Patrick's College, Maynooth, gave a wonderful presentation on the role of spirituality in modern Ireland and on how it can be incorporated into an understanding of the expression of suicidal behaviour. It is an aspect this committee should consider.

I was a member of the Joint Committee on Transport before being appointed to this committee and my work on the former involved examining research conducted in Canada which attributed some single vehicle motor accidents to driver suicide. Is any information available or attainable on the number of single vehicle accidents which may be a consequence of driver suicide? Has any research been carried out into the area of copycat suicides, a phenomenon which affects mainly young people, whereby a person whose friend or relative commits suicide may subsequently do the same?

Professor Malone

No research has been done in this State on the number of road fatalities which may be a consequence of driver suicide. In countries where such research has been undertaken, it is estimated that as many as 10% of single vehicle accidents may be driver suicides. Such findings have been influenced by the testimony of relatives that a percentage of those killed may have been depressed or expressed suicidal ideation in the weeks before the fatality. Given the carnage on our roads, a study of the possibility of road deaths caused by driver suicide seems worthwhile, in parallel to that which we are undertaking. However, the limited funding available for research into suicide means we were obliged to raise private funds in order to commence the study immediately. With the support of rail agencies, we are also conducting a study of rail deaths. There should be a similar urgency in respect of the issue raised by Senator Browne.

In regard to copycat suicides, there is a notion — particularly in Ireland — that what might be happening, grim as it sounds, is that we are almost incubating the phenomenon of suicide among young people. In other words, one suicide may trigger another two our four. We will be able to answer that question most effectively in the suicide in Ireland survey because our research will allow us to identify clusters. Senator Browne is correct in his observation that copycat suicides are more likely to arise among impressionable young people, many of whom identify with a suicide in what is termed a "grief response". This involves a significant grief reaction and identification with the tragedy and may ultimately cause suicide to be seen as a solution.

In the United States, three or four dedicated intervention teams are available throughout the country to identify clusters of suicides at an early stage and to bring in the cavalry before five or six have taken place. One is one too many and a comprehensive strategy for youth suicide needs to be developed to help prevent the anguish of such clusters.

I will start with theconcluding remark of Professor Malone's earlier address to the effect that there are few families that have not been affected in one way or another by suicide. Most families have been touched by its cold fingers at some time. It is, therefore, a problem of society and every member of society is a member of a therapeutic team to address the problem. The question is how we do that, given the old saying that evil is done when good people do nothing. Have we motivated all the resources that are available? Some five or six in this room today are involved but, notwithstanding the great work done by the Irish Association of Suicidology and others, the vast majority of society is not involved.

What role does Professor Malone believe drug addiction and alcohol abuse play in the increased incidence of suicide? I worked in the psychiatric services for a number of years. While I have always taken the view that community service is a better service, it is nonetheless more expensive. Therefore, greater resources must be devolved to psychiatric services. What is the incidence of suicide among rehabilitated psychiatric patients, those who have gone through all the stages of rehabilitation and who are discharged? Few of that category are repatriated to their families. They often find themselves in a bedsit or flat somewhere. As they are usually discharged from the psychiatric services, domiciliary visits from CPNs cease. Does Professor Malone believe that category to be at risk?

Reference was made to copycat suicide. I am from a rural part of the country and the incidence of suicide there is frightening. A substantial number of those committing suicide are in their teens and school-going. That is a worrying factor.

I have just returned from seeing a relative in England and I was speaking to some people there about suicide because I knew I was coming to this meeting today. The last point Deputy Neville referred to is a view, whether correct or incorrect, held in certain sections of society that the reduction in people associating with religion of some kind is a contributing factor. That view has been expressed on many fronts, not just here in Ireland but across the water. I have taken the time and the interest to explore other views from other people and it is a common view. How real or imagined it is I do not know.

Is there a drink culture similar to ours in countries with similar levels of suicide? Could Professor Malone provide information on the drink culture in countries which have the lowest rates of suicide? Many families have been touched by suicide. I attended a conference on suicide in Leitrim some months ago, and it was made clear to me on that day that many people have experienced its effects. I would like to concentrate on this matter because rather than just having a committee on the subject for its own sake, we will take direction and advice from the witnesses as time goes by with regard to how the committee is operating.

I will take into account the issue of how the committee might bring in bereaved families, young people and Professor Enda McDonagh. However, it is not easy to do this and I hope the joint committee might receive some direction on this. The timescale will be approximately two to three months; during this period I hope that people presenting before the committee will not just see it as a one-off event, but rather remain in contact with us. Perhaps the joint committee could send reports to relevant people who come before the committee to gauge the response to this topic. Many people are hoping that the Government can do something in this area.

At the conference in Leitrim, the point was strongly made that the general public, and in particular families who have experienced suicide, feel that the political process has no indirect or direct involvement with the subject. Although we have talked about doing something about suicide, little has been done over the years and there is no point in stating otherwise. I spoke briefly from the floor at the conference but felt my intervention as a politician did not impress those present. They had heard it all before. These people want a new direction, and I hope that the witnesses might take this into account and be blunt with the joint committee. We wish to make progress and not just sit here for the sake of it.

Professor Malone

Those are refreshing words. The grief associated with suicide is enormous and heart-wrenching, as behind the grief lies stigma, shame, isolation and loneliness. This joint committee and development of strategy is a sign that people are willing to listen. As grief associated with suicide is so enormous, and as a result of the associated stigma, it will take time and the presence of leaders willing to stand up and be counted to address matters.

It has been stated that evil prospers when good people do nothing, a point with which I agree. I speak as an individual, a staff member of the hospital in which I work, a member of the charity Turning the Tide of Suicide and a member of the largest university in the country. If all these are put together it forms a voice, just as all Deputies and Senators in the Houses have a voice. We need a louder, more action-oriented and sustained voice that has strategic aims. The Chairman's point of not being a committee just for its own sake relates to this. There should be a strategic focus with regard to how this issue can be effectively advanced.

The following is an example of the fragmentation that accompanies the grief of suicide. More than 300 organisations in the country contend they are involved with suicide postvention. These are small groups around the country, all grieving in their own way. The challenge for this type of committee, one faced by President McAleese when she put together the forum on suicide, is how to include everybody. The grief is such that it goes beyond the idea that a group can represent those affected. We believe that an important part of the suicide in Ireland survey is the opportunity for everyone to express their voice and the notion of contributing to an archive that may prevent one other family from going through an experience of suicide.

I will return to the idea of direction at the end, as Senator Glynn raised many important points. The role of alcohol in the expression of suicidal behaviour is very complex, as we know that alcohol is a dysphoric agent. In other words, it pushes down mood and increases impulsivity. The third component is that the adolescent and young adult brain is most vulnerable to these chemical influences. As one gets a little older, one does not get the same rush of adrenaline or the same depletion in some of the neurotransmitters associated with dysphoria and depression. Consuming alcohol in the doses that are being taken nowadays can almost induce a depressed state over an eight or 12-hour period. This has been tested in the laboratory by giving a person so much alcohol that it actually depletes the brain neurotransmitter levels designed to regulate mood, etc. It is a factor but it is not as simple as saying the alcohol intake has increased and, therefore, the suicide intake has increased. I could show members a graph indicating that the number of inpatient psychiatric beds has decreased while the number of suicides has increased. It is not as simple, therefore, as saying one equals the other or vice versa.

There could be a category of people who commit suicide who have never been exposed to psychiatric or consultant care or expertise.

Professor Malone

I mean this in no chastising way but it is important to realise that families have a big problem with the words "commit suicide". I can understand this because they have already suffered. One would use the word "commit" in respect of a crime or felony but it does not work to use it in the case of suicide.

On the question of whether there are people who never availed of health services, not to mention mental health services, it is something we will find out in the suicide in Ireland survey. The only other national study of suicide in Ireland was carried out by examining data from 1997 to 1999. They went the other way round, whereby they spoke to those in the psychiatric services and to GPs. They found that only one in four of young people involved in suicides had ever contacted a health professional. What we hope to do in this study is to talk to the families of the three in four people who have never visited health service practitioners.

The main reason for a male to visit a general practitioner is that his partner has made an appointment. The idea of going to a practitioner for an ailment is down the line when it comes to being a man. Something this committee might think about — it is a matter we have considered in the university — is that there are significant men's health issues in Ireland, of which suicide is one. Prostate cancer is another, as are cardiac disease and bowel cancer. These are significant men's health issues. There are many women's health departments, and rightly so, because there are women's health issues. However, there is not a dedicated and focused men's health strategy. One way to get suicide into the mainstream of discussion, funding and support is to say it is a particular men's issue. The number affected is almost 6:1 male to female young people, which identifies it as a significant men's health problem.

I wish to address the issue of psychiatric services. One problem is the ideology of the current psychiatric service structure, which is designed as a "one size fits all" model. I might have expertise in suicidal depression, having carried out research and been interfaced with new models of care and clinics internationally, and my colleague might have expertise in and great knowledge of schizophrenia, substance abuse or alcohol dependence, but the model of psychiatric service throughout the country is that one size fits all. It is a generalist approach. If one is a public patient in Ireland, it is bizarre that one is not allowed to choose one's psychiatrist or clinical team. In every other specialty in medicine one can be referred wherever one wishes with regard to one's clinical intervention. One's general practitioner can say that he or she gets on well with someone, that he or she knows a bit about this or that and is an expert on phobias and so forth.

When it comes to psychiatry, the ideology is that a patient must attend one professional, irrespective of whether he or she gets on with him or her. This is always because of where one lives. As long as geography is inextricably linked with care, we will encounter difficulties regarding the notion of expert help. For example, I have expertise and skills to understand depression. I have studied and researched depression and I have trained in and treated it. I do not have as much expertise in other areas but when I am appointed to a job, I must treat everyone who comes in the door as well as the other 39 people sitting outside. The patient is getting a quantity general service as opposed to a quality specialised service. I feel strongly about this because I have been trained in systems outside Ireland where dedicated teams can make a difference. Throwing more money at the psychiatric services will not work.

I defy the sub-committee to identify one properly resourced psychiatric service in the State. By that, I mean a general adult service, which has a psychiatrist, a clinical psychologist, a dedicated psychiatric social worker, a dedicated occupational therapist and dedicated community mental health nurses. I defy the sub-committee to find one such service. Operating as we do at present is the equivalent of doing surgery with one arm tied behind one's back. People are correct to ask why patients are using medication but when one is working in a clinical capacity, one has only two or three options to offer a patient while 35 people are waiting outside. That is the reality in Ireland and as long as we say that is good enough, it will remain that way. The voice for change will have to come to from the halls of power as well as from the tiny voices suffering in the community.

We underestimate the stigma associated with suicide. I refer to the direction of the sub-committee and I detect the Chairman's fear of reinventing the wheel with regard to the prevention strategy. However, a few things jump out of the strategy. First, no budget is dedicated to the initiatives and there is priority regarding which initiatives should get off the ground. It is suggested that a national suicide office should be established initially but prioritisation and urgency are needed within that.

I asked about the relationship between drug and alcohol abuse and suicide.

Professor Malone

The Senator is correct to ask about drug abuse, which is closely linked with despair, hopelessness, depression and core mobility. The next witness has expertise in this area. Our drug abuse services are, interestingly, relatively better resourced, as should be the case, than general adult services per capita. However, more is spent per capita on those with drug addictions than on individuals with general psychiatric problems.

The Senator touched on two populations close to my heart — one is those recently discharged from hospital and the other is those recently discharged from services. This refers back to the general versus the specialist service model. The pressure currently is to get people out of hospital. This defies clinical common sense because these patients are suffering to start with and it does not take much for them to feel like they are not wanted. They enter hospital feeling they are not wanted by the community and they are under pressure to leave. They comprise an important population. No hospital has a focussed, high observation, post-discharge strategy in place and there is a rush to discharge people back to their general practitioners because people are queuing up at the door. That does not serve patients and the survey on suicide in Ireland will reflect this.

I thank the professor for his presentation. Our intention is to send the professor the copies of the report or the recordings of each presentation. When the time comes to prepare the report the professor can read these and then make another written or oral presentation.

Professor Malone

Thank you very much. I offer my congratulations and will do anything required by this committee.

Sitting suspended at 3.15 p.m. and resumed at 3.20 p.m.

I welcome Dr. Declan Bedford, Alcohol Action Ireland, Dr. Conor Farren, consultant psychiatrist at St. Patrick's Hospital, Norah Gibbons, director of advocacy, Barnardos and Marion Rickard, chairperson of Alcohol Action Ireland. One of my first functions as Chairman of the Joint Committee on Health and Children was to attend a presentation by Alcohol Action Ireland some months ago. Statistics were provided on the involvement of alcohol in suicide and the issue of drink culture. I ask the delegation to speak on that matter today although it may speak on any issue. We are about to prepare a report and want to deal with this matter in three months. We look forward to the thoughts and recommendations of the delegation, given its background in Alcohol Action Ireland.

Ms Marian Rickard

I thank the Chairman and the committee members for inviting Alcohol Action Ireland to make this presentation. Our two main speakers are Dr. Farren and Dr. Bedford and I will briefly describe Alcohol Action Ireland. It is an umbrella group established in 2002, which includes Dr. Loftus, the Irish Medical Organisation, the Royal College of Physicians of Ireland, Barnardos and a number of organisations concerned about the ever-increasing levels of alcohol-related harm in a country with the highest per capita consumption in Europe. We wish to make clear we are not affiliated to any organisation in the drinks industry. We have an office in Dublin. Dr. Bedford will now commence the presentation.

Dr. Declan Bedford

I am a member of Alcohol Action Ireland for the faculty of public health medicine of the Royal College of Physicians. We examine alcohol in particular. Professor Malone mentioned how suicide rates in Ireland have risen over a time of fundamental changes in our society and this must be viewed in the context of all of those changes.

Research tells us that with major changes, such as an increase in divorce and separation, a reduction in population under 65 and an increase in population over 65, more women in the workplace, more tertiary education, increase in alcohol consumption and a reduction in church-going, one finds an increase in suicide rates. We have experienced all of those changes in society, and where there is less integration and greater fragmentation, with fewer boundaries for young people, suicide rates increase.

Recognising all of those factors, one sees that alcohol plays a role, and abrupt changes in alcohol consumption in society have been shown to be followed by increases in suicide rates. In Russia under Breshnev, following a period of turmoil for several years, it became more difficult to drink alcohol. Afterwards, in a more relaxed atmosphere, alcohol rates increased, as did the mortality rate from alcohol-related diseases, including suicide.

During the 1990s we experienced a 41% increase in alcohol consumption in Ireland. During that time, as members of the sub-committee will see from my presentation document, the suicide rates increased dramatically. The suicide rate per 100,000 population of males aged 25 to 29 increased from 18.3 in 1989 to 39.9 in 1999, more than double.

The role of alcohol is well-known. Professor Malone described how it can be a depressant, lead to self-destructive behaviour and increase the likelihood of a fatal outcome in suicide attempts. I was involved in the publication of "Suicide in Ireland — a national study"several years ago. We examined all of the suicides in Ireland, including the aspect of alcohol. GPs reported that 20% of their patients who died by suicide had a history of alcohol abuse, consultant psychiatrists reported that 27% of their patients who died by suicide had a history of alcohol abuse and only 46% of those people were known by their GP or psychiatrist to have attended alcohol counselling.

The study also showed that GPs and consultant psychiatrists reported that 20% of their patients who died were known to have taken alcohol immediately before their deaths. That is more common in males than females and much more common in men under 25 years of age.

A more recent study was carried out in Counties Cavan, Monaghan and Louth and involved examining coroner's records of all deaths that occurred by accident or suicide. In the three counties, 31 suicides occurred during the study period, and 93% of young men aged under 30 years who died as a result of suicide had alcohol in their blood, while 58% of them had levels of greater than 150 milligrams. As the limit for driving is 80 milligrams, there is no doubt that these young men were drunk. In comparison, no man over 30 years of age had the same levels of alcohol. All of the extremely high levels of alcohol were in young men.

Alcohol played an important role. Perhaps some of them used alcohol for Dutch courage. I speculate that some of those men did not have suicide on their minds when they went out that night to drink but they drank so much that everything changed. Some 25% had alcohol levels greater than 240 mg. These are high levels of alcohol.

The national para-suicide registry of Ireland reveals that alcohol was involved in 47% of male episodes of para-suicide in 2003, an increase on the previous year. The figures are slightly lower for women. The overall level of alcohol consumed by a country bears upon the alcohol problems its population will ultimately suffer. This is recognised by the strategic task force on alcohol. The task force recommends that we take a population-based approach to reducing alcohol-related harm and that all factors which impinge on society must be investigated. We agree with that.

The task force made nearly 100 recommendations. However, the most effective also appear the most unpopular among politicians and society. We do not like hard medicine. For example, the most effective method of reducing alcohol consumption and alcohol-related harm is to limit availability by means of increasing taxation and reducing numbers of outlets and times of sale. Unfortunately, these actions are politically difficult. Research in the USA has shown that an increase in the excise tax on beer reduces the number of suicides among males but has no effect among females. Suicides among males aged between 20 to 24 are positively related to the availability of alcohol.

The promotion of alcohol is targeted at young people, who are more susceptible. Research in Ireland reveals that young people consider that they are targeted and influenced by advertisements and it is difficult for them to avoid this influence. The task force's recommendations, particularly the more effective ones, must be followed for the population health approach to be effective.

The alcohol industry — I refer to multinationals rather than vintners — should have no role in setting our alcohol agenda. Unfortunately, that is not the case. Today we saw that the advertising code will be regulated by the industry. This seems to happen all the time. An article in the British Medical Journal of 10 September which discussed alcohol problems in the United Kingdom noted that the UK government’s new alcohol policy, which includes “partnership” with the alcohol industry, shows all the hallmarks of regulatory capture in that it embraces the industry’s diagnosis and preferred remedies for the alcohol problem. The outcomes sought by health and other social lobbies seem to come second to the industry’s idea of what should be done. The latter generally wins.

There is no alcohol policy in Ireland. If we want to solve our alcohol problems, and reduce harm and suicide rates, we must have an implementable alcohol policy.

Dr. Conor Farren

I am a consultant psychiatrist and director of a mood and addiction programme based at St. Patrick's Hospital. I have been a researcher and a clinician in the field of addiction and associated depression for between ten and 15 years.

Significant research has been conducted over the past 20 years into the causes of suicide and it is clear that a number of causes exist. I do not want to treat this in a simplistic manner by saying that alcohol is the sole cause. However, alcohol is an important factor. Fundamental causes of the rise in suicide rates are Ireland's particular patterns and the rise in alcohol consumption. Professor Malone observed that it is not possible simply to say that parallel rises prove causation. However, no other potential cause exists for the rise in suicide levels in Ireland. My handout to members includes a graph which describes explicitly the relationship between alcohol consumption and suicide. It is not an act of genius to see that the two lines are highly correlated. The increase in alcohol consumption during the past ten years was 41%, and in the rate of suicide in the same period, 44%. No other country in Europe, or the world for that matter, has experienced the same increase in alcohol consumption or in its suicide rate during that time. Ireland's unique culture has made it vulnerable to the increase in alcohol consumption and its drinking culture has made it vulnerable to the suicidal effects of alcohol.

I will deal with the causes of the increase in alcohol consumption first and then look at its relation with suicide. The increase in disposable income is an important factor in the former, as are the particularly liberal licensing laws and regulatory environment. Law enforcement in this area is liberal, as is our approach to young people drinking. We have an alcohol-permissive culture in general and there has been significant expenditure on promotion by the drinks industry. This is particularly aimed at young people, in the form of alcopops, drinks promotions in nightclubs and advertising such as the Heineken Cup, Guinness-sponsored festivals and the Bulmers comedy festival. This represents a vast expenditure on promotion of alcohol related to activities in which young people are interested.

There has been no increase in the past ten years in the incidence of depression, which is another major cause of suicide, and no change in the method of reporting suicide. Some 30 years ago, when suicides were under-reported, we could say a rise over a ten-year period may have resulted from an increase in reporting. That does not apply now. In the past 20 to 30 years coroners in particular have reported suicide as suicide. There have been no other changes in the way the causes of suicide are reported in the past ten years. Statistical correlation and elimination of alternative explanations leave no explanation beyond the increase in alcohol consumption.

Alcohol consumption is associated with depression and hence suicide and Dr. Bedford has mentioned the association with reference to particular countries. In Denmark in the 1920s a liberalisation of laws produced an increase in the suicide rate. A reversal of that liberalisation produced a corresponding fall in the suicide rate during the succeeding five years. A significant number of past studies show that when there is a significant rise in alcohol consumption, there is a corresponding rise in suicide rates.

A particular feature of alcohol consumption in Ireland is binge drinking by men under 30 and that accounts for the vast increase during the past ten years. Research has shown that binge drinking is particularly associated with suicidal acts. Binge drinking is defined as five or six units of alcohol for a man and four for a woman in one session. In Ireland, however, binge drinking involves vast quantities and it is not unusual for the people with whom I deal on a daily basis to consume 15 or 20 pints, not units. Binge drinking is increasing in the UK but to a lesser extent than here and is not on the rise in other EU countries. The increase in the UK during the past ten years was 5%, compared to a rise of 40% in Ireland in the same period. There has been no parallel increase in suicide rates in UK in that time. There has been a change in the availability of certain over-the-counter medications which decreased the availability of some poisonous material. Therefore, simple interventions need to be explored in order that a change in the rate of alcohol consumption does not necessarily have to produce the appalling rise in suicide rates that has occurred in this country.

It is important to explore how alcohol can make someone commit suicide. Most people will go out for a drink and not think they will be suicidal by the end of the night. Alcohol produces a significant fall in mood. This can be very variable but can be particularly associated with hopelessness. The fall in mood generally takes place in someone who already has a depressive disorder, but it is not necessary for a person to have a depression for this fall in mood to come about. This is important, as depression is associated with people who are suffering and in need of treatment. However, mood effects of alcohol may take place in a person with no depression at all.

Alcohol is disinhibiting. In other words, it allows a person to do what they might otherwise think about but not do. Normally, alcohol-induced disinhibition is linked to exuberant or reckless behaviour, but the disinhibition can also be connected to negative behaviour. If a young man is moderately depressed and goes on a binge-drinking session, leading to more depression, he may become disinhibited enough to act suicidally where he may not in a sober state. Significant research has shown that suicidality is disproportionately greater than any other psychiatric symptoms in depressed alcoholics, which indicates that suicidality rises as drinking increases.

Depression and suicidality may be delayed. A person might go drinking on a Friday night and have an alcohol-induced depression that night, the next morning or a number of days later. I experienced a distressing situation in receiving a letter in response to an article I wrote from a lady whose son had committed suicide. She had no explanation as to why he had committed suicide. She stated that the lack of understanding, coupled with guilt and shame over possible missed signals, was as traumatic as the suicide itself. She described the son as a happy man in his early 20s with a girlfriend, car and job, with everything going well. However, he had gone out drinking heavily with his friends the weekend previous to his suicide. Nevertheless, he had never complained of depression and was a happy man. The only explanation that she could come up with was that the drinking session had affected his mood and made the son commit suicide, even a number of days later. It is my clinical experience that this is true and a delayed response can occur, although the average person might not think so.

International investigations taking into account 56 published studies in the last ten years have found that the percentage of completed suicides of all ages with alcohol in the bloodstream to be 37% . This is a survey of surveys. The proportion regarding attempted suicide was 40%. The relative risk of suicide attributed to acute alcohol use, that is, binge drinking, is ten-fold for men and women relative to those in the same mood in a non-binge-drinking case. The lifetime risk of suicide in alcoholics is between 5% and 15%. Heavy drinkers have a five to tenfold risk of committing suicide relative to others, and 10% to 20% of all suicides are committed by heavy drinkers.

The nub of the matter is what can be done about this. Research is clearly required in Ireland to determine the exact nature of the relationship in this country between suicide, young people and alcohol consumption. Treatment programmes, such as our own, looking at mood and addiction should be made available to a wider group of at-risk individuals with both depression and alcohol problems. This is a significant need, especially in young people. The youngest patient I have with this problem is aged 15.

A programme of early intervention, particularly in the setting of emergency rooms and GP surgeries, should be set up and tied in with established treatment programmes around the country to target people with alcohol problems, especially young people. The recommendations of the strategic task force on alcohol, which aims to cut alcohol consumption overall in the country to prevent suicide and other alcohol-related deaths, should be implemented.

Ms Rickard

A great deal of research on public health has been heard in addition to Dr. Farren's submission. I will share my own experience of working in the public service in a community-based alcohol counselling service. As a service which was accessible and open to the public, referrals came from accident and emergency departments. There could be referrals from local community groups and spouses whose partners had drinking problems. We have not considered today the impact of the trauma, sometimes suicidal thoughts, on the spouses of partners with drinking problems and on the children. For example, it was stated in yesterday's edition of The Irish Examiner that recent research in Britain on the effects of parents’ alcohol dependency on children revealed that 70% of children hid their parents’ alcohol addiction from others.

This is my experience working as an addiction counsellor and psychotherapist in this community service. Children of parents who are alcohol-dependent are three times more likely to consider suicide, both as children and later as adults. Typical problems reported in such households with alcohol-dependent parents include shortage of money, violence to the spouse, violence to children, loss of confidence, low self-esteem, anxiety and children being too embarrassed to bring friends home. Undoubtedly a similar situation exists in Ireland but we have no idea of its extent because no research has been done.

Why do children not reveal their parents' alcohol dependency and its devastating effects? This question is similar to why a woman continues to keep silent about a spouse's violence towards her. The answer lies in emotional dependency and the overwhelming need to belong. Children know very well they cannot survive without a parent and, even though a parent may be neglectful, having such a parent is better than having no parent. There is also the added shame and embarrassment of having a parent who is neglectful and not wanting to take care of them. That was my experience working in the public service for 14 years. The majority of people presenting had made suicide attempts. Due to lack of funding, I do not have research figures. My experience was that a significant number of people presenting had alcohol problems and had come from families where alcohol was a problem. The partners who presented were often at their wits' end to know where to turn. They often had significant physical, mental and emotional problems as a result of the distress of living for years with an unnamed alcohol issue.

As Dr. Farren said, we are seeking, in particular, a dedicated system and resources for the implementation of the Government task force report on alcohol. We are concerned that the report will lie on another dusty shelf for a further 20 years. We are connected to Europe through an NGO system, and everyone is looking to us in terms of the highest levels of alcohol-related harm, but we have no answers. We are seeking an increase in access and availability in community-based alcohol counselling services and high level awareness campaigns to encourage male and female spouses to come forward. In the past, we thought of female spouses living with very serious male drinkers, but the level of drinking among females has increased dramatically hence male partners are also living with such distress. This is my experience and I would now like to ask Ms Gibbons to speak.

Ms Norah Gibbons

Barnardos is a child care agency. We have been concerned for many years about the effects of alcohol, in particular, on families and children. We have a particular service that is specifically concerned about sudden death. This is where suicide comes into our work.

Ten years ago we started a bereavement service for children up to 18 years of age. A few years ago we identified that one of the demands we could not meet was a demand for an immediate intervention service for children and young people who are bereaved suddenly. One of the reasons for sudden bereavement is suicide, whether suicide of parents or suicide of children. We try to offer an immediate intervention, a meeting within one week for the child or young person and his or her family members. We will continue to do some short-term work with them, come back after a while and look again at how they are and do some long-term work if that is still required.

In the suicide of parents and siblings alcohol is one of the reasons that come up when we are working with a child on what has happened and why it has happened in his or her family. For children who have lived with alcohol abuse and where there is a subsequent suicide in the family, they have often had the experience of being parented very erratically, on top of which they are then hit with a sudden bereavement. Members of the committee can imagine what the period of adjustment is like for them. The work we specifically do to help the child or young person concerned is first aimed at listening to what he or she thinks has happened. Sometimes he or she has a lot more information and understanding of what has happened than the adults around him or her give him or her credit for or wish to discuss with him or her because of the pain of trying to talk about these very difficult issues with children. We listen to the children and help them to make sense of what has happened. We also listen to family members, help them to express their feelings about what has happened and get them to talk to the children. They are the natural protectors of their children, but sometimes their own pain is such that they are unable to do this. I was reminded when listening to the previous speaker, Professor Malone, of the importance when working with children of ensuring they do not see suicide as the only answer or a possible answer, that they learn to live with the changed circumstances in their lives without looking to suicide as one of the ways problems are solved.

In addition, we are very concerned that much of the increase in alcohol sales recently has been aimed at the younger generation. We see this as a major problem and a major factor, particularly when talking to children about sibling suicide. We are also concerned that there are few psychiatric services designed to meet the needs of the young, particularly once children reach 16 years of age. They are then caught in the adult psychiatric service. We would like to see services designed that are youth-friendly and have a youth focus in order that children and young people can access and identify them more easily and not go away from them. We are aware that very many of the people with whom we deal have not gone to their GP. There is a problem around services for 16 to 18 year olds.

Before inviting committee members to contribute, I thank the delegation for its presentation. We recognise that it is very important for us to go through the task force document and are inviting members of the task force to attend the committee on 1 November. The recommendations of the task force are as important now as they were when they were made. There is concern about whether we are acting upon them. This committee will take all issues into account, including the presentations made today. Many issues have been raised, including that of alcohol, which plays a major part in the incidence of suicide. When we are writing our report, we will clearly have to address this issue.

We have previously discussed the question of increased taxation on alcohol, reducing the number of outlets, the issues of targeting advertising at young people and its relationship to alcohol dependency in young people. We have also discussed the issue of alcopops and binge drinking. These are issues the committee wants to address. In doing so it is important to receive expert opinion from all areas.

We have already gone through the issues involved. I do not want to resurrect the debate on café bars and the increased availability of alcohol. They are issues we intend to go into and there are different viewpoints abroad. Some suggest that having more outlets and café bars will reduce dependency on alcohol. I do not believe this and I never did. I am not saying this because I am from a public house background. I have said it publicly before. It is important that this committee should deal with all of those issues and clearly support recommendations, rather than merely paying lip service to them. When it is making its report, it will be more than conscious of what has been said by the task force, as time will prove.

I must first apologise because, as acting Whip of the main Opposition party, I will have to leave for the Order of Business in the Dáil.

The most important point, about which I have always felt very strongly, is that alcohol is a disinhibiting factor. I have believed this for a long time, not alone as a result of the reading I have done, but also from talking to people whose families have suffered from suicide bereavement where somebody has taken his or her life within 24 hours of coming home from a disco. This is very common, particularly among young people. While the disinhibiting factor is a major issue, many of these people also have suicidal ideation although perhaps not to the point where they would take their lives. This is linked to the question of facilitating people to be open about their problems. Stigma is a major issue and young people I have spoken to say that to visit a counsellor was one of the hardest decisions of their lives, even though they knew it was the correct choice. Not only did they fear labelling, they labelled themselves for life. People that have come through this experience reflect on their decision in a positive way. Some 99.9% of them live full, active and productive lives afterwards. Bringing oneself to seek help is vital.

The delegation has identified the reasons behind binge drinking in respect of the money available to young people. Several generations ago, young people did not drink until well into their 20s. That has totally changed and now young people do not relate to their peers without drinking. How can this be changed? One proposed solution is to link eating with consumption of alcohol. Perhaps this was the idea behind the proposal for café bars. Does the delegation have a view on this? Much of what the delegation has said is fully accepted so there is no point in posing questions on those points. The relationship between alcohol and suicide has been acknowledged for a long time, although suicide is a complex issue and alcohol is just one part of it. Perhaps it is not the most important part of it and I believe psychiatric and emotional problems are the main areas of difficulty. When alcohol is added to this, it creates a dangerous cocktail within a person's psyche. This is a very important issue.

Dr. Farren

I will reply to a number of points the Deputy made. Deputy Neville stated that a young person may need to be significantly depressed before alcohol makes him or her suicidal. People with various levels of depression — from their arrival in hospital in a depressed state to their departure in a significantly less depressed state — with whom I deal mention that alcohol can take them from a mild to a profound level of depression. It is extraordinarily variable. Alcohol can transform people from a positive state to one of profound depression. The next week they may go out drinking and alcohol does not affect their mood at all. I cannot explain this but I have heard it from enough people to believe it. Each incident of drinking or binge drinking can have a totally variable effect on mood. On occasion, alcohol can transform a mild level to a profound, suicidal level. Changing from beer to spirits may affect this or perhaps it is due to the social circumstances of the individual at the time. Alcohol does not necessarily increase depression from moderate to severe or from severe to profound but it can have influence across the gamut. This is my clinical observation.

The drinking culture 20 years ago was nowhere near as aggressive as that which exists today. That is not passive change; it happened actively. We cannot state we were always predisposed and the Irish have always been hard drinkers. A positive change occurred, brought about by investment by people who have a vested interest in making money from the situation, and a lack of a corresponding response by those of us in positions of authority or responsibility. Any 14 or 15 year old can get alcohol in this country. My nephews and nieces describe to me where they can obtain it.

A corresponding balance is lacking, and while the drinks industry spends a fortune on alcopops and promotions, no regulation corresponding to that massive increase in expenditure and focused activity has been made. Not only has the culture changed but our cultural response to it has been lax, and that has led to this massive explosion.

Dr. Bedford

I will respond to Deputy Neville's comments. With regard to taxation, we called for a general increase in excise duty. When it was increased on cider in 2001 and on alcopops in 2002 a drop in consumption of both occurred but it has risen again because that increase was not sustained with income.

We would like to see tax reduced on low-strength beers and encouragement to the industry to make such beers available. It is difficult to get low-strength alcohol beers in this country. Men in particular like to stand up and drink at bars, and they like to drink large amounts. In Australia the availability of these beers has helped to reduce some of the problems experienced, and along with rigorous enforcement of random breath-testing has reduced much alcohol-related mortality. These may be ways in which we can progress.

Regarding Deputy Neville's query on café bars, in theory we believe they are not a bad idea, as eating and drinking together would change our culture. Unfortunately, we feel that in the absence of any other reforms in our drinking environment it would be more like deregulation. My son and his friends, who go out at night to drink large amounts of alcohol, stop to get a hamburger and pizza on the way. If we had café bars, many young people would stop for pizza and have a drink to get started. It would add to our problems. Over the years wine has been added to our menu of drink in this country but has not increased our overall drinking. Until we learn to change, and as other environmental supports are available to us, we are against café bars.

What is Dr. Bedford's view on the fact that the introduction of café bars has been parked for a while and the emphasis is now on opening up restaurant licensing to make alcohol more available in restaurants? Is that of help, or does it change the situation?

Dr. Bedford

In one sense the situation remains as it was. Alcohol is probably available in a greater number of restaurants. To return to what was already stated, we always seem to go for the options on the side of the main issue as opposed to really tackling the problem. People complain about taxation on alcohol and I understand it is difficult for politicians to say to the electorate that tax is to be increased. However, it must be viewed in the context of how much disposable money we now have.

When I was a student, if we could scramble enough money together on a Friday night for two or three pints, we were extremely happy. Now all of the children have part-time jobs, they receive pocket money and they do not have too much to do with that money. Research on young men in the mid-west two years ago showed they found life extremely difficult because they have everything such as money, freedom and sex but are worse off. Men find it hard to understand the situation they are in; they react badly and do not cope well.

I opposed the notion of café bars. Dr. Bedford's position is not to impose it, but that it could be examined it if all other safeguards were put in place and if we deal with under-age drinking, alcopops, binge drinking and change the culture. I do not know when that can happen but it is part of this sub-committee's remit. There is no evidence whatsoever to suggest that rushing the introduction of café bars and increased availability for the sake of being more European-minded would result in reducing our consumption of alcohol.

Dr. Bedford

We have never shown ourselves capable of changing our drinking culture. A major and simple test would be to measure drink-driving; more than 25% of men still admit to taking two pints or more and driving. Many do not consider that as drinking and driving, yet people are put at risk. The introduction of rigorous random breath-testing represented a measure of change in our culture and it has had other spin-offs. We nearly changed our driving culture with penalty points, which led to lower driving speeds and a reduction in accidents. However, as soon as we realised they were not being sufficiently enforced, we resumed speeding.

We now have an interpretation of binge drinking which suggests that six pints is only a taste. That notion should also be challenged. We need to lay proper foundations by defining binge drinking and its effects. A notion also exists that advertising does not encourage further drinking. I believe that it does and it is up to us to ask why, if there is no expectation of a return, so much is invested in advertising.

We must appreciate that alcohol is a socially accepted drug. It has been said that many people are not concerned with increases in the price of alcohol, as long as it does not become scarce. Alcopops have been unashamedly targeted at teenyboppers. I often wonder why the drinks industry pursues this objective. Many products are primarily aimed at young people. I know many publicans and they are, for the most part, responsible people. I take a drink but endeavour not to let the drink take me.

My question on the correlation between alcohol and suicide has been answered by Dr. Bedford and Dr. Farren. I accept what they said. I posed the question to Professor Malone to confirm what I already consider to be the case.

Drink problems are often kept secret. The refusal of a young person to admit that he or she has one or two alcoholic parents is in itself a tactic to allow that person to continue drinking. Whether through personal volition or as a result of a crisis, a point may be reached where action must be taken. Personal volition can itself be a defence. What role does Alateen play in terms of young people whose parents have drink problems?

When I took a course in alcoholic therapy, it was not working well as a branch of the support structure for people with drink problems. Has that improved? Suicide is a societal problem. Every member of society should form part of the therapeutic team.

I appreciate the Chairman's opposition to café bars. They do not have a role to play because we have a sufficient number of outlets.

There is a view that alcohol is contributing in a major way to street violence and unprovoked attacks. Perhaps we are digressing from the route but we must be very clear on this matter. Professor Malone, Dr. Bedford and Dr. Farren have stated that it is a mood-altering drug. There is no question about it. If it lowers the inhibitions of people who would not normally act in a particular way, it is reasonable to assume that it contributes, in no small way, to street violence and unprovoked attacks.

It is my experience that alcohol contributes in a major way to lost working days. We know what the problem is; what are we going to do about it? How do we implement a programme? Where do we start? What can the Government do that it is not doing? What can society in general and the drinks industry do? The drinks industry is a major player. I am not talking about publicans, but rather about those who are making the big bucks by producing alcopops, shots or whatever one wants to call them. They are not the smallest villains of the piece.

Ms Rickard

I will reply to the Alateen issue. As members are aware, Alcoholics Anonymous, Al-Anon and Alateen are guided by the 12 traditions, one of which states that in terms of setting up an Alateen group, one must have two Al-Anon facilitators who can give of their time in order to facilitate a group of children from 11 to 18 years old. My experience with Alateen over the years was that the time dedicated decreased in terms of people's availability to provide these groups. If the problem was identified in the family, namely, if "Dad" or "Mom" had a drinking problem, very perceptive parents who were willing to allow their children to attend were needed. The person could easily become involved in an Alateen group, which would increase his or her self-esteem, allow him or her to learn about alcohol problems and how to cope with the ongoing daily crisis that the drinking of his or her father or mother presented.

As members know, the complexity involved was significant. One of numerous problems was how the children would get access to Alateen. It is not necessarily something about which any of us can take action because it is guided by the 12 traditions, which we must honour. I, as an addiction counsellor, and we, as a service, are not able to interfere. We would try to refer the children of parents or spouses we were counselling to Alateen but we could not interfere in the process. This leaves us with a terrible gap for children. If the problem is not named, where can they go for help? If there were greater numbers of local, accessible services available to their parents, be it the drinker or the spouse, to access easily, perhaps the child would enter Alateen at a much earlier age. One must increase services for parents in a variety of different ways in order to help the Alateen children.

Dr. Bedford

I will address some points on absenteeism and other work-related issues and so will Dr. Farren. Alcohol abuse in this country costs industry over €1 billion. The total cost of alcohol problems here is approximately €2.65 billion.

Does Dr. Bedford mean €1 billion per year?

Dr. Bedford

Yes. The cost to industry in poor productivity and absenteeism is €1 billion according to the latest figures from 2003. Excise duties and VAT do not match the total cost of €2.65 billion. Industry pays a heavy price for a problem about which it has been too lax at times. People who are absent from work due to a "hard weekend" have been treated too leniently by many employers.

On the point made about café bars, I agree there are too many outlets. A person buying petrol can now be greeted with special offers such as two bottles of wine for the price of one, which is nearly cheaper than the petrol. The more outlets there are, the more visible alcohol becomes and the more likely people are to buy it. Alcohol Action Ireland believes there are too many outlets selling alcohol.

Large multinationals should not have a role in developing policy for a number of reasons. The CEO of Anheuser-Busch — the large American corporation which makes Budweiser — said in a speech to his shareholders that every single action taken by his management team was aimed at maximising shareholders' profits. The only way they make profits is by selling alcohol. No matter what else they did, that was their underlying aim.

The interim report of the strategic task force on alcohol, published in 2002, contained a minority report by the drinks industry in Ireland which could not accept the fundamental principle underlying the entire report, that we needed to reduce our overall consumption of alcohol if we were to reduce our problems. The drinks industry is at the opposite end of the spectrum. Its business is to sell alcohol. We understand this entirely.

Why is Alcohol Action Ireland not surprised?

Dr. Bedford

While I accept this is the drinks industry's business, it should not set our policies to reduce the harm caused.

The point I make is that because the drinks industry is part of the problem, it should be part of the solution.

Dr. Bedford

I accept that.

Dr. Farren

On the points made about young people and binge drinking, there is some evidence that drinking at an early age has a massive effect on the development of alcohol dependence later. One study shows that if a person starts drinking at the age of 13 years, he or she is four times more likely to become alcohol-dependent than if he or she starts drinking at the age of 19. Drinking at an early age is now an independent risk factor, with family history, in all the research on the development of alcohol-dependence. It is a massive issue. We will reap the debris of what is happening in Temple Bar in ten years time in our treatment centres.

A point was made about it being a secret problem, with which I agree. Drinking can be very visible but the problems associated with it are hidden. We see people drinking in pubs and they look happy but when they begin to develop problems such as suicidality or violence, they disappear from view. One does not see the people I see up and down the country. I see the people who have problems with alcohol and come in for treatment. The problems associated with drinking at an individual level are, therefore, hidden behind closed doors. The sociability associated with alcohol is very visible but the two parts go hand in hand. One cannot separate them because it all has to do with the negative effects of drinking.

At times, one wonders whether this should be called the joint committee on bad health, as opposed to health. There is a great onus on us——

In that case, whenever we move forward, we will come to the committee in good health.

I hope so. On the last point made by Dr. Farren in his presentation that we are not counterbalancing the aggressive media campaign conducted by alcohol companies, I assume a person active in sport at an early age in life has less chance of becoming dependent on alcohol. I am sure there is a clear link between being very fit and realising alcohol is not good for one's fitness levels. There is definitely an onus on us, as parliamentarians, to increase spending to encourage young people to take an active part in sport.

Someone mentioned low-strength beer. There is also an obvious point to be made about minerals. Why would one buy a mineral when one can buy a nice bottle of beer instead? There are simple practical solutions. Why can we not stop drinking, like our European colleagues who go for one or two drinks and stop? Why must the Irish keep going until they literally drop?

When I taught English to foreign students, I saw they could go to a pub, have one beer and then go home. I do not know why we cannot do this. Perhaps it is genetic, or nurture versus nature. Solving that problem would play a part in this process.

Dr. Farren

We are no more genetically predisposed to excessive drinking than many other races. Twenty years ago we went for two pints and stopped but young people do not do so now. The difference is not genetic in that the genes have not produced the great change of the past ten years. The environment has changed. It has been changed actively by the drinks industry and passively by anybody in a regulatory or enforcement position. Young people can drink from 5 p.m. until 10 p.m. and have 20 drinks for several reasons, including "happy hour", the promotion in the nightclub pushing a certain vodka or alcopop and the lack of regulation. They know they will not be stopped if they are 17 years of age. The pub will not be raided and they will not be asked to show identity cards. These factors, plus disposable income, lead to the 16 year old girl having seven, eight, ten or 12 alcopops. Twenty years ago she would have had one gin and tonic in the corner. The environment has changed dramatically.

Sport is a wonderful way to distract people from spending time drinking but it does not help if one goes to the rugby club on a Saturday night and sees significant quantities of alcohol being consumed. It is wonderful that the GAA has changed its attitude to sponsorship by alcohol companies. That is a significant positive step which we need to be distributed widely across all sports organisations. Why is there a Heineken Cup, or a Guinness stand in Lansdowne Road? All the associations need to be dropped.

Ms Rickard

I concur with Dr. Farren on all those points. When we see the picture of alcohol at the centre of society, we laugh. We are all tied into the imagery associated with alcohol and drunkenness. It acquires a positive aspect as we laugh at it. For example, broadcasters comment on having sore heads. It is in our language and deeply ingrained in our culture. People like us are accused of being anti-drink or killjoys. It is often difficult to speak about alcohol in the way we do.

All of Dr. Farren's points are true. We need to make those changes bit by bit but we also need leadership from politicians. Thousands of people came to our service from families where drinking was already an established problem. The culture was soaked in drink. I saw communities where drink was as normal as food. To help a person change his or her thinking and move away from this type of cultural soaking is extremely difficult.

We have been successful over 15 or 20 years in changing smoking habits. That happened because there was leadership and some NGOs were willing to stick their necks out. We hope Alcohol Action Ireland will not be alone but will be supported by politicians like the members of this committee. It may be politicians such as members of the committee — as one is already doing in respect of suicide — who take up the cause. It is a very long haul and, as Dr. Farren said, a huge area.

Dr. Bedford

Sport is extremely important and very good for everyone. It also receives saturation coverage on television nowadays. There is hardly a sports event that we can watch without an alcohol advertisement. The European championships are currently under way and every event starts with such an advertisement. Heineken Cup rugby will be starting soon. In France, such advertising is not allowed. Even the referee at a European rugby championship match will have Heineken written on the back of his shirt. In France, it is styled the "H Cup" because the authorities there will not allow the full name to be used. The French were the first to tackle smoking in car racing. Ireland signed up to the European Charter on Alcohol and one of the actions thereunder is breaking the link between sport and alcohol promotion. We have not yet done so.

Ms Rickard mentioned leadership. This is definitely an area where we need political leadership. In the newspapers at the weekend there was something about a pub being moved over to a museum in America.

In Ballyporeen.

Dr. Bedford

Yes. It reminded me that every time we have important visitors such as Reagan, Clinton or Gorbachev, they seem to be pictured at the Guinness brewery with a pint of Guinness in their hands. When one comes to Ireland, one has a pint. That is our culture.

Pint-scoring.

We thank the witnesses for attending. The sub-committee will continue to meet for a few months and intends to be proactive. I know the witnesses will concentrate for most of their presentations on the task force, rightly so. Let them not confine themselves to that, however, particularly if there are other issues about which they feel they need to talk to us. We will send out to them reports of other submissions and presentations so that they might track them too. They should feel free, before we end our hearings, to make another presentation or written submission.

As they said, there are huge areas for us to tackle. We are a new sub-committee starting out on this issue. We have already had an alcohol report and this is somewhat different, in that we are dealing with suicide and other issues. However, we see a clear link with alcohol. The witnesses' points are quite delicate in some regards. Increased taxation is a difficulty in the overall context. However, if we are to make any impression on reducing alcohol consumption, we will have to tackle that area too.

The witnesses may be aware that I have a background in the licensed trade. When I talk to publicans they make the point that they have no difficulty with reducing advertising. There are clearly two tiers in the industry, the ordinary public houses where one can look in and experience a happy mood and the larger type of pub that does not have a one-to-one relationship with its customers. There is not the same level of responsibility in the latter. Publicans have supported the "Drive Home Safe" campaign and they will also talk about under-age drinking. Those are only individual aspects. I also realise that the drinks industry being involved in the problems of alcohol can often be a guise for doing nothing at all; we must also be careful of that.

We will take note of everything that the witnesses have said and as we prepare the report we may have to contact them again. We are glad to have had them here today, and we thank them for an excellent presentation.

The sub-committee adjourned at 4.25 p.m. until 2 p.m. on Tuesday, 11 October 2005.

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