JOINT COMMITTEE ON HEALTH AND CHILDREN (Sub-Committee on High Levels of Suicide in Irish Society) díospóireacht -
Tuesday, 18 Oct 2005

High Levels of Suicide: Presentations.

Chairman

I welcome Mr. Michael Egan of the organisation Living Links. He knows Deputy Neville. Senator Leyden and Deputy Connolly are also present. The other committee members will join us shortly. They are attending the Oireachtas Joint Committee on Justice, Equality, Defence and Law Reform.

I heard Mr. Egan speak in Leitrim last year and commend him on his speech that evening. We look forward to his presentation here. We are trying to assess the high levels of suicide on which we have heard advice from experts in recent weeks. The process will continue until the end of November.

Mr. Michael Egan

I thank the Chairman and the committee for inviting me here today and giving me the opportunity to speak on this area, particularly in regard to Living Links.

Some years ago in an effort to provide support to the suicide bereaved, Ms Mary Begley, the then suicide prevention officer with the then Mid-Western Health Board, and I conducted research. At the time I was a Garda sergeant attached to the Garda College, Templemore, County Tipperary; I am now retired. We conducted the research over an 18 month period. This entailed making personal contact with relatives and friends of the deceased and inquiring from them what their immediate requirements were following the suicide. We made contact with those who had been bereaved by suicide varying, in terms of time, from weeks to months to years following the death. We called to these people's homes, attended funerals and met the bereaved at conferences.

We discovered that within the first 12 to 14 months following the suicide, most people were in a state of confusion, experiencing multiple emotions such as anger, guilt, denial and suicidal thoughts. Friction within the family unit was often a major problem and some families became totally dysfunctional.

Families told of grief being at different levels within the family unit which led to accusations of "you have forgotten very quickly" or "you were always the selfish one". Circumstances such as these prevent conversation and prohibit the exploration of feelings. Even though help was available by way of suicide support groups, people rarely availed of this service. Reasons given by the bereaved included a fear of having to express their feelings in a "public" domain. Sometimes they were fearful of meeting members from their own community. Many of the bereaved would travel great distances to maintain anonymity.

Taking all these various issues into account it was decided to start a suicide outreach support programme, which would meet the requirements of the bereaved by suicide. With this in mind a group of people, who had experience in dealing with general bereavement, were approached and offered the opportunity to undertake a three-day training course specifically designed to develop support for those bereaved by suicide.

The training programme comprised formal lectures and workshops relating to the immediate needs of the bereaved, exploration of their own grief and how they had dealt with that, the role of the Garda and the Coroner's Court. This in turn led to the formation of Living Links in October 2002.

Outreach support became available in north Tipperary early in 2003 and is now available in County Clare, Limerick city and county, east Cork, County Meath, County Kerry, Galway city and county, County Wicklow and Dublin city and county. Trained volunteers are now available to offer confidential, practical support and advice to families who have experienced a death by suicide. At the request of the family, the suicide outreach support person can call to the home or meet at a location appointed by the family.

The outreach worker can provide information and practical support on the following — the funeral; the inquest; entitlements; what to say to children; how to deal with the neighbours; helping a person to clarify her or his personal grief; connecting the person to other support services in her or his area; and information on suicide and attempted suicide. Above all, he or she will be there as a friend for the person affected. The objectives of Living Links are to liaise and exchange information with similar support groups nationally and internationally; to support and encourage relevant research; to produce leaflets and associated literature to be provided to survivors; to liaise with families and provide them with information on health services available in the region, and the referral pathways to such services should such professional counselling be required; to provide and facilitate a group healing programme for the suicide bereaved; and to encourage the suicide bereaved and/or suicide affected to establish and foster an ongoing support group among themselves.

I do not have the information for the other Living Links groups, but since the formation of Living Links in north Tipperary we have received 168 contacts, either personally, through one of our volunteers, or by telephone. I am personally aware of 31 completed suicides. We have had 39 contacts with regard to the same completed suicide; 17 with regard to attempted suicides, including persons with suicide ideation; 24 completed suicides outside of north Tipperary; 19 inquiries regarding Living Links; and 38 inquiries relating to other issues, such as the Coroner's Court, the role of the Garda and issues surrounding Living Links. We are currently arranging a training programme for a further 15 volunteers which we hope to run in early January.

The establishment and continuing development of Living Links would not be possible without the generosity and support of Mr. Pat Brosnan, Ms. Bernie Carroll and their staff in the mid-west area of the Health Service Executive.

Deputy Neville

I welcome Mr. Egan to the committee. I know of his work in two areas. With regard to bereavement by suicide, the resulting trauma has long been recognised in its difference from trauma created by any other tragedy. Suicide creates many serious difficulties for the bereaved.

Mr. Egan might comment on how children can be dealt with when suicide occurs in a family. People often find it difficult to deal with children in such an eventuality. We know from Professor Michael Fitzgerald that children as young as six and seven years discuss suicide at their level. They do so because of its presence in today's world. What advice would Mr. Egan give to a parent whose partner has taken his or her life, or to a parent whose teenager has taken his or her life, a parent with young children? This is a very difficult area. Heretofore, such advice as that proffered by Mr. Egan, Console and others was not available, yet people remain unaware of its availability now.

I know Mr. Egan was formerly involved with training the Garda in this area. He might give us the value of his experiences in the Garda training college in terms of how to deal with suicide, and perhaps how improvements might be made in the area, because the Garda is one of the first three points of contact for those bereaved by suicide. The immediate family probably has contact with a priest, a doctor and the Garda. The Garda is often contacted very quickly. We have seen some excellent handling of suicide by gardaí but we also know of less than acceptable approaches, something we discussed recently.

Mr. Egan

Regarding children and family suicides, the old way was to exclude the children from what was happening. Adults who, as children, experienced a bereavement due to a normal sudden death say they were farmed out to relatives and friends where their imagination was far worse than the reality from which they were protected. For example, children found it difficult to relate the size of the deceased person to the size of a coffin and wondered how he or she could fit in such a small space. This has stayed with them for years.

Usually we advise the parents or surviving parent in a case of suicide not to exclude the children. One should let the children see it is natural to cry when a bereavement occurs, that crying is a healing process. One should answer children's questions using age-appropriate language. According to the late Dr. Michael Kelleher, children generally ask closed questions, to which the answer is usually "Yes" or "No". One should let them deal with one answer and come back with further questions if they wish.

In difficult situations we contact Barnardo's for advice. In some cases where there is a particular difficulty with a child, for example he or she has become abnormally aggressive or changed following the death, Barnardo's has contact with the family. We generally find that including children in the conversation helps them. We also advise that the child is informed of the death by a parent or person very close to him or her, ideally by somebody who will be in the house with the child in the early hours of the morning. We know about the 3 a.m. syndrome, when everything seems to go wrong. If the child wakes up, the person who broke the bad news is there to give comfort and answer questions.

With regard to the role of the Garda, one of the most difficult tasks anyone will ever face is breaking news of a sudden death, and when it is death by suicide it is extremely difficult. This requires particular skills. The late Dr. Kelleher suggested a good method. The gardaí, depending on how well known they are in the community, call to the house in uniform. This alerts the person that something terrible has happened. They initially say they are sorry they have bad news, then state the first name of the person who has died and his or her relationship to the person. Thereafter they let the person concerned ask questions rather than volunteering information. This is the initial stage of grieving, even though the person might not realise it at the time.

Most people are not aware of what is involved at the Coroner's Court. The mere mention of the word "court" is frightening because they have an image from television of a person on trial being cross-examined by barristers. Apart from learning the legislation surrounding the Coroners Act, gardaí must be trained to explain who is a coroner, how coroners are appointed, what is their background, that a coroner's inquest is not a trial, what a coroner is entitled to do, who is entitled to attend the court and why, and why inquests are held in public. If a garda has more information, he or she will be more confident when dealing with the bereaved and will be able to offer greater comfort.

Senator Glynn

I thank Mr. Egan for his remarks, which I was extremely interested to hear. I commend him on providing this beneficial service. He mentioned emotions such as anger, guilt, denial and suicidal thoughts. In my experience, I have discovered that close relatives and friends react with anger because they consider that the person was selfish in taking this course of action. They then feel guilt and ask themselves what they could have done. As I am sure that Mr. Egan has experience of people who have indulged in blame games, I ask him to speak to that issue.

On the issue of support and co-operation with Living Links — a name which I consider appropriate — what other agencies could be involved? Are organisations such as schools, the church or sporting organisations involved? Mr. Egan mentioned a number of locations in which services are available. However, these services are unavailable in many other parts of the island. What could be done by the Department of Health and Children, the Health Service Executive and other organisations including the Irish Association of Suicidology? I commend the latter on its pioneering work in this area. I am sure the media would also offer its help.

The services offered by Living Links, such as funerals, inquests and entitlements address the entire post-suicidal situation. It is a great service and I again commend Mr. Egan on it.

Mr. Egan

People from other counties have expressed an interest in forming Living Links support groups, including a group from Belfast which attended our last conference in County Armagh. We have several contacts but all face similar problems in terms of money. For example, it costs approximately €4,000 to train 15 people.

Senator Glynn

That is buttons.

Mr. Egan

We have acquired a premises in Nenagh. Living Links was formed in my former parish of Cloughjordan, County Tipperary and was named by the local parish priest. It is a good name because we want to link with the living and other support services. We would like support services to get the message that we are prepared to help rather than take over from them. When people contact us, we ask them the type of service they require and whether they would prefer one-to-one counselling or to attend support groups. We will arrange the appropriate service for them.

In regard to setting up the other groups, if we can accumulate sufficient money, we hope to be able to help those who are less well off than ourselves, even though we do not have much money. We would like to be able to encourage people to set up committees. All one requires in an area is approximately six dedicated people on a committee, who will identify people in need. We would insist they identify people in the locality who have experience of dealing with general bereavement. Therefore, it is just a matter of training them in suicide bereavement.

Senator Glynn

How is the organisation funded?

Mr. Egan

We are funded by the HSE mid-western area and sometimes receive donations. We purposely avoid having collections because we are fearful that the people who would donate the most would be those who are bereaved. For that reason, we do not approach them. Neither do we approach companies because, for example, the managing director might have been bereaved by suicide and might feel it incumbent on him or her to make a considerable contribution. The health board has looked after us very well. When we began in October 2002, we did not have money. We had to borrow money to pay for our first speaker. The health board subsequently provided funds for us within a short period, and has continued to do so.

The suicide resource officers, who have a prevention role, are inundated with work. However, they are prepared to work to set up groups such as Living Links. Others have done this throughout the country. I have no doubt that if people in a locality form a committee, they will be helped through the initial stages.

Deputy Neville

As this committee is drawing up a report for Government, what two or three actions should we recommend at the top of the list?

Chairman

I agree with the Deputy. That is exactly the reason we are here and I thank Mr. Egan for what he said. Our brief is to examine the high levels of suicide in Irish society and to establish the reasons for this problem. While I would like to ask Mr. Egan for his views, I do not want him to enter into areas he might not wish to go. Has he considered why there are high levels of suicide among the younger age groups — people in their late 20s to early 30s? He referred to the inquest in the Coroner's Court. How can we make the follow-up procedures more appropriate, caring and easy than is the case at present?

Deputy Neville

A Bill has been promised.

Chairman

I am sure the Deputy has some ideas on the matter in advance of the Bill. Members referred to how individual cases of suicide are covered in the media. First, how can we as a committee try to reduce the high levels of suicide and, second, how can we deal with the actual levels of suicide?

Mr. Egan

If I had been asked this question a week ago, I would not have been able to respond. However, last Sunday, we had a Living Links stand at a secondary school in Nenagh, among other stands, and the only people who spoke to us were either those who had been bereaved, people in the health service or people who were already providing support through Living Links or other groups. As people read the particular notices and saw the heading "suicide", their reaction was to quickly turn away from our stand. This highlighted that stigma still remains a big part of suicide. While I do not know how we can educate the public in the matter, we must try to find some way to destigmatise suicide. We have a gone a long way, particularly since the formation of the Irish Association of Suicidology in 1996 and other developments in the meantime. However, that is one of the greatest problems. A certain taboo surrounds suicide such that if one does not speak about it, it will not happen. Even in some cases, we get the impression that people think that if they do not read about it, it will not happen in their area or in their family. To destigmatise it is a major issue.

Chairman

What is the end product of dealing with and resolving the stigma surrounding 400 suicides a year? Let us assume there is a way to deal with the stigma. What would be its benefit? For example, would people be more open about suicide?

Mr. Egan

People would not be as afraid of it and would be prepared to speak about their feelings. However, side by side with that, we would have to change their attitude towards mental health. For example, we hear all too often that the person who died by suicide was the last person in the world one would have expected to do it. One then wonders whether there were underlying causes and if, in different circumstances, the person would have spoken to someone. I refer to people who have displayed certain anxieties among professionals. In one or two cases I asked the question directly, "Are you feeling suicidal?", which opened the gateway for people to speak about their feelings. Three people telephoned me who had a worry about someone else. When I delved into their concern, the someone else they were speaking about was the person himself. That has happened at least three times.

This goes back to an experience I had years ago when I was contacted by a member of the Garda who expressed a great worry about a friend of his and described the methods by which he and his colleagues were successful in preventing him from dying by suicide. The following morning he was found, having used the very method he had described. When people ring up and express a great anxiety about someone else, I ask the questions, "How are you? Have you suicidal feelings?" On three occasions I was told the person had. I knew those people very well and, thankfully, they are still alive. If someone approaches another person out of the blue and says he or she is feeling suicidal, it will terrify him or her and the person will not be given the opportunity to speak about how he or she feels. If people were given the opportunity to speak in a safe place and destigmatisation was addressed, however we go about it, it would help to reduce the incidence of suicide.

Edwin Shneidman, who is deemed to be the expert on suicide bereavement, says suicide post-sanction is suicide prevention for future generations. That is why we are hopeful that the help of Living Links, Suas, the Irish Association of Suicidology and other established groups following suicide bereavement will lead to a reduction in the incidence of completed suicide.

Senator Glynn

Mr. Egan illustrated how resourceful a person contemplating suicide can be and how he or she will make plans. He gave a textbook example, which I have come across. Is the funding available to the group adequate for its work or does it require more?

Mr. Egan

We would love more.

Senator Glynn

Earlier I referred to the church, schools and sports organisations. What role are they playing in your organisation and in sister organisations associated with suicidology?

Mr. Egan

With regard to Living Links in north Tipperary, one of the parish priests is involved. A number of suicides have taken place in his parish. His celebration of mass is excellent and priests are usually among the first to respond. The same is true of doctors but both groups need further training.

As Deputy Neville stated, some people are good and some are bad in this situation. Sometimes the bad are there because they do not know what to do. They are bad through ignorance and I mean that kindly as they cannot be blamed for doing something if they do not know what to do. I do not know whether general practitioners are trained to cope with suicide bereavement. There are conflicting reports on this in the media, some say they are, others say not. I do not think the clergy are trained in dealing with suicide bereavement. There is some process for the gardaí but I am not sure what it involves.

The first responders should certainly have specific training in that area, for their own good as well as that of the bereaved. This is particularly true of the clergy who at the funeral service must praise the person who has died, yet dissociate that person from the act he or she has carried out. That is extremely difficult because it is possible for the priest to be accused of glorification of the act or the person. The danger is that someone listening may think death by suicide is a way to get his or her name in lights. Everyone, including perhaps the public, should be better educated about suicide.

Chairman

I thank Mr. Egan for coming before the committee. We are hearing from many groups and will prepare a report for November. I am not sure how well Living Links is funded. I ask Mr. Egan and his group to consider making a written submission to us as to how we might deal with the stigma attached to suicide, and more important, to focus on the practical benefits of removing that stigma.

Sitting suspended at 2.45 p.m. and resumed at 3.05 p.m.

Chairman

Apologies for the delay. We had a cancellation and because of that we got into some difficulty in terms of time. I welcome Mr. Fran Gleeson, regional co-ordinator, and Ms Sandra Hogan, public relations officer, from Aware to the meeting. I will ask them to commence their presentation shortly. Senators Browne and Glynn are with us. Deputies Neville and O'Connor will join us shortly.

We have had hearings in the past few weeks, which will run up to the end of November, dealing with the high levels of suicide in this country. We are in the business of preparing a report for Government on how we hope we can deal with those high levels and offering solutions based on the presentations we hear during the course of our deliberations.

Mr. Fran Gleeson

Thank you, Chairman. We are grateful for the opportunity to express our views and concerns to the sub-committee today. To give some information about Aware, we have 20 years experience helping those affected by depression and their families. Our objectives are threefold — to help those with experience of depression by providing support groups, a helpline service and factual information about the illness; to foster an increased public awareness of the nature and extent of depression and mood disorder; and to promote research into the causes and effects of mood disorder.

Aware sees its services as being ancillary to the standard treatments currently available for mood disorder. Those services include the provision of over 50 support groups nationwide, a helpline service that is available from 10 a.m. to 1 a.m. seven days a week, a depression awareness educational programme called Beat the Blues for post-primary schools, a free information service and a depression research unit. Aware is also a member of GAMIAN Europe, a European alliance of patient-driven federations of 88 national organisations across 32 European countries supporting people affected by mental illness.

Research has shown that only 50% of those with depression seek appropriate treatment. A likely factor in that is the public perception that depression is not a real illness but a sign of weakness and that those who claim to suffer with it need only pull themselves together. That perception fails to create the necessary climate of support for the individual with the illness and dissuades him or her from seeking available treatment. The negative effect of the illness on the individual's thought process and motivation renders the sufferer weak and culpable in feeling as he or she does. That serves only to hamper his or her access to treatment.

Studies have also shown that psychiatric disorders, usually depression, or an intoxicant problem is present in 90% of people who take their own lives. Aware considers, therefore, that a greater awareness of depression and its effects, coupled with a heightened sensitivity to recognising depression in oneself or a loved one, is crucial in helping to reduce the number of people who die by suicide. To that end, we recommend a concerted and well resourced awareness education campaign directed at the general public and second level schools.

The provision of factual information is of extreme importance in raising awareness of depression among the general public. Its importance lies in correcting misinformation about the illness, its causes, effects and treatments. There is a need to differentiate between what might be described as everyday depression, normal low mood experienced by everybody from time to time, and depression, a recognised illness that is more prolonged and severe than these everyday feelings of upset and unhappiness. The message is that depression is an illness like any other illness and it can be treated.

Aware recommends a campaign to educate the general public about depression recognition, encourage early detection and treatment and inform it of available means of treatment. That would create a less stigmatising culture for those with depression, more conducive to the sufferer seeking appropriate help. Aware recommends that such a campaign be afforded similar scope and resources to those conducted to tackle road accidents, which claim fewer lives than suicide annually. Aware considers it extremely important that an educational programme focusing on depression recognition and positive mental health be made part of the social, personal and health programme in second level schools. Aware is currently the only voluntary organisation in Europe whose staff provide an on-site dedicated depression awareness programme for schools. Education and general coping skills training would have a beneficial effect on the potential for suicide and depression.

Depression affects society generally, with implications for the economy, social welfare, employment and housing. It poses a risk to physical health, family life and relationships. Consequently, Aware suggests responsibility for such a two-pronged educational campaign lies not only with the Department of Health and Children but also with the Department of Education and Science and others. Other relevant factors concerning suicide and depression also need consideration. Research data indicate a domino effect of three components, the first being depression and related disorders. Many have a recognisable psychiatric disorder at the time of their suicide attempt. The second is traumatic losses in life, while the third is the depressing effect of alcohol abuse or illicit drug use. Recent research commissioned by Aware shows alcohol consumption and suicide rates increased in parallel by 40% in the ten-year period from 1993 to 2003.

With the increasing mental distress experienced as this chain of factors unfolds, individuals' thinking becomes restricted and predominantly negative, preventing them seeing solutions to their problems. A binge pattern of drinking can also lead to disinhibition and a sharp drop in mood. It is at that stage that suicide is seen as a meaningful alternative. At-risk groups are young men, those isolated or living alone, those with a history of depression, those without a supportive relationship, those without religious beliefs, those with poor problem-solving ability, the unemployed and those who feel alienated from society. These are the areas that require attention when considering future suicide prevention strategies. Aware suggests any educational campaign must target those segments of the population and those who may have less well informed attitudes to depression, for example, single young men, those over 65 years of age and members of the farming community.

While suicide is the principal cause of death for men in the 15 to 35 year age group, with 100 attempts for every completed suicide, it should be remembered that those in the over-75 age group are also at risk, with one completed suicide for every two attempts. We also recommend increased public awareness of suicide as an issue for the elderly, while emphasising that depression in old age is not inevitable.

Regarding support and treatment, discussions concerning the treatment of depression regularly focus on the efficacy of psychotherapy versus that of medication. Such polarisation must be avoided, as the individual requires a combination of the two to be treated effectively. However, the misconception that anti-depressant medication is addictive and simply a stop-gap solution must be addressed and overcome. Psychotherapy, on the other hand, urgently requires more qualified personnel. While accessing counselling appears to be more acceptable publicly than medical treatment, it remains an ill-afforded luxury for many, and means a lengthy and distressing wait for those availing of it free from the health service.

An extremely important aspect of privately provided psychotherapeutic services is regulation. Aware considers the lack of a regulatory body to be very worrying and dangerous; the absence leaves vulnerable persons open to exploitation. Primary care practitioners have been identified as a potential point of assessment and management for those at risk of suicide. Some 84% of Irish people, when asked directly whether they would seek help from their GP if they suffered from depression, stated they would do so. Aware's depression awareness and recognition campaigns have highlighted general practice as a source of treatment. We recommend initiatives to improve frequency of use of general practice facilities for those suffering from depression and a user-friendly out-of-hours link with specialist mental health care services.

Support groups such as those provided by Aware allow people experiencing depression to come together in order that through identifying with other sufferers, they can support and be supported by each other. The efficacy of such ancillary services provided by voluntary organisations must be recognised, promoted and supported financially through core funding. Research has shown such groups to be cost effective, aiding compliance with medication and helping individuals avoid relapse.

Given the complexity of suicide and the frequency of contact with family, friends and school or work colleagues, it is essential that all members of society are encouraged to play their part in determining a successful suicide prevention programme. Aware suggests each agency identified as having a role in suicide prevention must be directed and assisted in its responsibilities. In assessing need Aware considers it important initially to support and resource established initiatives, for example, existing educational programmes, helplines or support groups, that can be assessed and their effectiveness measured. This avoids duplication and fragmentation of personnel and financial resources and allows for a more co-ordinated and comprehensive approach to suicide prevention. In establishing new initiatives to meet unmet needs Aware considers the use of expertise, experience and the views of service user groups as of paramount importance in planning and delivering services.

We are grateful for the opportunity to address the committee and thank the Chairman for the invitation.

Senator Glynn

I thank Mr. Gleeson for his presentation and commend the work done by his organisation in providing such a tremendous service. He referred to studies which show that psychiatric disorders, usually depression or an intoxicant problem, are present in 90% of people who take their own lives. There is a gathering view that alcohol plays a significant role in suicide. The counter argument, however, is that people have been drinking alcohol here and elsewhere for a long time. Why is it suddenly such a problem? Does Mr. Gleeson agree that in many suicide cases people have taken other substances apart from alcohol, including illegal drugs? Has he found that the combined ingestion of illegal substances and alcohol is a significant component of the suicide statistics?

Mr. Gleeson

The Senator makes a fair point. I mentioned the domino effect in regard to suicide, part of which relates to the misuse of illicit drugs and alcohol. The Senator is correct in his observation that people have been drinking alcohol for many years. However, the pattern of drinking seems to have changed in that there is an increasing number — young people in particular — who binge drink. The effect of binge drinking on a person's mood can be dramatic. The associated dip in mood may be even more significant if the drinker is in a low mood to begin with, perhaps as a consequence of either diagnosed or undiagnosed depression. I agree with the Senator's point. It is difficult to quantify illicit drug use, particularly in conjunction with alcohol. The pattern of drinking has also changed. It is worrying that young people tend to be binge drinkers, which might not have been the case years ago.

Senator Glynn

As a society, we should intensify our activities to prevent the distribution and use of illegal drugs. I know one young person in my home town who does not have a problem if he takes a drink during the week, but who does have a problem at weekends when the suspicion is that he is taking something else with the alcohol. I am glad Mr. Gleeson confirmed what is generally known.

Mr. Gleeson

An attitudinal shift in society is needed. Some feel certain classes of drugs are all right. However, they fail to realise the effect they have on people's moods. That effect is increased when coupled with alcohol.

Deputy Neville

I welcome Mr. Gleeson to the meeting. In his paper he devotes a lot of time to the issue of awareness, which is vitally important. A study last year in Kildare showed that most suicides among young men were as a result of undiagnosed depression. People do not realise they are suffering from a depressive illness which requires intervention. I often quote Patricia Casey who said that if one intervened at an early stage of depression, there was a 90% chance of a cure and that it would not recur. An awareness campaign is important. Suicide and psychiatric illness must be destigmatised in order that people do not face barriers when seeking help. They must not feel they are labelled if they visit a psychotherapist, counsellor or psychiatrist. Sometimes people label themselves for life. It is important Mr. Gleeson raised that issue.

As regards the provision of resources, what is Mr. Gleeson's view of the level of services provided by multi-disciplinary teams? What is his view on medication versus psychotherapy? Both have a role to play. Psychiatrists are extremely busy. Some have 400 to 600 patients, but they do not have a counsellor or psychotherapist available to them. They have little choice in dealing with someone with an illness. A recent report by the Irish College of Psychiatry highlighted the fact that child and adolescent psychiatric services were underfunded. It is a vital area. While we must raise the level of awareness, we must also provide the appropriate services. The provision of services in health centres in communities can raise awareness of the problem. There is a vast amount of work to be done. How would Mr. Gleeson approach this? What three things would Mr. Gleeson recommend that this sub-committee should prioritise in its report to the Government?

Mr. Gleeson

The Deputy's point is valid. We tried to include in the presentation the fact that awareness and resources go hand in hand. As the Deputy said, if there is an educational programme of awareness and we try to make people aware of depression, the resources must be available for people when they are encouraged to be treated. They work in tandem. One cannot have one without the other because one generates the other.

A child and adolescent psychiatrist told me recently that there were approximately 15 multidisciplinary teams in child and adolescent psychiatry, although the recommended and internationally acceptable number is 49. Research suggests 10% of children suffer from depression after puberty but he thinks this is an underestimate and that the true figure is probably 20%.

As we pointed out in a previous submission on mental health issues, there has been a shift in attitudes. Depression is an illness and those who have it are stigmatised, often by themselves. They are a silent minority because that is how the illness may affect them.

Deputy Neville has pointed out that while €22 million is spent per year to prevent road traffic accidents, in the region of €600,000 is spent on suicide prevention measures. While road safety is an important issue and the number of young lives lost in that way, even recently, is serious, the comparison with the level of expenditure on suicide prevention measures shows the gap in resources. This is a serious issue which will not go away unless we do something about it. If we are determined to deal with it, we must be prepared to spend money on it. Otherwise, there will be numerous reports sitting on shelves which will have no effect on people's lives. We need increased resources for the recognition of depression, primary health care and child and adolescent psychiatry services. It is also important to adopt a positive approach to mental health in the school curriculum. Ours is the only voluntary organisation in Europe which brings an education programme to schools. While that is laudable from Aware's point of view, it indicates the lack of such a programme as part of the school curriculum.

It is important to enable the young to grow up in a society that is less apt to stigmatise than the one in which we grew up. Mental illness should be seen as just another illness in the range of illnesses, physical and mental, from which any of us can suffer. While more are prepared to admit to undergoing counselling or psychotherapy, which is good, we must address the imbalance because counselling is not always the answer. The right approach to dealing with depression is often a combination of medication and counselling.

Aware finds the lack of a regulatory authority in training counsellors worrying. This is not intended as a criticism of those who give of their time to undertake these courses but we would like something done about regulation.

Deputy Neville

We are discussing that matter in the context of the Health Professionals Registration Bill but the Minister wants the four bodies involved to get together to agree because there can be only one unified body for recognition. The four existing bodies are competing for space.

Senator Browne

There is a clear pattern in the timing of road accidents. Are there similar data available for suicide? For example, weekends and early morning are the key times for road accidents. If there is a pattern for suicide, could we develop a media campaign focused on those times?

At recent meetings we have discussed the connection between alcohol and depression which, in turn, leads people to commit, or attempt to commit, suicide. Are we missing the basic point of why people are drinking such volumes of alcohol in the first place? Are we skipping ahead? Is that a bigger issue at which we should look, or is it beyond our control? I know that Aware is part of GAMIAN, the Global Alliance of Mental Illness Advocacy Networks. What countries would it recommend this committee study in this regard? What countries have best practice?

I presume that the issue of waiting times to see psychiatrists, counselling services or psychotherapists is a major one. Even when people get the courage to seek help, the waiting times are so long that they might contribute to people committing suicide. We are told we should have 49 child psychologists but have only 15. Clearly this has a major knock-on effect in terms of waiting times.

Mr. Gleeson

Regarding the first point, some studies have shown that "at risk" periods tend to be early morning and weekends, which may correlate to the use of alcohol. Many of the services for mental health would be available to people only from 9 a.m. to 5 p.m., which is clearly inadequate, especially if, as some of the figures suggest, more suicides occur in the early hours of the morning, particularly at weekends. There is a need to look at the provision of out-of-hours services in accident and emergency units or in care-doc facilities around the country.

The Senator's point about why people drink and abuse alcohol is valid. I do not want to sound like a cracked record but it is quite fundamental — as a society we do not grasp it — that depression, when it presents in people, does not always manifest as a person experiencing low mood. Depression is a very physical illness and because we cannot separate our heads from our bodies it will often appear that way. A person can be depressed without realising it. That mood can lead to self-medication with alcohol, which in turn makes the person more depressed. Often, people are depressed without realising it, and then they use alcohol. People around them do not realise the fact either, because we are not good at depression recognition.

Regarding our involvement in GAMIAN, it is my experience that — being a little positive — in terms of what we do as a voluntary organisation, we are a little ahead of some other such organisations in Europe. However, in terms of mental health services and particularly the reduction in the suicide rate, Finland and, outside Europe, Australia, would be countries worth looking at. Their services and provision thereof would certainly be worth looking at.

Waiting times, particularly for child and adolescent psychiatry, are a problem. When someone is facing a crisis, a wait of six weeks for an appointment is not acceptable.

Senator Browne

Has Aware any statistics on waiting times?

Mr. Gleeson

I only have anecdotal evidence but I can probably get the statistics. Anecdotally, I have heard of young people in crisis, and the waiting time to see a psychiatrist would be six weeks.

Deputy Neville

In regard to helping families of the depressed I have noted two issues and would like the deputation's views. Some families are concerned about the discharge from psychiatric hospitals of suicidal patients. Too often, families are deeply upset that in their view the person being discharged continues to be suicidal, with a high risk of suicide. Too often, we attend funerals of such people. Some services will say they are under-resourced and ask what they can do. This is a serious issue for many families with members who have particularly persistent suicidal ideation.

Another issue is the refusal by psychiatrists to discuss a patient's condition with his or her family. Psychiatrists have mixed views on this. Psychiatrists in Ireland say they cannot break patient confidentiality. In a public lecture, Professor Michael Fitzgerald said the most important thing is to save the life. If talking to the family saves a life, it should be done. This is the approach in America. Concerned families with whom a psychiatrist refuses to have any discussion become very upset. This is too prevalent in Ireland. Psychiatrists may not have asked their patients' permission to keep information from their families. It is often the case that they just do not want to provide it. Is Mr. Gleeson familiar with these two issues?

Mr. Gleeson

Yes, although I am probably more familiar with the second because, given that Aware deals with deals with people who have been discharged from hospital, many of our clients are treated in the community or by general practice. The issue of a refusal to talk to family members often arises. We published a booklet for family members a number of years ago stressing the importance of their being part of the management team of a person's illness.

Deputy Neville

Could a copy be provided for the sub-committee?

Mr. Gleeson

Yes, I will send one. Our founder and medical adviser, Professor Patrick McKeon, said at a lecture that it is dangerous for a psychiatrist not to involve a family member or a key carer. It is important for a psychiatrist managing the person's depression to know what the person is like at home. Therefore, it is important to listen to the family member as well as inform him or her of the way the illness presents in the patient. Aware encourages family members to contact the doctor. There is an issue of confidentiality but that does not preclude a person from contacting a psychiatrist and giving information about the patient's behaviour at home.

Deputy Neville

Either the psychiatrists are too busy or they are not tuned in to involving the family. In general medicine, I have rarely heard of a consultant not prepared to discuss a patient's illness with a family member. There is a reasonable freedom of information, which is positive. Nobody has a problem with it, including the patients. Why is there this barrier in Irish psychiatry? When a patient is sent to a psychiatrist in America, the family is immediately involved as part of a team effort to overcome the illness. Mr. Gleeson has experience of this.

Mr. Gleeson

The nature of depression, as opposed to a physical illness, makes it more difficult. Consultants dealing with physical illnesses inform families about treatments, whereas with psychiatry the confidentiality aspect is more complex. With the multidisciplinary team approach in the USA, it is taken for granted that one is dealing with a team which has access to the patient and which can deal with family members in a broader approach. I hope that having more multidisciplinary teams in Irish psychiatry will foster increased openness on the psychiatrist's part to involve family members.

Deputy Neville

Some psychiatrists are effective at doing so, even if that is not true in every instance.

Mr. Gleeson

That is important. It is also important that family members appreciate their input in treatment. We often find that family members are passive and leave it to the psychiatrist to address the matter. They do not realise that they also have a role to play in providing information to psychiatrists, who are willing to listen, and by giving support to patients newly discharged from hospital.

Deputy Fitzpatrick

Perhaps part of the answer to Deputy Neville's question is that psychiatrists are legally constrained in their actions. This is the only branch of medicine in Ireland where law and medicine have equal importance. In some cases, the psychiatrist may take away a person's freedom of movement. It is necessary to exercise care.

When treating people with psychiatric illnesses, it is important to have as much background information as possible. Mr. Gleeson's suggestion of multidisciplinary teams may break down these barriers in the future. Is it Mr. Gleeson's experience that waiting times vary across Ireland for urgent appointments in cases of sudden onset of psychiatric illness and for appointments with psychiatrists?

Is the relationship between alcohol and depression unique to Ireland or is it common across Europe? Other countries have higher alcohol intakes per head of adult population than Ireland but have different drinking patterns. They do not have the under age or binge drinking cultures that we appear to be developing.

Chairman

While Mr. Gleeson referred to older age groups, we regularly hear about the high incidence among those aged 15 to 35. Do other countries with high suicide rates also experience this problem? Why is there such a high incidence among that age group?

Senator Browne

Mr. Gleeson discussed the targeting of specific groups. One such obvious group comprises non-nationals. It may be imagined that an immigrant from Poland or further afield may experience isolation upon discovering that the reality of a strange country varies from his or her expectations. Does Aware make any special efforts to target such people, has it experienced an increase in calls from them and is it in a position to help?

Mr. Gleeson

From my experience in the south east, I have anecdotal knowledge of varying waiting times. People in one part of the country may wait a number of weeks for an appointment, while those in another may be seen earlier. Follow-on services such as psychotherapy or counselling may be accessed quickly in some areas but may require a long wait in others because the availability of therapists varies. I have forgotten the question on the relationship between alcohol and depression.

Deputy Fitzpatrick

Is the relationship between alcohol and depression unique to Ireland?

Mr. Gleeson

It is.

Deputy Fitzpatrick

Other European countries do not face this problem, even though alcohol intakes there may be higher per head of population. While statistics can be bandied about, we appear to have a unique drinking culture. Many of our people appear to consume a large number of drinks in a short period, whereas many people in other European countries, particularly those to the south, space their alcohol consumption over a longer period. I do not know if the correlation between alcohol intake and depression that is found here is also found in France, Italy, Spain or Portugal.

Mr. Gleeson

I am not sure about that. I know that the incidence of depression would be pretty much the same across Europe, although that does not take account of the incidence of seasonal affective disorder which is more prevalent in northern Europe than it is in the south. A key factor in this context, as the Senator mentioned, is our pattern of drinking. People in other European countries have a steadier alcohol consumption rate and consume as much, if not more, alcohol than we do.

Senator Browne

Mr. Gleeson might reply to my query relating to non-nationals.

Mr. Gleeson

Our support groups tend not to receive calls from non-nationals, which is probably due to the language barrier. I recently attended a conference held by the Chinese Mental Health Association in the UK from which I brought home literature in Chinese. There is a large Chinese population in the UK as there is here. While our priorities tend to relate to personnel and financial resources, the making available of such literature is something we would consider in the future. The voluntary sector and the services sector need to consider the provision of such material because of the increasing number of non-nationals living here. As Senator Browne correctly pointed out, isolation is a factor in the incidence of suicide. Isolation and social exclusion are factors affecting elderly people in rural communities. I neglected to mention non-nationals because such people have not really been in contact with us.

Deputy Neville

Does Mr. Gleeson think that exam pressure can cause a person to commit suicide?

Mr. Gleeson

I do not think that exam pressure alone can cause a person to do that. In the past, people did not speak about their appointments with counsellors or psychotherapists but now it is more acceptable and that is a healthy development. However, there is a tendency to go to the other extreme, where people feel they must have counselling services and helplines in place to deal with every event that happens in their lives. That would be a mistake because it would prevent people from developing coping skills. We need to be balanced and to adopt a common sense approach that allows people, when faced with difficulties, to develop coping skills to deal with them. In the event, however, that they have difficulty coping, we should provide support through counselling and other services. There is a difference in that regard which I pointed out in my presentation. There is a difference between the ordinary ups and downs we experience in life and depression, the clinical illness that is more severe and prolonged. I do not believe exam pressure alone would cause a person to commit suicide. If, however, it were part of a package of factors, including loss, alcohol and depression, it could do so.

Chairman

Are we unique in having such a high incidence of suicide among those in the 15 to 35 age category?

Mr. Gleeson

The high incidence of suicide in that young age group tends to be universal. I referred to primary care services, including attending general practitioners. A factor is that young men in particular do not tend to seek treatment for depression. Statistics show that twice as many women as men suffer from depression but there is a school of thought that claims that such statistics are based on the fact that women who are depressed seek treatment while men who are depressed are more reluctant to do so. Some people are of the view that depression is equally divided across gender and that as many men as women suffer from depression. However, the statistics show a high level of depression among women because they are more likely than men to seek treatment. Depression, therefore, is a major problem for young men who suffer from it.

Chairman

I thank Mr. Gleeson and Ms Sandra Hogan for their presentation. The presentation by Aware will become part of our report to the Government. We will meet various groups in the next few weeks. On behalf of members, I thank Mr. Gleeson and Ms Hogan for coming before the sub-committee today.

The sub-committee adjourned at 3.50 p.m. until 2 p.m. on Tuesday, 25 October 2005.