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A vision for better mental healthcare
[ by Niall Hunter, Editor www.irishhealth.com]
The director of one of the country's major psychiatry services has said high suicide rates and a rise in the number of referrals to mental health services are clear signs that the recession is taking a heavy toll on Ireland's mental health.
Prof Jim Lucey says it is important to note that many of those who take their own lives have not been accessing mental healthcare.
Dr Lucey, who is Medical Director of St Patrick's University Hospital, says there has undoubtedly been an increase in the suicide rate in the context of the recession.
While provisional suicide figures for 2010 have shown an 8% drop, this followed dramatic increases in 2008 and 2009. Recent statistics have shown that Ireland recorded one of the highest suicide rate increases in the EU between 2007 and 2009.
"There are experts who would argue that the suicide figures are still a substantial underestimate. You have had official figures in the high 400s to early 500s recently, but there are those who say the real figure could be near to 700 a year."
Prof Lucey says the increase in suicide has mainly been recorded among young men.
"What is notable is, and this has been our experience in St Patrick's, that the rise in suicide is largely not among people who are accessing mental health services but who clearly have mental health needs. As far as we can see, the suicide rate among those who access mental healthcare has not increased since the recession."
"You do not have to be diagnosed as mentally ill to take your life. However, we know that the vast majority of people who end their lives by suicide have suffered an extreme depressive or despairing episode."
"The numbers ending their lives has risen in recent years and in our experience, these are people who are not accessing mental health services, or else whose attendance at these services has been very recent and not satisfactory."
Recession and mental health
Dr Lucey says there is no doubt that referrals to the St Patrick's service have 'hugely increased' since the onset of Ireland's economic crisis. Attendance at St Patrick's day services has doubled in two years.
"What is important to know is that if you have mental health issues during these difficult times, attending a mental health service can protect you and help you."
"It's also important to know that mental health services work. People do get better, and this might not always have been the case in the past. The problems of people are complex and we can't solve life, or the recession, but we can provide health services that can help people."
Dr Lucey, who heads up what is Ireland's largest independent mental health service providers, is keen to put the message out that mental health services, which often have an negative image, are a force for good.
"We have certainly moved on. In 1959, the year I was born, two per cent of Ireland's population was in a mental hospital. Between every three counties there was an asylum with thousands of beds. That is no longer the case and that is a great achievement."
"Mental health services, I believe, are now committed to being open and accessible. St Patrick's, as an independent provider, is responsible for one-fifth of psychiatry in Ireland. But the role of the HSE must be acknowledged. I previously worked in the HSE mental health services and I would always stress the good work that they do."
"There are gaps of course, but they can be addressed by having a whole of health, whole of society, whole of Government approach. We are all in this together."
Dr Lucey says there is a need to present mental health services in a balanced and fair way in order to make the public aware that these services can be of quality, reasonable, accessible and fair. "They are open to criticism and comment and they are inspected. Overall, they are effective."
Asked if he believes there is, as in acute services, a two-tier public-private divide in mental healthcare, Dr Lucey agrees that it exists.
"Absolutely there is a two-tier system and this is something we in St Patrick's are very exercised by. We don't see ourselves as a 'private hospital' catering for one tier of patients. We want to be a national facility. We have been around for 250 years and we have made a contribution to care which we are proud of. We have had to put our own house in order... we are not being smug. We must constantly ensure our services are relevant. We are regularly inspected by the mental health services inspectorate."
Dr Lucey says St Patrick's is one of only four mental health centres in the country fully approved by the mental health inspectorate. In addition to treating insured/private patients, It also provides some services for the public sector on a needs basis.
With the current Government planning to change the way healthcare is delivered and paid for, he believes mental health services can be transformed into a one-tier system.
"I see the whole two-tier care debate as essentially something that's in the mind of other people. Yes, the bulk of people who access our service have bought insurance. But that isn't what defines how you operate. There is no reason why a State sector person cannot come here, but whether you are being paid by a state insurance scheme, or the VHI, ultimately it's the quality of the product that matters and the outcomes for patients. If we are to have a one-tier system, it should be a system based on outcomes."
Dr Lucey agrees that there is fat too much of an emphasis on medication in the context of treating mental illness.
"Yes, overmedication is a problem throughout the mental health system and it would be wrong to deny that. In St Patrick's, through simple measures, we have already dropped our use of sedatives and sleeping tablets (hypnotics/benzodiazepines) in a year by one-fifth."
This has been achieved through forbidding PRN ('as-needed') dosages of medication in hospital and through a requirement that a benzodiazepine review be incorporated into the care plan review by the multidiscplinary team treating the patient.
However, Dr Lucey points out that 60% of the people who come for treatment with the St Patrick's service for the first time are already on a benzodiazepine (tranquillizer). "Nationally, nine out of 10 people in an approved mental health treatment centre will be on a benzodiazepine-type drug."
Is that a terrible indictment of the system?
"No, I think the issue really is that these drugs are very widely prescribed. Also, they are culturally seen as a remedy when of course they are not really a remedy. They are culturally misunderstood and their use is often accompanied by alcohol use, which is also wrongly seen as a remedy for mental health problems."
In addition, he points out, overuse of medication is a by-product of having insufficiently available alternatives to drugs, such as counselling. "There is also a lack of focus on issues such as poor sleep hygiene and lack of exercise in terms of how we manage tension and anxiety. These remedies aren't promoted enough and this needs to be addressed."
While GPs are sometimes criticised for handing out too many psychiatric drugs, Dr Lucey said it is unfair to blame them as GPs are providing the bulk of mental healthcare in Ireland at the moment, and he believes it is right that GPs should deal with the bulk of mental illness problems.
"However, GPs are also faced with the issue of lack of therapeutic alternatives and cultural expectations that believe all remedies for insomnia and anxiety come out of a tablet."
He says to get people off medication where necessary, people need to be directed to alternative non-drug therapies.
Vision for Change
Dr Lucey, like many others in the mental health field, welcomed the 'Vision for Change' blueprint for the future development of mental healthcare published in 2005.
"It's obviously a positive thing to have an emphasis on the multidisciplinary approach to looking after patients, accessibility of services, an emphasis on community treatment and moving the emphasis away from hospitalisation."
"However, the delivery of Vision for Change came unstuck once the Celtic Tiger went asleep and resources dwindled. Those who believe in this vision now have to take a long hard look at practical ways of realising it, and everyone needs to look at how they can contribute and rise to the necessary standards."
"There is much debate on spending and lack of resourcing for mental health, but a key issue is that very little of the spending on mental health has traditionally been based on need. The spend has usually been greatest in areas where the old asylums used to be.
"People say it is a resource issue. I would say it is actually a resource allocation issue - dividing up the funding properly, governing the service properly and responding to people's needs. Spending on community services has tended to be concentrated mainly where the old asylums used to be, rather than being allocated where need is greatest."
Dr Lucey says Vision for Change was all about undoing and distributing resources in a needs-based way, but it did not have a financial strategy for achieving its aims.
He stresses that if Vision for Change is to be fully implemented 'we need to take a one-tier, whole society, whole nation approach to healthcare. I believe that in St Patrick's we have a model for a contibutor to such a system.'
With 600 staff, Dr Lucey points out that St Patrick's provides one fifth of the Irish national general psychiatry service.
"We are a not-for-profit hospital, and we return any income we generate into improving and developing our services."
"Our service has moved into the community, we have opened community clinics in Leinster and Cork and we are planning to open another in Galway. Currently, only about one-in-10 of the people we see actually comes to us in the St Patrick's main building in James's Street in Dublin."
"Mental health needs to be in the community and needs to be locally available and accessible. This is why we set up the clinics, known as the Dean clinics. These provide multidisciplinary care. You will see a psychiatrist but you will also see allied therapists and have your assessment as distant from a hospital setting as is possible."
He said he would hope, and would be confident that Minister Reilly's major plans for reforming healthcare provision and funding would be inclusive of mental health.
"The Minister is very aware of the public health benefits of maintaining good mental health. Five of the top 10 causes of disability are mental health issues. Of course it's got to be in there."
"We are offering our services to the nation because that is what our founder, Jonathan Swift, put us in a position to do."
|Anonymous Posted: 28/07/2011 11:37|
It seems to be a catch 22 - peope who are at risk and under severe stress due to financial strain will often delay getting help prescisely becuase of financial circumstances as it may be a chioce between 60 euro for a doctor + more for treatment or feeding their family for a week.
|MarthaMary Posted: 28/07/2011 17:00|
Glad to see that St. Patrick's is leading the way in getting away from an over-reliance on medication when dealing with people from all walks of life who for one reason or another find themselves in unbearable emotional distress. Thanks to people like the great Dr. Anthony Clare R.I.P. for helping to bring mental illness into the public arena. Mindful of the dreadful economic times we are living through, the area of mental health must be better funded if we are to make progress in helping people to recover and go on to lead fulfilling, productive lives.
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