Refer to where? Mental health and the dilemma facing professionals

Citizens are encouraged to talk and to seek help for mental health. When they do, they need to get it. Recently, a national 24-hour mental health phone line was launched. While such initiatives are a welcome support for those in difficulty, there is urgent action needed for those in crisis.

Such vulnerable people are often unaware they are becoming unwell, or entering a psychotic or manic episode. Families, friends and professionals are on high alert and desperate for urgent help when someone is feeling suicidal, has made a suicide attempt, self-harmed or is in the midst of a psychotic episode. This is even more complicated when out of hours.

If someone is having a heart attack, the ambulance is called, the person is assessed as a priority, treated in hospital and followed up with outpatient care. It is treated as a life or death situation. It would be shocking and considered medically negligent if the patient was told to see their GP, placed on a waiting list for a cardiologist, or be allowed home without after care.

Yet if someone is in an acute psychiatric phase, many professionals face a “refer to where?” dilemma. GPs, other professionals and myself included, have had suicidal patients presenting to us with nowhere to go to. Accessing an urgent psychiatric evaluation may take days or weeks. If admission is deemed necessary, it may be hit or miss whether a bed is available in a psychiatric hospital. Such hospitals do not operate walk-in assessment units. Families may be left at home to cope with loved ones severely ill. It is distressing trying to care for those experiencing paranoid delusions, hallucinations, disturbed thoughts or being out of contact with reality. For some, being at home may be more appropriate, but they need regular monitoring and intervention. People often end up at A&E seeking help, but this is not an appropriate environment for someone who is spiralling out of control. That is like sending someone having a heart attack to run around in a gym.

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Long-term neglect

Following suicide attempts or engagement in self-harming behaviours, people are assessed, then often sent home to wait on follow-up. A young person I was working with in such a situation had to wait a couple of months to be linked into psychiatric services post discharge from A&E. That wait involved family and friends being on watch, taking time off work, arranging rotas and cancelling holidays and events. Recently, a GP and I struggled to access a psychiatric evaluation for a patient in crisis. Both private and public options involve a waiting period. These people cannot wait for assessment, intervention or admission. It can be a matter of life or death, or deterioration resulting in inpatient care for months.

Consultant psychiatrists have asserted that patients on waiting lists become more unwell. Mental health can deteriorate rapidly if untreated. Dr Susan Finnerty, inspector of mental health services, has blamed the long-term neglect of people with severe mental illness on "revolving door" admissions. Intervention needs to incorporate quick access and appropriate treatment. Progress has been made with A Vision for Change and the HSE's 2020 National Service Plan, but specialist and in-patient services are still under resourced. Paul Gilligan, chief executive of St Patrick's Mental Health Services proposed that highly specialised services for children and adults should be established. As with medical emergencies, psychiatric and psychological emergency services are needed. Dedicated emergency mental health units could be introduced and more home visits by professionals made available.

According to Mental Health Europe’s report, 90 per cent of mental health difficulties are handled in the primary healthcare system, but there is a lack of specialised knowledge with long waiting lists. There are significant differences between mental health issues treated in primary care and in specialised mental health services. It is unfair and unrealistic to assume GPs can handle it all. Due to time restrictions and other factors, thorough assessment and diagnosis is problematic in the local surgery. While the expansion of primary care counselling services is positive progress, it does not facilitate those in crisis or who do not have medical cards.

Hugh-risk categories

According to a report by the College of Psychiatrists of Ireland, there have been increased demands on psychiatrists. Recruitment, training and retaining psychiatrists has been problematic. Mr John Saunders of the Mental Health Commission has flagged recruitment and staffing issues, as well as the need for high levels of training. We also have a high level of alcohol misuse in this country but there is often a lack of collaboration between addiction and psychiatric services. And what about mentally unwell homeless people? Others in crisis have ended up in prisons, and children placed in adult units. As is evident, the issues involve not only funding to develop structured and uniformed rapid access and intervention for those in high-risk categories.

Individuals in crisis need to be treated by professionals who have expertise in the biological, social and psychological model. Evidence based interventions and psychoeducation are needed daily until the crisis phase subsides. Empathy, trust, kindness and care are also factors fundamental to recovery. Public and private patients report different experiences. Collaboration could be implemented between public and private psychiatric and psychological services in each area. Health insurance companies need to provide cover for all accredited or registered therapeutic interventions.

Inpatients and outpatients do not always receive any counselling, and may not even fully understand their diagnoses. Recovery and relapse prevention is limited, with families feeling helpless when loved ones are discharged with no specific rehabilitation plans. Reform of the mental health system has come some way but acceleration beyond programmes, research and reports is essential. Action plans informed by service users and those on the frontline need to be implemented. It is also every community’s responsibility to develop creative ways to support those in crisis and to know mental health first aid. Churches, schools and local clubs can all play their parts. Mental health programmes need to be rolled out in every primary school.

In Limerick, the Haven Hub has been launched integrating all services to offer after-hours compassionate support and suicide prevention. Suicide patrol teams bring people in distress away from the river to a safe environment. Organisations such as Pieta House also help people in crisis. Everyone wants positive change for the most vulnerable in society.

If you or someone close to you is in crisis, it needs to be clear as to what to do and where to go in every part of the country. Rapid access and appropriate intervention is a human right.

HSE Your Mental Health 24-hour mental health phone line: 1800 111 888. Pieta House: 1800 247 247. The Samaritans: 116 123.