MIND MOVES'Insanity is quite different from physical illness, and quite unlike normal behaviour. It is generally caused by poor heredity, or by drink, or possibly by starvation. Insane people should be sent to asylums, and most of them will have to stay there for life. Special authorities should be set up for the running of asylums, under strong central control. Patients have to be treated under compulsion and they must be locked up, in case they try to escape," writes Tony Bates
The above view, quoted in a report released today, entitled Reflections on the Rise and Fall of Institutional Care, by Dermot Walsh and Antoinette Daly, captures the essence of how mental illness was viewed at the beginning of the 19th century in Ireland when the first official asylum was established in Dublin. Perhaps it is a measure of how far our thinking has changed that we can read it with a sense of horror.
This very readable report details the pattern of institutional care for the mentally ill in Ireland over the past two centuries. Despite a decreasing population as we moved into the late 19th century, the numbers of people confined in these institutions continued to rise until 1958. While the authors do not make comment as to the moral or ethical principles underpinning this trend, they point out that there were undoubted benefits to communities surrounding these asylums. In a depressed rural economy, they provided a rich source of steady employment and saved many from having to emigrate. Their very success in helping to sustain surrounding communities led to a resistance in more recent times to accepting alternative community-based forms of care for the mentally ill. Another consequence of the walled-in asylums which dotted our landscape was the increasing stigmatization of people with mental illness, and indeed of those who looked after them.
His role as inspector of mental hospitals gave Dermot Walsh a unique appreciation of the downside of these facilities. In 1984, he co-authored the report Planning for the Future, which set in motion a radical trend to de-institutionalise the care of the mentally ill. This document has guided mental health policy since then, and resulted in the reduction in the number of those hospitalised at any one time from 21,000 in 1958 to 4,000 in 2001. The growth of community-based alternatives provided by health boards and voluntary bodies has played a key role in this reduction.
These figures speak of radical changes, but they conceal some facts that should cause concern in respect to mental health care. For example, there may be fewer people in hospital at any given time, but this is partly because of the policy of discharging people more rapidly than ever before. Some 24,000 people were admitted to mental hospitals in 2002, the vast majority of these being re-admissions. Many of these were probably there because it was the only way to ensure some level of acute care. The likelihood of being hospitalised is significantly higher if you are female, aged between 33 and 44, disadvantaged, economically stressed, isolated, and widowed or divorced. Patterns of admission vary enormously across the country, reflecting different service policies rather than different morbidity levels in particular counties. For example, the highest admission rate in 2002 was recorded in Westmeath, and this was five times greater than that recorded in Monaghan.
While the rate of admission for schizophrenia has dropped by 47 per cent over the past 30 years - perhaps as a consequence of tighter diagnostic policies, early intervention and community-based support - the rate of admission for depression and manic-depression has steadily increased. This rise has paralleled the rise in suicides, from 183 in 1976 to 451 in 2002. This has happened in spite of the proliferation and easy availability of newer anti-depressant medications.
While there were definite cost savings from closing down large mental institutions, the burden of mental distress in our society has remained and grown. In spite of this, the percentage of healthcare expenditure allocated to mental health services has been almost halved over the past 20 years, down from 12.5 per cent in 1988 to 6.9 per cent in 2002.
Reflections on the Rise and Fall of Institutional Care raises important issues as to where the gaps lie in our care of the mentally ill, and begs the question as to what constitutes a truly humane and creative mental health service. The Mental Health Expert Group has been assigned the task of picking up where Planning for the Future left off, and for drawing up a framework for guiding Government policy in the coming years.
By coincidence, one of the group's first publications also appears this week. Entitled What We Heard, it is based on interviews with 100 people in acute or long-stay psychiatric facilities. This report articulates at first hand the experiences of people with mental illness, one of the most silent of groups in our society. It shows that, primarily, they want to be respectfully included in treatments offered to them. Their collective voice is a refreshing contrast to the sentiments in the quotation that began this column. No matter how distressed they may become, people with mental illness are mostly highly sensitive and insightful individuals who have survived many indignities. They simply want an opportunity to be treated with dignity and afforded a genuine sense of belonging.
tbates@irish-times.ie
Dr Tony Bates is a principal psychologist at St James's Hospital Dublin