Last week, it emerged that a brain-damaged, homeless man spent more than a year in Mountjoy Prison’s high-dependency unit. The man had a history of mental disorder but did not meet the legal requirements for involuntary psychiatric admission (“sectioning”). This tragic situation is unsurprising. Ireland’s rate of involuntary psychiatric admission is less than half of that in England, and Ireland has the third-lowest number of psychiatric beds per head of population in the EU – only Italy and Cyprus have fewer. Belgium has four times as many.
But this shocking story is just one of a number of mental health issues in the news in recent months for all the wrong reasons. In September, the National Office for Suicide Prevention released figures showing that Ireland’s suicide rate remains below the European average, but later that month an Oireachtas Committee heard that the rate among Travellers is six times that of the general population.
Ireland has a comprehensive mental health policy, A Vision for Change, but in October, a mother who was severely mentally ill when she smothered her child was committed to the Central Mental Hospital, only to have her case brought back to court the following day because there was no bed. And another Oireachtas Committee heard that just over half of the staff recommended for child and adolescent mental health services are in post, with almost 2,500 children on waiting lists.
What’s going on?
The good news is that positive change is possible and many reforms are already underway. The bad news is that most of these initiatives are only partly completed or mysteriously stalled mid-way through implementation.
First, suicide. Globally, suicide decreased by a third between 1990 and 2016. The greatest outlier is the US, where suicide increased by a third between 1999 and 2017. Availability of guns is critical: despite having just 4 per cent of the world’s population, the US has 35 per cent of the world’s gun suicides. Suicide accounts for 60 per cent of US gun deaths, far outstripping gun homicides.
Ireland’s suicide rate is below the European average, but is very unevenly distributed. The high rate in the Traveller community is clearly linked to discrimination and social exclusion.
Broader commitment
Our suicide rate among 15- to 19-year-olds is the ninth-highest of 33 European countries. Mental Health Reform recommends that “a cross-departmental agency approach is essential. This must be complemented by the required investment and resourcing”. The HSE has made progress in these areas in recent years, but deeper, broader commitment is needed from outside the health service.
Next, forensic mental health services, which treat people with mental illness and offending behaviour. Following the closure of Ireland’s mental hospitals in the late 20th century, the number of prisoners with mental illness increased steadily, but services did not keep pace. Today, Ireland has just 103 secure forensic beds, one of the lowest per capita rates in Europe. The new forensic hospital in Portrane, due to open next year, will provide 130 medium- and high-secure beds, 30 low-secure beds, and ten beds for children and adolescents.
This is still substantially below the European average. At any time, there are between 25 and 30 people on the waiting list for the Central Mental Hospital. Many spend months in prison awaiting transfer. Prison is toxic for the mentally ill.
We don’t need more committees or reports. Many reforms are already underway and should be expanded and completed.
Amendments are overdue.
In 2015, a review recommended 165 revisions to the Mental Health Act, 2001. These amendments are overdue. Also in 2015, the Assisted Decision-Making (Capacity) Act outlined enhanced supports for people who lack decision-making capacity, but the legislation has not been commenced. Research has found that 29 per cent of medical and surgical inpatients and 53 per cent of psychiatry inpatients lack full decision-making capacity. These people require the supports of the 2015 Act.
In September, the Minister for Health notified the European Commission of plans to regulate promotions that incentivise alcohol consumption, under the Public Health (Alcohol) Act, 2018. This legislation is being implemented and should proceed apace. The evidence in favour of minimum unit pricing is overwhelming. Recent experience in Scotland confirms its benefits, as alcohol-related deaths in Glasgow fell by 20 per cent.
Two final points. There is growing public understanding about the link between cannabis and serious mental illness. As the US National Academies summarised in 2017: “The higher the use, the greater the risk”. This confirms clinical experience and speaks against full legalisation. Judicious medicalisation of our response to individual cannabis use is, however, clearly indicated.
Finally, people with mental illness remain at increased risk of homelessness and poor physical health. Men with schizophrenia die 15 years earlier, and women 12 years earlier, than the rest of the population. Deeper links with social care are urgently needed, along with better support for primary care, where most mental illness is treated.
Implementing these changes requires cooperation across multiple government departments, all our public services, and – most of all – politicians and the public. The HSE does the best it can with the resources it has, but broader commitment is needed if we are to avoid a bad case of implementation deficit disorder.
Brendan Kelly is Professor of Psychiatry at TCD