Opinion: Prisons now a dumping ground for mentally ill young men

Despite having one of the highest levels of severe mental illness when compared with other advanced European nations, Ireland has fewer adult psychiatric beds than almost any other country in Europe.

New research looking at the number of beds across the EU shows we have even fewer secure (forensic) psychiatric beds compared with other countries.

Psychiatric bed numbers in Ireland have fallen drastically, and since 2011 beds have fallen to below 20 per 100,000 people, where the European average is still over 40 per 100,000.

The beds that remain are on wards open to the public and to other wards in the same hospital. It is often difficult to care safely for young people with disturbed and challenging behaviour due to acute delusions and hallucinations in such wards.

With the closing of the old-style asylums across Europe, many countries recognised that, even with the development of community mental health services, there would always remain a significant need for some inpatient beds. They are required so the most unwell and difficult to treat patients could receive the help they need in a stable and safe therapeutic environment. Unfortunately we have failed to plan for the needs of such patients in this country, and the most unwell and difficult to treat patients increasingly find themselves either homeless or placed in prison rather than treated in hospital and supported in the community. Strangely, these well known facts are regarded as neither a failure of policy nor a cause for shame.

In 2016 the current 10-year plan, A Vision for Change will have run its course. It is timely to wonder what policy reforms will come next. A Vision for Change has led to considerable positive achievements. The experts who drafted the policy should be congratulated for the universal adoption of the ethos and language of recovery. However, while recovery is a commendable policy priority, it is not the same as cure, and it is increasingly obvious that people with severe, enduring and disabling mental illnesses have lost out in the recent changes that our mental health service has undergone.

Replaced asylums

People who have complex and difficult to treat problems are excluded from a “mental health” model that struggles to include the needs of those with severe, enduring and disabling mental illnesses.

Many of the acute inpatient psychiatric units which replaced asylums lack the short-term high observation units that could provide for the complex needs of such patients. Across the modern world, such patients are provided for in acute local psychiatric intensive care units.

Typically, in other European countries there are 10-15 beds serving every 250,000 people. This contrasts with Ireland, which has only 30 such beds in the entire country. Again, in other European countries the closure of the old asylums has been compensated for by opening high quality, therapeutically secure, forensic psychiatric hospital beds.

Ireland has not developed any such system and the number of forensic psychiatric beds at the Central Mental Hospital has stayed static at about two beds per 100,000 people.

In England and Wales, by contrast, asylum closures over the last 30 years have been associated with the development of a system of more secure forensic hospital beds so that there are now 7.5 secure forensic beds per 100,000 for the mentally ill.

Scotland, Northern Ireland, the Netherlands, Germany, Austria and many other modern mental health services provide between eight and 10 forensic secure beds per 100,000 population. Not surprisingly, Irish prisons have increasingly become the emergency department “trolleys” for young men with any form of psychotic mental illness. The great majority of young people remanded to Irish prisons, while actively unwell with diagnoses of severe and enduring mental illnesses, are charged with very minor offences. These patients have fallen through the net of a public mental health system which is not designed to meet their needs. Mental health legislation has reformed the rights of people detained for care and treatment, and further reform is needed. But reforms that exclude mentally incapable people from access to care, treatment and protection do them a disservice – it is already too difficult to intervene when a person with a severe mental illness is obviously relapsing and at risk of self-harm and neglect.

Violence is rare

Fortunately, Ireland is an inherently peaceful country where violence is rare and we are very tolerant of the mentally ill. Tolerance, however, is not enough when young people with the most severe, enduring and disabling mental illnesses are ill-served by policies that fail to meet their needs. To be able to engage with community services, it is almost always necessary to first have the benefit of the acute treatment needed to restore the basics of mental health.

The next Vision for Change should help to direct resources towards services that are demonstrably effective in engaging and retaining severely mentally ill people to prevent homelessness and imprisonment. Should we fail to do this we are at risk of repeating the kind of discrimination and inhumane treatment which the closure of the asylums and the development of community mental health teams were designed to remedy. Harry Kennedy is clinical professor of forensic psychiatry at the Central Mental Hospital. He is writing in a private capacity