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What is wrong with Ireland’s mental health services?

A 1984 national mental health policy promised that service provision would be changed from an institutional model to one that is community and home based. This was never fully implemented, so that we still have a mix of institutional care and community and home based services.

For decades, reports, such as the annual reports of the Inspector of Mental Hospitals, have revealed widespread neglect of mental health services. The Inspector of Mental Health Services was established in 2003, and its first annual report published in 2005 highlights the enormity of the problems and concluded that mental health services “are in need of radical reform at all levels”.  The Mental health Commission’s Annual Report 2005 finds that, “in some areas, a picture of services inappropriately institutionally-based, lacking true multidisciplinary community mental health teams with limited user involvement and poorly structured inadequate management systems”.

• GPs in Ireland say they need increased mental health skills training, access to counselors and psychologists, and improved access to mental health providers.
• Primary care access to psychological or counseling services is very limited. Psychotherapeutic services at primary care level are available on an ad hoc basis, and many only on a private basis, either through referral by a GP to independent private practitioners or counselors/psychotherapist employed by GP practices.
• The limited availability of psychotherapeutic services in the public health services means there is an overemphasis on medication therapy.
• There is a dramatic shortfall across all mental health services in essential interventions including social work, psychology and occupational therapy.
• There is a five-fold difference in resources available to different mental health services around the country. Socially disadvantaged areas are the worst resourced.
• Ireland has an unnecessarily high rate of treating people in in-patient units, leading to a culture of maintenance rather than recovery. Admission rates are almost five times higher in the service with lowest rate than that with the highest. There are 735 admissions each year for every 100,000 persons aged 16 and over compared with …
• Ireland has one of the highest rates in Europe of involuntarily admitting and detaining people in in-patient care. Furthermore, involuntary admission rates vary by a factor of four between catchment areas and a factor of two between Health Services Executive (HSE) areas.
• There is an inconsistency in practices among mental health services. For instance, there is a four and a half fold difference in the rate of use of Electroconvulsive Therapy in different HSE areas.
• Due to the inadequacy of mental health services for children, children continue to fall through the cracks, and only a fraction of those with mental health problems receive the necessary services. When seriously unwell, children are placed inappropriately in adult psychiatric facilities or in general paediatric wards.
• There are virtually no dedicated adolescent mental health services on a national basis. The lack of specialist services and treatment facilities for 16-to-18 year olds with mental illness in this country is in breach of the UN Convention on the Rights of the Child.
• Specialist mental health services, such as services for people with eating disorders or brain injuries are generally not available outside of Dublin, while access within Dublin is limited.
• Many people with mental health difficulties needlessly end up in prison. Nearly one-quarter of both life sentence and fixed sentence prisoners currently have a mental illness of some classification.
• Ireland does not have a formal system to divert people with mental health difficulties from the criminal justice system to mental health services, or adequate forensic mental health services to treat these people. Neither does it have satisfactory mental health services for the prisoner population.
• There is a vicious cycle of mental health problems, imprisonment and homelessness. A study of prisoners published in 2005 by the Department of Justice found that, of the quarter of the prison sample who were homeless on committal to prison, over one-third had previously been diagnosed with a mental illness, and two-thirds of these had been hospitalised in a mental health facility. Of the third of female prisoners who were homeless on committal, two-thirds had a previous diagnosis of mental illness.

The Annual Report of the Inspector of Mental Health Services for 2005 contains a comprehensive review of mental health services, including those in your area, and is available at http://www.mhcirl.ie/annualreports.htm.

How does this impact on people working in the mental health system ?

People working in mental health are also under strain. The mental health service as it currently stands can be a very difficult sector in which to work due to the widespread under-resourcing. The Mental Health Commission of Ireland has noted that inadequate mental health funding yet at the same time demands to provide high quality services, can demoralise staff.