The Message: Why Mental Health Needs a Re-Evaluation

A lot has changed in Ireland. Not very long ago at all, you couldn’t even begin to discuss mental illness here for fear of being incarcerated. The stigma associated with acknowledging any sort of condition was far too great. You were better just to shut up, get on with it and hope for the best. Until the worst happened.

Of course, that culture of repression and shame was a recipe for disaster. Instead of talking about the issues that were weighing on them, people who suffered from depression, anxiety, panic attacks or even schizophrenia bottled it up as best they could. In general, those affected by mental health issues were made to feel like lesser human beings. And as a result many people suffered complete breakdowns that most likely could have been avoided. No one knows the real figures in relation to suicides historically in Ireland, but there is no doubt that a huge number occurred. Most of them were recorded, essentially because of religious scruples, as “death by misadventure”. Stigma ruled in this regard too.
The responses of families to real evidence of mental disorder, or breakdown, varied greatly. Some just wanted to be rid of problematic sons or daughters, conniving to have them certified as discreetly as was allowed. Others did everything they could to help and protect their children – and frequently ended up living under a form of siege, forced to deal with behaviour that was often deeply troubling and sometimes downright intimidating, almost entirely on their own. And in between were the rest: people who simply didn’t know how to cope one way or the other. In effect the State did as little as it could to help either those dealing with their own mental health issues – or their families. But the essential modus operandi of the authorities, once a mental health issue had been acknowledged, was to lock those grappling with the problem up, and throw away the key.
The conventional wisdom is that Ireland has always had more than its fair share of cases of people with psychiatric disorders. Modern research, however, indicates otherwise. More people were locked up here, certainly. But this was part of a process which has recently been characterised as “coercive confinement”. Psychiatric hospitals were used, in effect, as places where society – and families – could dispose of people who were outcasts, and who were treated accordingly.
These might include women and girls who had transgressed by being sexually active; boys who were homosexual; or people of either sex who had shown signs of being in one or other form of psychiatric distress.The problem was that hospitals became dumping grounds, places from which it became increasingly hard to re-emerge in one piece.
The first record of public provision for those with mental health issues in Ireland was in 1708, when cells were erected for what were clumsily termed ‘pauper lunatics’ in the Dublin City Workhouse. Later that century, in 1757, the great Protestant clergyman and satirist Jonathan Swift opened the doors of the so called ‘Hospital for the Insane’ in Dublin, to 50 fee-paying patients.
Swift’s intentions were good, as were those of the men and women who followed in his footsteps. The idea of providing asylum for individuals who were finding it difficult – or in some cases impossible – to cope is an essentially humanitarian one. But that initially generous impulse became perverted along the way. In 1851, there were 3,234 people in ‘asylums’ in Ireland. By the beginning of the First World War, in 1914, that figure had increased to 16,941.
The population of the 26 counties may have diminished in the years that followed independence, hitting an all-time low of 2.7 million in 1957, but the number of people who were effectively locked away continued to grow. In 1963 it peaked, at an astonishing 20,000. But as the increasing enlightenment of the 1960s took hold, that number began to decrease.
There is no obvious reason to believe that the underlying incidence of serious mental health issues has changed significantly here. In the 1960s, a new school of thought emerged in psychiatry that challenged the prevailing assumption that a mix of incarceration and invasive treatment was what was required to address mental health issues. It is almost impossible now to understand how a treatment like lobotomy, or indeed Electroconvulsive Therapy (ECT), could possibly have found such widespread acceptance within the medical profession, except that it was part of a wider culture of contempt for ordinary people, which was underpinned by the sense of moral superiority cultivated by Ireland’s grim romance with Christianity, and with institutionalised Catholicism in particular. The same impulse reigned in the Mother and Baby homes. And in the Industrial Schools.
The individuals slung into these gulags were viewed as being less than fully human. They had no rights.They were coerced intowhat amounted to slave labour. And they could be detained permanently where they were, at the whim of their (generally) religious jailers. And that is what happened in Irish psychiatric hospitals too.
At first glance, the topline figures in 2013 do not seem that different. Then, 18,457 people were admitted to psychiatric units and hospitals in Ireland. Of these 51% were female and 49% male – more or less reflecting the male / female bias in the population at large. The highest number of admissions was in the 55 to 64 year age group, at .59% of that demographic. The highest proportion of first-time admissions was among 18 to 19 year olds, at .26%.
These Irish figures have to be understood against the backdrop that the incidence of mental health issues is currently high throughout the world. According to the World Health Organisation, over a third of people worldwide have reported sufficient criteria to be diagnosed at some point in their lives. In 2001, the WHO estimated that 450 million people suffer from some form of mental disorder or brain condition. By far the highest number of cases relate to ‘Unipolar Depressive Disorders’, running at approximately three times the volume relating to alcohol use disorders, followed by schizophrenia, bipolar disorder and ‘alzheimer and other forms of dementia’.
Social deprivation is a significant factor in mental health issues. This is confirmed by the fact that the highest rate of admission in Ireland is among the ‘unskilled’ group, at just over .8%. Study of homeless people in Dublin and Limerick carried out in 2013 confirmed that 58% had at least one mental health condition. In addition, there was a 36% increase of admissions of homeless people to psychiatric units between 2006 and 2013.
While these figures are frightening, as indeed is the increase in the numbers taking their own lives, there is some light on the horizon. With the exception of those who are homeless, the majority of people affected are not at risk of long- term institutionalisation. During the course of 2013, there were 18,335 discharges from psychiatric units in Ireland, more or less equalling the number of admissions. The vast majority of these discharges (95%) occurred within three months of admission. The most common diagnoses recorded were depressive disorders (28%); schizophrenia (20%); mania (11%); and alcoholic disorders (8%). The number of long-term psychiatric inpatients in Ireland was down to just 2,812.
In 2006, the policy document for the transformation of Mental Health services in Ireland, A Vision For Change, was published. In it, a progressive increase in the proportion of overall health funding given to mental health was recommended. Since then, the State has badly failed to deliver on the promises made in that blueprint. To an extent, this is a result of the economic collapse, which forced successive Governments into making brutal decisions to reduce expenditure. However, that is only part of the story. In 1984, 13% of total health expenditure was dedicated to Mental Health. This had plummeted to 7.2% in 2006, when the report was published. Shockingly, this had further decreased to 5.2% by 2012.
Overall, this suggests that the State has effectively dumped the problem of dealing with Mental Health issues back on families and the community. Managed in the wrong way, ‘community care’ is one of the great modern deceptions. There is no question but that it was imperative to end the era of compulsory hospitalisation, and the effective imprisonment of people who were wrestling with mental health issues of one kind or another. But, equally, it is grossly wrong and unfair to load the problem of caring for those with serious mental health problems onto their individual families.
And, furthermore, it is deeply misguided to discriminate against those with long-term mental health conditions by insisting that they have to pay for their medication, where patients with, say, heart conditions or diabetes have their medicine paid for by the State.
Inevitably, the recession has had the effect of exacerbating the incidence of mental illness. Anecdotally, it is generally accepted that the number of suicides in Ireland has increased significantly, especially among people who found themselves in financial difficulties. What is less widely recognised, however, is that young people have been similarly affected.
According to a report produced in 2012 by Amnesty International, between October 2011 and September 2012, 8,671 new cases among the child and adolescent population were seen by community CAMHS teams, compared with 7,849 in the previous 12 months, representing an increase of 10%. In the same period, there were 9,973 referrals accepted by CAMHS teams, representing a 17% increase on the previous 12 months.
On the positive side, what has certainly changed is the awareness of mental health issues among ordinary people. The stigma which had attached to mental health problems has to a considerable extent been shed. Popular culture, including music, movies, literature, TV, and journalism have played a huge part in this shift. Increasingly sporting icons and rock ’n’ roll stars alike have publicly acknowledged the battles they have personally fought, and the demons they have dealt with. In Ireland, Niall Breslin of The Blizzards and The Voice of Ireland is currently at No.1 in the bestsellers with his book Me and my Mate Jeffrey – an account of his battle with depression, anxiety and panic attacks. As a result, young people are now operating in a far better and more responsive climate than was the case even ten years ago. It makes a crucial difference. But that does not mean that we are on the high road. Far from it.
Because the flip side of the old way, of not acknowledging mental health issues, is the modern far too blasé prescription of drugs by GPs, to people who present with anything which might be interpreted as depression, or indeed any other of a myriad of mental health related conditions. This is an issue not just regarding mental health. In general, there is a chronic over-reliance by the Irish medical profession on prescribing drugs, as if they are the answer to everything. But the issue is potentially even more problematic where depression and other mental health issues are concerned.
Prescription drugs have a role. They can be very helpful and effective. But there is an increasing concern among some medical professionals that they are prescribed far too blithely – and, in many cases, for far too long.
There is a huge cost involved in using prescription drugs to treat mental health problems. But there is also an issue with the addictiveness of the drugs themselves. And with the too pat diagnosis by over-stretched GPs, who feel the need to get every patient out the door quickly, so that they can deal with the queue more efficiently.
There is no quick-fix solution to any of this. Where the mental health of young people in particular is concerned, however, what we have to do, as a society, includes the following:
(a) effectively encourage better self health- management;
(b) increase awareness and support in schools and colleges;
(c) empower individuals by cultivating lifestyle improvements, especially among those at risk;
(d) address issues of bullying, isolation and harassment, especially via social media;
(e) develop and support effective non- pharmaceutical therapies;
(f ) insist on the careful use of drugs by GPs and psychiatrists;
(g) and, finally, provide drugs free of charge to patients, where there is a long-term need.
These seven steps would, at least, be a first important shift towards improving the long- term mental health of the nation. The big question is: do we have the political will to make it happen?