Improving the length as well as the quality of life

OPINION:MENTAL HEALTHCARE is different. A substantial proportion of us will have mental health problems at some point in our lives.

Current policy, based on the 2006 report A Vision for Change, aims to provide services “equitably and across all service user groups”. It calls for an orientation towards recovery and more social inclusion. I welcome this, but I am struck by how different policy is from general medical care, which is based on treating specific illnesses to improve outcome.

Perhaps these, more fundamental aims, have already been met in mental healthcare? Having spent almost 20 years as a clinician treating and researching severe mental illness I do not believe this is true. I find the difference disturbing.

If you have a heart attack or stroke and are too incapacitated to consent, you will receive medical care using the “best interests” principle. Many people with serious mental illness don’t believe that being admitted to hospital is in their best interest. However, there were 2,057 involuntary admissions in 2011 under the Mental Health Act 2001.

At least three-quarters of these were for treatment of two disorders: schizophrenia and bipolar disorder. What the figures reflect is that these two conditions are more common than generally appreciated (there are likely to be more than 50,000 people in Ireland affected).

Most treatment is actually provided in the community by teams including doctors, nurses, psychologists, social workers and occupational therapists. Involuntary admission is reserved for where this approach fails because a person’s judgment is impaired by illness. This could mean that you develop a complete conviction that others are involved in an international conspiracy to kill you or that you have uncontrolled mania causing you to behave recklessly.

This is likely to affect your decision-making, but admission under the Act is reserved for situations where “judgment of the person is so impaired that failure to admit would result in a serious deterioration in the condition, or immediate and serious harm to the person or others”. The average duration of admission, unclear to me from annual reports, is probably fewer than 21 days.

Similar legislation is present in other EU countries. With the implementation of the 2001 Act, Irish admission rates, average by European standards, have fallen by more than a third.

Representative of much of the debate about mental health is a piece in this paper (Irish Times, Friday July 6th) by Dr Pat Bracken, a consultant psychiatrist, arguing that this practice is too “paternalistic” and “at odds with” national policy. I couldn’t help wondering how this might sound if applied to acute medical care. Would one argue that the provision of care to incapacitated medical patients is too “paternalistic”? Unlikely.

He appears to argue for a person’s “right to define the nature of one’s own problems” even if judgment is impaired by illness. Do we expect patients suffering heart attacks or strokes to “define” their own problems? No. He questions the central role of the consultant in providing acute psychiatric care. We trust hospital consultants to manage acute medical problems.