Slow progress in mental health service as tide goes out on Victorian-era hospitals

Many patients say an understaffed community mental health service has left them isolated and disempowered

Miriam O’Shea was looking for help. She had spent several months in a psychiatric hospital, where she was treated for bipolar disorder. But after she was discharged and looked for support in the community, she felt she couldn’t find any.

“Drugs work for some people but for me they just numb my emotions,” said O’Shea, who left hospital last February.

“I needed the kind of peer support in the community and the kind of therapy that treats you as someone with emotional and spiritual needs. I couldn’t find any of that . . . All I was being offered was medication and more medication.”

Under a seven- to 10-year Government policy to modernise the State’s mental health service, old-style Victorian-era psychiatric hospitals are being closed down and replaced with community mental health teams.

Slow progress

These teams are supposed to offer a range of treatment options, such as talk therapy, that promote a recovery-based approach to mental ill-health, replacing an increasingly outmoded and heavily medicalised approach. But, seven years after A Vision for Change was published, progress remains slow. Few parts of the country have a fully staffed community mental health team. In fact, just 17 out of a promised 414 staff due to be appointed to these teams and other services were hired and in-post during the year.

In the meantime, some regions say they are pulling their professionals out of the community and filling gaps in inpatient hospitals or residences.

The result is an understaffed community mental health service many patients say is leaving them isolated, disempowered and starved of meaningful treatment options.

There is little doubt that the recession is bad for people’s mental health. A recent study published in the British Medical Journal, for example, found levels of stress, anxiety and mental ill-health have risen significantly since the start of the economic crisis.

“The onset of the global economic downturn, heralded by the collapse of Lehman Brothers in September 2008, can therefore be considered as a potential threat to public health,” according to the research.

The same seems to be happening here. Last year at least 525 people took their lives in the Republic, a 7 per cent increase between 2010 and 2011. Nearly 10,000 people reported to hospital with self-harm, a 4 per cent increase during the same period. It was the fourth successive annual increase recorded. In the meantime, the rate of first admissions to inpatient psychiatric units increased by 5 per cent in 2010.

Just when mental health services are needed most, however, many claim they are fraying.

The Psychiatric Nurses’ Association said services had been allowed to go into “freefall” in recent times, with hundreds of nurses retiring this year and not being replaced. An independent monitoring group established to oversee the implementation of A Vision for Change this year said progress was “slow and inconsistent”. It estimated there were some 1,500 vacant mental-health posts.

Serious concern

Internal records show serious concern at how the “floor” of staff to run services is falling and funds are leaking out into other areas of the health budget. One Health Service Executive document states that even though there is an exemption on the recruitment moratorium for psychiatric nurses it “could not be implemented as services could not retain the resources to fund the replacement posts”.

There are also signs of significant pressure in some parts of the country. The clinical director of mental health in the Louth-Meath area warned in an email that already stretched services were being “decimated”.

“With the huge exodus of nurses who are retiring, coupled with the recruitment embargo, the community services of which we are so proud are being decimated,” she wrote.

“Nurses from the home base, assertive outreach and community mental health are being pulled in to cover the 24-hour residences.” She added that the region did not have any rehabilitation, addiction or mental health services for people with an intellectual disability.

This, too, was the theme of a recent report by the Inspector for Mental Health Services. It expressed extreme concern for the welfare of intellectually disabled residents at a facility in Wexford who have been deprived of essential therapies.

“It was evident from observing the residents that maladaptive behaviours, self-stimulation, institutionalisation and withdrawal were prevalent, all issues that could be addressed by providing appropriate therapies and an appropriate environment,” inspectors said.

Government commitment

What is the future, then, for our embattled mental health services? The Government points to the fact that another €35 million in development money has been set aside for mental health during 2013 as a sign that it is fully committed to modernising this neglected quarter.

“In these difficult times, it is vital that our mental health services continue to be developed in line with the blueprint set out in Vision for Change,” Minister of State with responsibility for mental health Kathleen Lynch said. “This funding is a demonstration of this Government’s commitment to protect the most vulnerable.”

She pointed out that many of the 414 staff due to be hired during 2012 were being hired. For example, 270 of the promised posts have been accepted and appointments are proceeding.

Base funding

But if these posts are to have a real impact, observers point out that base funding for the sector cannot be allowed to keep falling. Appointing additional staff to community mental health teams at a time when the original team membership is being reduced is like pouring water into a bucket full of holes.

There are many encouraging developments on the ground. The independent monitoring group found evidence of many local and regional “bottom-up” initiatives providing high-quality community services and led by local leadership. Older facilities not fit for purpose are also being closed down. There is major progress in delivering long-neglected child and adolescent mental health services. It’s not all gloomy, by any means.

The experiences of former patients such as Miriam O’Shea are an example of how a recovery approach to mental health service can work for some.

She has had several admissions to psychiatric hospital over the past two decades. But only now does she feel she has made real strides in recovering, largely through her own initiative and the support of others former patients in county Cork.

“I’m a human being with emotional distress. But the system gives you a label and then goes on to give you even more labels. Your choices are taken away,” she said. “Groups like MindFreedom Ireland make you realise that you do have choices.”

She finds music and art therapy particularly therapeutic. She takes part in “A little help from my friends”, a weekly meeting in which participants play musical instruments. There’s also the Next Step, a drop-in centre that uses arts and crafts to help boost people’s self-esteem and confidence. It might not work for everyone but she says it has for her.

“Looking back, I really don’t think I was mentally ill. I had a lot of loss in my life, culminating in losing the rearing of my son to an open adoption . . . I feel now that I needed to address that grief, rather than medicating it.

“These days I feel I’m on a new journey. I’m living life again. I’ve known great loss but I’ve also know great joy and I’m living life to the full.”

525

number of people who took their lives in the State in 2011

11,966

number of self-harm cases reported in 2010

1,500

estimated number of vacant posts across mental health services

414

number of professionals due to be hired to improve services during 2012

17

the number of these promised professionals who were in place by mid-December 2012