OPINION:There may not be increased resources for mental health services this year, but there are some reasons to be optimistic about the future, writes DR PATRICK DEVITT.
YESTERDAY WE published the fifth report of the Inspectorate of Mental Health Services. Like the previous four reports it highlights the fact that too many patients are housed in antiquated Victorian institutions; that community mental health services have not developed as envisaged in Government policy; and that there is still no sense that a coherent vision and philosophy drives the delivery of services.
At a time when resources are scarcer than ever, this may sound grim. But first, it must be acknowledged that since the enactment of the 2001 Mental Health Act there have been changes for the better. There have been improvements in terms of patients’ rights. Thanks to the Act all patients admitted involuntarily to an approved centre must have their admission order adjudicated upon by a Mental Health Tribunal. There are new rules on seclusion, restraint and electro-convulsive therapy and regulations governing the operation of approved centres.
This is all good. Yet from the broader perspective of the quality of care and treatment little has changed, despite the introduction of A Vision for Change (Government policy on mental health services) and the reorganisation of the delivery of health services under the Health Service Executive (HSE).
Our wish to see mental health services run from a specific directorate for mental health within the HSE may sound like a dull bureaucratic point. But it goes to the heart of what is missing. Right now, mental health services are run from the directorate which deals with overall primary, continuing and community care. So there is no champion for mental health services, and no clear, coherent philosophy and set of values. In the present all-encompassing directorate, specialist mental health services are easily regarded as being secondary in importance.
As a result, people with serious mental illnesses requiring hospitalisation are in many cases still accommodated in 19th-century buildings unfit for purpose.
Apart from some local successes, no meaningful attempt has been made on a national basis to tackle the restrictive work practices that still operate in some parts of the country, impeding the implementation of new initiatives.
Damning as these indictments are, and damaging as they are to the dignity of those with mental illness, there may be some tentative causes for optimism.
We may now be seeing the beginning of a cultural shift in terms of increased professionalism, accountability and awareness of the importance of governance. The central importance of service users/patients is increasingly recognised by clinicians. Human rights obligations are increasingly understood. Impatience with Victorian psychiatry may be reaching critical mass.
Further cause for optimism is the continuing high calibre of mental health service staff of all disciplines, particularly in such areas as understanding of, and compassion for, human suffering and a deeply embedded philosophy of care.
In defining mental health services for the future, we must make the distinction between serious mental illness requiring specialist psychiatrist-led care, and those vastly more numerous, less serious mental health conditions more properly treated in primary care. Specialist mental health services, with resources assigned for that purpose, should, therefore, be careful not to medicalise “problems of living” which should appropriately be dealt with through counselling or psychotherapy.
Examples of serious mental illness are schizophrenia (characterised by severe impairments in thinking, feeling and perception and often associated with negative symptoms such as apathy and lack of motivation); bipolar disorder (alternating intense episodes of elation and depression and often associated with loss of contact with reality, impulsive behaviour and poor judgment); severe depression (which may be associated with lack of interest in food or normal activities, psychosis or suicidal intent); and severe personality disorder (characterised by severely maladaptive, long-standing patterns of behaviour, emotional instability, and frequent self-harm).
These types of conditions, especially in the acute phase, may require, in a medical environment, careful monitoring, care and treatment to minimise the risks of danger to self or others. As the acute phase subsides, psychosocial needs become more prominent to effect rehabilitation, recovery and successful reintegration into the community.
It is now regarded as international best practice that specialist mental health services be provided primarily in a community setting. Ideally, in this type of arrangement, an individual with serious mental illness can obtain needs-based individual treatment of an acute or ongoing nature, without stigma and without unnecessary recourse to hospitalisation.
Some 15 of the 63 approved centres inspected in 2008 are from the Victorian era and older. Despite valiant efforts by local staff, these buildings are inadequate for the purpose of providing treatment to vulnerable individuals with serious mental illness according to human rights standards. We have recommended to the Mental Health Commission that these asylums should only continue to be approved if they provide detailed plans for closure and provision of appropriate alternative accommodation.
The sub-speciality of Child and Adolescent Mental Health Services has recently been charged with the responsibility of providing services to those up to the age of 18. Manifestly, the services were unable to fulfil this obligation. More than 200 children have been admitted to approved centres for adults in 2008. This practice is inexcusable, counter-therapeutic and almost purely custodial in that clinical supervision is provided by teams unqualified in child and adolescent psychiatry.
There is an urgent need to recruit adequately staffed, community-based child psychiatry teams. These teams should devise new and appropriate methods of screening new referrals and set a target for new appointments to be seen within a reasonable time (less than three months).
Having an intellectual disability does not, per se, require mental health treatment. Unfortunately many intellectually disabled people with challenging behaviour have been placed inappropriately in psychiatric hospitals designed for the general adult population without adequate provision of consultant psychiatrist-led specialist teams in intellectual disability.
In an era of economic gloom, additional resources will probably not be forthcoming. The effects of cutting resources to mental health services are often only apparent on a gradual basis after a number of years. This factor may make mental health cutbacks a soft target for administrators, but the detrimental effect on vulnerable people is no less devastating in the longer run.
Financial cutbacks, however, do offer an opportunity for clearer and more coherent thinking with respect to what services should be provided, and to whom. Cutbacks also provide an opportunity to weed out inefficiencies and unproductive activities and may force the redeployment of existing staff and resources in more creative ways.
In short, we have a long way to go before Ireland takes its place among those countries with enlightened, modern mental health services. However, despite the difficulty in attracting new resources, there is much that can be done to improve services. What is needed is the translation of the coherent philosophy that is at the heart of written Government policy into practical effect in the day-to-day running of the services.
Dr Patrick Devitt is the Inspector of Mental Health Services