Building a better mental health service

Mental health currently attracts a great deal of discussion, but more resources and work are required to improve services.

October 10th was World Mental Health Day. One person in eight lives with a mental disorder, according to the World Health Organisation. Globally, anxiety and depression are the most common conditions, but only one-third of people with depression receive mental healthcare. 

In Ireland, this year’s Budget increased funding for mental health by €58 million, but vastly more is needed – and not just more money. We need more trained mental health professionals, more reasons for them to stay and work in Ireland, and – yes – more resources for treatment: Expanded counselling in primary care, supported housing for people with acute crises and enduring illnesses, and enhanced specialist services for those who need them. 

Mental health currently attracts a great deal of public discussion. Issues relating to psychological wellbeing, psychiatric diagnoses, and services are constantly in the public arena. 

Covid-19 brought further focus and a serious reality-check. During the pandemic, one person in every five experienced symptoms of stress, anxiety, or depression that exceeded their usual coping mechanisms. This rose to two-in-five healthcare workers. 

Today, many people struggle with long Covid and the losses of the pandemic: Loss of loved ones, loss of financial security, loss of a sense of safety in the world. A combination of informal support, counselling, and formal mental healthcare is needed.

While GPs, psychiatrists, and other mental health professionals do excellent work, our mental health service struggles with recruitment and retention. We have the third lowest number of inpatient psychiatry beds per 100,000 population in the EU. Public expectations are rightly high, but there is a mismatch between expectations and service provision. 

In addition to enhancing resources over and above the additional €58 million in the Budget, four other issues require attention if we are to build a better mental health service. 

First, we are all on a spectrum between mental health and mental illness, but we need to distinguish between problems of living and serious mental disorders, such as depression, bipolar disorder, and schizophrenia. Psychiatric services are at their best when we focus on treating mental illness rather than the emotional ups and downs of life. Conflating problems of living with mental disorders medicalises unhappiness, disempowers people, decreases understanding, and increases stigma. Everyone who suffers needs support, but not everyone who suffers is ill. 

Second, we need to be more pragmatic about psychiatric treatments. Once they are used correctly, most common medications offer substantial benefits, although they are imperfect and never enough on their own. Psychological engagement and social support are vital. The keys lie in focusing on the individual person, being realistic about medication, emphasising community treatment, and ensuring that inpatient care is available when needed. A balance is required, delivered with humanity, holism, and hope. We are not just brains; we have souls, too. 

Third, mental healthcare is a social endeavour. We suffer, heal, and help each other in families, communities, and societies. For people with problems of living, the best solutions are rooted in communities rather than psychiatric services. Formal psychological care is the next step for more pressing issues. GPs and primary care teams are well positioned to assist, but require rapid access to low-threshold psychological programmes. The Counselling in Primary Care scheme needs to be expanded. 

People with serious mental illness require specialist services in conjunction with social interventions. Homelessness and imprisonment make psychiatric care exceptionally difficult, although not impossible. Prison is toxic for people with mental illness. The opening of the new forensic hospital in Portrane is a step in the right direction. 

Finally, we need to update our legislation. The Assisted Decision-Making (Capacity) Act 2015 is due to commence in the coming months. This development is around a century overdue, but better late than never. Last-minute amendments should ensure the legislation delivers benefits in practice and not just on paper. Further measures are needed to regulate deprivation of liberty in nursing homes. Revisions to the Mental Health Act 2001 should also be amended and expedited. 

To make all of this happen, social and political activism is essential: To achieve better funding for services, more supported housing, a meaningful safety net for people who fall between the cracks, and reform of criminal law, court procedures, and prison policies. 

To effect change, stakeholders can campaign for better services, advocate loudly, write to politicians, register to vote, and ensure that all public representatives and decision-makers promote the rights of people with mental illness and their families – the right to treatment as well as the right to liberty, with particular emphasis on social justice. 

Prof Brendan Kelly is Professor of Psychiatry at Trinity College Dublin and author of In Search of Madness: A Psychiatrist’s Travels Through the History of Mental Illness (Gill Books).