Don Lydon (Fianna Fail)

I welcome the Minister of State and the report. When we get a report in this country it is assumed to be gospel. Even though it is prepared by a group of experts it does not mean it constitutes the only approach. Most of the report is very good and I have no complaints about it. A Vision for Change is a comprehensive model of mental health service provision for Ireland. It is a very wide-ranging and ambitious report and the expert group has done a very good job. I will go through its points in the order in which they appear in the report.

The report emphasises the need for multidisciplinary teams to operate in a truly integrated way and offer a wide range of treatment options to service users, which is extremely important. When I began working in a psychiatric hospital 30 years ago that was not the norm but it is now, importantly so. Each person in the team has something to contribute that the others do not.

The Minister of State mentioned the demand for psychological and social therapies, which is a very important feature of the report. It does not dismiss the need for medical treatment such as psychotropic drugs or treatments for depression, manic depressive psychosis, schizophrenia, etc., but it does emphasise that therapy is necessary.

The report also stresses the need for services to become community-based. We in the hospital have always had a problem when people were ready to be discharged in that there was nowhere to discharge them to. They could be sent back to their GP but there were no supports in the community, so I welcome the emphasis on that in the report. We were always the Cinderella of the health services. However, under the Tánaiste, who is fearlessly dedicated to improving the health services, and the Minister of State, funding will be put in place over time.

Integration into mainstream community life is of great importance. People with psychiatric illnesses cannot simply be discharged into the community without support. Social workers must work with families and constant therapy is needed over the long term. The development of these supports would be welcome.

The majority of people do not realise the serious impact of mental health problems. The WHO has calculated the global burden of disease and found that mental disorders rank second after infectious diseases. Mental disorders extract a greater toll on the health of the world's population than AIDS, TB and malaria, combined. Of the ten leading causes of disability worldwide, five are mental health conditions and the impact of mental health problems at a population level continues to grow. Apart from the physical costs to people in terms of health, it will become a significant economic burden if it is not addressed. However, it can be treated, although the report is welcome in its emphasis on primary care prevention rather than on cures.

The scale of the problem is enormous. For example, the total financial cost of mental ill-health in Northern Ireland has been estimated at £2.8 billion. What that phenomenal figure would amount to when multiplied across the entire island can only be imagined. In addition to helping people, anything that can reduce the cost to the Exchequer must be welcomed.

The report mentions social exclusion, which is an important issue because, while most people believe they do not know anybody who suffers from mental health problems, the issue is widespread throughout the community. People can develop mental health problems as quickly as physical ones but, while the stigma attached to psychiatric problems is gradually decreasing, fears of so-called mad or depressed people continue to exist. Most of these illnesses are transitory in nature, although some are long term, and sufferers can be helped.

Social exclusion, whether in terms of mental health or other areas, has to be tackled. The report suggests greater contact with individuals suffering from mental health problems, although demands for privacy are understandable. I have encountered people in good jobs who were passed over for promotion because of a short spell in a hospital or day care centre, even though they were capable of the responsibilities involved. This would not happen in the case of a recurring physical illness.

Priority issues in mental health include the following: promoting positive mental health and well-being; raising awareness of the importance of mental health; enhancing the capacity of mental health service providers and the wider community to promote mental health; and suicide prevention. Suicide is an ongoing problem in the country because it is difficult to prevent but nobody could disagree that we must establish its causes as best we can.

The report states:

Effective multidisciplinary working is dependent not just on having the requisite mental health professionals in place. It depends on mental health professionals changing how they practice and work together, so that they work as a team. An assumption that this will somehow happen if a variety of mental health professionals is appointed is somewhat naïve.

I have seen a wonderful multidisciplinary approach in England, where equal responsibility was assigned irrespective of profession. However, there is an occasional tendency on the part of some medical professionals to look down on social workers, occupational therapists, psychologists and other professions.

If the Minister of State is ever in Lisbon, he should visit the establishment there run by the order of St. John of God. The centre's patients, who have psychiatric illnesses, learning disabilities and other issues, are largely treated by occupational therapists. It is the only place in the world where such therapists practise the contents of their manuals and they shine in their work. We ignore these professions at our peril.

With regard to child and adolescent mental health, the report recommends 100 inpatient beds nationally for under-18s in five units of 20 beds each. I hope they will be composed of separate units for different age groups because there is a need for adolescent psychiatry. As some 12 year olds behave like 20 year olds and others like five year olds, there has to be a degree of leeway. Many years ago, I received a Council of Europe medical fellowship to study the residential treatment of disturbed adolescents, a service which is needed here. We also need two or three units for grossly disturbed adolescents where intensive work can be carried out over a long period of time.

I do not see any recommendations in the report in terms of ranks of psychologists and social workers, but that may not be important. All I will say is that they may need to be senior in rank.

Difficult to manage behaviours come in two types, namely, acute short lived disturbance, typically resulting from psychotic illnesses, and more enduring mental health problems. The former require close observation for a short period, while longer term care and rehabilitation in purpose-built accommodation is required in the latter case. I am most concerned about longer term problems because I have met a number of disturbed adolescents who have no place to go for care. There are beds in a unit in St. John of God's and some other places but they are not sufficient. The issue must be carefully investigated.

I laud the recommendation that any person aged 65 or over with primary mental health disorders or with secondary behaviour and affective problems has a right to be cared for by the mental health services. We need to learn the reasons for the increase in Alzheimer's disease and other illnesses.

The recommendation for a liaison mental health service is one of the most important elements of the report. Such a service will help hospital patients deal with a range of matters. Years ago, when I lectured nurses studying oncology in St. Luke's Hospital, somebody would go into hospital for something like a testicular biopsy or to have testicles or breasts removed — those features that made them essentially a man or a woman — with no counselling or preparation.

Some of the more horrific operations, particularly involving the genitals, were needed for lifesaving purposes but the patients were never tutored or counselled beforehand. This is an important area and I am glad to see that it is mentioned in the report.

On the area of neuropsychology, I note that such services will be sited at St. Vincent's, St. James's and the Mater hospitals. Why will there not be a unit located at Beaumont Hospital? Perhaps there is a good reason for this and I would welcome an explanation from the Minister of State.

People with borderline personality disorders are horrendously difficult to deal with because they need ongoing, and at times intensive, care.

Although this is an excellent document, it has one major flaw. Mr. Jung said that people could never be cured of mental illness or mental problems unless their souls were cured but I see no reference anywhere in the report to chaplaincy. The Minister of State mentioned the holistic approach, the bio-social model of care which has psychological, social and biological elements but there is also a spiritual side to this issue. I have witnessed, first-hand, cures effected by the intervention of chaplains in certain cases of mental illness which I can prove. Chaplaincy must be included and perhaps should form part of the proposed multidisciplinary teams. It certainly has a very important role to play in the area of mental health.

I agree with the Minister of State's intention to close the large mental hospitals but the smaller psychiatric hospitals still have an important role to play. I do not think they should be closed because in my own experience, patients are constantly referred to such hospitals from units attached to large general hospitals. The general hospitals could not deal with them and dumped them on the psychiatric services, and I use the word "dumped" advisedly. A properly-run, small psychiatric hospital of 150 beds or so can have a pleasant, peaceful ambience, considerable interdisciplinary interaction and provide patients with a feeling of privacy and safety. In general I welcome this report.