Seanad debates

Tuesday, 11 November 2014

Suicide and Mental Health: Statements


4:05 pm

Photo of Diarmuid WilsonDiarmuid Wilson (Fianna Fail)
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I welcome the Minister of State, Deputy Kathleen Lynch, to the House and call on her to make her contribution.

Photo of Kathleen LynchKathleen Lynch (Cork North Central, Labour)
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I am pleased to have the opportunity to discuss in this House the important issues of mental health and suicide prevention. Mental health and well-being are important to each and every one of us. This is a complex and sensitive issue and something I know that Members will keep in mind when discussing the matter here today.

A Vision for Change is widely considered to be a progressive, evidence-based and realistic policy document, based on a new model of service delivery which will be patient-centred, flexible and community-led. We have been working to move away from the old institutional model of service delivery to providing more comprehensive care in a variety of settings, including the home, the community and in hospital. This common objective requires a change in attitudes generally towards mental health, especially in eliminating the stigma associated with mental illness, as well as the prioritisation of the limited resources which are available to us.

I acknowledge that implementation-----

Photo of John CrownJohn Crown (Independent)
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I call for a quorum as this is a very important topic.

Notice taken that 12 Members were not present; House counted and 12 Members being present.

Photo of Diarmuid WilsonDiarmuid Wilson (Fianna Fail)
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I apologise to the Minister of State.

Photo of Kathleen LynchKathleen Lynch (Cork North Central, Labour)
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There is nothing to apologise for. I thank Senator Crown because this is, as he rightly says, a very important issue.

We have been working to move away from the old institutional model of service delivery to providing more comprehensive care in a variety of settings, including the home, the community and in hospital. This common objective requires a change in attitudes generally towards mental health, especially in eliminating the stigma associated with mental illness, as well as the prioritisation of the limited resources which are available to us. I acknowledge that implementation of A Vision for Change has been slower than we would have liked, delayed by a number of factors including the changed economic context, constraints in public spending and the moratorium on recruitment. However, let me put it on the record that this Government remains firmly committed to reform of our mental health services. This is in line with our clear programme for Government commitment to implement this widely agreed policy.
I wish to stress, as evidenced by the significant funding provided by the Government since 2012, including in particular the €35 million given in the recent budget for next year, that the strong momentum to improve all aspects of our mental health services is being maintained. As reflected in the agreed HSE service plans, developments are taking place across all HSE regions, driven by the new mental health division, and monitored by the Department of Health. The additional funding of €35 million in budget 2015 brings to €125 million the total investment for mental health services since 2012, for the development and modernisation of the services in line with the recommendations of A Vision for Change,mostly in the way of additional posts to strengthen community mental health teams for both adults and children. The additional funding is also being used to enhance specialist community mental health services for older people with a mental illness, those with an intellectual disability and mental illness, forensic mental health services and suicide prevention initiatives.
Progress has been made with the closure of old psychiatric hospitals throughout the country and the development of new modern facilities to support the community-based, recovery-focused model of care recommended in the vision document. Almost 20 "old" psychiatric hospitals across the four HSE regions have either closed completely, or have closed to new admissions, with closure plans in place for the remaining old hospitals. We are also making satisfactory progress on new infrastructural developments for the national forensic mental health service. The project to replace the Central Mental Hospital in Dundrum with a new 120-bed unit in Portrane, together with modern facilities for forensic child and adolescent mental health services, CAMHS, and a new unit for mental health, which will deal with intellectual disability on the same site, is on target. Subject to planning permission, the hospital should be delivered by mid-2018.
The establishment last year of the HSE mental health services division, including the appointment of a national director for mental health, was a fundamental step to progressing the inter-linked policy and service issues raised by Senators. This delivers on a key recommendation of A Vision for Change.
The community mental health teams are the first line of acute secondary mental health care provision, and their presence allows individuals to be supported in their recovery in their own community. The teams are the primary mechanism for the delivery of community-based mental health care across the full range of mental health services - from child and adolescent services to general adult services, through to psychiatry of old age services. These teams provide a range of interventions in a variety of locations, including the service user's own home. In that regard up to September last, almost 75% of accepted referrals or re-referrals to general adult community mental health teams nationally were offered a first appointment and seen within three months. Similarly, 97% of accepted referrals or re-referrals to psychiatry of old age community mental health teams were offered a first appointment and seen within three months.
My priority is to advance the position regarding child and adolescent mental health services in both acute and community care settings. Acute inpatient admissions for children and adolescents are prescribed in A Vision for Change as relating to age-appropriate acute inpatient units, which are approved centres registered with the mental health commission. While there has been significant progress in reducing the numbers of children admitted to adult acute inpatient facilities, I accept that this remains a challenge for the HSE.
In 2008, only four out of every ten admissions of children to HSE acute inpatient units were considered age-appropriate - this figure had increased to almost eight out of every ten admissions by 2013.

While this is still not acceptable, nor in line with Mental Health Commission regulations which require that all children under 18 should be admitted to age-appropriate acute inpatient facilities, except in exceptional circumstances, it is clear that progress on this issue is being made. Where required, and if no public bed is available, inpatient beds are utilised in private hospitals. There is also a small number of children who may require placement outside of the State where this is deemed to be the best service option in such cases. Nationally, bed capacity has increased from 12 beds in 2007 to 46 at present. In June of this year, the operational capacity of the child and adolescent acute inpatient units was 56 beds. However, due to building works and temporary difficulties arising from loss of certain staff in three of the CAMHS units, capacity nationally has reduced to 46 beds. It is planned that these issues will be resolved as quickly as possible and that capacity will increase to 58 by the end of the year, which will help alleviate the current situation of placing children in adult units. In addition, construction work is continuing on the new 22-bed unit at the Cherry Orchard hospital site in Dublin, which will be completed in September of next year.

The child and adolescent mental health service is a key service improvement project for the HSE. I have recently asked the HSE to concentrate improvements in the areas of access to and co-ordination of CAMH services for all presenting needs, additional CAMHS bed capacity to tackle eating disorders and developing a community-based CAMHS forensic mental health team. The improvement project aims to improve access to and use of CAMHS inpatient, day hospital and community-based services, particularly in the context of agreed protocols governing the area of 16 to 17-year-olds. The first meeting of a multidisciplinary group established to progress this project took place recently. It is intended that meetings will be held on a monthly basis. The group has also met with the management teams of all four CAMHS inpatient units to review various operational issues including eliminating any restrictions inhibiting full operational bed usage in certain circumstances. Overall, the ring-fenced allocations provided by the Government since 2012 have allowed for an additional 230 posts in the area of mental health services for children in 2012 and 2013, with more posts approved in 2014. As of now, about 80% of those are in place with the remainder being recruited. This is proof in real terms of our commitment to improve these vital services for children with mental health issues.

At the end of September, 770 or 86% of the 890 posts approved for mental health services overall in 2012 and 2013 had been filled with the remainder at various stages in the recruitment process. There are some difficulties in identifying some outstanding candidates for geographic and qualification reasons. In relation to 2014, while €20 million was provided for mental health services, the HSE national service plan outlined that this expenditure would be phased in in order for the HSE to live within the overall available resources in 2014. Accordingly, it was decided that the recruitment of 2014 posts would be commenced to provide for posts to come on stream during the last quarter of this year. To this end, and informed by the analysis carried out, some 200 posts have now been identified from the 2014 allocation and the recruitment process has now commenced. The issue of whether a further €15 million should have been provided in 2014 has also been raised. Given the logistical and phasing issues arising around recruitment and properly planned service reconfiguration, the Government considered it more efficient to restore the annual programme for Government allocation to its 2012 and 2013 levels in 2015 which, coupled with the unspent 2014 moneys arising from the overall HSE expenditure management requirement in 2014, represents a considerable commitment to increased funding for and expenditure on mental health services.

I would like to reiterate today the value that I and the HSE put on the work of the Mental Health Commission. I like to think of it as the HIQA for mental health services. Similar to reports in previous years, the report of the inspector of mental health services for 2013 provides a balanced and valuable insight of what has been achieved in mental health and what improvements require to be effected.

The HSE and I take full account of the inspector's report and consider the views of the commission to be most important for the ongoing improvement of services for all users of the mental health service. As Members of the House will be aware, a review of the Mental Health Act 2001 has been under way and the expert group conducting the review has concluded its meetings with the final report to be presented to me within the next couple of weeks. Those with an interest in mental health know only too well the importance of having robust legislation, in particular to protect the rights of those who are involuntarily admitted to mental health facilities for necessary inpatient treatment. I look forward to receiving the report and expect that its recommendations will be progressive and in line with both A Vision for Change and the UN Convention on the Rights of Persons with Disabilities.
I wish to take this opportunity to say that Senator Gilroy last week mentioned in the health debate in the Senate his wish to see mental health legislation changed to remove the right to administer electroconvulsive therapy, ECT, to a patient without consent. While I have not yet seen the report of the review group, the Senator can take it that the removal of this power will be recommended. I wholeheartedly support that position.
Senator Gilroy also mentioned that he sees no reason to reference psycho-surgery in the Act and that it should be deleted. I urge caution on this. I accept that this is rarely used, either on a voluntary or involuntary basis, but I am informed that it has a role for a very small number of patients, especially those with treatment-resistant obsessive compulsive disorder, OCD. Banning any treatment for any patient group is not necessarily a good idea if a treatment might help. It should be available, albeit with appropriate safeguards. The reference to psycho-surgery in the current Act is about the safeguards for patients in the event that it is recommended as an appropriate treatment.
Dealing with the current high levels of suicide and deliberate self-harm is a priority for the Government. Policy in this area is guided by the national strategy document Reach Out. The HSE's National Office for Suicide Prevention, NOSP, has responsibility for the implementation, monitoring and evaluation of Reach Out and has been tasked with coordinating suicide prevention efforts around the country as well as supporting agencies and individuals interested in and active in suicide prevention.
The NOSP annual budget has increased significantly in recent years from €4 million in 2011 to almost €9 million this year. The increased investment has been targeted at front-line services and organisations working to reduce suicide and providing support for people in distress. In 2013, NOSP provided funding of €5 million to 33 non-profit and community organisations such as Samaritans, Console, Pieta House and many others. Other initiatives funded by NOSP include the recently launched #LittleThings media campaign - which highlights some simple, evidence-based, little things that can make a big difference to how we feel - and the yourmentalhealth.iewebsite - which contains the most comprehensive online database of mental health support services ever developed in Ireland. It is also locally based. In other words, if a person is in an area, the information the person will get will be about that particular area.
There is the Samaritans' new free phone number, 116123, for people in emotional distress. This took two years to pull over the line because it was necessary to deal with six mobile providers at that stage. Competition being what it is in terms of tariffs and so forth, they were all watching one another. However, all are agreed now that it was a good thing and something that will prove beneficial. There has been the establishment of a community resilience fund, which in 2013 provided investment of €413,000 directly to community organisations. This investment aims to resource local programmes and services focused on supporting communities responding to suicide. There is the roll-out by the end of the year of the suicide crisis assessment nurses, SCANs, initiative to eight new services. There has been an increase in the training for GPs. There has been the roll-out of dialectical behavioural therapy, DBT. There has also been the provision of the applied suicide intervention skills training, ASIST, and SafeTALK programmes. Some 3,400 people were trained in the ASIST programme in 2013, and 7,000 were trained in the SafeTALK programme.
Reach Out, the national strategy for action on suicide prevention 2005-2014, will come to an end at the end of its ten-year term this year.

As a consequence, at my request, the Department of Health and the HSE developed a new strategy framework for suicide prevention earlier this year. The aim of the new framework will be to support population health approaches and interventions, and it will assist in reducing loss of life through suicide, while aiming for improved co-ordination and integration of services and responses in this area. The number of people who were willing to come on board and partner in that approach had to be seen to be believed. The goodwill on this issue is astonishing.

Work is well advanced on the development of the new framework. The process includes consideration of all available national and international evidence and existing good practice, addressing areas such as research, policy, practice improvement, engagement, communications and media. The process also incorporates a review of the implementation of Reach Out, a public consultation process and a review of the evidence base for suicide prevention. The framework will take account of all public submissions received and the best evidence available internationally on this sensitive area. The strategy will be focused on a whole-of-Government approach, including engagement with several other Departments; the obvious ones that spring to mind are those which are face-to-face with the public, such as the Departments of Social Protection, Education and Skills and Health. People often do not link mental health with the Department of Transport, but one would be amazed at the number of people who interact with public transport every day.

I assure the House that the Government remains fully committed to mental health and suicide prevention and to the continued development of modern and responsive services in line with A Vision for Change.

4:25 pm

Photo of Colm BurkeColm Burke (Fine Gael)
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I welcome the Minister of State to the House and thank her for her very comprehensive overview of the progress that has been made in the provision of mental health services and the health policy reform that is progressing in this area. There are two major challenges. First, there is the whole area of reform, on which A Vision for Change sets out a clear pathway. The second area that is the subject of public debate on a daily basis is suicide. There have been number of references to how we have tackled road traffic accidents and the deaths associated with them over the past ten or 15 years, but we have not made the same progress on suicide.

In 2009, 2010 and 2011, 552, 495 and 554 people, respectively, died by suicide. The figures for 2012 and 2013 show that more than 500 people died by suicide in each of those years. Suicide affects not just the person who dies, but a wide group of people. Between 2009 and the present, at least 25,000 people have been directly affected by suicide. There is a multiplier effect beyond that, particularly in terms of knock-on effects for young people attending school or college. It is frightening.

In regard to dealing with young people, we need to consider having a greater emphasis in the education system on new ways of dealing with the issue. There are some programmes in place, but I wonder whether we should be doing a lot more in that area in our secondary schools, in particular. Councillor Liam Brazil from Waterford wrote to me to highlight this issue recently. He said, "Suicide is not for a day, a night, a week or a holiday. Suicide is final. It is a permanent solution to a temporary problem." Young people, in particular, have temporary problems which make them think that the only way forward is to end their lives. We need to do a lot more work on helping young men aged between 18 and 25 years, especially in the education system.

We have set out a clear programme for mental health and the development of the health care sector, involving new systems and staff, upgrading and further training. This is a new approach. In fairness to the Minister of State and the Department, an additional €135 million has been allocated for mental health since 2012 when this year's budget is included. The Minister of State outlined the figures. In 2012, 416 new posts were approved, of which 411 have been filled. There were 447 new posts in 2013, and the most recent figures available to me indicate that 352 of these have been filled. This is impressive, given that the funding was not easily obtained, and it is indicative of the commitment of the Department and the health service to growing and developing this service.

Staff have been taken on to further strengthen community mental health teams in adult and child mental health services and to advance activities in suicide prevention. These staff will be pivotal to improving the services made available to people who have mental health problems or who suffer from depression. The reform programme includes development and reconfiguration of general adult teams to include psychiatry of later life, as well as child and adolescent community mental health teams. It is not easy to introduce reform in any health service. Set procedures and policies have been in place for many years, and making changes is a slow process. It is not possible to change overnight, because people will have worked the system for many years. One finds that many of the people who work in the health service initially sought change, only to become frustrated when the change never came. They themselves became entrenched. One good thing about what is happening now is that it provides a clear pathway and targets.

The report published by the Mental Health Commission made interesting reading. While some progress has been made, much more is required. We need to expedite that progress. In its report dated 25 June 2014, the commission noted that there was 90% to 100% compliance with 15 of the 31 standards for the provision of inpatient mental health services among inspected providers. However, fewer than half of these services met the standards for therapeutic programmes and staffing, and only 60% provided individualised care plans. There were 408 child admissions to approved centres in 2013, including 91 children who were admitted to adult units and subsequently discharged and admitted to dedicated adolescent units when beds became available. Of all child admissions in 2013, 68% were of individuals aged 16 or 17 years.

The Minister of State is correct that the Mental Health Commission plays a similar role to HIQA. The latter has improved standards in a range of areas of the health service, and I have no doubt that the commission will do likewise in assisting in the upgrading of services and providing health care. We have a lot of work to do in this regard. A huge number of dedicated and committed staff are working in the area.

It is important that there be no watering down of funding in this area. That is the worst thing that could happen because people would suddenly find, having set out a clear programme for the next three to five years in a particular unit, that funding is not available and the programme must be brought back a step or, in some cases, ten steps. It is important that the commitment given by the Minister, the Department and the HSE continues and that we can work towards improving mental health. We have made very little progress on suicide and we need to prioritise it. We must work to provide a support mechanism for people so we can reduce the rate of suicide and, for once, make real, serious inroads, as we did regarding road traffic accidents and deaths. I thank the Minister of State for the work she has done to date and wish her well during the term of the Government in ensuring the targets she has set in her Department and the HSE are met over the next 12 to 18 months.

4:35 pm

Photo of Thomas ByrneThomas Byrne (Fianna Fail)
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I thank the Minister of State and all the contributors. This is such an important issue. There is not a family in the country untouched by mental health issues in general, and there is not a community or extended family unaffected by suicide. It is a terrible affliction which needs radical action and which would be best dealt with on a cross-party basis. We need to get together and show we are serious about it. This requires responsibility on the part of the Opposition and honesty on the part of the Government because we have had the whole rigmarole about the budget.

According to the media, the Minister of State, Deputy Lynch, spoke out within the Government about this and was very annoyed about how the budget was dealt with last year. Funding was not restored this year. If it were restored, I would advocate a cross-party approach on the issue and that we would support the Government. There was always a cross-party approach on road safety. There was never an argument about establishing the Road Safety Authority and when we controversially changed drink driving legislation, it received great support. Despite the fact that individual Members of the Oireachtas would receive many phone calls from everywhere about it, there was always full support for it. Such support should exist, however the financial support and commitment from the Government should also be there. The €15 million that was cut, which the Government promised to restore but did not, should be restored as soon as possible as a precondition to cross-party support. While there is much confusion about it, there is less money there than was committed to.

Suicide remains a major silent crisis and despite the best efforts of the many organisations, volunteers and professionals working in suicide prevention and awareness, the statistics, sadly, underline the scale of the problem. Loss of life through suicide, attempted loss of life through suicide and the injuries sustained represent the equivalent of the loss of the population of entire villages annually. Many people are doing great work on suicide awareness and how to deal with somebody who expresses suicidal thoughts. Members of the Oireachtas receive communications from people in this situation and I am sure members of the clergy and the medical professions also do.

People in the wider community often hear from people who express themselves to be suicidal. I heard my party colleague, Dr. Hillery, the eminent psychiatrist speak at a meeting, and he was very keen to advocate not just the role of the medical profession and the Government, but the entire community. He feels the entire community has a role to play in suicide prevention. Often there will be a reason for suicidality, for example, a person is in deep financial trouble and there may be somebody in the community, such as an accountant, who can come to the person’s help. There may be other issues that do not always require a psychiatrist or a doctor and the entire community has a role and responsibility. That was a very interesting point by Dr. John Hillery. The skills of the community may help particular individuals in their times of trouble.

There is much awareness, and I pay tribute to the organisations that provide awareness training for politicians and the members of staff in their offices. Members of staff speak on the phone regularly to people expressing suicidal thoughts. An all-party group met on this issue and a community organisation in Kells, County Meath, organised awareness training. A group in Nobber, County Meath, is staging a Cycle Against Suicide this weekend. It is not a fund-raiser, although it will raise some funds; the main goal is to raise awareness and keep suicide and mental health issues on the agenda.

The Road Safety Authority was established on a cross-party basis, effectively, and it has helped to cut by half the number of deaths on our roads. More than 200 lives have been saved per year by the consensus and the commitment to funding. Many young men are affected by road safety issues. Fianna Fáil believes a similar approach could be taken to mental health, and that is why we have proposed the establishment of a national mental health authority to lead a national programme promoting positive attitudes to mental health and to reduce self-harm and suicide.

I welcome the Minister of State's commitment to the policy of A Vision for Change, which was a Fianna Fáil Government policy that has always had cross-party support. We want this policy on future services in the area of mental health to be implemented fully and are concerned that progress has been slow. Under A Vision for Change, a new and very welcome unit was opened in Drogheda, and at the time of the opening Government Deputies said there was no threat to the psychiatric unit at Our Lady's Hospital, Navan. However, I have received word that the psychiatric unit in Navan is to close next year, with services moved to Drogheda. This confusion is unhelpful. The Navan psychiatric unit is an essential component of mental health services in County Meath. The facility in Drogheda is fantastic, but we must keep facilities open. Some people who campaigned on the issue of suicide have been quoted in the media as saying that the Navan psychiatric unit has saved lives and that closing it could cost lives. Along with the people of Meath, I seek clarity on this issue.

There are many issues to discuss in this area, and talking is crucial. Silence, stigma and embarrassment regarding mental health have led to many deaths. The stigma still exists, but when people open up and talk it can diminish. Some parts of the country have excellent public psychiatric nursing services, and anonymous nurses in different areas, available to people in moments of distress, have saved countless lives. The service is not the same throughout the country - I have seen it work well in one part of the country but I am not convinced that is the case everywhere. I pay tribute to the psychiatric nurses who do a very difficult job travelling around and saving lives through their words, actions and referrals.

We will keep up pressure for funding to be restored. I advocate a cross-party approach to this issue and a genuine commitment at senior, ministerial level. That cross-party approach is conditional on promises of funding being kept.

4:40 pm

Photo of Jillian van TurnhoutJillian van Turnhout (Independent)
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I welcome the Minister of State, Deputy Kathleen Lynch, to the House and welcome the opportunity to have this debate. As I told the Minister of State recently when she appeared before the Oireachtas Joint Committee on Health and Children, I am disappointed that we do not have actual figures. Since the monitoring group for A Vision for Change was disbanded in 2012, I have found it difficult to obtain real figures. How can we applaud measures or focus on issues without such figures? I am concerned about their absence.

How can we track what is happening if we do not have that information? Ensuring the money is ring-fenced is good but not good enough, because the impact is not being felt by people.
In preparing for today's debate, I set out to discover what the reality of the mental health service is for people who need to avail of it. I have permission from an individual who has been in hospital for eight weeks receiving treatment for depression to quote from her blog. She says:

We are always told to reach out and surround yourself with people who care about you. But the one thing no one tells you about depression is that it is a lonely place to be even if you reach out and are surrounded by lots of supportive people. You feel alone and stuck in your head no matter how many people are around. That can be a scary place to be.
She says of her depression:
I felt myself retreat into a place of darkness and anxiety which has left me feeling invisible. Forget Harry Potter and his invisibility cloak. If you want to experience invisibility in real life, try a bout of depression.
Of the treatment she has received she has this to say:
While the nurses and doctors have been wonderful and are working under pressure and with a lack of resources, the mental health system in Ireland leaves a lot to be desired. The fact that I have been in hospital for almost three months and for the most part the only intervention I have been offered is medication says a lot about the lack of recovery-focused support.
In talking to this person, it is clear there is an urgent need for therapeutic supports. As it stands, we rely far too much on medication. People working in the system have told me that children are being drugged. By the time those children get to see a specialist, their mental health needs are masked. We must talk about how money and resources are being utilised in a situation where services are stretched and cannot meet demand. The person writing the blog explained that she has been kicked off a HSE service user group because she has missed two meetings during her stay in a HSE hospital. I am appalled by that.
The Minister of State said in her speech that there has been significant progress in reducing the numbers of children admitted to adult acute inpatient facilities. Mental Health Reform, on the other hand, has pointed out that there was actually an increase in the numbers of children in adult facilities last year. I have not met anybody who agrees that a child should go into an adult psychiatric ward, but the figures show the numbers are increasing. The Minister of State also referred to additional bed spaces for the child and adolescent mental health services, CAMHS. I understand she shares my view that we must have national co-ordination rather than self-selection by units.
My main concern relates to children with complex needs, most of whom are being moved around the country and end up in an adult bed. For most people, their first experience of mental health difficulties will be in their teenage years. Their treatment by the health service at this point will frame how they deal with mental health issues and recovery for their entire life. It sends the wrong message when young people with complex needs are shunted around the country. Moreover, the most recent report by CAMHS shows that more than 50% of children and adolescents are waiting longer than one year for treatment and only 24% are treated within 13 weeks of presenting. That is just not good enough. By the time an appropriate adult knows enough to refer a child for treatment, so much has already happened in that child's life.
Several Members referred to the Health Information and Quality Authority. A recent report by that body on foster care in Carlow, Kilkenny and south Tipperary found there were 45 children waiting to access psychology and mental health services. The majority of these children have complex needs and some are waiting in excess of three months. As the Minister of State will recall, I argued that CAMHS should have been transferred into the Child and Family Agency. Within this small geographical area and in the case of a particularly vulnerable group of children, namely, those in foster care, HIQA is telling us that 45 are not getting access to the services they need.

I agree with Mental Health Reform when it referred to improving our evidence base. We need to make sure that the National Suicide Research Foundation ensures that homeless status and ethnicity, including the Traveller community, are used as identifiers and caught in our statistics. We have much more to learn.

The Minister of State is aware of my views on direct provision. It exacerbates and increases the likelihood of such problems arising. At a recent meeting of the Joint Committee on Health and Children we heard Dr. Carol Coulter, when speaking about the child care law reporting project, say that when women suffer a total breakdown, their child ends up in care because of their mental health condition.

I welcome the Minister of State's support when Senator Gilroy spoke about the removal of the practice of ECT. It is barbaric and I cannot understand why it is still practised.

4:50 pm

Photo of John GilroyJohn Gilroy (Labour)
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I welcome the Minister of State to the Chamber. The time available only allows me the merest mention of some of the many challenges facing our mental health services. I would like to talk about them under two headings, one being what we would call operational matters, which are the function of the HSE to deliver. The challenges facing the HSE in delivering these are great and some people might even say they are insurmountable in the current circumstances. Only for the tremendous hard work of our staff, our mental health services would hardly exist. Some of the services to which I can point that are poorly resourced, include addiction services. I refer to few or poor specialist treatments for eating disorders. There are woefully low numbers of child and adolescent beds in the country, which require that children be admitted to adult wards or - almost as bad and I come across this all the time - to totally unsuitable beds in medical wards of general hospitals. We could usefully check out the numbers here. If the anecdotal evidence I am hearing is correct, we are in real trouble in this regard. There is a shortage of staff, incomplete mental health teams and the list goes on. We could devote our entire energy to discussing those matters.

The second element I want to raise involves policy issues. They should be addressed by the Government, the Department and the Minister. My comments are critical of the mental health services and I hope they are not understood to be critical of the Minister of State. She and I are old friends, constituency and party colleagues and have soldiered long and hard together for 20 years or more. Any criticism I make cannot be understood to be about her. It is about our policy implementation or the lack of it. The Minister of State was appointed and given responsibility for four areas, any one of which could usefully carry a junior Minister. International evidence tells us that at the top of all priorities for the creation of a modern and effective mental health system is the placing of mental health as a priority by policy makers. Having a Minister with four areas of responsibility shows that from the outset, we as a Government have failed in this regard. In the circumstances it is not possible for us to achieve the high standards of mental health services that we and our people require.

One of the frustrating aspects is that we have probably one of the best documents on policy that I have come across. We have examined policy in seven English speaking countries and A Vision for Change is up there as probably the best of them. It will be nine years next January since it was published and it has not been implemented in any strategic or coherent way. In 2006 all stakeholders embraced this policy and front-line staff, of which I was a member at the time, enthusiastically welcomed it as the blueprint for a fantastic way forward. Today the same staff are asking whether A Vision of Change as a policy even exists any more. That is what my former colleagues have told me. It has been a wasted opportunity and it is no longer good enough for the HSE, the Department, the Minister or the Government, when asked about our mental health policy, to quote the success of A Vision of Change because it has not been properly implemented.

The Minister of State spoke, as she often does, of the crucial necessity for a change of culture. She is 100% right about that. To achieve this, leadership is needed at every level There is a clear lack of leadership in the services. It is my understanding, and I stand to be corrected on this, that the post of director of mental health services is currently vacant. It has only been filled by a person in an acting capacity and the director has been seconded to another area. That is not acceptable. I cannot understand how that could be acceptable. I cannot understand how at a crucial time of change delivery we have not got a permanent change driver in place. Leadership at a local level is patchy at best and there seems to be no guiding principle about what our services ought to be.

These issues are constantly being brought to my attention by my former colleagues in the psychiatric service, as well as service user groups and service users. Under the old policy of Planning for the Future, we closed most of our old institutions but I fear that all we did was move the institution mindset from the old institutions to the community. There is an over-reliance on the biomedical model and there is a lack of alignment with the community and voluntary sectors, which are vital in this process. There seems to be hostility from some service delivery agents in fully engaging with community and voluntary groups. This again points to the paternalistic view of many of our senior clinicians and managers in the mental health services.

The Government cites an additional €120 million as proof that we are making progress and money is of course welcome. Nevertheless, it is not what this is really about. We must consider how services are set up, and money will not sort that out. I do not want anybody to interpret my comments as a criticism of the Minister of State but I am calling on the Government to reconfigure the Department and decouple mental health from the Minister of State's other areas of responsibility. We must stop paying lip service to the delivery of mental health services and create a Ministry with sole responsibility for mental health.

There is no question we inherited a mental health service that was in crisis. From what I am hearing around the country, it seems that mental health services are now in chaos and we must sort out the issue. As a Government Senator I am probably not supposed to make such comments but I have listened carefully to the Minister of State's contribution. It seems that the view of the Department as outlined in the document and my views are divergent on almost every point. A Vision for Change, as I mentioned, is not being implemented in any coherent way, and if I am correct, the national director of mental health is not in place, community mental health teams are not complete and child and adolescent mental health services, CAMHS, are not as they should be, although that project is to be welcomed. There has been discussion of how additional mental health posts are being achieved and I can speak to the Minister of State privately in that regard, as I certainly would not like to put incorrect information into the public domain. The Mental Health Commission does great work in many areas but the reports being published generally deal with the structure of the environment in which care is delivered rather than the quality of care. We must consider such issues.

I will briefly speak to the review of mental health legislation. I am absolutely opposed to electroconvulsive therapy, ECT, being given involuntarily to people unwilling or unable to give consent on the word of two consultant psychiatrists. There is no other element of health where two doctors can decide to give a person a treatment which he or she does not wish to have. If there is a requirement for ECT to be given on an unwilling or involuntary basis, the issue should be decided by the Circuit Court or High Court. The idea of psycho-surgery under section 58 of the Mental Health Act still being on our books is barbaric and there is no place for it. If this is relevant to a very small number of people, it is again the Mental Health Commission and psychiatrists who decide if an irreversible psycho-surgery is required. I do not agree with that and if it is necessary, the issue should be decided by court. It is alarming to see the reference in the Minister of State's contribution, although I accept it is rarely used. I cannot understand how we could contemplate doing psycho-surgery on somebody who does not want it.

The suicide prevention strategy Reach Out has not worked and it is now ten years old. It has not delivered objectives and it was flawed in its initiation because it did not set targets or direct responsibility to named individuals. It did not have a review period. I met Mr. Gerry Raleigh, who is working on the national framework for suicide prevention, and I made a contribution to that as well. I am hopeful that Mr. Raleigh can deliver on this and he deserves our full support.

5:00 pm

Photo of John CrownJohn Crown (Independent)
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I welcome the Minister of State. I know she takes this problem very seriously and I am grateful to her for giving it such a priority. Earlier, I was going through a mental checklist of people I know who lost their lives, sadly, through self-harm, and I came up with 14 names. These included a few nurses, medical students, doctors and world-famous cancer experts. There were also a couple of patients or family members of patients, as well as a relative of mine. Every one of these is a tragedy and these people came from all strata of society and age groups, although the average age was very young.

I am doing mental arithmetic on the median average age of death for this personalised cohort, which was the early 30s. We are talking about decades of lost life of the folks who sadly died and decades of bereavement for parents, siblings and others. They are all tragedies but we must suspend sentiment and look at the problem as policymakers and people who scrutinise policy in a scientific way to work out how to go forward.

It is a health care and health professional problem as well as being a personal problem and a public policy problem. We need to get a whole lot of metrics, and know how many people die in Ireland through self-harm, how many people attempt self-harm, and how many have recovered from the illness that led them to the awful brink. We must also know the metrics of the service we provide, including the ratios of consultant psychiatrists per head of population compared to other countries, of practising clinical psychologists per head of population, of trained psychiatry nurses per head of population, and of social workers per head of population.

We must also know, comparatively speaking, the level of access we provide, the days of the week and hours of the day provided to people suddenly facing a crisis. In those cases, an intervention may be lifesaving. We also need to know the waiting lists for people accessing routine psychiatry care where they do not express self-harm ideation but where such ideation may be lurking in the pathology affecting them. This may not be something they admit the first time they see a doctor or a nurse. We must ask ourselves critically the effect the blunt instrument of health service staff level embargoes have had on the problem. This is perhaps the time for introspection and self-scrutiny and a collective consideration of our contribution to the problem. We all understand the economic context in which the health system exists but we must seriously think about priorities within the service. Money is still being spent poorly, inefficiently and unwisely on aspects of health policy that are considered luxurious compared to the absolute necessity of doing things that save people's lives.

I urgently asked the Minister of State to really make it her business to have a root and branch discussion, not with the experts in the expert groups but with the practitioners on the ground, with whom it is critical important to speak. The Minister of State should ask what these people would like and what they believe would have saved the life of people who took their lives. She should ask what practical steps should be taken and whether that involves more clinics, more centralisation or more diversification of services, more staff on the ground, or greater availability of out-of-hours services. These strategies and practical advice should be taken on board. Perhaps the Minister should have a series of informal visits, where the supervisors and bosses are not present. The Minister of State should talk to the mental health nurses in a unit or the junior doctors in psychiatry and the consultants. Perhaps she can talk to the social workers and may find practical suggestions come to her in this regard. It may be that some of them are not expensive and practical suggestions can be offered.

The colleagues with whom I work most closely are not specialist medical health workers and interact with the psychiatry and mental health support services in the area called liaison psychiatry. It is a critical area and some patients primarily present with a psychiatric complaint to a doctor and seek psychiatric help. Others will develop it in the context of another type of illness. Many mental illnesses are physical illnesses but we have not yet worked out the physical basis for them. We will get there. Patients with more traditionally defined physical illnesses often need psychiatry support.

In my experience, this is an area which is desperately under-provided for at multiple levels within the service. In the case of psychiatry support for patients who primarily present with very distressing medical problems and may have a psychiatric problem develop or unmasked because of the physical, psychological, social and familial stress of an illness such as chronic neurological disease, stroke or cancer, the needs are often not well met.

I do not know much about this issue, but I ask the Minister to examine the care provided by private insurers for patients with psychiatric and mental health diagnoses to ensure they are pulling their weight also. They take a great deal of money from people who may become patients. I am aware that they reinvest in some cases; some of them are for-profit, while some are not for-profit organisations. However, there is, potentially, a pressure escape valve for some parts of the service and we should ensure these services are being provided with the moneys being paid.

Ultimately, on a day when we have seen rather distressing figures for what appear to be economic disparities in cancer mortality rates, let us ensure something similar does not emerge in the case of death resulting from self-harm.

5:15 pm

Photo of Paul CoghlanPaul Coghlan (Fine Gael)
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I welcome the Minister of State and I am glad to have the opportunity to speak briefly on this very important topic. I am not very familiar with it and not qualified like Senator John Crown, but I lost two friends, two first cousins, to suicide. Like everybody else, I fail to understand why two young people with great lives ahead of them ended their lives in this way. However, I am greatly informed by Councillor Liam Brazil from Lemybrien, County Waterford who has written to me and probably the Minister and most Members of the House on the issue, about which I have spoken to him a number of times. He believes that every year more than 600 people take their lives by suicide. He says this figure represents those deaths by suicide that are reported, but the figures show that for every two deaths reported, there is one unreported. The Minister will know if that is right or wrong. Councillor Brazil believes that adding these statistics together would give a corrected figure of 750 suicides per year. Obviously such a figure is frightening and implies that there are 64 deaths every month or 16 per week by suicide.
Councillor Brazil believes we must treat mental health as a priority, as I am sure the Minister does. As Councillor Brazil says, it is often spoken about in the medical profession as striving to provide holistic care for patients, but he wonders if this can be achieved when there is such a deficit in the care we provide for people with mental health needs. He further states he believes a committee on mental health and suicide should be established, with an inclusive membership from all disciplines associated with mental health care and those who have been affected by suicide.
Councillor Brazil says there must be an investigation of the need to introduce mandatory annual counselling sessions for all second level students, which could be achieved through an initiative similar to the Green Flag initiative and could provide for positive health. He says:

It could make a huge difference and it might help to break the stigma that is attached to mental health and suicide. We need to let the youth of our country understand that suicide is not for a day, a night, a week or a holiday. Suicide is final.
As my colleague, Senator Colm Burke, said, it is a permanent solution to a temporary problem.
We are all hugely concerned but feel powerless and ask ourselves what we can and should do. Like the cross-party Oireachtas group on mental health, I welcome the progress made in appointing new multi-disciplinary staff for community mental health teams. The group notes that, as of last September, 721 of the 891 posts allocated for 2012 and 2013 have been filled. Obviously, we wish that there were more.
There has been an improvement in reporting activity in mental health services, with information being collected on the numbers being referred and on waiting times for a first appointment.

The commitment to increasing the involvement of service users, family members and carers has been progressed with the appointment of an interim head of service user, family member and carer engagement to the HSE's national mental health management team. The group also acknowledges the personal commitment of the Minister to the implementation of the Government policy, A Vision for Change, and to the reform of mental health services. However, it states that Ireland's mental service continues to be under pressure. Recent figures from the Central Statistics Office show that there were 554 deaths from suicide in 2011, although Mr. Liam Brazil believes the figure is higher. In 2012, the national registry of deliberate self-harm recorded 1,210 presentations nationally to hospital due to deliberate self-harm. Demand on child and adolescent mental health services continues to increase, having risen by 10% between March 2013 and 2014. Waiting times had increased by 8% at the end of March 2014 compared to the same period in 2013. It has been reported that demand for counselling in primary care service has been outstripping capacity, with 1,000 people on the waiting list for this service at the end of February 2014.

Although homeless people are extremely vulnerable to mental health difficulties combined with addiction problems, dedicated mental health services for this group have been under-resourced. One recent study of a homeless hostel in Dublin found that 82% of residents had a current mental health diagnosis and that many also had difficulties with substance abuse. Obviously we are all disappointed that the budget 2014 allocation for community mental health services was €20 million rather than the €35 million which, apparently, was committed.

I am ill-informed despite the fact that I am aware of the issue of suicide. It is a frightening situation. None of us know what we should do. I look forward to hearing further from the Minister.

5:20 pm

Photo of Labhrás Ó MurchúLabhrás Ó Murchú (Fianna Fail)
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There is no doubt that suicide is the nation's silent crisis, in spite of the good work and the great efforts of many organisations, volunteers and professionals who are working in the community, making themselves available and providing hope where they are given the opportunity to do so. The statistics speak for themselves. How often have we said in this House that the statistics are a wake-up call? Year in, year out, we have been making the same points here. We all know somebody, perhaps many people, who took their own lives. To us these people appeared to be exceptionally normal, and it would not have been evident that they had any problem that would drive them to suicide. When we hear of suicides we are absolutely bewildered as to why people did not ask for help. There is no single issue where suicide is concerned, as is evident from the age groups. Suicide affects all age groups and all strata of society. Therefore, one cannot pin down precisely what has happened. In a fundamental way, society, community life and old-style interactions have changed, as has family life. In the old days there was always one parent at home to provide a listening ear for the big problems and the small problems, but that is no longer the case.

The only place where we might find some indication as to what puts a person in that position is the unfortunate, sad and tragic suicide note which is often left behind. I saw one recently that was left by a young man who had everything to look forward to in a rural town in Munster. That suicide note simply made the point that he was into drugs, was not able to pay his bills and was being bullied and threatened. The question one asks in that particular case is why he did not turn to someone - either his parents, his friends, his relations or the Garda. That does not happen. These are the types of question we have to ask ourselves. Is there something missing so far as that is concerned? People who commit suicide have decided they are no longer able to take whatever stresses or pressures they may have and no can longer see any light at the end of the tunnel. Nothing could be further from the truth, because there is hope and there is always a listening ear. There are always people who will talk through the problem, and if a person is being threatened or bullied something will be done.

Let us look at young students who have taken their lives and have posted messages in which they said they could no longer bear the bullying they had to put up with in school. In America, in one of those cases, four young students were prosecuted for doing precisely that. I do not think prosecution offers any answer in the bigger picture. I wonder why that young person who is being bullied does not feel there is someone to listen. That is why I am a little disappointed at the downgrading of guidance counselling in secondary schools. From my knowledge of the service, there was a person in the counselling room who provided a confidential service. The services of that guidance counsellor were not always used to discuss careers. That is not what it was always about. That should be looked at. The provision of guidance counsellors in primary schools should also be examined, as that would be a step in the right direction. There were 475 suicides last year, but, as Console has made clear, the number may be much higher if some of the drownings and car crashes that occur are also linked to suicide.

Photo of Paul CoghlanPaul Coghlan (Fine Gael)
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I thank the Senator.

Photo of Labhrás Ó MurchúLabhrás Ó Murchú (Fianna Fail)
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We do not get much time in a debate here to make other points. However, I ask the Minister of State, given the huge challenge that exists, to examine the issue of guidance counsellors not just for secondary schools but for primary schools also.

Photo of Mary MoranMary Moran (Labour)
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I welcome the Minister of State, Deputy Kathleen Lynch, to the House. I will not reiterate much of what has been said. The Minister of State is aware of my views in this area.

This debate is on mental health and suicide. When I saw the title I asked why we were intending to have a debate on both mental health and suicide. When will we separate the two? There are people who have mental health issues but who never contemplate suicide, while many people who commit suicide do not have mental health issues. We are constantly banding mental health and suicide under the same umbrella. They are interlinked, in the same way as many other things, but they are two separate areas. I ask that we separate these issues next time and have a full debate on suicide and suicide prevention and a full debate on mental health issues.

I welcome the fact that the new strategic framework will be cross-departmental. That is vital. The Minister of State said it had to include the Department of Transport, Tourism and Sport. I am aware that transport is an issue, as people in rural communities cannot get from A to B because they do not have transport or access to it. The Department of Education and Skills is also involved. This an area I am going to mention also, as nobody else has raised it. Let us have a recovery-based approach rather than a medical approach, as referred to already. We all know of cases in this regard. In a debate here in February I mentioned a child with an intellectual disability and severe behavioural problems who is taken to a doctor and handed medicine. When people are told they do not want medicine, they are told it will calm them down.

What about the therapy? I raised this in the House last February. I am not putting it on the Minister of State, because she cannot chase everything, but I have received no response since last February - that was not the first time I raised the matter - regarding the availability of a child psychiatrist in County Louth. I have been raising the matter for the last two years but there is still no child psychiatrist. Once an individual reaches the age of 16 years he or she is out of the paediatric service, but a child cannot access the adult service until he or she reaches the age of 18. When I raised the matter previously on an Adjournment debate I was told that CAMHS had agreed to see 17 year olds, but it will not see anybody with an intellectual disability. I stand to be corrected in that regard, but that is my experience. The person who came to me in that crisis situation was told he would have to wait at least one year because the case was being sent to adult services in Beaumont. Meanwhile, this individual's family must cope with a mental health issue alongside an intellectual disability. I can cite several such cases. I have also dealt with a case involving an adult child who has serious behavioural problems and who needs residential care because the parents are elderly. Nothing has changed in the last two years. I welcome the benefits, but let us have value for money.
I welcome the Little Things campaign. In preparing for this debate, I visited the website The map on that website makes it clear that services are clustered around the cities. In rural areas, there are no services. Again, this is where transport is important. Mental health issues do not arise solely in the big cities. Often they arise in the most rural of places.
I also spoke to several counsellors and other people who work in the area of mental health in advance of the debate. I told them we are singing the same song every time we have this debate but that I wanted to investigate the issues arising. One interesting issue that arose was that two counsellors told me separately that service users - I hate that term - report that the generic medicines now being prescribed do not offer the same benefits as prescribed named medication. I thought it noteworthy that these two individuals, who come from different areas, reported that the medication did not appear to be working as well as expected.
The most effective deterrent to suicide is removing access to the means. More than 30,000 people took part in Assist training programmes last year. I spoke to somebody who works in this area about the programme. The individuals who take part in the training do not have to commit to working in the area of suicide. The cost of the training is €300 per person, but we have no documented evidence that it is helping to reduce suicide rates.

5:30 pm

Photo of Gerard CraughwellGerard Craughwell (Independent)
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There is a song that contains the following lines:

... suicide is painless,
It brings on many changes.
There is no doubt it brings on changes, although sadly none of those who have committed it has come back to tell us whether it is painless.
I refer to the 2013 guidelines Well-Being in Post-Primary Schools, which were jointly prepared by the Departments of Education and Skills and Health, and, in particular, the issue of teen suicide and the role of school guidance counsellors in supporting teenagers experiencing crisis. Ireland has the fourth highest rate of youth suicide in Europe, and suicide is among the top five causes of mortality in the 15-19 age bracket, according to CSO figures from 2012. In 2012, it was reported by the child and adolescent mental health service that one in ten children and adolescents had experienced mental health disorders which had an impact on their families, relationships, learning and day-to-day coping skills. Most schools now adopt a whole-school approach to mental health promotion, but regardless of how caring or supportive the school ethos may be, some young people require targeted and specific interventions when they are experiencing a crisis or displaying early signs of mental health difficulties. Imagine a guidance counsellor being approached by a child in a state of crisis and in need of immediate support who must say to the child, when the bell goes, to wait until he or she comes back from class. That is what is happening in our schools.
The 2012 Headstrong survey of 14,500 young Irish people aged between 12 and 25 years found that the most important factor for young people is the presence of a supportive adult in their lives. For those experiencing difficulties at home or with peers, the school guidance counsellor plays a critical role, as is acknowledged by numerous departmental supports which have existed on a statutory basis since the Education Act 1998, which provided for one-to-one counselling as a key part of the school guidance programme. In addition to providing one-to-one counselling, guidance counsellors are expertly positioned to know when to refer a young person to other medical professionals. I have been informed by guidance counsellors that, far from getting an increase in the number of guidance counsellor hours available to allow schools to deal effectively with the increasing prevalence of suicidal ideation and mental health difficulties, at least 200 schools are unable to provide any one-to-one counselling, and there has been a reduction of 59% overall in the time available for one-to-one counselling.
I visited a school in the north-west of this country, the principal of which sits in his car from 7 p.m. until midnight while the teachers monitor social networking sites. They report issues to the principal, who contacts parents to advise them that their children may be in trouble. This is not good enough. While I fully appreciate that guidance counselling falls under the remit of the Department of Education and Skills, the time has come to stop talking and start acting. We need counsellors to be available all day in our schools and we need a strong mental health programme. I have been in a school in which two children committed suicide. The suicide of a child must be the most devastating experience for any parent. I recall one student in my own college who was the brightest and cheeriest young woman I ever met. On the Friday when she left us she was in great form. Her parents told me they had spent the weekend with her, the likes of which they had not remembered in a long time. At 7 p.m. on Sunday evening, she went to a barn and hung herself. Not unlike Senator Crown, I have encountered suicide approximately 15 times over my life, including from drowning, hanging and overdoses. It is a pretty horrific thing. There is no answer left when it is over. I ask the Minister of State to work with her colleagues in the Department of Education and Skills to prioritise the provision of counselling in our schools on an ex quotabasis.

Photo of Imelda HenryImelda Henry (Fine Gael)
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I welcome the Minister of State to the House to discuss this important issue. I know many families who have lost somebody through suicide. County Leitrim has one of the highest rates of suicide in this country. I will not repeat what many others have said in this debate because the points they made have been very good. Education from a young age is very important. I refer to education in primary schools. There are programmes on alcohol abuse and cyber-abuse, but we also need to educate children about mental illness and depression.

We need to educate them about mental illness and depression. At the start of the school day, when pupils said their prayers, a young boy in fifth class stood up and prayed for a friend of his father who had died by suicide. Some of the children in the class did not know what suicide was. Education is, therefore, very important. Depression is a common illness and affects children, teenagers and adults, young and old. It can only be overcome by proper treatment. Teenagers and young people need immediate access to help. This is a problem because we do not have the resources to provide help immediately. No child or adult should have to wait for help because in many cases it would be too late.

5:40 pm

Photo of Paul CoghlanPaul Coghlan (Fine Gael)
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The next speaker is Senator Susan O'Keeffe who will share time with Senator Ivana Bacik.

Photo of David CullinaneDavid Cullinane (Sinn Fein)
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On a point of order, I thought it was to move from a Government speaker to an Opposition speaker. The Acting Chairman allowed an Independent Senator, not part of any independent grouping, to speak ahead of me.

Photo of Paul CoghlanPaul Coghlan (Fine Gael)
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I was following the list.

Photo of David CullinaneDavid Cullinane (Sinn Fein)
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The list is wrong.

Photo of Ivana BacikIvana Bacik (Independent)
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We are happy to let him in.

Photo of Paul CoghlanPaul Coghlan (Fine Gael)
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As there is no Independent university Senator offering to speak, I call Senator David Cullinane.

Photo of David CullinaneDavid Cullinane (Sinn Fein)
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I justed want to make sure the Acting Chairman was following due process.

Photo of Paul CoghlanPaul Coghlan (Fine Gael)
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I always like to be fair to the Senator.

Photo of David CullinaneDavid Cullinane (Sinn Fein)
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I welcome the Minister of State on the fifth occasion in the lifetime of this Seanad that we have discussed the issues of mental health and suicide. The two, while linked, are separate in many ways and should be dealt with separately, as Senator Mary Moran suggested. Both are complex because, in the case of suicide, many families have been left without answers where there was no previous history of mental health problems and no suicide note. Such families are left behind wondering what happened. In other cases, young men and women were bullied in school, while young men who are gay find it difficult to come out. There are all sorts of reasons people commit suicide. There is closure, as well as answers, for some families but not for others. It is a complex topic.

Equally, there are complexities in the case of mental health because depression takes different forms. Some suffer from anxiety and panic attacks and there is no one response, treatment or one way of supporting them. I appreciate the fact that it is complex in terms of those who provide support and services.

The figures have been outlined. We should look at the resources allocated to fund mental health services. Despite the commitment of the Minister of State to do so, we have not had the add-on of €15 million to meet the shortfall in 2014 or the €35 million ring-fenced for 2015 in A Vision for Change. I am a supporter of the policies outlined in A Vision for Change and the service provision envisaged within it. A Vision for Change includes many good policies on social inclusion and integration which could be greatly improved. Just 18% of people with a mental illness are in employment. A new report ranks Ireland 14th out of 30 European countries for its commitment to the social integration of people with mental illnesses. The mental health integration index is compiled by the Economist Intelligence Unit, the research and analysis division of the UK-based Economist group, and the first of its kind to rate 30 European countries - the EU 28 and Norway and Switzerland - according to government support for people with mental health issues. The report states integrating into society is important. Overall, Ireland scored above average and was 14th out of 30 countries. Its biggest strength was in the provision of advanced mental health policy in the shape of A Vision for Change. Unfortunately, the slow pace of implementation was seen as one of its many weaknesses. The report on Ireland points out that subsequent reports from the independent monitoring groups set up to oversee implementation of A Vision for Change found that it was slow and inconsistent. Health service upheavals such as the creation of the HSE and funding cutbacks, as a result the Government's austerity programme, were cited in the report as factors that slowed implementation of A Vision for Change. The authors said the reduction in mental health funding from €937 million in 2006 to €750 million in 2013 meant that just 5.3% of overall health spending in Ireland was provided for mental health services. The target is 10% and the figure needs to return to the level recommended in the report - 8%.

There is sympathy in the House and interest in dealing with the issue which has been debated most in the Chamber. Much work has been put into committee reports by Members of the House who worked on the issue outside the House. All of these issues comes back to the allocation of resources. We must ensure the service is properly resourced. Each Minister must fight his or her corner, but one of the issues on which we all agree across the political divide is the need to fund mental health services more efficiently and robustly. I wish the Minister of State well in her endeavours to obtain more funding, but we also consider the criticisms, as well as the advances made. We must take the criticisms at face value and view them as constructive. Unfortunately, the international criticism shows that we are lagging behind in the provision of funding, an aspect that needs to be improved.

Photo of Ivana BacikIvana Bacik (Independent)
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I propose to share time with Senator Susan O'Keeffe.

I welcome the Minister of State and pay tribute to her personal commitment on these issues - mental health and suicide prevention. I welcome the positive points made in her contribution, particularly on the project to replace the Central Mental Hospital. We know about its highly vulnerable population of prisoners and the high number of mental health issues among the prison population, on which the Irish Penal Reform Trust has worked. I asked the Leader earlier for a separate debate on the national dementia strategy. The Alzheimer Society of Ireland is seeking to achieve a roll-out of the strategy, on which a separate debate would be worthwhile.

I welcome to the Visitors Gallery Mr. Mark Vincent Healy who has done huge work on the particular issue of suicide prevention. He has reminded me that, on Remembrance Day, we will see two Irish citizens take their own lives and will 40 self-harm as potential suicides. Others have talked about the figures, but Mr. Healy has undertaken major work in researching the links between clerical child sexual abuse and suicide, of which the Minister of State is well aware. As Mr. Healy says, it is important to see an evidence-based approach targeting suicide prevention services for this known and highly vulnerable group. The Minister of State gave a commitment to exame the funding of such research and I ask her to consider providing some resources to look at the link between this group of people, to whom society owes an enormous amount, and the experience of child sexual abuse, particularly by clerics, and alarming suicide rates.

There is also a huge amount of work being done on the cost associated with suicide. We all the human cost and have been touched by suicide among friends or family members, but there is also an enormous economic cost to society. The money allocated for suicide prevention services, almost €9 million, is only a small amount when compared to the enormous cost to society suicide represents. There is a human and economic cost. I ask the Minister of State to look at the link between child sexual abuse and suicide rates.

Photo of Susan O'KeeffeSusan O'Keeffe (Labour)
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Like Ivana Bacik, I thank the Minister of State for her personal commitment to tackling what is a difficult issue. We are always fighting about funds. I would go further than Senator Mary Moran and say that as well as splitting suicide from mental health, culturally, we also seem to want to split mental health from health. I do not understand why we persist with this because it involves the health of our minds and bodies. There always seems to be segregation of the money for mental health services. The job of the Minister of State is to pursue money and be an advocate for them. Culturally, closing the old institutions is helpful in terms of realising this is not the way to help people with mental health issues.

Notwithstanding those positive changes, so long as we persist in separating mental health and physical health, we will continue to have a dilemma about how we deal with these issues and fund the different services.

The Minister of State is aware of continued calls by the Irish Association for Counselling and Psychotherapy for proper regulation of professionals working in this area. Some progress is being made in this area but, as the association has pointed out, without agreed standards it is impossible to monitor professionals effectively. Ireland is not a country with a long-established counselling culture; it is only in the past 30 years or so that these types of services have been available. The problem at this time is that I could go online this afternoon and pay €49 to obtain a diploma on counselling people with eating disorders. I know nothing about such disorders and would not dream of doing such a thing, but it would be easy for me or anybody else to avail of the proliferation of such offers. What it boils down to is that words and phrases like "counselling" and "mental health" are dirty words. If we persist in keeping mental health provision separate within the overall health system, we facilitate a situation where people can obtain a diploma after three days or three weeks training and set themselves up to help people with mental health problems.

I acknowledge that this issue is on the Minister of State's desk and she is aware of it, among the many other challenges she faces, but I am taking this opportunity to emphasise the need for action. The professionals who are offering these services want regulation and proper standards for people who are suffering. We must avoid a situation where vulnerable people end up taking advice from individuals who are not appropriately qualified.

5:50 pm

Photo of Martin ConwayMartin Conway (Fine Gael)
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I welcome the Minister of State to the House to discuss this very important issue. As colleagues have pointed out, the matter has been raised on numerous occasions in this House between Private Members' motions and statements. The Minister of State is doing her best under very difficult circumstances, bearing in mind that we are barely out of a troika programme, but I am not satisfied she is getting the necessary support from Government to deal with these issues head on. All we need do is compare the impact of suicide on society with other issues which cause injury and death. In the case of road traffic accidents, to give one example, the Road Safety Authority is overseeing a focused, strategic and effective strategy and its campaigns are having an impact. When it comes to suicide, which claims more lives every year than are lost on the roads and affects many others, I do not see that type of strategy. As I said, the Minister of State is doing her best to make it happen, but on this particular issue it comes down to resources.

I acknowledge the phenomenal work being done by thousands of volunteers throughout the country in a myriad of organisations, raising money and providing counselling and peer support. Most people are aware of the important work done by Pieta House and Aware, among others. A lot of work is happening locally as well. In my own constituency the William Winder Rainbow Foundation is a good example of this, while in Leitrim there is an organisation very closely associated with a former colleague of ours. I commend the various councillors around the country, from all parties, who have done enormous work in raising awareness and money and providing support. I also acknowledge the great work done by our colleague, Deputy Dan Neville, in this area. He is regarded not just as a national but an international expert on these issues.

There are lots of good people doing lots of good things, but the question arises as to whether all of this work is being channelled effectively into an overall coherent and focused strategy. It is a cause for concern that there is such a proliferation of organisations, some very much local and others national, all of them doing great work but not necessarily in a coherent way. I acknowledge the efforts of professionals, most of whom are working under very difficult and challenging circumstances and often go above and beyond the call of duty in order to deal with this scourge. Lots of ordinary people want to help but do not know what to do. Many of them end up fund-raising to support existing organisations or set up a new body. There must be a greater effort to impose coherence on the services that are there as part of the strategies the Minister of State outlined.

A vital component of any strategy must be the introduction of focused educational programmes in every primary and secondary school in the country. We need to start dealing properly with the issue of cyberbullying, of which I spoke at length recently. The Department of Education and Skills and individual teachers up and down the country have done a lot of work in putting in place and implementing policies to deal with bullying, whether in the playground or on the Internet. Those programmes must be monitored constantly and where schools are not up to scratch or where flash-points are identified, there must be immediate and effective intervention.

This is a battle we have to win and we can do so with the right resources and commitment and the Minister of State driving us forward. This House has a role to play in constantly reminding her of the hundreds of thousands of families throughout the country who have been devastated by this issue. We are doing our job by keeping the pressure on the Minister of State. I am sure she is doing hers by keeping pressure on Government to provide the resources and ensuring the message is driven home within her Department. We have a maximum of 17 or 18 months left in government. The best legacy we could provide is one of improved mental health and better access to services for people in this State.

Photo of Kathleen LynchKathleen Lynch (Cork North Central, Labour)
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It is difficult to know where to begin in responding to all the points made. Senator Bacik noted that the 11th hour of the 11th day of the 11th month is a time when we remember lives lost in war. It is a very poignant day to have this debate. I always make a note on this morning every year to remind myself of the sacrifices others have made in the past.

Several Members referred to the Road Safety Authority. I have a particular view on this issue and it irritates me to hear some of the arguments that are made in this regard. The bottom line is that one can never compare road safety with suicide. We have no way of penalising people who self-harm or complete suicide, nor should we contemplate anything of that kind. We have advanced beyond that.

Photo of Martin ConwayMartin Conway (Fine Gael)
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I was referring specifically to strategies to raise awareness and so on.

Photo of Kathleen LynchKathleen Lynch (Cork North Central, Labour)
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That is not always explicitly spelt out when the comparison is made.

Photo of Martin ConwayMartin Conway (Fine Gael)
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I am clarifying what I said, not what anybody else said.

Photo of Kathleen LynchKathleen Lynch (Cork North Central, Labour)
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I understand that. There is a range or menu of actions that can be taken in regard to road safety. One can ensure limiters are installed in cars, implement road improvements, introduce penalty points and so on. One cannot go down that route with suicide prevention because it is a different and far more complex area.

People die by suicide for a range of reasons. Some of those people are in receipt of mental health services, but many are not. There are undetermined deaths, as mentioned by Senator Paul Coghlan. As long as those deaths are undetermined, who are we to make a judgment on them? The families of those people would not thank us if we made a judgment call on those deaths; those deaths are undetermined and are defined as undetermined. We have mechanisms by which we evaluate whether people have died by suicide, such as those operated by the Garda, the CSO, the coroner and a range of others. We just need to be cautious in what we are doing.

I love coming to the Seanad to hear debates and I always make myself available for these debates, although perhaps I should not be so available. It strikes me, however, that everybody has an agenda. While everyone's agenda might have the same central aim, it is the agenda of that individual. It is obvious, for example, that our newly elected Senator has an interest in education. We all have an agenda. My agenda is to ensure A Vision for Change is implemented in so far as it can be, but I must point out the facts also. A Vision for Change was published in 2006, but it had a stop-start beginning. There is a difficulty, therefore, in that it is not being implemented as quickly as possible. Until 2012, it stopped and started. One year it seemed about to happen, but it did not and only bits of it were implemented.

Since 2012 we have had a clear view on the strategy, and we are driving it forward, although we have not fully implemented it yet. Perhaps if we had had what we have now since 2006, we would be further down the road. I cannot say the reason for the delay is the fault of anybody and I do not lay the blame at anybody's door. I do not do that. I just say to myself that it is now my job and I get on with it. I realise that some people believe the job I do is not good enough and others believe I have too much to do, but we will never agree on that. The reason we have not progressed further at this stage is the stop-start nature of the programme until 2012.

I agree with Senator Bacik that all the research suggests that early childhood trauma is a significant issue. This may not emerge in the formative years - at 14, 15 or 16 - but even when issues emerge later, they can all be traced back to early childhood trauma. We must, therefore, cherish our children far more than we do.

Senator van Turnhout spoke about child and adolescent mental health services, CAMHS. This service will remain within the mental health service rather than moving over to Tusla, the Child and Family Agency. I admit that I question my judgment on that. I put up a substantial fight and dug my heels in to ensure the service stayed within the mental health services and that it would be a seamless service, but I question that judgment more and more. While I am not convinced that I made the wrong decision, I question my judgment, because we are not getting the results we want for the resources we are putting into the service. I will keep this under review and will continue to question my judgment on the issue.

There is a difficulty in regard to child and adolescent psychiatrists. We are looking for one currently, and not only have we trawled for one in Ireland, we have gone to an agency in England through which we had some success previously. We have not succeeded so far. At the same time, a private provider has been offering a salary far in excess of what we can offer, but it has not been successful either. There is clearly a difficulty in getting people for this area and we have a problem in that regard at this time.

The strategy to ensure we have a follow-on strategy on suicide and suicide prevention is completed and will be published. This will ensure there will be no gap between strategies, and it is a sign of success for the Department. I still have a copy of the Planning for the Future strategy introduced by Barry Desmond in 1983 on a bookshelf at home. The strategy previous to that was published in 1964. There have been enormous gaps between plans. I should mention that apart from including tables on the staff required, there is little difference between A Vision for Change and Planning for the Future, although the latter was not as intricate or as detailed. I intend to ensure we no longer have significant gaps between strategies. A Vision for Change will run out in 2016 and we intend to put a group in place to plan for the time beyond that.

We are also preparing to deal with other areas. The gap in the services available for children and adolescents between the ages of 16 and 18 is unacceptable, but the bigger issue relates to what happens when a person reaches 18. Should these young people fall off the cliff and go automatically into an adult service that they may not be ready for or that may not be ready for them? We are looking at what has been done in regard to mental health services in Birmingham by Professor Swaran Singh. A transition programme has been put in place there for young adults between the ages of 16 and 25, and the two services interact so as to ensure not only that the person is familiar with the service but that the service is familiar with the person. We are considering this seriously because it is what needs to happen.

It is difficult to get everything one wants to say into a speech, despite its being 24 pages in length. I am constantly being told that it should be possible to spot the signs of suicidal intent if an approach is made by the person. If a person approaches his or her GP, a family member or a health professional, it should be possible to spot the signs of suicidal intent, even without the person expressing that intent. I have asked somebody to put this in writing for me and to explain these signs for me. I do not mean that I want 40 pages of a single assessment tool. I am talking about a list of questions on a page that could be ticked that would lead us further, provided the person ticked enough of the questions.

Suicide crisis assessment nurses, SCANs, will be important in our programme. Significant numbers of people who self-harm go on to die by suicide. A significant proportion of the 12,000 people who self-harm are repeat visitors to our services. Why are we not picking up on those people who are returning again and again for help? Why are we allowing this sort of behaviour to become embedded? SCANs and specialist nurses within emergency departments will pick up on this issue and will ensure that these people do not simply get patched up and let go. Follow-up appointments will be made and people will be phoned and reminded to attend again later. It is important all of this happens.

Counselling in primary care, CIPC, is important. We did not know how successful this initiative would be when we put it in place last year and had no idea of the numbers that would be involved. The initiative has been so successful that we already have waiting lists, and clearly we need more resources in the area. GPs can now refer people without going through the psychiatry model. We realise now how important this is and the need for more resources.

We have difficulties in some areas in regard to recruitment of clinical psychologists. A friend of mine has told me it is good that our graduates are going abroad because they get experience that we will benefit from in the future. Rather than standing up here every month and telling the House that I cannot get clinical psychologists, we are now going to retrain social workers and nurses in dialectical behaviour therapy, DBT, which has a significant impact.

It is about the progression, but it is also true that we have not done everything wrong. There are some people who will say that I have done nothing right since I came into the post, but that is not true either. There is a balance there somewhere; sometimes the scales go one way, sometimes they go the other way. We are making progress, contradicting all the negativity that we hear constantly, day in, day out.

There is a difficulty in filling specialist posts in the area of intellectual disability. We are addressing that this year. There is a similar difficulty in the fields of old-age psychiatry and eating disorders, with the clinical pathways and so on. We know about them and we have a plan in place in order to get the specialists. Sometimes it is quite difficult but we are going to do it. We are going to try our very best, and are now going further afield to try and bring them in. There are obstacles and there are people who will stand up and say they are completely in favour of A Vision for Change but really they are not. They will oppose and block and do all they can in order to stop it. I must admit that I cannot really blame them. If one is working in a particular area all of one's life and there is a particular set of values in the organisation it is difficult enough to move that along. It is not all bad. It is not all right - there is a lot to be done - but it is not all bad either.

I appreciate being asked to the House. We have made enormous progress in terms of our attitudes and our ability to say it out loud. Up to now we had been hiding in shadows and we should stop that. It is not health or mental health, it is part of what we are. Some days we feel good, some days we feel bad and that is the difficulty with it.

6:10 pm

Photo of Michael ComiskeyMichael Comiskey (Fine Gael)
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When is it proposed to sit again?

Photo of Maurice CumminsMaurice Cummins (Fine Gael)
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At 10.30 a.m. on Wednesday, 12 November 2014.