According to the World Health Organisation (WHO), depression is the leading cause of disability in the world, and a major contributor “to the global burden of disease.” It estimates that over 300 million people suffer from depression worldwide. It says that almost 800,000 die of suicide each year, and that suicide is the leading cause of death for 15 to 29-year-olds. While levels of depression are usually higher in women, the suicide rate is higher for men. Depression is largely under-treated and under-resourced in many parts of the world. The WHO says that 4 out of 15 people suffer from some form of depression or anxiety each year in the European region.
In 2013, The Royal College of Surgeons prepared ‘The Mental Health of Young People in Ireland’ report, which stated that 1 in 5 adults between 19 and 24 experience mental health problems. According to a recent report by UNICEF, Ireland has the fourth-highest suicide rate of affluent countries, with 1 in 10,000 15 to 19-year-olds dying by suicide, although that was based on data from 2011. According to the HSE’s National Office for Suicide Prevention, Ireland is now slightly below the 4.97 per 100,000 average suicide rate for EU countries. A report released by the Central Statistics Office in 2013 shows that the suicide rate for men in Ireland, at 18 per 100,000 men, was almost four times that of women. The same report states that 401.6 men per 100,000, and 391.2 women per 100,000 were admitted to psychiatric units, with the highest cause for admittance being depressive disorders. In the National Suicide Research Foundation statistics for 2014-2016, Limerick city topped the list in terms of suicide rates at 23.7 per 100,000 of the population by a significant margin: the next highest was Roscommon, at 17.3. The rate for Limerick county was 9.7. A 2016 Health Ireland Survey said that 10 percent of the population believed they have a probable mental health problem.
In September of this year, St. Patrick’s Mental Health Services, in anticipation of World Suicide Prevention Day, released a report highlighting the extent to which stigma still surrounds the topic of mental health. According to the survey, 28 percent of people who took part said that they had experienced mental health issues in the past, and 44 percent said that they have a family member who has. Despite this intimate knowledge of the issue, 38 percent said they would not confide in their partner that they were taking anti-depressants, while 36 percent said they would not tell their partner if their child was being treated for depression. One of the most concerning aspects of the report reveals that 64 percent of respondents to the survey believed that seeking treatment was a sign of failure. Most troubling, however, is the fact that 25 percent would not tell anyone if they were having suicidal thoughts.
CEO of St. Patrick’s, Paul Gilligan said that “one of the biggest barriers to seeking help for mental health difficulty is stigma,” and that “Irish attitudes to mental health are still fraught with stigma and negativity.” He also said that recovery “is not just possible but should be expected with the right support and help.”
There are a number of Irish and international celebrities that are unafraid to speak out about mental ill health and wish to dispel the stigma surrounding it. Bressie and The Rubberbandits are two such examples. The Limerick-based Rubberbandits released a song and music video earlier this year in an attempt to combat the shame surrounding the issue.
Yet despite media focus on mental health stigma, Ireland may be insufficiently equipped to deal with mental health issues.
In 2006, A Vision for Change, which aims to reform the Mental Health Care system was launched. In 2013, a new Mental Health Directorate was organised with the function of overseeing financial and operational responsibility for making A Vision for Change a reality.
Despite the existence of this scheme, progress on the improvement of facilities has been slow.
In the 2018 Budget, an additional €35 million was added to improve mental health services. This is an increase to the 2017 budget for the sector, which was around €861 million. The figure for 2018 includes €20 million assigned to mental health service improvements for the previous year, meaning the actual additional allocation of funds is €15 million. Some scrutinised the low amount promised for the sector. Under pressure from Mental Health Reform, Minister for Health, Simon Harris addressed a letter to the organisation, promising that the combined additional spending for the years 2018 and 2019 would be €109 million. In response to the letter, Director of Mental Health Reform, Shari McDaid welcomed the early commitment to funding for the following year, though she did acknowledge how urgently financial support is needed. She said that “there is a need to review the overall adequacy of funding for mental health to deliver the mental health services needed in Ireland. Services are overstretched and coping with increased demand.”
In October, the Minister of State for Mental Health and Older People, Jim Daly told the Dáil that 8,415 people were waiting for psychological appointments nationwide. He said that 2,584 of those people had been waiting for over a year, and that most of them were children. For Counselling in Primary Care, which one may avail of if one has a Medical Card, there is also a significant waiting list. According to the latest figures provided to Limerick Life by the HSE, the average number of people waiting for care during the first five months of 2017 were: 1,336.2 for 1-3 months, 489.6 for 3-6 months, while those who were waiting longer than this averaged at 124.2. A HSE representative told us that not all people referred will receive counselling since people can be referred by their GP in error, and some may simply not turn up for sessions.
The HSE website states that CIPC services are for those with “mild to moderate psychological difficulties,” and for those “who want help with psychological problems that are appropriate for time limited counselling in primary care.” When asked what is the next step for those on medical cards who have availed of the full eight counselling sessions but still need help, we were told by the HSE that “the CIPC service model allows for additional counselling sessions where clinically indicated.”
They said that patients can also be referred to the National Counselling Service. This is free of charge and is open to the public for self-referral. It has been running since 2000, and was set up as a resource to aid people who have been abused while in the care of the state as children. Alternatively, patients may be referred to community health services through their GP. Yet with the challenges for patients waiting for service from the CIPC, it is difficult to know how effective this aftercare may be.
Alternatives to State Care
There are counselling support alternatives to State services. These may be of particular interest for people who have experienced trauma in a specific area or have specific mental health issues. Some of the organisations that provide counselling support are Adapt, The Rape Crisis Centre, and the Simon Community. The services offered deal with specialised areas such as coping with the emotional fallout of domestic violence, rape, and homelessness. Pieta House offer non-specialised counselling, and organisations such as The Samaritans and Aware offer support through their helpline services. The latter also offers support groups and educational programmes. These services provide much-needed resources but are often under great pressure to deliver them.
Noeleen Devlin, a representative from Pieta House said that, in terms of the counselling service that Pieta House provide, they “rarely don’t have a waiting list” in any of their centres throughout the country. She says there is always pressure on the organisation, knowing that they have “people of all ages on our waiting list,” and that they do offer “holdover sessions to high risk clients and link in with them weekly to offer support until [they] can allocate them a therapist.”
She does not think that the funding outlined in the recent Budget is enough. She says that, “in particular, services for under-18s are limited and those that are in place have waiting lists of up to months at a time,” and there is “a need for a specific service in relation to this age group, outside of CAMHS [Child and Adolescent Mental Health Services].” She says the situation for adult support is not much better, and that “there are not enough services to facilitate people with mental health issues which are affordable and accessible.”
The Dublin Rape Crisis Centre recently announced that it is also suffering with delayed support-delivery, and that rape victims will have to wait up to eight months for counselling. Unfortunately, like many voluntary services, many of those that provide counselling have had funding cuts. The Rape Crisis Centre has suffered significant funding cuts in recent years and no effort has been made by the government to replenish them, despite increased economic stability in the country, and the rising demand for support from the organisation.
In September, it emerged that anti-depressant prescriptions rose by 50,000 over the last five years. Medical Card records show that Limerick has the highest prescription rate of anti-depressants in the country. When the figures were released, Fianna Fáil TD, James Browne said that he was concerned that doctors “feel compelled to rely on medicated solutions to treating illness.”
The WHO stresses that drugs should not be the first port of call for treating depression, saying, “Antidepressants can be an effective form of treatment for moderate-severe depression but are not the first line of treatment for cases of mild depression.”
It states that “Health-care providers should keep in mind the possible adverse effects associated with anti-depressant medication, the ability to deliver either intervention (in terms of expertise, and/or treatment available), and individual preferences.” Side effects vary depending on the type of medicine: they include nausea, increased appetite and weight gain, decreased libido or sexual function, drowsiness, insomnia, dry mouth, blurred vision, constipation or diarrhoea, and even irritability and anxiety. This is because these medications often alter brain chemistry, which can have varying effects on different patients.
Medications can be switched if symptoms are persistent. When asked about possible over-prescription of anti-depressants due to pressure on counselling services, a HSE representative stated only that “prescribing of medication is a clinical matter for the treating doctor of each patient.”
The WHO acknowledges that issues with treatment of depression is a world-wide problem and that, “In countries of all income levels, people who are depressed are often not correctly diagnosed, and others who do not have the disorder are too often misdiagnosed and prescribed antidepressants.” It is possible, given the surge in prescriptions for anti-depressants in Ireland recently, that the medication may be over-prescribed to accommodate insufficient Mental Health facilities. Despite this, and deterrence in uptake of support services due to stigma, both State and voluntary organisations seeking to shoulder the burden of the country’s mental health, are still under significant duress.
Winter can be a particularly difficult time for people who suffer with depression. Darker mornings and evenings can trigger Seasonal Affective Disorder (SAD). For the elderly, homeless, and those without close family and friends, it can be an especially lonely time.
Noeleen Devlin, of Pieta House, gave Limerick Life some advice for those struggling at this time of year. She encourages people to “have a plan each day to make a connection with somebody, to get out of the house for a walk if possible . . . to focus on doing something, even if it is going to the local library so that they can read a paper.” She also recommends calling The Samaritans or The Pieta House crisis helpline if they are feeling suicidal. She says, “The main message is that the person stays connected and not to isolate themselves, talking to someone on a helpline is a connection.”