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Ill mental health is the greatest health challenge the world faces. At any given time, 10% of the adult population across the world experience a mental or behavioural problem. Globally, more than 300 million people suffer from depression – the leading cause of disability – with many of these people also suffering from symptoms of anxiety. Some 264 million people are living with an anxiety disorder. Schizophrenia affects about 21 million people and bipolar disorder affects about 60 million people worldwide. Approximately 47.5 million people have dementia worldwide.

10-20% of children and adolescents experience mental disorders. Neuropsychiatric conditions are the leading cause of disability in young people in all regions. Worldwide about 10% of pregnant women and 13% of women who have just given birth experience a mental disorder; primarily depression. In developing countries this percentage is even higher.

In Ireland, it is estimated that one in two experience a mental health difficulty. A recent WHO-led study estimates that depression and anxiety disorders cost the global economy US$ 1 trillion each year in lost productivity. In Ireland the loss to GDP is estimated to be €3 billion. Health systems across the world are not adequately responding to the burden of mental health difficulties. As a consequence, the gap between the need for treatment and its provision is wide. In low and middle income countries, between 76% and 85% of people with mental health difficulties receive no treatment. In high-income countries, between 35% and 50% of people with mental health difficulties are in the same situation.

There are three main obstacles to tackling the problem; deep stigma engrained in every society regarding mental health difficulties, a lack of understanding of what treatments actually work and a lack of investment.

Mental health awareness

Over the last number of years, awareness regarding mental health and mental health difficulties has grown substantially in most societies. This has been driven by education, a growth in personal awareness and declarations by high profile individuals. In Ireland, there is now a component of the school curriculum dedicated to building awareness of mental health. Information regarding mental wellbeing is easily available to everyone on the Internet and high profile people such as rock stars and sports personalities have publicly declared their personal stories regarding mental health difficulties.

Yet negative and inaccurate attitudes to mental health difficulties and those who experience them remain deeply engrained within Irish culture. Recent research carried out by St Patrick’s Mental Health Services indicates that despite the fact that 28% of respondents had previously been treated for a mental health difficulty themselves and 44% reported having a family member who had been previously treated, 25%, would tell no one if they were experiencing suicidal thoughts, 38% would not tell their partner if they were taking anti-depressants and 36% would not tell their partner if their child was being treated for depression.

There is still an inaccurate belief that those with mental health difficulties are likely to be more untrustworthy or more likely to commit violent acts. In Ireland, 44% of people would not trust someone who experienced postnatal depression to babysit, 23% would not willingly marry someone previously hospitalised with depression, 19% said they would not be

entirely comfortable living next door to someone who is bipolar and 29% do not think someone who experiences panic attacks could be head of a company. Across the world when people engage in horrific unexplainable acts, like murder of their own children or deliberately crashing a plane, we attribute their behaviour to mental health difficulties, yet people with mental health difficulties are no more likely to be violent than others and indeed are more likely to hurt themselves than to hurt others.

Stigma

Stigma is best understood through the following model:

Gilligan Stigma Model

Gilligan Stigma Model

The greatest impact of stigma is that it prevents people from seeking help. The research indicates that the majority of people who experience mental health difficulties still do not seek help. In Ireland the research indicates that 64% of people believe that being treated for a mental health difficulty is seen as a sign of personal failure while 25% of people would tell no one if they had previously been an inpatient for a mental health difficulty. Only just over half (55%) would tell a partner. In most countries historically, we have dealt with people experiencing mental health difficulties by locking them in asylums or in prisons causing most families to hide away their loved ones who needed help, or to feel shame and guilt.

There is still significant disagreement and uncertainty regarding our understanding of mental health difficulties and how best to treat them. The debate between the biological and social causes – the medical versus the talk therapy treatment approach – rages on, leaving in its wake the people experiencing difficulties. Yet the evidence indicates that mental health difficulties are most often caused by a combination of biological, social and personal factors and that treatment at all of these levels is the most effective. This view has now been encapsulated into the ‘recovery model’ which seeks to address difficulties in a holistic manner through empowering the person experiencing the difficulties.

Central to this approach is ensuring that treatments and services are grounded in a human rights approach, giving the person control and choice over their own life and treatment decisions.

Stigma and uncertainty lead to a lack of investment and funding of the services. Who will fund prevention and treatment approaches if they are not convinced they will be effective, or if they have deeply held beliefs that nothing can be done to help those experiencing mental health difficulties and that they are in some way different from the rest of society? Across the world, there is a concern that we are spending too much money on healthcare and that there is substantial waste in the system. Mental healthcare has been the largest victim of this belief. Most countries spend less than is required on mental healthcare and prevention.
Ireland spends between 6-7% of the National Mental Health Budget. The estimated necessary spend is 12%. Of course we need to spend wisely, applying the value principle outlined by the Michael Porter, ensuring we measure outcomes per euro spent.

St Patrick’s Mental Health Services’ role in treating mental health difficulties

St Patrick’s Mental Health Services is the largest and oldest independent provider of mental healthcare in Ireland. Since its founding through the legacy of Jonathan Swift over 250 years ago, the Organisation has sought to protect and care for those who experience mental health difficulties. In the last 10 years this journey has brought the Organisation to the realisation that it must strive to create a Society in which all citizens are given the opportunity to live mentally healthy lives. We aspire to provide the highest quality mental healthcare, to promote awareness and understanding about mental health and to advocate for the rights of those experiencing mental health difficulties.

Our journey and challenges in the last 10 years are not unlike those faced by many other organisations in many other countries who are leaving behind their histories of placing those who experience mental health difficulties in institutions and asylums towards a more community-based model of care. Many countries now have mental health strategies underpinned by legislation. Obtaining good committed staff is problematic across the world as working in mental health is not seen as attractive. Trust in health services is at an all-time low. Improving standards alongside controlling costs is a challenge. Reaching out to those needing help and helping them to overcome the prejudice and stigma is a core component of this journey.

In the last 10 years St Patrick’s Mental Health Services, has been grounded in the human rights values of believing in and promoting people’s rights to be treated with dignity and respect, believing in and promoting people’s rights to be protected against discrimination, seeking to provide the least restrictive, least intrusive treatment, seeking to promote independence and personal autonomy, giving people the opportunity to make decisions about their own care, seeking to empower recovery by fostering positive coping and management skills, providing individual care plans grounded in evidence-based best practice and believing in and promoting the full inclusion and equal opportunities for those experiencing mental health difficulties has focused on four key essential and complimentary areas of activity; service delivery, advocacy and awareness raising, service user engagement and research and training. We believe that a modern, progressive mental health service must entail each of these activities.

Advocacy

For 10 years we have sought to establish and provide the highest quality mental health care through in-patient, day care and community-based clinics, providing a complete care pathway. The interventions we provide are multidisciplinary, recovery and evidence-based and we produce outcome measures on a programmatic and organisational and financial basis.

We have transformed an asylum/institution into a therapeutic campus of excellence, supported by a day service providing the most contemporary and modern group interventions and enhanced by a network of community clinics. We employ a full range of nurses, doctors and allied health professionals, ensuring we can provide
individual care plans with the most suitable treatment packages. Our services are consistently assessed by the Mental Health Commission as being of the highest standard. Public perceptions of our work are positive as are referrers.

We have introduced major advocacy and awareness raising campaigns. During 2017, our #StillJustMe campaign, through a series of short films and blog articles written by mental health experts and those with lived experience, has aimed to shine a spotlight on some of the most poorly understood and stigmatised mental health problems in Ireland today.

We focus on lobbying for peoples’ rights to receive high-quality mental health-care and for services to be compliant with the Mental Health Commission’s (MHC) standards and regulations, making submissions on Capacity Legislation and reform of the Mental Health Act, seeking full ratification and compliance with the UNCRPD and European Social Charter and running public and school-based mental health awareness raising campaigns. Our flagship preventive, awareness raising and anti-stigma campaign, Walk In My Shoes, has had tremendous success and is recognised by the majority of the Irish population.

We have been at the forefront of developing service user participation initiatives. We have a service user advisory council, a service user representative on our Board of Governors and service users participate in all interviews for staff and all project teams. Reports and policy documents produced by our Service User and Supporters Council are acted upon as a priority. We have also established the first advocacy service for adolescents in the care of approved centres in Ireland.

Underpinning all of this is a continued commitment to research and training. We are a University Hospital affiliated to one of the oldest and best universities in the country, Trinity College Dublin. We are one of the largest trainers of mental healthcare professionals in Ireland, providing professional training for doctors, nurses, and all allied health professionals.

Children’s mental health is one of the greatest challenges facing Irish society in the last number of years. Research indicates that Irish children experience higher rates of mental health difficulties than their European counterparts. St. Patrick’s Mental Health Services recognises that alongside providing a full range of adolescent mental healthcare services, including in-patient, day service and community-based care, the Organisation must work to prevent mental health difficulties arising for children and to support them to seek support earlier.

The Organisation has focused its efforts in this regard on building young people’s awareness and working with schools and parents. One of our most successful campaigns has been the #MindYourSelfie Campaign which utilises the internet and mobile phones to promote mental health awareness. Working to prevent and treat child and adolescent mental health difficulties is recognised as a key part of our work. We appreciate that tackling childhood mental health difficulties will reduce the likelihood of adult difficulties and will help change societies’ attitudes towards mental health. More importantly, it will ensure children challenged by mental health difficulties will have a happy fulfilling childhood.

Paul Gilligan, Clinical Psychologist and Chief Executive of St Patrick’s Mental Health Services

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