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THE STATE RESPONSE to the Covid-19 pandemic, flattening the curve and shielding vulnerable citizens, has undoubtedly saved many lives.
We also know that restrictions on personal liberty and the socio-economic impacts thereof will have indirect implications on health, for years to come.
A lot has been spoken about the impact on our nation’s mental health, and this has translated into widespread presentations to General Practice.
However, we must move on from saying ‘we need to do more’ and outline practical solutions to mitigate the secondary impact of Covid-19.
It all comes out behind the closed door of a GP’s consultation room.
A mother might call about her adult-son, who is avoiding friends and sleeping all day.
A house call to an isolated widow, cocooning from Covid-19.
The local school principal worried about a bullied Transition Year pupil.
The father who breaks down as his daughter has anorexia.
If the GP asks, ‘is he hitting you?’.
A new mother, overwhelmed, with little support.
Someone’s anxiety and depression has recurred, faced with unrelenting job-stress.
Someone who says they are back drinking.
Asking, ‘Is there something else on your mind?’ at end of the consult, prompting tears and the uncovering of the real issue at play.
Surfing on couches, with no house, and turning to heroin to cope.
Possibly 25% of GP-workload relates directly with managing mental health symptoms, including anxiety symptoms, depressive symptoms and addiction.
We listen, provide hope, coordinate the many psychosocial components for recovery and sometimes consider medication options.
We see patients again and witness their recovery or relapse.
We assess the risk of self-harm, mitigate that risk and absorb it in our evenings and weekends.
We rarely refer to secondary care services.
Patients with severe or psychotic depression, bipolar affective disorder, schizophrenia are cared for between General Practice and the adult mental health services, whose members include doctors (psychiatrists), nurses, occupational therapists and social workers.
For these patients, with life-long mental health conditions, GPs prescribe their medications and monitor and coordinate their care between specialist appointments.
It is within General Practice where the care for most patients with mental health conditions is coordinated.
But you wouldn’t think this, if you judged it by media commentary or in the funding of our healthcare services.
There are multiple stakeholders in ‘mental health’ advocacy, including the Mental Health Commission, the College of Psychiatrists of Ireland, the Irish College for General Practitioners, unions (Irish Medical Organisation and Psychiatric Nurses Association), the very visible charity-sector and an increasing number of well-meaning celebrities and influencers.
Mental Health Reform is one such stakeholder, representing over 70 organisations, which lobbies for increases in the mental health budget and the implementation of a Vision for Change, our long-held mental health strategy.
Many of these groups say little about where people turn to when patients first encounter a mental health crisis. The HSE website states that ‘most people with mental health problems can be treated by their GP’, yet GPs and the patients who seek their care, are left with little support.
More than health
It is to the credit of the Mental Health Reform alliance, that it highlights the social determinants of mental health and the role of the departments of Education and Skills, Housing and Justice in its advocacy.
The pathways to recovery reside in minimising societal inequalities and ensuring there is security in housing and employment.
We cannot ‘fund mental health services’ without first ensuring access to housing and security at work.
We also need to look at the absence of State-run parenting supports, which can mitigate the development of behavioural problems. The problem and solution to the majority of mental health conditions is social and political.
Pickett and Wilkinson in The Spirit Level have demonstrated that more unequal countries suffer with higher levels of mental illness, including drug addiction and anxiety.
Psychological and medication options can only do so much when we face the chaos of homelessness or the insecurity of zero-hour contracts and the inability to disconnect from work.
And then Covid-19 hit.
The economic, social, educational, cultural and occupational impacts are profound.
Supporting mental health means supporting the economic livelihoods and cultural resilience of our nation.
This is not the role of the Department of Health, but rather every other government department.
Over-focus on charity has exposed the State’s derogation of primary care based mental healthcare management has led to a vacuum, which has been filled by charities.
We are lucky to have them.
Many of the charities have wonderful volunteers and staff, providing well-intentioned services, events and awareness campaigns.
No health system in the world exists without a charity sector, but we do need to ask questions and interrogate their usefulness and cost-effectiveness.
Pieta House (€13.4 million), Samaritans (€2.2 million), Aware (€2.8 million), Spunout.ie (€0.7 million) and Lust for Life (€0.2 million) have a combined turnover of around €20 million, judging by their public accounts.
Some other mental health charities are less clear about their funding arrangements and activities.
I am not questioning the motives of these charities or their volunteers, but they exist because the State’s response to mental health management has been suboptimal.
It is not intentional, but they fragment mental healthcare, when services should be streamlined and embedded within existing healthcare services, as much as is possible.
Mental health charities are endlessly promoted by the media, but we need more critical analysis. Embedding mental healthcare within existing services, and less charity, is needed if our mental health services are to deliver on the aims of a Vision for Change.
State funding of GP-based mental health presentations
There is an absence of funded-mental-healthcare in General Practice for all patients, be they General Medical Scheme (GMS or medical card) holders or not.
Providing the space and time for patients is a loss-leader in the current business model of General Practice.
The €987.4 million allocated to ‘mental health services’ in the 2020 National Service Plan does not even factor GP-based care for mental health difficulties.
The service plan is informed by A Vision for Change and Connecting for Life: Ireland’s National Strategy to Reduce Suicide 2015-2020.
Goal 4 of this plan aims to ‘enhance accessibility, consistency and care pathways of services for people vulnerable to suicidal behaviour’ and recommends psychiatric and psychological interventions.
Nothing is said of the burden of workload in General Practice or how most of the population have to pay for this at the free-market cost, or that this service is outside the remit of the GMS contract for GPs for GMS-eligible patients.
In Canada or Australia, GPs are supported with counselling billing codes, to enable practices provide time and reassurance.
Government ministers and the multitude of strategic reports might speak of the need to ‘resource our mental health services’, but in reality, we leave primary care mental health to the market.
A universal counselling payment, for GPs, would alleviate this stress for all patients.
The Vision for Change strategy opens with a call for ‘each citizen to have access to local, specialised and comprehensive mental health service provision that is of the highest standard.’
We should finally enable this care within General Practice.
Funding GP-based psychological therapies
The main non-GP, professional support that is required for patients with a mental health difficulty, is psychological therapy. And the main public psychology service available to GPs, is called Counselling in Primary Care.
Have a look at their website.
The following problems preclude a patient from accessing this service: those with moderate to severe psychological problems, longstanding depression, severe anxiety, behavioural problems or personality disorders.
You couldn’t make it up.
That is before the minefield of getting a patient to attend this service after posting a letter, getting the patient to opt-in and then repeatedly travel to the counselling-location.
Other public HSE psychology services, which GPs are ‘allowed’ to refer to, can have wait-times of over six months.
For non-GMS (private) patients, the cost of attending psychotherapy or a course of cognitive behavioural therapy can be between €1,000-€2,000 per annum.
These services should be publicly funded- or part-funded- ideally within GP premises. Most practices have available rooms, which could facilitate this work, which would de-fragment the management of mental health conditions.
Inequality accessing services
At rare times, a patient might need onward referral to adult mental health services.
Up to one in 10 people in Ireland are labelled with a personality disorder, such as ‘emotionally unstable personality disorder’, a pejorative term characterised by mood swings and a fear of abandonment.
The label of ‘personality disorder’ often stays with patients and they are refused access to primary care psychological and adult mental health services.
Another deficit is in our management of addiction and specifically ‘dual diagnosis’, which means that a person suffers with both an addiction, and symptoms of anxiety and depression.
These patients can fall between cracks in our specialist services, with referrals by GPs often not ‘accepted’ by some general adult mental health services.
As excellent as our psychiatry colleagues are, GPs are not always looking for a psychiatric opinion when we refer to adult mental health services, but for ongoing community psychiatric nurse, occupational therapy and psychology input.
Yet it can be hard to access these services for some patients, with referrals sometimes rejected before a patient is seen in person, on the assumption that a patient does not meet referral-criteria, that a personality component is at play, or that there is a co- existent addiction.
The failures in funding and organising our Child and Adolescent Mental Health Services (CAMHS) have been articulated by the Mental Health Commission, our statutory mental health regulator.
We can all agree the waiting lists for CAMHS is too long, yet little has been done to increase staffing and reduce waiting lists.
A particular gap in services for families, is when adolescents fall between the CAMHS and adult cut-off-limits for referral, which is typically 16-17 years of age.
Whilst funding is sorely needed to support CAMHS and adult psychiatry colleagues, listening to GPs and accepting patients in this age group, could alleviate immediate problems for families facing a crisis.
There are also inequalities in accessing specialist mental healthcare services, based upon ability to pay.
Concurrent to an absence of supports for GP-based care, and delays to public CAMHS and adult specialist services, we have a private sector which can promote lengthy, deconditioning admissions, which are reimbursed by private insurance companies.
Like all healthcare inequalities, this relates to an absence of regulation and governance in the health sector by the Department of Health and a lack of leadership from the Minister for Health and Minister of State with responsibility for Mental Health and Older People.
A solution?
When you hear a commentator state ‘we need to resource mental healthcare’, please cut through this and specifically ask what exactly should be resourced.
We need a GP-based universal payment for mental health presentations, we need GP-based psychological supports for all patients with mental health symptoms, we need to trust GP-coordinated referrals, moderate our over-reliance on a well-meaning charity sector and most importantly acknowledge the socio-political root-causes which can impact our mental health.
Covid-19 will brutally expose our deficiencies in caring for our most vulnerable, unless real changes in policy happen soon.
A de-fragmentated holistic system caring for patients with mental health problems can be achieved, but only when we start from where a patient first presents to the healthcare service – their GP.
Mark Murphy PhD MICGP works as a GP in South Inner City Dublin. You can find him on Twitter @drmarkmurphy
An earlier figure used in this article for the income of the Samaritans was based on finances for the UK and Ireland. This has now been updated to reflect the Irish income.
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They really were just expecting Ireland to just comply and make things easy for Britain. They got quite the shock. And if they think the negotiations are difficult now, I don’t think they’ve seen anything yet.
@JJ O Riordan: isn’t it great.
“want Britain to leave the single market and customs union, and see the Irish government’s attempts to avoid a hard border as denying them the kind of Brexit they want for the UK.”
They can blame themselves and the DUP for that. Isn’t it ironic that it is the six counties in the north that will ultimately deny them a hard border and they will be someway tied into the customs union and single market because of the north. It will hinder them as they are bound to the GFA. The North will be a headache for them. Karma I would say for occupying a part of a country that never belonged to them in the first place. On our side, all parties are united, calm and composed, on the british side, chaos.
And the DUP’s Nelson McCausland in an RTÉ interview referring to Enda Kennedy :)
@Stephen Duffy: he’s been called worse down here
Brexiteers were like kids who were let into a sweet shop and started crying because they got sick tummies when nobody came to drag them home. Now they are home alone with no dinner. What will they do next..
I wouldn’t pay a blind bit of notice to these things, a sure sign of childish behavior is to misspell a name or things like that – it normally exposes a weak position or as a defense mechanism . I did say it would be February before British politics sorts itself out but the DUP mentality will never again dominate the politics of our two islands like it did before in tone or in content but to be fair to them, they have opened up the influences of regional differences are more important than the weal Labour opposition.
So why all this sabre rattling from the Irish government when all it resulted in was the British government agreeing to not put in a hard border (which they never wanted to do in the first place) and affirming that there’d be no “special status” outside the UK for NI (which they’d left unsaid previously)?
Just a young leader who surprised the EU and UK with sudden unnecessary demands at the whims of the people who do his twitter account?
@Damocles: come on, you’re an intelligent enough fellow to realise what the last few days actually mean in the grand scheme of things. Ireland and the EU have been very firm in what they expect and the British have been scrambling around trying to ensure it’s complied to.
Whilst the wording is vague, at best, it’s set the tone and shown the UK how the negotiations will be played out
@John Flynn: yes. The UK has always offered a soft border to Ireland and Ireland has shown that it’ll bleat like a wounded sheep to get what was always being offered to it as if it wasn’t, wasting everyone’s time in the process. That’s beyond clear.
@John Flynn: Not intelligent at all, he merely spins a perspective while having no foresight and that becomes tedious. In the absence of a strong UK opposition, it turns out that the UK regions including London have discovered they have to do the job in the coming months. The fact that the DUP won’t represent the majority of their electorate speaks for itself but the had better start.
@Damocles: I think we have every right to push for what suits us as a country. Why shouldn’t we come out strong? We have every right to be suspicious of the British considering our history. I know things have moved on and we need to acknowledge that but we don’t need to be fools either.
I just wish we had represented ourselves like this during the troika years. I cant see anyone patting Varadkar or Coveney on the head like a pet poodle.
@Ser Barristan Selmy: You sound like a Unionist but then again you follow the scientific version of the brexiteers who make things up as they go along.
@Jane: what you were pushing for as a country was what was being offered in all May’s speeches on this subject. From her initial speech all the way through to Florence.
@Damocles: as we well know, what’s said and what’s written can be two very different things. Don’t be so naive
@John Flynn: so you got the UK to write down what it had always been saying in the report it would have been written in anyway. But with an additional commitment to not separate NI out from the rest of the UK.
Wow. That’s really standing up for yourselves.
@Damocles: so we should have accepted that? And when they changed their minds, caved to pressure, couldn’t find a way or left the EU without a deal, what then? Could we have gone to them licking our wounds crying ‘but you promised’. Considering what’s at stake I think that would be foolhardy in the extreme.
@Damocles: you’re really showing your naivety now. How’s that 350 million a week working out for the Brits? Face it, Brexit was a bunch of lies perpetuated by xenophobic fools trying to hark back to the imperial days and you expect us to take their word for it? I take back my comment above describing your level of intelligence
@Jane: nothing is agreed until everything is agreed. If there is no deal then this is not actually binding. But the UK will abide by it. Because, contrary to what you people seem to think, the UK is not actually out to “get” Ireland.
@Damocles: England giving rhetoric about a soft border and having a written agreement are very different things. Nobody wants a return to the troubles and nobody wants an invading army on our Island, but if British boots make a return it will be inevitable the troubles will begin again. And with a Country full of dissillousioned youth that cant get work, that have been shafted and discriminated agsinst by FG & Labour. The pickings are ripe for a return to the 80′s
@John Flynn: I’m glad I never made any suggestions regarding your intelligence given the paucity thereof in your latest remarks.
@Damocles: you’ve got it the wrong way round. All we wanted was an assurance that the UK government would stick to its word regarding no hard border, an assurance they could not immediately give us. Had they just given the assurance from the start then there’d be no need for all this nonsense.
@Damocles: the U.K. will abide by it now because of the agreement they have come to. If all of this was promised already and the British were always going to abide by it then why did it take them so long to agree it? You are saying the Irish made a big deal out of something that was a forgone conclusion, if that’s the case what was the problem on the British side? Why wasn’t this agreed weeks, months ago?
@Jane: as far as the UK was concerned it was agreed months ago. The sabre rattling at the 11th hour from Ireland took everyone by surprise.
Dublin: “Promise not to impose a border.”
London: “OK, we promise.”
Dublin: “Now promise that we won’t impose one either.”
London: “But that’s up to you, surely?”
Dublin: “Why are you being so difficult?”
Brussels: “Yeah! Show some flexibility!”
@Damocles: pushing further lies. That isn’t what happened and you know it.
Honestly folks, you’re wasting your time with someone like this
@John Flynn: mute
@Damocles: nope
Britian: We promise no hard border
Ireland: Great can we have that in writing?
Britian: No need for that, trust us, would we lie? Is there anything we have ever done that could make you doubt us?
Ireland: We’ll just get that in writing, thanks.
@Damocles: Ireland has long experience of UK not keeping its word.
The present border was supposed to be temporary and its final shape was supposed to be determined by a boundary commission. We have been waiting for that since 1922 and there is still no sign of it happening. There is a reason that Britain is known as “Perfidious Albion”.
@Damocles: Idiot troll.
@Kian: And, historically, treaties or agreements with the British state have always caused chaos. Pakistan, Israel, N.I.
@Jane: it would have been in writing in the progress report anyway.
@Nick Caffrey: mute.
@John Flynn: He’s an idiotic troll, don’t mind him.
@Jane: Nice! Love it.
@Damocles: http://www.thejournal.ie/brexit-ireland-9-3730804-Dec2017/
You regurgitated the same rubbish before the deal was struck but it turned out even better than expected when the UK regions showed themselves to look for the conditions the DUP didn’t want.
@Damocles: so you think a mention in a report is the same as an agreement signed by 2 sides?
@Kevin Barry: if you don’t trust the UK regardless why even bother with trying to make an agreement at all?
@Jane: that’s what you got. The whole thing has been specified in the progress report.
@Damocles: muting those who prove you wrong…that’s one way to stay ignorant I suppose
@Damocles: Nope. Not sabre rattling. Demanding competently written policy. And we succeeded in getting that and effecting a change in said policy. Please do correct me if you disagree.
@Damocles: It’s hard when you lose, but you can always take lessons from the experience .
@Ser Barristan Selmy: I’m sure he’s very hurt by that insult as it comes from someone who doesn’t even have the courage to stand over their own opinion.
@Damocles: Speeches and aspirations are not enough. It is reasonable for us to expect competently written policy. We got it. We then effected changes to it. We succeeded in our aims and will continue in the same manner going forward.
@Nick Caffrey: He’s muted me for stating the good things I like about British people. It’s funny behaviour isn’t it? Getting up early on a Saturday to anonymously taunt responses from possibly thousands of people and then be annoyed when get those responses.
I don’t know what the world is coming to.
@Kian: no. Muting people who resort to personal abuse.
@Damocles: ah you dont believe thats what happened really ?? The irish position was to -rightly- force clarity during Phase 1 of the talks on the border position. This effectively meant that the trade talks couldn’t get to a stage further down the road (very possible ) where the 500bn trade deal between the Uk and EU was being concluded and a hard border ended up feasted on us – theres no telling what the Brits /EU would marginalise such a small player for the so called greater good down the road !!! THATS why the negotiation tactic of getting this as a floor at this stage was so important – trying to claim it as as a nothing burger is just dead wrong mate
The photograph showing the EU and British teams at negotiating table. David Davis arrogant smile/demeanour says it all about how the British see themselves. That after being ripped apart at the House if Commons select committee. Now they have to learn about Irish politics.
Why is this relevant?
This country needs to take a good long hard look at itself and it’s OWN MISTAKES before jibing at the UK. God knows Ireland has made plenty of them over the years.
@Pat Butler: Great point. Every country has it’s own problems and Ireland has it’s fair share of politicians stating ill-informed opinions.
@Pat Butler: Yeah, God forbid that anyone would suggest that Britain engage in a little introspection. You can take down the Union Jack now, there’s a good man.
@Pat Butler: Really? The people in charge of the UK don’t know what they’re talking about and we should look at ourselves?
Yeah Pat, we will.
What have England done to Ireland over 800 years…did their utmost to destroy our language,culture,starved our people,murdered the innocent…the list goes on and on. …and they call us troublesome
They’re not that terribly keen on us Scots either: https://twitter.com/snapdragon6469/status/856461895334842368
Typical brits, that’s the mentality that wants to close their borders shining through. They don’t give a toss about anything except their own comfort.
Is there no end to the constant self-obsession about what England thinks of Ireland so we can play the victim card. Is there even the slightest recognition of the positive aspects of our relationship with Britain. Since independence Britain has continued to treat Irish people as de facto citizens in Britain. After we left the UK & long before the EU existed we were able to go to Britain for work have equal access to social housing, health service, equal voting rights etc. but we only ever focus on the negatives & past injustices.Many in Ireland insecurely seek approval from Britain whilst at the same time bashing Britain at every opportunity. It is utterly tedious at this stage.
http://ardevine.blogspot.ie/2017/07/what-have-british-ever-done-for-us.html?m=1
@AR Devine: well in the interests of balance…..look closely at the history between the two nations , for hundreds of years the UK has a pretty shabby track record in terms of how it mistreated Ireland – the act of union /penal laws / famine / wars sectarianism / cromwell/occupation / plundering of resources unto the more recent century of botching home rule ,the north , treatment of catholics as second class citizens and the fact so many irish fought and served in the British military services – its not simply that we only focus on the negatives – its that the irish history with the UK has been so overwhelmingly negative for Ireland in the relationship that it doesn’t really cut it to say we should be more positive because its tedious…the more you learn about the real history -tedious is not really a word that best describes it – sad , tragic -maybe , not tedious.
I’m going to make a very unpopular prediction There will eventually be a hard border and it will be imposed not by the Brits but by the Republic when South American meat, cheap booze and cheap Chinese goods start flooding in from N.I. Before the single market the border was on this side, it will happen again.
@John Mc Donagh: doubt to hat , the one thing that has become clear from the negotiations so far , that the UK are actually keen on keeping trade and markets to mirror as close as possible to the existing EU single market , thats why they have moved on any issues so far , even as far as openly suggesting that the status applied to trade for NI /EU/ ire would be similar for all the UK , so I think Brexit is going to end up looking very Brexit light , very similar trade deal as single market , called or labeled something else but almost identical – and the only noticeable differentiator will be their UK desire to limit immigration / not get cheaper booze and South American meat -even the US have said they wont do any trade agreement of there is risk the UK market is a gateway for poor quality food etc – so I dont agree with your predictions
It’s not their fault that they where been denied the right to leave the EU by a country where the people are not capable of living together in a civilised way . We can’t have a hard border because the Irish might end up killing one another again . The Scots , Welsh and English seem to be capable of sharing an island together but us Irish don’t .
@Tommy Whelan: The cause of the strife has always been British interference in Ireland. Primary school children could tell you that ffs.
@Tommy Whelan: They’re not being denied the right to leave my anonymous coward friend. They want to negotiate a “deep and special” relationship while they are doing it and they have just realised we are not beholden to give them any deal.
If they just dropped that expectation they could have left ages ago.
Once again: not our problem, not our circus, not our monkeys.
BBC still calls us the Irish Republic.
Get Farage to negotiate for them, oh wait their champion of Brexit is missing and laughing at the stupidity of the British for following him. Don’t think he would do much better on knowledge of Irish history or politics. Long live the Empire!!!!
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