Mental Health: Healing The Hurt
A Major Philanthropic Initiative
By
The Ireland Funds

1. The Context

At any given time 300,000 people in Ireland suffer from depression.

Over 500 people die by suicide in Ireland each year, up four-fold since the 1970’s. 50% of these deaths are under the age of 30 and suicide is now the number one killer of young men in Ireland. Twenty years ago an Irish family physician might, every three years, have seen one patient who would have died by suicide. Now, it is increasingly common for doctors to have two to three patients a year die by suicide from within their clinical practice. Suicide attempt rates have also escalated dramatically in Ireland. In 2002 a shocking 8,500 people attended hospital emergency departments in the Republic with overdoses and other self-inflicted injuries suffered when attempting suicide. Some of these children were as young as five. A further 200 children aged 10 to 14 were also treated for attempted suicide.

2. The Reasons

Why is this occurring?

It is not that the Irish people are any more prone to depression than they were in the past. The nation has ever been prone to depression- masked in different ways. However, the tumultuous changes in Irish society over the last 15 years have made young adult life more pressured while, at the same time, traditional environmental and social sources of support have been weakened. As a result, depressive episodes are more likely to be triggered. In addition the traditional religious, cultural and legal barriers to suicide have diminished. Thus, suicide is now perceived as a more viable option for those experiencing the pain of depression and, indeed, is not infrequently expressed in influential international pop culture.

Prosperity has yielded greater disposable income, leading to greater spending on alcohol, a potent solution to Irish problems. Alcohol is a powerful accelerant to suicide rates in Ireland, with its combined disinhibitory and dysphoric effects, particularly on the younger male adult brain. In addition, there has been a sharp increase in poly-drug abuse often combined with alcohol.

Thus, a changing Ireland has a dark side. Among the key developments in Irish society causing this are:

2.1 Social Changes

Ireland has experienced unprecedented economic growth. At the same time society has become much more demanding in terms of work pressure and expectations of success. These pressures to succeed are felt most acutely by young men. People have had to become much more responsive to change. This is easier for some then others. At the same time tolerance of and preparedness for failure have lessened. The population has become more mobile and footloose. This has lead to the breakup of communities. Now, many young people find themselves alone in large cities and conurbations without the comfort of their community, working harder and with little sense of job security.

2.2 Religion

Religious observance continues to be high in Ireland by western standards. However, it has declined dramatically in the last 20 years in face of the rapid modernization of Irish society and scandals involving the Church. The decline in the importance and visibility of religion has diminished greatly a source of certainty and solace for those experiencing emotional turmoil.

2.3 Image of Suicide

Suicide in the past, not least for religious reasons whereby a victim of suicide could not be buried in consecrated ground, was stigmatized. This barrier has been lifted and suicide was de-criminalized in Ireland in 1993. In the absence of more compelling life-orientated solutions, a depressed person is more likely to see suicide as much more feasible option to resolving their pain. Indeed, in certain cases suicide is almost glamorized following, for instance, the death of such high profile victims as Kurt Cobain.

2.4 Alcohol

Alcohol is a depressant and when under the influence of alcohol young men, in particular, are prone to carry out irrational and violent acts, often-suicidal acts. Young people are consuming far more alcohol in Ireland and are also consuming different types of drinks with more potent spirit based products being available. This compounds depression and reduces their inhibitions about suicide.

2.5 Lack of Services

While the factors leading to suicidal behaviour have increased, the services available in many parts of Ireland are woefully inadequate and outdated. The rapid modernisation of Ireland has far outstripped the development of psychological support services. Indeed, the Government’s mental health budget has decreased by 2% this year. The average spend per capita on mental health in Ireland is a quarter of that in the UK. A critical gap is the lack of mental health core services for adolescents because they fall between the child and adult psychiatric services. This cohort is at a particularly increased risk of suicide. Considering the fact that currently, the highest rates of attempted suicide are in adolescents and that those who make a first attempt have a high risk of repeated suicidal behaviour, the prognostic value of this phenomenon should be seriously addressed by politicians and health care professionals.

In summary, the social, economic and mortality fall-out from depression has deepened greatly in Ireland. There is no simple explanation for this. Suicidal depression and suicide is a complex biological, psychological and social reality which has been left in the margins of the success of modern Ireland, shrouded in secrecy and shame. What is clear is that responses are needed urgently to tackle these twin issues, the consequences of which are horrific for a growing number of families across Ireland, North and South.

3. Solutions

3.1 Overview

Society has changed so much in Ireland that the old forces that tended to cushion those suffering from depression and which inhibited the recourse to suicide, no longer apply. We now need to find new methods in a new Ireland of dealing with these problems. The solutions should be based upon de-mystifying suicidal depression and assuring sufferers that they are not alone, unstable or cursed. Rather, they have a disease, and a highly treatable one at that, and are in need of care and support.

3.2 Statutory

The Irish Government responded by establishing a “Task Force” in 1992 to examine the problem and a National Suicide Review Group was put in place. The final report was produced in 1998 and made multiple recommendations, many of which were laudable. But little has been achieved and the suicide rates remain unchanged. An action-oriented National Suicide Prevention Plan is currently being developed by the Department of Health in conjunction with regional Health Board executives and the National Suicide Review Group.

3.3 Research

Despite the many “theories” about suicidal depression and suicide in Ireland, one of the major problems is that very limited high quality bio-psycho-social research data on suicidal depression exists in Ireland. Innovative internationally recognized research projects have gradually developed in Ireland in the past decade including the National Parasuicide Registry, The Ireland North South Urban Rural Epidemiological (INSURE) Collaborative Study of Suicidal Behaviour in Major Psychiatric Disorders, a novel neuro-imaging research programme of suicidal depression and a programme of research with teens and young adults, both at University College Dublin. These and other research projects around Ireland in prisons, schools and in the substance abuse services represent a promising start in a time of very limited and minimal research funding. These programmes need to be sustained and enhanced to deliver their full potential to guide service development and knowledge.

3.4 Voluntary

Within the Voluntary Sector there are hundreds of volunteers trying to plug the gaps and offer support to Irish people in suicidal crisis and suffering with suicidal depression all around the country. From help-lines to crisis drop-in centres to counseling and support services, the resources of these organizations are paltry despite the Trojan work being done by them at the clinical coal-face. Various dedicated advocacy groups nationally raise awareness in different and often creative ways and also lobby government for additional resources to tackle the problem. Other voluntary groups have dedicated their work to supporting those bereaved by suicide who suffer enormously.

What can we do?

There is an urgent need to fund initiatives which

- Increase public awareness of depression and suicidal behaviour in Ireland
- Address deficiencies in the mental health education of younger people and address depression and suicidal behaviour as part of a broader health promotion programme in schools.
- Reach out and target those at high risk such as young adults. Positive role models, such as sport or pop personalities, can be particularly effective in this regard.
- Significantly enhance support services to those in depression e.g. befriending services, emergency counseling services and bereavement support services. In particular, expand mental health care services for adolescents.
- Focus on developing specific sustained programmes of research into the bio-psycho-social aspects of suicidal depression in Ireland with particular relevance to suicidal acts
- Support the development of regional centres of particular expertise in the management of suicidal depression.
- Introduce new models of early detection of depression, particularly in young adults, in which barriers to care are reduced
- Focus on up-grading mental health training for health professionals including primary care, and support for developing advance mental health academic qualifications.
- Provide specialized training programmes for General Practitioners, in order to improve early detection of depression and suicidal behaviour, safe prescribing practices and appropriate referral pathways.
- Improve accessibility of services for young people, e.g. under 18s should have access to psychological support services without the need of parental consent or a letter of referral from GPs.
- Establish protocols of response to suicide. There appears to be considerable diversity in the responses of mental health care professionals to next of kin following a case of suicide, often related to the absence of specific knowledge and skills. Therefore, we recommend protocols for mental health care professionals on how to respond following a case of suicide, and the provision of brief training in applying the protocol.
- Mount a sustained advocacy campaign to seek the resources and offer recognition that these problems require attention.

4. Conclusion

Very many of our fellow citizens are suffering great anguish, distress and anxiety. For some, they see no way out but by ending their lives. The impact on their loved ones and friends is incalculable.

Individuals, communities, society and cultural attitudes can all influence national suicide rates. Suicide in modern Ireland is not someone else’s problem; it is everyone’s problem. Turning the tide of suicide in Ireland will require leadership, dedication and commitment over time to avoid this tragic legacy being passed onto the next generation.

The Ireland Funds are determined to play their part in lifting the veil on mental health issues and helping to direct the attention and care that those affected deserve.

5. Healing The Hurt: A Major Philanthropic Initiative

Based on this analysis, The Ireland Funds are proposing a programme of intervention in this, one of the least understood and feared issues in Ireland, and, yet, one of the country’s most acute and pressing problems.

The Ireland Funds therefore propose the establishment of a Major Philanthropic Initiative- an MPI.

5.1 Purpose

To concentrate in a focused way on destigmatising mental health issues, on delivering greater and deeper research and on directing more support to those affected.

5.2 Period

From 2004 to 2007. This is to say; lasting and measurable change would be realized over three years.

5.3 Process

A small number of key projects under each of the headings listed in Section 5.5 would be identified. Ireland Funds’ personnel would work directly with each project over the next three- year period agreeing priorities, monitoring change, advising on initiatives and reporting back to Donors.

5.4 Cost

TBD

5.5 Target Areas

Awareness
Public attitudes to depression and suicide must change to give those affected the space and confidence to deal with their problems openly and without fear of ridicule or rejection. Other countries have successfully tackled awareness without glorifying or idealizing the tragedy of youth suicide. Examples include:

• “Beyond Blue” in Australia
• “Choose Life” Scotland
• “Defeat Depression” UK

Research
There is a need for strategic research initiatives to identify the individual, community and cultural factors associated with depression and youth suicide in Ireland. Areas where research should be concentrated included:

• Psychological autopsy studies (i.e. interviewing next of kin in detail) in other countries have yielded critical culture-specific insights regarding youth suicide which then can guide targeted intervention strategies.
• Research strategies in particular high-risk groups.
• Sustained research in the bio-psychological aspects of suicidal depression in Ireland.
• Research on alcohol drinking patterns in Ireland.
• A focused, dedicated Youth Suicide Project team.

Leadership
Irish cultural attitudes can be positively or negatively influenced by leaders and/or example. There is an urgent need to recruit positive public figures to support the campaign against suicide and suicidal depression. Leaders should be identified from all walks of public life in Ireland and internationally.

Intervention
There is a need for specific user-friendly crisis intervention programmes and services across regions of Ireland. Often these services are the only recourse that those slipping into a deeper depression or suicidal phase have. Such critical services and programmes include crisis hotlines, face-to-face expert counseling with support backup for schools, parents etc.

Prevention
There are many elements associated with the prevention of suicide. These include awareness and education at all levels of society (avoiding misinformation), fast track programmes to care, and proper longitudinal multidisciplinary resourcing of services for those at long-term higher risk, especially those with mental illness.

Demonstration Projects
Internationally, demonstration projects, illustrating the positive effects of intervention strategies, have been very persuasive in motivating a response from governments and the release of additional resources (not dissimilar to Breastcheck developments for reducing breast cancer). Such projects include those in Norway, Finland, Denmark and Hungary. There is an urgent need for such demonstration projects in Ireland to activate public opinion around the problem of depression and youth suicide in Ireland (i.e. can do, will do, do it now and it will work).

By focusing our efforts on key and acute needs, measurable results can be achieved. Our aim is simple- to ensure that those with mental health problems are never as ignored nor misunderstood as in the past an that a more open an creative approach is taken to a problem that affects every region, every class and every age group in Ireland today. With honesty, determination and resources the huge hurt so many fell can be reduced. We wish to play our part.

Maurice Hayes
Chairman
The Advisory Committee
September 2004

Prepared in consultation with:
3 T’s (Turning the Tide of Suicide)
Aware
The Mater Hospital, Dublin
Department of Adult Psychiatry, UCD
Samaritans
Tara Centre, Omagh
National Suicide Research Foundation, Cork