Psychiatry in Ireland

Ireland is the third largest island in Europe and the twentieth largest island in the world, with an area of 86 576 km²; it has a total population of slightly under 6 million. It lies to the north-west of continental Europe and to the west of Great Britain. The Republic of Ireland covers five-sixths of the island; Northern Ireland, which is part of the United Kingdom, is in the north-east. Twenty-six of the 32 counties are in the Republic of Ireland, which has a population of 4.2 million, and its capital is Dublin. The other six counties are in Northern Ireland, which has a population of 1.75 million, and its capital is Belfast. In 1973 both parts of Ireland joined the European Economic Community. This article looks at psychiatry in the Republic of Ireland.

Health spending and organisation

The Health Service Executive (HSE) is responsible for managing and delivering health and personal social services in the Republic of Ireland. It is the largest employer in the state. The €12.4 billion budget in 2006 was the largest of any public sector organisation (Health Service Executive, 2008). In Ireland, nearly 80% of health spending is funded by government revenues, above the average of 73% among member states of the Organisation for Economic Cooperation and Development (OECD). In 2001, public spending accounted for roughly 78% of all money spent on healthcare. Spending has been increasing in recent years on a per capita basis but is lower as a percentage of gross domestic product (GDP) (7.1%) or gross national product (GNP) (8.5%) than the OECD average (8.9%) (Health Research Board, 2008). The 2004 Health Strategy estimated that Ireland’s health spending per capita in 2004 was US$2596 and thus slightly above the average in the rest of the European Union (EU) (US$2550) (Health Research Board, 2008).

In Ireland, as in the UK, general practitioners (GPs) act as gatekeepers of the psychiatric services and specialists can generally be approached only through GPs. As of 1 January 2003, there were 276 permanent consultant psychiatrist posts (171 general adult, 49 child psychiatry, 21 old age psychiatry, 30 learning disability and 5 forensic psychiatry) and 439 non-consultant hospital doctors (NCHDs) (40 senior registrars, 164 registrars and 235 senior house officers) in the public sector and it was proposed that a national target of 421 consultant psychiatrists by the year 2009 and 596 by the year 2013 should be achieved to implement the European Working Time Directive (Department of Health and Children, 2003). This target has not yet been reached.

Irish psychiatry is organised around sectors or catchment areas, based on zones of 25 000–30 000 inhabitants for general psychiatry. Within each sector a multidisciplinary team is in charge of all the mental health needs of the population, from prevention through to rehabilitation, under the direction of a consultant psychiatrist.

Government policies and planning

In the modern era there have been only two national planning documents for mental health, one a report of a commission of inquiry into mental illness (1966) and another entitled Planning for the Future (1984). Both promoted a move to community care. Planning for the Future, in particular, was a prescriptive document, describing in detail the mechanisms for phasing out traditional mental hospitals and placing considerable emphasis on the relocation of acute units in general hospitals. That, though, is a quarter of century old and can no longer respond to new developments in psychiatry such as advanced community models of care.

A Vision for Change is a strategy document which sets out the direction for mental health services in Ireland (Department of Health and Children, 2009). It describes a framework for building and fostering positive mental health across the entire community and for providing accessible, community-based, specialist services for people with mental illness.

Mental health legislation

Mental health legislation in Ireland has not been given priority. A replacement for the 1945 Mental Treatment Act has only recently been implemented: the Mental Health Act 2001, signed into law in July 2001, was implemented on 1 November 2006. The purpose of this Act is to provide a modern framework within which people who are mentally disordered and who need treatment or protection, either in their own interest or in the interest of others, can be cared for and treated (Mental Health Commission, 2008). The Act brings Irish legislation in relation to the detention of patients with a mental disorder into conformity with the European Convention on the Protection of Human Rights and Fundamental Freedoms (Mental Health Commission, 2008).

The Act also has a second purpose, which is to put in place mechanisms by which the standards of care and treatment in mental health services can be monitored, inspected and regulated. The main vehicle for change will be the Mental Health Commission, which was established on 5 April 2002 under the terms of this Act. Mental health tribunals, operating under the aegis of the Mental Health Commission, will conduct a review of each decision by a consultant psychiatrist to detain a patient on an involuntary basis or to extend the duration of such detention. The Inspector of Mental Health Services, as provided by the Act, will be putting in place a system of annual inspections and reports (Mental Health Commission, 2008).

Mental health service delivery

We have seen major changes in the delivery of mental health services in Ireland in recent years. Enormous strides have been made and continue to be made in developing a service that is comprehensive, community based and integrated with other health services. This shift in the delivery of services from predominantly hospital-based care has been extremely successful. Under the National Development Plan, approximately €190 million in capital funding has been made available for the provision of acute psychiatric units attached to general hospitals, additional day care, mental health centres and community residences throughout the country.

The development of psychiatric services in Ireland has mirrored the developments taking place internationally. There has been a move from institutional to community care and a marked decline in hospitalised morbidity. This decline has resulted primarily from a reduction in the number of long-stay patients. At the same time, however, admissions to mental hospitals have risen substantially, placing considerable pressure on acute psychiatric beds. A phenomenon has developed of rapid turnover, with a cycle of readmission, short length of stay and often premature discharge, leading to further readmissions (Health Research Board, 2007).

In Ireland, the rate of private health insurance has increased steadily over time, from around 22% in 1979 to around 50% currently (Health Research Board, 2008). Private hospitals in psychiatry are not very numerous in Ireland compared with other high-income countries: there are in fact only two, St Patrick’s Hospital and St John of God Hospital, both in Dublin. Very few psychiatric patients with severe and long-term illness have private insurance.

Central Mental Hospital is probably the oldest forensic secure hospital in Europe, having opened in 1850. The hospital admits approximately 150 patients per year, from the criminal justice system and also from the psychiatric services under the provisions of the Mental Health Act. It also provides a consultative assessment service for the prison service and for hospitals throughout the country. As the prison population has expanded in recent years, the services of the Central Mental Hospital have come under increasing pressure, resulting in delays in the transfer of prisoners with a mental illness to the hospital (National Forensic Mental Health Services, 2008).

The voluntary sector plays an integral role in the provision of health and personal social services in Ireland. The Commission on Health Funding in 1989 highlighted the immensely important role of voluntary organisations in Ireland. A recently published Amnesty International report acknowledged the funding which is being made available by the Department of Health and Children to support groups and organisations such as Schizophrenia Ireland, Mental Health Ireland, GROW and AWARE to heighten awareness and develop support services for mental health service users and carers (Department of Health and Children, 2008).

Training and education

The academic departments of psychiatry in all medical schools have undergraduate training programmes, which feature 6 weeks of clinical attachments as well as classroom teaching of psychiatry.

In Ireland, psychiatric specialisation follows the Royal College of Psychiatrists’ guidelines in terms of training and assessment. There is no specialisation examination in Ireland at present, except the Diploma in Clinical Psychiatry (DCP), which is designed for GPs. There is the possibility of an MD, which is usually research based, and which most psychiatrists do after they have passed the membership examination. After an overhaul of training, assessment and accreditation in the UK, Ireland has to develop its own system of psychiatric specialisation before 2011, but work is very slow, probably owing to lack of financial resources for educational research.

The All Ireland Institute of Psychiatry arranges two scientific meetings every year.

Since 1 January 2009, the College of Psychiatry of Ireland has been fully operational as the sole body responsible for continuing professional development (CPD), postgraduate training, mental health policy and external relations.

Research and publications

Lack of indigenous research has been a major hindrance to the rational planning and allocation of resources; however, over the past few years a number of research papers have been published.

‘Reach Out – A National Strategy for Action on Suicide Prevention’, a 10-year strategy, was launched on September 2005, which was developed by the HSE and National Suicide Review Group (Department of Health and Children, 2008). The National Office for Suicide Prevention is committed to supporting research in the areas of suicide research/prevention and mental health promotion (National Office for Suicide Prevention, 2009).

The Health Promotion Research Centre is located at the National University of Ireland, Galway. The Centre was established in 1990 to conduct research on health promotion in an Irish context. It is the only designated research centre in Ireland dedicated to health promotion. The Centre collaborates with regional, national and international agencies on the development and evaluation of health promotion strategies and has published widely in the field of mental health promotion (National University of Ireland, Galway, 2009)

The quarterly Irish Journal of Psychological Medicine, Ireland’s only peer-reviewed psychiatric journal, has been supporting and encouraging original Irish psychiatric and psychological research. Irish psychiatric literature has a low international impact factor and Irish psychiatry is relatively underresourced in terms of research.