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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