‘Mental Health’ improving the length as well as the quality of life is paramount
Mental healthcare is different. A substantial proportion of us will have mental health problems at some point in our lives.
The Government current policy is based on the 2006 report A Vision for Change, it aims to provide services “equitably and across all service user groups”. It calls for an orientation towards recovery and more social inclusion. I welcome this, but I am struck by how different policy is from general medical care, which is based on treating specific illnesses to improve outcome.
Perhaps these, more fundamental aims, have already been met in mental healthcare? Having spent almost 20 years as a clinician treating and researching severe mental illness I do not believe this is true. I find the difference disturbing.
If you have a heart attack or stroke and are too incapacitated to consent, you will receive medical care using the “best interests” principle. Many people with serious mental illness don’t believe that being admitted to hospital is in their best interest. However, there were 2,057 involuntary admissions in 2011 under the Mental Health Act 2001.
At least three-quarters of these were for treatment of two disorders:schizophrenia and bipolar disorder. What the figures reflect is that these two conditions are more common than generally appreciated (there are likely to be more than 50,000 people in Ireland affected).
Most treatment is actually provided in the community by teams including doctors, nurses, psychologists, social workers and occupational therapists. Involuntary admission is reserved for where this approach fails because a person’s judgment is impaired by illness. This could mean that you develop a complete conviction that others are involved in an international conspiracy to kill you or that you have uncontrolled mania causing you to behave recklessly.
This is likely to affect your decision-making, but admission under the Act is reserved for situations where “judgment of the person is so impaired that failure to admit would result in a serious deterioration in the condition, or immediate and serious harm to the person or others”. The average duration of admission, unclear to me from annual reports, is probably fewer than 21 days.
Similar legislation is present in other EU countries. With the implementation of the 2001 Act, Irish admission rates, average by European standards, have fallen by more than a third.
Representative of much of the debate about mental health by Dr Pat Bracken, a consultant psychiatrist, arguing that this practice is too “paternalistic” and “at odds with” national policy. I couldn’t help wondering how this might sound if applied to acute medical care. Would one argue that the provision of care to incapacitated medical patients is too “paternalistic”.
He appears to argue for a person’s “right to define the nature of one’s own problems” even if judgment is impaired by illness. Do we expect patients suffering heart attacks or strokes to “define” their own problems? No. He questions the central role of the consultant in providing acute psychiatric care. We trust hospital consultants to manage acute medical problems.
Maybe serious mental illness is not medically important compared to cardiac disorders, strokes or cancer? Tragically, this is not so. People with schizophrenia have an average life expectancy 17 to 25 years shorter than the general population; for bipolar disorder the figure is 10 years. This is based on international data – Irish figures are not collated – but I doubt the picture is better here.
The facts and their potential consequences for thousands of people go unmentioned in the Irish mental health policy document. If these conditions were physical, with this information, wouldn’t health policy focus on improving the length, not just the quality, of life?
Perhaps psychiatry has nothing to offer? Dr Bracken echoes a prevalent view that effective medical treatments are unavailable and describes current treatments as “a mess” and “toxic”. This is wrong. Take schizophrenia; we know the condition is debilitating and 80 per cent of patients relapse within five years.
Treatment with medication is effective in reducing initial symptoms, but staying on medication, from early in the illness, reduces risk of relapse by more than 50 per cent.
This is similar in efficacy to treatments for diabetes, and better than current treatments for asthma and high blood pressure. Despite the evidence, medical nihilism has had a damning impact on investment in the development of new and better treatments compared to other medical areas. (Pre-empting criticism that as an academic psychiatrist my opinions are “corrupted” by the pharmaceutical industry, I don’t receive funding from industry for my work.)
Rather than helping people to live with serious mental illness, our focus could include improving life expectancy. People with serious mental illness die because of suicide, increased rates of accidental death, from heart disease and as a consequence of poor health related to smoking, low physical activity, poor nutrition and medication.
Can we improve life expectancy? Yes. One function of the Mental Health Act is to allow the management of immediate risk of suicide or serious accident. Patients who take antipsychotic medication live longer. Treating depression in schizophrenia with antidepressant medication reduces death by suicide.
Addressing lifestyle changes and reducing smoking rates is challenging but achievable. People with heart disease and schizophrenia die because of poor medical care. Across international studies, it has been shown that these patients receive fewer heart surgeries and are less likely to be prescribed heart medication than the rest of the population.
Mental healthcare policy is different, but it shouldn’t be. All patients should have access to the best medical care irrespective of whether their condition is physical or mental. The focus of this article has been on only one aspect of treatment. Regrettably provisions for psychological or social interventions are also neglected. Limited mental health resources are currently spread “equitably and across all service user groups”. Based on medical need and available medical interventions, people with serious mental illness may have the greatest claim.
Irish Government appoints a new head of banking policy
John Hogan has been appointed to the new position of head of banking policy in the financial services division in the Department of Finance.
According to a statement from the department, Mr Hogan will be responsible for developing and delivering policy in key areas such as credit and lending to small and medium-sized businesses, mortgage arrears and consumer issues.
The department appointed Mr Hogan following a competitive process ran by the Top Level Appointments Committee.
The head of banking policy is a newly created position in the restructured financial services division as set out in the department’s strategy statement, which was published in May. Mr Hogan’s appointment will complete this restructuring.
Mr Hogan has held a number of positions in the department to date and joined the financial services division in 2009. He is head of credit and lending policy and played a key role in the completion of the inter-departmental report on mortgage arrears (Keane report).
How & why our muscles become paralysed during sleep?
When you are asleep, you cycle through different phases, including one called rapid eye movement or REM sleep. This is the phase where you typically have the dreams you later recall.
Did you know though that in normal REM sleep, your eyes may be moving but many muscles in other parts of your body don’t act like they do when you are awake? Why is that?
The muscles that go offline in normal REM sleep are skeletal muscles, which are involved in moving parts of your body like your arms and legs, rather than other muscle types that keep the heart or other vital processes chugging along.
One theory is that these skeletal muscles go into a temporary state of paralysis during REM sleep to literally stop us acting out movements from our dreams.
Quite how that happens at a biochemical level is still a matter of debate, and a new study on a rat model suggests that multiple brain chemicals and receptors could be involved.
The research, carried out at the University of Toronto, found that chemicals called GABA and glycine shut off motor neurons during REM sleep and appear to trigger REM paralysis, according to researcher John Peever from the University of Toronto in a press release about the findings.
“But we also identified the way cells detect GABA and glycine,” he adds.
“Motor neurons, like all brain cells, listen to these transmitters through receptors and we identified the receptors that allow GABA and glycine to shut the motor neurons off – the three different types of receptors that are required.”
The study was published this month in The Journal of Neuroscience.
W.B. Yeats was ‘conflicted’ about death of close friend Lady Gregory
YEATS SUMMER SCHOOL SLIGO:
Had she lived longer, Lady Augusta Gregory might have tempered the increasingly strident political views WB Yeats adopted in the late 1930s. She might also have discouraged the poet’s “somewhat adolescent dalliances” with women half his age, students at the 53rd International Yeats Summer School in Sligo heard yesterday.
James Pethica, director of the school, explored Yeats’s “massively conflicted” feelings on the death of his oldest friend, concluding that, as well as being a blow he had dreaded, her passing was a “liberation”.
Students heard that the woman Yeats had described as “more than mother or father or friend . . . the only person in the world to whom I could tell my every thought” had also been his moral compass up to her death in May 1932.
Pethica, who is writing a biography of Lady Gregory, said critics suspected that the owner of Coole Park in Galway would have tempered the “increasingly strident political views Yeats adopted in the late 1930s”, including his flirtation with fascism and the Blueshirts.
She would also have disapproved of his dalliances with “name hunters, would-be bohemians and hostesses”.
“It is hard to imagine that she would have remained silent about his treatment of his wife and his disingenuous effort to hide his last affairs from her,” Pethica said.
Lady Gregory had been quick to reprove Yeats, and when he fell “too obviously” for a young London actor called Florence Darragh, who performed at the Abbey Theatre, she had told him “with relish” how Darragh had mocked the way he “trotted all over the theatre after her like a little dog”.
When another young woman told Yeats, in 1913, that she was pregnant by him, which turned out to be untrue, his sometimes “domineering and unforgiving” friend told him that the episode “has not been worthy of you”.
But Yeats’s devotion to the long-time friend, who helped found the Abbey, was underlined when he stayed at Coole for the last nine months of her life.
The poet was not there when Lady Gregory died in the early hours of May 23rd, 1932, but arrived at Gort station hours after being summoned by telegram.
Lady Gregory’s granddaughter Catherine, then 18, told Pethica how she and Yeats had travelled from the station, facing each other in a side car, in total silence. “He wasn’t in a state where he could talk to anyone. He was sobbing.”
Pethica said there had been a claustrophobic co-dependent aspect to the Yeats-Gregory relationship, and, after her death, the poet had embraced the possibility of new beginnings.
While he was bereft at the loss, he also felt freed from the judgment of a woman he regarded as thoroughly Victorian.
HSE to fund blood-thinning Pradaxa drug for some Irish patients
A Heart drug that could prevent up to seven strokes a week that the Health Service Executive (HSE) had refused to fund will now be funded for some, according to the HSE.
Pradaxa, a prescription blood thinner, is claimed to be safer and more effective than the widely used warfarin for many patients with atrial fibrillation, a condition that affects some 57,000 people in Ireland.
One clinical trial showed it reduced the risk of stroke 35 per cent more than warfarin.
While some Irish clinicians switched their atrial fibrillation patients to Pradaxa when it was approved by the Irish Medicines Board last year, the HSE said that while those switched before November 9th would be reimbursed under the GMS scheme to remain on it, future patients would not.
Last week, however, the HSE said while warfarin remained the default treatment, it would now reimburse Pradaxa for patients with poor coagulation control, those whose other medicines interact poorly with warfarin and those allergic to it.
The HSE said physicians would have to justify prescribing Pradaxa, which has a wholesale cost of €2.35 per patient per day, before it will be reimbursed.
Separately, the chief executive of the Cystic Fibrosis Association of Ireland, Philip Watt, has called on the HSE to expedite its approval of the cystic fibrosis drug, Kalydeco, also known as Ivacaftor.
The oral drug, the first to treat the underlying causes of a particular form of CF, has recently been approved by the European Medicines Agency.
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