Mental Health in Ireland - A Vision for Change

As a relatively fascinating topic in relation to Irish historical record, very little attention has been dedicated to discussing the impact of ‘A Vision for Change’ on Irish society. This article will intend to exam stigmas towards mental health difficulties while also considering the recommendations for implementing a new strategic national mental health policy aiming to address elements of tackling mental health difficulties. Through the investigation of contemporary sources including Mental Health Commission minute books, Cabinet debates, Public Health Committee reports, annual reports from the Department of Health and national and local government board documents, this paper will draw issues, concerns and effectiveness of ‘A Vision for Change’. Newspaper articles as well as Independent Monitoring Group articles will aid reflecting the concerns of service users’ reactions to the policy. Surveys indicating the social impacts and collective memory of suicide and mental health will also be reviewed. This paper plans to increase the growing body of resource on stigmas towards mental health and the effectiveness of ‘A Vision for Change’ by investigating recommendations and the delivery of a ten-year blueprint to transform the implementation of mental health services in Ireland.

Notes on Sources

A vast number of primary sources relating to ‘A Vision for Change’ and mental health, can be located from the Lenus, the Irish Health Repository Archives. These reports providing the foremost understanding into how ‘A Vision for Change’ was managed and to what extent successful implementation was achieved during its roll out. Briefing Reports on the on the efforts of the Expert Group to promote positive mental health thinking and suicide prevention demonstrate the awareness and necessity to deliver a quality framework service. Particular observation into the impact on service users through the allocation of staff during the period is provided via detailed reports on the absence and retirement of staff which includes names, roles and when the staff required subsequent leave hindering the effectiveness of implementation. With inadequate academic attention devoted to such historical records to fate, this paper intends to display the failings of implementing a reformed mental health service to the population of Ireland.

Why is Mental Health Important?

Mental health is signally one of the most important things relating human well-being and interaction. Mental health affects how we think, act and feel, therefore it can affect our emotional, psychological and social well-being.[1] These range of factors ultimately determine how we handle stress, trauma and loss, as well as making life choices and how we relate to one another. Understanding the importance of mental health is the key to preventing stigma as mental well-being exists at every stage of life. Mental health beings at childhood, continues into adolescence and also exists in adulthood. Good mental health enables individuals to control their mind and emotions which in turn improves your thinking, mood and behaviour. The negative results and burden poor mental health has can be devasting. These problems can directly affect the individual, family dynamics and friends. It is evident that if you can recognise these early warning signs that it is easier for an individual to seek help and improve their mental state.

Overview of ‘A Vision for Change’

‘A Vision for Change’ was a national policy incentive under government control placed in 2006, that forecasted to change the direction of mental health services within Ireland. It outlines the framework for a building platform of fostering mental health services across communities and providing a professional service, community based to deal with cases of mental health. It wished to implement a multidisciplinary approach to integrate areas with a holistic view of mental illness.[2] These disciplines included experts from various sectors such as researchers, health service managers and many other groups to develop a nationwide policy.[3]

In the case of mental health services in Ireland, it has been extensively documented and suggests for a variety of circumstances that Ireland was ‘hospital prone’ and provided a significant number of hospitals beds for mental illness.[4] Many organisations wished implement policies such as Report of the Commission of Inquiry on Mental Illness[5] and Planning for the Future[6], to lower the use of in-patient care and provided substantial recommendations of various ways to improve mental health services. Ireland has undergone momentous change ranging from population growth, economic success and misfortune and also a shift in attitudes towards mental health in the past 20 years which we will now discuss. In a social and demographic context, the population has increased by half a million people, measuring the level of people suffering from mental illness may be difficult but we can be sure that the increase in population brings with it a larger number of people suffering from mental health.[7] The age categories have also resulted in change, with less young people and more older people in the Republic. Despite somewhat economic success within the country during the Celtic Tiger era, where the GDP rate growth expanded, there are still filtering fragmentations in Irish society from the economic downturn suffered during the recession. The prosperity of economic and financial profit also brings visible new challenges. These challenges are notably recognised when discussing mental health, the growth in population presents a challenge of more people suffering from mental illness and therefore creating a larger problem for mental health services which still exist in Irish society. The structural dimensions of families have shifted which presents overwhelming challenges for many households. The statistics show that more women are now in the labour force which therefore results in fewer informal carers.[8] A significant number of mental health services still assume that informal care is available and provide at home which is not possible for many families in the current climate. Ireland has seen a shift in societal changes, more qualitative changes which judge society as more materialistic, rushed and lacking feeling towards others. In the past the country may have tolerated unconventional behaviour by integrating those oddities into a communal atmosphere. The actions of such individuals are now viewed with an ambiance of indifference and trepidation. These attitudes towards mental health has made it a strenuous battle for mental health providers to deliver a quality service and can generate direct social conflict between individuals’ rights and the necessity for safety.[9]

Thirteen years on from the publication of ‘A Vision for Change’ of our national mental health policy, is a good time to reflect on the campaigns impact on the country of Ireland since 2006. The policy received widespread recognition and support within the political spectrum and among those who predominantly benefit from the use of the mental health services and specialists supplying the service. Mental Health Reform supplied leverage to the wide consensus to make apparent the public interest in an improved mental health system.

Ireland has experienced enormous changes in its mental health service which are somehow today overlooked. However, no other sector of health or social care in the country has seen change of a considerable detail than mental health in this period. The area of mental health in Ireland has been met with many obstacles to the development of services, a lack resources being provided has acted as an obvious hinderance to its progression.[10] Provisions of mental health services has been met with a considerable debate to focus on the issue of resources, which many maintain is the main factor for changing not occurring within the area of mental health services. However, there are several pivotal matters concerning the orientation and purpose of mental health services that may need to be addressed if the implementation of the policy is to be effectively issued.

Among young people (especially young men) in Ireland and internationally, suicide is the leading cause of death which is a scary statistic. While the rate of suicide in Ireland over recent years has steady decreased, the number of suicides and the way we offer services to prevent suicide needs to be addressed in an urgent manner to combat such frightening figures. From the diagram we can see the spike from 2008-2009 in the number of suicides committed, this could perhaps be acclimatised due to the economic downturn suffered in Ireland, but it can also be a result of a growth in population. The more people in a country, the chances are the more people that suffered from mental health difficulties, thus adding an extra burden to the already lacking mental health services.

Ireland endorsed a national mental health policy known as ‘A Vision for Change’ granted by the government in the later half of 2005 and formally launched the campaign in January 2006. The policy outlined the extensive framework for constructing and promoting positivity towards mental health across the wider community of the Irish population while providing specialist services, accessible and community established programs to tackle mental health issues.[12] The policy of introducing ‘A Vision for Change’ was broadly greeted embraced by all parties as the bodywork for developing resources with mental health difficulties.[13] Alongside the Expert Group were a service user and carer who represented the interests of the people and an extensive consultation to inform the policy was being administered.[14] It comprehensively welcomed to incorporate the perspective of service users and carers. There was subsequently an array of optimism to introducing a mental health policy to reform the service structures within the country. It would seek to profoundly impact the nature of delivery concerning the mental health services that were already there but to improve the outcomes for service users. Moreover, it required substantial funding to launch the policy for the first two years of the project. Furthermore, optimism regarding the potential prosperity of the project was met with overwhelming disappointment with the lack of progress in enforcing the policy. It, therefore, was insignificant in implementing changes to the mental health services which was desperately required in the country. The perturbed voices acting on behalf of various groups express the dismay of the failure of ‘A Vision for Change’ to come to the forefront of reforming mental health attitudes and services in Ireland. The complexity of the policy suffered in a system already undergoing a significant challenging procedure. In specific sectors of the Health Service Executive (HSE) progress had been streamlined, however unfortunately for mental health it highlighted an agonizing deterioration in services. Mental Health Commission sanctioned a lawful mandate to bolster the standards regarding the conveyance of mental health solutions. The Commission published ‘The Quality Framework for Mental Health Service in Ireland’ hoping to execute the mandate.[15] The framework for the document incorporated standards encompassing the eight significant themes which seek to clarify a valuable mental health service. The recommendations outlined in ‘A Vision for Change’ complement the quality framework. Mental Health Services suffer from the slow momentum and lack of unveiling ‘A Vision for Change’ to the public which overlook the potential services available to service users of mental health facilities which therefore is of direct concern to the Mental Health Commission.[16] Several publications have highlighted the fundamental central issues and themes wrong with the effectiveness of the policy and the potential possibilities for constructing a new pathway to tackle the issue of mental health services in Ireland which the HSE need to carefully consider for resolving the complication and focusing on the priorities to reform mental health.

Concerns of Implementation

The Expert Group involved with mental health policy making acknowledged that failure to implement such a policy to reform mental health services in Ireland would be met with severe consequences that would impact service users. And if implemented that gradual application of the policy would be unsatisfactory due to the indispensable recommendations highlighted in the policy. The previous mental health policy enacted by the government would create an obstacle for the implementation of a new policy in which the Expert Group were apprehensive of, Planning for the Future. The recommendations suggested that an Independent Monitoring Group be formulated to oversee and detail the implementation of the new mental health policy.[17] In March 2006, the Independent Monitoring Group came to the forefront and produced three Annual reports concerning the enactment of ‘A Vision for Change’. Each report has conveyed serious worries on the slow-moving implementation and the lack of awareness to certain central actions performed by the HSE. The Independent Monitoring Group in their first report found issues of the utmost concern, such as the lack of a systematic approach to the implementation of ‘A Vision for Change’ and the absence of coherence in the responsibility for implementation in the Health Service Executive. The Monitoring Group put forward recommendations for consideration as to how to the impediment of policy implementation may be tackled by the HSE and other liable governing bodies. In the second report drawn up they concluded that the recommendations put forward in the first report were subsequently not addressed by 2007. The Monitoring Group were particularly concerned with the absence of distinguishable leadership within the Health Service Executive.[18] It failed in appointing a proper governing body to implement ‘A Vision for Change’ and that they failed in addressing the policy as a complete package with the suggested recommendations. This policy received an overwhelming response of concern about how allocated funds were to be utilized in its implementation. The Monitoring Group established in the third report that recommendations outlined in the second report had also not been addressed. The policy of ‘A Vision for Change’ was recognised as a shamble, a policy with no basis for implementation and prosperity. A policy obtaining no clarity on how mental health services would be reform and also no resources to forefront its implementation into society. The slow rate of progress and initiative to fundamentally implement a comprehensive plan is still not visible in the country with a high level of mental health issues.

Key Recommendations

The key recommendations for ‘A Vision for Change’ involved many aspects of service reform and the potential ways to delivery a quality service. It wished to seek the involvement of service users and carers to be included in every aspect of service evolution and delivery to the population. Mental health services should be promoted to be available to all age groups of the population while applying protective factors to the service and an incentive to lower the risk for developing mental health problems. They wish to implement a plan to provide comprehensive range of therapies to service users whether medical, psychological or social reflected by the needs of service users and their families. The care plan model should reflect the specific requirements of service users and tackle any subsequent obstacles that may impede the recovery process. This would also entail addressing contributors that may also help or assist a speedy recovery regarding the mental state of the service user. Many different aspects concerning organisation and management of mental health services should co-ordinate through regional Mental Health Catchment Area Management teams and other organisations working nationally through the Health Service Executive. Connections of various elements between primary care services, specialist mental health operatives and voluntary groups should be formalised due to their supportive nature of mental health in the country. Well-trained groups across multidiscipline of mental health providers should be formulated to provide mental health service across all lifespans of the Irish population. An effective service to community-based areas should be offered with a home-based service for individuals deeply suffering of mental illness. The mental health system should be assorted nationally in catchment areas for populations between 250,000 and 400,000, they wished to redevelop catchment boundaries. The previous demographic and social compositions of the population therefore needed to be taken into account with geographical and administrative boundaries. This outreach of care may show the diversity of the proposed recommendations for a mental health service policy within the country. The policy ultimately wished to address a particular significant area where service provisions lacking. Therefore, wanting to prioritise and evolve area needing considerable transformation. The transformation would have to carried out effectively and evenly throughout all service user groups. All relevant services should be assessed prior to provisioning of governmental funds and annually to evaluate indicators regarding their importance and performance to the mental health service. These annual assessments would revise the added value of the service and whether it is assisting to the mental health of local catchment area population. The closure of mental hospitals and institutions should be drafted to further the plan of implementing such a recommendation. Following successful closure of mental hospitals, the resources should be maintained and reinvested to strengthen mental health services and potentially deliver a majorly changed service to service users. To lessen the stigma associated with mental health in Ireland, they recommended to develop mental health information systems at a local level and with successful implementation carrying on the framework to a national level. These information systems should present the national minimum mental health data to a central mental health information system. A wider understanding regarding mental health service research should be adopted, embraced and funded correctly. Significant preparation and financial backing of educating and training mental health professionals should be featured in the fresh strictures to be constricted by the Health Service Executive. A diverse experienced systematic plan to link projected service plans should be established and focus on looking at the skill set of teams and what way the staff are deployed between specific teams which viewing the recommended services models in ‘A Vision for Change’. One further key recommendation was that the National Mental Health Service Directorate should devise this plan while consulting services users and providers, the Health Service Executive and the Department of Health. The implementation of such an intrinsic and diverse national policy would require a committee to oversee the advancements of the policy. One of the most necessary recommendations was the provision of extra funding to financially maintain correct implementation of a new Mental Health Policy is carried out. The reorganisation of mental health services within the country should be coordinated in parallel with a programme of capital and non-capital investment regarding mental health serveries tasking into account inflation which will see the implementation of a complete plan in the blueprint of ten years.

Surveys suggest that Ireland knows very little about mental health. The policy wished to introduce a model to inform the population on the understandings behind mental health needs. Moreover, the way that mental health is viewed can have many misconceptions and blind ignorance to the approach in handling emotional distress. The factors of understanding what influences mental health issues is therefore half the battle to helping a prevention system to promote a better service for dealing with mental health. To effectively conduct prevention methods across the nation, then educating the population of the reasons for mental health behaviour is a method in tackle the societal issue of stigmas towards mental health. The biopsychosocial model consolidates with key attributes on the mental health of an individual’s suffering from distress and demonstrates the relation of communal psychological, biological and social functions. The natural understanding of mental health can be formalised through the distinct separation of social, psychological and biological factors that act as formidable hurdles to the acceptance of mental illness. The interconnection of mental and behavioural disorders is now observed as intricate interplays of the mental health that we have above discussed. The innovation to adopt a model of biopsychosocial understanding gives due regard to the notion of mental health problems. The outcome of reaching such a complex platform of understanding concerning mental health develops a significant care when formulating care plans for service users. The usefulness in implementing programmes regarding suicide prevention is not feasible without significant understanding of the theories and causes of suicide. For the provision of efficient services, the demographics and dynamics of suicidal behaviour is essential to recognising what the suicide process must be like for people suffering with suicidal thoughts. Understanding such methods and causes of suicide can enable prevention organisations to potentially quash self-destructive behaviour that such services users may suffer under. Such contributors to the phase of self-destruction behaviour are pessimism, despair, and the discernment of death that one sees as the sole solution for a short-lived issue. One that indulges in such suicidal tendencies is in immediate danger of falling into a state of despair. ‘A Vision for Change’ wished to intervene at this phase of despair hoping that if they could address issues during the self-harm stage of suicidal tendencies that they could potentially prevent further notions of suicide. They realised that individuals who had previous self-harmed were more likely to proceed to the next step of taking their own lives. With the help of significant funding and support they hoped to deliver a quality framework service to cease the numbers of suicide in Ireland.

Concerns of the strategic policy

The national policy of reforming mental health services in relation to ‘A Vision for Change’ would face substantial challenges hindering its pace of implementation. Ongoing challenges and delays within the HSE made it difficult to provide a certain level of service with a reduction in resources and the preservation of core service elements at local and national level in a lowered environment. Existing services needed significant alterations in the remodelling of a better-quality service. This would entail a change in staffing, by implementing elements of redeployment, retraining and facilitating for the mixture of skills needed to execute the organisation of an efficient service. The reconfiguration of any service would require a significant stable resource base to finance the running of a smooth quality service. While staffing presents considerable difficulties, the retirement of psychiatric nurses creates issues in the context of achieving goals regarding the delivery of the service. The estimated departure of 140 nursing staff in 2012, alongside the requirements to re-accommodate staff to old persons services will have a significant burden in mental health service budget. This set back would reduce the ability to reconfigure such services to the extent required in ‘A Vision for Change’. The wake of the biggest economic/financial crisis the country had ever witnessed, impacted substantial investment in the Public Private Partnerships. This also affected the intended sale of mental health property such as old psychiatric institutions that had been directly closed during the implementation of the strategic document. While the policy has been widely criticised for its slow implementation pace and effectiveness, significant success within the HSE South characterises the capacity of a service that had positively battled against the challenges faced in staffing. These positive responses would feed motivation and influence regarding adding clinical leadership.

While recognising the challenges the policy faced, it is important to adhere to the clear legal obligation of the Policy and Procedures outlined in such literature as the Mental Health Act, 2001, the Quality and Framework Mental Health Service document and Capital Infrastructure initiatives, in which technical aspects of care and service use would need to be established to offer a recovery oriented organisation direction of mental health in Ireland. The policy would intend to deal with a recovery model when talking about ‘recovery orientation’ to develop a particular focus on evidence displayed by service users in order to discuss such priorities and learning from the messages that surfaced from the recovery literature. Services that wish to take this course of non-technical aspects of ‘recovery orientation’ primary importance concerning mental health. The recovery program entails aspects of radical reconsideration in terms of understanding mental health difficulties and which facets require help and what the priorities in dealing with mental health should be. This would intend to consider the worries of service users and bring them to the cabinet table for further discussion while not being anti-drugs or anti-psychiatry. The core of ‘A Vision for Change’ is the recovery philosophy that arises from their holistic approach to mental health. The primary knowledge of mental health is developed from the response of service users and the secondary knowledge is that of the support and care provided by mental health services and providers in Ireland.

Suicide in Ireland has consistently been a problem over the last twenty years, with young men being the most like to commit suicide. Midleton, Co. Cork in 2004 had been label the suicide capital of Europe and second in the work in terms of the number of suicides committed. Suicide is certainly a major issue of public concern due to the high suicide rates year by year. It is a process of one of the saddest happenings of human experience that leaves families, friends and communities in devastation. Statistics provide disturbing evidence concerning suicidal behaviour. The reality is that intense emotional distress effects the behavioural pattern of an individual, in which the individual resorts to self-harming. Mental health has been viewed as a taboo subject within Ireland, where politicians have shied away from the realities of its effect and it has therefore not received the essential funding to somehow prevent suicide. Without funding vulnerable and distressed individuals will undoubtably continue be unsafe and scarce of adequate support.[19] Today thousands of children and adolescents with mental health difficulties have to endure the struggle of being placed on waiting lists for assessment regarding their level of mental health.[20] Circumstances like this are unacceptable and need radical rethinking and action. Reports suggest that mental health services in Ireland are poor and unresponsive to young people and their families. The lack of in-patient services and facilities for children resulted in children being admitted to adult mental health facilities. Serious government consideration needs to be addressed quickly to ensure that children do not endure the suffering of dealing with such issues. If things weren’t already difficulty for children, adult facilities still aren’t developed to a reasonable standard that is needed to develop a quality changed service. Essentially, substantial investment and reorganisation of the mental health service is direly needed to provide major change and a better service.

Resources

To implement such recommendations highlighted above, it requires adequate resources to ensure the smooth implementation of a successful mental health policy. However, ‘A Vision for Change’ acknowledge several contributors that solely label the invariable considerable underfunding of mental health services in Ireland over the past decade. While we realise the difficulties of funding a service during the greatest financial crisis this country have endured, it must be stated that the government consistently underfund mental health services. The uneven distribution of financial resources ultimately raises immediate concern on how to implement a strategic reformed mental health service to the population. The Expert Monitoring Group highlighted the need two reorganised systems of approach concerning resourcing, these included a reconfiguration of the current service provisions that were in place in relation to resources and the provision new funds regarding mental health. The need to endorse a non-capital investment of just under 22 million for a period of seven years implementation was expressed by the Expert Monitoring Group (2006-2012). A significant quality of money to establish infrastructure in the range of 800 million was also recommended. While this large substantial figure of money was met with concern, the closure of old psychiatric institutions and the sale or re-use of their affiliated buildings and land banks could therefore provide financial support.

‘A Vision for Change’ in 2006 and 2007 was closely supplied full funding. The figures highlight a 26.2 million provision for 2006 and 25 million for the following year 2007. However, the HSE Implementation Plan noted in 2009 that only 19 million of the provided funding had been allocated for 2006 and 10.5 million for 2007. The HSE Plan, predicted that 94% of the total 51.2 million resources would be assigned by 2009. Furthermore, no detail had been provided to fundamentally derive how providing the resources would be accomplished. It was emphasised that the provision for 2006 would take four years to be used (2006-2009). These reports on funding display a disconnect between implementing a success policy without utilising the funds required to deliver a severely needed service. Although a significant amount of money over 20 million had been spent, there is virtually little proof of advancements in the sphere of providing an accessible quality mental service which caters to the needs of service users. Therefore, evidence unfortunately demonstrates that the additional resources have not fulfilled any benefits identifiable to helping service users.

The HSE admitted that the funding allocated to mental health was used to cover other voids in deficits tallied up by the HSE in other areas of health services. Thus, leadings to delays in the allocation of funding for a badly need service regarding mental health services in Ireland. This issue had significant set backs in delivering the proposed recommendations in the pre-implementation discussion of the policy. Resources of funds weren’t the only set backs in factors delaying the momentum of implementation. Other factors included the absence of a descriptive execution plan and the subsequently insufficiency of leadership to govern successfully implementation. Furthermore, burdening the progression of such a policy with negative consequences. Service users were the most impacted as they weren’t receiving the required benefits they deserved and diminishing any further hope that the government would provide provisions in funding for mental health in the future.

Conclusion

From reviewing a combination of primary sources, the actual extent of failure to implement a quality extensive service is evidently visible through the literature. Following the impact of the national policy on service users provides a greater understanding to what regions and services were affected the most. Finally, although some of the aspects regarding the high rate of suicides in the East Cork area are identifiable through the numbers. The true magnitude of Ireland’s suicide craze and its effects on the population can be measure through the lack of attention and discussion concerning the topic of suicide. Many aspects of such a frightening topic fundamentally requires further investigation on its effects on families and the population.

From further review of primary and secondary literature, some recommendations have been implemented with some notable success such as the closure of psychiatric institutions and the paving for community based mental health services development but still not fully developed to potential. The formation of the National Service Users Executive (NSUE) and progress in creating child and adolescent mental health success must be acknowledged. The finalisation of mental health catchment areas and provisions, alongside the assignment of new executive clinical directors, an Assistant National Health Director for Mental Health, National Care Groups and Regional Directors can be viewed as optimistic developments. These improvements add to establishing essential infrastructure needed for affirmative implementation of ‘A Vision for Change’. Evidence provided has shown that reforming process undertaken by the Health Service Executive presented monumental difficulties to the implementation of ‘A Vision for Change’. However, further consideration to the stages of achieving success implementation could have assisted transforming mental health services in Ireland. While this paper considers the recommendations in ‘A Vision for Change’, there is undoubtably evidence to show that the mental health system outlined by the Expert Group had not been realised within the country. Primary care resources to date are lacking in resource and uncoordinating with mental health services. The lack of success implementation has left people suffering from mental health issues with considerable social exclusion due to failings from ‘A Vision for Change’.

Service users and mental health organisations expressed frustration and dissatisfaction on the process of implementation regarding ‘A Vision for Change’. The absence of attributes such as a detailed plan, leadership qualities, changes to catchment areas and a structure of implementation were necessary factors needed for the establishment of a quality service. These requirements could have been relatively been rapidly installed but a lack of awareness to do so shows the failings of the policy. By 2009, there was no identifiable targets, no leadership team in place, absence of accountability regarding implementation and a plan issued without the necessary funding resources identified. All these factors contribute to the HSE and governments lack of awareness which presents a burden on service users who require a transformed mental health service.

[1] https://www.mentalhealth.gov/basics/what-is-mental-health

[2] January 2007 Press Briefing for the launch of A Vision for Change at www.dohc.ie/ press/releases/2006/briefing_20060124.pdf?direct= 1 Accessed July 2009.

[3] Department of Health and Children (2006) A Vision for Change. Report of the Expert Group on Mental Health Policy. Stationery Office, Dublin.

[4] Robins, Joseph. Fools and mad: A history of the insane in Ireland. Inst of Public Administration, 1986.

[5] Report of the Commission of Inquiry on Mental Illness, 1966.

[6] Planning for the Future, 1984.

[7] Finnane, Mark. "Insanity and the Insane in Post-Famine Ireland (London: Croom Helm, 1981)." Arthur Williamson,“The Beginnings of State Care for the Mentally Ill in Ireland,” in Economic and Social Review 10, no. 1 (1970): 280-91.

[8] Central Statistics Office (2005) Population and Migration Estimates. Dublin: CSO

[9] Mental Health Commission (2005a) Quality in Mental Health – Your Views. Report on Stakeholder Consultation on Quality in Mental Health Services. Dublin: Mental Health Commission.

[10] Conry, Mary C., Karen Morgan, Philip Curry, Hannah McGee, Janas Harrington, Mark Ward, and Emer Shelley. "The clustering of health behaviours in Ireland and their relationship with mental health, self-rated health and quality of life." BMC public health 11, no. 1 (2011): 692.

[11] https://www.stpatricks.ie/media-centre/news/2017/october/mental-health-survey-reveals-extent-and-effects-of-stigma

[12] Shergold, Peter. "A foundation of ruined hopes? Delivering government policy." Address to the Australian Public Service Commission SES Briefing, Canberra (2003).

[13] Independent Monitoring Group (2007) First Annual Report on Implementation February 2006 to January 2007. Department of Health and Children.

[14] Kieran Crowe of the Irish Advocacy Network on behalf of the Expert Group on Mental Health Policy (2005) What We Heard. Department of Health and Children and Speaking your Mind (2005) Report prepared by Carr Communications on behalf of the Expert Group on Mental Health Policy. Both accessed on www.mentalhealthpolicy.ie

[15] Mental Health Commission (2007). Quality Framework for Mental Health Services in Ireland. MHC, Dublin.

[16] Mental Health Commission (2009) Annual Report for 2008 including the Report of the Inspector of Mental Health Services. MHC, Dublin.

[17] Independent Monitoring Group (2007) First Annual Report on Implementation February 2006 to January 2007. Department of Health and Children.

[18] Kelly, Brendan D. "The power gap: Freedom, power and mental illness." Social Science & Medicine 63, no. 8 (2006): 2118-2128.

[19] Indecon International Consultants. Review of Government Spending on Mental Health and Assessment of Progress on Implementation of A Vision for Change. Dublin: Indecon/Amnesty International, 2009.

[20] Department of Health and Children. (2003) Second Report of the Working Group on Child and Adolescent Psychiatric Services. Dublin: Department of Health and Children.