The bigger picture on mental health

Donna Cosgrove MPSI provides an overview of the many considerations in mental health provision, including the current Irish landscape

Introduction

Mental health refers to a state of wellbeing where people can enjoy their lives, cope with life’s stressors, realise their abilities, and are able to learn, work, and contribute to the community.¹ It is more than just the absence of mental disorders. To promote or prevent mental health issues in a population, the various determinants need to be defined so that interventions can be designed to mitigate risks, enhance protective factors, and overall increase resilience. Wide-ranging individual, family, community, or structural factors can either enhance or damage mental health. Such factors include:

• Individual factors, ie, emotional skills, substance use, genetics;
• Economic/geopolitical/environmental factors, ie, poverty, violence, inequality, environmental deprivation;
• Risks that occur during early childhood or other developmentally sensitive times: Harsh parenting, physical punishment, bullying;
• Protective factors that strengthen our resilience, ie, individual social skills, positive social interactions, quality education, work, safe neighbourhoods, sense of community.

Mental health in Ireland

Aware, the national organisation providing support to people impacted by depression and related mood conditions, started collecting data in 2023 to examine the public perception of depression and anxiety in Ireland. Results from the second of these annual surveys in 2024 (n=1200) highlight the prevalence of depression and anxiety in Ireland.² Over half of those surveyed reported experiencing depression, and 40 per cent reported experiencing anxiety. Results of the 2024 survey indicate that:

• One in four adults are living with a chronic illness, and these individuals are most likely to experience moderate depression;
• 60 per cent find that anxiety makes work and fulfilling responsibilities difficult;
• Half of respondents still find stigma to be an issue: Shame and fear of judgement caused a delay in accessing support. Furthermore, 25 per cent feel they have been treated unfairly because of their mental health difficulties, mainly in terms of issues with employment (51 per cent), followed by friendships (44 per cent), family relationships (44 per cent), and romantic relationships (36 per cent).
• Financial worries cause mental health stress for 56 per cent of people surveyed.
• Overall, there was a narrow understanding of depression symptoms: Despite 72 per cent claiming to have a good awareness of depression, when asked to list the main symptoms, the majority only mentioned symptoms linked to mood, ie, feeling low, loss of interest, and low energy. Awareness of physical symptoms and those linked to overall wellbeing was limited;
• One in 10 under 25 believe they are currently experiencing depression;
• 20 per cent of respondents had an official diagnosis of depression. Females and those aged 35-54 are most likely to have received a diagnosis;
• 53 per cent reported an experience of depression over their lifetime;
• 12 per cent scored within the range for moderate levels of depression at the time of completing the survey (using the validated PHQ-2 clinical assessment).
• Nearly two-thirds of those with moderate depression say that their mood is so low, they can’t function most days;
• 17 per cent of those surveyed had a diagnosis of anxiety disorder, increasing to 25 per cent for those aged 25-34;
• A further 17 per cent experience anxiety frequently. The condition is most prevalent among those aged 18-34 and appears to reduce with age;
• 27 per cent say that most days their anxiety is so bad that they can’t function;
• 60 per cent say their anxiety makes going to work and attending to responsibilities difficult.

Overall, financial worries are the number one issue (56 per cent). This is followed by family responsibilities (36 per cent), relationships (34 per cent), and work (31 per cent). Topical issues such as the current economic climate and housing were reported to negatively affect 24 per cent and 21 per cent respectively.

A positive finding from this survey is that more people are addressing their mental health difficulties in 2024 (81 per cent) compared to 2023 (74 per cent). Nearly half of respondents have attended their GP, psychiatrist, or psychologist. Counselling services were accessed by 28 per cent and medication was used by 26 per cent. When people were in touch with a healthcare professional, they were most satisfied with the information they received about lifestyle changes (64 per cent), medication, and side effects (56 per cent).

However, nearly half were dissatisfied with the information given about healthcare supports like talking therapies, an evidence-based first line treatment for depression and anxiety. A separate research study³ examining the treatment of mental health conditions in general practice in Ireland identified a lack of referral for CBT. Of those identified as having mental health issues in the study, only 19 per cent were referred for counselling, and most patients were instead managed with medication. The authors describe this low rate of referral for psychological interventions as concerning, given the strong evidence base for its efficacy in this setting.

People’s perception of loneliness and social isolation are widely considered to be key indicators of mental wellbeing. Results of the first ever EU-wide survey on loneliness (EU-LS 2022, 25,000 Europeans in 27 member states) indicated that out of all countries included in the study, loneliness is most prevalent in Ireland, with over 20 per cent of respondents reporting feeling lonely.⁴ There was a correlation seen between moderate depression and higher levels of loneliness (59 per cent versus 35 per cent of the whole sample).

Actions taken by Aware survey² respondents to support their mental health included the following:

• Getting a good night’s sleep (67 per cent);
• Spending time on enjoyable activities (64 per cent);
• Exercise/movement (63 per cent);
• Connecting with others (58 per cent);
• Balanced nutritious diet (49 per cent);
• Mindfulness, meditation, or other relaxation exercises (26 per cent).

Types of mental health disorders in Ireland

Research suggests that nearly half of the adult population meet diagnostic requirements for a mental health disorder at any one time (eg, data from New Zealand’s Dunedin Birth Cohort Study, Danish registry data). Having one mental health disorder also significantly increases the likelihood of being diagnosed with any other mental disorder. Data collected as part of the Covid-19 Psychological Research Consortium Study⁵ (a multinational, longitudinal, internet-based project) was used to assess the Irish population’s psychological and social adjustments to the pandemic (n=1100). The prevalence of 12 mental health disorders in Ireland were assessed using well-established self-report measures. Table 1 shows a prevalence estimate for each of the 12 disorders in the study.

Table 1. Prevalence estimates for 12 mental health disorders in an Irish sample (n=1100).⁵

Additional key findings indicated that:

• 42.5 per cent of the survey population had a mental health disorder;
• Lifetime history of attempted suicide was reported by 11.1 per cent;
• Individuals aged 18-24 were eight times more likely than people aged 55 and older to have a mental health disorder, with 63 per cent of people with a mental health disorder reporting onset before the age of 25;
• Shift workers (ie, those working outside the hours of 7am and 6pm) were 70 per cent more likely to meet the criteria for having a mental health disorder.

Results of this study are in line with many international mental health disorder diagnosis rates, both in terms of the disorder-specific rates and overall rate. The US (47 per cent), New Zealand (39 per cent), and France (38 per cent) have similar proportions of their adult population meeting diagnostic criteria for mental health disorders. However, rates of mental health disorders in other neighbouring European countries such as the Netherlands (31 per cent), Spain (19 per cent), and Italy (18 per cent) are significantly lower.

The World Health Organisation recommends that 12 per cent of the health budget be spent specifically on mental health. Our expenditure – despite the high prevalence of mental disorders in this country – was still less than six per cent of the health budget in 2024, and there is still less than six per cent planned again for 2025 (although there will be a 10 per cent increase compared to 2024).⁶ This is less than half of the WHO recommended budget, and also well below the 10 per cent target by Slaintecare.

Mental health education

Authors of one research study⁷ suggest that mandatory, standardised basic mental health crisis education and training is needed for pharmacists to contribute to the public health response to suicide prevention and mental healthcare. While such training is not currently mandatory for most pharmacy professionals, some jurisdictions are mandating Suicide Prevention Training for pharmacists (eg, the State of Washington), and mental health training is being rolled out for pharmacists in Australia.⁸ The evidence-based, internationally recognised training course founded in Australia – Mental Health First Aid (MHFA) – was also introduced in Ireland, and is now included in the MPharm programme in RCSI.⁹ The MHFA course aims to provide people with mental health awareness, improve confidence in recognising the signs of mental health problems, reduce stigma, and focus on initial management of mental health crises, such as suicide and psychosis. A further course, ‘Let’s Talk About Suicide’ is a free, online suicide prevention training programme, developed by the HSE National Office for Suicide Prevention.¹⁰ It is designed for use by everyone, especially for people who are supporting a loved one, working with others, or those involved in their local communities. It helps participants to identify people who might be at risk of suicide, confidently ask about suicide, keep them safe, and connect them with resources that can help.

Role of community pharmacy in mental health

Community pharmacists are among the most accessible healthcare professionals, well placed to identify and screen for people who are at risk of many illnesses. As the scope of the community pharmacy profession broadens, expanding from the traditional dispensing roles, more emphasis is on service delivery and disease management.⁷ Services in the pharmacy such as nicotine replacement therapy and weight management can improve health outcomes for people with mental illnesses who have higher rates of morbidity and mortality. This is, at least, partially attributed to poor physical health among the population that might be as a result of medications; eg, weight gain due to antipsychotics as well as related to the illness itself. Smoking rates, which are also higher among people living with mental illness, contribute to a lower life expectancy in this population. In addition to these physical treatments, pharmacists can contribute to the reduction of stigma against people with mental illness, and promote awareness of and access to mental health services.

Author: Dr Donna Cosgrove PhD. Donna’s overall aim is to improve patient outcomes through education. After graduating with a BSc in Pharmacy, she returned to university to complete a MSc in Neuropharmacology. This led to a PhD investigating the genetics of schizophrenia, followed by
a postdoctoral research position in the same area. She has worked in hospital, research and community pharmacy settings and is currently a community pharmacist in Galway and a clinical writer.