1. The human cost of the economic crisis: A review of the evidence on economic adversity and mental health Rosemary Smyth EPSO Meeting Dublin September 2014

2. Presentation Aim Introduction to Ireland & some features of the recession Overview of Mental Health Commission Publication “ The human cost of the economic crisis: A review of the evidence on economic adversity and mental health”

4. Ireland Population

5. The Recession – Some Features Swift and dramatic decline: negative growth, high unemployment, high national debt, banking crisis Personal debt levels much higher than ever before Personal debt combined with dramatic reductions in property and investment values Group of people who have never experienced economic adversity before Perceived effect of the recession more marked in Ireland due to the rapid and steep decline from a period of unprecedented growth - living standards increased by 1/3 in 10 years.

7. Inflation & Unemployment Rate

8. Public Debt Before 2007 the levels of Irish public debt were low and declining. As a consequence of the very deep recession which began in 2008, combined with significant levels of public money injected into the Irish banking system in 2009, 2010 and 2011, the level of public debt soared. National debt increased from 20 % of GDP in 2007 to 84 % of GDP in 2012, The general government debt increased from 25 % of GDP in 2007 to 117 % of GDP in 2012.

9. National Debt

10. Annual GDP Growth

11. Health Expenditure Following rapid increases during the first part of this ten year period, a decrease of 11% in total public health expenditure has taken place since 2009. Capital expenditure, which accounts for only 3% of total expenditure, was 32% lower in 2012 than in 2003 and 41% lower than in 2008.

13. Mental Health Budget A Vision for Change (Government Policy on mental health) was published in 2006, if fully implemented the mental health budget would be expected to account for 8.24% of overall on-going health spending. Spending decreased from 7.2% in 2006 to 5.2% in 2012 - averaged 6.11% of overall health spending. As a percentage of overall health spend, the budget for mental health has always been lower than recommended for a developed country. In the UK, mental health is 12% of the health budget. The overall amount of funding for mental health services has dropped from €937 million in 2006 to €733 million in 2013. Before the recession in Ireland, the percentage was down to 7%, and since the recession has reduced to nearer 5%.

15. Mental Health Commission The Mental Health Commission (MHC) is an independent statutory body. The principal functions of the Commission are: to promote, encourage and foster the establishment and maintenance of high standards and good practices in the delivery of mental health services; to protect the rights of individuals who are involuntarily admitted.

16. Background The Commission was concerned about the impact of the current economic situation on the mental health of the wider population and on those with pre-existing mental health conditions in particular The Commission was also concerned about the resultant impact on the mental health services The Commission wished to propose helpful, pragmatic actions that could be easily implemented and which may help alleviate some mental distress and difficulties A review of evidence was undertaken and a workshop convened

18. Who is affected? People with pre-existing mental health difficulties: Most are already ‘at the margins’ in terms of high unemployment and high debt levels – 1 in 4 with mental health difficulties is in debt (English study) Features of specific mental health difficulties can lead to/exacerbate debt Stigma attaching to mental illness leads to a reluctance to engage with financial institutions The rest of the population: Many with no experience of dealing with financial hardship and hence few coping skills In the general population, 50% of those in debt have a mental health difficulty compared to 14% of those with no debts

19. Mental health & public health Do not wish to ‘medicalise’ financial, social and economic problems – no need to bring large numbers of people into specialist mental health services The most effective actions are those which will change the social circumstances of those affected – long term solution Workshop focused on actions that can occur in the short term and are ‘resource neutral’

20. However... impact on mental health services At time of increased demand, mental health services (along with other health services) face cuts ‘Hidden’ cuts – no staff replacement – 10% of psychiatric nursing staff left the mental health services in 2009 Funds attaching to staff who leave are also lost permanently

21. Poverty, unemployment & mental health Strong inter-relationship between the three: Poverty in itself related to psychological distress (particularly deprivation of basic necessities) Unemployment related to psychological distress Poverty and unemployment obviously related but have cumulative effects on mental health Many people with mental health difficulties are unemployed and reliant on social welfare

22. Debt/economic hardship & mental health Debt and mental health difficulties related – 1 in 2 adults in debt has a mental health difficulty Debt can have indirect effects on household psychological wellbeing over time as it impacts on parental depression, conflict-based family relationships and potential mental health problems among children

23. Childhood adversity Strong evidence that the presence of factors which adversely affect mental health in childhood can have significant and long-term impacts on the child in many life domains Economic adversity or poverty is one such factor which has a strong association with mental health problems in childhood In adolescents, awareness of financial difficulties in their families has a negative impact on their mental health

24. Suicide Relationship between economic adversity/recession and suicide People who are unemployed are two to three times more likely to die by suicide than people in employment The suicide rate in Ireland increased from 424 in 2008 to 527 in 2009, an increase of 24%

27. Consequences for the wider ‘mental health system’ Community level – increased calls to Samaritans, increased demand on variety of community support organisations Primary care level – increase in allocation of medical cards – increased workload on GPs and primary care system, increased prescription of drugs Increase in self-harm leads to increased admissions to psychiatric units, general increased demand on mental health services

28. Proposed actions: Health and social care sector Financial services sector Within and across sectors Actions by government Health and social care practitioners do not need to become ‘financial experts’ and financial sector employees do not need to become ‘mental health experts’

29. Health and social care sector C – consider debt as a possible underlying factor in ill health – physical or medical A – ask about debt – the person may be too embarrassed to bring it up R – refer consenting clients to a money adviser E – engage with financial advisers Share information and create tools to do this – Debt and Mental health Evidence Form (England)

30. Financial sector Recognise the existence of consumers with mental health difficulties and define best practice in dealing with such consumers – progress here already Become ‘mental health aware’ Be informed of sources of referral for people in distress Support staff who have to deal with unaccustomed situations

31. Government policy Improving the practice of financial services: Mortgage Arrears and Personal Debt Expert Group Financial Regulator consultation on the Consumer Protection Code – proposal to include concept of ‘vulnerable consumer’ Longer-term actions: Actions to support employers to keep people with mental health difficulties in work Take long-term view on health cuts/investment Action on the recommendations of the Report of the Mortgage Arrears and Personal Debt Expert Group

32. Public Health & Wider Society Many of factors contributing to mental health problems occur within a much broader context than health Therefore actions within a public health or & wider societal context was recognised. Actions identified in the workshop: –Training, communication and resources

33. Training Who? Frontline line workers Financial services Charities/voluntary agencies Government agencies What? Mental Health Awareness – MABS ASIST - Teachers, Gardaí, youth workers, volunteers, family friends Safe talk - workshop - National Suicide Office

34. Communication The need for improved communication across sectors Training central to improving awareness and equipping staff with appropriate and helpful communication skills. The development of Arrears Support Units in financial institutions (January 2011) provided a locus for expertise and training within banks. Establish secondment schemes Financial Regulator allow third party to engage with a lender on behalf of vulnerable person.

35. Resources Information/Leaflets examples: Look after your mental health in tough economic times. Managing your mental health A Revised Consumer Protection Code from the Financial Regulator A published Code of Conduct on Mortgage Arrears (CCMA), a statutory code of the Central Bank. Mortgage Arrears Resolution Process (MARP) established within lending institutions for dealing with customers in arrears and pre-arrears. Lending institutions are required to establish an Arrears Support Unit to assess arrears and pre-arrears cases. The Irish Banking Federation and MABS have developed a joint Consumer Guide to Dealing with Mortgage Repayment Difficulties.

36. Available @ www.mhcirl.ie

37. Thank you www.mhcirl.ie