Mohrag Fischer is a mental health nurse in addiction services in Easterhouse, councillor in East Dunbartonshire and a member of NHSforYES
Ulrich Fischer is a consultant clinical psychologist in inpatient services in Paisley, a member of NHSforYES and a EU citizen
MENTAL health is defined as a state of wellbeing in which every individual realises his or her own potential, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to her or his community” (World Health Organisation definition, 2014).
This could almost serve as a mission statement for those wishing for Scotland to be an independent country, able to run our own affairs, with a successful economy and socially cohesive communities.
Scotland’s mental health care is currently in a paradoxical situation: We have a modern structure of increasingly integrated services – NHS health care, addiction services, social care services, education – which, due to their public nature, can achieve much more than any (even partially) privatised system. However, our hands are tied in dealing with unique challenges, such as poverty and a high rate of substance abuse, due to being part of an austerity-driven Westminster system investing fewer health resources then most other EU countries. That’s the very same Westminster system that wants to take us out of the EU, potentially open up the NHS UK-wide to private health care companies, and restrict much needed immigration.
WHAT IS CAUSING MENTAL HEALTH PROBLEMS?
OVER and on top of a universal base rate, a large percentage of mental health problems can be linked to stress factors. We call this the “stress-vulnerability model”. We are born with a differing genetic vulnerability to developing mental health problems, outside stresses then interact with this individual vulnerability, leading to mental health problems. And the most powerful of these stress factors are: poverty, adverse childhood events, un(der)employment, substance abuse, trauma, loss and bereavement.
However, societal factors can also protect from stress: social security, integration and the social cohesiveness of our communities, education and a balanced healthy lifestyle. Poverty is the biggest single driver of poor mental health. People face a network of poverty, trans-generational unemployment, lack of social security, levels of depression and drug-alcohol abuse.
Unemployment over generations leads to a loss of aspiration, which leaves people vulnerable to involvement in (drug) criminality. “Learned helplessness” (which means giving up all hope and efforts to change circumstances, even if change becomes possible) is a major cause for depression. Hopelessness, together with substance abuse, is one of the strongest predictors for suicide. We can see some improvements following the “positive destinations” initiative for school leavers by the Scottish Government – but an independent Scotland with control over all economic levers would be able to tackle this triangle of poverty, substance misuse and mental ill-health even better.
SUBSTANCE MISUSE
WHEN we talk about substance misuse, most people think about drug use. But alcohol misuse presents a huge problem for our communities. Cheap high-strength alcohol was readily available and a report by NHS Scotland in 2017 showed that alcohol-related deaths in Scotland were 54% higher than in England and Wales. These deaths and the related problems from alcohol misuse are not spread equally throughout our society – it is the most deprived areas that are hit the hardest.
The Scottish Government’s introduction of minimum unit pricing targets harmful and hazardous drinking. It is not a stand-alone policy and will be supported by health boards, drug and alcohol services and support services throughout Scotland. Should we lose the ability to make these kinds of policy decisions, it will be the most vulnerable in our societies who will suffer, not only the alcohol user, but mental health of families and society as a whole.
Safer drug consumption rooms have been established in many countries across the world. Some countries in Europe have had them for more than three decades. Glasgow recently sought to establish such a facility, but in January the UK Government refused to allow it and also refused to devolve powers to Scotland that would enable a change of law. This is despite overwhelming evidence that these facilities reduce drastically infection rates from HIV and other blood-borne viruses. Improved treatment options for service users who are injecting lessen the risk of overdose, improve public safety by removing used needles and other drug paraphernalia from the streets, and cut crime. The debate is ongoing with the aim to devolve relevant powers. An independent Scotland would have the ability to make this decision ourselves.
ADVERSE CHILDHOOD EVENTS
A FURTHER strong driver of mental health problems (such as depression, self-harm, drug use) are so called “adverse childhood events” (ACEs). These could include emotional, physical or sexual abuse, as well as emotional and physical neglect. Research by Public Health Wales has shown that preventing ACEs could substantially reduce levels of violence perpetration, heroin/crack use, early sex and unintended teen pregnancy and more. Poverty and emotional and physical neglect by substance-using parents or carers are often interrelated. The Scottish Government is improving child support and protection.
It is only the public and integrated nature of all of these services (health, addiction, social care, education) that makes policies such as “Getting it right for every child” work. An independent Scotland would not only be able to tackle root causes by eradicating childhood poverty, it would also be able to protect services from privatisation and disintegration.
SCOTLAND LEADING THE WAY
THERE are, largely unnoticed by the general public, already several examples where mental health and addiction services in Scotland are excellent and internationally leading. Community mental health and community addiction services are now a cornerstone of mental health care.
Whereas in Europe hospital-based care for mental health problems is common, Scotland has been able to develop modern community mental health care, supporting social integration of clients in their communities and de-stigmatisation. (Clinicians are, however, concerned that this shift towards community-based care has now reached its practical limits and that further shift of beds into the community would leave no redundancy in the overall system to cope with peaks of demand)
All this has also led to a culture of true multi-professional working, away from a medically dominated model of “mental illness”, towards a greater understanding of mental health, with different professions such as doctors, nurses, psychologists, occupational therapists, social workers working together with service users and carers/families in a holistic fashion. The recent integration of health and social care services in Scotland has brought huge improvements.
Over the last 10 years, Scotland’s NHS has significantly improved access to psychological therapies. Before 2007, waiting times of over 12-18 months for psychological therapy were not uncommon. After the introduction of a waiting time target of 18 weeks from referral to start of treatment, overall waiting times have drastically improved.
However, there are still regional differences. It is just a pity that the Unionist parties at Holyrood seem only to be capable to point at the occasions where targets have been missed, instead of acknowledging the hard work of NHS staff.
Scotland is also among the world leaders in research on new psychological treatments, for example, in therapies and early psychological intervention for schizophrenia and psychosis.
SUICIDE
SCOTLAND has introduced a progressive suicide prevention strategy, which aims to raise awareness of and de-stigmatise thoughts of suicide (most people experience suicidal thoughts in a crisis situation at some point in their lives) and encourages support by family members, friends, colleagues in these difficult situations. It is disappointing to see the opposition parties bringing tragic single cases of suicide to First Minister’s questions.
The decision to admit a person with suicidal thoughts to hospital or not is sometimes one of the most difficult to make. It can depend on the person’s own history and in some cases hospital admission can do more harm than good.
A person in suicidal crisis is never denied hospital admission due to lack of beds. If need be a bed in a different area will be found. And yes, sometimes even very experienced clinicians make the wrong decision (which is also the single most stressful event for mental health staff) Suicide of a family member is a tragic and hugely devastating event. It should not be brought into the public spotlight for political reasons.
INDEPENDENCE IS THE WAY FORWARD
SCOTLAND as an independent country would have the levers to tackle poverty as the biggest contributor to mental health problems. But only with independence will we be able to protect what we are already doing well in mental health care through integrated public services. We need to protect our NHS (and our, in Scotland fully paid up, NHS staff superannuation pensions) from privatisation after Brexit and private US healthcare companies. All this might be under threat should we allow Westminster to ride roughshod over devolved powers.
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