Delivering optimal mental healthcare in a changing clinical and legislative environment

Introduction

In this June 2023 issue of the Irish Journal of Psychological Medicine, a broad range of topical themes for clinicians are explored. The issue includes papers related to Ireland’s new capacity legislation, efforts to reduce coercive practices, addiction, and data related to child and adolescent mental health among several other subjects. The issue highlights some of the clinical and legal changes occurring in the delivery of mental healthcare today.

Capacity legislation

With the recent commencement of Ireland’s Assisted Decision Making (Capacity) Act 2015 in April 2023, an editorial by Murphy and colleagues (pp 109–113) is particularly pertinent for clinicians. The authors succinctly outline how the Act will change clinical practice, including: moving from a ‘best interests’ approach to one giving primacy to a patient’s ‘will and preferences’; the new legal standing of advanced healthcare directives; and the three new tiers of decision-making supports. The authors provide helpful algorithms illustrating the differences between previous practice and the changes under the new act.

Coercive and restrictive practices

Another editorial by Duffy and Kelly (pp 114–117) highlights the World Health Organisation’s ‘QualityRights’ initiative, which seeks to bring mental health care in line with the United Nations Convention on the Rights of Persons with Disabilities, with a particular emphasis on reducing coercive practices. Again, this is an editorial that emphasises the centrality of individual autonomy and capacity in 21^st century mental health care. This initiative is particularly relevant in the Irish context, given the Mental Health Commission’s drive to reduce seclusion and restraint use, and the Commission’s new seclusion and restraint rules introduced in January 2023. In a related correspondence piece, Duffy comments on the limitations of the data presented in the Mental Health Commission’s ninth report on the use of seclusion and restraint. This report shows wide heterogeneity in the use of restrictive practice across different units without, Duffy argues, adequately contextualising the findings. He suggests that these reports would be greatly enhanced by the inclusion of additional data (for example by including the use of sedating medications as a means of chemical restraint) and further analyses (for example subgroup analyses inclusive of only centres that have seclusion rooms).

Child and adolescent psychiatry

This issue also presents several interesting original articles from the field of child and adolescent psychiatry. Maguire et al., (pp 175–183) focus on children under 12 years seen by a child and adolescent liaison psychiatry service. The authors report that under 12s make up a rising proportion of overall referrals in their service, and that the total number of referrals of under 12s has particularly risen sharply since 2016. These findings are in keeping with other Irish data and international trends among child and adolescent mental health services.

Cotter et al., (pp 118–126) present an analysis of data from the Growing Up in Ireland study, showing that change in body mass index (BMI) from normal to overweight increases a child’s risk of developing psychopathology. They also demonstrate that, conversely, a change in BMI from overweight or underweight back to a normal BMI decreases a child’s risk of developing psychopathology. The findings underline the importance of BMI as a determinant of both physical and mental health and the need to address obesity at a societal level. Ó Donnchadha et al., (pp 152–165) also examine the issue of childhood obesity and its links to mental illness. These authors present further analyses of the Growing Up in Ireland data, specifically examining the association between Attention Deficit Hyperactivity Disorder (ADHD) and overweight/obese BMI, on a background of mixed international findings on this relationship. The authors report that although they found a relationship between ADHD symptoms and raised BMI, when they controlled for confounders using regression analysis, the relationship was largely explained by a variety of psychosocial factors.

Parental supports in intellectual disability services

Staunton et al., (pp 192–199) focus on children attending a child and adolescent mental health intellectual disability service and examine stress and quality of life measures among parents. The report describes high levels of psychological distress among the parents studied. The findings are consistent with previous studies reporting that parents caring for children with an intellectual disability experience higher levels of stress than those of typically developing children. The authors highlight the crucial importance of delivering resources to reduce parental stress and carer burnout, including parenting programmes and peer support.

Self-harm presentations

Moloney et al., (pp 245–248) pose the interesting question of whether the Christian period of Lent impacted self-harm presentations to an Irish Emergency Department in a predominantly Catholic area of Ireland. They note that religious affiliation is identified as a protective factor against self-harm across several faiths, particularly at times of heightened religious significance, such as times of religious worship, celebration and fasting. However, the authors did not find a significant difference in numbers presenting to the Emergency Department with self-harm during the Lent period compared to the preceding 40 days. In fact, surprisingly they showed an increase in self-harm attendances among the over 50s during Lent.

Gambling advertising and gaming disorder

Finally, two reports on addiction merit mention. Firstly, Columb et al., (pp 134–142) outline their descriptive study of gambling advertisements during televised sporting events broadcast in Ireland. The authors report that over three quarters of broadcasts had at least one gambling advertisement and note that such advertisements typically occurred before the adult television watershed. The authors propose that gambling advertising needs regulation to minimise potential harms to vulnerable groups, including children and adolescents, through the normalisation of gambling associated with sporting events. Columb and colleagues (pp 200–208) further present an original study of the underexamined diagnosis of ‘gaming disorder’ (a diagnosis introduced for the 11^th revision of the International Classification of Diseases) in an Irish population. Based on survey data they report a prevalence of 2.4% for gaming disorder among the regular gamers studied. They suggest the need for increased screening for gaming disorder and highlight the need for further research to enhance our knowledge of this disorder.

Conclusion

This issue highlights topical themes relevant to clinicians today such as new capacity legislation, reducing coercive practices, the changing needs within child and adolescent mental health services, and novel data in relation to the diagnosis of gaming disorder. Hopefully the papers presented in this issue can drive further research and service development in a changing clinical and legislative landscape.