Why should we worry about anxiety?

Why should we worry about anxiety disorder? Perhaps because it is so common; or maybe because it can be so disabling for those that experience it; or even because it is so often the harbinger of another mental health difficulty.

Although all of the above would be reason enough perhaps, there is another more pressing reason to take the problem of anxiety disorder very seriously. It is this; the prevalence of anxiety disorder appears to be increasing, at least in our young people.

So is the problem of mental health disorder really more common today?

The evidence is not straightforward. For many mental health problems often referred to as "major mental health disorders" such as bipolar mood disorder, schizophrenia, psychosis and even autism, there is no evidence of change in prevalence. These problems do not appear to be rising in our society or in our time. However, anxiety disorders, PTSD and substance misuse disorders do appear to be increasing. This increase is likely to be a huge mental health challenge.

These data come from the United Kingdom (UK) Office of National Statistics' Adult Psychiatric Morbidity Survey, published in 2016. They have been highlighted recently by Professor Sir Simon Wessley, President of the Royal College of Psychiatrists in London who has described them as "worrying trends".  This increasing level is “mainly in anxiety disorders in young women - 19% in 1993 to 26% in 2014. Compared to the much smaller changes in men (8% in 1993 to 9.1% in 2014), this means the gender gap has widened significantly”.

We could try to ignore these problems by pretending that a different reality exists in Ireland but, unfortunately, the facts speak for themselves. An impressive data set produced by Mary Cannon and Helen Coughlan and others at the Royal College of Surgeons in Ireland (RCSI) has confirmed that the mental health needs of our young people are some of the highest in Western Europe. It is no use trying to ignore these data any longer.

Let’s start by putting these statistics into more human terms. The real problem is that people experiencing clinically significant degrees of anxiety and other common mental health problems are more likely to persist in distress or at least relapse without treatment unless effective care is offered. Many people wait for years before presenting for effective treatment. The consequences for lives lost through avoidance, depression, substance misuse and suicide are very large.

So, what is the answer for us today?

Is Ireland’s national mental health strategy, A Vision for Change (2006), fit to address this challenge? In short, A Vision for Change proposes a community care model of mental health service, with close integration between primary care and secondary mental healthcare. This vision anticipates that most common mental health problems will be treated in the community and also that specialised services will be provided to meet such demand. The reality acknowledged by the subsequent implementation group is that the delivery of this vision has been patchy at best. Difficulties with funding are often cited but the problems with A Vision for Change go much further than that.

Today’s mental health challenges are complex and they are in a community; a community that is already over-stretched. The problems include increasingly unmet needs for those at the extremes of the lifespan, as well as some unforeseen problems for many in between. Most mental health problems arise before the age of 25 and, yet, our children’s mental health services still lag far behind service levels proposed by A Vision for Change. In today’s 21st century Ireland, the mental health needs of our young people are not being adequately addressed. This does not bode well for the future. The increase in anxiety, substance misuse and suicide that has occurred in our country is mostly in the young and this is neither anticipated by our national strategy nor provided for by our current policy.

How could the A Vision for Change authors, the expert group, have got it so wrong? It seems ironic that a document whose ambition was to see into the future actually failed to anticipate that future by such a margin.

Perhaps this failure is understandable. The mindset of A Vision for Change was actually about the major mental health disorders and this mindset was unchanged since its parent document entitled Planning for the Future was published in the 1980s. The assumption was that most of the minor disorders would simply be managed more cheaply in the community. To paraphrase George Orwell, their ideological position was "community care good; asylum care bad". Unfortunately, nothing in mental healthcare is that simple. There is more to good community care than the relocation of the asylum into the community. A community care service that is disconnected, demoralised and underfunded may also be bad.

No one wishes to be critical of A Vision for Change's authors. They were sincerely dedicated to the completion of the largest 20th century mental health project of all: the closure of our shameful asylum system. This closure project was necessary, but hasn’t the time has come to acknowledge this project is over?

There is a need for a new national mental health project.

21st century Ireland urgently needs a modern mental healthcare system. To be effective, this modern system must be data driven, human rights based and integrated right across the community, with appropriate services ranging from primary care, secondary care and onwards if required to tertiary care.

Is this too much to ask? Surely not! A modern mental healthcare system would be a great psychological and economic boost for our country. It could provide Ireland with a stepped response to our current mental health problems: Step One for those at the lower end of complexity would be met entirely in the community, rising to Step Four for those with the most complex and challenging problems whose needs will require more integrated care. Examples of such stepped care models for anxiety disorders (as well as many other common mental health problems) have been described by the National Institute for Clinical Excellence (NICE) and by others elsewhere.  

A 21st century response to the management of anxiety disorder, substance misuse and other common mental health difficulties in Ireland could meet the needs of the whole community by developing better integrated multidisciplinary care. Creating this new, better connected health service will require more than a new vision; it will require a renewed desire to make it a reality.

Isn’t it time for us to acknowledge that the service we need today has not been achieved by simply relocating the asylum? Providing a meaningful modern and effective mental health service is about more than the closure of the discredited system of the past. It is about responding meaningfully to the changing needs of the present day.