Health in a time of austerity
Here is my Medical Independent column from 29 August 2013. It is too early to say what effect the economic crisis is having on the nation’s health, despite recent claims in the BMJ. Writing in the British Medical Journal (BMJ) recently, Dr Dermot Walsh, Consultant Psychiatrist, said that despite the economic crisis, there is little evidence that the austerity programme “has had a significant adverse effect on basic health indicators”. This is contrary to findings in other countries experiencing similar or worse economic contractions.
Prof Walsh uses crude death rates, suicide rates, hospital admissions for depressive disorders and self-assessed health status to make this point. And with these figures he is right. However, there is more going on here than may appear on the surface.
Crude death rates between 2007 and 2012 do not take into account the time lag effect. Improvements in life expectancy take a long time to achieve. Likewise disimprovements could take decades to have an effect and be seen in crude death rates. Neither do these figures take into account the inequalities in mortality that exist in Ireland, with on average a six year gap in life expectancy between people from the highest and the lowest socio-economic groups.
Given the significant increases in unemployment during the economic crisis from 4 per cent to 14 per cent, the declining incomes of most households, the increases in poverty, especially deprivation levels, it is reasonable to assume that death rates amongst the poorer sections of society will disproportionately increase due to the economic crisis. But again this may take years or decades to appear in the death statistics.
Suicide rates are an extreme manifestation of a mental health or life crisis and are also problematic due to cultural and reporting issues. Similarly, there are difficulties using hospital rates for depressive disorders. It has been Government policy for decades, reinforced by A Vision for Change in 2006, to reduce the numbers of in-patient psychiatric admissions and shift care from hospital to the community. Although, there has been limited success in shifting budgets and staff, as detailed in this column two weeks ago, there have been significant decreases in the numbers of psychiatric hospital admissions over time.
Hence the decline in admission rates for depressive disorders may be a sign of progress in securing better services in the community rather than the impact or lack of the impact of the recession on mental health. Also, the same figures also show that the decrease in admissions seems to be driven by a reduction in ‘re-admissions’ rather than a decrease in ‘new admissions’ and the high numbers of new admissions might reflect the impact of the economic crisis on mental health.
The international and national literature is clear in this regard; declining incomes, higher unemployment, and increased poverty and deprivation cause varying, but usually increasing, levels of psychological distress which can manifest itself in an acute or enduring mental health episode.
Self-assessed health is an interesting one. Ireland always comes out top or close to the top of self-assessed health and happiness indices. However, reanalysis of the SLÁN data has shown that our self-assessed health is not what it seems. Work which followed up on a cohort of the SLÁN study showed that Irish people overestimated their height and underestimated their weight, thereby undermining the self-assessed health indices. It will, however, be interesting to see, in time, the impact of the ongoing economic crisis on self-assessed health.
There are other indicators of mental health/distress. For example, the Samaritans, the Money Advice and Budgeting Service and Free Legal Aid Centre have each experienced increased numbers of calls to their services year on year since the onset of the crisis. GPs are also reporting increasing numbers of patients presenting with psychological/mental health issues, while the demand for free counselling services has increased. The recent announcement of €7 million for those with medical cards to access brief counselling through primary care is welcome. Even if it is a tiny drop, in a big ocean, it is progress nonetheless.
Figures from the HSE’s Primary Care Reimbursement Service show that there has been a 25 per cent increase in the prescribing of sleeping pills, antidepressants and benzodiazepines since 2008. While this might be more of an indicator of poor mental health services or poor management of mental health in primary care, it is a startling figure all the same and shows increased demand and prescribing practices.
Causal relationships are hard to determine in public health statistics. Given the time delay in Irish health statistics and the time lag effect of circumstances on health and death outcomes, it is too soon to conclude that austerity has not had negative consequences on people’s health. It seems inevitable that fewer people in work, lower incomes, and increased stress associated with debt will impact on population health and most likely on the health of the poorer members of society.