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The Scottish solution

'Look good but feel crap?'

Scotland has become a leader in tackling mental illness, thanks to innovative legislation and high-profile public-awareness campaigns. The suicide-prevention effort features everyone from football teams to the pop duo the Proclaimers

From Friday's Globe and Mail

EDINBURGH, SCOTLAND — Seventeen years ago, when Eleanor Trebilcock visited her doctor in the Scottish town of Arbroath, she knew something was terribly wrong but was too ashamed and confused to explain it. The doctor didn't recognize the symptoms of depression and sent her home with a relaxation tape.

Two days later, she attempted suicide, cutting her forearms.

“Like a lot of people who are depressed, I wasn't completely honest with him,” said Ms. Trebilcock, now 43, from her home on Scotland's North Sea coast. She'd had an abusive relationship and an upsetting divorce. “I didn't tell him how bad things really were,” she said.

She survived her suicide attempt, but for years afterward was trapped in an overburdened mental-health system that didn't have an integrated plan for dealing with people who had deep-rooted illness. Scotland prides itself on self-reliance and, at the time, was uneasy with public discussions of mental illness. “We're hardy people,” she said.

Two years later, Ms. Trebilcock gave birth and was diagnosed with puerperal psychosis, a severe form of postnatal depression. She and her infant daughter were placed in a general psychiatric ward where male and female patients were housed together.

“That was a horrible experience,” she said. “When the men let off steam in the ward, it could get quite wild. It was awful.” That wouldn't happen in the new Scotland, she says: A woman in her position today would be placed in a ward for mothers and children.

Ms. Trebilcock is a product of Scotland's old thinking about mental illness, but she's also benefited from its innovative approach to solving a national problem. In the past five years, thanks to new legislation, a complex partnership of local and state authorities and several high-profile public-awareness campaigns, Scotland is now a leader in dealing with mental health.

For one thing, Ms. Trebilcock, as a survivor of the system, has a valued opinion. She's on the advisory board of a new health-care facility being built in the district of Angus; in the past, nobody would have thought to solicit the opinion of the people who'd been in hospital. She also works part-time as a care worker for the elderly.

“The stigma,” she said, “is slowly disappearing.”

Welcome change

Certainly the signs are everywhere, from the posters in Edinburgh that feature two handsome teenagers under the slogan, “Look good but feel crap?” to the anti-suicide campaign spearheaded by the pop duo the Proclaimers.

The change was sorely needed. In 1998, when many legislative powers were devolved from London to the new Scottish Parliament, the country's five million people faced overwhelming social ills, including widespread drug and alcohol abuse, and one of the highest suicide rates in Europe. Between one in three and one in four Scots had some instance of mental illness, which was severe and persistent in about 3 per cent of the population.

In response, the government created the National Programme for Improving Mental Health and Well-Being seven years ago. In 2003, Scotland passed the Mental Health Act, which put in place new systems for providing care and mental-health tribunals to ensure those systems were administered fairly. Agencies were set up to further the main objectives, and each was launched with an ad campaign.

The strategy was to have nationally mandated goals that were developed in partnership with health-care professionals and Scotland's 32 local authorities, and administered locally. There would be only a handful of targets – each to be met by a specific date.

Of the 14 goals, these are the primary four: Reducing suicide by 20 per cent by 2013; halting the increase in anti-depressant prescriptions by 2010; reducing the rate of hospital readmissions by 10 per cent by next year; and improving services for people with dementia.

“So far, we've met all the targets we've needed to meet,” said Geoff Huggins, deputy director of the government's Mental Health Division. He said they've learned that “simply publishing policy documents, issuing them in the field and telling people to get on with it didn't produce change. We had to be much clearer about what changes we wanted to see.”

The problem, Mr. Huggins says, was paradoxical. Mental-health services for so long had been regarded as a poor, undeserving relative – a “Cinderella service” – that even those on the inside had stopped expecting to make progress.

“It's not like other health services, because people have cared less about it,” he said. “Patients are seen as less deserving than other patients. We wanted to show that change is possible and that we could show benefits quickly.”

Spotting the signs

Scotland is taking small but significant steps at early intervention. It has made progress in everything from ensuring that each patient who shows signs of depression is assessed using a standard model, to getting physical checkups for those with severe illness, to providing a mental-health liaison for every school in the land.

On a much broader level, the government's next goals will look at public health – the notion of prevention and physical well-being tied to mental health. Everything from diet to physical environment to the role of drug and alcohol use will come under scrutiny. This is a much longer-term strategy but a crucial one if Scotland is to take on one of its major scourges – suicide.

In the early 1970s, Scotland had a lower suicide rate than England's, but over the next three decades the figures soared, leaving it with one of the highest rates in Europe. On average, there are two suicides a day in Scotland, and three out of four of those are men.

“We don't know why that figure's so high, except that there's no one cause,” said Dougie Paterson, program manager of the government's suicide-prevention group Choose Life. In many ways, Choose Life represents the Scottish model in miniature: It's a system of targets and directives that come from the top down but will only work if tailored locally. Each authority is left to come up with a plan allied to the national goal of reducing suicide by 20 per cent in the next five years, but tied to regional needs.

“That's crucial,” Mr. Paterson said, “because all the areas in Scotland are different, culturally and geographically.”

In Glasgow, a tough city with high suicide rates, “stress centres” offer relaxation techniques such as massage. In isolated rural areas, where the elderly population is high, care workers are trained to look for early signs of depression – Scotland has put 14,000 people through suicide-training courses in the past five years.

Part of the strategy also revolves around reaching high-risk groups such as prisoners and young men. Several Scottish football teams, for example, have handed out cards at their matches with the team's colours on one side and suicide-prevention information on the other.

“There's a saying in Scotland: ‘Men don't talk,'” Mr. Paterson said. “There's a feeling that they don't talk about their emotions, but it's my experience that, given the right opportunity, you can't shut them up.”

Keir Hardie is one man who benefited by talking through his suicidal feelings, but he says it's often not easy for others: “A lot of men aren't used to talking about their feelings, and talking about it makes them feel vulnerable. Or they might talk about it when they're drunk, and pretend the next day that it never happened.”

Mr. Hardie, 37, lives in Inverness, in the Scottish Highlands. He didn't recognize the first symptoms of depression that overtook him as a teenager, and neither did anyone around him, even though his journals were full of black thoughts. He tried to commit suicide by overdose in his 20s.

Now, he says, the clues to his mental state would have been noticed much earlier. “These days things are different. It would probably have been picked up at school. We've got a lot better at looking for the signs in young people.”

Learning to put his problems into perspective and just the simple process of getting older helped Mr. Hardie deal with his depression. Now, he said, “I feel a lot less vulnerable.”

Scotland's key innovation in handling suicide, Mr. Paterson says, was to take a much broader approach, looking at early intervention, stigma reduction and public-health issues such as drinking. Since 2002, suicide rates have fallen by 13 per cent, although it's too early to tell whether that's a trend or a statistical blip.

“We're not saying the problem is sorted,” Mr. Paterson said, “but it is encouraging.”


Scotland isn't the only country that has made concerted efforts to combat mental illness:

AUSTRALIA: The country adopted a mental-health strategy in 1993 and has updated it several times. The focus is early intervention and shifting services to the community. Australia has also tried to break down barriers between the health-care, social-welfare, housing and legal systems, and it has doubled funding for mental-health programs in the past decade. A leading politician's high-profile battle with depression generated enormous media interest. Australia's anti-stigma campaign, beyondblue, centres on depression.

NEW ZEALAND: The country established its mental-health commission in 1998 and adopted a national strategy in 2003. Work has focused principally on prevention of mental-health problems, particularly in children, and supporting families of people with mental illness. New Zealand has invested heavily in community services, while maintaining a commitment to acute hospital care. It has also targeted Maori communities for improved mental-health care and addiction services. The anti-stigma campaign, Like Minds, Like Mine, has been copied around the world.

ENGLAND: Mental health has been a priority in the National Health Service since 1995, with an emphasis on providing timely, appropriate care. The NHS established a set of standards on what must be delivered by trusts (regional health authorities), including mental-health promotion, access to services, help for caregivers and suicide reduction; there are financial incentives and penalties based on performance. Rather than focusing on stigma, England opted for a campaign that jointly promotes mental and physical health, dubbed Moving People. By 2011, the country has committed to adding 3,500 new therapists, most practising cognitive behaviour therapy, to treat anyone meeting the newly developed criteria for depression and anxiety disorders.

André Picard

Sources: Mental Health Commission of Canada, Canadian Mental Health Association


25 to 33 - Percentage of Scottish people experiencing mild to moderate mental-health problems, out of a population of five million 3 Percentage of the population with severe and enduring mental illness

1 - Ranking of suicide as the cause of death for Scots under 35 years old

765 - Number of suicides in Scotland in 2006

13 - Percentage decline in the suicide rate since 2002

20 - Percentage drop that Scotland wants to see in the suicide rate by 2013 (from the base year 2002)

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Return to Breakdown: Canada’s Mental Health Crisis

Face it. Fund it. Fix it.

In Breakdown, The Globe and Mail documents the enormous, unaddressed cost of mental illness to Canadian individuals, families and society. The series closes with a search for solutions.


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