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Protecting the protectors: Inside the Defence Forces' year-long mental health care crisis

The military has been without an in-house psychiatrist since May and an appointment is unlikely to be made until nearly 2020.

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AS MANY AS 50 Defence Forces personnel were placed on a months-long waiting list for psychiatric appointments due to the failure to find a replacement for the military’s retired in-house clinician during the past year.

Representatives for enlisted personnel say people with debilitating conditions such as post-traumatic stress disorder (PTSD) have been left languishing on leave from active duty for months without proper treatment due to the vacant post.

However a long-term solution to the lack of psychiatric services within the military is unlikely until the end of the year with Defence officials only recently receiving sign-off to continue the laborious process of looking for a replacement.

The crisis within the Irish Defence Forces’ mental health services began in May with the departure of the service’s long-standing psychiatrist, who had been working on a contract basis since his official retirement in 2011.

A competition was launched in July to fill the lieutenant colonel-ranked post – which had been officially vacant for seven years - however it received no applications by the end of September.

The post carried a starting salary of €112,550 including allowances, well below equivalent civilian roles for full-time consultants in the public health system – where base salaries are more than €20,000 higher and the pay scale goes up to nearly €188,000.

Internal documents, obtained by TheJournal.ie’s new investigative journalism platform Noteworthy, reveal the behind-the-scenes scramble to produce a solution as public scrutiny around the vacancy swelled.

Minutes of a meeting between Department of Defence staff and Defence Forces medical officers from late October said that there was “no scope to increase the rank or salary being offered” for the post to make it more attractive – and that other options may need to be considered.

Personnel had been referred to HSE-employed psychiatrists in the public system, but long waiting lists for appointments meant the military had also started sending cases to private practices.

In an email exchange between departmental officials the following month, one senior civil servant noted: “Given the perceived risk to the wellbeing of patients requiring psychiatric assessment and care, coupled with the department’s obligations, there is an urgency to implement a sustainable solution.

Media and political pressure is beginning to mount … at this point we have exhausted almost all options for providing these services.”

Irish Soldiers Training Missions A Defence Forces training exercise Source: Laura Hutton/RollingNews.ie

Traumatised

A letter earlier in November from PDFORRA, which represents rank-and-file members of the Irish military, highlighted two cases of Defence Forces personnel who it claimed had been waiting weeks or months for psychiatric appointments despite serious mental health issues.

One had been diagnosed with PTSD but had not been assigned another doctor since the previous psychiatrist retired, the letter said, adding that the association wanted to convey its “sincerest concerns” about the vacant post.

“This member was involved in a serious incident while in service with UNDOF (in Syria) and is scheduled to be placed before a medical board in the coming weeks,” PDFORRA general secretary Gerard Guinan wrote.

The Department of Defence has said there is no delay in treating patients requiring immediate psychiatric care or assessment with those deemed to be in crisis referred to emergency departments. This procedure was in place before the military’s former psychiatrist retired.

Meanwhile, a soldier told last year’s annual conference for the association that he had been traumatised by an incident in Lebanon when a patrol he was leading was set upon by Hezbollah, leaving the group trapped for hours as the militia threatened to burn their vehicle with the personnel inside.

A 2017 review of Defence Forces mental health services said that there had been a “considerable increase” in referrals for in-house appointments in recent years.

This was at least in part due to the return of personnel from overseas missions, with around three-quarters of all of those who returned from missions to Syria requiring some level of psychological support or counselling.

The Defence Forces also employs two full-time clinical psychologists, the second of which was taken on through an agency in late 2016 to help cope with the increased demand.

Ireland joined the UNDOF peacekeeping force in the Golan Heights in 2013 to help police a ceasefire between Israeli and Syrian forces.

There they have faced battles with Islamist insurgents, who have targeted parts of the international contingent.

Experts have found that even those on non-combat peacekeeping missions are frequently exposed to traumatic events, often exacerbated by factors such as restrictive rules of engagement.

Ireland has also had a significant presence within the UNIFIL peacekeeping force in Lebanon for the past 40 years in addition to smaller deployments in other regions.

90325547_90325547 An Irish soldier with the UNDOF in Syria Source: RollingNews.ie/Defence Forces

Defence Forces concerns

Behind the scenes, it appears frustrations at the lack of progress in filling the vacant psychiatrist’s post were also building among senior figures in the Defence Forces’ central medical unit.

In an email to the department from late November, Colonel Paul Carey, who oversees the unit, said he was “strongly of the view” that the Defence Forces needed a dedicated full-time staff psychiatrist to address the growing backlog of cases.

“Given where we currently are with mental health services and a current waiting list of over 50 personnel (and increasing) I believe it prudent to make the position full-time,” he said.

The Defence Forces’ former psychiatrist had treated at least 193 personnel in his final year before retirement.

Since his departure, some personnel had been referred to the public system, however there they faced waits of up to 20 weeks, according to a January email from another officer in the Defence Forces’ central medical unit.

A handful of cases had also been referred to private psychiatrists since July “as an exceptional measure” to try to overcome the long waiting lists, but personnel faced similar waits of up to three months in Dublin, Galway and Cork.

The most urgent cases were being referred to hospital emergency departments, however Defence Forces medical officers believed the current waiting lists for other cases were “unacceptable”.

The lack of an ‘on location’ psychiatrist for members of the DF (Defence Forces) has proven to be extremely problematic for all concerned, inclusive of the patients,” the email to departmental officials said.

The officer added that a psychiatrist at Tallaght Hospital who could treat acute cases within two weeks of referral had recently been found and 12 Defence Forces staff had been referred to the doctor. The remainder continued to be treated within the HSE system.

“We are again requesting an extension of this (private) service for all DF ranks on the grounds that there has been no progress in relation to the recruitment of a permanent military/civilian psychiatrist,” the email said.

The Department of Defence has denied discrimination between ranks when assigning personnel for treatment, telling Noteworthy via a spokesperson that people were referred “based solely on medical need”.

Some 21 personnel had been referred to private services since July according to the most recent figures available, the department added. Figures on the number of personnel referred to the public system were not available.

File Pics THE ASSOCIATION REPRESENTING members of the Irish Defence Forces has said poor pay and conditions are pushing members out of the job Source: Sasko Lazarov/RollingNews.ie

A civilian recruit

In November, after two unanswered letters from PDFORRA demanding details of the current delays in referring personnel for treatment, Department of Defence officials began looking at the option of employing a civilian psychiatrist at higher HSE consultant rates on a possible two-year contract.

In addition to enjoying better pay than a lieutenant colonel-level psychiatrist, a civilian appointment was flagged as potentially more attractive as it did not carry the restrictions that came with a military commission.

“It is not a given that attempting to appoint a civilian will be successful, but … we need to exhaust every possibility to address the issue,” one internal email said.

The urgency of the appointment is noted with a recommendation to attempt to advertise the position before the end of this year.”

However later that month a senior staff member in the department’s HR section raised concerns about the plan, noting that “the use of (fixed-term) contracts is generally discouraged centrally on public service pay and pension grounds”.

He added that filling a civilian vacancy would be “a laborious and resource intensive process, requiring advertising, shortlisting, interviewing, ministerial approval and finally medical and security vetting”.

This process would take at least six months, including two months for security vetting due to backlogs at the National Vetting Bureau, the email said. 

Nevertheless, ministerial approval was sought in early December to appoint a civilian psychiatrist on HSE pay scales, which begin at €135,644.

The request to the minister noted that there was no evidence to suggest there were higher rates of mental illness in the military than across the general population, although the job did come with added complications.

“Given the unique nature of the work including overseas deployment in areas of conflict, coupled with access to firearms, any diminution in the level of mental health support, perceived or otherwise, give rise to greater political and media scrutiny,” the memo said.

A two-year contract was sanctioned by the minister shortly before Christmas, however it wasn’t until early February that a formal request was sent to the Department of Public Expenditure for approval citing the “urgent requirement for the position”.

In the meantime, PDFORRA head Guinan again wrote to the Department of Defence seeking a response to its previously unanswered letters.

“This association has been advised that personnel reporting sick with mental health issues are routinely being downgraded until a report is received from a psychiatrist within the public system, which is taking months,” he wrote.

“The foregoing practice impacts on the ability of personnel to undertake duties, courses or travel overseas.”

90398781_90398781 Minister of State for Defence Paul Kehoe Source: Sasko Lazarov/RollingNews.ie

Political pressure

In parliament, Minister of State for Defence Paul Kehoe faced repeated questions over the unfilled psychiatrist post – however he downplayed the impact of the vacancy.

In a response in late February to Seanad questioning, he identified that there was a three-month waiting list for public psychiatric appointments and added that the Defence Forces had been authorised to refer cases to private psychiatrists.

However Kehoe did not mention that months-long waiting lists also applied for private appointments in many parts of the country.

An internal Defence Forces email from earlier in February said around €14,280 had been spent on private psychiatric treatment since July, suggesting relatively few appointments had taken place outside the public system.

It is estimated that the military’s former psychiatrist was paid more than €100,000 for the 664 appointments he conducted in the year before he retired as a contractor.

Kehoe told the Seanad that he hoped the psychiatrist contract would be filled “in the very near future”.

I assure senators that members of the Defence Forces receive the attention that they require,” he said.

In a separate response to Dáil questions, Kehoe said that problems recruiting clinical psychiatrists were not unique to the military.

“As I have outlined on a number of occasions, there is a nationwide shortage of trained psychiatrists, with recruitment issues in a number of sectors of the health service,” he said.

Some 61 consultant psychiatrist posts within the HSE were vacant last year with a number of competitions to fill the positions attracting zero applicants.

Impact

Guinan told Noteworthy that the lack of an in-house psychiatrist for the military had a number of impacts such as delaying diagnosis and implementing care plans, as well as restricting personnel from armed duties and applying from overseas posts. 

“However, most importantly, the lack of care impacts on morale and the health of personnel, which are essential to the efficient running of a uniformed service,” he said.

Last year, the State lost its appeal over damages awarded to former private Victor Murtagh for the failure to diagnose and treat PTSD he sustained after serving in Lebanon during the 1980s. He eventually received a €150,000 payout.

The Defence Forces have also faced a mounting crisis over poor pay and conditions among both enlisted and officer ranks in recent years.

Personnel numbers have continued to fall and are well below the agreed strength of 9,500 permanent recruits. There were only 8,857 people, including new recruits, in the permanent Defence Forces in February.

The government recently announced a rolling recruitment process for the military while it waited on a report from the Public Service Pay Commission on remuneration in the Defence Forces. Ireland has the lowest defence spending as a share of GDP of any country in the EU.

4 NEW ARMY OFFICERS 758A4143_90535354 A Defence Forces commissioning ceremony Source: Eamonn Farrell/RollingNews.ie

The long wait

In response to a series of questions, a Department of Defence spokeswoman said sanction had recently been received to recruit a civilian consultant psychiatrist, although the competition was yet to be formally launched.

That means an appointment is unlikely to be made until at least late this year based on a six-month recruitment and vetting process.

The spokeswoman did not give a timeline for the appointment, saying the process would launch shortly but the time taken to fill the vacancy depended on several factors.

She said that information on the number of personnel of Defence Forces personnel on waiting lists for psychiatric treatment was not available, nor was “confidential medical information” relating to the number of personnel removed from active duty due to waiting lists.

“Waiting times for (non-emergency) referrals to the public psychiatry service vary with location from one to three months,” she said in a statement.

“Where the medical officer deems it appropriate they may refer cases to a local external private psychiatrist with a waiting time of approximately three weeks in the greater Dublin area.”

She added that Defence had been “rigorous in its efforts to provide a dedicated in-house psychiatry service” and there was a nationwide shortage of qualified clinicians.

Guinan said PDFORRA was “deeply disappointed” with the delays personnel were experiencing in receiving psychiatric attention.

“Members put themselves in harm’s way both overseas and at home – they deserve better than the current treatment,” he said.

- With Ken Foxe

Know more about this story or want to share your experiences? Email the author via peter@thejournal.ie or send a message using the secure Threema app, ID: ESUCBYMK.

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