I AM a psychiatrist, a doctor specializing in the treatment of mental illness.
Psychiatry is different from other branches of medicine. Psychiatric diagnoses are based on symptoms and history rather than tests and scans. Every person has a unique set of difficulties and strengths, problems and solutions. Everyone is different.
That’s why I love psychiatry: nothing is stable, everything changes and every person is unique. The suffering is real, but so is recovery after a period of crisis. I am in constant awe of the body’s ability to heal and the mind’s ability to grow.
It helps that psychiatric treatments work for most people most of the time, even for serious illnesses like depression, bipolar disorder (manic depression), and schizophrenia. Numerous research studies show that cognitive behavioral therapy (CBT) and antidepressants not only relieve depression, but also reduce relapses. Mindfulness-based therapies are also effective, making the range of options very wide. Even psychedelics could play a role.
Some treatments offer benefits beyond what I could expect. Antipsychotic medications reduce the symptoms of severe mental illness but are also associated with a reduced risk of early death in schizophrenia. When combined with psychological interventions and social support, treatment can make an enormous difference.
Psychological and psychiatric treatments are not perfect. Side effects can occur. Sometimes it takes time to find therapy that will help. But there are a growing number of psychological approaches and new drugs that work in different, better ways to suit a wider range of people. One size doesn’t fit all.
I graduated from Galway Medical School in 1996 and have worked in the Irish Psychiatric Service for almost a quarter of a century. By this point, I must have seen tens of thousands of people with depression, anxiety, bipolar disorder, schizophrenia, and a host of other conditions.
I have also seen many people who were unhappy or with life problems rather than mental illness. These problems require family support, help from friends, and strong social networks. Mental health services are at their best when we focus on mental illness rather than the emotional ups and downs of everyday life. It is harmful to medicalize misfortune.
We suffer, heal and help one another in families, communities and societies. We need community solutions to life’s problems, accessible psychological care for mild mental health problems, and specialized inpatient and outpatient services for severe mental illness.
Mental health services have changed significantly over the past few decades. In the 1960s Ireland had over 20,000 people in psychiatric hospitals, the highest rate in the world. By 2020 we had 1,826 adult psychiatric inpatients and 50 under the age of 18 – a dramatic reduction.
We have the third lowest number of inpatient psychiatric beds per 100,000 inhabitants in the EU. Our involuntary sectioning rate is half that of England.
This shift towards community-based care is very positive, but low admission rates come at a price – people with mental illness in prison, homeless or at home, too ill to seek treatment but not ill enough to receive treatment without consent under the statutes mental health.
We need more inpatient beds, but nobody wants to go back to the days of “psychiatry”. Social services need a significant boost, especially for children and young people.
Ireland only spends 5.1% of our healthcare budget on mental health. Sláintecare recommends 10 percent. The World Health Organization suggests 12%. In the UK it is almost 13%.
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This low budget has knock-on effects. Recruitment problems are endemic in psychiatry. Consultant positions typically attract zero applicants. Better resource sourcing would help with recruitment, morale and employee retention. Like all healthcare professionals, physicians enter medicine to help people, but need support and a robust framework to do so.
Positive change is possible. Between 1990 and 2016, the global suicide rate fell by a third. While there is much more progress to be made and even one suicide is one too many, this is a tremendous change by any measure. Even amid the Covid-19 pandemic, the U.S. suicide rate has fallen nearly 6% in 2020. Even in the worst of times, some things can get better.
Properly used, psychological and psychiatric treatments work most of the time for most people, but they are not perfect and are not enough on their own. Psychological engagement and social support are essential. A balance is required, delivered with humility, wholeness, and hope.
We need more services to make this possible. Social and political activism is essential to achieving better funding for mental health services, more housing for people with mental illness, a meaningful safety net for those who fall through the cracks, and reform of criminal law, court procedures and prison policies to provide better protection the rights of people with mental illness.
These issues go well beyond healthcare. Every family in Ireland is affected in some way by mental health issues, mental illness or suicide.
When it comes to mental health, there is no “they”; there is only “us”. We have to change that – and we can.
Brendan Kelly is Professor of Psychiatry at Trinity College Dublin and author of In Search of Madness: A Psychiatrist’s Travels Through the History of Mental Illness (Gill Books).