The great debate on mental health

In her column
in the the Irish Times of Saturday November 11 2006, Breda O'Brien launched an intemperate and ignorant attack on the views of the then junior Minister for Health, Tim O'Malley, when he stated in an interview with the Irish Medical News that "it's very welcome that there is a debate about the whole treatment of people with mental health difficulties.
"For far too long we had the situation where people just went to the doctor and accepted whatever the doctor said as being gospel. I think there is a school of thought now, especially in the mental health area, that there should be a much greater involvement of counsellors and psychotherapists and psychological methods of dealing with people with mental health difficulties."
Here's the bit that the right-wing columnist took such particular exception to:
"There's a very strong view with a lot of people that depression and mental illness is not a medical condition, that it's part of life's events that people get depressed or get unhappy. Years ago people were unhappy, they weren't depressed, they weren't given the name depressed. Society has changed as well. In former times people had much more time to liaise with each other and discuss things and if there were difficulties people discussed those difficulties and sorted them out."
The view he referred to, of course, is our view and the view of many others, and it's very welcome that the minister in charge of mental health matters acknowledges it as a valid view which must be taken account of. But the response of O'Brien and her friends in the biological psychiatry establishment is to try to shut down debate, no doubt rattled by the fact that our conference on this very theme attracted almost 700 people on 21 October last, including strong representation from local health boards, caring organisations, the HSE, practising psychiatrists and psychotherapists, and government, as well as survivors of the mental health services, patients, their families and carers.
O'Brien's column is a hymn to the efficacy of psychotropic drugs. Here are a few choice quotes, with comments:

[In] the University of Pittsburgh research on maintenance therapy, where in longitudinal studies, maintenance medication was proven to be vital in preventing recurrence of depressive episodes. In other words, if people take the appropriate medication, they have a far greater chance of remaining well.

Unfortunately for O'Brien's case, this very quote disproves it. The point which we, and many others, make, and which the minister is taking note of, is that the drugs don't work; they do not cure or lead to recovery, but merely to maintenance of a condition, a form of stabilisation €” if they even do that. We could produce contrary evidence to show that SSRIs do not even prevent recurrences of depressive episodes, as she claims they do, but that is not the point. Even if they work, their advocates admit no more than a maintenance effect. In practice, this can mean years or an entire lifetime on medication with serious adverse effects and some potentially fatal effects. To say that people in this state "remain well" is absurd.

The advent of anti-depressants, anti-psychotic and mood-stabilising medication has revolutionised the management of mental illness. It has given people back their lives.

Well, what can you say? This is a line that a drug company PR would be proud of. It is also entirely Orwellian, in that the truth is the exact opposite. A lifetime on medication suffering from tardive dyskinesia is not a life returned.

Medication is only part of the picture, but often, it is a vital aid on the road to wellness.

Here, we cannot disagree strongly enough. Continued use of psychiatric €˜medications' is not alone no "aid on the road to wellness", it actively promotes unwellness and fails to bring about recovery, often postponing and making recovery more difficult.
O'Brien had many responses to her column. Two weeks later, in a second bite at the cherry, she admitted that 80% or more of these disagreed with her view, and supported the minister's acknowledgment that many feel another approach is needed. She then proceeded entirely to ignore this fact, merely repeating herself via an attack on Dr Terry Lynch and on his book, Beyond Prozac.
However, her diatribe provoked a public debate in the Letters columns of the Irish Times and on RTE radio, with the dissenters, in our view, winning on points.
Perhaps one of the the unintended consequences of the minister's remarks and of O'Brien's column was to bring into this debate a proponent of biological psychiatry who generally tries to avoid debate: the eminent Dr Patricia Casey, FRCPsych, FRCPI, Professor of Psychiatry at University College Dublin and Matermisericordiae University Hospital. Dr Casey and four of her colleagues wrote demanding that minister O'Malley resign on account of his "ill judged, ill informed and imprudent € comments".
O'Malley did not resign, nor did he withdraw his views. In fact, in an interview on RTE Radio 1's Drivetime programme the day following an appearance by Dr Casey, he appeared to strengthen his view that other approaches needed to be tried. He again insisted, correctly, that there is no empirical evidence that mental illnesses are physically or biologically-based or that the medication has an effect.
In any case, why should he have withdrawn? What he said was unexceptional, and merely stated the facts. O'Malley began by welcoming the fact that there is now debate on these issues, and went on to say that accepting the word of a doctor is no longer enough: "I think there is a school of thought now, especially in the mental health area, that there should be a much greater involvement of counsellors and psychotherapists and psychological methods (our emphasis) of dealing with people with mental health difficulties." Why would people like O'Brien and her supporters such as Dr Casey take any exception to this, if not to resist change and attempt to retain the status quo?
Clearly, the vested interests of institutional, biological psychiatry are rattled by the fact that the first-ever minister for mental health in this country has a healthy scepticism towards their claims to a monopoly of knowledge and wisdom in these matters, as witnessed by his words that "there's a very strong view with a lot of people that depression and mental illness is not a medical condition, that it's part of life's events that people get depressed or get unhappy."
Well, the minister is right: there is indeed a very strong view to this effect, most prevalent among so-called 'service users', perhaps better described as 'service survivors' or even, as some of them prefer, victims of the psychiatric services. And their views will have to be taken account of: they can no longer, and will no longer, be excluded.
Here, we present the columns written by Breda O'Brien, all but one of the letters published by the Irish Times, and a most perceptive column by Roisin Ingle from the Irish Times' Weekend magazine of Saturday November 25.
On our Comment & Analysis pages (the Vantage Point link), you will find further comment from several sources.

The great debate: instalment I

MINISTER'S VIEW ON MENTAL ILLNESS DANGEROUS

Breda O'Brien

Well, it's been a vintage week in politics. Fine Gael has a councillor who thinks driving after three or four pints is grand, and that random breath-testing is destroying the fabric of Irish rural life. The Progressive Democrats have some interesting ideas, too.
The PDs have a Minister of State in the Department of Health and Children with special responsibility for mental health, and he isn't sure if depression and mental illness are medical conditions.
In last Monday's Irish Medical News, Tim O'Malley declared: "There's a very strong view with a lot of people that depression and mental illness is not a medical condition, that it's part of life's events that people get depressed or get unhappy. Years ago people were unhappy, they weren't depressed, they weren't given the name depressed."
Tim O'Malley is a pharmacist.
"During that time I developed an interest in the whole area of mental health particularly because of all the areas of prescribing medication, I was aware that unlike other areas of health like cholesterol, diabetes, or coronary care, where you can measure the results of taking medication, in mental health, it is impossible to measure, scientifically, the results."
Well, that will be news to hundreds of researchers. Let's just look at one set of studies: the University of Pittsburgh research on maintenance therapy, where in longitudinal studies, maintenance medication was proven to be vital in preventing recurrence of depressive episodes. In other words, if people take the appropriate medication, they have a far greater chance of remaining well. It is even more important in the case of psychotic illness.
Someone in Tim O'Malley's position saying that there is no way to measure scientifically the results of taking medication for mental illness is downright irresponsible. To imply that years ago there was no such thing as depression, only unhappiness, is to risk restigmatising those who have serious mental illnesses. It is not true that years ago there were no depressed people. What is true is that years ago, people with serious depression and psychotic illnesses were incarcerated, often for a lifetime, because there was no real alternative. Mental hospitals were shocking and frightening places because of the severity of symptoms suffered by patients.
The advent of anti-depressants, anti-psychotic and mood-stabilising medication has revolutionised the management of mental illness. It has given people back their lives. Of course it is not a panacea, and it does not work for everyone, but few people would choose to return to the so-called good old days.
Families who have a member with serious psychiatric illness are bitterly aware that there is still a stigma attached to being on medication.
Well-meaning people tell the person that they are grand now, that they don't need all those oul' tablets. As a result, people abandon medication, and after an initial honeymoon period, often suffer severe relapses. It is no help to have the Minister of State with responsibility for mental health casting doubt on the efficacy of medication, and reinforcing the idea that all that people who suffer from mental illness need is someone to talk to.
Of course other factors are important, including things that help people to cope, such as adequate support services, strong family ties and spirituality. Medication is only part of the picture, but often, it is a vital aid on the road to wellness.
There is a grain of truth in the Minister's dangerous over-statement.
Depression in particular, is often mistakenly diagnosed, and there is no doubt that over-prescription of medication happens. What else would you expect except over-prescription when public patients get 10 or 15 minutes with a doctor, and little else?
If the Minister is genuinely serious about a holistic approach, why does he not make funding multi-disciplinary teams a priority, with clinical psychologists, psychiatric social workers (not just general social workers), occupational therapists and community mental health nurses?
He declares that liaison nurses, that is, nurses who have received some training in assessing suicide risk factors, are now present in accident and emergency. He neglects to mention that in many places they are only there nine to five, Monday to Friday. Suicidal intentions are apparently expected to keep office hours.
The Minister also repeats the nostrum that there is too much emphasis being placed on the need for additional beds. He says that 95 per cent of cases could be treated in the community. He sees no contradiction in the fact that he also says that community life has been greatly eroded.
"Nowadays people are flying around in their motor cars going 70 or 80 miles an hour and people are commuting a long way to work and families and parents don't have time often to discuss things with their children."
A pre-requisite for community-based care is a community. It works reasonably well in rural areas, but often fails disastrously in urban areas, particularly in disadvantaged urban areas. You cannot treat an acute psychotic episode in a bedsit where no one knows anyone in the building.
A debate is needed on mental health, but it has to begin with recognising the reality of mental illness. No one bats an eyelid if someone with a coronary condition or diabetes requires hospitalisation, but somehow a stigma still exists if someone with a mental illness needs hospital treatment, or ongoing medication. Why are community care and hospital treatment always being pitted against each other?
There will always be a need for psychiatric in-patient treatment, and there is an even greater need for caring communities, where adequate resources are provided to help people cope.
We have a huge problem with suicide in this country. In the last edition of the journal Crisis, research from the National Suicide Research Foundation in Cork indicates that it may be even worse than we suspected. Due to the slowness of the inquest process, in recent years the registered figures for any given year may be higher by as much as 20 per cent by the time the final figures are collated.
The final figures never make it into the public arena. This is very serious, as accurate data is vital. That is bad enough, but it is worse if the Minister responsible for this area can't decide if mental illness is a medical condition, and makes deeply unhelpful comments about the impossibility of scientific proof as to whether medication works or not.
Irish Times Saturday Nov 11 2006

MINISTER'S VIEW ON MENTAL ILLNESS

Madam, - Breda O'Brien (Nov 11th) would like depression to be understood as a medical condition, just like heart disease and diabetes. She even calls Tim O'Malley, the Minister of State with responsibility for mental health, "downright irresponsible" for saying that "there's a very strong view with a lot of people that depression. . . is not a mental illness". In the same article she also calls for a debate on mental illness.
I have no doubt Ms O'Brien can readily find research which proves that medication is beneficial, since the drug companies fund this kind of research all the time. However where is the proof that depression or any "mental illness" has a physical cause? When psychiatry can produce physical evidence that depression has a medical cause, then it can be scientifically concluded that mental illness is indeed a medical condition. Until then, the view of "a lot of people" that depression has to do with emotions and life events should be respected by journalists like Ms O'Brien. - Yours, etc,
PAUL MAHER,
Knockroe,
Anacarty, Co Tipperary.

Madam, - Breda O'Brien calls Minister of State Tim O'Malley "irresponsible" for questioning the efficacy of drugs marketed as anti-depressants (Opinion, Nov 11th).
In reality, the Minister is only echoing a growing concern in the medical profession that these drugs have been overused.
Ms O'Brien maintains that these drugs and others have "revolutionised" the management of mental illness. As practising psychiatrists, we would beg to differ. We prescribe psychiatric drugs and some patients benefit but the fact is that many do not. And there is also an ongoing debate about how these drugs have their effects.
Some prominent medical commentators have pointed to a very large placebo effect in studies of anti-depressants. In addition, it is now clear that studies carried out by researchers who have ties to the pharmaceutical industry are much more likely to show a benefit compared to more independent research.
There are increasing concerns that the serious side-effects of these drugs have been systematically played down. These debates take place in a context where "market expansion" is top of the agenda for the pharmaceutical industry.
In our opinion, the Minister is quite correct when he highlights the fact that the field of mental health is one of debate and discussion.
He is simply acknowledging the reality and the importance of this debate.
He is also right in his assertion that there are valid alternatives to the biomedical framing of states of sadness, distress and alienation. Mental illness can be life threatening.
Many service users report difficulties engaging with services that are dogmatic and narrowly biomedical.
In this context, if any views can be labelled "dangerous" it is the sort of dogmatic dismissal of these alternatives put forward by Ms O'Brien.
Genuine science is always a matter of questioning and doubt and not of certainty and dogma. - Yours, etc,
Dr PAT BRACKEN; Prof MARCELLINO SMYTH,
West Cork Mental Service,
Bantry General Hospital,
Bantry, Co Cork.
IT Tues Nov 14 2006

DEBATE ON MENTAL ILLNESS
Madam, - Breda O'Brien's article (Nov 11th) calling for a debate on mental health was heaven sent. However, her caveat that "it has to begin with recognising the reality of mental illness" is nonetheless limiting. Her comments are a slap on the wrist for Minister of State Tim O'Malley for having "declared" in the Irish Medical News that "there's a very strong view with a lot of people that depression and mental illness is not a medical condition, that it's part of life's events that people get depressed or get unhappy".
Thank you, thank you, Mr O'Malley, no truer words have ever been spoken by a member of Government. Words that will resonate with millions. He dares to point to the huge faultline running through the medical approach to those suffering with mental distress.
We don't need the pharmaceutical industry to tell us what causes mental distress. The roots of serious mental distress are inseparable from abandonment, physical and sexual abuse, family breakdown, substance misuse, financial worries, school and work pressure, bullying, life-threatening illnesses, ageing and the titanic sense of being overwhelmed that sensitive children and teenagers experience.
Many of our young are driven to suicide, alcohol, street drugs and into the worlds of fear, inner withdrawal, terrible mental anguish, panic attacks, depression and psychosis.
As soon as mental distress is diagnosed as a disease, and medication prescribed as a cure, one view predominates - the disease-biological model - and the other, which sees mental distress as a response to life events and experiences, is elbowed out, along with its non-pharmaceutical solutions.
Doctors are primarily healers, passionate about their work. We have been given the responsibility to treat and save lives. We are also in part the creators of medical terminology, and the gatekeepers to medication.
I believe the time has come for the medical profession to embrace change, and reframe psychological distress as psychosocial in origin. There is a world of difference between these two stances. One leads to the continuation of the existing psychiatric service, which is evidently failing, at huge human and financial cost. The other ushers in the era of prevention of mental distress, from which follows a multitude of innovative changes such as the creation of learning environments for our children which equip them with personal, emotional and interpersonal skills, knowing how to take personal responsibility for their minds and bodies, and enabling them to live creatively.
It also paves the way for crisis intervention centres, therapeutic communities, and various forms of psychological rehabilitation. - Yours, etc,
Dr MICHAEL CORRY,
Consultant Psychiatrist, Institute of Psychosocial Medicine,
2 Eden Park, Dún Laoghaire.
IT Wed Nov 15 2006

MINISTER'S VIEWS ON MENTAL ILLNESS AND VALUE OF PSYCHIATRY
Madam, - We read with great interest the incisive and insightful column by Breda O'Brien (Nov 11th) concerning the interview given by Minister of State Tim O'Malley recently to the Irish Medical News (Nov 6th). We too were astonished and dismayed by this interview, in which he stated, "There's a very strong view with a lot of people that depression and mental illness is not a medical condition, that it's part of life's events that people get depressed or get unhappy". He then expanded on the theme by suggesting that the problems incorrectly defined as mental illness are the result of having nobody to talk to, adding that ". . .in former times people had much more time to liaise with each other and discuss things. . . if there were difficulties people discussed those difficulties and sorted them out".
This interview highlights for all how ill judged, ill informed and imprudent are the comments of our Minister with responsibility for mental health. His comments have restigmatised many thousands of people with mental illness and by suggesting that they simply lack somebody to chat to he has undermined the suffering of this particularly vulnerable and frequently silent group in Irish society as well as trivialising the suffering of their families.
His belief that the benefits of the medications used to treat mental illness cannot be proven scientifically in the way that other medications can is not only completely erroneous but irresponsible and positively dangerous. His casual undermining of the effects of medication in mental illness may well encourage those who are being treated with such medications to abandon their treatments, to the detriment of their personal health and safety and even of their lives. In implying that mental illness cannot be the subject of scientific methodology, he disparages the output of thousands of researchers working in psychiatric epidemiology, psychobiology, genetics, neuro-imaging, pharmacology etc, whose results are accepted by the wider scientific community and published in the most prestigious peer-reviewed journals.
Mr O'Malley correctly states that 95 per cent of people with mental health problems can be managed in the community. That is in fact what happens, as most patients are treated by general practitioners or in psychiatric out-patient clinics. Only a minority who are psychotic, disturbed or presenting an immediate suicide risk are admitted to hospital.
Even so, practising psychiatrists regularly have to discharge patients before they are fully recovered in order to create a bed for somebody more desperately ill, or find themselves forced to keep patients in an accident and emergency department for several days until a psychiatric bed becomes available. Such psychiatrists, nationwide, will be more than alarmed at the Minister's stated views about mental illness and his questioning of the need for more acute beds and may reasonably suspect that it is the financial cost of in-patient treatment rather than a genuine ignorance of mental health that is informing his alarming and ideologically toxic comments. Rather than this casual dismissal of our concerns about bed shortages, especially in urban areas, we would urge the Minister to meet us and other concerned parties to discuss the real crises in mental health provision in Ireland and the resources required to alleviate them.
The Irish psychiatric services that are the responsibility of Mr O'Malley are in a perilous state of neglect, lacking full multidisciplinary teams including psychologists, psychiatric social workers, occupational therapists and clinical nurse specialists throughout the country.
Perhaps we can now understand the reason for this. The man in charge does not believe that mental illness exists and reckons that all that is needed is a buddy.
We strongly urge the Minister to properly inform himself about the speciality he is supposed to be serving, in particular the needs of those with severe, enduring and relapsing mental illness, instead of singing off the hymn sheets of vested interest groups who deny the existence of mental illness. Alternatively, on behalf of the thousands of men, women and children of Ireland with such mental illnesses whom he has insulted and restigmatised by his comments, Mr O'Malley might wish to consider his Ministerial position. - Yours, etc,
PATRICIA CASEY MD, FRCPsych, FRCPI, Professor of Psychiatry, University College Dublin and Matermisericordiae University Hospital;
TIMOTHY DINAN, MD, PhD, FRCPsych, FRCPI, Professor of Psychiatry, University College Cork;
MICHAEL GILL, MMRCPsych, FTCD, Professor of Psychiatry, Trinity College Dublin;
COLM McDONALD, MB, PhD, MRCPsych, Professor of Psychiatry, National University of Ireland, Galway;
KEVIN MALONE, Md. FRCPI, MRCPsych, Professor of Psychiatry, School of Medicine and Medical Science, SVUH/University College Dublin;
KIERAN MURPHY, M Med Sci, PhD, FRCPI, FRCPsych, Professor of Psychiatry, Royal College of Surgeons in Ireland and Beaumont Hospital.
IT Thur Nov 16 2006

DEBATE ON MENTAL ILLNESS
Madam, - Minister of State Tim O'Malley's comments on mental health as published in the Irish Medical News (Nov 6th) and referred to in the Irish Times (Breda O'Brien) last Saturday are largely in conflict with the findings and recommendations in the report of his own expert group, published in A Vision for Change and which is now Government policy.
It is a cause of concern that these views as expressed by the Minister are in conflict with his own Government policy. I wish to remind people that he himself launched this policy document.
It is imperative that the Minister clarify his position regarding his commitment to Government policy on mental health. - Yours, etc,
Dr KATE GANTER,
Chairman, Irish College of Psychiatrists,
St Stephen's Green, Dublin 2.

Madam, - Tim O'Malley, our Health Minister of State, must have been born rattlin' (a Donegalism for bonkers). To publicly state that he isn't sure if mental conditions are medical illnesses, to question the efficacy of ongoing medication and hospital treatment of sufferers of same, is not only irresponsible but downright ignorant.
As a victim of bipolar disorder, I know what it's like to suffer the delusions of going off the "aul medication", to have been in an emergency locked ward where I lived with harrowing scenes of true mania; to be grateful for medication to control my own demons, and to suffer the stigma of being mentally ill in modern Ireland.
Mr O'Malley, or any member of his family, has obviously not been there. He can come and talk to me any time if he's not too busy flying around in his motor car and I'll tell him what it's like. - Yours, etc,
EILEEN LAWLOR,
Ellesmere Court,
Bundoran, Co Donegal.
IT Fri Nov 16 2006

MINISTER'S VIEWS ON MENTAL ILLNESS AND PSYCHIATRY
Madam, - I was very surprised to read the letter in your newspaper from six professors of psychiatry calling for the resignation of Tim O'Malley, Minister of State in the Department of Health and Children, with special responsibility for mental health (Nov 16th).
On whose behalf do these psychiatrists speak? It is clear from the letters in your pages in recent days that there are psychiatrists in Ireland who do not share their view. Prior to their joint decision to raise the issue of the Minister's "position", did these six psychiatrists consult with the most important relevant group of all - the users of the mental health services, and service user groups? If not, why not? Are they not worth consulting? Are they not entitled to a voice?
Internationally, there is indeed a debate going on as to whether mental health problems should be seen as purely or indeed primarily medical conditions. Rather than castigate the Minister for mentioning this reality, perhaps these six psychiatrists might consider entering a public debate on the matter.
Medication certainly is an important part of the response to mental health problems. The fact remains that the presumed biological nature of mental health problems remains an unproven hypothesis.
I would hope that these six psychiatrists would be open to reasoned, rational debate on the matter.
Tim O'Malley has been an excellent Minister with responsibility for mental health.
I look forward to a public response from these psychiatrists regarding a public debate on mental illness as outlined above. - Yours, etc,
Dr TERRY LYNCH,
Member, Expert Group on Mental Health Policy 2003-6,
Member, Independent Monitoring Group for A Vision for Change 2006-8,
Member, HSE Expert Advisory Group on Mental Health 2006,
Ballykeeffe, Limerick.

Madam, - I agree with Breda O'Brien (Nov 11th) when she says that "a debate is needed on mental health". Hopefully, we will have an informed debate. Ms O'Brien would appear to have some way to go along that road.
Minister of State Tim O'Malley is to be praised rather than excoriated for his welcome comments. Rather than being "downright irresponsible", it is Ms O'Brien who appears to be downright dogmatic in her solid conviction of the efficacy of medication. Such dogmatism sits comfortably with Dr Patricia Casey and her five fellows (Nov 16th), a dangerous dogmatism that has resulted in the human rights abuses of forced injections, compulsory treatment orders and involuntary detention.
Is Ms O'Brien aware of what are euphemistically called the "side-effects" of medication? Has she heard of tardive dyskinesia or tardive akathesia? How does she think an already depressed young man feels when experiencing impotence as a "side-effect"? Is it just coincidence that the profits of the drug industry today are second only to the arms industry? If Dr Casey and her five fellows are concerned about "vested interests" they don't have to look too far themselves.
And rather than sarcastically dismissing Mr O'Malley as reckoning "that all that is required is a buddy", it would be welcome to see the professionals, as well as Ms O'Brien, appreciating the Minister's comments for what they are, namely that there is far more to dealing with emotional distress than just medication. An enlightened debate should not be beyond looking at realistic and viable alternatives, which, as we all agree, requires Mr O'Malley to put the Government's money where his mouth is. - Yours, etc,
JIM MADDOCK,
MindFreedom Ireland,
Manor Close, Rochestown, Cork.

Madam, - I read with great distress the letter of response from the team of six professors of psychiatry led by Prof Patricia Casey concerning the article "Minister's view on mental illness" by Breda O'Brien (Nov 11th).
Their letter highlights the attitude within psychiatry of "my way or no way". Those psychiatrists are definitely not open to debate.
How can patients be "restigmatised" by the Minister's comments, as they claim, when the stigma is within the labels of sickness that psychiatry chooses to pin on people who are in severe distress in their lives?
I would like this team of professors to show me the neuro-imaging of depression, to let me know the exact normal levels of serotonin in a human brain, and the exact gene involved in depression, please. - Yours, etc,
NURIA O'MAHONY,
Holistic Action Group,
Bandon, Co Cork.

Madam, - The knee-jerk response of six senior psychiatrists (Letters, Nov 16th) to Minister of State Tim O'Malley's questioning of the medicalisation of mental health problems is disappointing though not surprising. This group claims that the Minister has "restigmatised" thousands of Irish people with mental health problems but fails to justify how this is the case. Stating that depressed people may not be "ill" or "sick" but may simply be going through difficult times for which they have inadequate support seems, to me, an attempt to normalise, rather than stigmatise.
The placement of psychological distress in a biomedical framework within psychiatry is unsurprising considering the ways in which seniority is determined in the field. The decisions to appoint consultant posts, professorships and department heads depend hugely on the research success of the candidates - that is, their number of publications and the amount of research funding they have obtained. Drug companies are the largest funders of psychiatric research, with the result that there is a massively disproportionate focus on the medicalisation of psychological distress and on attempts to find biochemical, rather than psychosocial, interventions. Those who believe, with good reason, that psychosocial interventions would be better for their clients tend not to have the golden stamp "supported by an unrestricted educational grant from [insert drug company name here]" on their research papers.
The statement by the psychiatrists that the Minister should consider his position for shining a torch on a massive debate within the field of mental health is a scandalous attempt to silence debate. Their letter reflects authoritarian and dogmatic mindsets - appalling characteristics for psychiatrists. The claim that the Minister's words reveal "vested interests" is laughable. What are they suggesting, that he has shares in a psychotherapy firm? It is those who work with drug companies that must be questioned about vested interests. Nobody receives free trips to exotic destinations from social work companies. - Yours, etc,
PATRICK O'MAHONY,
Camberwell, London.

MINISTER'S VIEW OF MENTAL ILLNESS
Madam, - The six professors of psychiatry who signed the letter in your edition of November 16th have rightly been criticised for their narrow and dogmatic stance on the use of medication. They are very well aware of the long-running international debate on the over-prescribing of psycho-active medication by psychiatrists and general practitioners. Minister of State Tim O'Malley is far from the first responsible politician to raise questions in this regard.
It would, however, be misleading to say that what we have is a clash of ideology between proponents of the medical model and those who espouse the talking therapies.
It is known that 95 per cent of patients presenting with mental health issues in Ireland are treated by GPs at primary care level. Most prescriptions for psycho-active medication are written by GPs and not by psychiatrists.
Irish and international research on primary care shows that GPs tend to prescribe such medication not out of conviction but largely because of high case-loads, poor support and a lack of time to devote to individual patients.
Recent research on the attitudes of GPs in Ireland also indicates that most are reluctant to refer patients to psychiatrists. The vast majority are anxious to have adequate resources available at primary care level, such as psychologists and psychotherapists, to provide a realistic alternative to medication.
The recent expert group report on mental health services, A Vision for Change, strongly endorses the provision of psychotherapeutic services at primary care level. Given that group comprised a majority of senior psychiatrists it would appear that the six professors do not represent a consensus, even within the ranks of their own specialism. - Yours, etc,
EDWARD BOYNE,
Psychotherapist, (Member of Expert Group on Mental Health 2003-2006),
Tivoli Institute,
Clarinda Park East, Dun Laoghaire.

Madam, - I wish to respond to Breda O'Brien's column of November 11th based on an interview I gave to the Irish Medical News of November 6th.
I am committed to developing a world-class mental health service for the people of Ireland. This will involve the continued development of our service in line with A Vision for Change, which was launched last January after wide-ranging consultation with all stakeholders, including - most importantly - service users and their relatives. It outlines a set of values and principles that will guide the Government, the Health Service Executive and others in developing a modern, high-quality mental health service over the next seven to 10 years.
The report, which have been accepted by Government, proposes a holistic view of mental illness and recommends an integrated multidisciplinary approach to the biological, psychological and social factors that contribute to mental health problems. It recommends a person-centred treatment approach which addresses each of those elements through an integrated care plan reflecting best practice and, most importantly, evolved and agreed with both service users and their carers.
It is in the context of the recommendations of A Vision for Change and indeed my own experience both as a pharmacist and as a Minister who has met with many groups in the mental health arena, that I hold the view that there continues to be an over-reliance on medication in the treatment of mental illness. I did not at any stage question the role of medication within psychiatry; rather, I raised concerns, as I have done on many occasions, about the level of prescribing in the treatment of mental illness. Clearly prescribing is one therapeutic response to mental health conditions. There are other responses to deal with the very wide range of mental health problems and indeed the difficulties which individuals encounter in their lives.
I accept that there is pressure on beds in certain parts of the country but it is envisaged that with the further development of properly resourced community-based treatment services more cases can be managed without the need for hospitalisation. There will always be a need for in-patient treatment and the appropriate bed capacity will be provided. A properly resourced, community-based care model is needed and again the actions to achieve this are outlined in "A Vision for Change". I accept that traditionally our mental health services have been under-resourced and, of course, action plans need to be properly funded to be effective. This year an additional ‚26.2 million was provided for mental health service development, bringing our annual revenue spent in the area to ‚835 million. Further additional funding will be provided in 2007 to progress the modernisation of our mental health services.
I welcome the debate that has arisen out of my article in the Irish Medical News. I will continue to listen to the views of all stakeholders in this very important debate, as I have been doing for the past four years.
I expect all service providers to work together over the next seven to ten years in a spirit of co-operation to develop a top-class mental health service that we can all be proud of. - Yours, etc,
TIM O'MALLEY TD,
Minister of State with special responsibility for Mental Health,
Dáil ‰ireann, Dublin 2.

Madam, - It is worrying that the traditional fault lines have emerged so quickly in the recent debate on mental illness. I remain unconvinced that this is really a debate between psychosocial and biomedical views on mental distress. Mr O'Malley's comments seemed, more simply, to be dismissive of the severity of these conditions.
Ireland needs leadership in promoting good mental health services - medical and psychosocial. It seems instead to have a Minister who is unsure about whether depression existed in the past at all. This surely is a concern. - Is mise,
Dr PDRAIG COLLINS,
Clinical Psychologist,
Walthamstow, London E17.
IT Tues 21 Nov 2006

MENTAL ILLNESS AND MEDICATION
Madam, - We would like to express concern about the response of six psychiatrists (November 16th) to Minister of State Tim O'Malley's questioning of the medicalisation of mental distress.
The psychiatrists' certainty about the benefits of antidepressant medication fails to account the ongoing debate in medical and service-user circles about the long-term balance of risks and benefits associated with these drugs. There is a lack of independent scientific research on antidepressants. Most of the studies indicating a benefit have been funded by the pharmaceutical industry.
Moreover, there is significant evidence of the drug industry's commercial interest in the debate about depression's status as a disease. Industry forecasts for the "lifestyle" drug market put depression at the top of the list of conditions that provide opportunities for companies to boost their value.
The accusation that the Minister is "singing off the hymn-sheets of vested interest groups" is most intriguing. Who are these vested interest groups? Are they service-user/advocacy groups? If psychiatry is not about the interests of service-users, then whose interests are served?
Perhaps we need to reverse the question and ask the professors to consider the hymn-sheets from which they are singing. Do they or their departments have links with the drug industry? Are they engaged in any academic and research activities funded wholly or partially by a drug company?
We think the response from the group of psychiatrists provides us with an opportunity to enquire into such vested interests and to open a debate that they themselves are trying to suppress. - Yours, etc,
LYDIA SAPOUNA,
ORLA O'DONOVAN,
Department of Applied Social Studies,
KATHY GLAVANIS-GRANTHAM,
Department of Sociology,
University College Cork.
IT Wed 22 Nov

MINISTER'S VIEW OF MENTAL ILLNESS
Madam, - We were pleased to read the position taken by Minister Tim O'Malley in your Letters page of November 21st - a position which reads very differently from the views he expressed to the Irish Medical News two weeks previously, when he suggested that mental illness was not a medical condition and was not amenable to scientific assessment.
It was these extreme and ill-informed views about mental illness which provoked our letter of November 16th, and not the issue of whether antidepressant medications are over-prescribed for mild conditions, as several subsequent letters suggested. Indeed one of us (PC) has published several papers in peer-reviewed journals on the over-diagnosis of "depression" and overuse of antidepressants, including an editorial in the British Journal of Psychiatry in December 2001.
Another of us (KM) has received international charitable funding to explore brain function during suicidal depression. Another of us (TD) has received funding from the Irish Health Research Board - a Government-funded research agency - to conduct advanced research into the biology of depressive illness. These studies seek new knowledge about significant biological factors evident during depression.
In light of these facts, surely the Minister did not wish to undermine his own research funding agency (nor those of prestigious international charities) by his misguided comments about biological factors at play during major depression - a condition that by definition is "qualitatively and quantitatively different from normal sadness/unhappiness".
Like most clinical psychiatrists in a modern mental health service, we endeavour within the scarce resources available to operate a multidisciplinary model of care where psychosocial interventions, including psychotherapy, form a vital part of clinical practice. Our letter called for greater provision of trained professionals to deliver non-medication-based approaches, such as psychologists, psychiatric social workers, occupational therapists and clinical nurse specialists. Indeed the views expressed by the Minister two weeks ago, when he indicated that not just depression but mental illness generally could be cured by having a friend to talk to, was equally disparaging of treatment with psychotherapy as it was of treatment with medication.
Mental health clinicians in Ireland and the patients we care for have seen the proportion of the health budget devoted to mental health reduced by nearly 50 per cent in the past two decades, as the funds saved by closing hospital beds have been diverted elsewhere instead of being reinvested in psychiatric community services. This has left services grossly under-resourced and struggling to cope. To correct this imbalance, we need a properly informed Minister who can act as a strong advocate for the best resources for people with mental illness, rather than one who seriously questions the existence of such a condition. This position is hurtful and stigmatising to patients and their families who struggle with severe, enduring and incapacitating mental illness.
We hope the Minister will act on his stated commitment to improving resource allocation and will help psychiatric services in this country to catch up with the level of care taken for granted by most of our European neighbours.
We sincerely thank the Irish Times for facilitating this important debate. - Yours, etc,
PATRICIA CASEY,
Professor of Psychiatry, UCD and Matermisericordiae University Hospital;
TIMOTHY DINAN,
Professor of Psychiatry, University College Cork;
MICHAEL GILL,
Professor of Psychiatry, Trinity College Dublin;
COLM McDONALD,
Professor of Psychiatry, NUI Galway;
KEVIN MALONE,
Professor of Psychiatry, School of Medicine and Medical Science, SVUH/University College Dublin;
KIERAN MURPHY, Professor of Psychiatry, Royal College of Surgeons in Ireland and Beaumont Hospital.
IT Fri 24 November 2006

HOLISTICALLY SPEAKING
Roisin Ingle

My father, after suffering from schizophrenia for years, eventually took his own life.
At various points he had been prescribed a cocktail of drugs, locked in mental institutions, and given electric shock therapy. So, although I claim no expertise in the subject, I've been following, with a degree of personal interest, a row that has recently broken out regarding mental-health care.
On one side we have the PDs' Tim O'Malley, the Minister of State at the Department of Health with responsibility for mental health. In an interview with Irish Medical News recently he said: "I think it's very welcome that there is a debate about the whole treatment of people with mental health difficulties. For far too long we had the situation where people just went to the doctor and accepted whatever the doctor said as being gospel. I think there is a school of thought now, especially in the mental health area, that there should be a much greater involvement of counsellors and psychotherapists and psychological methods of dealing with people with mental health difficulties." The Minister went on to put forward the controversial view that "depression and mental illness is not a medical condition", that "it's part of life's events that people get depressed or get unhappy".
On the other side are the big guns in psychiatry who responded to the Minister with a letter to this newspaper declaring that his comments had "re-stigmatised" those suffering from mental illness. "The man in charge does not believe that mental illness exists and reckons all that is needed is a buddy," concluded the six leading professors of psychiatry, calling for O'Malley's resignation.
I found their letter surprising. O'Malley's assertion that depression is not a medical condition was always going to leave him open to criticism, but he should be applauded for encouraging a debate. He has simply asked whether the treatment of the thousands in this country who suffer from mental illness could be improved. Anyone who cares about ending suffering and stigma should be big enough to speculate about whether the current practice is the right one. In some cases drugs will help, of course, but in others they can make things worse. Is it so outrageous to suggest that a more holistic approach, including talking therapy, could provide a better way?
The psychiatrists' indignation reminded me of another row, this one played out on the Late Late Show a few weeks ago. The psychologist and nutritionist Patrick Holford was on to talk about his book Food Is Better Medicine than Drugs, in which he explains his belief that inexpensive substances such as chromium and cinnamon can control the blood sugar levels of people with type 2 diabetes. He also claims that taking niacin, the vitamin B3, combined with a change in diet and lifestyle, can be effective for patients with high cholesterol.
On the show with him was a GP who gave Holford about as much time as you might a quack selling miracle cures off the back of a wagon. Holford was suggesting that doctors begin to prescribe the kind of inexpensive substances you can find in your local health store instead of drugs supplied by a multibillion-euro industry. When Holford suggested doctors be given information about things such as chromium, the GP was dismissive. She said she already knew this information because "Kellogg's provide it on the back of a packet". "So nutrition is what you read on the back of a packet?," asked Holford
His main point was that if it is possible to reduce, say, the pain of arthritis, to stabilise blood sugar and to improve your mood by using certain foods and nutrients - and changing your lifestyle - then we should be encouraging sick people to do that. Who, especially in the healing professions, could disagree?
Both these rows have worried me. Could professional egos and the powerful drug companies be a cocktail of interests that is bad for our health? When the likes of Holford and O'Malley are castigated for suggesting alternatives, you can only wonder. Still, it's been heartening to see some psychiatrists and, more importantly, some of those who suffer from mental illness coming out in support of O'Malley in recent days.
I can't help thinking of my father - robbed of his spirit by all the pills and electric shock therapy - making that terrible decision to end his life. Perhaps with a more enlightened, holistic approach to his condition, he might still be here. A brother of mine who has done much research into alternative therapies and mental illness has been saying this for years. For the first time, I'm starting to believe him. It's too late for my father but an agenda-free debate might yet help save the lives of others. So thank you, Mr O'Malley.

MEDICATION HAS A ROLE IN MODERN PSYCHIATRY
Breda O'Brien
In a debate hosted by Maudsley hospital in London last June, consultant psychiatrist Adrianne Revely told a chilling story.
A man was convinced that his dead twin was watching him from his hand. The therapist to whom he was referred belonged to the anti-psychiatry movement, and believed that this was not evidence that he needed medical treatment or hospitalisation, but instead was his way of coping with his brother's death.
With adequate psychological support, the delusions would resolve themselves. Shortly afterwards, the distressed man cut off his hand.
Since I wrote about Minister of State at the Department of Health Tim O'Malley wondering aloud in the Irish Medical News whether depression and mental illness were medical conditions or not, my inbox has been pinging on a regular basis to announce the arrival of yet another passionate e-mail on the topic.
Some of the e-mails were three times the length of this article. They ran roughly four to one in favour of the Minister. They could be summarised as follows: there is no blood test, or any other physiological test that establishes a biological basis for mental illness.
Depression can cause biological symptoms, but not the other way round. Drug companies are intrinsically corrupt, are only interested in profits, and regularly sponsor research that is published under the name of eminent doctors who had nothing to do with the research.
Drugs are dangerous and addictive. There is little or no evidence that they work any better than placebos. The side effects far outweigh any dubious benefits.
Psychiatry is attempting to present itself as scientifically based and a valid branch of medicine, but it is no such thing. Depression and other conditions categorised as mental illnesses are understandable reactions to severe emotional stress, not medical conditions. When a therapeutic relationship is established which values the person in distress and helps to raise their self-esteem, they can recover fully.
Some correspondents are completely against medication. Others allow it a very small, short-term role, but emphasise the therapeutic relationship above all else.
The Minister has since distanced himself from his original comments and presented a much more mainstream view in the letters page of this newspaper.
Mind you, it is also interesting to see who rushed to write in his defence. For example, Dr Terry Lynch calls him an "excellent Minister".
Dr Lynch, in his book Beyond Prozac, claims to be able to enable people to recover from schizophrenia simply by developing a relationship of trust with them and engaging with the underlying meaning of their symptoms. Perhaps Dr Lynch should be the subject of research himself, since in his book he appears to have a 100 per cent success rate.
Eating disorders, addiction, schizophrenia, depression, bipolar disorder - all apparently respond successfully to his approach in a relatively short time. He does use medication, despite declaring that there are inherent dangers in all drugs, and that Prozac, for example, is addictive. Apparently, he can always judge when such medication is justified, unlike psychiatrists, who are blinded by their dependence on a biomedical model.
It might shock Dr Lynch to discover that I agree with quite a few of his ideas. It is true that we are living in a world where normal unhappiness is becoming medicalised. Medication is over-used, and people's emotional distress is often ignored. It might shock him still further that the six professors of psychiatry, who came in for a fair share of abuse for their call on the Minister to consider his position, also agree that depression and mental illness are frequently diagnosed wrongly.
For example, Prof Patricia Casey has written about the need to carefully distinguish between "an understandable but exaggerated response to a stressful event", and major depression. The former will resolve itself "when the stressor is removed or when a new level of adaptation is reached".
It requires no intervention except support, or medication for the relief of symptoms, such as short-term prescription of sleeping tablets. She is critical of the fact that "transient depressive responses to stressful events are increasingly regarded as illnesses requiring specific intervention".
Her approach could hardly be described as dogmatic, or as close-minded adherence to a biomedical model. Dr Lynch parts company with Prof Casey in that he apparently believes that all depression and mental illness can be categorised as a response to severe emotional stress.
I am fascinated by those who refuse to countenance that there could be any underlying physical cause for depression. It seems to me that the mind and body are so intimately linked that this position is closer to dogmatism than the positions ascribed to the professors of psychiatry. It is a dualistic standpoint, despite claims to being holistic, because it demands such a sharp division between the physical and the psychological.
While the anti-psychiatry advocates point to the side effects of medication, they often refuse to acknowledge the side effects of inappropriate use of counselling.
One does not have to resort to the unfortunate man who cut his hand off. As a writer for this paper, I have heard many accounts of people becoming dependent on counsellors, or experiencing severe relapses when advised by counsellors to come off medication.
What about the side effects of untreated depression and mental illness? The prospects for people with schizophrenia get more and more bleak, the longer it is undiagnosed and untreated. Why are the testimonies of every person who found medication helpful all discounted? For example Lewis Wolpert, the eminent professor of biology, credits his recovery from major depression to appropriate use of medication, as did the writer William Styron, who moved from being suicidal to a decent quality of life. Perhaps they are ignored because their testimony does not suit those convinced that only psycho-social factors matter.
Psychiatrists use a range of therapies, and are constantly calling for funding for multidisciplinary teams who can provide a wide range of interventions. Our mental health services are in many ways inadequate, mental illness is often diagnosed wrongly, medication is by no means a panacea. Yet in spite of all that, many people have a renewed and happier life today because of the advances of modern psychiatry, including medication.
IT Sat 25 November 2006

DEBATE ON MEDICATION IN TREATMENT OF MENTAL ILLNESS
Madam, - Having read the letter from the group of six professors of psychiatry in response to the piece by Breda O'Brien, "The Minister's View On Mental Illness," I do not share the view that the Minister's remarks were "downright irresponsible". I feel obliged therefore, to enter what is becoming a national debate on the nature of mental illness.
It seems an obvious thing to say that from before and after birth to adult death, human beings experience things that cause them suffering, but this is a fact of life that is overlooked. Some can bear more than others, some understand more than others; but suffering is a part of life and may become so unbearable that we want to fix it. At that point we look for help, usually from a doctor, and often find that our feelings are called "mental illness". There is such a thing as mental illness, of course, but not all sufferers are mentally ill.
Because of the mechanistic attitude which has accompanied the enormous advances in science and technology, the Western mind has fallen into the illusion that there is a remedy for every ill. The belief has grown up that it is the doctor who cures. The body is seen as a machine with which something has gone wrong, and the doctor's job is to fix it.
Similarly, we have tended to fall into the error of thinking that the therapist cures the patient. When applied to psychotherapy, or to psychiatry generally, this is an erroneous notion. In dealing with psychiatric illness there is no treatment which you can apply to people which brings about real change in them. People have to undertake the work themselves and this is involves pain and suffering.
The only lasting positive change anyone can make is within him/herself. The deeper the change to be accomplished, the greater the amount of pain and suffering involved. People resist change for this reason, even when they realise that change will be positive .
By giving tranquillisers and relieving symptoms, something has been achieved temporarily. But no real change has taken place, and sooner or later most people will have a recurrence of their symptoms with the added burden of the side-effects which most drugs inflict. Many drugs are useful on a temporary basis but are not treatments for specific "psychiatric diseases". However, no psychiatrist who deals with the full range of psychiatric disturbance could manage without them. The question is whether they are given as a treatment themselves or as aid to working in psychotherapy with the person. Often the drug is the only way of facilitating the initial contact so that therapy can begin.
It is not the drug, it is the message which accompanies the drug which is really damaging. Typically, if a person is "clinically " depressed they are told that whenever they feel a depression descending on them they must contact their psychiatrist and commence the appropriate medication. It is because of this, more than anything else, that many people are gradually entrained into a pathway of illness. Perceiving themselves as "ill" and helpless, they move into a state of chronic ill health.
Clusters of symptoms tell one little about the cause, or the natural history, of these so-called "disorders". They have a more ominous significance however, for once you can name symptoms as a "disease" you have created an apparent reality. Then, if you have a specific "disease", due to some, as yet unidentified, underlying biochemical abnormality, there should be a "specific" remedy to deal with it. This suits the pharmaceutical industry perfectly. Unfortunately, most psychiatrists have taken this great falsehood on board.
All that drugs can do is to temporarily reduce symptoms, making life bearable. No drug can teach you what you need to know to manage life or have a personal identity. Often in life we cannot see how we got to where we are, or why we continue to make the same mistakes no matter how hard we try. If a person could undertake whatever change is necessary to manage their life successfully, there would be no need for a psychiatrist or therapist. Of course, the person who comes to our aid need not be a professional; indeed, a great deal of helpful intervention is carried out by self-help organisations such as Alcoholics Anonymous, Grow, etc. but in many situations a friend is not enough and the objectivity and understanding of a person with experience and training is necessary.
Finally, I return to the fundamental principle that it is people themselves who have to undertake the work if they are to bring about any real change in their lives. If what we are attempting to change is ourselves, our deepest personalities, then this can be painful indeed.
If the person who is "mentally" ill is not prepared to suffer, then, to put it bluntly, you can have all the skills and training and be the most experienced psychiatrist, but you will be absolutely helpless to do anything for them. - Yours etc,
IVOR BROWNE,
(Professor Emeritus, University College Dublin),
Ranelagh, Dublin 6.
IT Tues Nov 28 2006

MEDICATION IN TREATMENT OF MENTAL ILLNESS
Madam, - I strongly support the views of the six professors of psychiatry regarding the statement by the Minister of State in the Department of Health on mental illness.
Had the Minister consulted the website regarding the credentials and publications of these colleagues he would have found that they are internationally recognised experts in the fields of social psychiatry, psychopharmacology, psychoendocrinology, psychogeriatrics, psychogenetics and brain imaging.
Even the briefiest consideration of the impact of these fields of expertise on our understanding of the pathology of mental illness, and how psychotropic drugs act to treat such conditions, would persuade any fair- minded person of the pathophysiological basis of mental illness.
While no professional person, least of all professors of psychiatry, underestimate the role that non-pharmacological methods play in the treatment of mental illness, the fact remains that drug treatments for severe depression, schizophrenia, bipolar disorder and the anxiety disorders have revolutionised psychiatric practice for the good of the patients and their families.
One does not need to be a mental health professional to appreciate the impact of drug treatments in changing mental hospitals from long-term custodial institutions for the mentally ill to their widespread closure today because of the effective treatment of the severely mentally ill.
It seems as though it is not only the general public that needs education in how the brain works in health and disease! - Yours, etc,
BRIAN E. LEONARD,
Emeritus Professor of Pharmacology,
NUI Galway,
Immediate Past President, International College of Neuropsychopharmacology.

Madam, - Breda O'Brien's column of November 25th presented a largely uncontroversial, relatively balanced summary of the recent dispute on psychiatry and the use of medication, which was precipitated by the insightful remarks of Minister of State Tim O'Malley.
However, in Ms O'Brien's piece, and in other comment on the issue, the matter is presented largely as a theoretical debate. The vital message that I fear is not getting across is that people's lives are being blighted by mistreatment by psychiatrists and their inappropriate prescription of powerful drugs. What Patricia Casey or others may or may not write in academic journals is of no consequence to the poor souls who continue to suffer from maltreatment at the hands of the dozens of misguided psychiatrists who are simply following the handbook.
If Mr O'Malley can help rescue these helpless unfortunates from psychiatry, then I for one will welcome it. - Yours, etc,
NORMAN STEWART,
Malahide, Co Dublin.

Madam, - I appreciate Brenda O'Brien's summary of the position of those who question the direction taken by modern psychiatry, with its emphasis on the medicalisation of human problems. She has clearly listened to those who disagree with her, which is an admirable quality.
However, when she says she is "fascinated by those who refuse to countenance that there could be any underlying physical causes for depression", I suggest she is misreading the position of many. I am opposed to the treatment of psychological or psychosocial problems as though they had an identified pathology. Nevertheless, I must of course be open to the possibility that such pathology may be discovered some time in the future, however much I may doubt such a development.
My problem is with the certainty of a psychiatric profession which prescribes drugs with significant negative side-effects, both physical and psychological, on the assumption, or under the illusion, that such pathology is scientifically established, when clearly it is not.
William Glassner, the psychiatrist and founder of Reality Therapy, has been an advocate of positive, non -medical approaches to mental health for the past 40 years.
I would like to put on record the support of the William Glasser Institute for Tim O'Malley's initiation of a debate on this issue. - Yours, etc,
ARTHUR DUNNE,
National Executive,
William Glasser
Institute Ireland,
c/o The Crook,
Mornington,
Co Meath
IT Wed Nov 29 2006

DEBATE ON MEDICATION IN TREATMENT OF MENTAL ILLNESS
Madam, - Since Breda O'Brien saw fit explicitly and disparagingly to comment both on me and my book Beyond Prozac (Opinion, November 25th), please afford me the opportunity to reply.
Ms O'Brien admits that 80 per cent of the letters she received in response to her previous article "Minister's view on mental illness dangerous" (November 11th) did not support her views. Considering that six professors of psychiatry enthusiastically endorsed her (Nov ember 16th) and suggested that the Minister of State with responsibility for mental health should consider his position, an 80 per cent disagreement rate is striking. This should be food for reflection for Ms O'Brien and the six professors.
Undaunted, Ms O'Brien last Saturday listed the legitimate concerns raised by the public in their letters, and then proceeded to ignore them. Apparently, she had a far more important task to undertake - to comment on me and my book Beyond Prozac.
Ms O'Brien is "fascinated by those who refuse to countenance that there could be any underlying physical cause for depression". If she is including me in this, she is grossly mistaken. As I have outlined in Beyond Prozac and elsewhere, I am open to the possibility that there may be physical causes for depression and other mental health problems. I also recognise the obvious common sense in the idea that mental health problems may be multifactorial in origin, and that responses need to be comprehensive and holistic.
But unlike many of my medical colleagues, I am not prepared to presume with certainty that there are physical causes for mental health problems until such time as they have been adequately and reliably identified and understood - a situation which is far from the current state of play. In the meantime I will keep an open mind as to any future identification of biological causes of mental health problems such as depression, schizophrenia and bipolar disorder. Furthermore, I do not allow myself to confuse correlation with causation, as some of my colleagues do. This very important issue is outlined in detail in Beyond Prozac.
Perhaps Ms O'Brien failed to understand these matters. I support a balanced approach to research, including biological research, into all possible causes of (and responses to) depression and other mental health problems. The future direction of mental health should not be a simplistic battle between medication and counselling, but rather an enlightened, comprehensive holistic approach, with a wide range of appropriate interventions being available,and with the person's needs, views and best interests being central.
If Ms O'Brien is suggesting that I "discount" the "testimonies of every person who found medication helpful", she is again grossly incorrect. I fully acknowledge that some people find medication helpful. I have said so on many occasions. Indeed, Ms O'Brien herself acknowledged that I do prescribe medication, something I would hardly do if I felt it had no benefit.
Although she does not outline why, Ms O'Brien finds it " interesting" that I wrote to the Irish Times (November 18th) in response to her original article. Apparently, I "rushed" to write in "defence of the Minister". We live in a democracy. Like all citizens, I have the democratic right to express my views. In the past I have spoken out, and I will continue to speak out when I feel it is important and right to do so.
Surprisingly, Ms O'Brien apparently cannot seem to get her head around the fact that I prescribe medication "despite [my ] declaring that there are inherent dangers in all drugs". Perhaps she might feel more comfortable if she could package me neatly into a box, as a doctor who is prepared to see only one side of the equation. Every prescribing doctor knows - or should know - that there are inherent dangers in all drugs. Did it not strike Ms O'Brien that it might actually be a good thing for a doctor to be very aware of the inherent dangers of the drugs that he/she prescribes?
I have never stated anything remotely like her comment that I have a "100 per cent success rate" in working with people experiencing mental health problems. Nor have I stated that people diagnosed with eating disorders, addiction, schizophrenia, depression, bipolar disorder "all apparently respond successfully to € approach in a relatively short time". Nor have I ever stated that I alone "can always judge when such medication is justified". Had she bothered to take the trouble to speak to me before launching her tirade, Ms O'Brien may have found that such arrogance is not part of my make-up.
The tone of her column was in sharp contrast to an excellent article in the Irish Times Magazine of the same day, in which Roisin Ingle addressed similar issues. Ms Ingle's article exuded humanity and openness to dialogue, qualities which are essential if we are to work successfully towards providing more effective responses to mental health problems. Ms Ingle successfully got her point across without resorting to confrontational, aggressive or disparaging language or style.
Finally, I am unclear as to why Ms O'Brien believes that letters from people who are prepared to engage with, challenge, and disagree with the six professors of psychiatry should be described as "abuse ". - Yours, etc,
Dr TERRY LYNCH,
Member, Expert Group on Mental Health Policy 2003-6;
Member, Independent Monitoring Group for A Vision for Change 2006-8;
Member, HSE Expert Advisory Group on Mental Health 2006;
Ballykeeffe, Limerick.
IT Thurs 30 Nov 2006

Madam, - Roisin Ingle misses the point in her response to the six psychiatrists who have written expressing their dismay at Tim O' Malley's comments on mental illness.
The over-reliance on medication is less the result of a rigid adherence to the medical model in the treatment of psychiatric illness than of the under- resourcing of the service by successive governments. A modern mental health service should be underpinned by properly resourced multi-disciplinary teams working from dedicated centres.
These teams, consisting at the very least of a psychiatrist, community mental health nurse, psychologist, social worker and occupational therapist, would facilitate holistic care and reduce the reliance on medication alone as treatment. Such a service is the norm in other first -world health services. Why not in ours?
Surely, as Minister with special responsibility for mental health, Mr O'Malley should bear some responsibility for the dearth of the most basic services in the mental health sector.
The aspirations in the document A Vision for Change are welcome. However, those of us who work in the area will continue to provide a fire brigade service until a real effort is made to resource services for the mentally ill.
Psycho-social interventions have a very important role to play in the treatment of mental illness, but in the current patchy, ill-planned and under-resourced system, the over-reliance on medication will continue in the absence of other alternatives. - Yours, etc,
MARY DINEEN,
Community Mental Health Nurse,
South Lee Mental Health Services,
Cork.
IT Fri Dec 1 2006

QUICK GUIDE TO
THE MAIN ELEMENTS

THE INTERVIEW THAT STARTED IT
Minister Tim O'Malley's original interview with the Irish Medical News
GO>>
BREDA O'BRIEN'S FIRST COLUMN
Attacking from a condition of ignorance
GO>>
PSYCHIATRISTS TAKE ISSUE
A punter lands the first punch, while two eminent practitioners attempt to enlighten Ms O'Brien
GO>>
WHERE ARE WE GOING?
Michael Corry explains how the biomedical model 'elbows out' the chances of healing mental distress
GO>>
MINISTER MUST RESIGN
Six prominent professors of psychiatry demand O'Malley's head
GO>>
The same six professors of psychiatry lodge their complaint with the
Irish Medical News
GO>>

And the Irish College of Psychiatry adds its condemnation, while a sufferer from bipolar disorder decries his stand
GO>>
OH, NO, HE MUSTN'T
Dr Terry Lynch takes on the six professors, while user groups oppose O'Brien's views
GO>>
THE MINISTER REPLIES
But sticks to his guns; does not resign. And a psychotherapist lends him support
GO>>
WHOSE HYMN SHEET?
The six professors taken to task by three eminent researchers at UCC
GO>>
THE SIX PROFS WRIGGLE A LITTLE
Dr Casey and friends claim that O'Malley changed his views
GO>>
THANK YOU, MR. O'MALLEY
Roisin Ingle writes of her father's suicide, calls for a balanced debate and questions rthe €˜vested interest' of doctors in medication
GO>>
LET ME REPEAT MYSELF
Breda O'Brien admits that 80% of correspondents disagree with her€ and goes on to say they're all out of step
GO>>
WHAT'S REALLY INVOLVED
Dr Ivor Browne injects a major dose of wisdom into the debate
GO>>
TWO AGAINST, ONE FOR
Three more professionals have their say, split two to one
GO>>
MISREPRESENTATION AND ATTACK
Dr Terry Lynch says O'Brien misrepresented his views and his book
GO>>
RESOURCES THE PROBLEM
Mental health nurse calls for community teams to be properly resourced
GO>>

THE DEBATE ELSEWHERE
Patricia Casey on RTE's Drive Time interviewed by Mary Wilson: GO>­>
Tim O'Malley stands his ground against her attack next day: GO>>

To listen you'll need RealPlayer. If you don't already have it, you can download it free by clicking the icon below
get realplayer

IN THE IRISH MEDICAL NEWS
In the columns of the Irish Medical News,a debate, too.
An interesting piece from George Winter: GO>>
And this from Fine Gael health spokesperson Dr Liam Twomey: GO>>
Here's a prominent medic who either kept his views out of the Irish Times or failed to have them published: Dr Seán “ Domhnaill, Senior Registrar at St Vincent's Psychiatric Hospital Dublin and visiting psychiatrist (pro bono) to Cluain Mhuire Alcohol and Drug Treatment Services: GO>>
Most telling of all, the voice of a former patient who found that psychotherapy worked best for them: GO>>
And if anyone has found other items which add to the debate, please let us know.



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