Sir, – Prof Harry Kennedy speaks passionately and compassionately about people with severe psychosis, especially those who are in the criminal justice system (“Ireland needs a centre of excellence for treatment of severe mental illness”, Opinion & Analysis, October 13th). He argues for the creation of a research centre of excellence to improve outcomes for this group of people.
Prof Kennedy argues that poor outcomes have developed due to the “de-medicalisation” of mental illness and seeks a return to seeing psychosis as a “brain disorder”. Although, ostensibly, a centre of excellence is a benign recommendation, the assumptions underlying this proposal speak to a fundamentally retrograde vision of mental health care in Ireland.
“Severe psychosis” is not a diagnostic category. It is an outcome of a series of missed opportunities to intervene, often over decades. Many people who ultimately have a severe psychosis will have been in contact with educational services, child mental health services, adult mental health services, or drug treatment services earlier in their lives. As recent issues with the Child & Adolescent Mental Health Service (Camhs) have highlighted, there is significant potential for better, earlier treatment.
Although Prof Kennedy has highlighted the forensic aspect of psychosis, as the American Psychiatric Association (APA) has emphasised, schizophrenia has a very small relationship with violence. According to the APA, someone with schizophrenia has only a 3 per cent increased risk of committing a violent crime, compared to a 28 per cent increased risk of experiencing violence.
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For the last 50 years, the most common understanding of psychosis has been the bio-psycho-social model, not a “brain disorder”. In this model, biological, psychological and social factors interact to increase or decrease the risk of illness or the severity of symptoms. For instance, people with psychosis consistently highlight the importance of back-to-work schemes, social supports, and stable housing in their well-being and recovery. There is significant evidence that the family’s role is central, and psychological therapies have a moderate but very clear evidence base. Treatment plans may include medication but only as one intervention among many.
Prof Pat McGorry, also an expert on severe mental illness, offers an entirely different perspective on preventing severe psychosis: organising mental health services around the critical risk period of young adulthood.
Ireland needs a centre for excellence in mental health, but it needs one with a fundamental vision of prevention and early intervention, designed with people who experience mental health problems. A vision like this can ensure that severe psychosis is a “rare, poor outcome”. – Yours, etc,
Dr KEITH GAYNOR,
Senior Clinical
Psychologist,
Detect,
Early Intervention Service,
St John of God
Community Services,
School of Psychology,
University College Dublin,
Belfield,
Dublin 4.