Sir, – Kitty Holland outlines the devastating institutional excesses of Ireland’s “mental hospitals” (“Stolen destinies”, News Features, April 5th). These were fuelled by social need, bad laws, excessive diagnosis, a lack of alternatives, and professionals’ search for prestige. In the 1960s, Ireland had over 20,000 people in “mental hospitals”. Today, we have 2,000 psychiatry inpatients on a given day, mostly on a voluntary basis.
This shift is attributable to diminished tolerance of institutions, better treatments, and more accountable diagnosis. But diagnosis, like institutions, can go to extremes.
Also last weekend, Paul D’Alton expertly explored the most recent set of books querying certain diagnostic practices (“Questions of immense public importance”, Ticket, April 5th). Suzanne O’Sullivan spoke about autism, ADHD, long Covid, and “the relaxation of how we diagnose people in order to diagnose milder cases” (“A doctor’s theory of overdiagnosis”, Weekend, April 5th). Breda O’Brien wrote that “we live in anxious times” (true) and that a condition such as ADHD “can be both overdiagnosed and underdiagnosed” (also true) (“Children can be shocked by setbacks”, Opinion & Analysis, April 5th).
So, where does this get us?
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First, diagnostic systems were designed for flexible use. The American Psychiatric Association’s Diagnostic and Statistical Manual warns that “it is not sufficient to simply check off the symptoms in the diagnostic criteria”. Careful, compassionate diagnosis brings understanding, treatment, and empowerment. Done poorly, diagnosis brings confusion and a label. One size does not fit all. Diagnosis must serve a clear purpose for the person.
Second, many people now use the word “depression” to describe unhappiness, and “anxiety” for day-to-day worries. It is important not to downplay the challenges many face, but medicalising unhappiness helps nobody.
Third, we need better services for people with mental illness (for example, schizophrenia), but we also need to address toxic socio-economic landscapes that generate so much suffering and unhappiness for everyone. There is no point repurposing the language of mental illness to describe normal reactions to abnormal social and political circumstances. The impossibility of finding a home can fuel depression, but the fundamental problem is political, not personal.
In the past, it was politically convenient that awkward social issues and people who did not fit in could be “psychiatrised” into “mental hospitals” with inadequate medical gate-keeping. Let’s not allow the language of psychiatry to serve a similar dystopian purpose today.
Proper diagnosis and treatment help many. A better, fairer society helps all. – Yours, etc,
BRENDAN KELLY,
Professor of Psychiatry,
Trinity College Dublin,
Dublin 2.
