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All sides of the story

One-in-four individuals will develop a mental illness at some point in life. Virtually everyone knows someone with a mental illness or a family affected by suicide.

Each year, hundreds of thousands of people attend GPs for mental health problems and tens of thousands attend community mental health teams. The Health Research Board reports that, in 2015, there were 17,860 admissions to Irish psychiatric units and hospitals, a small increase since 2014, when there were 17,797 admissions. Roughly equal proportions of those admitted were male (51 per cent) and female (49 per cent) and the 20-24 year age group had the highest admission rate. As in previous years, the most common admission diagnoses were depressive disorders (27 per cent) and schizophrenia (20 per cent).

Statistics such as these are essential for service planning, but they tell only one part of the story. Behind each admission and attendance, there is an individual human story and each story affects not just one person, but a network of family, friends and colleagues, as well as the broader community.

Each individual’s experience is different and complicated and personalised and each occurs at a specific point in time. This is duly reflected in the many and varied strategies that people pursue when they have psychological problems: they talk with family and friends, try to change their habits, go on holidays and seek to resolve matters themselves in many other ways.

And, most commonly, these strategies work very well: problems pass or are resolved, difficulties ease and we move on with our lives. People are strong and resilient and resourceful. For the most part, families and friends and colleagues are generous and understanding. We solve most of our problems within these informal networks without any need to move beyond these resources. We get back on the road. We move forward.

Primary care and mental health services take up the story when these normal responses prove insufficient, when a person’s resilience feels exhausted and when further assistance appears to be needed. In this context, engagement, tolerance, and compassion are three key values in delivering mental healthcare and promoting recovery. These values apply to public discussion about mental healthcare as much as they apply to individual therapy, which is also equally informed by the principles of personal choice, recovery and empowerment, rooted in evidence-based care.

Happily, recent decades have seen increased public discussion about mental health. Public discussion is crucial and much of it is constructive, reflecting the key values of care provision and recovery. A minority of public exchanges, however, lack all of these values. Nowhere is this more evident than in certain discussions about specific treatments, such as antidepressant medication (to select just one example).

Many people benefit from antidepressant medication. Some do not. When the benefits of any medication outweigh the adverse effects, it should be continued for the course of treatment. When, after a proper trial, the adverse effects outweigh the benefits, the medication is not useful and should be carefully stopped. Other strategies or other medications can be considered. Different combinations of treatments suit different people.

Public discussion about antidepressants (and all aspects of mental healthcare) is absolutely vital for sharing information, challenging vested interests and progressing understanding. There are, however, tendencies for some debates to become unhelpfully polarised, with very negative effects.

Let me give an example. Last year, a woman came to see me, having had two episodes of severe depression in the past and benefitted greatly from antidepressant medication, along with psychological therapy. She was still taking the medication, with no side effects. It helped her overcome her symptoms, go back to work and get on with her life. She was happy again. A week earlier, however, she was devastated to read in a newspaper that campaigners were saying that antidepressants were highly dangerous and should be banned. She was in tears when she came to see me. I assured her that this was not true, but she was virtually inconsolable.

Public debate is vital, but it needs to be informed by humility. If one person finds antidepressants helpful, that does not mean everyone will find them helpful. If another person finds antidepressants unhelpful, that does not mean everyone will find them unhelpful. The same applies to all treatments, be they other medications, cognitive-behaviour therapy, various other psychological therapies, electroconvulsive therapy, or no treatment at all.

Conventional psychiatry has many powerful tools to help people, but does not, of course, have all the answers. As a result, real-life experiences of illness and treatment matter deeply. But everyone’s experience matters. The fact that one specific person has a particular experience with a specific treatment, either positive or negative, does not mean that everyone else will share that experience. Even when people come together in groups of hundreds or thousands with similar experiences, either positive or negative (eg, in clinical trials or public campaigns), there are always hundreds or thousands more who have different experiences.

All experiences and all lives matter. The vocal minorities matter and so do the silent majorities. Most of all, it is important to remember that one size does not fit all. Patterns recur, but every person is unique; every story is different. 

We need to seek out and listen to all stories, positive and negative.

Even the quiet, unspoken ones.

Especially the quiet, unspoken ones.

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