Insights into depression, suicide and PTSD from Northern Ireland

Domhnall_pic_resizeby Domhnall MacAuley, CMAJ Associate editor

In her inaugural professorial lecture Professor Siobhan O’Neill of Ulster University had some fascinating insights into the psychological manifestations of the patients we see in practice and the long term influence of the Northern Ireland troubles on people’s psyche.

Women get anxious; men get angry. A generalization, of course. But, it does explain consultation behavior. Women tend to internalize their feelings becoming anxious and moody- they over think. And, come to the doctor. Men, on the other hand, externalize their feelings becoming more impulsive, aggressive and self-medicate through alcohol or substance abuse. Family doctors know that if a middle aged man actually consults with depression, it’s serious. Middle aged men and those with relationship problems are high risk. So, how can we identify depressed men? They are more likely to turn up to the police, lawyers or in seeking child access. The feminisation of the mental health services has not helped. According to Siobhan “We don’t need any more nice pink counseling buildings, smelling of pot pourri and staffed by kind listening women”- we need to actively seek out troubled men.

Qualitative research gets to areas that other research methods just cannot reach - providing insights beyond the quantitative work with which most of us are familiar. But terms like “interpretative phenomenological analysis” tend to make even an editor’s eye glaze over. Yet it is just about taking meaning from your experiences. Everyone suffers some trauma in their lives but not all of us become depressed or suicidal- it’s the meaning that leads to the disorder not the experience itself. So with Post Traumatic Stress Disorder, patients may tell us about the flashbacks and how they relive the experience and the nightmares. But they don’t appreciate how they subconsciously adopt safety behaviors to prevent it happening. They avoid trigger situations and develop a protective numbness in response. They make no plans in life and see only a foreshortened future. No wonder their lives begin to feel so meaningless.

What proportion of PTSD in Northern Ireland is conflict related? Interestingly, and some might think it relatively low, 26% was conflict related. But PTSD in Northern Ireland is more severe and more enduring. Siobhan also asked a fascinating question- could conflict be protective? My personal impression of working in a troubled area was that, while there were many difficult problems, there seemed to be less depressive illness during the conflict. Her theoretical background supports this view- there was a certain common goal and focus, the conflict increased connectedness and connectedness tends to be protective against low mood. Post conflict, however, connectedness reduces but there are still victims. While the troubles are over, many have lost loved ones or limbs and are in danger of being forgotten. Understanding the importance of connectedness has wide ranging relevance for the many victims in society. We must create a culture of connectedness. Reach out. Show that seeking help is a sign of strength. Although suicide is associated with mental disorder, many people have mental disorders but relatively few commit suicide. So what makes a difference to rates of suicide? Acceptability of behavior is a factor. Public perception is important. Cognitive therapy access and the means to address problems. Media guidelines also help so as not to increase risk of suicide contagion.

Siobhan left us with a quote attributed to James Addison.  "Three grand essentials of happiness in this life are something to do, someone to love, and something to hope for."

I thought it a superb lecture, but it is possible that I am biased. Siobhan was my first PhD student!

 

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