The Medication Debate

by Ed Boyne

Readers will probably recall before Christmas a debate which ran in the national news bulletins and in the letters page of The Irish Times. The debate was ostensibly around the issue of psychiatry and medication and arose out of statements made by Minister of State with responsibility for mental health policy, Tim O’Malley TD. I’ve no wish to rehearse all the various points made but there are a number of important issues arising which still deserve attention.

The debate about medication versus ‘the talking therapies’ is not a new one. Aspects of this debate have been rumbling in the media for many years. The debate has tended to take the form of ‘mainstream expert psychiatrists’ speaking ex-cathedra about the virtues of the pharmacological approach on the one hand and a scattering of replies from the minority of post-enthusiastic psychiatrists and sundry advocates of alternative approaches on the other. The professional bodies representing ‘the talking therapies’ have traditionally abstained from the fray for reasons best known to themselves.

The most recent round of this debate was somewhat different however. In this case we had a Minister of State putting his head above the parapet, openly  questioning some of the cherished assumptions of psychiatry and suggesting that the ‘talking therapies’ might have something important to offer. Lined up on the other side were the professors of psychiatry from the State’s universities, led by the inevitable Dr Patricia Casey. The Minister (who is himself a pharmacist) was encouraged to consider his position for daring to venture into this territory and for asking questions. All good knock-about stuff and one would have thought a perfect opportunity for our professional bodies to at least support the Minister’s positive public stance on psychotherapy and gain some positive political exposure along the way. Alas this was not to be and the traditional silence prevailed.

The apparent ideological stand-off between pro and anti medication camps masks a wider and important reality. Research recently by Copty and others into the attitudes and needs of doctors in primary care in Ireland shows that the vast majority of GPs do not want to refer patients presenting with psychological difficulties to psychiatrists and certainly do not want psychiatry to be the only referral option. Given that 95% of those with mental/psychological difficulties are dealt with at primary care level this is a remarkable finding and a remarkable opportunity for those of us who wish to in any way promote the ‘talking therapies’. GPs are also uneasy about prescribing medication themselves and often only do so because of lack of surgery time and lack of adequate referral options. Other research indicates that while progress has been made in the provision of psychotherapy services, the vast majority of patients presenting at primary care level do not have the full range of treatment options made available to them. The prescription of medication remains the default setting in most cases.

I’m quite certain that if Copty and her research team were to conduct the same research on psychotherapists as a group she would discover that most referrals to psychotherapists already come from the primary care sector. There is an obvious ‘fit’ between the needs of GPs on the one hand and the profession of psychotherapy on the other.  If we are to move beyond mere debate and into the possibility of real change with psychotherapy available on a widespread basis as an alternative to medication, then the official and practical relationship between the primary care sector and psychotherapy must be substantially and significantly developed.

As I mentioned in the last edition of ‘Inside Out’ the official blueprint for services in this area is now contained in the report entitled ‘A Vision for Change’ which has been adopted as Government policy. It is provided for in that report that a key role for psychotherapy should be in the primary care area. This could mean being part of the new primary care teams or being part of a looser referral network at primary care level. This does not mean that  psychotherapists would be obliged in any way to change the basic principles by which they work. For example there would be no obligation to engage in brief psychotherapy simply because of links to primary care. Notwithstanding this the area of brief psychotherapy is well represented within the ICP with 3 out of 5 sections of ICP devoted to brief work. Cognitive therapy, Systemic therapy and Constructivist therapy are acknowledged internationally by academics to be ‘brief’ forms of work. Involvement in the primary care area does not preclude involvement in other areas as opportunities arise in the future.

Under the new National Development Plan announced by the Government in January 2007 a sum of €2.1 billion has been allocated to the development of primary care up to 2013, including the setting up of 500 primary care teams nationwide. Given the provisions of ‘A Vision for Change’ there is now every reason why the psychotherapy profession should be included as part of this huge funding plan. Funding could be given for training, premises, explanatory literature, research etc. The potential is enormous and the time to act is now in order to maximise this potential.

The status of the psychotherapy profession, legal and otherwise has been under discussion in terms of statutory registration etc. No firm written commitments have been given by Government to date  in relation to statutory registration. Of equal if not greater importance is the role of the profession in society and how it fits in with and relates to other key professions. In my view the best way to safeguard the profession’s status is to clarify and consolidate its role at every level in both practical and in policy terms. This will, for example,  involve our profession responding positively to service users who are demanding more treatment options as well as pressing for funding for services and the full implementation of ‘A Vision for Change’.

Unfortunately we seem to be a long way from achieving this clarity and consolidation if the recent ICP circular to all members is anything to go by. Let’s hope that the ICP’s  apparent hostility to ‘A Vision for Change’ is not deeply rooted.

In my view there is little doubt that the real and practical terms of the ‘great medication debate’ will only be changed when the providers of the ‘talking therapies’ are present in numbers on the ground to provide an acceptable alternative to medication and are working within the context of a coherent and supportive Government policy and in full mutual co-operation with other key professions.

Edward Boyne MA. M Phil. is director of the Tivoli Institute, Dublin and Galway. He served on the Board of Amnesty International (Irl), and was chair of the Irish Penal Reform Trust (2003/5).