In Search of Madness: A deep dive into the history of mental illness

Lunatic asylums and lobotomies may be consigned to the past, but psychiatrist Brendan Kelly reflects on how our understanding of the brain is still shaky and insufficient

Professor Brendan Kelly

In Search of Madness by Brendan Kelly

Professor Brendan Kelly

Danielle Barron

April 16 2022 05:00 AM

A word of caution for those approaching Professor Brendan Kelly’s latest book, In Search of Madness. If your self-esteem has recently taken a pummelling, do not attempt to read his mini-biography on the back book jacket where his numerous academic degrees and doctorates are listed.

The psychiatrist is also a researcher with hundreds of peer-reviewed publications to his credit, as well as a prolific author. You may have heard one of his regular contributions on daytime radio and, if you didn’t catch the name, thought to yourself “who is that voice of reason among the chaos?”

In this book, the good doctor manages to incorporate all of his interests, both professional and personal — history, travel and the speciality he clearly holds so dear. Indeed, his thirst for knowledge is matched only by his wanderlust; he travels to Belgium, Italy, Germany, India and the US as part of his research.

“Most of us secretly worry about our sanity, at least from time to time,” he writes. He’s not wrong. And when he writes that the criteria for mental illness “have never been more negotiable”, we realise that the progress made in the past half century when it comes to how society acknowledges and deals with serious mental illness is shaky and insufficient.

When it comes to mental illness, the medical mantra of “first, do no harm” has not always been applied in practice. Kelly tells us eloquently that much harm has been done to those with mental illness in the not too distant past and that cruelty, no matter how unintentional, continues to be inflicted upon them even in these enlightened times.

As he takes us with him on his travels, Kelly illustrates how our understanding of mental illness changes dramatically with time and geography. In India, we learn that the mentally unwell are “neglected, chained or beaten” in rural villages, echoing historical practices of confinement. Other more gruesome and distressing “treatments” included blood-letting and purging using laxatives and emetics, as well as forced bathing, “the continuous bath”. Lobotomy was “without doubt the single greatest mistake in the history of psychiatry”, he states unequivocally.

Taking a deep dive into the social history of the topic, he covers this barbarism doled out in the 19th century “lunatic asylums” and laments the “great injustice” of the institutionalisation proffered by the psychiatric hospitals throughout much of the 20th century.

Kelly admits he remains troubled by long-stay psychiatric facilities: “While kindness is good, freedom is better”. By 2003, there were fewer than 3,700 psychiatric inpatients in Ireland, a more than 80pc decrease in four decades, but dismantling the psychiatric hospital system does not mean these people have disappeared — Kelly maintains that people with serious mental illness are often neglected, homeless or confined to inappropriate settings such as prisons.

On a brighter note, he writes enthusiastically about how many of the old asylums and institutions have been creatively reimagined. His description of the “mid-range hotel” in Sligo that was once St Columba’s Mental Hospital gave me shivers — I stayed in this hotel and the high windows of the claustrophobic room left me in no doubt what this majestic building had once served as, even knowing none of the history. I later found out it was the one depicted in Sebastian Barry’s The Secret Scripture.

In the meat of the book, Kelly strips away our preconceptions and presumptions. For example, he says that there is “no logical division between mental and physical phenomena”, yet the language of biology is ultimately “currently inadequate” in its understanding and description of depression. “We simply do not know fully how the human brain works, even when it is having a good day, let alone when a person is depressed or suicidal,” he writes.

Schizophrenia is still widely misrepresented and misunderstood; all mental illness is, “sometimes deliberately so”, he muses. And for most people of a certain vintage, their understanding of electroconvulsive therapy (ECT) comes from the Jack Nicholson movie One Flew Over the Cuckoo’s Nest. Portrayed as punitive, it is now a mainstream therapy for depression with a solid evidence base. This may still be news to some.

Kelly is dismissive of the impact of neuroscience on psychiatry, calling it “neurobabble” and saying it has not delivered on its promise when it comes to mental illness, resulting in no appreciable improvements in the management of any condition. He is even more dismissive of what he calls “broccoli, jogging and mindfulness” as a cure-all for anxiety and depression — you know who you are.

As humble as he is, Kelly is the expert here and vignettes depicting some of his own patients bookend each chapter, illustrating in practice what he is at pains to explain to us about manic depression, schizophrenia and one particularly distressing case of postpartum psychosis.

This is a man at the pinnacle of his chosen field of expertise but clearly always seeking to give it context, whether social, historical or personal. He retains an insatiable curiosity for his speciality and one senses the books come almost as an offshoot or byproduct of the vast amount of reading and research he does for his own satisfaction, not for continuing professional development. Indeed, it is a massive understatement to say Kelly reads widely — one of his many reading recommendations is an article from Elle magazine.

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At one point, he describes sitting in a beautiful square in the Belgian city of Antwerp enjoying some burgers and drinks with a colleague after a conference. As they munch and sip, they discuss challenging cases — a topic he admits is incongruent with their surroundings. He simply says: “We are psychiatrists. This is what we do.”