Specialist areas of Psychiatry

General Adult Psychiatry involves looking after people between the ages of 18 and 65 years of age who have a mental illness. Within General Adult Psychiatry a wide range of disorders are treated. These include manifestations of “organic” brain disorders such as Huntington’s Disease, psychoses such as schizophrenia, severe or difficult to treat depressive illness, and personality disorders. More so than ever, the psychiatrist works as an integral part of a team of many different professionals.

The General Adult Psychiatry specialisation is developing. In many areas of the country, psychiatrists are specialising into different areas. Some work solely with inpatients and others solely in the community – the challenges are often different and require different skills in different measures.

In addition to specialising as a result of how or where mental health services are delivered, there are other areas of subspecialisation. These include Rehabilitation (or Recovery) Psychiatry, Liaison Psychiatry, Addiction Psychiatry, Eating Disorder Psychiatry and Perinatal Psychiatry. All of these areas require General Adult psychiatrists to employ a subtly different mix of skills and knowledge base to care for each person on an individual basis.

Psychiatry’s understanding of the disorders treated is developing, as are the treatments themselves. These include better understanding how to deliver treatments effectively to those who need them. This is therefore a rapidly changing area of psychiatry.

Children’s lives do not occur in a vacuum; therefore, psychiatrists in this specialty promote best practice which requires a holistic approach to be taken to the needs of children and adolescents with mental health problems.

Child & Adolescent Psychiatrists are mainly responsible for the treatment of mental, behavioral and emotional disorders of children and adolescents. As with other psychiatry specialties, they work with a team of professionals – GPs, community psychiatric nurses, social workers, psychologists, occupational therapists, and physiotherapists.

Mental health problems in children that are more severe than their parents can deal with without professional help are not solely the concern of mental health services. The development and overall functioning of children and adolescents are the concern of a wide range of services and agencies, such as education, community care and paediatric medicine. Mental health services cannot respond to mental health needs in isolation.

Psychiatry of Old Age (or later life) focuses on the mental health needs of people over the age of 65. Mental health problems for those over 65 are similar to those in the general adult age group.

The role of a psychiatrist specialising in Old Age Psychiatry involves pharmacological, psychological and social aspects of dealing with people with mental health problems and cognitive impairment (such as dementia).

An Old Age psychiatrist can work with many different professionals – community psychiatric nurses, social workers, psychologists, occupational therapists, physiotherapists, geriatricians and neurologists – in a wide range of settings such as community bases, general hospitals and/or university hospitals.

Old Age Psychiatry aims to provide a comprehensive psychiatric service for elderly people; therefore, services are usually based on the principle of domiciliary assessment and close co-operation with general hospitals and community care programmes since the needs of elderly people are frequently complex and require an integrated approach.

Those looking after patients in Old Age psychiatric services closely monitor them so that their needs can be met as they arise . The community mental health nurses have a key role in this monitoring process and also in liasing with public health nurses, in particular, to ensure the necessary support is provided to maintain people, for example with dementia, at home for as long as possible.

Residential Care
It is important to assess the patients (particularly those with dementia) requiring residential care on the basis of their needs, rather than assuming dementia equates with psychiatric care.

Most people with dementia require a safe environment with supervision of activities of daily living or general nursing care when cognitive function has deteriorated severely. Such patients can be looked after in nursing homes. A few people remain so disturbed in association with dementia, despite treatment, that they can only be looked after in a psychiatric setting.

Addiction Psychiatry

Addiction Psychiatry is the branch of Psychiatry that specialises in the understanding and treatment of those who have problems with their use of alcohol or drugs. They often work in multidisciplinary teams with nurses, addiction counsellors, occupational therapists, psychologists and social workers. They often work in liaison with other doctors such as GPs, other psychiatrists and hospital-based specialists treating conditions such as liver disease or HIV. They can work in a variety of settings such as outpatients, community centres, methadone clinics, psychiatric and general hospitals or prisons.

The World Health Organisation states that “the enjoyment of the highest attainable standard of health is one of the fundamental rights of every human being.

”The Faculty of Addictions promotes this right for those with an addiction by encouraging best practice amongst its members, advocating for effective treatment and extending the evidence base in the Irish setting.”

What is addiction?

Addiction is a chronic, relapsing brain disease that is characterised by compulsive alcohol or drug seeking and use, despite harmful consequences. It is a brain disease because the alcohol or drugs change the brain’s structure and how it works. These brain changes can be long lasting and can lead to harmful behaviours.

Consequences of addiction

Everyone can be affected by addiction. Listed below are some of the possible consequences of alcohol or drug use.

Consequences to the person

1. Babies: Premature birth, underweight, physical abnormalities. Later as a child: Impaired intellectual and behavioural development
2. Adolescents: Poor academic performance, dropping out of school, unplanned pregnancies, violence, infectious diseases
3. Adults: Problems thinking clearly, remembering, paying attention, poor social behaviours, poor work performance, relationship breakdown, poor physical health, premature death
4. Families: Chaotic, stress-filled homes, child abuse and neglect. These can lead to addictions for children when they become adults.

Consequences to society

1. Death: Between 1998 and 2007 there were 3,465 drug-related deaths. Between 1995 and 2004 there were 1,775 alcohol–related deaths.
2. Crime: In 2007 there were 30,340 offences due to alcohol (drink-driving and drunkenness). In 2007 there were a further 55,930 offences where alcohol had a substantial role (public order and drunkenness).
3. Size of illegal trade: In 2003 illegal drug market estimated 650 million euro. In 2006 illegal alcohol sold to 16 to 17 year olds was estimated to be worth 145 million euro.
4. Family: In 2009 109,476 children had parents with alcohol problems. In 2002 around 7,500 families were coping with a heroin user.

Why People use alcohol or drugs

People take alcohol or drugs for a variety of reasons. Listed below are some of the reasons:

• To feel good: Feelings of pleasure, euphoria
• To feel better: Cut down feelings of stress, social anxiety or depression
• To do better: Improve athletic performance for competitions, improve cognitive performance for exams
• Curiosity: May include peer pressure

What is the problem with alcohol or drugs

At first people may only notice the positive effects when consuming drugs or alcohol. When intoxicated, people may do harm to themselves or others. Over time the positive effects decrease and alcohol or drug use is needed to feel “normal”. Some people will become addicted to alcohol or drugs. No single factor determines whether a person will become addicted. The risks for addiction are caused by the interaction between biology/genes of a person, the environment they are in, the stress they are under and how they use alcohol or drugs.

Examples of risk and protective factors:

• Risk factors: Early aggressive behaviour, poor social skills, lack of parental supervision, parental alcohol or drug use, drug availability, poverty, early use, method of administration.
• Protective factors: Self-control, positive relationships, parental support, academic competence, strong neighbourhood attachment.

Treatment and recovery in addiction

Addiction is a treatable disease. Treatment is a combination of medication and behavioural therapy. Medication can be used to treat withdrawals, help a person stay in treatment and prevent relapse.

• Behavioural therapies help people engage in treatment, modify their attitude and addictive behaviours and increase their life skills to handle stress and environmental cues that trigger intense craving. An addiction can affect many aspects of a person’s life. For successful recovery, treatment must address all the needs of the person. Treatment can be a comprehensive programme and may involve a number of rehabilitative strategies, settings, healthcare and other professionals.

Forensic Psychiatry is concerned with helping people who have a mental disorder and who present a significant risk to the public. It covers areas such as the assessment and treatment of mentally disordered offenders, investigation of the complex relationships between mental disorder and criminal behaviour and working with criminal justice agencies to support patients and protect the public.

Forensic Psychiatrists work alongside many other services including the criminal justice agencies such as the defence, prosecution, gardaí, probation, courts, and prisons. Inpatient services are located at the Central Mental Hospital in Dundrum.

The Central Mental Hospital
The Central Mental Hospital is the only secure therapeutic service in Ireland, identified in the Criminal Law Insanity Act 2006 as a designated centre for the admission of mentally ill offenders. It was opened in 1850, five years after the bill that commissioned it was passed. It stands on a 35 acre site, 4 miles from the city centre of Dublin and remains both the oldest secure hospital in operation and the first of its kind. It currently accommodates 91 men and 8 women. It provides treatment under conditions of therapeutic security for mentally disordered individuals who present with substantial risk factors related to mental disorder and violence.

• Pathways to Care
  Pathways to care at the Central Mental Hospital exist within the criminal justice system where mentally ill people are referred to visiting Forensic Psychiatrists in prison, or by the courts, defence or prosecution. In addition, community mental health services may refer patients with complex psychiatric needs who require specialist treatment in conditions of therapeutic security.
• Treatment
  Treatment at the Central Mental Hospital is delivered by a multidisciplinary team including consultant and NCHD psychiatrists, psychologists, social workers, nurses and occupational therapists. There are seven consultant led teams divided into acute male and female admissions, rehabiliation, recovery and aftercare, and a prison based court liason team in Cloverhill.
  The purpose of this structure is to enable the stratification of patients according to the severity of illness, level of risk and degree of recovery in order to lead to a safe community reintegration.
• Future developments
  Proposals for future developments include a new forensic psychiatric hospital, and the establishment of intermediate levels of secure care. Deliberations on these matters have been ongoing for several years.
  As yet no definite plans have been advanced.
  The Central Mental Hospital is fully accredited by the College of Psychiatry of Ireland for training purposes.

A general learning disability is not a mental illness.

However, children and adults with learning disability are more likely to develop psychological, behavioural and mental health problems. For example anxiety, depression, autism spectrum disorders or Attention Deficit Hyperactivity Disorder (ADHD).

Learning Disability Psychiatry is concerned with people who have mental health problems associated with a learning disability, such as behavioural and emotional disorders. A Learning Disability Psychiatrist works to diagnose and treat mental health disorders including behavioural and emotional problems.

Learning Disability Psychiatrists work as part of a multidisciplinary team to provide treatment and to support patients with learning disabilities and mental health problems. Learning Disability Psychiatry work may take place in general hospitals, but will typically be carried out in places like clinics, community care centres and family residences.

Social and Rehabilitation Psychiatry specialises in the area of rehabilitation and recovery services for people who suffer with a severe mental illness. Psychiatrists specalising in this area therefore focus on the needs of people with longer term and complex mental health problems.

Liaison Psychiatry involves assessment and treatment of, as well as research into, mental health problems among patients who attend general hospital healthcare services.

There are four National Clinical Programmes (NCPs) for mental health all at various stages of design and implementation. The Mental Health Clinical Programmes are a joint initiative between this office, HSE Mental Health Services, and the College of Psychiatry of Ireland. The overarching aim of the NCPs is to standardise quality evidence based practice across the Mental Health Services.

These include:

• Assessment and Management of Patients Presenting to Emergency Departments following Self-Harm
• Eating Disorders Service (spanning Child and Adolescent and Adult Mental Health Services)
• Early Intervention in Psychosis
• ADHD in Adults

For more information about NCPs, click here.