Today I’m preparing for my 11th meeting with the World Mental Health Survey initiative, in Harvard. At my first meeting in 2005, Professor Brendan Bunting, Dr Sam Murphy and myself were planning the NI study of Health and Stress (NISHS), the largest study of mental health in NI, and part of an incredible initiative, which studied the rates of mental illness, treated and hidden, in countries all over the world. In 2005, we were having discussed whether people here would answer “these sorts of questions” and how NI would compare to other places. The results were astounding, NI ranked in the top 3 countries worldwide for most mental illnesses. Our rates of Post-Traumatic Stress Disorder (PTSD) was the highest of all the countries who participated (8.8%) and traumatic experiences that were due to the Troubles accounted for the excess1. Dr Finola Ferry interviewed some of the worst affected for a follow up study, and what we heard was truly horrific2. What was emerging was a portrait of a society where almost 4 in 10 people experienced a violent trauma, one in 5 had a mood disorder such as depression and almost 40% met the criteria for any mental disorder1. Importantly, 13.9% had a higher risk of mental illness due to their exposure to the conflict, and this group had a profile of trauma related mental illnesses that were quite different from those found in other places. We also identified a group (4.3% of the population) who had witnessed violence related to the Troubles, who had 15 times the rates of suicidal behaviour of the general population3.
This trip to Boston is particularly poignant for me as it is the first time that I will be making the journey as a parent. My daughter is now one, and this time “preparation” also involves making lists of her favourite food, nap times, and how to manage six o’clock grumpiness. The past year has been joyful, chaotic, and incredibly, unimaginably demanding. I’ve been doing a lot of reading about the importance of childhood attachment and sensitive parenting and maternal mental health, and how this impacts on the child’s mental health. I’ve thought a lot about how a parent’s capacity to cope with stress shapes their child’s fight or flight response and their own ability to cope. Children learn by social modelling, by copying what they see, including how their parents cope under pressure, and manage difficult emotions. It’s a huge responsibility, and it often seems that no matter how hard we try, we are destined to mess it up one way or another.
It has got me thinking about those parents in NI who have raised children, whilst coping with the effects of trauma exposure and the horrors that they have witnessed. PTSD is characterised by hypervigilance, constant anxiety, rumination, fear and paranoia. People can be literally plagued by flashbacks and nightmares, and they report an inability to experience positive emotions such as love. Alcohol and drugs can provide relief, but they often bring further problems. The studies show very clearly that untreated parental PTSD and trauma related mental illness increases the risk of mental illness in their children. There is even emerging biological evidence that trauma impacts on the developing foetus and alters how the next generation responds to stress, ultimately increasing their risk of mental illness4,5. These parents, like all of us, are doing their very best, but the shadow of trauma looms large, and the impact is felt by the next generation in NI too. Trauma exposure in parents is linked to the adverse childhood experiences (ACEs), and recent papers from the NISHS show how these also increase the risk of mental illness here. One in 10 people lost a parent in childhood and over 8% reported economic adversity. Levels of known parental mental illness were 6.1%, and abuse and family violence were 3.7% and 5.4%6. The links between Troubles related trauma and suicidal behaviour were also demonstrated in the NISHS7 and are also all too evident in our suicide figures. Our male suicide rate is currently twice that of England8 and our recent study of university students (again, part of the World Mental Health Surveys) shows that 31% have considered suicide9.
This body of work has shown that NI is different from other places, and yet our mental health budgets do not reflect this. Our rates are high, but our problems are different, we have more serious, chronic and enduring mental illnesses. A trauma-informed approach is needed because inappropriate care can literally trigger re-experiencing, which consolidates the illness. The National Institutes for Health and Care Excellence give guidance, based on solid evidence, about the type of treatments that are effective. “More of the same” services that we have always had is not enough. We must also recognise the impact of ACEs on the next generation. This means developing a framework for mental health in schools, providing adequate maternal health care, and investing in perinatal mental health. I am impressed daily by the thousands of committed mental health workers here, who are doing great work to try to fix things. However, we need a functioning executive to make the courageous decisions about policy and expenditure that really will minimise the suffering of future generations.
Siobhan O’Neill is Professor of Mental Health Sciences at the Ulster University.
1. Bunting, B.P., Murphy, S.D., O’Neill, S.M., Ferry, F.R. (2011) Lifetime prevalence of mental health disorders and delay in treatment following initial onset: evidence from the Northern Ireland Study of Health and Stress. Psychol Med, 42(8):1727-39.
2. Ferry, F., Bolton, D., Bunting, B., Devine, B., O’Neill, S., Murphy, S. (2008). Trauma, Health and Conflict in Northern Ireland: A study of the epidemiology of trauma related disorders and qualitative investigation of the impact of trauma on the individual. Ulster University: Belfast. Available from: https://docs.wixstatic.com/ugd/198ed6_19350bebdb2648e383c9598322208f13.pdf
3. McLafferty, M., Armour, C., O’Neill, S., Murphy, S., Ferry, F., Bunting, B. (2016). Suicidality and profiles of childhood adversities, conflict related trauma and psychopathology in the Northern Ireland population. J Affect Disord, 200:97-102.
4. Yehuda, R., Daskalakis, N.P., Bierer, L.M., Bader, H.N., Klengel, T., Holsboer, F., Binder, E.B. Holocaust Exposure Induced Intergenerational Effects on FKBP5 Methylation. Biological Psychiatry, 1;80(5):372-80.
5. Yehuda, R., Daskalakis, N.P., Lehrner, A., Desarnaud, F., Bader, H.N., Makotkine, I., Flory, J.D., Bierer, L.M., Meaney, M.J. Influences of maternal and paternal PTSD on epigenetic regulation of the glucocorticoid receptor gene in Holocaust survivor offspring. Am J Psychiatry, 171(8):872-880.
6. McLafferty, M., Armour, C., McKenna, A., O’Neill, S., Murphy, S., Bunting, B. (2015). Childhood adversity profiles and adult psychopathology in a representative Northern Ireland study. Journal of Anxiety Disorders, 35:42-48.
7. O’Neill, S., Ferry, F., Murphy, S., Corry, C., Bolton, D., Devine, B., Ennis, E., Bunting, B. (2014). Patterns of suicidal ideation and behavior in Northern Ireland and associations with conflict related trauma. PLoS One, 19;9(3):e91532.
8. Scowcroft et al., (2017). Suicide statistics report, 2017. https://www.samaritans.org/sites/default/files/kcfinder/files/Suicide_statistics_report_2017_Final.pdf
9. McLafferty, M., Lapsley, C.R., Ennis, E., Armour, C., Murphy, S., Bunting, B.P., Bjourson, A.J., Murray, E.K., O’Neill, S.M. Mental health, behavioural problems and treatment seeking among students commencing university in Northern Ireland. PLosOne, Dec 13;12(12):e0188785.
This is a guest slot to give a platform for new writers either as a one off, or a prelude to becoming part of the regular Slugger team.