"Policy Outcome" - On Ireland's mental health system and the people it was built to fail - 1/2

This Friday I walked into my GP's office with a plan. I knew what was wrong with me. I knew which medications had failed and why. I knew what I wanted to try next. I had the name of the drug, the mechanism of action, the clinical rationale. I'd spent weeks researching, because no one else was going to do it for me.

My GP interrupted me mid-sentence. He told me he could only prescribe SSRIs. He told me I didn't understand what I was talking about and that I needed to leave it to the professionals. Then, in the same breath, he told me he couldn't help me. He said my symptoms were mild. He said I was articulate, as though the ability to describe your own pain is evidence that the pain isn't real. I am articulate. I enjoy writing and like having a wide vocabulary, I have also spent most of my conscious life unable to enjoy being alive. Those things are not mutually exclusive.

He told me that if he referred me publicly to the HSE, they would likely send me back to him and recommend SSRIs, the same class of medication I've already tried twice, with zero effect. That was it. No prescription, no referral, no blood test I requested, even though he'd done blood tests during routine appointments before. I walked out with exactly what I walked in with, minus seventy-five euro.

This isn’t a one-off anecdote, but one tiny occurrence within a web of people who have experienced the same or much, much worse.

I am twenty years old. I have a condition called anhedonia, a chronic inability to experience pleasure, motivation, or emotional engagement with life. It’s been with me for as long as I can remember, and has stayed completely unshaken no matter the changing circumstances, negative or positive, in my personal life.

I have tried sertraline. It did nothing. I have tried venlafaxine. It did nothing, but seemed to worsen the emotional blunting I was already struggling with. Nobody told me this when they prescribed it. Nobody told me that venlafaxine is one of the hardest psychiatric medications to stop taking, either. I found that out when I tried to come off it and my brain started sending electrical shocks through my skull along with overwhelming signals to kill myself.

A previous GP identified that I likely have ADHD. He could see the condition clearly enough to name it to me, but not diagnose it, because in Ireland, a formal ADHD diagnosis requires a psychiatrist, and a psychiatrist costs far more than it should. Recent reporting has found private ADHD assessments reaching over two thousand euro, while public waiting lists can stretch beyond two years. So I have a recognised-but-unrecognised condition, visible to medicine but inaccessible to the system that's supposed to provide it.

This is what mental health care looks like in Ireland if you don't have the money. 

I was put on sertraline at sixteen. It didn't work, but I was sixteen, and nobody presented alternatives because SSRIs are the first and apparently only page in the system’s playbook. So I went back. And back. Adjusted doses, adjusted expectations, adjusted myself to the idea that maybe this was just what life felt like and I should stop complaining.

One time, also when I was sixteen, I was in such a dark place I had no idea where to turn. So I told the truth, the unfiltered truth. I told a health worker I was suicidal, and the response was to threaten me with an adolescent psychiatric hospital, to pull me out of my life and away from the small support network I had. I cried and cried until they backed off.

After that I was never seen as anything more than mildly depressed. The word has followed me for years. Mild. Too articulate to be struggling. Too good at remembering details. Too functional, as though showing up to school while wanting to die is evidence of wellness rather than desperation. The anhedonia, the inability to start things, to sustain things, to feel any reward from completing things: I raised it, repeatedly.

I described what I now know are textbook ADHD symptoms. But I could hold a conversation, remember appointments, and string a sentence together, so it couldn't possibly be ADHD. The condition was dismissed not because it was assessed and ruled out, but because I didn't look like the stereotype, a hyperactive boy who can't sit still in a classroom. 

I had to keep asking, keep pushing, keep performing the role of informed patient in rooms full of professionals who resented me for it, until finally I got given the time of day and prescribed methylphenidate (Ritalin). Not because the system worked. Because I refused to stop asking.

Private psychiatry appointments run to hundreds of euro. Follow-ups the same. The result of mine was a prescription for the antidepressant venlafaxine. The psychiatrist suggested it casually, "let's try venlafaxine," as though it were interchangeable with any other antidepressant. No discussion of side effects. No mention of withdrawal risks. No mention that venlafaxine is widely regarded as one of the more difficult antidepressants to discontinue due to its severe withdrawal effects. It was presented to me like trying out a calcium supplement.

It didn't work, and in fact blunted me even further emotionally. When I needed the prescription renewed at the same dosage, not adjusted, not reviewed, just renewed, I was told I'd need another follow-up appointment. Another several hundred euro to be handed the same piece of paper. For a drug she knew I couldn't safely stop taking without medical supervision, and that she was about to stop supervising. I couldn't afford it, so I was referred back to my GP. The psychiatrist's involvement ended not because I was better, but because I ran out of money.

My GP took over management of a drug he didn't prescribe. When I told him I wanted to come off it, he advised me to taper by taking it every other day. This is specifically contraindicated for venlafaxine. The drug has a half-life of roughly five hours; taking it every other day means your brain enters withdrawal every second day. In the UK, NHS guidelines explicitly warn against this. He didn't know. In the same conversation, he called venlafaxine an SSRI. It is not, it is an SNRI, a different drug class entirely. He then told me I didn't understand what I was talking about, and that I needed to leave it to the professionals.

So I am tapering myself off venlafaxine using a method I found on the internet. I open the capsule, eyeball roughly half the beads, swallow them with water, and hope for the best. I am doing this without medical supervision, not because I chose to of course, but because the medical system's supervision was worse than none at all. I am managing my own withdrawal symptoms: the dizziness, the mood crashes, the mornings I can't get out of bed, because every professional I've paid to help me either didn't know enough to help or didn't care enough to try.

But the truth is I am immensely privileged. I have a support network. I have friends. I have a partner who is more supportive and thoughtful than I could ever expect from anyone. I have a job that I am high functioning enough to show up to on all but my worst days. I have a family that can help me financially if I get hit with a bill that I simply can’t afford. I have the stubbornness to spend nights researching my own neurochemistry and show up to a doctor's office with a treatment plan. I am the best-case scenario for someone failed by this system.

Now subtract my privileges, one by one.

Take away the research ability. Take away the so-called articulacy. Take away the support network. Take away the job. What's left is a person who hears "mild" and believes it. A person who takes the SSRI that doesn't work and stays on it for years because they were never told there was an alternative. A person who doesn't make it through the summer, and whose death is recorded as a tragedy rather than what it actually is: a policy outcome.

Too many deaths in this country are treated as isolated personal tragedies rather than the foreseeable outcome of a system that leaves people untreated until they reach crisis point.

Ireland is one of the wealthiest countries in Europe, yet consistently allocates a smaller share of its health budget to mental health than many comparable European countries. We have chronic staffing shortages, overwhelmed public services, and some of the longest waiting lists in the system’s history. You can bypass the queue if you have the money. If you cannot, you wait; sometimes months, sometimes years, or you simply go without.

The fundamental purpose of a state is to care for its citizens. A government that allows its mental health system to decay to this point has not failed in some passive, accidental way. It has decided, through budgets and staffing decisions and policy priorities, that this level of suffering is acceptable.

Every morning, I open a capsule and count out chemical beads so I can get back my life because the professionals didn't know how. I am the best-case scenario. In Part Two, I'd like to look at the blueprint of this failure: the numbers, the waiting lists, and the exact state of the system that has decided we are not worth the investment.