This fascinating book draws in the reader from the first page with compelling accounts of the lives of individuals in Grangegorman asylum over the last few centuries. The first page describes the experience in 1908 of a 28 year old married mother with a three month old baby. At a time long before perinatal psychiatry supports were available, the tragic end to her life provides an immediate sense of the care provided for mental illness at this time. The tragedy in this initial anecdote is sadly echoed throughout the book.

The author, with a deep knowledge of the history of Irish psychiatry, very nicely describes the trajectory of institutions in Ireland in the 1800s and 1900s. The widespread institutionalisation might be difficult to comprehend until we consider the descriptions of how mental illness was treated prior to the creation of these institutions in the mid 18th century:

‘the only way they have to manage is by making a hole in the floor of the cabin not high enough for the person to stand up in,… the hole is about five feet deep, and they give the wretched being his food there, and there he generally dies’.

With these descriptions the asylums seem like a compassionate development in society, even though the institutions themselves were likely miserable for many, and inadequate by today’s standards.

There was a rapid increase noted in the numbers of people institutionalised in Ireland in the early 1800s and the first patients were transferred to Grangegorman in 1814. People admitted included ‘the mentally ill, the intellectually disabled, the physically ill and people from various other walks of life, who were abandoned or rejected by their communities for any of a wide array of reasons’. The admission to asylums for social and legal reasons is well described in the book. Poverty and alcohol misuse, often reasons for homelessness in modern society, were also reasons for asylum admission.

The book provides a picture of the approaches taken to deliver care in the asylum. In this preneuroleptic era some of the methods for helping people may be viewed in a positive light, such as Connolly Norman promoting exercise for chronic ‘melancholics’. The early use of occupational therapy is nicely described, as is the approach of using work to help patients at a time when little other evidence based treatments were available. One quote in the book from 1838 highlights the substantial benefits from employment approaches:

‘Of the advantages of this system of employment….and to its salutary effects I mainly attribute the recovery of numerous cases, some of which were at first most unpromising…I can confidently say, that at least eight out of every ten lunatics will be found in a fit state for some useful pursuit’.

‘Moral management’ was a term used for strategies employed at various times in the history of asylums, which consisted of a good diet, occupation, engaging in activities, and conversing ‘for a few minutes with each patient, on the subject which appeared to be most welcome to his humour’.

More controversial biological treatments from the twentieth century are also described including malaria therapy (giving patients malaria to treat general paralysis of the insane), insulin therapy (administering insulin to induce coma), and frontal lobotomy (surgery on the front part of the brain). While these are now considered outdated treatments, the early use in Ireland of electroconvulsive therapy (ECT) is also recounted. This is the only biological treatment from this era which remains in use today. ECT continues to have a strong evidence base as an effective, and sometimes life saving treatment for severe mental illness.

The striking sense of the injustice delivered within a society without modern day human rights protections are notable in the book. Several examples are described of individuals being transferred to the asylum, never to be released before their death. One anecdote narrates an incident in which a man was given a sentence of one calendar month in Mountjoy prison for attempting to commit suicide in the early 1900s. The man was subsequently admitted to Grangegorman where he was reported to be hearing voices in the context of alcohol use. He was later discharged ‘recovered’ after five months in the asylum.

The book also provides an interesting angle of several aspects of Irish history such as the impact of tuberculosis, beri beri disease, the famine, the Irish revolution and the First World War (and early descriptions of ‘shell shock’). Important historical figures are described, such as the first female psychiatrist in Ireland, Dr Eleanor Fleury, who was put forward for membership of the medico psychological association in 1893 by Dr Norman Connolly. Another female psychiatrist in the early 20th century, Dr Ada English, also had nationalist sympathies at the time of the Irish civil war, and the book outlines how asylums in general could be used for nationalist political protection purposes at this time. In 1920 a stand off in financing between Grangegorman and the British local government board apparently resulted in a threat by the asylum to release 400 inmates (which ultimately did not materialise).

Asylum admission rates continued to climb until the late 1950s and the book describes the transition out of widespread institutionalisation contributed to by several Irish figures in the 20th century such as Prof John Dunne, Dr Evelyn O’Brien, Dr Dermot Walsh and Professor Ivor Browne. In 1961 a report highlighted that Ireland appeared to have the highest rate of psychiatric beds in the world (7.3 beds per 1,000 of the population). Thereafter, assisted by a shift in thinking and policy, as well as the introduction of effective novel antipsychotic medication and psychosocial treatments, the figures slowly reduced (from 19,801 psychiatry inpatients in 1963 to 2,228 in 2014). This reduction may have come at a cost of increasing the mentally ill homeless population and increasing mental illness in Irish prisons.

The book allows an appreciation of how far we have come as a society (while we should continue to acknowledge that current mental health services have substantial limitations). I found the insights into the care of individuals with serious mental illness in the pre-neuroleptic and pre-psychosocial interventions era to be fascinating. With these insights it might be easier to understand why schizophrenia was originally regarded as a dementia (dementia praecox), given that the deterioration of cognitive and mental faculties might be more pronounced without the possibility of recovery using modern day evidence based interventions.

As a trainee I gained great benefit from reading classic historical texts such as those by Krapelin and Bleuler, and this book gives similar insights but within an Irish context. I would highly recommend the book to trainees, as well as to experienced clinicians, policymakers, service users and their families.