Since Ireland’s vast asylum system was built in the early-nineteenth century, the country’s mental healthcare system has been lamented as stigmatising, inadequate and controversial. Admission rates remained disproportionately high in comparison to other countries until the late-twentieth century. Although conditions have now improved, mental health remains a controversial and heavily debated topic in present-day Ireland. In Hearing voices: the history of psychiatry in Ireland, Brendan Kelly provides an authoritative, perhaps definitive, account of Irish mental healthcare history which investigates patients, psychiatrists, asylums, policies and experiences. Hearing voices offers detailed historical analysis while outlining potential future possibilities for progression.

Hearing voices focuses mainly on the period after around 1800. The nineteenth-century Irish asylum system is an increasingly well-trodden area, having been covered in national studies as well as local studies of asylums in Galway, Dublin and Carlow. Ireland’s national asylum system, implemented in 1815 (some thirty years before its English equivalent) quickly filled up with incurable, long-stay patients, many of whom lingered for decades in unsatisfactory conditions until they eventually died. Complex interactions took place between patients, families, psychiatrists and institutions. By the end of the century, admission rates appeared to be spiralling. Kelly skilfully synthesises the extensive pre-existing historical literature while also adding new insights and sources of his own. Alongside details of legislation, psychiatrists and asylum building, the reader learns of patients who were neglected and restrained, the mental impact of the Famine and ‘insane ears’.

Hearing voices really hits its stride when Kelly’s begins to discuss twentieth century mental healthcare, a relatively neglected area of study. Inevitably, the asylum system was impacted upon by the turbulent decade of the First World War and Irish revolution. Shell-shock victims were transported from the battlefields to Irish asylums; the Easter Rising disrupted services, particularly in Dublin; staff at Monaghan Asylum went on strike and raised a communist flag on top of the building; the War of Independence and Civil War raised their own problems. Contemporaneously, the therapeutic pessimism rife in asylums was encouraging psychiatrists to start experimenting with new methods. Kelly traces the introduction of various problematic treatments into Irish asylums: electro-convulsive therapy, compulsory lobotomies, induced comas. Much is known about these controversial treatments in international contexts, but Kelly opens up discussion about their use in Ireland for the first time. The closing sections of the book cover late-twentieth-century deinstitutionalisation and the return of many mentally ill patients to the community, aided by new psychotropic drugs and improved non-institutional services. Kelly concludes by speculating on current mental health policies and the potential futures of Irish psychiatry which, he hopes, will draw from the challenges and mistakes of the past.

Kelly’s Hearing voices avoids the trappings of many internalist, practitioner-written medical history books by refraining from offering an optimistic, but narrow, account of progress and improvement in knowledge, therapeutics and institutional care. Instead, Kelly, a psychiatrist, provides a reflective and meticulously researched book which refuses to shy away from the problems inherent in Ireland’s mental health care system (past and present) and willingly uses historical analysis as a critical tool for interrogating present-day issues. Hearing voices is pragmatic but also deeply contextual.

There are few problems with Kelly’s book. However, the north of Ireland is dealt with rather cursorily, even in the pages dealing with the pre-partition period. This is surprising given that extensive records exist for asylums in cities including Belfast and Derry. The author’s self-imposed restriction to the south provides an occasion for strong analysis of the politics of mental healthcare in the southern jurisdiction. However, an opportunity seems to have been missed for examining (or at the very least commenting on) the trauma studies conducted after the west Belfast internment riots of the early 1970s, the strain placed on Northern Irish mental healthcare by conflict, not to mention ongoing controversies about Bloody Sunday and post-traumatic stress disorder (PTSD). Perhaps, also, more could have been said about the development of psychological services in Ireland and their relation to twentieth-century psychiatry and the integration of non-acute categories such as stress into psychiatry’s diagnostic repertoire.

Nonetheless, overall, Hearing voices: the history of psychiatry in Ireland offers a comprehensive account of Ireland’s mental healthcare system, covering the nineteenth to twenty-first centuries. This well-researched and well-written book will appeal to both historians and practitioners and is likely to become the standard text on the history of mental healthcare in Ireland. Relatively unexplored themes are covered which could form the basis of future research: intellectual disability, deafness, the categorisation of homosexuality as a psychiatric problem. The book is also well-designed and illustrated.