"Critically Underfunded"

or Critically disorganised?

I wanted to discuss an important paper on the biology of schizophrenia by a most influential overseas psychiatrist but it seems there's a typo in the text so I've emailed for clarification. My experience is that the charismatic megafauna of the psychiatric jungle don't respond to emails but we'll wait a week.

Meantime, somebody sent an article from The Weekend Australian, on "Diagnosis Overload." Maybe I'm reading too much into one article, especially as I never look at any Murdoch stuff, but it seems there could be a slight shift in the prevailing winds, from the standard Hickie-McGorry * line of "Look out, mental disorder is everywhere and we need heaps more money to deal with it," to "Do you think we're perhaps overdoing this whole mental disorder thing?" We can hope, but one feature is a constant, as the article said: Mental health support facilities are "critically-overloaded and underfunded" while seriously disturbed people are dumped in "critically-overloaded health services." That's what they all say, but is it true?

My position is perfectly clear: Mental health services, as funded by state and Commonwealth governments and supported by insurers, etc, are not underfunded. The problem is not a shortage of money, it is that the funds are seriously misallocated. Similarly, health services are "critically-overloaded" only by virtue of their breath-taking levels of inefficiency and incompetence. I will give some examples.

Twice, I have been head of department of a general hospital unit with regional and/or state-wide responsibilities. Each time, the wards were full and outpatient bookings banked up for months. Both hospitals had used ECT for decades. I never used ECT. Over the next year or so, the bed occupancy rate dropped from 100% to about 70%, meaning there were always empty beds, and mean duration of stay in hospital was nearly halved. In each case, it was possible to close a ward and reallocate staff. It became clear that most patients had not been assessed properly and were being admitted "just in case," which is never a good reason.

Some years ago, I did a locum to cover the chief psychiatrist of an in-patient unit. He was present on my first day and conducted the weekly ward meeting for staff to discuss the cases. There were seventeen staff present, to discuss about fifteen patients, the same fifteen they had discussed each week for several months. The meeting lasted nearly five hours and consisted mainly of people reading lengthy reports they had written for tribunals, courts, etc. By the time I finished there, the meetings involved eight staff over 2.5hrs, a saving of over 75% of the staff time. When he returned, the psychiatrist was surprised but not pleased to see I had managed to discharge two patients and take two more: "I never discharge them," he said grumpily. "As soon as I discharge one, everybody rings up and want me to take two more." I thought, but didn't say, Er, yes, but isn't that the name of the game?

In 2012, I went to the US to talk at a conference and at a number of universities. In one city, renowned for its "urban decay," I was shown through the hospital's psychiatry admitting ward by the director. He was a charming psychiatrist of Middle Eastern origin who was fluent in four languages and could get by in several others. At the time, methamphetamine was a major problem. Patients were brought in, often by police, and were admitted directly to a locked ward. They were stripped of their clothing and dressed in a hospital gown, then they were put in a large ward area with beds down one side of the ward, and left to mill around. Hours later, a large and elderly nurse trundled a trolley down the ward and pulled out a chair. With all the other patients and security staff standing around listening, she spent an hour or so laboriously going through a questionnaire with the newcomer. Patients were in that area for 24hrs "observation" before they were even seen by the medical officer.

I said to my escort that this seemed a rather inefficient way of doing it: "It must cost you $1000 every time a patient comes through the door." "It's $1,132," he replied briskly. I made a suitably concerned noise: "I could show you how to do it for $250." "Not here you couldn't," he replied grimly, "due to institutionalised inefficiency and corruption." As we went around, it was clear there were swarms of staff sitting around doing nothing. The "treatment" consisted of drugs and ECT. They didn’t do the talking cure. Because of various union and other regulations, staff could not be deployed to out-reach services, so the hospital had none. Patients were never seen until they were in crisis.

On another locum, my second and the last of my career, I went to an outpatient centre in a working class area not far from my practice. Bizarrely, patients could not walk in to be seen, even with a referral from a GP. I spoke to one young woman with two small children and a baby in a pram who had to catch a bus to the train station, then catch the train to the city, to be assessed whether she was "suitable" for the outpatient centre. She lived 200m from the outpatient building but had to spend four hours traveling with her children as she was not allowed to be seen near her home. Nobody in the unit thought this was inappropriate. As it turned out, she was assessed as "unsuitable" so she got a referral and came to my practice. Just before I left, I went through their figures. It was costing the department $275 for each half-hour appointment, 90% of which involved nurses, social workers, etc. One kilometre down the road, in my practice, a half hour appointment with a senior consultant cost $78.

A lot of my patients were serving military or veterans. Over a two year period, my costs averaged $1,012 per patient, from beginning to end. The costs were kept low because I almost never admitted them to hospital. However, serving personnel who were seen in other private practices ran up costs of about $10,000 each, mainly because the patients were admitted to hospital or were referred to expensive ($20,000) "PTSD" or "anger management" courses, etc. Private psychiatric hospitals are an incredible racket. While it would take a lengthy book to go through all the ruses they use to extract money from the patients, insurance companies, governments, etc, excessive use of ECT is right at the top of the list. Patients are routinely charged three times the recommended fee for ECT that, by all objective standards, they don't need [1]. Admitting a person to hospital for twelve ECT costs the government and insurers about $60,000, which means it is largely reserved for people who can pay and won't object, i.e. older middle class women, the one demographic who, if it is necessary (which I dispute), don't need it. Also, private psychiatric hospitals are remarkably skilled at keeping out of the limelight. The last thing they want is anybody peering into their affairs. Billions of dollars are wasted each year on providing the rest cure for weary gentlefolk. The young mother with the pram got nothing, not even her bus fare.

I could go on. And on, and on, but you get the message.

There are two reasons for this woeful state of affairs. First and foremost is psychiatry's lack of anything like a formal, scientific model of mental disorder. The widespread trope that "mental disorder is brain disorder" is an ideological position which has no justification in science [2] but leads to the relentless medicalisation of normality. Yes, I know that psychiatry has all the trappings of science but, at the centre of this huge and ever-growing machine, where there should be an articulated and publicly-available model with predictive power, there is nothing, only an intellectual black hole wall-papered over with shibboleths like "biopsychosocial model" or "evidence-based practice" [3]. For example, there is no evidence whatsoever to establish that, on balance, the community is better off by locking people up and forcing them to take addictive, seriously unpleasant, life-shortening drugs. None. All the psychiatrists bleating about their "evidence-base" have not bothered to glean one skerrick of evidence that abusing the human rights of the mentally-troubled is necessarily in their best interests, especially when the UN Human Rights Commission says it isn't.

There is a statistic used in epidemiology known as "number needed to treat," or NNT. This is the number of people you need to treat in order to prevent a particular bad outcome or to cure a condition. Ideally, the number should be one, meaning every person treated results in a cure or a death prevented, etc, but it never is. Due to statistical rounding, the best result is 2, two people need the treatment for one to get better or to prevent one death. The converse is NNH, the number needed to harm. This is the number of people who can be given the treatment before one of them shows an adverse effect (which has to be specified beforehand so the results can't be fudged). NNH should be very high, e.g. one hundred, meaning of a hundred people treated, only one will show the bad outcome. There is probably no treatment in medicine that is so effective, mostly NNH is five or six, something like that. In psychiatry, NNH is one. Every person treated with a psychiatric drug will show some adverse effect, many of them serious.

Trouble is, psychiatrists don't believe their drugs can cause harm. Most, for example, don't believe in akathisia, the terrible sense of inner physical and mental tension that forces patients to keep on the move (once known as the "Stelazine stomp"). I'm sure akathisia contributes very significantly to the sudden suicides and homicides that occur soon after a drug is commenced or the dose changed. Similarly, psychiatrists almost never ask about sexual side effects of their drugs or, if they do, will dismiss them as minor and transitory. That's not true. Loss of sexual interest and function is not minor, and it can be permanent (normally, psychiatrists will dismiss the idea that the drugs are doing it by blaming the "illness"). And above all, psychiatric drugs shorten the lifespan. That is, people are dragged into locked wards and injected against their will with drugs that will eventually lop an average of 19 years off the person's lifespan [4]. This is not trivial, but where is the objective cost-benefit analysis to show involuntary treatment is justified? There isn't one, it doesn't exist. Psychiatrists convince legislators to write mental health acts allowing involuntary treatment without anything like a proper analysis.

The second reason flows from the first: In the absence of an articulated, proven model of mental disorder, the psychiatric industry falls back on what they call "process." This means the vast panoply (original meaning: a full suit of armour, which is a good analogy), the panoply of rules, procedures, legal acts, questionnaires, surveys, algorithms, mission statements, where diverse core competencies are seamlessly synergised to produce a caring matrix with the whole patient as its operational focus. As an example, the current Queensland Mental Health Act of 2016, all 639 pages of it, is an act about incarcerating people. There is nothing in the Act to guarantee that detained people will be treated properly, that's left to the good offices of the psychiatrists.

While the overt purpose of this huge machine is to set up a semblance of a smoothly integrated industrial process, where the raw material is fed in at one end and, without any effort, the finished product is spat out at the other, the "process" becomes a fortress, the modern equivalent of the tall walls topped with broken glass that used to surround mental hospitals, where staff hid from the real world of mental disorder and convinced themselves they were doing a great job.

Meantime, psychiatry's lack of actual competence to understand mental trouble, concealed under its fog of mechanistic rules, is strongly reinforced by a culture of institutionalised paranoia over the fantasied risk of being sued or reported or somehow penalised by "the system" if anything goes wrong. Therefore, stick to the rules regardless of the patient's needs. And, of course, the indeterminate rules are often used as a means of control designed to block any initiatives, especially if it threatens some time-honoured, covert benefit such as avoiding work, free meals and so on. It ends up with too many people being admitted because there weren't enough outreach services to deal with the problem before the police were called, then being held too long in a rigid and dehumanising corporate structure that serves the interests of the staff better than those of the supposed patients, and is therefore resistant to the changes necessary to convert from a "warehousing" system to a genuinely human-centred, community-based service. There is a very great difference between a system and a service.

How did we get on to this? Oh yes, money. Despite all the bleating, there is plenty of money available to treat mental disorder, it is just badly allocated and half is wasted. Private psychiatric practice is a major offender, especially private hospitals; as are the huge sums spent on the eternally fruitless search for the "biological cause of mental trouble;" institutions that serve the interests and needs of their staff before they serve the patients; and let's not forget the cherry on the cake, the rubber stamp mental health tribunals that authorise business as usual while carefully dissipating responsibility among swarms of nameless staff. According to their annual report, in FY2022-23, the Queensland Mental Health Tribunal spent $20,986,546 on themselves. In my view, that money would be better spent on public housing for the mentally-troubled.

I'm sure that lots of people won't like that but before any of them start squealing, let them declare their financial and other interests and we'll see where their priorities lie.

* The Hickie-McGorry line is the view of the psychiatric industry pushed by the country's two most visible psychiatrists, Profs. Ian Hickie and Patrick McGorry. See here.

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References:

1. McLaren N (2017). Electroconvulsive Therapy: A Critical Perspective. Ethical Human Psychology and Psychiatry 19: 91-104

2. McLaren N (2013). Psychiatry as Ideology. Ethical Human Psychology and Psychiatry 15: 7-18.

3. McLaren N (2023). The Biopsychosocial Model and Scientific Deception. Ethical Human 15: 7-18 Psychology and Psychiatry, 25: 106-118

4. WHO (2016) Premature death among people with severe mental disorders. WHO reference number: WHO/MSD/MER/16.5. Accessed Feb 7th 2020 at:

https://www.who.int/mental_health/evidence/excess_mortality_report/en/

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