Forward to the Past.

A couple of papers came my way this week. The first, titled “Back to the future: A call to generalism in psychiatry,” comes from Perth, West Australia, where I trained [1]. The authors, from the Rural Clinical School, proposed that too many medical graduates specialise, leaving the very important field of general practice (primary or family medicine) increasingly bare. Despite raiding India, Pakistan, the UK and other places for doctors, this country is likely to be short of 10,600 GPs by 2030. That’s not far off, only since the beginning of the pandemic. The problem, an ageing workforce as baby boomers retire and lack of interest in graduates, will be at its worst in outer metropolitan, rural and remote regions. I live in outer metropolitan Brisbane: there are no local medical graduates in this entire area. They are all foreign graduates, which is nice for us as they’re very conscientious but not for their home countries who trained them. The paper briefly puts the case for raising the status of general practice as an entry to talking about the same issue in psychiatry.

Again, the current workforce is rapidly ageing (the average psychiatrist here is ~57) and lack of interest in medical students, for which they rightly blame the profession itself:

As with the concept of ‘geographical narcissism’ in psychotherapy … the lexicon associated with specialism in medicine can be considered an unconscious form of elitism that prioritises the expertise, knowledge and esteem of specialists over generalists.

I’m not sure why they thought elitism in medicine is “unconscious” when the whole profession drips with it. It’s built in: we constantly put each other down and unite only to attack critical outsiders. With remarkably few exceptions, medical professors think their farts don’t stink; this sense of faux superiority fairly oozes from them and heaven help any student or recent graduate who questions it. It’s worth mentioning that in the US, there are two sorts of medical schools. There are the traditional, big-name, big money allopathic schools that award the degree of MD, and then there are 42 osteopathic schools, awarding the degree of DO, that train about 25% of medical graduates. The MD is generally the entry to specialisation and to academia, which is why you hear about it all the time, while DO graduates mostly head for general practice and the military (a big employer). Osteopathic medicine began in 1874 because, after its performance during the Civil War, conventional or allopathic medicine was so terrible that it was felt to be beyond redemption. Their students study the standard medical course as well as gaining additional training in osteopathic techniques. Having met quite a few DOs, they are very down to earth with none of the pretention of MD graduates.

So we come to psychiatry, particularly the needs of the same outer metropolitan, rural and remote regions that are short of GPs. This interests me as I spent 35 years in such areas, including six years as the world’s most isolated psychiatrist in West Australia’s remote Kimberley region [2]. The paper’s authors are careful not to cause offence but, having been on the receiving end of lots of highly offensive behaviour by the very superior beings who occupy the lush pastures of academic and private city practice, I think they should put the boot in because, until they do, nobody will take any notice of them. The academics, who are driving the relentless fragmentation of psychiatry into ever-tinier specialties, don’t believe they need to listen to anybody but themselves. Their attitude is: “We speak, you listen, so kindly be seated.”

Roughly speaking, psychiatrists in Australia fall into three groups: academic, private and public, and each of these will include psychiatrists who can be general (including C/L), old age, child and adolescent, forensic or administrative. Public psychiatry is a disaster. In NSW, something like 200 psychiatrists have resigned this year over working conditions although it’s not clear where they’ve gone. Public psychiatry in the rest of the country is so inefficient and so unrewarding that it’s not surprising they can’t get enough applications. As for academia, people do not go into it because they like dealing with agitated people or difficult relatives.

Overwhelmingly, private psychiatrists are in it for the money. They can charge what they like, and they do. Today’s red hot diagnosis is ADHD: anybody smart enough to use the internet can quickly memorise the symptoms and rush off to see a “neurodiversity-affirming psychiatrist,” i.e. somebody who will simply authorise a lifetime of amphetamines at government expense without asking too many questions. For $3,000 a pop. Two or three of them a week and you’re in clover, but most will be aiming for 10 or even 20 a week, up to a couple of million a year. And why not? Psychiatrists tell everybody all mental disorder is a brain disease that only they can fix; they go to conferences at expensive resorts where they tell each other that it’s all biological, they read journals that say it’s all biological, written by academics who firmly believe the mind is a biological thing, and everybody sleeps very well at night. Meantime, all the statistics say that the mental health of the country is steadily declining. More and more people are taking more and more drugs for much longer, suicide rates are up, disability pensions are up, and nobody is allowed to question the burgeoning industry of psychiatry. Certainly, the people raking in all the money aren’t doing too much questioning.

Public psychiatry is another world. Their breathtaking inefficiency and clumsiness means that anybody who gets tangled in the mental hospital system is likely to stay there in the long term. The paper concludes with the same old call:

Health workforce challenges are a major issue across Australasia. The necessity of a generalist mental health workforce to meet the growing demands on a perpetually under-resourced mental health system is without doubt.

Wrong again. The field of mental health does not suffer from lack of resources. The problem is misallocation of resources, spending the money on the wrong things just because it suits the people who have all the power. There are two issues here. First, hospitals are exceedingly expensive places to run. Therefore, you should do everything you can to keep people out of them, otherwise they consume the entire budget with next to nothing to show for it. This particularly applies to private hospitals, most of which are now owned by shell companies in tax havens. Hospitals are also unbelievably inefficient in dealing with your actual mentally-troubled people. In fact, they can’t. They’re not set up for it just because they do not have a formal model of mental disorder, apart from saying “Well, it’s all biological so book him for ECT.” If they did have a proper model of mental disorder, they would know that the correct approach is to provide readily-accessible management for people in their homes and workplaces, out there in suburbia and in the bush. That way, you can get rid of 90% of hospital beds. But they won’t do that, they will never do that, for a variety of unflattering reasons.

First, as mentioned and as readers are probably tired of hearing me say, mainstream psychiatry doesn’t have a model of mental disorder. It doesn’t have anything that could count as a “biomedical model,” meaning reducing mental disorder to brain disorder, or their vaunted “biopsychosocial model,” which has not grown another word since it was launched nearly half a century ago. Both of these are myths, crutches to allow psychiatry to bluff its way into the party. This means that regardless of what mainstream psychiatry does, nobody can say “You’re wrong.” So: locking up people for years on the basis they might stop their drugs is OK. Locking people in solitary confinement (“low stimulus seclusion”) is fine, even though it is banned by international law. And taking a psychiatric history by ticking a few boxes on a ten page form is just dandy.

Second reason is that, just as the kings of yore were attached to their castles, psychiatrists like their hospitals. Having an empire says something, it counts in the status stakes and, as we all know, psychiatrists are sufficiently insecure without giving up their walls. But third, and most important, they don’t know what else to do. They don’t practice psychotherapy, that went out with the Ark or DSM-III, whichever came first, and the idea of leaving all their mates behind and trekking out into the bush is just too too scary. They actually can’t conceive of life on their own. When I left Perth to go to the Kimberley all those years ago, all psychiatrists said the same few things: “The Kimberley? You must be mad. What will you do when you come back? Oh well, we can come and visit you,” although none of them did. This was long before the internet, and phones were too expensive to keep ringing the city so I got by without them. For them, isolated psychiatry wasn’t a career option as they couldn’t conceive of life without their meetings and conferences and retinues trailing around behind them. They just can’t function without their life support systems, somebody has to breathe for them and, in reality, think for them. I should point out that, far from providing support and encouragement, the college of psychiatrists and the Health Dept of WA never once contacted me to see if I was still alive.

My figures showed that having proper outreach services in psychiatry can cut costs by up to 97%, or see 20 times as many people for the same money. Even my outer metro practice here was 75% cheaper than the local mental health clinic. However, these figures were all ignored or, in one case, actually suppressed. For several years in Brisbane, I provided a contracted consulting service to the military, which worked out at about $1,050 per patient. It was certainly much quicker than the old system of sending them to see private psychiatrists in private hospitals, where the costs were about $10,000 per patient. One day, without any discussion, audit or explanation, my contract was cancelled. Every attempt to find out why or to reinstate it was blocked, by the people who were making all the money (long version here, at the Royal Commission into ADF and Veteran Suicides). Doesn’t matter what the patients thought, nobody is allowed to question the status quo. In a rather bitter paper from about twenty years ago, when the college of psychiatrists was having one of its occasional spasms of guilt over not servicing the bush, I provided detailed figures to show how it could be done, concluding:

The Australian Federal Department of Health now subsidizes outer urban and rural general practices very handsomely. To my knowledge, nothing has been said or done about helping those few psychiatrists silly enough to bother rectifying this country’s notorious imbalance of service provision. The situation in New Zealand, I take it, is just the same. Dr Hosford concluded: ‘Our current strategy (of provincial psychiatry) is not working. The College needs to be assertively advocating solutions’. As the present paper shows, there is at least one perfectly adequate model of remote area service provision already available, entirely without cost to anybody. All that is lacking is the political will among our leaders to begin implementing it [3].

Nothing changed. They didn’t lift a finger. As they say, there’s no interest like self-interest.

Moving briefly to paper No. 2, published a week ago, it details quite a remarkable plan by a lot of well-connected people on handsome government allowances using the very latest high-tech genomic research and practice to develop new applications of old drugs for schizophrenia. This involves taking blood from normal people, reprogramming blood cells to make pluripotent stem cells then using these to grow neural tissue. All the relevant genes will then be stimulated to see exactly what they produce, and to find the points where genes in people with schizophrenia differ. Thus armed, they can scan the world’s lists of drugs to see what could rectify the genetic deficiencies in the mental disorder. It’s a bit like taking a lock apart to get an imprint of its mechanism, then going through a large box of loose keys to find one that could fit the lock. Interesting. The project is to run for five years in the first place although we can be sure it will be extended because they will be on the verge of a breakthrough.

There’s only a couple of problems. First, nobody has ever shown that schizophrenia is a “genetic disease.” That’s an assumption that flows from the same “biomedical model” that nobody has ever written. Wouldn’t it be better to work out how genes control thought before you start spending millions over half a decade? Perhaps it would be but they’re not going to do it, they all agree this will work.

Second: why bother? With a bit of organisation, we can take psychiatry out to the suburbs and to the bush and deal with the problems before they get out of control. That’s so easy, but it doesn’t happen. Some years ago, I visited the psychiatry unit in the Receiving Hospital in Detroit, Michigan. It was like stepping back a hundred years. Patients were brought in, mostly unwillingly, by police and relatives, stripped and dressed in a hospital gown, then left to wander around in a large ward with beds down each wall. After a while, a fat old nurse trundled in, pushing a trolley with a computer, and parked herself at the patient’s bedside where she “took the history.” This consisted of asking a rather short list of very pointed questions which anybody could evade, while the other patients sat around and offered suggestions. As we were leaving, I said to the director, a charming Iranian psychiatrist who was perfectly fluent in six languages, that it was pretty inefficient:

“It must cost you $1000 every time somebody comes through that door. I could do it for $250 and keep half the patients out of hospital.”

“It’s $1,132,” he replied briskly, “and not here, you couldn’t. Corruption and institutional inefficiency, that’s the problem.”

He was right. The various hospital unions, the AMA and APA, the police union, the city council, the state health department, the private hospitals and so on, all had their territory to protect so the patients’ needs didn’t register.

Third, who needs more drugs? The evidence is now in. As Bob Whitaker has just shown in an article published this week:

Antipsychotics Do Not Provide a Clinically Meaningful Benefit Over the Short-Term. Seventy years of RCTs have failed to provide evidence that antipsychotics provide a clinically meaningful benefit for treating acute psychotic episodes [4].

The whole issue swings on the difference between “statistically significant” and “clinically significant.” Researchers are weaned on the idea that finding a statistically significant difference between drugs vs. no drugs is all that is required, but they’re wrong. Whitaker’s typically careful analysis shows that what counts is clinical significance, not a trivial difference on the score on some questionnaire. The goal is to get people settled and home again, back to school or work or looking after the kids, and that can be done perfectly well without forcing them to take drugs that even their defenders say will shorten their lives by up to 20 years [5]. Twenty years. That’s a lot of life to lose just to keep hospitals bustling and drug companies running to the bank.

The core of the problem is that mainstream psychiatry has become an echo chamber where everybody agrees to stick to the biological agenda because they can’t conceive of an alternative. It’s also a lot easier, no intellectual effort involved and certainly none of the emotional effort of trying to put yourself in the patient’s position and understand what it all means. Just give ‘em more drugs.

References:

1 Coleman M, Cuesta-Briand B (2025) Back to the future: A call to generalism in psychiatry. Australasian Psychiatry, https://journals.sagepub.com/doi/full/10.1177/10398562251351507

2 McLaren N (1995). Shrinking the Kimberley: Isolated psychiatry in Australia. Australian and New Zealand Journal of Psychiatry ; 29:199-206.

3 McLaren N (2003). Only martyrs need apply: why psychiatrists should avoid isolated practice. Australasian Psychiatry; 11: 456-459. https://journals.sagepub.com/doi/pdf/10.1046/j.1440-1665.2003.02037.x

4 Whitaker R (2025). https://www.madinamerica.com/2025/06/antipsychotics-do-not-provide-a-clinically-meaningful-short-term-benefit-a-review-of-the-evidence/

5 Firth J, et al. (2019) The Lancet Psychiatry Commission: A blueprint for protecting physical health in people with mental illness. The Lancet Psychiatry 6: 675–712