This Week’s Crisis in Mental Health

Crisis (n): a time of intense difficulty; a point at which major decisions must be made in order to avert serious risk or danger

In a couple of articles, a scribbler for the Australian Broadcasting Corporation (ABC, which used to be a plain commission) has knocked out the usual breathless stuff from the usual “experts” on how the widespread drugging of children in this country is not only justified but has to increase because our children are falling apart and only drugs can put them together again. The first asks the very important question: “Antidepressants, antipsychotics and stimulants up: Why are children taking more mental health medication?” Throughout the decade 2013-2023, prescriptions for these drugs for 18yrs and under have been rising exponentially. Stimulants, used for ADHD, have leapt from 101 scripts per 1,000 people to an amazing 380; at 196 scripts per 1,000, antidepressants have risen 165% in 10yrs (including SSRIs up 247%); and antipsychotics are up by a third.

I’d be wary of these figures, we don’t know whether that is “authorised prescriptions” or “dispensed prescriptions” because each authorised script has five repeats (probably dispensed, because that’s what the government pays on). Also, we know that a lot of people stop the drugs within a year due to side effects so the figures are only a proxy at best, or misleading at worst. But if we take them at face value, it says that prescription rates for psychoactive drugs for young people are going through the roof. This is a serious matter, and we need to know why. Because of who the reporter contacted, we already know the answer she has for us.

The second article is a rambling puff piece saying how important it is for parents to ignore everybody and make sure their little darlings are all on drugs. This one uses the case of a “neurodivergent” child who was prescribed stimulants for ADHD, which revealed severe anxiety so he was given SSRI antidepressants and made a miraculous recovery. This leads the reporter to ask why so many children and adolescents are complaining of mental health “issues.” It’s stress, the article concludes: rising cost of living, global warming, intergenerational inequality, global instability, social media, the usual suspects. Add to that the changing social milieu: one researcher said: “There's less stigma in that teenage group because it's becoming more socially acceptable.”

In fact, there’s a lot of competition to see who can acquire the most diagnoses, which indicates a major factor the article doesn’t mention: as the diagnostic criteria for mental disorder are steadily loosened, so the rates of diagnosis of mental disorder rise relentlessly. What was just a quirk last year, or naughty, or nothing to worry about, has suddenly been promoted to the level of a national crisis in mental health which needs entire new clinics and buckets of drugs to resolve. According to one of the reporter’s go-to experts on youth mental health, Prof. Patrick McGorry, “39 per cent of young Australians had a diagnosable and treatable condition.” Why she bothered asking him we don’t know as he always says the same thing.

That figure of 39% seems entirely implausible but whatever is causing the “surge in mental distress,” we can be sure of one thing: it isn’t biology. The human genome has not changed in one generation, and distress does not mean “a diagnosable and treatable” mental disorder. Despite the self-reported “stress” and the numbers of overdoses, the actual levels of frank mental disorder among young people have not changed. In the absence of any remotely convincing biological explanation for the huge increases in drug prescription, this whole thing has to been seen, not as a medical “epidemic” in any useful sense of the word but as a social trend.

But, the drug-pushers shriek, what about all those poor children with ADHD? Yes, what about them? Fifty years ago, there were none. They did not exist. When I was at school in a small country town, there were 48 children in each class, which was the maximum allowed. There were three rows of eight desks, all screwed to the floor, with two children per desk, all facing forward, and no child ever stood up and walked around without permission. That didn’t happen, ever. The eagle-eyed teachers stood at the front of the class and knew exactly what was going on at all times. No child talked or interfered with the next child without the teacher seeing it and jumping on it. Yes, school was boring (and freezing cold in winter) and true, lots of children left school to work the day they were old enough but children were not drugged to get them through the school gate.

However, it’s not just children, the adult ADHD industry is roaring ahead. In most cities in this country, the waiting lists to see private psychiatrists are mostly 3-6 months, and the reason is all the people queuing for their “ADHD screens.” For anything up to $3000, adults can be given the label of ADHD and authorised to have stimulants for the rest of their natural-born. Of course, heaps of those stimulants will leak on to the black market but that’s another matter. The psychiatrists who are seeing two or three of these people a day are making very big money – and having a great time doing it. They see the patient once, write a script, dictate a quick, stereotyped letter to the referring doctor, and that’s pretty well it. Patients come back for review every few months, no after hours calls, no worrying about their jobs or families, so what’s not to like?

Meanwhile, their counterparts in public practice aren’t having such a fun time. In a survey, about 70% of psychiatrists said they were experiencing “multiple symptoms of burnout.” A report from South Australia says 77% of psychiatrists said they feel “exhausted and drained all the time” while 40% said they are likely to leave the profession in the next five years. However, we have to be careful about these figures. The 40% are those planning to retire in the next five years. Once you’re in psychiatry, it’s very difficult, verging on impossible, to go to another field. The real question is: what’s happened to the younger generation? Why is the average psychiatrist so old? Ideally, there should be two new trainees enter the profession for every old codger who leaves but that isn’t happening. Medical students and recent graduates aren’t interested in psychiatry, and training jobs are unfilled, so there aren’t enough people coming through the pipeline. But this is true right across medicine as this country has never trained enough medical graduates. We have always relied on immigration to fill the jobs, although I have no idea why.

However, let’s go back to that quote: “psychiatrists feel exhausted and drained all the time.” If they do, it’s not from overwork. Of my 47 years in psychiatry, I spent 23 years in public practice and the rest in private. As a private psychiatrist, I ran a bulk-billing practice in working class areas, meaning I billed the government rather than the patients. I saw patients all day, every day, but the fees were definitely not high. Most private psychiatrists charge two to three times the Medicare rate, sometimes much more, for a superficial assessment and a couple of prescriptions, it not a quick trip to hospital for ECT. Public practice is even more biological in orientation. Assessment is a simple matter of asking a few questions, ticking some boxes on a form and issuing a prescription. Very often, the assessments are done by nurses and the psychiatrist simply glances at the form, perhaps asks a few questions and then moves on to the next one. Bureaucracy consumes a huge part of the psychiatrist’s week.

Some few years ago, I did a locum in a medium security unit of a free standing mental hospital (the last one in town). First day, the psychiatrist who was going on leave showed me around then we went to their weekly clinical meeting. There were seventeen staff present to discuss 26 patients and decide on their management. The meeting started at nine, broke for lunch, then resumed and continued to 2.15pm. About half the staff didn’t speak during those hours, probably because the 26 patients under discussion were the same 26 as had been discussed the previous week, and the week before that, and before that, for months. There was practically no turnover in patients and it dawned on me that all the staff were seriously bored in their jobs (which may explain why they squabbled and bickered all the time). However, due to the rigidly hierarchical nature of hospitals in general and psychiatry in particular, there was nothing they could do about it.

During that time, I met quite a few trainees and psychiatrists and if they were suffering “stress and burnout” and were “exhausted and drained all the time,” it was not through having too many patients (I was seeing far more in my practice), it was because they were bored shitless and driven mad by pointless bureaucracy. The registrars (trainee psychiatrists or residents) spent about two thirds of their time either in the endless clinical meetings or writing reports for the mental health tribunal. The clinical meetings weren’t much fun for them as they hadn’t assessed the patients themselves, nurses did that so, hour after hour, week after week, the registrars had to sit and listen to some laboured recitation of the ticked boxes on the proforma. Their reports for the tribunals were simply copy and paste jobs based on all the old reports and whatever else they could find to fluff them out. Then there were the tribunal hearings. OMG, that’s a world of its own, we’d better not start on it today. And that was pretty well their week. I actually felt sorry for them. If this was all they could look forward to, 45 years of the same old same old, no wonder they were staying away from psychiatry in droves.

With all the bureaucratic folderol, the psychiatrists and trainees had practically no contact with patients. They didn’t know their patients, and without that, what’s the point in psychiatry? Why bother? But. But. This is the crucial point: none of them knew what else to do. I don’t mean as in “leave the profession for something better,” I mean they didn’t have any clues as to how to make psychiatry interesting and exciting. Biological psychiatry is inherently boring and uninspiring:

Are you feeling low? Have you been feeling high? OK, you’ve got ups and downs disease, take these and come back to see me in a month.

None of them, in particular the “key opinion leaders” of the profession, had any way of breaking out of the rigid walls of reductionist biologism they had carefully erected around themselves. They had no way of seeing patients, not as biological preparations but as troubled humans, humans who could be reached and understood in the sense of “Wow, that could have been me.” The core of biological psychiatry is that it converts the mentally troubled into The Other, as in “His brain is abnormal, he cannot be understood so we won’t try.” Later, they say to the tribunal: “Of course he’s mad, nobody can understand him, he doesn’t make sense,” which closes the vicious circle. Biological psychiatry is a trap. It seems promising at first, but it quietly deskills its practitioners, it defangs their critical faculties and dulls inquisitive minds until all that’s left is a tick-the-boxes mentality. And that is very, very boring, exhausting and draining, except nobody is allowed to say “I’m bored at work,” it’s all an undefined “burnout.”

So we go back to this business about Australian children suffering a “surge in mental distress,” due to  some ill-defined “stress.” As I said, it’s not biological, it has to be social, but it also isn’t due to anything that could be defined as a universal stressor. The children of Darfur are suffering severely from “stressors,” both physical and mental, as are the children of Gaza and now of Lebanon. Rohingya children who have been driven into refugee camps in Bangladesh are having a bad time, but compared with them, the vast majority of Australian children have got it easy. Too easy, if you ask me, although nobody ever does. Its also true that the kids who are genuinely having a bad time in this country are not the kids being dragged off to see the private psychiatrists to get their repeat scripts for drugs.

One day, the drugging of children will be seen as a disaster, a national disgrace bigger than the sexual abuse of children by churches and schools. However, this is actually  worse as it’s all out in the open, proudly brought to you by the medical profession and governments and drug companies and schools and everybody else who feels like joining the party. Will they have a Royal Commission over it? I doubt it, the people who decide those things are the same people who are pushing the medicalisation of normal life. It's all very discouraging, especially as the ABC never provides a balance to the academic shills for the drug companies.

As an afterthought, the question of whether the “surge in mental complaints” is biological or social is not rocket science. The null hypothesis is that there has been no change in the human genome in recent times, no change in diet nor any new intoxicants in the air we. Therefore whatever is precipitating all the complaints is not genetic/biological, which leaves only social causes breathe (I exclude Martians shining X-rays on us and lizard people taking over governments). Biological psychiatry says “Aha, but social causes are only the trigger of the biological disease, the frail brain that was waiting to be triggered.” Sure, but without that trigger, the “disease” remains quiescent for life, just as a leg remains unbroken without a pushbike to fall off. The children of Gaza will certainly show a great deal of mental disturbance for life, but without the social triggers of bombs falling on them, they wouldn’t have done. And drugs won’t fix them.