When "You're fine, go home" doesn't work.

In my post of April 16th, I said:

In due course, we can expect the psychiatric research industry to put its hand out for more money to "study the problem," but nothing will come from it apart from the usual calls to spend more money on keeping more people detained in hospitals longer and on more drugs. That will be throwing good money after bad. The problem in psychiatry is not lack of money, it's where the money goes. In Australia, a large and growing chunk of the mental health budget is spent on private hospitals. My limited experience of them is that they are a total racket, allowing well-heeled psychiatrists to fleece patients, governments and insurers by providing "treatment" for people who, overwhelmingly, could be managed as out-patients, if they need anything at all.

A psychiatrist with over half a century of experience in public practice, whom I've known forever, was moved to comment:

I have long been banging the table to say that at least 80% of inpatients at any time could have been treated as outpatients, only to see nothing change. However, I don’t think the persistence of the trend can be attributed solely, of even mainly, to psychiatrist self-interest. It is very much a two-sided arrangement/collusion between psychiatrist and patient, both in the public and private sector. Things have changed a lot since the time we started our training. Back then patients wanted to sue shrinks for detaining them, today they want to sue them for discharging them!

Discharging patients has become a stressful and problematical matter. Patients will openly say, ‘You discharge me, and I will commit suicide and name you in my suicide note’. Fear of adverse outcomes, whether deliberate or by misadventure, has made psychiatrists seek a second opinion about discharging someone and I have been asked to provide such an opinion on several occasions. Some patients have had to be literally evicted from the ward with the help of security guards.

Family members are often worse than patients when it comes to discharge. Parents and other family members have not infrequently lodged formal complaints about someone in the family being discharged too soon. Too many parents want their wayward children hospitalized for at least one year … to stop them taking drugs! Parents recently reported me to (the Medical Board) for discharging their drug-taking son too soon, even though there was no justification for detaining him. Thankfully nothing came of it but the paperwork involved in justifying my decision caused me (considerable upset).

Not only do patients want to remain in hospital far longer than can ever be justified (and for obvious reasons) but far too many insist on continuing their largely useless medications – because taking them helps to define the severity of their illness and need to remain in hospital! Many times I have persuaded patients to come off unnecessary medications when they were inpatients, only to discover they were back on the very same medications and often a few more, when they returned to outpatient follow-up.

My bottom line is that it’s not just greedy, self-serving shrinks - patients and their relatives contribute at least equally in perpetuating unnecessary inpatient treatment and persistence with ineffective medication that only achieves side effects.

Not having worked in hospitals for 25 years, I haven't seen that side of it so I asked him: "Why has this happened? Does it have anything to do with the relentless 'chemical imbalance/sick genes' propaganda? It seems like the law of unintended consequences is up and running." His reply followed promptly:

The idea of ‘chemical imbalance/sick genes’ has been a godsend for a growing percentage of the population in Australia and in the USA, because it adds medical-sounding legitimacy to their often self-diagnosed mental illness. People are no longer ashamed of mental illness. They openly advertise and exploit it to deal with everyday problems such as shitty jobs, nasty line managers, homelessness, etc... Knowing they are suffering from neurotransmitter imbalance adds legitimacy to their mental illness, stress leave, and application for disability benefits. Well-conducted studies at the Black Dog Institute (University of New South Wales, in Sydney) published in the Medical Journal of Australia have found that:

"The prevalence of common mental disorders such as depression and anxiety in Australia was fairly stable between 2001 and 2014, but the number of working-age individuals receiving a disability support pension (DSP) for psychiatric conditions increased by about 50% over the same period, according to new research."

The increase in mental disability pensions has been even higher in the USA. Different studies report mental DSPs have more than doubled during the last 2-3 decades, despite much the same prevalence of mental illness.

You probably know that a patient’s chances of receiving National Disability Insurance Scheme funding or the DSP increase if they have received extensive inpatient treatment. From personal experience, I can vouch that some patients aim for protracted inpatient treatment for that reason – just another reason why discharge might be problematical.

Too much of what is regarded as mental illness is just people struggling with everyday problems and I don’t blame them for capitalizing on opportunities when they present themselves. “Chemical imbalance/sick genes” provide them with such opportunities and even psychiatrists continue to milk benefit from them! 

The late Thomas Szasz said psychiatrists and patients are engaged in an elaborate fraud, where patients pretend to be ill and psychiatrists pretend to diagnose and treat them, knowing all along there is nothing mentally wrong with them. I believe Szasz was right about fraud but he picked the wrong fraud: psychiatrists say they know the nature of mental disorder when, as a matter of demonstrated fact, they don't. For years, psychiatry has been trumpeting: "Mental disorder is brain disorder and we have the cure." What we now see in many countries is pigeons coming home to roost. If you consistently tell people there are all these unsuspected diseases "in there" just waiting to explode and take control of their lives, some will panic and demand treatment, some will realise it's a good way of avoiding prison, and some will think: "Everybody says I'm a prick but it's really because I've got ADHD/ASD/ODD/BAD so they owe me a pension." Psychiatry is actively medicalising normal life.

The process has been greatly accelerated by the "discovery" of hundreds of new catetories of mental disorder, along with dramatic loosening of the diagnostic criteria for all mental disorder. This has led to an explosion in the rates of diagnosis of mental disorder and, invariably and inevitably, of the rates of consumption of psychotropic drugs and rates of people being granted lifelong pensions for mental disorder (Bob Whitaker gives a lot of figures for this, see [1]). While the social, psychological and financial returns for having a psychiatric diagnosis are now immense, the social penalty for being branded "mental" is far less than it used to be. This is the direct and intended result of saying "All mental disorder is brain disorder, so don't feel bad about it. Just keep taking your tablets, and pay as you go out."

We see this clearly in child and adolescent psychiatry in Australia, where the rate of diagnosis of "paediatric bipolar disorder" (which didn't exist 30 years ago) went up by a totally implausible 40,000% over about 20 years. In 1990, 2% of the population were taking antidepressants; now it's 16%, and even higher in the UK and US. And, despite the propaganda coming from the psychiatric/drug industry nexus, despite this wonderful treatment, the rate of suicide is trending steadily up, not down, which it would if the treatment were effective (see Substack, April 16th).

In the US, the total expenditure on psychiatric drugs is said to be $640billion (with a B) per year. However, the suicide rate and death rates from drug abuse and inappropriate prescription are such that the average life span in the US is going down (for more details, see Peter Gotzsche's excellent commentary in Mad in America last week). That doesn't happen very often anywhere in the world, and it's all due to psychotropic drugs. Not guns and not traffic accidents, although they help, and it wasn't Covid. It's psychiatric drugs and opiates given to distressed or unstable people for the wrong reasons, as my colleague said above: "Too much of what is regarded as mental illness is just people struggling with everyday problems." That has come about just because new diagnoses were invented and the diagnostic criteria were loosened, so "patients" have to be found. Or manufactured.

Which brings up the point of who is getting all these drugs? My case is that psychiatry is engaged on a massive, long-term program of shifting people from the category of "personality disorder," for which it has no treatment and therefore can't make any money, to the category of "mental illness," for which it has swarms of drug companies and private hospitals desperate to make money [2]. In particular, anybody who is a bit up and down (which is the anxious personality in a nutshell) will be given the label "bipolar disorder," slung into hospital and then put on drugs for life. And they will never get better. That's in addition to all the people going through a rough patch who follow the advice displayed in public toilets: "Feeling low? Feeling anxious? See your doctor." But beware, because your doctor. Will. Prescribe. Drugs.

There are two themes to follow here, the first being the processes by which people are labelled "mental" and the second concerning what happens to them after that. Oh boy, what an enormous (and thankless) task. My starting position is that mental disorder is a reality [3]. It is the case that, by virtue of the nature of the human mind, people with perfectly normal brains can either get pushed into states of such distress that they are no longer able to function, and/or as a result of life experiences (including early life), people can get stuck in states of self-reinforcing mental distress or disturbance from which they are unable to escape. Either way, and after rational assessment, some will decide that life is no longer worth the trouble. It is our social duty to recognise these unhappy people and offer them whatever assistance we can. Whether that duty extends to taking total control of their lives, incarcerating them and inflicting mind-damaging and life-shortening "treatments" against their will is another question.

Recent reports from Gaza by Médecins Sans Frontières (MSF: Doctors Without Borders) say that children as young as five are saying they would rather die than continue to live under bombardment. Young people, especially those who have seen their families blown up in front of their eyes, are weepy, intensely agitated, unable to look after themselves, unable to concentrate or think or make simple decisions. This is a stress response, meaning the psychological response to major life stressors (now with the absurd name 'adjustment disorder') but it has reached such intensity that the sufferer is completely disabled.

This is not a "mental illness" in any useful sense but is a "normal reaction to abnormal events," i.e. any other person who experienced the same would react in the same way. These people are not right but they're also not wrong: they don't need antidepressants or antipsychotics or amphetamines to aid their concentration, and even though they say "I want to die," they don't need ECT. They need something to calm them physically so they can lift a spoon to their mouths without spilling it, something to slow their racing thoughts and help them sleep, and care and consideration in a safe setting until they can take over their lives again. That's simple first aid, little more than common sense, but psychiatry grabs these people, drugs them and adds them to their ever-expanding list of "mental patients needing lifelong treatment." The overwhelming majority should not be anywhere near hospitals: being locked up only adds to their distress, and the noise and nonsense that goes on in hospitals means they can't rest when they need to.

It's not just war time in Gaza, we see exactly the same symptoms in this country and all others, just because they're universal: that's how the human animal reacts to intolerable psychological pressure. Sure, because of pre-existing anxious personality [4] or through mistaken beliefs etc., some people are more likely to react badly than others, but it's essentially the same process. All too often, it leads to a state of self-reinforcing distress and agitation, now known as PTSD, but in itself, a stress reaction is not mental illness. This is part of what Horwitz and Wakefield described in their classic work, The Loss of Sadness [5].

The other group, people who, because of life experiences, get stuck in states of self-reinforcing distress, seem to defy explanation because even they will say "I know I should be happy, I've got a good life, plenty of people have it much harder than I do but I don't want to live." Faced with this, psychiatry simply shrugs its collective shoulder and says "Hmm, must be biological. Wheel out the ECT machine." The reason it "must be" biological is because, nearly fifty years ago, the idea of a psychological cause for mental disorder was finally smothered and buried in the garden. That was when the psychodynamic approach of the Freudian movement was declared non-scientific, but that, of course, presumes we know what the word 'scientific' means and when it should be used. Which psychiatry doesn't. What it does know, however, is how to spin a narrative of science to convince the general public that Wow, these clever psychiatrists have really got mental disorder by the tail. Far from it.

This topic is very big: is mental disorder the sort of thing that should be managed in hospitals? Can it be "managed" in the sense of something we do to you to change your life regardless of your wishes? Is it the sort of thing that demands physical intervention, or are there better approaches? Can psychiatrists actually make it worse? We will slowly chip away at these critically important questions. And we haven't even started on the private hospitals.

****

Could readers post comments directly to the Substack file rather than email them to me. It's helpful for other readers to see them, also I get too many emails and lose track of them. With thanks.

****

Talking of frauds, which we aren't quite, Bob Whitaker's article on the infamous STAR*D study in this week's Mad in America should be required reading for every citizen, not just psychiatrists. I'd be most interested to hear how mainstream psychiatry is reacting to the unfolding scandal as my experience of trying to unfold scandals is that they are quickly smothered and buried in the garden. As for antidepressants, it's possible to practice psychiatry and hardly ever prescribe them, but you will never read of that study as it was rejected by the journals.

****

References:

1. Whitaker R (2009). Anatomy of an Epidemic: Magic Bullets, Psychiatric Drugs and the Astonishing Rise of Mental Illness in America. New York: Random House.

2. Chapters 14-16 in McLaren N (2012). The Mind-Body Problem Explained: The Biocognitive Model for Psychiatry. Ann Arbor, MI: Future Psychiatry Press.

3. McLaren N (2021): Natural Dualism and Mental Disorder: The biocognitive model for psychiatry. London, Routledge.

4. McLaren N (2018). Anxiety: The Inside Story. Ann Arbor, MI: Future Psychiatry Press.

5. Horwitz AV, Wakefield JC (2007). The Loss of Sadness: how psychiatry transformed normal sorrow into Depressive Disorder. New York: Oxford University Press.

****

This material is copyright but can be copied or quoted provided the author is acknowledged.