Is Australia’s Psychiatric System Redeemable?

The Australian Productivity Commission (APC), which is a division of the Federal Treasury, is holding an enquiry into mental health. The APC functions by “providing quality, independent advice and information to governments, and on the communication of ideas and analysis.” It has extensive powers of investigation of government but is not a judicial body. At present, they are looking into why youth incomes have stagnated and setting up a policy for Integrated Water Management, so mental health fits neatly into their portfolio.

Normally, the APC  brings outside experts to assist in its studies. In this case, Prof. Harvey Whitefordof the University of Queensland, was invited to sit as a commissioner of the mental health enquiry. There is no question that Whiteford has the CV to qualify for this post, including having served as Director of Mental Health Queensland, Director of Mental Health for the Commonwealth Government in Canberra, and holding an appointment at the World Bank in New York.

I sent a lengthy submission last year, available here. It has several appendices and concludes that psychiatry is a mess but nothing short of a revolution will fix it:

The institution of psychiatry wants everybody to believe that they have the matter firmly in hand, that theirs is the only conceivable approach to mental disorder and that all criticism is malicious: “Move on, nothing to see here.” Nothing could be further from the truth. We have reached the point where we have to ask: Is psychiatry doing anything useful for society, or has it degenerated to an insatiable, high-cost and self-sustaining rentier gorging on the public purse? It is to be hoped that this honourable Enquiry will assist in the process of uncovering that truth.

In particular, I emphasised that a lot of what passes as standard practice in psychiatry is little more than institutionalised corruption. I was gratified to see another, anonymous submission, which detailed a case of frank corruption at the highest levels of psychiatry, here, and hope something comes of it.

The APC has been holding hearings in major cities and, on December 3, 2019, it was Brisbane’s turn. I was lucky enough to get a slot and ended up with nearly 45 minutes to give the following presentation, followed by questions from the panel. Audiences at these sorts of hearings are never large; in Melbourne and Sydney (both of which are considerably larger than Chicago), they attracted only a half-dozen stalwarts, but in Brisbane I had an audience of about twenty people. To my surprise, at the end of my presentation, I got a brief round of applause from the audience.

With a few minor explanatory amendments, this is what I told the Commissioners:

The overview of the draft report crams a lot into a small package. There are many recommendations, most of which are uncontentious, but they won’t come cheap: the bill for specially-trained teachers in every school is nearly $1 billion a year. That item is part of a very large expansion of the bureaucratic, regulatory, and research machinery governing the institution of mental health practice. This is not surprising: if you ask a group of bureaucrats, lawyers and epidemiologists for their advice, their answers will automatically orient in a particular direction.

The only surprise lies in the fact that they are suggesting something we already know won’t work. Fifteen years ago, in a review entitled Do nations’ mental health policies, programs and legislation influence their suicide rates? An ecological study of 100 countries,¹ the authors concluded: “It is of concern that most mental health initiatives are associated with an increase in suicide rates.”

It’s not clear why they were so concerned as this was first shown in the mid-1960s. After mental health services were introduced to the Baltic island of Bornholm, everything got worse. In 2014, an exhaustive Danish study showed what an editorial by two Australian psychiatrists called “the disturbing possibility that psychiatric care might, at least in part, cause suicide.”² It emerged that contact with mental health services didn’t cure suicidal urges but seemed to make them worse.

The editors, Matthew Large and Christopher Ryan, appeared shocked by the thought that the trauma and stigma of being hospitalised may push people over the edge, that a visit to the local emergency department was “suicidogenic,” as they put it. They shouldn’t have been shocked. You only have to talk to patients to find out what they thought of their “hospital experience,” and it isn’t nice. The more we spend on mental health, the more prescribed drugs people take, the more ECT we give, the worse the outcomes.

An earlier 2004 paper, whose authors included Prof. Whiteford (i.e. a member of the panel of enquiry), asked whether “there may be acceptable reasons for the observed findings.” This tends to be the response of the great majority of psychiatrists who only want to hear answers acceptable to themselves. As the late Carl Sagan noted:

“…at the heart of science is an essential balance between two seemingly contradictory attitudes – an openness to new ideas, no matter how bizarre or counterintuitive, and the most ruthlessly sceptical scrutiny of all ideas, old and new. This is how deep truths are winnowed from deep nonsense.”

I submit that the reason massive expansions of the bureaucratic, regulatory and research machinery don’t achieve what they are supposed to is because the entire model on which it is based is not just broken but, in fact, doesn’t exist. All the recommendations listed in the overview won’t change this because psychiatry is riven by deep nonsense.

Take the recommendation that children should be screened for signs of mental disturbance. Will the psychologist tell the parents: “Your little Johnny is playing up at [kindergarten]  because of all the arguing at home, he’s just copying what he sees.” Or “Your little Emma is seriously anxious because her father yells and punches walls while her mother is out doctor-shopping for drugs.” That won’t happen. What will happen is that the parents will be told “Johnny has ADHD and needs to be on drugs for life,” or “Emma has ASD and Social Phobia and needs to be on drugs for life.” And they won’t get better.

Let’s look at my bete noire, ECT. I provided all the figures in my critical review of ECT, published last year, which was appended to my submission.³ From 2005-2015, private ECT in Australia increased by 87%, including an implausible 191% in West Australia. In the UK from 1985-2015, ECT usage went down by 90%. In my 42 years as a psychiatrist, including 25 years in the far north, I have personally assessed and managed somewhere from 12,000-15,000 unselected public patients.

Today, I run a bulk-billing practice in a working-class suburb, with about 300 new referrals per year, patients who would otherwise go to MHS, if they got any treatment at all.⁴ In 42 years, not one of my patients has ever received ECT. Not one. If I can practice public psychiatry in Perth, in the Kimberley, in Darwin and in Brisbane without using ECT, so can every other psychiatrist in the country.

According to the [Royal Australian & New Zealand College of Psychiatrists], ECT is an essential (their word) treatment for severe, life-threatening depression. If that is the case, can they explain why the overwhelming bulk of ECT in this country is given to distressed, middleaged, middle class, white women in private hospitals? The answer, of course, is money. The psychiatrist gets about $200 for pressing an electrode against an anaesthetised patient’s head, about two minutes “work” at most. Yesterday, I saw a 47-year-old veteran with a wrecked back whose wife had just left him. He hates psychiatrists, so we had an interesting hour. I did my report last night, another half hour. $225 for an hour and a half of difficult and potentially dangerous work; naturally, psychiatrists like ECT. An admission to hospital for twelve ECT costs something of the order of $57,000, so private hospitals profit handsomely. ECT in Australia is a $500-million-a-year industry, yet none of it is medically necessary.

As it happens, I get the same results as they do in the same or less time for under $1,000, about 98% saving. I am utterly unconvinced that ECT is essential, safe, necessary, or effective. Over many years, psychiatrists have shown themselves unable to self-supervise, and it should therefore be banned. There is not a shred of evidence to suggest that mentally troubled Australians would be worse off, but the Commission will not hear this from mainstream psychiatry.

Same goes for the suggestion that the “emergency department experience” should somehow be made less awful. That is completely wrong. The only way to prevent the “suicidogenic stigma and trauma” of going to hospital is to provide accessible local services. Of my 300 new cases this year, practically none will be admitted to hospital. If service is locally available in a pleasant setting, if people are seen on time and don’t have to wait, if they see the same person each time, if they are not brutally forced to take unpleasant and/or dangerous drugs, if they’re not treated as cattle, then people will happily stay away from hospitals. Nobody wants to go to hospitals; they’re dreadful.

The problem is that mainstream psychiatry controls the narrative of mental health, and I use that word in its very worst, post-modernist sense. Results like mine threaten mainstream psychiatry’s narrative: that they know all about mental disorder and it only needs a few tweaks and a flood of money to make it all come together. This is false. Mainstream psychiatry does not have a model of mental disorder;⁵ therefore, their treatment is a hotch-potch of serendipity, ideology, and blind poking. However, they routinely mislead the general public. For example, the claim last year by the RANZCP that “The prescription of medications is something that a psychiatrist only ever does in partnership with the patient and after due consideration of the risks and benefits.”⁶ Or that ECT is “essential.” No, it’s not.

ECT is part of the deeply entrenched, institutionally-sanctioned soft corruption of over-servicing. I note somebody else has commented on this at Submission No. 513. I urge the Commission to study that in detail, and impartially. But it is not just in the private sector. I remind you that it costs Queensland Mental Health Services four times as much for their junior staff to see their outpatients as Medicare pays me, a senior psychiatrist, and we are seeing exactly the same patients.⁷ The only figure I have seen for their in-patients came from Brisbane’s Princess Alexandra Hospital, $2,237.65 per day. Every day I keep a person out of hospital is a massive saving, but it can’t be done under the standard model of treatment.

More of the same, as suggested in this enquiry’s draft report, will not achieve anything except create lots of jobs for bureaucrats, lawyers, and epidemiologists. All too often, more means worse. Down at ground level, where I practice, nothing will change. At $65 million a year, you can believe me when I tell you Beyond Blue has had zero effect in Redbank Plains. At $11 million a year, [Queensland]’s Mental Health Review Tribunal has not led to any improvement in practice. More likely, it has made it worse because medical staff spend more time writing reports than they do talking to patients. Headspace? Forget it, a non-event, and $350 million of new money isn’t going to change that. Digital files? If this⁸ is what will be stored, why bother? GIGO. Garbage in, garbage out. All this money would be better spent on public housing just because the real problem in psychiatry lies much deeper than the proposed solutions can reach.

It has reached the point where psychiatrists routinely attack anybody who has the temerity to criticise their entrenched view. For example, the UN [Human Rights Council]  Special Rapporteur on Mental Health has issued two reports critical of mainstream psychiatry’s reliance on drugs and regulatory systems. For this, he has been subject to a barrage of ill-mannered and factually wrong criticism. When psychiatrists are so insecure that they need to assail the UN HRC, we know there is something seriously wrong.⁹

There is indeed something rotten in the state of modern psychiatry, and it is the artfully concealed absence of a formal, articulated model of mental disorder. When medical students vote with their feet in not choosing psychiatry as a career, they are showing that they are at least intuitively aware of this. All the money in the world, all the committees and research projects aren’t going to do more than rearrange the deck chairs just because deep nonsense has now taken control.

No doubt for daring to expose this, I will be subject to the usual barrage of secret complaints by anonymous authors, which will be investigated in camera by an unnamed committee considering evidence I am not allowed to see, who will reach a decision that favours the status quo, and for which there will be no effective appeal. Because that’s how psychiatrists operate. The one thing they will never do is have a fair, open, transparent and, above all, honest debate about the realities of being mentally disturbed in Australia.