Post by Shy Ted
Once upon a time I was young and naive. I didn’t realise how naive until I entered the mental health profession. Having done my training in a lunatic asylum, though they had changed the name to mental hospital and not long after psychiatric hospital, later still mental health facility and so on, a lunatic asylum is the best descriptor. What can go wrong with the brain is truly astonishing and though I went on a different trajectory to most other nurses, that training and experience stood me in good stead for what was to come.
The children graduating from uni, heads full of left wing propaganda but quite unable to identify what’s wrong with the person in front of them never had this basic introduction and, as the years went by, left the profession or were promoted into management where they continue to spout the words they were taught and, confronted with negative outcomes, say “we didn’t do enough of it”. It’s like listening to the ABC.
The least desirable job is on the front line dealing with people in the acute phases of their particular malady. The suicidal, violent, angry, bereft, tragic became my daily fare. In the absence of a clear cut condition, which is actually quite rare, it’s judgement that counts. Will this suicidal person go home and kill themselves despite their assurances they won’t? If they do, you’re to blame and it’s a career-ender.
Over the years, with increasing drug use, drug-induced psychotic illnesses became increasingly prevalent. What to do? Hospitalise for safety? Send home with family support, medication and home visits? Just keep in ED overnight and see how they are in the morning became the best option. Most were completely better, essentially they were just intoxicated. Some were less ill, not at risk and could go home with supports and follow up. Some were still clearly ill, needed inpatient care and treatment for psychosis, antipsychotics. Different psychiatrists and GPs had their favourite medications. Some used minor tranquilisers, like Diazepam, for a few days to allow the illicit drugs to be secreted and mental state to return to normal. Others used major tranquilisers like Chlorpromazine for the sedating effect and, though they have no actual antipsychotic effect for several weeks, attributed the resolution of the psychosis to them. A few didn’t get better, they had schizophrenia and a lifetime of medication beckoned. But youngsters, being youngsters, back with their dope-smoking mates, began getting stoned again and “relapse” was not uncommon. Repeat and use Chlorpromazine as the first line treatment but for a longer period, usually a few weeks.
Along came the novel antipsychotics, Risperidone and Olanzapine. No change in actual efficacy but said to not cause the long term movement disorder, tardive dyskinesia, which the earlier generation often did. Pretty amazing how big pharma knew this despite there being no long term use data!
One day it all changed. “Best practise” became the mandatory treatment, using Olanzapine. Chlorpromazine cost 10c a pill back then, Olanzapine $10. 2-3 tablets a day. 30c vs $30 per day! Minimum 6 month “course”. $54 vs $5400!
Early comments from Psychiatrists I worked with were “it’s bullsh*t, these bureaucrats don’t know the patient, we do” but it worked it’s way through the various Federal and State health departments and they had no choice but to follow the protocol. Occasionally a budget manager would be alarmed at the increased costs in that particular budget – “Protocol. No choice”. And so it was.
Things changed in my life and I went out bush, lots of different places. 20 years went by. Just me and the local GP on the ground. Visiting Psychiatrist occasionally in some places. They could be a pleasure and an asset or a sufferance and a meddler but to each I would say the same thing but in a different tone – “no deaths, no evacuations”. And the GPs liked and trusted me. Mostly. And we used only minor tranquilisers for acute management of DIP. 1 Valium costs only a few cents.
Mental illness in the country and outback is a different ballgame. You do get a steady flow of serious mental illness but mostly it’s about doing a solid interview, providing excellent paperwork that supports that and your conclusions and a recommendation that the GP can agree with or not. And a far wider scope of mental disorders than the city has. Far wider. It was a waste of time contacting the on call Registrar because you’re asking a doctor who has never seen the patient to prescribe something and if it goes wrong it’s on their head, not yours. They would only ever recommend evacuations even though they weren’t necessary or couldn’t be provided in the Wet Season. I lost touch with the city and didn’t really know what the latest and greatest was.
One day I came back to the city I began to pick up agency work in the various “Centres of Excellence” as they had come to call themselves. I never worked out why. Some inpatient units are not at all “sexy”, usually because they’re full of scary, volatile characters, and those were the available shifts. The Olanzapine protocol remained but had added Sodium Valproate, an anticonvulsant and mood stabiliser, which, big pharma funded research showed, “augmented the Olanzapine”, and reduced the hospitalisation time. The patients involved were essentially the same characters of 20 years earlier but had become chronic drug users and were happy to take whatever they were offered, even asking every few hours for some Diazepam. It’s a wonderful pill if you want to chill. 2 are even better. I thought the drug induced psychoses resolved at about the same rate as they always had but “Best Practice” had decided these, now well, patients had to spend a few days on a not-locked ward from which they routinely absconded to get another fix of their fave street drug. Pretty obvious this would happen but it did extend hospitalisations, use more big pharma meds and create backlogs in the system. And the paperwork involved!
One of the saving graces of this type of work was that a cigarette or just the freedom to “have a smoke” would be enough to calm an agitated patient but the Public Health zealots had come along with their university research and banned smoking (at the patient’ own expense) and replaced it with nicotine replacement therapies, (big pharma, of course) and at the taxpayers expense. The patients didn’t approve and work was becoming scarier than I wanted to deal with. The document that detailed all these initiatives was called Duty To Care. All it really did was give people foods they didn’t want to eat, put them on a diet, subject them to medical tests and stop them smoking so they just ordered dial a pizza and smuggled in drugs and cigs. Discharge medications went from a single medication to a cocktail which people took ad hoc or sold the tranquilisers to people who were coming down from stimulants, sufficient to buy more drugs.
Somewhere along the way, more research decided that if you had two or more psychotic episodes in a period exceeding six months you earned the diagnosis schizophrenia, a lifetime diagnosis and drugs to go with it if the person was cooperative. Sometimes people stopped using drugs and their symptoms went away but the diagnosis remained. The intractables were put on a long-lasting injection every two weeks and there’s no doubt the incidence of relapse and re-admissions went down. But there’d usually be some pills as well, for use to aid sleep. Or for sale. Psychiatrists knew, patients knew psychiatrists knew but that was the game.
The pills have become a steady source of income for those who get them, selling to users of stimulants to make the “crash” easier. Anecdotally, creative drug users use the various components of the pills to test for any psychoactive effect, scraping off the coating and crushing the contents which are then smoked or injected to see if there’s a high. Some say there is with some.
So big pharma gave us more formal diagnoses, much more expensive medication, a cocktail rather than a single medication, longer hospitalisations, longer treatments, a black market in tranquilisers and nicotine replacement which ain’t cheap. And did I mention the incredible number of drug screening kits and tests? Emergency departments wouldn’t do them because the cost was on their budget. A day or two later, on admission to the ward, the test would be done. Usually negative because the street drugs were already metabolised and excreted. And the notes read “drug screen negative”. Cannabis hangs around for several weeks in your system and would often show up positive and be suggested as the cause for the psychosis. Everybody knew it was the street drugs though. It can easily explain extended symptoms.
I’m no longer young nor naive. It’s about the money, money, money. Big pharma-funded research is seduction, plain and simple. You don’t get your PhD without that research and there are PhDs everywhere, except in clinical practice. You get the conferences and the presentations and the job offers and if the ABC needs an “expert”… The tangible outcome of all this research is usually another checklist – side effects, constipation, BMI, weight and many more. And you don’t bite the hand that feeds you. Especially if that hand can sell more product.