How much of human behaviour, in the end, can one understand?

“But does psychological sophistication override a sense that some actions are just plain bad? How much of human behaviour, in the end, can one understand?”

Joe Cinques Consolations, Helen Garner

Introduction

Writing in Joe Cinques Consolations, Australian author Helen Garner presses us to ask whether psychological understanding of human behaviour is sufficient to overcome our intuition that some actions are simply bad. This question lies at the heart of forensic psychiatry and has broader application for general psychiatrists as we seek to navigate the path between morality and psychology. The critical discussion that follows examines Garner’s question through different lenses, and concludes that the dichotomy she offers is a false one: a person’s behaviour can be both bad and understandable.

Some actions are just plain bad

Throughout history, humans have been preoccupied with questions or right and wrong. From Biblical imagery of heaven and hell, through to this week’s debate about two young women with COVID-19 who lied about their travel, people are eager to label others as ”good or bad”, “right or wrong”. This moralistic approach to human behaviour has been a strong thread in the history of psychiatry: from the burning of witches, to the use of cold baths and beatings as punishment in asylums, people with mental illness were frequently considered to be “social deviants or moral misfits” deserving of punishment for their transgressions (Lieberman, Shrinks). It was not until Philippe Pinel – at the urging of his friend and former patient Jean-Baptiste Pussin – removed the shackles from patients at Salpetriere in 1800 that we entered an era of more humane “moral treatment”.

From a legal and ethical perspective, the consequence of labelling behaviour as “bad” rather than “mad” is that punishment can follow. The touted aims of punishment are several: (a) deterrence (dissuading this person specifically, and other people generally, from doing the bad thing again), (b) incapacitation (physically preventing this person from doing the bad thing eg through incarceration), (c) retribution (giving the wronged party a sense that justice has been done), and (d) rehabilitation (changing this person’s future behaviour). In order to distinguish between “mad” and “bad” behaviour, lawyers and forensic psychiatrists look to the twin limbs of the M’Naghten rule: (1) did the person know the nature and quality of what they were doing? and (2) were they capable of understanding that it was wrong? If the answer to both questions is “yes”, the person is unable to plead insanity as a defence, and the court can conclude that their conduct was – to use Garner’s phrase – “just plain bad”.

Most human behaviour is understandable

This binary approach to “good and bad”, is at odds with modern psychiatric practice. Research shows that a complex array of biological, social, and psychological factors influence a person’s behaviour. From a biological perspective, studies of twins adopted by different families show that about 50% of the variance in antisocial behaviour is explained by genetic factors. Recent research into transcranial magnetic stimulation has found that focusing a magnetic stimulus on a part of the brain known as the salience network can improve impulse control, which in turn reduces unwelcome behaviours such as gambling. From a psychological perspective, poor attachment as an infant and adverse childhood experiences are associated with higher rates of antisocial behaviour, which may include criminal offending. From a social perspective, nearly 50% of young people under youth justice supervision are aboriginal though they make up only 5% of the youth population overall (AIHW). These appalling figures cannot be separated from the devastating effects of colonisation on connection with land, language, and customs among indigenous peoples.

Under a recovery model, consumer activists urge mental health practitioners to reframe the question: “Don’t ask what’s wrong with me, ask what happened to me” (Eleanor Longden, The Voices in my Head). This approach seeks to understand the background behind the behaviour. For example, someone who lashes out against clinicians during a medical procedure may be re-experiencing an earlier trauma. In this situation, offering calm clear explanations, and asking for consent before beginning the procedure, is far more person-centred than the punitive use of physical restraint or seclusion. Under the CHIME model (Leamy 2011), connectedness, hope, identify, meaning and empowerment are key elements of recovery: none of these are served well by labelling someone as “simply bad”.

Actions can be both bad and understandable

In my clinical experience, actions can be both understandable and bad. By way of example, a clinical interview with a man accused of murdering his wife yielded a rich biopsychosocial formulation. His childhood upbringing, personality structure, and recent stressors all contributed to his violence against his wife and child. In one sense, it was possible to understand the background behind the behaviour. At the same time, he knew what he was doing and he knew that it was wrong. As such, it was appropriate that he face the consequences of those actions. Given that a key aim of punishment is rehabilitation, it was possible for me to both see the behaviour as bad, and to seek to understand it, in order to protect other women and children in future. A rich understanding of bad behaviour is helpful at both an individual level, in informing rehabilitation, and at a social level in advocating for reform to address the drivers of antisocial conduct.

Conclusions

In the end, Helen Garner offers us a false dichotomy. It is possible for “psychological sophistication” and a belief that “some actions are just plain bad” to co-occur: we need not choose between one or the other. Some actions are clearly bad: the wilful taking of innocent human life is perhaps the clearest example. Yet, in describing such behaviour, psychiatrists need not feel trapped by binary religious notions of saints and sinners, nor by binary legal notions of sane or insane. Instead, we can use research evidence, biopsychosocial formulations, and person-focused models of recovery to create rich and three dimensional understandings of human behaviour. In turn, we can use these formulations to say “this behaviour is bad, and here is how we can support this person, and others like them, to find a better path in life”

Mother’s Little Helper

Beyond their established efficacy in anxiety distress and insomnia and fuelling the debate between “pharmacological Calvinism and psychotropic hedonism”, these medications can also offer transient relief and comfort from stress; in a world replete with distress, it may be difficult for people to refrain from seeking a comforting remedy. This, these medications’ potential for non-medical use, and their associated risks and side effects, is a concern but is not of itself a reason always to deny comfort and relief. As the aphorism guides us “To cure sometimes, to relieve often, and to comfort always.” There may be times when the best or only way to comfort will be to use or add a benzodiazepine.

– Jerrold Rosenbaum, Benzodiazepines: A perspective

Introduction

Hippocrates famously said that the role of the physician is to cure sometimes, to relieve often, and to comfort always. Writing in the American Journal of Psychiatry, Rosenbaum draws on this aphorism to argue that it is appropriate – and indeed sometimes necessary – to use benzodiazepines for the purpose of comfort and relief. This essay will explore the pros and cons of such use from a range of perspectives.

Benzodiazepines are a class of medications, including diazepam, lorazepam, and temazepam which act on GABA receptors. They have a rapid calming and sedating effect, which can be useful in treating insomnia, anxiety, and agitation. However, they are also addicting and patients may find that they become dependent on higher and higher doses to achieve the same effect.

Benzodiazepines are a dangerous form of comfort

Looking back on the history of psychiatry, the use of psychotropic medications to relieve and comfort has a fraught history. During the 1950s, benzodiazepines were popularly known as “mother’s little helper” as immortalised in a song by the Rolling Stones. Such use has been widely criticised by feminists as a way of pacifying women who were angry and frustrated by the constraints of a patriarchal society.

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In modern psychiatric practice, the Royal Commission into Aged Care has criticised the use of “chemical restraint” with medicines including benzodiazepines and antipsychotics. As psychiatrists, we need to appreciate the cultural and historical reasons for our patients living in “a world replete with distress”, and advocate for a more equitable society rather than simply seeking to medicating away their distress.

From an ethical perspective, we have a duty of non-maleficence. Or as Hippocrates would say, primum non nocere (first, do no harm). There is a strong argument that offering benzodiazepines as transient relief and comfort may betray this ethical duty if the end result is that the patient fails to develop their own internal coping skills or becomes dependent on benzodiazepines. In the United States, deaths from prescription drug overdoses now outnumber deaths from illegal drug overdoses. (Frances, Saving Normal) In my own clinical experience I have cared for several young people who have become addicted to diazepam or lorazepam which was first prescribed by a well-meaning clinician. We all need to remain aware that benzodiazepines can cause real harm.

Benzodiazepines are sometimes the best or only way to comfort

On the other hand, evidence-based guidelines indicate that benzodiazepines have an important role to play in psychiatric practice. The RANZCP guidelines for managing acute agitation includes diazepam and lorazepam as first-line agents that can be used to provide relief to an acutely agitated person. Even those psychiatrists most firmly in the camp of “pharmacological Calvinism” are likely to see a role for benzodiazepines in the early days of treating a patient with acute psychosis.

As a “comforting remedy” benzodiazepines are sometimes offered to people in acute distress who do not otherwise have any form of mental illness. The prescription of a few days of temazepam to help a grieving relative sleep after a sudden bereavement is one example. In this situation, benzodiazepines – when used as an adjunct to other forms of emotional support – may offer a rapid and compassionate response to acute suffering.

Rare occasions when such use is appropriate

In seeking to find an appropriate balance, it helps to return to our fundamental role as psychiatrists and to ask “will this help my patient?”. In doing so, we must consider both the patient’s current distress and their longer term recovery. The CHIME model of recovery (Leamy 2011) emphasis the importance of hope. The judicious use of benzodiazepines may offer patients hope that their suffering can be alleviated and help to generate trust that prescription medicines can be helpful. These prescribing decisions should be made in partnership with patients and their chosen family or carers, with a clear aim of supporting their recovery goals.

Importantly, Rosenbaum acknowledges the risks and side-effects of benzodiazepine use. When prescribing benzodiazepines, these risks and side-effects need to be carefully weighed. Wherever possible, non-pharmacological options such as verbal de-escalation, breathing exercises, and enhanced support from family and carers should be tried first. If benzodiazepines are prescribed, they should be given at the lowest dose possible with a clear plan for ceasing their use (RANZCP practice guideline). We can, and should, also be advocating for a kinder, fairer, and more connected society, to reduce the inequities and isolation that contribute to human suffering.

Conclusions

In the end, benzodiazepines are best thought of as a powerful but dangerous tool in our toolbox. Their powerful calming and sedating properties make them a reasonable choice in alleviating acute distress and suffering. However, as Rosenbaum acknowledges they have serious risks and side-effects. While benzodiazepines may offer transient relief, this should not come at the expense of efforts to address the underlying causes of suffering and distress in society. Benzodiazepines can provide temporary relief, but ultimately a more holistic approach is required. As Prof Ron Paterson, the Chair of the NZ Inquiry into Mental Health and Addiction says “we cannot medicate our way out of this epidemic of mental distress.”

Those who cannot remember the past are condemned to repeat it

Those who cannot remember the past are condemned to repeat it.

George Santayana. The Life of Reason

Introduction

In today’s fast paced world, it is easy to always be looking for what is novel and upcoming. Yet as any student of history will tell you, some of our most profound learnings can come from the past. Writing in the “Life of Reason”, Santayana warns that, unless we learn from history, we will be destined to repeat it. Over one hundred years on, his warning remains relevant to the profession of psychiatry. In this essay we explore the importance of learning from the past, at both an individual and a systems level, to avoid stepping into the same traps over and over again.

Individuals repeat the past

A historical milestone in psychiatry was Sigmund Freud’s development of the theory of the unconscious. Through his work as a psychoanalyst, Freud came to understand that the human mind resembles an iceberg, with our conscious thoughts reflecting only the small piece of ice above the water while a large body of unconscious urges, memories, and motivation remain hidden beneath the surface. The unconscious mind has a profound impact on our behaviour, with childhood experiences leading us to re-enact past relationships and traumas in what has been termed a “repetition compulsion.” According to Freud and his followers, patients can escape their sentence of repeating unhelpful behaviours by delving into the past to reveal and resolve unconscious conflicts.

In professional practice, learning from the past is important for individual practitioners as well as their patients. Research into patient complaints by Bismark et al (2013) shows that past behaviour is the best predictor of future behaviour. Fewer than 5% of doctors received more than 50% of patient complaints, with some doctors receiving multiple complaints about the same pattern of misconduct – whether that be poor communication or violation of sexual boundaries. Improving professional practice requires each of us to remember, and learn from, our past errors and remain engaged in continuing professional development across the course of our clinical careers. (Principle 8 RANZCP Code of Ethics; CanMEDs Scholar domain)

Systems repeat the past

The risk of repeating the past occurs at a system level too. We look back in horror on asylums, like Salpêtrière, where patients were shackled in chains prior to Pussin and Pinel’s reforms at the end of the 18th century. Yet many consumer advocates, including Melbourne-based Indigo Daya, argue that modern psychiatry continues to abuse patients with excessive use of force and chemical and mechanical restraints. Similarly, in New Zealand the Inquiry into Mental Health and Addiction (2018) heard frequent calls for an end to seclusion and restraint. The Inquiry found that many clinicians opt too readily for coercion and control at the expense of human rights and recovery: a haunting echo of abuses from asylums in our past.

In modern Australia, one of the starkest illustrations of history repeating itself is found in the treatment of refugees and asylum seekers. Despite clear warnings from the United Nations, Amnesty, and other human rights institutions, Australia continues to treat refugees and asylum seekers harshly with the use of offshore detention in dehumanising conditions. These policies are reminiscent of the harmful exclusion and marginalisation of Jewish refugees during World War II. The Royal Australian and New Zealand College of Psychiatrists has rightfully drawn attention to the mental health implications of this ongoing violation of ethics and human rights.

Conclusion

Santayana was right to warn us of the risks of forgetting our history. The past carries important lessons for our patients who, through therapy, can overcome unhelpful relationships and responses once recurring patterns are elucidated. The past can also help us to learn from our own oversights and errors to become better psychiatrists. At a system level, we need to remain constantly vigilant to re-enacting abuses of the past through the use of force and coercion, whether in our hospitals or in society’s treatment of “others”. There is profound wisdom to be found in a traditional Maori proverb: “I walk backwards into the future with my eyes fixed on my past”.

Freud says 50 yr olds are no longer educable (an essay by a nearly 50 yr old psychiatry trainee)

“Persons near or over the age of fifty lack, on the one hand, the plasticity of the psychic processes upon which the therapy depends – old people are no longer educable.”
Sigmund Freud, On Psychotherapy. (pub. 1912)

Introduction

Writing in “On Psychotherapy” Sigmund Freud – the father of psychoanalysis – argues that beyond the age of 50 people lack the cognitive plasticity required for effective therapy. If true, this argument would have profound implications for the delivery of mental health services. This essay explores Freud’s contention from a range of perspectives, including cultural and biological developments in our understanding of ageing, legal and ethical prohibitions on age-based discrimination, and patient-centred approaches to care and recovery.

People over the age of 50 have less brain plasticity

Clinical experience shows that, on the whole, older adults are less open to change than their younger peers. Ways of thinking, responding, and relating have been embedded over many years. The aphorism “you can’t teach an old dog new tricks” seems apt for some of our more rigid and inflexible older patients. Conversely, the enhanced potential to change the trajectory of mental illness at younger ages is embedded in the philosophy of early intervention models, such as the EPIC program for early intervention in psychosis run by Prof Pat McGorry and colleagues at Orygen.

From a biological perspective, research evidence also lends weight to Freud’s proposition. As discussed in Sherwood et al’s research on ageing surgeons, older adults tend to be less flexible in their thinking styles and rates of cognitive decline increase with each decade beyond the age of 60. While older adults benefit from accrued wisdom and pattern recognition, on average our overall ability to respond flexibly to new situations decreases with age.

People over the age of 50 are still educable

On the other hand, there are good reasons to think that older adults may still benefit from therapy. In modern culture, the age of fifty is now reasonably considered “middle-aged” with average life expectancy in Australia being over 80 years. Historically, this is a significant change from the 1890s when Freud developed his “talking cure”. At that time, anyone over the age of 50 could reasonably be considered an elder in their community (a fact that is still sadly true in aboriginal communities in Australia where average life expectance is more than 10 years less than for non-indigenous Australians). Freud himself went on to make important intellectual contributions for nearly three decades after “On Psychotherapy” was published in 1912.

From a legal and ethical perspective, we should be cautious about writing-off a group of patients from accessing any particular therapeutic modality based on their age alone. Human rights and anti-discrimination laws in Australia and New Zealand explicitly list age as a prohibited ground of discrimination. As such, any decision to exclude a patient from therapy based on his or her age would need to be carefully thought through and robustly justified to avoid falling foul of the law.

The right therapy for the right person

From a patient-centred perspective, psychiatrists should choose therapeutic modalities based on the needs, strengths, interests, and goals of patients rather than their demographic characteristics alone. An intelligent and curious 75-year-old may gain more from psychodynamic psychotherapy than a 25-year-old with rigid beliefs and low psychological-mindedness. An important element of the CHIME model of recovery (Leamy 2011) is retaining hope for recovery at all ages and stages of life.

Conclusion

Modern psychiatrists would be wise to approach Freud’s claims about ageing and therapy with a healthy dose of cynicism. It is true that older adults have less cognitive plasticity than their younger peers, and that the trajectory of mental illness can best be influenced through early intervention. However, we all retain the capacity to learn and grow across the life course, and an adult who entered therapy at age 50 could potentially reap decades of benefit. A human rights and recovery-focused approach encourages us to attend more to the needs and abilities of the patient before us, than making generalisations based on age-alone. Further research could usefully explore which modalities of treatment offer the greatest benefit for patients with differing cognitive styles and abilities.

The Goldilocks prescription: too much, too little, just right

“When my previous therapist took out his prescription pad, I knew I could never tell him anything important”

– Healing Schizophrenia

Introduction

Candour is central to the relationship between patients and psychiatrists: patients need to to feel safe talking about deeply sensitive topics and psychiatrists need to be worthy of their trust. So it is concerning to hear a patient say they felt unable to tell their therapist anything important after the prescription pad made an appearance in the room. This essay explores the claim that prescribing detracts from the therapeutic encounter, and identifies ways to mitigate the potentially negative impact of the prescription pad on the relationship between patient and practitioner.

Prescribing can detract from the therapeutic encounter

The juxtaposition of the prescribing pad with therapy is a fairly recent development in the history of psychiatry. Until the synthesis of chlorpromazine in the 1950s, there were few effective medications for mental illness. Certainly, when Freud first developed his “talking cure” in the 1890s, the focus was on the relationship between therapist and patient, rather than pharmacological manipulation of brain chemistry. For patients who want to feel deeply heard and understood, a face-to-face encounter with an attentive therapist may still be the best medicine of all. In this context, the premature offer of a prescription may feel, at best, like a let down and, at worst, like an invalidation of their experience and suffering.

In reality, the model of a weekly 50 minute session where the patient speaks – and the therapist listens – has largely become a relic of the past. Apart from the privileged world of private psychotherapy, it is far more common for psychiatrists to treat depression with an SSRI like fluoxetine (Prozac) than with an extended course of therapy. Pharmacotherapy is big business, with psychoactive and pain medications being the most profitable market of all for pharmaceutical companies (Frances, Saving Normal). In many medical settings, writing a prescription is both more lucrative and less time-consuming than comprehensive assessment, psychoeducation, psychotherapy, and multidisciplinary care.

Used incautiously, prescription medicines can become a coarse substitute for deep personal and cultural understandings of mental health and wellbeing. The NZ Inquiry into Mental Health and Addiction (2018) cautioned: “We can’t medicate our way out of the epidemic of mental distress”. By focusing on symptom relief, the patient’s underlying strengths and causes of distress may be overlooked. Indeed, many consumer advocates including Indigo Daya, a Melbourne-based “mad activist” claim that it wasn’t until the prescribing stopped that their real healing began. Framed within this context, a prescription can be the antithesis of the connectedness, hope, identity, meaning, and empowerment required for meaningful recovery. (Leamy 2011)

Prescribing can enhance the therapeutic encounter

Importantly, the opening quote represents just one patient’s perspective. For other patients, medications are an essential part of their treatment and a valued adjunct to talking based-therapies. The heterogeneity of views on prescription medicines is well illustrated by the contrasting experiences of Eleanor Longden and Elyn Saks: both highly intelligent women, both diagnosed with schizophrenia after experiencing auditory hallucinations and paranoia, both treated by psychiatrists for many years. Yet Professor Saks believes that medicines were central to her recovery, while Dr Longden encourages people to find metaphors and meaning in hearing voices rather than seeking to medicate them away. Where some patients might feel shut down by the appearance of a prescription pad, others might be encouraged by the prospect of achieving symptom relief.

In many cases, the patient’s best chance of recovery will come from a thoughtful combination of pharmacology and psychotherapy. Offering both accords with our ethical responsibility to provide the best attainable care for patients, including the use of up-to-date evidence-based treatments. (RANZCP Code of Ethics, Principle 3) For example, the CAMS study of children and adolescents with anxiety found that the combination of sertraline and cognitive behavioural therapy was more effective than either treatment alone. Within the multidisciplinary team, prescribing is an important part of the psychiatrist’s role as, by law, psychologists and allied mental health clinicians are not permitted to prescribe. Prescribing wisely is both a privilege and a responsibility.

Time and a place for prescribing

In seeking to ensure that our prescribing does not become a barrier to communication, it may be helpful to think of the prescription pad not as an object but as a symbol which becomes embedded with meaning across the course of multiple clinical encounters. Clinical experience shows that patients are highly attuned to the dynamics within a consultation. If a psychiatrist is rushed, bored, or irritated and turns to their prescription pad to bring the session to a close, it is entirely understandable that their patient would feel unwilling to disclose anything of importance from that point onwards. Conversely, if a therapist shows “unconditional positive regard and empathic understanding” (Rogers, 1957), and takes time to understand the patient’s hopes and goals before forming a treatment plan, the therapeutic relationship might be enhanced by including a prescription in the menu of options available to support recovery.

Conclusion

Prescribing is an important aspect of psychiatric practice but needs to be carefully managed so that it complements, rather detracts from, other aspects of care. Failing to take out the prescription pad at all may deprive patients of a highly effective treatment. Taking out the prescription pad too early may result in therapeutic rupture and premature diagnostic closure. Psychiatrists need to be attuned to the dynamics in the room and to consciously reflect on whose interests are being served by our prescribing practices. As Baroness Onora O’Neill (Reith Lectures) would say, if we want our patients to trust us, we need to be worthy of that trust.

Propaganda, Reason, and Truth

Propaganda is the enemy of reason and truth.
– Silove, ANZJP

Introduction

From Hitler’s polemic about ridding the world of the disabled and mentally ill, through to climate change deniers’ attempts to discredit Greta Thunberg by focusing on her autism diagnosis, propaganda has a long and complex relationship with psychiatry. Writing in the Australian and New Zealand Journal of Psychiatry, Silove argues that truth and reason are under threat from propaganda. Propaganda can be defined as biased communication, intended to influence public perception towards a particular point of view. This essay explores the complex  relationship between propaganda and truth as it relates to the field of psychiatry.

Propaganda is the enemy of reason and truth

Propaganda can have a profoundly negative impact on the lives of individuals living with mental illness. Over the course of history, high profile campaigns have contributed to the three dimensions of stigma described by Thornicroft et al: ignorance, prejudice, and discrimination. Taken to its extreme, during World War II Hitler’s propaganda led to thousands of people with mental illness being sterilised or gassed to death to support his quest for a “superior race”. Closer to home, conservative christians in Australia led a campaign opposing safety and inclusion for queer and gender diverse young people in schools. Despite clear evidence that LGBTIQ young people experience higher rates of depression and anxiety in the context of bullying and discrimination, the Safe Schools initiative was obstructed by biased and misleading claims about its nature and intent.

Biased or misleading information can also suppress critical thinking and lead to irrational decision-making at a social level. One enduring example is the so-called “War on Drugs”. As pointed out by psychopharmacology researcher Professor David Nutt (Imperial College London), efforts to criminalise some drugs – such as cannabis and ecstasy – and not other drugs – such as alcohol and tobacco – are founded in political rhetoric rather than scientific evidence on their relative harms. False claims about drugs and the people who use them have contributed to immense public harm, through a focus on criminalisation and punishment rather than treatment and harm minimisation.

Psychiatrists also need to be alert to the risks of propaganda in day-to-day clinical practice. Pharmaceutical companies make more money from psychoactive and pain medications than from any other class of drugs (Frances, Saving Normal). As a result, the incentives to persuade psychiatrists to prescribe more medications are high. The research paper “Why Olanzapine Beats Risperidone, Risperidone Beats Quetiapine, and Quetiapine Beats Olanzapine” (Heres et al) found that in 90% of published studies funded by pharmaceutical companies, the outcome favoured they sponsor’s drug. As a consequence, an essential part of psychiatric training involves the ability to critically analyse research to help identify biased and misleading information.

“Propaganda” can be an ally of reason and truth

However, it is vital not to dismiss all information with which we disagree as propaganda. Important human rights campaigns, such as efforts to obtain the vote for women, to ban slavery, and to decriminalise homosexuality were repeatedly dismissed as propaganda by those opposed to these ideas. Yet, profound social reforms arose from these campaigns. Today, few people would wish to return to a world in which we apply psychiatric diagnoses to women who express strong emotions (“hysteria”), to slaves who escape captivity (“drapetomania”), or to men who have sex with men  (“sexual orientation disturbance”). Nevertheless, in their time these were well-established psychiatric diagnoses.

Challenges to conventional methods of mental health care delivery can feel discomforting and threatening. When people with lived experience of mental illness, such as Melbourne-based “mad activist” Indigo Daya call for force and restraint to be banned from psychiatric practice, it can be tempting to dismiss these views as idealistic and unrealistic. Undoubtedly, Philippe Pinel’s colleagues experienced similar emotions when he proposed unchaining patients in the asylum at Salpetriere to support their recovery. Achieving meaningful reform requires a willingness to hear opposing views with an open mind, to sit with feelings of discomfort, and to seek commonalities of interest within apparently divergent views.

Conclusion

In conclusion, psychiatry has a long history of being used as a pawn in the propaganda of of dictators, religious zealots, and pharmaceutical companies. Tremendous harm has been done by pathologising difference and non-conformity as a form of mental illness. At the same time, new ideas often conflict with social norms when they are first introduced and it is important for psychiatry to remain open to challenge and reform. In our roles as clinicians, leaders, advocates, and teachers, we need to retain a clear-eyed ability to use evidence and reason in distinguishing fact from fiction, and inspiration from manipulation.

 

Are we blind to the influence of the social environment?

 “However, the truth was that my own preconceptions had made me blind to the influence of the social environment”
– Robin Murray. Mistakes I have made in my research career. Schizophrenia Bulletin

Introduction

Writing in Schizophrenia Bulletin, Robin Murray reflects on errors in his career as a researcher. In particular, Murray acknowledges his oversight of the social environment due to pre-existing personal views. The term “social environment” encompasses all of the wider social determinants of health, defined by the World Health Organisation as the conditions in which people are born, grow, live, work, and age. This  essay explores the role of the social environment in psychiatry and the extent to which psychiatry – and psychiatry research – has been blind to such influences.

Psychiatry has been blinkered to social influences

From its earliest days, psychiatry has favoured individual explanations of mental illness over social ones. Over the course of history, researchers and clinicians have variously ascribed mental illness to an individual struggling with evil spirits, anatomical anomalies (such as a “wandering uterus” being the cause of hysteria), unconscious drives or defences, or an imbalance of brain chemicals. For example, Hippocrates and Gaden thought that mental illness arose from an imbalance in the four humours; echoes of their approach are still felt in our description of personalities as “sanguine” or “melancholic”. These individualistic theories have in turn influenced the nature and focus of research in psychiatry.

From a research perspective, randomising individuals to receive one intervention or another is considered the gold standard of good clinical research. Most randomised clinical trials in psychiatry are focused on the effectiveness of medications, and many are funded by pharmaceutical companies who have a vested interested in selling more pills. This has important implications – for example, Royal Australia New Zealand College of Psychiatry Guidelines refer heavily to evidence from clinical trials in formulating recommendations for treatment. Dr Ben Goldacre, in his UK policy paper Test, Learn, Adapt, argues that there is an urgent need for randomised trials that assess the impact of interventions that occur at a social policy level, such as housing and employment initiatives, rather than always focusing such trials on treatments for individuals.

In clinical practice, our conventional history-taking process is also skewed towards understanding the individual with less of a focus on their social environment. There is little attention devoted to social determinants of health, such as the effects of poverty, patriarchal culture, intergenerational trauma, or institutionalised racism. For example, social history usually takes up less than a tenth of a conventional psychiatric history. Even this element has an individualistic lens – who does the patient live with?, does the patient have a job? – rather than addressing broader social determinants such as levels of violence against women, taxation structures, and affordability of healthcare. It is fair to say that day-to-day clinical practise is blinkered against seeing the full influence of the social environment.

Psychiatry is increasingly recognising social influences

Importantly, not all psychiatrists and psychiatrist researchers share Murray’s preconceptions against the role of social environments. There is an important (and growing) body of research at the intersection of public health and psychiatry. Beginning in the 1960s, Professor Michael Marmot led the Whitehall Study which analysed the impact of social status on the health of British civil servants. He found that men in the lowest grade (eg doorkeepers) had twice the mortality rate of men in the highest grade (eg administrators) even after controlling for other risk factors such as smoking or exercise. More recently, a Lancet paper by Hughes et al synthesised the findings of nearly 40 research studies into the impact of adverse childhood experiences (ACEs) on health, and found strong correlations between ACEs and subsequent mental illness. Closer to home, Milner et al’s research on suicide by health practitioners analysed a national dataset of coronial inquests and found that female doctors are twice as likely to die by suicide as women in other occupations. These sorts of large scale epidemiological analyses shine a bright light on the role of social environments in understanding mental illness.

Indigenous models of health care offer valuable understandings of the importance of social environments for mental wellbeing. Family and social well-being is one of the four pillars of the whare tapa wha model of Maori health, and aboriginal health is rooted in the health of the community and the health of the land. And yet for many indigenous people, colonisation and intergenerational trauma have had a devastating effect on their traditional lands and communities. IndivIdual clinical efforts to improve aboriginal health will always be limited while we live in a world where over 50% of the young people in prison are aboriginal, despite making up less that 6% of the population. In New Zealand, many Maori elders say that reclaiming mental well-being requires reconnection to land, cultures, whakapapa (genealogy), and history. There is a deep wisdom in indigenous knowledge of health and mental health which psychiatry has much to learn from.

These public health and indigenous approaches are slowly but steadily having an impact on mental health policy. In New Zealand the recent Government Inquiry into Mental Health and Addiction, chaired by Professor Ron Paterson, found that improving mental health requires attention to poverty, housing, employment, domestic violence and other forms of trauma. Similar themes are evident in the Interim Report of the Royal Commission into the Victoria’s Mental Health Service, which states that we need to build a society that is safe, equitable, and inclusive if we are serious about improving mental health.
Conclusions

In conclusion, psychiatrists have historically viewed mental illness through an individualistic lens, with a focus on psychological and biological explanations of illness. This approach is reflected in clinical trials, which typically evaluate the benefit of treatments by randomly allocating individuals to receive interventions or not. In clinical practice, we are far more comfortable with asking our patients about their personal histories than the social forces, such as inequality, racism, capitalism, and patriarchal norms, that have shaped the context of their lives.

However, alternative understandings of mental health are challenging these preconceptions and promoting more holistic approaches to mental health. First, public health approaches challenge us to lift our gaze and consider upstream social determinants of mental health. Second, indigenous understandings of mental health underscore the profound interconnection between an individual’s health and the health of their family, communities, and natural environment.

Looking to the future, recent inquiries in both New Zealand and Australia have recommended a stronger focus on social determinants as an integral component of mental health reforms. Like Robin Murray, we are beginning to acknowledge the “mistakes we have made” and opening our eyes to the profound influence of the social influences. Important work remains to be done in integrating these insights into training, practice, and policy.

Diazepam, temazepam, olanzapine, quetiapine: Who is behind the growing use of polypharmacy in psychiatry?

“In the majority of [psychiatric] patients worldwide, polypharmacy is practised in the face of all guidelines and textbooks on psychopharmacology and the discussion is ongoing as to whether it is our practice or our guidelines that are at fault…”
– Naber D and Pincus H (2003) Current Opinion in Psychiatry

Introduction

Writing in Current Opinion in Psychiatry nearly 20 years ago, Nader and Pincus draw our attention to the problem of polypharmacy in psychiatry. They note the ongoing debate as to whether polypharmacy arises from problems in professional practice or from inadequate clinical guidelines. This essay explores both sides of this debate, and identifies some promising interventions to turn back the tide of polypharmacy.

Before we begin, it is helpful to clarify what polypharmacy is and why it is a problem. Polypharmacy has various definitions, but two commonly used definitions are the concurrent use of five or more medicines (Page et al) or the simultaneous use of two or more drugs from the same class of medicines eg two or more antipsychotics. It is problematic for four main reasons: first, it makes it harder to know which medicine is the cause of any observed improvement (or deterioration); second, it may increase the risk of poor adherence due to the complexity and cost for the patient; third, it increases the risk of medication errors; and fourth, it can compound the risk of side-effects and drug interactions including potentially serious events such as serotonin syndrome or neuroleptic malignant syndrome.

Polypharmacy in clinical practice

Polypharmacy in one form or another is as old as human civilisation. The body of a prehistoric man, frozen during the ice age, was accompanied by a bag of multiple medicinal herbs – presumably provided by a traditional healer of some form. Today, the pharmaceutical industry is big business and psychiatry pharmaceuticals are the biggest of all. Prescriptions for psychiatric conditions and pain are the largest source of pharmaceutical profits in the United States (Allen, Saving Normal). In Australia the government spends over $500 million a year on government subsidies for mental health prescriptions (Australian Bureau of Statistics, 2019j.

Many patients with mental or behavioural conditions receive multiple medications, sometimes with serious consequences such as serotonin syndrome or neuroleptic malignant syndrome. In my clinical experience it is not uncommon to see medication charts that extend across multiple pages in psychiatric inpatient units, with some patients experiencing acute psychosis receiving a cocktail of olanzapine, quetiapine, promethazine, lithium, diazepam, and temazepam with the addition of more medications such as benztropine to address the subsequent side-effects.

Drug charts like this largely reflect the personal clinical practice of individual psychiatrists (and sometimes the practice of multiple psychiatrists and psychiatry registrars adding and removing medications on different shifts over days or weeks). In the absence of clear aetiological understanding of the causes of mental illness, psychiatric treatment often involves imprecise efforts to influence brain biochemistry through various receptors (eg dopaminergic, serotonergic, and histamingeric) with the hope of alleviating symptoms and improving functioning. Given these underlying vagaries it is perhaps not surprising that many psychiatrists perceive prescribing as a deeply personal endeavour, reflecting their own personal experience and the handed down wisdom of generations of teachers and mentors.

Guidelines and polypharmacy

What is the role of clinical guidelines in all of this? Most guidelines are written with the aim of rationalising treatment in accordance with evidence-based best practice. As a result guidelines are usually more parsimonious in their use of multiple medications than clinical practice. However, some guidelines allow for, and sometimes even encourage, the prescribing of multiple medications. For example, many hospital guidelines for acute arousal support the concurrent use of both olanazpine and diazepam, with more potent antipsychotics such as droperidol or zuclopenthixol acetate added-in as additional treatments for severe behavioural disturbance.

Perhaps the larger problem rests not with individual guidelines, but with the fact that guidelines – and indeed most clinical trials – address individual conditions rather than the messy reality of life. Having separate guidelines for depression, anxiety, and insomnia overlooks the fact that for many patients these conditions co-occur. A clinician who diligently followed the prescribing guidelines for each individual psychiatric condition could well end up prescribing multiple medications in a way that was neither foreseen by the guideline authors, nor tested in any clinical trial. All of that is before you even begin to add in common co-morbid medical conditions such as heart disease or chronic pain, whose treatments can also have psychiatric implications (such as the depression that can be associated with use of beta-blockers).

The future of polypharmacy

In seeking to address polypharmacy, there are at least four promising interventions that are proving their worth in clinical practice. The first is the introduction of electronic clinical records. Through the effective use of interaction alerts and embedded prescribing guidance, electronic medical records can draw prescribers’ attention to potentially harmful interactions and duplicates within the same class of drugs. Second, clinical pharmacists can significantly improve the safety and quality of prescribing by reconciling medications on admission, identifying unsafe prescribing practises, and assisting psychiatrists with deprescribing unnecessary medicines. Third, national initiatives such as Choosing Wisely seek to reduce the overuse of unnecessary investigations, procedures, and treatments. From an ethical perspective, such initiatives help clinicians with their duty to do no harm (primum non nocere, Hippocrates) but also support a more just healthcare system by helping to ensure that scarce resources are available for those in need rather than spent on unneeded and potentially harmful polypharmacy. Finally, patients themselves are driving the move against over-prescribing. Advocates with lived experience, such as Indigo Daya and Eleanor Longden, underscore the harm that can be caused by psychiatric medicines and advocate for a more holistic understanding of recovery.

Conclusion

In conclusion, polypharmacy is a real and pressing problem in psychiatry, and its incidence has continued to increase in the two decades since the writings of Nader and Pincus. The causes are multifactorial. Centuries of clinical practice have normalised the role of “personal judgement” in the selection of medicines, pharmaceutical companies have a vested interest in maximising profits, and research trials and clinical guidelines often assume an artificially tidy world in which patients only experience one condition at a time.

Thankfully, several promising interventions are helping to push back the tide. These include electronic medical record alerts and algorithms, campaigns such as Choosing Wisely, the involvement of pharmacists as core members of the multi-disciplinary team, and advocacy from patients with lived experience of the harms of polypharmacy. As encouraged by both the RANZCP Code of Ethics (Principle 11) and the CaNMEDS framework, psychiatrists can and should play a leadership role in advocating for such reforms to reduce the harms of polypharmacy.

Exclusion. Inclusion.

“Being excluded blights the lives of the mentally ill. Exclusion is both cause and consequence of mental ill-health and extends beyond material deprivation to exclusion from the activities which give meaning to life.”

-Alan Currie, Mental Health and Social Inclusion

Introduction

Writing in Mental Health and Social Inclusion, Alan Currie highlights the damaging impact of social exclusion on mental health. Social exclusion can take many forms: difficulty finding employment or housing; being refused access to goods and services; being left out of social activities or treated differently by family and friends. Currie alludes to the complex inter-relationship between exclusion and mental health noting that exclusion can both lead to, and flow from, poor mental health.

This essay explores Currie’s claim that “being excluded blights the lives of the mentally ill”, and reflects on opportunities to strengthen social inclusion as a core element of mental health and recovery.

Historical exclusion

There is no question that exclusion is harmful to mental health. A systematic review by Leigh-Hunt et al found that loneliness increases all-cause mortality and has an adverse impact on mental health. Among people with schizophrenia, insecure housing, unemployment, and estrangement from friends and family are all associated with a poorer prognosis.

Exclusion of people with mental illness has a long and painful history. Early pagan and Christian communities conceptualised mental illness as a curse by a god, moral weakness, or sinfulness. People with mental illness were shunned or punished – as illustrated by violent exorcisms during the Dark Ages and, more recently, death by hanging during the Salem witch trials. Superstitious fears of mental illness persist in many cultures. For example, human rights organisations in India and China regularly draw attention to cases of people with mental illness being chained and confined away from community life to “keep them safe from spirits” (Human Rights Watch).

In modern day Australia and New Zealand, social exclusion of people with mental illness is not as stark as being shunned, stoned, or shackled, yet the impact remains devastating. In the communities where we live, people with serious mental illness are less likely to own their own home, to have a secure job, or to get married. People with mental illness are regularly denied income protection insurance, barred from joining the armed services, and asked to leave university halls of residence (personal clinical experience at Orygen Youth Health). At a more profound level of social exclusion, people with mental illness, especially indigenous peoples – are overrepresented in youth justice facilities and prisons.

Modern day inclusion?

Thankfully, social exclusion is not inevitable. A more biopsychosocial understanding of mental illness, as espoused by modern psychiatry, has led to an improved understanding of mental illness as an illness rather than a weakness. At the same time, the recovery movement – led by consumers – has highlighted the importance of inclusion with its focus on Connectedness as the first element of the CHIME model of recovery. Recovery initiatives, such as prevention and recovery centres, provide valuable support to people with mental illness by building social skills, establishing connections with social groups, and addressing barriers to social inclusion.

Within the education and disability sectors we have also seen positive moves towards greater social inclusion. Schools have moved from a system of special schools in the 1950s to the inclusion of children of a wide range of needs and abilities in mainstream schools with individualised assistance and support. The National Disability Insurance Scheme has given people with psychosocial disabilities greater control over the supports that they want and need. Indeed, one of the objectives of the scheme is to support the social and economic participation of people with disability, including disability associated with serious mental illness.

Research by Pirkis et al shows that over recent decades Australians have developed improved mental health literacy, greater willingness to seek help for mental illness, and better understanding of consumer perspectives (Pirkis et al). These are all important precursors to improved inclusion of people with mental illness.

A long way to go

However, we still have a long way to go before we can be confident that all people with mental illness benefit from a sense of belonging and inclusion. Effectively addressing the remaining barriers to inclusion will require attention to three components of stigma: (1) ignorance arising from insufficient knowledge, (2) prejudice arising from negative attitudes, and (3) discrimination arising from unjust behaviours (Thornicroft et al). Exclusion arising from ignorance can be addressed by dispelling myths, such as the myth that people with mental illness are violent or shouldn’t hold leadership positions in society. Exclusion arising from prejudice can be addressed through campaigns such as the Like Minds, Like Mine campaign in New Zealand which encourages high profile New Zealanders to speak publicly about their own experience of mental illness. And unlawful discrimination can be addressed through legal instruments, such as the Code of Health and Disability Consumers’ Rights in New Zealand and the Equal Opportunity Act in Victoria prohibit discrimination on the grounds of illness or disability.

Beyond these basics, full inclusion requires not just tolerance of, but appreciation for, the diversity of life experiences and viewpoints that people with lived experience of mental illness bring to our communities. As Currie points out, inclusion goes beyond access to material goods and services, and includes connection with activities which give meaning to life, including arts, music, spirituality, activism, and leadership.

Conclusions

In conclusion, Currie rightfully draws our attention to the blighting impact of social exclusion as both a cause and consequence of mental illness. Historically, people with serious mental illness have often been ostracised from workplaces, education, housing, and social networks due to ignorance, prejudice, and discrimination. However, there are promising signs that these three forms of stigma are reducing with a concomitant increase in social inclusion. Psychiatrists can play a crucial role in addressing stigma and exclusion, through our leadership and advocacy roles, as encouraged by CaNMEDS and the RANZCP Code of Ethics (Principle 11).

By advocating for more inclusive communities, psychiatrists can help improve outcomes for our current patients, and protect the wellbeing of future generations, through the health-affirming power of belonging and connectedness.

What do Sarah Cooper’s comedy and patient advocacy have in common?

“Physicians are required to do everything that they believe may benefit each patient without regard to cost or other societal considerations. In caring for an individual patient, the doctor must act solely as that patient’s advocate, against the apparent interests of society as a whole, if necessary.” – Norman Levinsky, “The Doctor’s Master”

Introduction

At times, doctors feel torn between two masters (or mistresses): our obligations to the individual patient in front of us and our wider obligations to society. Writing in the New England Journal of Medicine, Norman Levinsky addresses this challenge and concludes that doctors are obligated to serve our patient’s interests first, even when that duty conflicts with other social considerations.

While Dr Levinsky’s proposal is superficially attractive, a deeper consideration reveals its flaws. This essay argues that rather than blindly doing everything we can to benefit each patient, doctors have a duty to consider the moral dimensions of competing financial and social considerations.

We have a duty to keep patient’s interests front of mind

First, it is important to acknowledge that there are strong ethical, legal, and professional reasons to always keep a patient’s interest front-of-mind when delivering clinical care. The principles of autonomy – respect for self-determination – and beneficence – the duty to do good for our patients (Beauchamp and Childress) both support a patient-centred approach. Similarly, Principal 3 of the RANZCP Code of Ethics calls on psychiatrists to provide the best attainable care for their patients.

At a clinical level, psychiatrists advocate strongly for our individual patient’s needs on a daily basis – for timely access to services or increased housing support or an inpatient bed when they are acutely unwell – despite known limitations on funding for mental health services. At a wider societal level, many doctors have taken courageous stands to advocate for individual patients in the face of considerable social resistance. Consider Philippe Pinel – who at the urging of his colleagues Marguerite and Jean-Baptiste Pussin – removed the chains from patients at Salpetriere in 1795, or obstetrician Ron Jones who exposed the “unfortunate experiment” of unethical cancer research that was harming his patients at Auckland National Women’s Hopsital in the 1980s.

This duty is not unfettered: the interests of society matter too.

However, the duty to advocate for patients is not an unfettered one. There are many occasions where careful consideration of broader social issues interests is required. This competing master (or mistress) of social good is also recognised in ethical and professional codes. Beauchamp and Childress include justice – the duty to ensure that costs and benefits are fairly distributed – as one of their four core ethical principles. The RANZCP recognises that alongside the duty to promote the welfare of individual patients, psychiatrists have a parallel duty to promote justice for all mental health patients through the fair distribution of mental health resources.

The CaNMEDS framework acknowledges the multiple roles that doctors play in society. Being a medical expert involves being a leader, a collaborator, and an advocate; these roles all require us at times to “lift our gaze” higher than the individual patient before us. When we are working in the emergency department and four unwell patients are waiting for one available inpatient psychiatric bed, good professional practice requires us to engage in a collaborative discussion with colleagues about which patient has the most acute needs rather than blindly advocating for our patient alone. When we are considering an expensive test with extremely low pre-test probability, good professional practice requires us to consider the potential costs and benefits of that test – not just for the individual patient – but within the context of a resource constrained environment where those dollars could be used much more wisely.

The moral determinants of health

In seeking to reconcile the apparent tensions between the interests of our patients and the interests of others, one helpful analogy comes from an unexpected place: comedy. Comedians are urged to punch upward in their comedy. In other words, the target of their jokes should be those who are more powerful and not those who are more vulnerable. When Sarah Cooper mocks Donald Trump’s comments on hydroxychloroquine she is punching up. When Donald Trump mocks a reporter with a disability he is punching down. A similar rule of thumb can be helpful for psychiatrists in assessing whether to advocate for an individual patient in the face of resistance.

Advocating against more powerful interests is not only permissible, but arguably required of us. Think of the countless doctors, caring for asylum seekers, who have written letters and reports advocating for their patient’s release from offshore detention centres. Or the many psychiatrists who appeared before the Royal Commission on Mental Health advocating for services that would meet the needs of underserved patients under their care. In the words of Norman Levinsky, these doctors are doing “everything that they believe may benefit each patient without regard to cost or other societal considerations”.

In contrast, advocating for the rights of individual patients at the expense of others who are more vulnerable is ethically tenuous, and often clinically unsound. For example, a man with a history of repeated family violence may benefit personally from having custody of his young children, but as doctors we have a duty to consider the rights of those children as well as the man before us. In another example, if we are planning to conduct a routine patient interview and the nurse asks to delay the interview for an hour so that she can attend to the needs of another patient (not under our care) who has been assaulted it would be churlish to follow Dr Levinsky’s advice and keep advocating for our own patient’s needs.

Conclusion

In conclusion, doctors face a real tension between advocating for the interests of our individual patients and responding to social demands. Keeping our patients interests front-of-mind is always appropriate, and we will often be called to advocate courageously for their interests in the face of fiscal, operational, and political constraints. However, our decisions regarding advocacy for our patient’s interests, above the interests of others, should be tempered by considerations of equity, rights, and justice – the so-called moral determinants of health (Berwick, JAMA, 2020). When we are advocating for patients, the needs, interests, powers, and vulnerabilities of those whom we are advocating against matter.