Doctor and activist


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Category: Mental Health

Mental Health and Physical Health

11 November 2021

The Health system has a major divide that is not often spoken about- the divide between mental health and physical health. 

Physical health tries to be a science and likes to think that its diagnoses and treatments are based on sound experimental evidence. If someone is sick and there are not enough facilities there is a fair effort from the medical profession and relatives to get more resources and they are mostly successful.  There is a highly respected system and career structure.

Mental health has similar endeavours, but has less of a scientific base for its diagnoses and treatments.  There has been a lot of work on neurotransmitters associated with depression and drugs that supposedly increase the good ones, but no single test is associated with a diagnosis, and diseases are defined.  It gives it a lingering stigma of imprecision.

The workforces in mental and physical health have relatively little crossover, even isolated within the same hospital. When I last worked in the health system 9 years ago in a hospital that had both an active ED and a mental health facility, patients were triaged as physical or mental, different teams saw them, and neither team wanted much to do with the other stream’s patients.  There was a shared waiting room, but different personnel, assessment areas, practices and wards.  Getting one of the other team to assess someone was an afterthought, or only when the pathology was fairly gross.

When I was in tobacco control, there was a lot of reluctance to try to get mental health patients to stop smoking as ‘they needed it’, which was another way of saying that to add the nicotine withdrawal to their generally stressed situation was merely making trouble.  But the public health statisticians said that people with mental health problems had a lot of physical problems and died about 14 years earlier (AIHW).  So glossing over the physical health of mental health patients is not without consequence.

It was interesting to note recently that a COVID-19 infection in a mental health inpatient went undiagnosed for 4 days, and drew attention to the fact that mental health patients had a poor vaccination rate also.

www.smh.com.au/national/nsw/hospital-patient-s-covid-19-infection-undetected-for-four-days-20211105-p596aw.html

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Sex, God, Anger, Mental Health, Guns, and Racism

20 March 2021

In a recent article about a mass shooting in a number of brothels in Georgia, USA, the Police were criticised for saying that the alleged killer had ‘had a bad day’.  Obviously his day was not as bad as those who were shot.  The Police were in trouble for not being condemnatory enough in their statement.  There was a lot of discussion whether the shootings were racially motivated as they were in Asian massage parlours.  An alternative explanation was that he was getting rid of the outlet for his temptations.

The study of accidents or ‘adverse events’ is a somewhat neglected science.  The legal system has graduated from ‘guilty or not guilty’ to ‘at fault or not-at-fault’, as this makes it simple to dispense justice.  The more nuanced study of adverse events has been mainly done in the aviation and oil industries where a number of small errors or omissions may magnify each other.  The oil industry has tried to quantify the probabilities, which of course is much beloved by the insurance industry, which wants to set its premiums on some sort of rational basis. (How many valves are there in the plant? What percentage of valves leak? What percentage of the valves control volatile liquids?  How many areas can form explosive clouds? What sources of ignition are there? etc.)

A common analogy used for major accidents is that there are a series of discs with a hole in each of them all revolving at different rates, and if all the holes line up, something can get through.  So if each disc is something that can fail, the combination of failures leads to the disaster.

There is then discussion of the environment, the primary, secondary and tertiary causes and the immediate precipitant.

So the headline of this article was an attempt to put some discs in line to look at why the shooting happened.  It is obviously a tragedy and totally unethical, but it is still helpful to discuss its elements coldly and logically.

Sex is a primal drive. An explanation offered for many species is that the males try to reproduce as much as possible, with the females acting as ‘quality control’ selecting who they will mate with and when.  Male libido is rarely discussed except as an embarrassment to harmony or a non-justification for unwanted sexual advances.  The Christian churches have generally had a very negative attitude to sex.  It seems that sex is defined as only acceptable in a monogamous relationship, the alternatives being states of either abstinence or immorality.  The word ‘morals’ has come to mean sticking to a sexual code, rather than behaving ethically in business, commerce or anywhere else.

This attitude to sex has made it an exceptional act.  When a baby girl first rolls over, everyone claps. When she first sits, stand, walks, talks or rides a bicycle everyone is similarly delighted.  But when she first has sex, the world seems terrified.   With boys it is similar, but there is much less terror.  Christian-ethos-based  societies do not seem to have come to terms with our basic humanity and its natural functions.  In consequence prohibitions and guilts are major elements in our society.

In Shakespearean society the serfs had nothing to inherit, so were not really concerned who fathered the village children. The middle class had money to inherit, so were very fussy who slept with who, and the kings staffed the Court with eunuchs just to be on the safe side.  In some Asian societies the men visit the brothels on the way home so that they will leave their wives alone. This also occurs in Western societies, but with the sex industry more marginalised. 

So if a man is at the extreme end of the libido spectrum, but due to personality characteristics is continually denied sex, he may become angry and frustrated.  This is unsurprising.  If his libido is then defined as abnormal, he may be termed ‘sex-addicted’.  Is this then a psychiatric diagnosis?  Probably not.  There is no real connection between psychiatric diagnoses and physiological brain function, and mental illness is often a question of definitions, which change significantly with time.  The diagnosis ‘nymphomaniac’ has gone out of use.

In the US with guns readily available, killing people is much easier; uncontrolled anger is much more dangerous.  Obviously an angry man is far more likely to kill 8 people if he has a gun that if he does not.

In that brothels tend to be staffed by people who are marginalised either by race or income, it is observed that many are staffed by Asian women.

If one accepts that there were 6 discs that had holes in them, one could argue which causative factor was the most important.  The Police may have been keen to play down the racist element.  They may assume that the guns and the ‘moral framework’ are not able to be changed, hence not worthy of mention.

Australia has no gun problem like this, but sexual consent is certainly the topic of the moment. A more natural and secular approach to sex education would seem to be necessary, and an obvious approach is to put it into a civics and ethics class into schools.  The crunch question will be whether it displaces scripture, which increasingly seems an anachronism.

www.smh.com.au/world/north-america/alleged-killer-says-sex-addiction-not-racism-motivated-atlanta-shooting-spree-20210318-p57bqb.html

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Police Leaving the Police On Medical Grounds Triples- Why?

7 February 2021

We might ask why NSW Police leaving the force on medical grounds has increased from 150 a year in 2014-15 to 420 in 2019-20, almost triple.

There is talk of a culture of bullying.

We might ask what they are being asked to do. Public perception seems to have changed when the changed their name from ‘Police Service’ to ‘Police Force’. The perception that they are now revenue raising, and that their cameras are so that they cannot use their discretion as they themselves are being watched may have contributed to this.

My own view is that the ever-more invasive laws that they are expected to enforce tends to have this result as they are more often thrown into conflict with ordinary citizens who they thought that they were there to help.

www.smh.com.au/national/nsw/fish-swimming-amongst-sharks-why-so-many-police-are-quitting-the-force-20210202-p56yp6.html

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Veterans’ PTSD costs $241 million 3/1/21

Some time ago. I was driving through Western Sydney and saw a huge billboard for army recruitment.  An interesting and challenging job, training for a trade etc.  I then stopped in a supermarket and there was a much smaller ad for a charity that helped Veterans who were victims of Post-Traumatic Stress Disorder.  I wondered why they needed a charity when the Dept. of Veterans’ Affairs has a much larger budget per patient than anyone else.

I asked a clinical psychologist friend of mine about this.  The psychologist had a good practice and admitted that a lot of work came from ex-Veterans, commenting nervously that almost all the Veterans had PTSD, but that it was a closely guarded military secret.  I was not surprised.  I had read ‘Exit Wounds- One Australian’s War on Terror’ by John Cantwell, the ex-commander of the Australian forces in Afghanistan.  He had PTSD and took himself off the short-list to be the chief of Australian defence to go into a psychiatric hospital for treatment.  He wrote in 2013 that the war in Afghanistan could never be won and that every Australian life lost there was wasted.  Troops are still there, presumably until the Americans all leave.

In 2019 I went to a pub dinner with a group I knew vaguely at a hotel in Kings Cross.  I had arrived late from work and as I moved to the end of our table, a man sitting alone on the next table moved his pack so that I could get in. I nodded thanks.  My group said a brief ‘hullo’ and went on with a conversation about people I did not know, so I remained a little detached.  After a while the man on the next table stood up and asked me in a broad Scottish accent if I would mind looking after his pack while got another beer.  He was unshaven and looked very dejected, perhaps in his early forties in age but his clothes were new.  I moved his pack so that it was more directly in my line of sight, and noticed that it was a state of art pack, perhaps a military one.  When he returned I asked him what part of Scotland he was from.  (This is always a good opening line for Scots as they hate being asked what part of England).  He said that he was a stonemason, who had lived with his single mother until she had become unwell with memory loss and needed institutional care. He wanted to get a ‘powder ticket’ so that he could have his own quarry. He could not afford this training so he had joined the British Army. Seemingly he learned his explosives quite well and was posted to Afghanistan. He had had to do ‘a job’ involving explosives and was praised by his commander as he had apparently done it well from a military point of view.

He did not elaborate much at this point as he choked back his tears, but he felt utterly worthless and had asked for an immediate discharge from the army. He had an elder brother in Australia from whom he had been estranged since his parents separated when he was young and he had in arrived in Australia this very morning to find his brother at the most recent address he had.  He had no phone number or email.  The brother had left the address, so he had stopped for a drink. He had no friends, no country and was very, very depressed. 

As his tale unfolded, I was increasingly wondering what I could do, but in this case luck was with us both.  One of the others on the table I was in theory still having dinner with had started to listen to our conversation.  She was a counsellor in the Kings Cross area and joined in. She took over and found him accommodation, promising to get him some PTSD counselling when she finished a morning appointment the next day, and quite subtly got him to promise reciprocally not to commit suicide overnight. 

I followed this up with the counsellor and she was apparently successful.  He went with an Australian PTSD sufferer to a farm in the Central West where rehab is done for ex-Afghanistan veterans. Hopefully it was successful longer term.

But this story is largely luck, and success is not assured.  Here was the real face of the foreign policy stupidity in the Middle East, and prevention is far better than any hoped-for cure. 

The Vietnam war may have been ‘lost’  on the TV screens of America, but it is highly dubious that it could have been won anyway.  Iraq, Libya, Syria and Afghanistan do not look like having any chance of the West winning. But since the Falklands war, journalists are embedded with the Army and so are on one side that gives them protection and restricts their information, so there is no peace movement of any political note to stop the foolish machinations of Australia in fawning to please the US in wars.

I am not sure that Veterans have ‘unlimited access’ to mental health services- if they did, why would there be charities appealing for support?  My experience is that all funding bodies including Veterans Affairs try to deny the existence of a problem.   It seems the concern of the article is the cost of the rehab. The answer of course is to stop the war. 

The Buttery mentioned was the one of very few live-in addiction rehab programs that I could find when I was in Parliament.  It was near Bangalow on the North Coast and had endless trouble getting funding.  If it is now exclusively used by Veterans others will be missing out.

www.smh.com.au/politics/federal/bill-for-veterans-mental-health-care-reaches-241m-with-20-000-in-rehab-20201030-p56a9w.html

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Mental Illness and Stupidity 3/6/20

Quite early in my Parliamentary career I was approached and discovered 4 problems with mental health in NSW. A fellow medical student, now psychiatrist approached me and said that the system was far worse than formerly.

I had worked as an after hours call doctor in 1977 and 1983 and found that mental hospitals did not want patients sent to them, and would try to talk referring doctors out of sending them. At first they would say it was not in their catchment area, then that the patients were not really mentally ill and I did not actually know what I was talking about. Eventually I tired of this game, so I would call and tell them a brief history, my diagnosis and that the ambulance with or without police escort was on its way.

So when my psychiatrist friend said it was a lot worse I was surprised. She explained that Nick Greiner closed all the long-stay mental hospitals for a supposedly community-based service with supported accommodation, but the alternative was never funded, and the system had staggered on ever since.

Then I was in an inquiry into the rise in the NSW prison population and a government prison psychiatrist had found large numbers of mentally ill and developmentally delayed people falling foul of the law. He explained that if they became dysfunctional they could not pay for the electricity and rent so became homeless. They had no chance of getting through the complexities of Centrelink and getting money, so eventually they were caught shoplifting in order to eat and ended up in the Magistrate’s court, where, if he did not divert them, they went off to gaol. He had a pilot scheme in Sydney and ?Port Macquarie to divert them to supported accommodation at hugely reduced cost.

I went for a long weekend near Port Macquarie and met an older lady on the beach, who, hearing I was a politician said that this made me a cad and a bounder who was of no use in the major social problem which was mental health. Accustomed to this assumption about politicians, I remonstrated mildly, and she told me her story of her schizophrenic son, who had gone in and out of supported accommodation and prison for 30 years without getting much help.

Finally I want to a conference on homelessness where I met a community mental health nurse who described how after long weekends she would go to the parks and under the bridges to look for her homeless patients, to see if they were alive to take their medication. I asked that she write a summary in point form of the problems of NSW mental health. She did so, and her excellent report formed the terms of reference of the NSW Mental Health inquiry which I initiated. I asked Brian Pezutti to chair it. He was a Liberal, and had the credibility of having been an Assistant Health Minister. He was also a very thorough and meticulous anaesthetist, retiring at the next election, and keen to do something useful before he went.

The Labor government agreed to the Inquiry because I had the numbers in the upper house. The Inquiry came out in 2002 (NSW Health System Worst in Aust SMH 10/12/2002).

It resulted in a number of things. The budget the following year in NSW rose by $320 million, but mental health money was also quarantined so that it could not be siphoned off to fund Emergency Depts or ICUs further down the budget allocation tree. Most significantly it triggered a Democrat-initiated Federal Mental Health inquiry which put psychologists on Medicare and hugely increased the mental health workforce.

Needless to say, diversionary schemes were part of the recommendations, as without support, mentally ill and developmentally delayed people cannot do the functions that are needed to manage a life in society. There appeared to be some progress and the complaints from mental health workers for some time changed from, ‘we cannot afford staff’ to ‘we cannot fill our positions’.

As the time has passed, it seems that the situation has slipped back. The history of these inquiries is that there is a fuss, things improve for a while, then go back until another inquiry finds the same problems.

So I was discouraged to read that a program to divert mentally ill people from Gaol is to be axed, because some bean counter thinks it is too expensive. According to the Dept of Corrective Services it cost $181.85 per day to keep a prisoner in NSW gaols, which is $1,273 a week, or $66,375 a year. It is dubious that a support scheme could not be organised for less than this, but the idea that the only thing that matters is whether it saves money seems an appalling way to run society. Surely we should figure out what we want to do, workshop how to do it efficiently, and then work out how to fund it.

If a diversion plan is to be axed, let the NSW government tell us that there are good diversion schemes already working and prove it by having an independent body affirm that there is not an excess of mentally ill or developmentally delayed people in prisons. If such schemes existed, why was there this new one set up? There is a long history of ‘pilot schemes’ being set up to deal with a political problem, and then quietly dying when the political heat goes off.

www.smh.com.au/national/program-diverting-intellectually-impaired-people-from-nsw-prisons-faces-axe-20200527-p54wve.html

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Mental Health. Small wins, more needed.

20 October 2019 When I was in Parliament, 4 things happened in quite rapid succession.  I was part of an inquiry into prisons and a Dept of Corrections psychiatrist who attended court to question accused people told the committee that it was much easier to get into Prison than the mental health system and that […]

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