Outcome vs Intention

There is a great quote by the late economist Milton Freriedman. In fact, quite a lot of good quotes from him. I think the man was a um, a genius.

But that’s beside the point.

One of the great mistakes is to judge policies and programs by their intentions rather than their results.

And we see this a lot in health care.

Seen in other areas of life as well, but particularly in health care. And for example, we’ve seen the failure of nicotine and vaping policies. And we’ve spoken about that a number of times on the um on the program. So that’s not the topic today. A report out from the center of independent studies by Professor Steven Schwarz.

Drowning in a sea of diagnosis. How medicalizing distress is overwhelming Australia’s mental health system and failing those most in need.

And this is a publication. We’ll put the link in the description as always, and you can download it. I think the executive summary gives you quite a bit.

And this is certainly, certainly um a phenomenon that I’ve observed over many years, sitting in practice, is that the people with the most severe mental health problems typically get shunted to the back of the queue, and the people who have a problem. Don’t get me wrong, they have a problem, but on the scale of severity, it really is at the milder end. And a lot of them could be described as life problems more than medical problems.

um sort of good enough, smart enough, whatever they have the wherewithal to get themselves to the um the front of the queue and you know in some respects that’s to ever thus. I’m going to quote here: at the center of Australia’s mental health system lies a paradox. Government spending has soared, doubling and redoubling over the past three decades.

Support programs such as the Better Access Initiative and National Disability Insurance Scheme have dramatically expanded access to therapy, medication, and support. Yet, for all this investment, the nation’s mental health has conspicuously failed to improve. Suicide rates have barely budged. Psychiatric drug use is at record levels. And each year, the number of Australians classified as mentally ill continues to rise.

So if policies and programs to improve mental health over the last 30 years are judged by their intentions, fantastic beauty. We should all pat ourselves on the back, as government and bureaucrats tend to do.

If we look at the outcomes, yeah, not so much.

The Diagnostic and Statistical Manual of Psychiatry, the DSM, which we’re currently at DSM5, is sometimes called the Psychiatry Bible. And the first edition in the 1950s had around 23 different psychiatric diagnoses.

the fifth edition published um circa 2014 could have been 13 but circa 2014 had nearly 400 diagnosis now I think it’s important also to understand the background of this how do these diagnoses get arrived at literally it’s by consensus group of psychiatrists sit around in a room and agree on what constitutes a diagnosis now that’s fine that’s the way it’s done but for example with high blood pressure we can measure measure your blood pressure and there is a cut off where we can say this is high above that level and that’s a whole separate argument about where these thresholds are drawn which again is a matter that we’ve discussed with diabetes there is a level which is classified as diabetes it is nothing subjective about that it is a measurement with mental health we can’t do that okay that’s fine but what it does mean is that these diagnosis are subjective and yes there are criteria but all of those are subjective as well and the medicalization of life means that we can reclassify what last week was look I’ve got a problem I’m not feeling that happy about for example I’ve got bills to pay or I’m not enjoying my work or you know I’ve had relationship problems maybe I’ve broken up with my partner boyfriend girlfriend whatever it might be and these are these are matters that are distressing are distressing, don’t get me wrong, and people may need support and or assistance for it, but it doesn’t mean that it’s a medical condition and therefore requiring medical intervention.

So essentially, by reclassifying normal life problems as mental health problems, we get an explosion in mental health diagnoses.

Um, I’ll read a little bit further from um Steven Schwarz’s uh paper. Uh, he gives an analogy with repetitive strain injury, or RSI, which was an Australian epidemic that peaked in the 80s and then disappeared.

Uh, he states, and I agree with this, RSI was not caused by a virus or a lesion but by the convergence of cultural narratives, financial incentives, and institutional responses. When diagnosis became a pathway to validation and compensation, case numbers rose sharply.

When those incentives changed, the epidemic faded. Once again, not saying people didn’t have pain in their forearms. They did. But I do remember um an orthopedic surgeon saying to me that he had never seen a case of RSI in a person who was self-employed. Maybe it’s a coincidence, maybe it’s not. I think it’s important to remember that it’s not saying that people are imagining symptoms and it’s not saying that they’re making it up, but it’s how it’s classified. And yes, there is such a thing as incentives and human beings tend to respond to incentives.

Uh to go on, Steven Schwarz says a similar trend is now evident in mental health. Uh diagnostic criteria have expanded. Some say that this is better because of improved diagnostic tools, awareness etc.

But um, the increase mainly in milder cases has enabled access to accommodation services or financial support. Um whereas the uh proportion of people with psychosis uh so the more severe end of the scale, has not particularly changed.

So the increase has partly been better recognition, accept that.

But part of it is also a reclassification of yesterday; you were just having a hard time, today we’ll give you a diagnosis.

And when diagnosis is an entry point to support and services, then, surprise, surprise, people will seek to go down that path. And when diagnoses are necessarily subjective, and I really want to again emphasize that, that doesn’t make it wrong. But when it is subjective and a clinician is sitting there thinking, well, this is on the borderline. Which side do I come down on? If I come down on one side, this person doesn’t access support and services. If I come down on the other side, you know, it’s not very difficult to see which side a person is going to come down on. And it’s for all the right reasons.

But this only happens because that is how the system is structured. If there were support for people based on the problems they’re experiencing rather than the need for a diagnosis, it might make life a little bit simpler and would save a lot of money as well.

But the step before that is the medicalization of life problems.

And we see this also in uh in teenage angst. I mean, teenagers, and you know, for those of you who are beyond the age of 19, have all been there and done that.

And for the younger listeners, if you’re still allowed to listen to a podcast in Australia, you know, hope you are, but um, you know, it does come to an end. It’s always been a time of transition, but these days, there is a lot of reclassing again. So you’ve had a bad day at school. It doesn’t necessarily mean that you have a mental health illness. You’ve broken up with your boyfriend/girlfriend.

It’s sad. You’ll get over it. It doesn’t mean that you have a mental health illness. You may be feeling anxious. You may be feeling sad. Sadness and depression are not the same thing. But the lines have become blurred.

And all the doom and gloom talk about the world ending because the weather might be a bit warmer in a couple of centuries doesn’t help. And of course, we’ve got the uh the pandemic issues from earlier in the decade. Uh study here again, which we’ll put in the description. Girls aged 11 to 17 had a 71% increase in anxiety diagnosis in primary care between pre and post-pandemic response periods, with boys in the same group experiencing a 62% increase.

When you tell like anybody, but particularly you tell children and teenagers, no, you’re not allowed to go out and see your friends. No, you can’t go outside. No, you can’t even go to, you know, a restaurant. You can’t throw a ball in a park. uh you know that has an effect on on teenagers has an effect on anybody and as we’ve obviously seen that it was all pointless anyway and then there will be the squeal oh we’ve got an epidemic of of mental health problems and it’s a crisis it is a medic it is a what we call an iatrogenic or medically created crisis and it didn’t need to beh [sighs] Ah, all right.

There are other ways of improving mental health. And unfortunately, a lot of this doesn’t get airplay. And for regular listeners, you can probably guess what I’m going to say next. That it doesn’t get promoted by big public health because there are no programs. They don’t get any funding for it. It’s too simple.

And if it’s simple and you can do it yourself, then you don’t need them.

36 minutes of uh-tuned music can reset an anxious mind. A new study found that scientifically designed music may provide better immediate relief from anxiety than pink noise. Now, some people like binaural sounds, some people like whale sounds, some people like ocean sounds, and some people like mantras. When you are listening instead of watching on your screens, listening to sounds, and you’re focused on that, you’re not focused on anything else. Keeping in mind, anxiety does arise in the mind from concern, worry, or trepidation about events that might be upcoming.

Predominantly, it’s more a concern about the future. Depression a little bit more rumination on the past. That’s a simplification, but those are the broad principles.

So as soon as you can click your mind out of worrying, to use a simple term, then you’re going to feel less anxious, and music can do that. Uh piece from worldhealth.net. Five creative hobbies that can help slow brain aging.

And again, they take your mind off what you’re worrying about. Painting and art activities, playing a musical instrument, dance, uh writing or journaling, and strategy games and puzzles. Now, all of those are good for brain health, but they also are going to take your mind off what you might otherwise be worrying about.

These are fairly these are very very simple, you know, simple things that we can all do ourselves.

Uh gratitude is the one other uh, and I think it was Mayor Angelo who said, and I quote is not exact, but you know, gratitude is my prayer.

There is evidence to support gratitude being good for mental health. Not surprising.

Um I want to this is again from an article I want to talk about critical component of wellness that we don’t talk about practice of gratitude consciously setting aside time on a regular basis to focus on the things that we can appreciative of and it’s not ignoring that we have problems but you know the very basic for those and again there’s some people in the world who don’t but suspect most of you listening to this podcast probably have a roof over your heads you’re probably not going hungry tonight you know just the very basics that our forebears, you know, couldn’t take for granted.

Look, yes, life is tough. There are tragedies, and this goes back to ancient times, and uh, as a reader more recently of meditations by Marcus Aurelius to ever thus, but despite that, and Aurelius talks about this, and in this article, despite life’s difficulties, it is also filled with joy and beauty. We can appreciate the sunset. We can appreciate the blue sky. can appreciate uh time in nature and regular practice of gratitude enhances our well-being and decreases stress or anxiety, and it’s free, and you can do it wherever you are. It is about getting into a habit. Uh, even some work has shown that it may decrease inflammatory markers and improve blood pressure because if you’re less stressed and you’re out of fight or flight mode, then that’s going to be good for your blood pressure, and it can lower inflammation.

None of this is difficult. None of this even costs any money, as free. You don’t need anybody’s permission.

But because it is so simple, it gets dismissed, and that’s really, really unfortunate is a reflection of our times that we think spending more money is somehow the answer. And to circle back to where we started, yeah, doubling of spending on mental health hasn’t produced any improvement.

I mean, the classic example probably is if one looks at health spending in general in the United States, it’s 17% of GDP, and that’s, you know, the average for the OECD is 10%. And the American GDP is a lot bigger than that of any other country. So if the Americans aren’t living 70% longer than the OECD average, and they don’t, then money is not the answer. Spending more money is not the answer.

There’s a role for it. And yes, services cost money. Of course they do. And assorted, you know, variable medications or other services and products cost money. Of course they do.

But they’re not the only solution.

We need to change what we’re doing if the outcome, as Milton Freeman would say, if the results and or outcome of our policies and programs are not aligning with the intention, which clearly they are not, but the likelihood of the government doing anything anytime soon, I wouldn’t count on. So, take matters into your own hands by doing some gratitude each day. We can all all of us find three things each day at least to be grateful for. Get into that habit. Doesn’t cost you anything.

Uh yeah, look at listening to some music or, as I mentioned before, doing puzzles or uh uh you know dance. I’m probably not the greatest person for dancing. I’m not greatly coordinated. Uh painting or art. We spoke about uh we spoke previously about the resurgence in craft groups. All of that is good because it gives the mind a focus and then you’re not thinking about that which distresses you. And most issues in life that are problematic will ultimately come to a conclusion and fruition. And you may not like that a certain event has happened, but that which is in the past can never be changed. What you can change is how you view it and what you do going forward.

So take matters into your own hands. You can do it. And I’d go as far as to say that adapting or adopting, you know, any or some or any or all of what we’ve spoken about, and please do your own research as to what else might work for you. You’re doing some trial and error.

Whatever you stick with that works for you will improve your overall quality of life.

Dr Joe

Dr Joe Kosterich – Doctor, Health Industry Consultant and Author

Doctor, speaker, author, and health industry consultant, Joe is WA State Medical Director for IPN, Clinical editor of Medical Forum Magazine, Medical Advisor to Medicinal Cannabis company Little Green Pharma and Course Chair, and writer for Health Cert. He is often called to give opinions in medico-legal cases, has taught students at UWA and Curtin Medical schools and been involved in post graduate education for over 20 years.

A regular on radio and TV, Joe has a podcast – Dr Joe Unplugged, has self- published two books and maintains a website with health information. He has extensive experience in helping businesses maintain a healthy workforce.

Past Chairman of Australian Tobacco Harm Reduction Association, current Vice President of Arthritis and Osteoporosis WA, Joe previously held senior positions in the Australian Medical Association and has sat on numerous boards.

www.drjoetoday.com
https://drjoeunplugged.substack.com/