Anecdotal discussion alert … aOOOOga! aOOOOga!

I’ve decided this morning that diagnostic restrictions on prescribing of medications are not helpful. What am I talking about? The more expensive a medication is, the less the funding agencies want you to prescribe it; they would rather we use dirt-cheap haloperidol than expensive quetiapine for example. These expensive medications are therefore regulated, generally by way of subsidising them only for particular conditions (not necessarily all for which the medication is indicated – quetiapine as an example again: it was indicated in bipolar disorder in Australia for much longer than it has been subsidised for that indication).

You might think that’s a reasonable approach, but I’m not sure it has the intended effect. It seems to me, working in an acute community team which receives referrals from all and sundry, that more and more people appear to have these diagnoses – particularly bipolar disorder, once quetiapine became subsidised for the treatment of that condition….

Bipolar disorder’s the flavour of the month anyway (and has been for quite some months), and I’m not shy of making the diagnosis myself, but I have a sense it’s being used in order to “justify” prescription of quetiapine (or sometimes olanzapine) to people with other problems – not even necessarily based in psychiatric illness. Someone talks about “mood swings” (which seems very often to mean “I get angry easily”) and you can almost bet nowadays that someone is going to think about “the bipolar”. It’s then not a terribly big step to give quetiapine (flavour of the month again) which will in fact help in a case like that: it’s calming, sedating, it’ll help them sleep.

But taking an antipsychotic drug in order to keep calmer, and to sleep a bit better? Arguably even if these medications were completely innocuous (which they’re not) and inexpensive (which they’re not) there would still be something wrong with that: it’s (again) pathologising normality/real life, externalising control, abdicating responsibility and so on. And of course these medications are neither innocuous nor inexpensive.

So why do I think the diagnostic regulations are bad? Don’t I want them restricted to only the people who should have them? Yes, but … I wonder if it’s really working, or whether it’s actually just resulting in pressure to give diagnostic labels to people without real justification, in order to give them basically a non-addictive tranquilliser.

Like everyone used to use thioridazine (Melleril).

… Until we found out it does nasty things to the conduction in your heart and might kill you dead without warning …

Again, it comes back to our profession’s inability to differentiate sufficiently between illness and reaction to life. If we could do so, this would be much less of an issue.