So why have I decided against it? Surely it would be good to have these starter packs, as then I can use it….

It’d be good for the drug company, certainly. The evidence is that when medications are available to hand out to patients, doctors are more likely to use those, even when there are other appropriate – and cheaper – options.

Sure, I might see myself as immune to the wiles of the pharmaceutical industry – but so does everyone, and we’re all wrong.

So it’s better that I don’t get the samples. If I want to use the medication I can see about asking the drug company to provide it pending PBS subsidy, I can entreat our pharmacy to provide it, the patient can pay (as much as my socialistliberalhumanistpinkoswine self hates that idea) … 

… or I can use another medication, or non-pharmacological treatment.

Fame, it seems, is a harsh mistress. There is a striking – and superficially surprising – dichotomy evident in the world of the popular musician. The rest of the world sees glamour, riches, obnoxious self-indulgence, glitz, parties and excess .. Oh, and quite a few early deaths. Yeah… There is that… Kind of a bummer, really.

But we then hear about how the dead star was lonely and unhappy, and feel kind of puzzled, because the image presented to us is of success and hedonism. We certainly don’t see them as alone, because they always appear to be surrounded by others. And if we see them unhappy we often regard it as spoiled petulance. I mean, how can they have anything to really be unhappy about? Look at their glamourous life and all the stuff and fabulous friends they have.

Right?

I guess Jani Lane might disagree were he here to do so….

The life these idols lead, it seems to me, is self-sustaining, but also self-defeating. As Sebastian Bach describes in the post I linked earlier, once the gig is done, and the after-party is finished, and everyone goes home, the star goes to their hotel room. Silent and alone. But all the rest of their existence is the total opposite, so how do they deal with that?

A common theme in rock star’s descriptions of their lives is that they basically exist on stage, and in buses and hotel rooms. So they are thrown wildly between adulation and abandonment. It’s no wonder that the latter is hard to deal with. No wonder the star often wants to just keep partying – because they know when it ends they’ll be alone.

A relatively common thing to see on twitter in a rock star’s feed is them retweeting positive things other people have tweeted about them. Sometimes this is remarked upon (not kindly). The more you think about it though, the less surprising it becomes. Of course, as the positive comments are just about the external appearance of their existence – them as an idol, rather than them as people – it is ultimately as defeating as it is immediately sustaining. It can prop up the ego, but that just leaves more space to crash into when the hotel room empties, as it were.

The first I saw of this – though I didn’t really grasp it at the time – would have been watching The Jimi Hendrix Story. He really was quite alone, despite all the people around him. I recall later reading about Brian May suffering depression, and thinking “how can that happen?” He’s a rock star. He’s got everything.

Right?

… Guess not.

Rock stars are really like Birds of Paradise: it’s a sexual display on a massive scale. Consequently they attract many people – but it is, or can be, superficial. Particularly when the music business itself is factored in, and you think about all the hangers-on and various sycophants, how is the star to figure out the real motives of the people surrounding them? How do they find or keep real friends? That’s not necessarily the easiest thing in the world for the average person; how much less so for someone who feels they must constantly be second-guessing the intentions of any friend or acquaintance?

That led us to reflect on rock star tweets in general. They’re not exactly replete with suggestions of time spent with friends. Music biz acquaintances, yes. Other stars, the beautiful people, yes.

“Catch you all later I’m off to a BBQ with me best mate”? Not so much.

Ok maybe they just don’t want to share that sort of thing… But I’m not convinced it’s really that simple. It just doesn’t seem that the sort of relationships most of us take for granted are that easy or common for stars. So it appears there’s not much middle ground to balance out the extremes of idolisation and isolation.

Lest you think I’m pitying the dude with the badass hair whirling a guitar around onstage, with the adoring cries of tens of thousands ringing in his ears, let me be clear that they choose (if any of us can truly be said to choose) their path, and they do get plenty of rewards for doing so.

The litany of premature deaths, alone and sad, is pretty sobering though (apologies for the unpleasantly hyper-religious tone of that link, but it seems to have driven them to collate a fairly thorough list – though they’re not all suicide, or drugs etc, they’re all pretty young).

I’m not sure I have an overall point … Other than to highlight the dichotomy, and the way that pretty much every aspect of the lifestyle accompanying that type and degree of success reinforces it. Without a balancing middle ground then, the unhappiness that these people talk about becomes much more explicable.

As perhaps do the deaths.

In memory of Jani Lane, here’s my favourite Warrant song (though I was never a big Warrant fan, I really love this song):

“I don’t need to be the king of the world.
As long as I’m the hero of this little girl.”

We often see people referred following some stress or conflict or other. Sometimes there is psychiatric illness behind it; often there is not. Sometimes when there is not, a suggestion is still made (not by me, nor generally by any member of my team) that involves medication (usually antidepressants, sometimes – perhaps often – quetiapine), and even referral for ongoing follow-up by a psychiatric team.

My question: why? Why would you give a psychiatric medication to someone not psychiatrically ill? Why would you have a psychiatric team have ongoing contact with someone not psychiatrically ill?

The usual response? They have “some depressive features”.

Honestly, that is like being a little bit pregnant, or having some features of a heart attack. It’s stupid.

In other areas of medicine, including pregnancy and myocardial infarctions, we have investigations which can tell us if the condition really is present: we can do a serum βHCG, and ultrasound scans; we can check your troponin-I, and do ECGs.

In psychiatry we don’t. That’s why we have lists of symptoms -crucially, with thresholds: for both numbers and duration of symptoms. Without that, everyone in the world could be diagnosed with some psychiatric illness or other. The thresholds (eg at least 5 of the listed symptoms, for at least 2 weeks, for major depressive disorder) are there in an attempt to differentiate illness, or at least legitimate cause for clinical attention, from not.

Now, I’m one of the first to point out the problems with DSM (and probably would do so with ICD if I was as familiar with it). However, that doesn’t give me licence to ignore it. For people to prescribe antidepressants to someone who does not have a depressive disorder, only “some depressive features” goes against all the work that has gone into delineating major depressive disorder as a real entity. It is also not supported by evidence: not only are the trials that show antidepressants to be effective done in groups of people with actual major depressive disorder (not “some depressive features”), recent meta-analyses suggest (despite their shortcomings) that antidepressants might not even be much better than placebo for mild or moderate depression … So how likely is it that they would help “some depressive features”?

It’s too common though. A recent study (sorry, I can’t find the reference right now) looked at antidepressant prescribing – in the USA, but I don’t see that we have cause to assume we’d be different – and found that around a third of the prescriptions were written in the absence of major depression.

Any question as to why so many people find that their antidepressants don’t work?

Grrrrrumble.

As I’ve written recently (well, not that recently; I have been slack and haven’t written much at all recently…), the efficacy of antidepressants has been called ini to question by a few meta-analyses – and while there are real problems with those studies, I do think there might be some truth to what they say. I’ve also written often about psychiatry’s lamentable role in social control or engineering, and being thrown at all of society’s ills, when people might not be actually ill, but just distressed by their life situations.

So why would I now be extolling the virtues of antidepressants?

Because I’ve had a wee cluster of patients suffering major life stressors (job stuff, marriage stuff, children stuff, losing a home stuff… Yu know: the real biggies), who have also presented with serious depression. In such situations I generally tell people my aim is not to make them happy, as I think that would be unrealistic – and in fact diminishes the importance of the stressors – but rather to treat that part that is illness, and thus allow them to function. (That distinction was somewhat more clear in these recent cases I’m thinking of, by virtue of pre-existing diagnoses.)

Anyhow, so I set about treating the illness part of their problems, and on review, despite no change in circumstances (in some cases a worsening) the illness is resolving (not just because I think so; not just because the patient thinks so; because we both agree AND a well-validated rating scale says so). Again, I wouldn’t say any of them are exactly happy, but they’re physically and functionally improved.

That’s what I want to do. That’s what I’m here to do. I can’t fix the vicissitudes of people’s lives, but I can treat the illnesses that stop my patients from addressing them (or just coping with them) adequately.

So: FUCKYEAHANTIDEPRESSANTS! (And mood stabilisers and antipsychotics, of course – for exactly the same reasons.)

“The Opposition’s motion proposes to fund 90 ‘Headspace’ centres and 20 ‘EPPIC’ centres across Australia.

Both are proven models of community-based mental health care for young Australians. Headspace centres are drop-in community services where young Australians can find help without going through a hospital system. EPPICs – Early Psychosis Prevention and Intervention Centres – are similar community based facilities but for those with advanced conditions.”

What these are, in fact, are boutique organisations which provide (no doubt high quality) care to a vanishingly small proportion of the psychiatrically ill population. Headspace is available from ages 12-25 but has no ability to care for people withserious psychiatric illness, such as bipolar disorder, schizophrenia, and serious depressive disorders. This is what the motion refers to as “those with advanced conditions”; they get cared for by EPPIC … if they’re psychotic, yes. That’s what one of the Ps stands for. True, bipolar disorder can get in to services like these, but non-psychotic depression? Hells no. That’s not epic enough for EPPIC.

And I mentioned the age range for Headspace; what about EPPIC? I don’t know exactly, but I do know it’s a youth service, which generally have an upper limit of 24.

So, if you have a serious illness, no Headspace. If you don’t have a psychotic illness, no EPPIC. If you’re not callow youth, no EPPIC. You just get me.

Oh, and one more – really important – thing: these boutique outfits are not set up to do acute or intensive interventions, so if you need intensive treatment (in hospital or at home) and/or there’s a sniff of danger to yourself or someone else, they will pass you on like a hot potato to the general acute psychiatry service.

Which no-one is jumping up and down making high profile motions to increase funding for.

While these boutique side projects are polished up with their glossy brochures, shiny new buildings and lovely research opportunities, the core psychiatric services languish in under-resourced chaos. This is despite us being the services which treat the most severely ill patients, the people most in need. Thus we get the bizarre situation where the less unwell you are, the better resourced the service you get.

Please to explain.

*I realise that Prof. McGorry might have done no more than provide requested costings for EPPIC, but it does appear as though he is supporting this hare-brained motion. No surprise, since EPPIC is his baby, and he’s done very well out of it.