July 15th 2000


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Articles from this issue:

Cover Story: Human Genome mapping milestone?

Editorial: Managing Australia’s interests in S.E. Asia

Canberra Observed: Defence: opportunity beckons for Howard Government

Families: The hollowing of the middle class continues

New South Wales: Follow Swedish model: drug forum told

Trade: Canberra capitulates without firing a salvo

Doctors suspended over 32 week abortion

Straws in the wind

Education: New Queensland syllabus attacked

Economics: UN to look at the Tobin Tax

Media: GST ads unchained media bias

Development: Amartya Sen: the return of humane economics

Comment: The politics of suicide

Law: Death penalty debate resurfaces in USA

United States: Rising tide leaves poor floundeirng

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Comment: The politics of suicide


by Helen Spring

News Weekly, July 15, 2000
Helen Spring believes that the suicide of a prominent politician should focus attention on how our medical system dispenses psychiatric care.

Much has been written on the suicide of a politician, Greg Wilton. The coverage highlights how our public psychiatric hospitals have fallen victim to bureaucratic meddling in administration and funding.

Hospital managers are offered the carrot of a performance bonus for keeping within budget; and funding is based on “key performance indicators” — the average length of hospital stay, according to bureaucratic dictum, should be 11 days, so staff are under great pressure to discharge patients in time. This cuts across clinical indications for the time required for good patient treatment.

But it is not only the hospital system which is failing patients — other avenues for treatment are also being closed off by bureaucratic meddling. Some key points need to be made.

Depression can be a life threatening illness, and patients need expert treatment. It has been well documented that intensive psychotherapy is usually the most effective — short-term treatments have only short-term benefits. It has also been shown that if you provide unlimited psychotherapy to a community you actually save that community general medical costs of about 20%.1

But if someone in Greg Wilton’s situation needed intensive psychotherapy, he might not qualify for Medicare rebates.

Why?

Because if he had friends, a job, an income — the outward marks of stability and success (in spite of being deeply distressed inside) — he would not fit the rigid criteria set up by health bureaucrats in 1996.

These criteria are used to deny treatment by means of the most glaring anomaly in the whole Medicare system, “Item 319”. It dictates that the patient must have:

1) a history of severe sexual or physical abuse (this wording was dropped in 1997, but patients, had already been exposed) which has led to a psychiatric illness, or borderline personality disorder or anorexia nervosa or bulimia nervosa;

2) a rating from less than 50 in the Global Assessment of Functioning Scale (GAF); and

3) a history of failed [!] related psychiatric treatment.

Patients have been denied treatment because of Item 319. A particularly malignant aspect is the GAFs (which, like many bureaucratic devices, originated in the USA). Patients who score above 50 on this scale are not eligible, no matter how ill they are.

The GAF is a series of superficial descriptions of behaviour. It completely misses the most important point — what is going on inside the patient. Some samples from the GAF scale show what bureaucrats are capable of:

- 100-91 (The highest category) “Superior functioning in a wide range of activities, life’s problems never seem to get out of hand, is sought out by others because of his or her many positive qualities. No symptoms.”

- 50-41 “Serious symptoms (e.g. suicidal ideation, severe obsessional rituals, frequent shoplifting) OR any serious impairment in social, occupational or school functioning (e.g. no friends, unable to keep a job).”

This is the crucial category in deciding eligibility for treatment.

Human beings are complex — they do not fit neatly into bureaucratic categories. And we all know how deceptive appearances can be. Many patients are deeply distressed, suicidal, while seeming, on the outside, to be happy and successful.

Grieving friends and relatives say, “But he seemed so together, he had everything going for him ...”. Many, having made the final decision to suicide, are deceptively calm, and expert clinicians tell us this is a cardinal sign — a danger signal.

But paradoxically that calmness would ensure a high score on the GAF scale — “Life’s problems never seem to get out of hand” (100 -91).

The patient’s own doctor is denied any role in this bureaucratic process, his clinical judgment considered irrelevant.

In this way the GAF scale, superficial and simplistic as it is, provides a powerful tool for managers.

And here we have the very essence of “managed care” — treatment decisions are taken away from clinicians and giver to non-medical managers, who can use their power to cut costs and ration treatment.

So a patient in Greg Wilton’s situation, who is “functioning in a wide range of activities” (100-91), would not qualify for treatment. He might qualify when he dropped to the crisis point of “suicidal ideation” (50—41).

But by that time it could well be too late.

1 Doidge, N., “Empirical Evidence for the Core Clinical Concepts of the Psychoanalytic Psychotherapies: An Overview”, in Cameron and Ennis (Eds) Standards and Guidelines for the Psychotherapies, Toronto1998.

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