An Ethical Approach to Involuntary Psychiatric Assessment and Treatment in Australia

This paper discusses the involuntary psychiatric assessment process in Australia and is in part based on my experience of being held against my will for assessment and treatment. It's main focus is to identify a number of ethical and medical weaknesses in the assessment process that often results in unnecessary suffering for many patients. Finally it also examines an ethical approach to the treatment of patients newly diagnosed with psychosis.

The first thing to note about the mental health system in Australia is the mental health tribunals, which are the mental health equivalents to courts of law except that they hear cases to decide on mental health issues such as psychiatric treatment and detention orders, do not adhere to the court of law rules of evidence or burden of proof requirements used to protect anyone charged with criminal or civil offenses. Essentially this means the tribunal may well hear a case against a patient that is in part or even entirely fictional, comprised of unverified allegations and hearsay, and the patient has no legal avenue of requiring that such evidence be substantiated.

Furthermore should a patient accused of ill mental health seek a second professional opinion and the second psychiatrist does not agree with the diagnosis of ill mental health, the tribunal is not bound to the second opinion. In short once a person accused of ill mental heath appears before the tribunal, they have little to no chance of defending themselves against the charge. In addition any person accused of ill mental health standing before the tribunal will likely have already been medicated with psychotropic drugs impairing their mental capacity and ability to accurately prepare and present their best case to the tribunal.

By contrast in the criminal justice system we can and do rely on the system to provide a high level of legal rights to the accused in order to minimise the chance of falsely sending an innocent man or woman to jail, as society today views sending an innocent to jail as an exceedingly undesirable outcome, preferring to allow many guilty people set free rather than falsely send a single innocent person to jail. So the accuser or accusers (from here on I will use the term accuser to include its plural) lay charges by speaking to the police, the police then have the task of verifying the accuser's story and collecting evidence against the accusee. If there is enough tangible evidence the public prosecuting team then presents the case in court, having to abide by the rules of evidence and prove their case beyond reasonable doubt to either a magistrate or a jury and then of course there are the appeals.

In a mental health tribunal, the rights and protection of anyone accused of ill mental health are almost completely absent, with only the slightest of hints of due process such as a lawyer being able to present the accusee's perspective and "independents" in the court. And so without any real ability to rely on the professional opinions of other psychiatrists, no rules of evidence, no beyond reasonable doubt and no jury, no penalties for breaches of the majority of the mental health act clauses, not to mention no way to avoid psychiatric treatment before the hearing, a person accused of ill mental health is the most legally oppressed segment of society, with society preferring to send many healthy people to psychiatric institutions for treatment against their will rather than allow a single mentally ill patient escape the system.

Notwithstanding the most unusual of circumstances, a mental health tribunal will always side with the hospital psychiatrist making the application for treatment or detention, as the tribunal is deciding on mental health and the only person in the room with a relevant professional opinion is the treating psychiatrist. Therefore with the current legal framework and operation of the tribunal, the treating psychiatrist is the accusee's only real chance of avoiding some of the most damaging treatments in modern medicine.

For a sane person antipsychotic drugs are psychotoxic showing a complete absence of benefit and only a truly terrifying raft of side effects including the risk of antipsychotic malignant syndrome, akathisia, dystonias, tardive dyskinesia, speech problems, depression, tardive and progressive dementia, psychosis, a permanent increase in the size of the basal ganglia and a corresponding reduction in frontal lobe volume, parkinsonism, sexual dysfunction, diabetes, tortcollis, ataxia, gait and coordination abnormalities, eye complaints such as glaucoma and blindness, edemas, hallucinations, cardiac complications, stroke, liver and kidney damage and any number of blood diseases including agranulocytosis, and the list really does goes on. In fact at high doses due to the number of metabolic pathways negatively affected, antipsychotics could even be considered instant Parkinson's, Alzheimer's, or Schizophrenia. Electroconvulsive therapy (ECT) provides a way to damage a brain directly with a current, but it is not possible to tell exactly where the damage will occur and psychiatric surgery results in permanent brain damage exactly where the surgeon decides it will occur. All in all the duty of care to protect the sane and arguably even the ill from such brain damaging treatments where possible is paramount (Breggin, 1994; Whitaker , 2002).

So an ethical psychiatrist's duty of care for their patients should include avoiding unnecessary diagnoses, doses, detention and psychiatric treatments.

One potential complication is that a psychiatrist may also feel they have a duty to the public to protect it from the potential criminal acts of the mentally ill. In this scenario there may be pressure on the psychiatrist to come to the tribunal with a DSM IV diagnosis and propose involuntary detention and/or psychiatric treatment even if the psychiatrist is not wholly convinced the patient is ill; indeed some patients completely lacking any mental illness symptoms are diagnosed with the potential to develop illness, called a prodrome, and are recommended for preventative detention and treatment.

However this presupposes a large threat to the public, that involuntary psychiatric treatment and detention reduces this risk, and that such action is ethical.

Are the people diagnosed with ill mental health really more likely to commit crime than other segments of society? Prior to the introduction of antipsychotic medication, there is significant evidence to suggest that rates of crime were roughly identical to the population in general (Whitaker, 2002). So the mentally ill are not an overly criminal bunch, but what about psychiatric treatment, does it reduce the potential for these patients to commit crimes? Unfortunately there is not any clear evidence to support the view that antipsychotic drugs in any way reduce the probability of patients committing crimes. Indeed many studies suggest that crime rates have actually increased since the introduction of antipsychotic medications (Whitaker, 2002). Further studies point out that antipsychotics accentuate psychosis and actually induce rather than curb violence (Breggin, 1994; Whitaker, 2002). Akathisia is a psychiatric condition induced by the use of psychiatric drugs and patients suffering from it display symptoms of extreme anxiety such as a constant need to pace or change positions while seated. Akathisia has also been recognised as inducing suicidal and homicidal thoughts and behaviours in patients who had previously been non violent (Breggin, 1994; Whitaker, 2002). Indeed depending on the drug and dose, akathisia has been reported in up to or even greater than 75 percent of all patients treated with antipsychotics (Whitaker , 2002). Unfortunately antidepressants also frequently induce akathisia (Breggin, 1994). This side effect can have catastrophic impacts; seven out of the last twelve high school shooting cases in America, including the Columbine tragedy, have been committed by young men and women on psychiatric drugs including antidepressants.

So the mentally ill actually committed a relatively low number of crimes until they were treated with antipsychotics and other psychiatric medications later found to induce criminal and violent behaviour. What about involuntary detention as a means to prevent crime? Let's start by extending the concept and applying it to not just the mentally ill, but to the entire population. Indeed we can never be sure when or where the next Ted Bundy will appear. So should we lock up everyone in order to prevent crime. Most people would argue that such a construct although highly effective in preventing crime, unnecessarily restricts the freedom of the individual. In fact an individual's right to freedom arguably defines a modern democracy.

Next let's identify subsets of the population who show a greater tendency towards violent crime. Statistically it is possible to identify demographic factors tied to high rates of violent crime. It may be that uneducated, unemployed black males between the ages of 15 and 45 show the highest rate of violent crime. Does this mean we should preventively detain these people to protect the rest of the society from such violence? Even though this action would no doubt reduce the amount of violent crime in our society, an individual's right to freedom remains one of the most fundamental of all rights and as such society does not see preventative detention as suitable in such circumstances.

What about the subset of ex-criminals convicted of violent crimes such as rape and murder? Should we preventively detain these known dangerous criminals in order to protect the public? Even though such detention is likely to protect the public and prevent violent crime, once a criminal has served out their sentence, they can no longer be held against their will and their right to freedom is restored.

From the above examples it is clear that it does not matter how likely an individual is to commit a crime in the future, an individual's right to freedom is always preserved over any potential benefit to society. Therefore compromising an individual's freedom on the grounds they may cause crime at some point in the future, even if there is a high probability of them committing violent crime, is not just unethical but also illegal and even undemocratic.

What about people who have a disease, let's consider patients with cancer, pneumonia, or even diseases that cause sufferers to display many of the symptoms of mental illness like Parkinson's or Alzheimer's? Does being sick allow us to compromise an individual's right to freedom? If a patient has any known disease physical or neurological, they are free to check themselves out of hospital at any time, or refuse any medication. So clearly being sick doesn't obviate an individual's right to freedom.

In fact an individual's right to freedom is so fundamental it cannot be taken from an individual, the individual must give that right up themselves by committing a criminal offense. Even then it must be proven in a court of law beyond reasonable doubt.

There is only one exception regarding an individual's right to freedom and it involves the public mental health system. In the public mental health system not only can a patient be held against their own will, such detention can continue indefinitely and does not have to be authorised by the patient by virtue of any crime committed, but rather by a psychiatrist who diagnoses an illness without any medical evidence. Indeed even the illnesses themselves are not scientifically discovered like any disease that we know of such as influenza or cancer; mental illnesses are fictional and the creation of new illnesses are voted on every year by the American Psychiatric Association (Szasz, 1976).

At this point I do not wish to diminish the suffering of any person afflicted with extreme melancholia or any other suffering whose cause cannot be identified by modern medicine; merely to point out the suffering of the individual is real, where as the mental illnesses are not. It is important to point out that a patient's suffering cannot be identified by a doctor or another member of the public, it is a subjective experience known only to the patient themselves. To ascribe suffering to a patient who rejects it, is to fictionalise the suffering. It should be noted that there are many patients who have been diagnosed as mentally ill even though they themselves were not suffering, that is they were not being tortured by voices or paranoia or extreme lows in mood, etc. Without the patient experiencing some degree of suffering, the only real component to mental illness vanishes, meaning that a patient's illness is then complete fabrication on behalf of the psychiatrist.

On one hand a hospital psychiatrist is a medical doctor doing the best they can to minimise the suffering of a patient in real and serious distress, on the other diagnosing fictional illnesses and forcing involuntary detention and brain damaging treatments on healthy patients without any medical evidence, effectively acting as jailer, torturer and sometimes even executioner.

A hospital psychiatrist is in possession by virtue of their position of an exceedingly large amount of power to use at their discretion. Indeed power is known to be intoxicatingly addictive, and it is understandable that a psychiatrist may enjoy exercising their power. As nice as it is to have, what is the point to all of this power based on fictional illnesses? And so we come back to the same two reasons again; the first is to help their patient, the second is to protect the public.

If the patient is not suffering, the illness is not real and there is nothing to treat; but the patient may still be held and treated against their will on an indefinite basis. The exercise of such power in such a circumstance can only be to protect the public. Protect the public from who? From healthy patients free from suffering, who have no real illness or disease, who have committed no crime? That is not protecting the public, that is not even real medicine, it is merely the illusion of protecting the public from healthy innocent people whom you are being asked to torture unnecessarily with physical restraints, solitary confinement, toxic chemicals, and electrical shocks.

The illusion of protecting the public makes a hospital psychiatrist into an instrument of control and punishment. Under this illusion, members of the public present their observations of inappropriate behaviours to the psychiatrist who is expected to medicalise these behaviours and then act by incarcerating and punishing (Szasz, 1976). And finally at the end of the process has the treatment served to protect the public? Not really, the patient is typically forced to ingest brain damaging chemicals that make them more prone to violence rather than less, and due to the damage incurred they are often transformed from independent to dependent on welfare and housing on an ongoing basis.

However, the moment a psychiatrist sees through this illusion, they are freed from their role as agents of control and punishment, if they so choose. There is a criminal justice system in place that is perfectly capable of dealing with criminal behaviours. These psychiatrists are capable of expanding their role as proper physicians and using their power to protect and heal their patients. A suicidal patient may well need to be sequestered involuntarily until they are no longer a danger to themselves, and a neurotic one may find a sedative helps them sleep, and a patient genuinely suffering from psychotic symptoms such as delusions or voices who doesn't respond to other therapies in need of a safe dose of tranquillizing medication, and a badly behaved father, son, daughter or wife with alleged symptoms of psychosis or prodrome shown the psychiatric ward exit. Identifying the presence of real suffering by the patients themselves guides an ethical psychiatric doctor in distinguishing those in need of care from illusion.

So what should a psychiatrist's duty of care for a person accused of ill mental health entail? Well that issue can be debated endlessly; however, I will try and outline a few practical areas that could be addressed including the admission to hospital before the assessment is conducted, sometimes known as emergency detention, the assessment process itself, and finally treatment of patients diagnosed with mental illnesses including psychosis.

Admission to Hospital before an Assessment

Let's start with the admission to hospital, and ask if it is ethical to treat a person with antipsychotic drugs or ECT on admission?

I would argue that unless an accusee is showing a consistent and/or extreme requirement to be restrained, then antipsychotic drugs should not be considered until a thorough diagnosis has been finalised. The reason for this is that a single dose of antipsychotics can and does induce extrapyramidal symptoms (EPS) such as akathisia, parkisonism, dystonias, significant cognitive impairment, drug induced psychosis, etc. For example a single 10ml dose of Haloperidol has been known to induce EPS in approximately 75% of patients particularly akathisia (Whitaker, 2002). Introducing such mental dysfunction on admission would prevent the psychiatrist from ever making a proper diagnosis. Does a person merely accused of ill mental health deserve to be subjected to the mental and physical trauma induced by antipsychotics which can take days, months or years to recover from or are sometimes even permanent depending on the severity of the reaction in the patient, without a proper diagnosis? I would argue that this course of action is not ethical and also potentially breaches the Hippocratic oath.

Likewise due to the brain damaging mechanism of ECT, it obviously follows that applying this treatment to a patient prior to a proper assessment and diagnosis breaches their duty of care.

Even if a person presents as distraught and potentially violent, could the patient not be placed in a room where they can be counseled to a point of calmness. Only a non responsive persistently violent accusee would then be exposed to antipsychotics. Perhaps even these patients could be sedated/medicated with less toxic medications before resorting to antipsychotics.

Lets examine a typical psychiatric admission, the patient is taken to a waiting area for some time before seeing the psychiatrist. After a brief chat with the patient who seems fine, the psychiatrist speaks with the accuser and receives evidence of behavioural problems from the accuser. The psychiatrist decides to medicate the patient with antipsychotics on the basis of the behavioural evidence received from the accuser. Is it ethical for a twenty minute chat with the accuser of ill mental health to result in the accusee/patient being exposed against their will to antipsychotics, one of the most psychotoxic chemicals used in psychiatry today, before the commencement of assessment and without a diagnosis? I believe that sound medical treatment requires a full and proper assessment and diagnosis to be completed before applying medications, particularly when taking into account the toxicity of the treatment involved. There would be a public outcry if we discovered patients were being treated with chemotherapy on admission to hospital without first being properly diagnosed with cancer.

Unfortunately, however, there are no specific guidelines in the mental health care and treatment acts, leaving such judgments up to the treating psychiatrist(s). Sadly it has become common practice for antipsychotics to be applied to the majority of patients admitted for assessment even if the patient is calm, lucid and responsive, and showing no signs of illness. Hospital psychiatrists are treating antipsychotics as if they are safe tranquillizing medications and using them off label on the majority of their patients, rather than recognising their inherent and extreme toxicity.

I would argue that this is not an ethical course of action in the majority of cases, as it subjects many patients to unnecessary toxicity and suffering, prevents a proper drug free assessment and diagnosis to be conducted, and breaches the Hippocratic oath. As a consequence I would suggest that the psychiatrist's duty of care should be extended to avoid unnecessary use of antipsychotics or drugs with similar levels of toxicity before a patient has been properly assessed and diagnosed.

Of course if the accusee/patient is suffering from delusions, hallucinations, hearing voices or other serious symptoms and suffering and is consequently in marked distress and importantly asks for treatment, then it would equally be a breach of oath to refuse treatment at this point. However, the psychiatrist may even in such a circumstance, wish to err on the side of caution and avoid the use of antipsychotics to ensure a proper diagnosis and consider other non drug or less toxic drug treatments before resorting to antipsychotics. So treatment even for a patient experiencing significant psychotic symptoms may be counselling until a sound examination and assessment can be finalised.

The Assessment

Unfortunately many members of the public comprehend how easy it is to have people involuntarily held against their will for assessment, and a person is held against their will every few seconds in Australia and America (Szasz, 1976; Whitaker, 2002). It is highly probable that many of these admissions have been based on reasons other than the health of the individual, such as financial gain or merely as a control mechanism in relationships (Szasz, 1976).

Just pick up a contract or family law textbook to see the number of family disputes that occur in order to realise that families deal with wills, businesses, children, property ownership and many other areas of considerable and significant financial and emotional value and that relationships do not always go smoothly between family members leading to disagreements, fights, court cases, and indeed involuntary psychiatric admissions.

It is not just families that fall out and accuse each other of ill mental health, if a business fails partners often blame each other and may sue or call the taxation department and offer a tipoff. An involuntary mental health admission can also be a cheap and easy way to discredit or punish an ex business partner.

All of this means that a psychiatrist can never be certain of the true motives of the accuser. This also means that the accuser may feed the psychiatrist anything they want to in order to try and develop a case of mental illness against the accusee. The way the current system is established the accuser does not have to prove his statements to be true, in fact they can make it all up and the psychiatrist may never know.

So now the psychiatrist really needs to make sure that they are not being misled by the accuser into medicalising behaviour and acting as their agent of control and punishment rather than making a diagnosis in their patient's interest (Szasz, 1976).

The most important point of course is ensuring that the patient is actually suffering; without this there is really no point progressing with the assessment, as one cannot treat a person free from distress unless one wanted to introduce iatrogenic illness. As I pointed out previously, a patient's suffering is the only tangible component to a mental health diagnosis, and without it the diagnosis would be entirely fictional, finalised only for the purpose of subjecting a person who has performed no crime, to involuntary detention and punishment called treatment.

Let's assume that the patient is found to be suffering from unbearable negative moods, or due to delusions that are causing them considerable distress in order to move forwards with the assessment process.

The psychiatrist required to make the assessment and potential diagnosis can now either speak with the accuser or avoid any such conversations in order to make an independent assessment. Also mental capacity testing is an often neglected area of mental health assessments.

Speaking With The Accuser

If the psychiatrist decides to speak to the accuser, they must enter such conversations with the expectation that the accuser will try and have the accusee unnecessarily diagnosed with mental illness based on their behaviour and for motives that are likely to be less than pure.

In obtaining the accusers evidence of madness, typically a patient's behaviours; a prudent psychiatrist would always question the veracity of the accuser's statements. The patient should also be given a chance to answer any and all behavioural accusations leveled at them in order that the psychiatrist make a diagnosis in the patient's interest and health as the patient's wellbeing rests in the hands of their psychiatrist's ability to discern a true health crisis from one being invented for ulterior purposes. Also on occasion an illegitimately based involuntary admission has resulted in tragedy for the accuser when the patient develops homicidal thoughts and behaviours due to the psychiatric treatment they receive, sometimes resulting in entire families being killed.

Is there any sort of personal or financial benefit that accrues to the accuser should the patient be deemed insane, perhaps the accusee can point out any motives. Can the accuser or accusee confirm their claims with relevant records? Is the admission merely evidence of a breakdown in the relationship between two people?

In almost all admissions for involuntary assessment there is a breakdown in the relationship between the accuser and the accusee, with the accuser being the first to point the finger and say, "they are no longer acting the way they were". Usually it is the person with the least power in the relationship who will be accused of ill mental health when a relationship begins to weaken. A housewife feeling mistreated or neglected by their professional husband over many years, may eventually become less loving as the relationship decays. As she withdraws from the relationship, she pays less attention to her personal appearance, makes less effort with the housework and cooking, becomes less talkative, seems distracted and lacks attention, is involved in less activities, and becomes more sensitive, irritable or even argumentative. This signals her withdrawal from a non beneficial relationship. Her eloquent and professional husband notices these behaviours, understands the situation, but would prefer that the relationship continue rather than end, and has her admitted for involuntary assessment citing these behaviours as evidence of psychosis. On admission she is given antipsychotics, a psychological profile is never sought, and she is diagnosed with psychosis the evidence provided solely by her husband.  After psychiatric drugs such as antipsychotics, such a housewife is likely to no longer be capable of moving on with her life to a new and more beneficial relationship.

Alternatively a father and son work together on a project over time developing a business together. Then the father insults the son rejecting his equality in the relationship, and as a consequence the relationship as well as the business starts decaying. The son becomes increasingly hostile towards the father over a number of months, behaving argumentatively and angrily and slamming door signaling there is a problem with the relationship and it is about to end. Rather than apologising and treating the son well, the father has the son committed for involuntary assessment and treatment for his insubordination and non conformist behaviour. Once treated with medium doses of antipsychotic drugs the son is damaged and unable to move on and enjoy the rest of his life as he would have without the psychiatric intervention.

It is very clear that when relationships break down, people's behaviours always change. Different people react in different ways, some people withdraw in a passive manner as the housewife in the above example, others alternate between passive and aggressive, while others take a more assertive approach like the son in the above example. The more likely the relationship breakdown is final, the more likely the the changes in behaviour will be amplified.

So one of the keys to a good diagnosis has to be developing an understanding as to whether the changes in behaviour cited by the accuser are merely indications of the impending finalisation of a relationship or evidence of madness. A prudent psychiatrist may involve a psychologist in making such determinations.

Although common practice, is it sound for the treating psychiatrist to base their diagnosis primarily by speaking only with the accuser regarding their complaint? I would argue that this mode of assessment is not in the patient's best interest as it relies on the accuser's version of events as the mainstay for their diagnosis. If the psychiatrist choses to interact with external parties as part of the assessment, then an ethical approach requires that psychological profiles of both accuser and accusee to be sought in order to get to the source of all of the psychological issues leading up to the involuntary admission, that the patient where possible should remain medication free, and the patient should be allowed to address all the allegations raised by the accuser.

Independent Assessments

An alternative to getting involved with psychological profiles of both the accuser and accusee to ensure the source of the problem is really ill mental health rather than relationship breakdown, commercial advantage, relationship control, etc, is to avoid that typically very difficult and complex scenario all together, and concentrate on making an independent assessment.

This means not applying any drug therapy until the assessment is complete, speaking with the patient to ascertain their current state of mental health, obtaining their psychiatric history, and requesting a psychologist to detail their psychological history. In addition the patient can then be observed with regard to their ability to communicate and socialise while in the ward. After a number of days, or maybe longer, the psychiatrist will be in a good position to deliver a considered diagnosis without even speaking to the accuser or resorting to antipsychotic drugs.

When resource and time constraints apply this may be a prudent approach as it avoids introducing bias into what should be an objective assessment. If the illness is not present and measurable in hospital, then the patient clearly cannot be ill, so speaking to the accuser about alleged symptoms of illness prior to the admission and making diagnoses on this may well be considered unsound and unscientific.

Mental Capacity Testing

In addition to examining the relationship between the accusee and the accuser another area that is often neglected by many psychiatrists conducting mental health assessments is mental capacity testing.

Although many if not all mental health assessment textbooks include a section on determining a patient's mental capacity by examining: cognitive function, attention, concentration, memory, general intelligence, abstract thinking as well as perception; lack of legislative requirements have lead to psychiatrists frequently avoiding this component of the assessment process (Hagerty, 1984; Hurt, Reznikoff, & Clark, 1991). This has meant that many competent patients have unnecessarily had their right to consent obviated by a protocol probably developed decades ago and passed on to psychiatric registrars as part of their training.

I believe that altering the protocol to always include mental capacity testing is an ethical approach to mental health assessment. Such a change would allow the psychiatrist in the context of the assessment to objectively identify those patients capable of understanding their condition and making decisions regarding their treatment options. For these patients the psychiatrist could then focus on informing them about the various treatments that are available, allowing the patients to ultimately make an informed decision regarding their treatment.

Treatment Following a Diagnosis of Psychosis

This next section examines the duty of care that a psychiatrist should offer their patients when considering treatment options for patients diagnosed with psychosis.

As I already pointed out, there are no medical tests capable of confirming the presence of any mental illness let alone any to show the precise location of mental illness like we can with brain tumors (Andreasen, 1984; Katona and Robertson, 1995). Without any medical evidence of an underlying physical disease, there can be no way of differentiating those patients suffering their illness based on physiological problems from those suffering due to psychological problems. Either way physical removal or destruction of brain tissue without being able to identify which part of the brain is diseased, cannot ever be considered an ethical front line treatment or cure for mental illness. Psychiatric surgery which is removal of tissue from a patient's brain, can therefore only be seen as a surgeon doing serious and permanent injury to the patient, which would in most circumstances breach their Hippocratic oath.

Exactly the same can be said of ECT, the difference being exactly which part of the brain is damaged by ECT depends on the path taken by the electricity through the patient's brain and is therefore brain damage by random chance, and should consequently not be considered an ethical front line treatment of psychosis or indeed any mental illness (Whitaker, 2002).

In addition antipsychotic drugs cause irreversible brain damage, with tardive dyskinesia the most popularly acknowledged form of drug induced permanent injury (Breggin,1994).

So how does a psychiatrist treat a patient only just diagnosed with psychosis? There is no medical proof that psychosis results in ongoing deterioration, that would require identification of a physical cause. There is also ample evidence to suggest that in a significant number of patients the initial psychosis is all they ever experience.

In the absence of being able to locate a physiological cause for the illness, the obvious ethical course of action is to focus on the lowest risk alternatives that are available to the patient as the front line approach to the treatment of psychosis, including all forms of psychological therapy. Indeed I would argue that it may be medically and morally apposite to refuse to medicate a patient in this situation as medicating the patient almost certainly exposes them to the highest risk of brain damage of all available alternatives notwithstanding.

ECT and Psychiatric Surgery

Should all front line alternatives fail to provide the patient with adequate relief, then the psychiatrist may want to consult with the patient to determine the next course of action. As part of the discussion the risks of the medication should be pointed out to the patient. Having been adequately briefed as to risks including progressive cognitive degeneration, permanent frontal lobe impairment, and movement disorders, some patients may still feel that they want to try such medication.

Should the psychiatrist and the patient agree that the patient will try the antipsychotics, only an experienced psychiatrist should decide on the exact medication and dose. The experience is needed as the psychiatrist will have not only read the drug company information, but actually have seen the long term impact of the various medications on the health of patients. Avoiding the most recently released medication is likely prudent as the medium and long term impact will have yet to be properly assessed. The medication should be as clean as possible, affecting the least number or metabolic pathways, and the dose as low as possible to minimise the sometimes life threatening and progressively degenerative effects of these most toxic of medications.

Avoiding EPS

EPS signals the emergence and development of serious long term irreversible brain damage (Breggin,1994). The best way to avoid EPS is to avoid the drugs that cause them. Non drug therapies should always be tried as front line treatments before attempting drug treatment with psychological therapies such as CBT and other mental health courses run by hospitals accepted as sound medical therapy for illness. With the recent increase in the government's Medicare rebate for psychological treatment, it makes this sort of therapy available to even the poorest of patients.

This together with spending time in rehabilitation houses and programs means that patients may make a sound recovery with significantly better long term prospects and a much better quality of life. Patients can also combine their therapies with acupuncture, exercise and diet programs in an attempt to obtain complete remission from their illness.

Should such front line treatments fail, then antipsychotics could be introduced as the next line of treatment.

If antipsychotics must be used, avoiding EPS is of paramount importance to maintain the wellbeing of any patient. Some argue that there are no safe antipsychotics just safe doses. Consequently knowing what the maximum safe dose of each of the antipsychotics is, and for some of the drugs perhaps that dose is extremely low, is the key to successfully avoiding EPS in patients.

Also the choice of antipsychotic plays a role as some antipsychotics are involved in so many of the body's metabolic pathways that triggering EPS would create a much more harmful result in the patient. Furthermore if a patient is stable and tolerates an antipsychotic without incurring EPS, trying further medications that could interact with previous medication and trigger EPS should be avoided.

So knowing and applying only the cleanest antipsychotics with tested and known safe doses has to be the best way to treat first time patients in order to maximise the chances that the patient avoid the terrible harm that such drugs can inflict.

Finally if EPS do emerge, avoiding the use of anticholinergic drugs where possible is likely to benefit the patient. As the patient is already suffering an intolerable torture, they do not need further mental health complications such as confusion, psychosis, disorientation or serious eye deterioration.

Conclusion

By virtue of the operation of the mental health tribunal it was established that a hospital psychiatrist has wide ranging powers allowing them to override basic human rights such as an individual's right to freedom and an individual's right to refuse treatment. Furthermore this power was shown to be available to help a suffering patient and to protect the public. It was shown that where a patient was not themselves suffering, that often other members of the public brought evidence of illness to the psychiatrist hoping for the psychiatrist to medicalise such behaviour and operate as their agent of control and punishment rather than as the patient's doctor. An ethical psychiatrist would operate to avoid such a role and choose to focus instead on their role as physician making sure patients merely guilty of misbehaviour are not unnecessarily deprived of their freedom or health as the criminal justice system is better equipped to deal with such matters.

As such a hospital psychiatrist needs to take appropriate precautions to ensure that they have correctly assessed and diagnosed their patients. To do this they need to avoid medicating patients with antipsychotics before diagnosis where possible, seek both psychological as well as psychiatric patient profiles, and to act as an intermediary between the accuser and the accusee with regard to determining the veracity of the "evidence of madness" so that the patient is not incorrectly diagnosed on the basis of half truths or lies offered by accusers with unscrupulous motives or simply because of a relationship breakdown. Finally a hospital psychiatrist should also conduct mental capacity testing to objectively determine the ability of a patient to consent to treatments. Patients with sufficient capacity would then be able to provide informed consent regarding treatment options.

Next in order to avoid the Pandora's box of physical and cognitive damage that antipsychotics, ECT and psychiatric surgery inflict, a hospital psychiatrist should promote lower risk alternatives such as psychological therapies as front line treatments for first time patients diagnosed with madness. This is because such therapies maximise the chance of a patient's full recovery to valuable and productive members of society and produce no physical harm. Patients who recover in this way require the least amount of ongoing medical and welfare support freeing up these valuable resources for more needy members of society.

Finally if non drug treatments fail, and antipsychotics are to be used, the psychiatrist must do all they can to avoid EPS and other harmful side effects of such treatment. This can be achieved by ensuring the patient is provided with the lowest doses of the cleanest antipsychotics available, and avoiding changing medications unnecessarily. Also if EPS are triggered avoiding the use of anticholinergics where possible is prudent to avoid worsening the patient's health.

References

Ackerman, M. (1999). Essentials of forensic psychological assessment. London: Wiley.

Andreasen, N.C. (1984). The broken brain: The biological revolution in psychiatry. New York: Harper and Row.

Breggin, P. (1994). Toxic psychiatry. New York: St Martins.

Katona, C. and Robertson, M. (1995). Psychiatry at a glance. Oxford: Wiley.

Hagerty, B. K. (1984). Psychiatric mental health assessment. St. Louis: Mosby.

Hurt, S.W. Reznikoff, N. and Clark, J.F. (1991). Psychological assessment, psychiatric diagnosis and treatment planning. New York: Brunner/Mazel.

Szasz, T. S. (1976). Schizophrenia: The sacred symbol of psychiatry. British Journal of Psychiatry, 129, 308-316

Whitaker, R. (2002). Mad in America: Bad science, bad medicine, and the enduring mistreatment of the mentally ill. Cambridge, MA: Perseus.