Beyond the Edge Beyond the Bar: 13.07 Te Awamutu: Psychiatric Practice in NZ & USA

Tuesday of next week, 5 March, is Census Day in New Zealand. New Zealand conducts a census once every five years. A worker from Statistics New Zealand dropped off forms this past weekend. She encouraged me to submit responses via the Internet. There were three forms to complete: a ‘Dwelling Form’ and one ‘Individual Form’ for Jean and one for me. All of this official business served to remind me that we’re in New Zealand because of Jean’s profession. Jean’s a psychiatrist and if you’re not interested in reading my impressions of differences of Kiwi and American psychiatric medicine, you’d be well advised to skip this post, or just check out the unrelated photos following this post.

In the USA most people who seek psychiatric or psychological help are normal and ordinary—not crazy or bizarre. Of all psychiatric patients, 90% present primarily one of three issues: depressive disorders (30% of all psychiatry patients), anxiety disorders (30%), and substance abuse disorders (30%). People in these three major cohorts can present more than one issue, of course, but by and large 90% of the ‘psychiatric population pie’ embraces ordinary people who have mind-related issues requiring treatment. This isn’t to suggest that ordinary people shouldn’t be seeing psychiatrists or psychologists. A mild depression, for example, may become severe and a severe one may have crippling or even lethal consequences. I merely suggest that, despite the stigma of seeking psychiatric help, the vast majority of people who need such help are quite normal. Only about 10% of American psychiatric patients fall outside the normal, exhibiting extreme disorders—psychoses, schizophrenia, severe dementia, catatonia, and so forth. People are people everywhere (How refute that?) and I suspect that in New Zealand you’d find a ‘psychiatric population pie’ comparable to that in the USA.

Jean for a number of years worked for a county government behavioral health service in Wisconsin. She also worked in private practice. Now in New Zealand she works again in governmental service. She works for an entity called the Waikato District Health Board, albeit the Waikato DHB’s reach is veritably the entire Waikato Region (not just one or two districts within the region). The Waikato DHB provides a full range of medical services throughout the Waikato Region. The board does this through hospitals and numerous clinics scattered across the region. The largest hospital—the mother ship, as it were—is Waikato Hospital, located in Hamilton.

In both governmental venues (in Wisconsin and in the Waikato) the psychiatric service bias, as one might imagine, is to serve people in the outlying 10% cohort, mentioned above. People in this cohort generally present the neediest cases, the ones most warranting the expenditure of public funds. It’s in this ‘10% cohort’, if you will, that you’re likely to encounter someone under a compulsory treatment order (‘CTO’ in medical lingo). In both Wisconsin and Waikato governmental service, the majority of Jean’s patients have been CTO patients. In her private practice, CTO patients were a much smaller percentage of her patients.

In New Zealand, patients with any of the issues of the main cohorts–depression, anxiety, substance abuse–are expected to present those issues to their general practitioner (‘GP’) or to a private-practice psychiatrist (or psychologist), not to a DHB psychiatrist. Outside the 10% cohort those Kiwis who want psychiatric or psychological services must seek and pay for such services outside the DHB network, generally starting with their GP.

One especially notable characteristic of district health board psychiatric practice is the common employment of electroconvulsive therapy (or ‘ECT’). Who would want a convulsion, especially an electroconvulsion? American media—not least in movies like One Flew Over the Cuckoo’s Nest—have done their part in stigmatizing a procedure that admittedly by its very name seems like something out of Dr Frankenstein’s laboratory. But ECT— let’s stick with the initials—is a therapy shown often to be effective when no drug has been effective or where no drug dare be used (as with psychotic pregnant mothers). To this day in the States, ECT is used for severe depression (unresponsive to drugs), severe catatonia, severe psychosis, severe schizophrenia, and so forth. It is usually quite effective, but numerous hurdles (lack of facilities, lack of trained personnel, cultural bias, etc.) must be overcome before it can be employed in any one case.

In New Zealand, on the other hand, ECT is an accepted and widely used practice. Institutional and educational resources are dedicated to ECT’s widespread use, at least among the 10% cohort. ECT training for medical professionals is widespread (not narrowly addressed to a small percentage of psychiatrists and nurses). And, for example, Waikato Hospital has a room set aside for ECT and a nurse whose sole occupation is to assist physicians administering the procedure.

ECT’s wider use in New Zealand isn’t merely a product of greater receptivity. It’s also the product of necessity. The governmental system must rely on ECT because the system has such a constricted ‘formulary’ of allowable psychiatric drugs. The wide formulary of psychiatric drugs generally available in the States (even cheap ones available thru Walmart) isn't present within the DHB system. Drugs outside the formulary are allowed to be used only upon prior authorization from bureaucrats at the national level. The national authorities—as the third party hovering over the patient and the physicians—act like third party payers elsewhere. They must strike a balance between cost containment and service provision. And when they do so, they don’t want to do so on a case-by-case basis. Perforce, they make rules, when the patient and practitioner might want something otherwise. This reality, alas, seems to be a characteristic of modern bureaucratized medicine everywhere.

Few people aspire to be mentally ill. ‘Mental illness’, all things considered, is a rather loaded term, connoting a long-term condition in which the patient is mentally off-kilter, maybe even crazy. The people who fall into those 30% cohorts—afflicted with depression, anxiety, or substance abuse disorders—rightly take offense at being labeled mentally ill. Yet that is a key term of the American legal system for placing people in CTO status. Proving a persistent mental illness places a considerable burden on agents of the American public, in part (rightly) to avoid assaulting individual liberty. But among other things it also leads to convolutions of reality when, say, persons with drug-induced psychoses present themselves. Such persons aren’t mentally ill, but their minds are off balance. Left to themselves in severe cases they may kill themselves or others.

New Zealand has lifted the burden of proving that someone is mentally ill when making a case for CTO before the legal system. Instead, it is enough to prove someone’s mind is aberrant, that disordered cognition, perception, mood, or volition is somehow impairing a person from acting in a mentally balanced fashion. It isn’t necessary to come up with a diagnosis, after all (as in the case of drug- or alcohol-induced impairment) mentally impaired persons may not be mentally ill. But they may be in a state of mind that prompts them to hurt themselves or others. While this makes it easier to confine certain individuals who are regarded as dangerous (if, perhaps, only to themselves), New Zealand, as in the US, has an independent judiciary that issues CTOs. The judiciary acts as a check and balance against high-handed governmental incursions against personal liberty, at least presumably in most cases. By focusing on mental impairment rather than mental illness, New Zealand may have struck a better balance in CTO cases than the USA in protecting the rights of individuals and of society. Of course, no system of justice is perfect.

Nor is any living arrangement. But arrangements can be bettered. When we originally came to New Zealand, Jean and I envisioned living in Hamilton. But we soon learned that all the outlying clinics Jean would work at were at points south of Hamilton, starting with Te Awamutu (30 minutes south), Te Kuiti (more than an hour south), and Taumarunui (more than 2 hours south). Learning this and finding Te Awamutu ('TA') attractive, we asked whether we could live in TA, thereby removing 5 hours of commuting each week from Jean’s schedule. The request was granted. We’re grateful that the local, TA clinic leadership was able to find a furnished place in which to live in Te Awamutu. Jean’s appearance at the three clinics is part of the Waikato DHB’s efforts to bring a higher level of psychiatric care to patients (many of them CTO patients) living some distance from Waikato Hospital.

Perhaps in a future post I’ll be able to provide a perspective on this outreach effort. In any event, the perspectives shared above are mine and mine alone. I hope they are insightful. Whether or not they are, I’ve decided to include with this post some (unrelated) photos of public art of various kinds that caught my eye in travels around the North Island. They are included below.

Warm regards,

Tim