Abstract
Dear Sir,
It is instructive to reflect back over nearly 30 years of living and working as a psychiatrist in Australia, and give a personal perspective on local, professional, alcohol and drug service delivery.
I was recruited to work at Pleasant View Centre, Victoria’s premier alcohol and drug treatment centre, around the time of the Bicentennial. Alcohol and drugs had already been dissociated from the Health Department and sat, somewhat anomalously, in State Wide Services. When the latter was itself axed, around 1990, alcohol and drugs took a further step away from psychiatry. It became a part of community health. Two decades later, alcohol and drugs in Australia is ‘part of nothing’. It has been shifted, inexorably, out of the mainstream public, medical sector, and into the domain of local government, and the non-governmental organization. There is a complete lack of service coordination, and a total lack of political will to halt the deteriorating situation. The problem is repeatedly re-defined in government white papers. 1
Currently there is a national ice epidemic. This drug is cheaply manufactured and illegally imported from Asia. It is available at the remotest locations in Australia. That epidemic supervenes on endemic alcohol dependence and poly drug abuse. The First Australian community is particularly affected. It currently accounts for the virtual dismantling of indigenous culture.
I have been working regularly as a psychiatric locum at an outback medical centre. There, the management of drug and alcohol dependence has been all but eliminated from local psychiatric service delivery. Ostensibly it is managed when dependence is deemed secondary to major mental illness. In practice it is sidelined whether it is primary or secondary. There are no in-service specialists. Off-(psychiatric) site detoxi-fication is a pre-requisite for psychiatric management. The community is being let down by its professional services. Why might this be so?
The usual reason given is under-funding. It is true that rural and remote psychiatric services are now mostly restricted to a combination of auxiliary-professional triage, case management and inpatient care. I believe, however, that that is not the reason for the lack of services. Alcohol and drug abuse are at one and the same time endemic to Australian culture and abhorred by it. Australian ambivalence to the misuse of substances is pervasive. Were ordinary Australians to address the ice epidemic, then for the sake of comprehensiveness and consistency they would also have to address cannabis and alcohol dependence. They are evidently not ready for that; hence the inaction. White paper follows white paper, but ambivalence and ultimately hypocrisy rule. The antipodean psychiatric profession has done little to reverse this state of affairs. Most likely this is because of its own reluctance to acknowledge that it is as much a part of the problem as the solution. It will require a Herculean effort to re-skill and re-equip psychiatry and address the problem.
1: (i) A (ii) H; 2: B; 3: C; 4: C.