Psychiatry, Risk and Tragedies: The Scandals That Will Never See the Light of Day

I’ve been casually following the Nottingham Inquiry into the 2023 killing of three people in the Midlands’ city by a psychiatric system user. Something struck me about it: what if the deaths were significantly influenced by the very psychiatric services that are supposed to prevent such tragedies?

I’ve been someone who, like the service user at the heart of the inquiry, didn’t adhere to psychiatric drugs for the most part. In my case, this was blamed on me being ‘non-compliant’, without officials once considering the real reasons why I hadn’t been able to tolerate certain chemicals, especially at high doses.

I’d persistently struggled with a series of side effects, most notably akathisia. This isn’t merely what’s popularly thought of: a movement disorder that makes you shake with ‘parkinsonian’ symptoms for which there are drugs to address.

The real picture goes further. Much further. Akathisia is most often an adverse drug reaction from many psychiatric chemicals, which can lead to aggression and even violence. Akathisia can persist whether you’re on or off the drugs and its effects can lead psychiatrists to even increase the dose of the offending drugs when faced with such complications, contributing to, and escalating risk.

The assailant had been violent and suffering psychotic symptoms before drugs were administered, but the causal factors haven’t been foregrounded beyond sleep loss and exam stress. Violence and psychosis don’t happen in a vacuum.

What’s more, he hadn’t killed anyone before psychiatric drugs. Between what had taken place and what would happen was a clear escalation. Akathisia and, in particular, persistent withdrawal effects — effects that can persist well beyond the point, more than a year earlier, when the killer was said to have stopped drugs — can’t be ruled out. What, specifically, was left behind when he stopped taking these chemicals?

Why did he, like many in the system, not place his trust in it? Why didn’t the relationship work? That so many service users find themselves in this situation points to a substantial problem with psychiatry’s approach, rather than suggesting it was a unique state of affairs with this particular individual.

The last time I was in a psychiatric institution, I’d experienced the aggression that akathisia can give rise to when, without having the time to pause for thought, impatience and intense anger took me over on the basis of the very drug I’d been coerced onto. Twice I had outbursts that came on so rapidly, and were so uncharacteristic, that they shocked me after the event. I had no idea what the cause was and put it down to an internal fault in me. No-one — psychiatrists or other practitioners — told me any different. Paracetamol has better information on offer.

Digging around, I found the Akathisia Alliance, a survivor-led website which details just how stark the situation is. Reading up on withdrawal effects and also deprescribing showed me just where I and psychiatry had gone wrong. Here were the missing links. They became significant factors in seeing my time involved with psychiatry in an entirely new light. Risk assessments conducted on me never took a lot of important contextual information into account and misrepresented what information they did contain, anyway.

I’d suffered from akathisia and withdrawal effects even years before my involvement with the institution, both on and then off the chemicals, and yet I was left in the dark, eventually wondering whether, in the end, I really had been an aggressive person.

Psychiatric practitioners merely write up your behaviour and reactions in isolation, as psychiatry tends to do, to make the worst possible case disregarding crucial context. What can psychiatry do when so many of its instruments and management techniques are so detrimental to so many people’s welfare, and the very opposite of support? Well, it can’t reform because it’s as closed and defensive a system as you’ll ever hear of.

Notions of risk are central to psychiatric power. Tragedies provide the fuel: the news media goes into overdrive, politicians duck for cover, and policies are rushed through to tighten the coercive mechanisms on offer to officials, as if they didn’t abuse enough of them already. And yet no-one in the system or in inquiries questions what may really be going on or what could be done that stands a better chance of success. What’s also worrying is that those who work in psychiatry often can’t see the flaws in the system and themselves.

Many people suffer as a result in the aftermath of the very few emotive cases that do take place. For example, coercive ‘Community Treatment Orders’, which condemn many to a life of misery, were brought into being in the wake of high-profile tragedies, and the supposed safeguards in place aren’t nearly robust or thorough enough.

What if akathisia and withdrawal symptoms are central factors? I emailed the Nottingham Inquiry and Counsel about akathisia, but never received a reply. I didn’t expect to, and I don’t think such inquiries are equipped to deal with such information. They never are, and there seems to be no answer on the table that will prevent similar failures from taking place in the future.

What should be on offer to those who can’t tolerate psychiatric drugs, especially akathisia, is a creative approach to management and support, including deprescribing, before things escalate — certainly before aggression on the basis of side effects becomes part of the picture. There’s no solid reason why this shouldn’t take place.

All this is just speculation on my part — a casual hunch, a guess, but if I’m right, akathisia and withdrawal effects are a huge story at the heart of a psychiatric power that’s rife with abusive practices, both deliberate and unwitting. What’s maybe worse is that the Inquiry will not address whether the drugs aggravated what they claimed to treat.

But it’s a story inquiries won’t go anywhere near. Why the killer didn’t remain on drugs — which they would ask — isn’t the central question. The more pertinent one is the question psychiatry doesn’t want asked, because that would put the system itself in the dock. Psychiatry, like such inquiries, is an arm of the state. Concentrating on that will never happen in the news media, either. In most instances, it’s an easier, bigger story to write emotive headlines about killers and victims, than it is to do the legwork for copy that makes it less likely that we’ll be here yet again in the future. If it bleeds, it leads.

It makes for an easier life to brush under the carpet the very thought that psychiatry might be more involved in such tragedies in how it can distress, antagonise, coerce, and drug its subjects, compounding the adversity many service users face, and thus putting some cases under unbearable pressure. Drugs can change who you are. The many I took down the years often did. Again, official records are often found wanting on this issue. The Inquiry will be taken at face value, however much it misses the mark, and the familiar cycle completes.

Without question, the next such inquiry will do the same. Politicians and the news media will once more follow the well-worn script they always do. Like with inquiries, refusing to take the testimony of psychiatric practitioners at face value is crucial, not least because we’re dealing with people who will often tend to cast themselves in the best possible light, and their charges in the worst possible one, while calling themselves ‘professionals’ with a straight face. Reputations are at stake, and psychiatric workers, infatuated with prestige and deference, are big on protecting their reputations.

It’s all so easy — and lazy — when the news media effectively writes the story for them.

In the end, I saw improvements in my involvement with psychiatry, but these only came after a fight. That shouldn’t be the case. Deprescribing and consideration of akathisia and withdrawal effects, as well as how the management of cases by psychiatry can do more harm than good, should be central to modern practice, and because of all the flaws in psychiatry and the structures around it, I decided to work on leaving it behind. It looks like I’m one of the lucky ones.