Controlling influence

Institutions such as nursing homes and prisons
are increasingly using psychoactive prescription drugs to control
people in their care. Natalie Valios reports.

How many social workers and care staff wish
that their disruptive, angry or aggressive clients could be calmed
down and sorted out with a simple pill? Frustrated or tired workers
may long for a magic chemical “cure all”, but few would admit
administering drugs to clients solely for control and restraint
purposes.

Despite this reticence, there is some evidence
that psychoactive drugs are being used as a means of social control
in institutions. Unfortunately, evidence tends to be anecdotal and
few of those involved are willing to speak out about it.

Paul Burstow, Liberal Democrat spokesperson
for older people, is not so retiring. He has been campaigning for a
number of years for an end to the over-prescribing of
anti-psychotic drugs to older people, nicknamed the “chemical
cosh”.

At the end of last year, he published a report
calculating that more than 35,000 older people in nursing homes and
as many as 53,500 in residential homes were being sedated for no
medical reason.¹ It reveals that between 1999 and 2000
there was a 70 per cent increase in the use of atypical
anti-psychotic drugs in one year for people aged 60 and over.

The National Service Framework for Older
People has set a target that by this month all people over 75
should have their medicines reviewed at least annually. Those who
take a cocktail of four or more drugs should be reviewed twice a
year.

While he says this is a move in the right
direction, Burstow wants new research and prescribing guidelines
brought in urgently – perhaps along US lines, where anyone taking
four or more medicines is reviewed on a monthly basis, while those
taking less than this are subject to a quarterly review.

Correctly used, anti-psychotics have a
sedating and calming effect. But side-effects can be grave:
cognitive impairment, uncontrolled involuntary movements (tardive
dyskinesia), muscular rigidity, constipation, sexual dysfunction,
seizures and depression. There is also evidence that the use of
these drugs actually accelerates the development of dementia.

And it seems that older people are not the
only ones being prescribed drugs to make them easier to handle.
Research reveals routine use of psychoactive drugs on prison
inmates, including those without mental health problems, to calm
them down. Figures indicate that about half of all female prisoners
are likely to be on medication, compared to a fifth of male
prisoners. Former chief inspector of prisons Sir David Ramsbotham
expressed his concerns about the level of prescribing to women in
prisons, especially the combining of anti-depressants,
tranquillisers and night sedation, as long ago as 1997.

This still goes on, says Medacs Forensics
Services, which provides health care services to prisons. It
carried out a health care audit of Holloway prison in 2000. The
report, which was never published, suggests that drugs were
dispensed in uncontrolled ways and without thought to their
appropriateness. Medacs concludes that “the overall impression in
terms of the prescribing and dispensing of medication…was one of
a serious lack of control, which, in view of the nature of the
environment, afforded considerable risk”.

Whether prisoners can really have consented to
taking these drugs is a moot point. Treatment in prison is not
covered under the Mental Health Act 1983, so patients treated
without consent are also not covered by the act’s safeguards.

This might account for the alarming difference
between the number of women being prescribed drug treatment before
and after they enter prison. According to the Office of National
Statistics last year, just 17 per cent of women were prescribed
drugs acting on the central nervous system before imprisonment.
This rose to 50 per cent once they were in prison.

As well as the possibility of debilitating
side-effects, evidence suggests that the misuse of these drugs can
result in people being misdiagnosed as suffering from mental health
problems. This, in turn, can lead to a prescription for further
inappropriate medication, compounding the problem (see panel).

According to a report published this week by
rehabilitation agency Nacro, there is a wealth of anecdotal
evidence to suggest that powerful anti-psychotics and
tranquillisers such as Melleril and Largactil are being prescribed
at high levels within women’s prisons.²

The Nacro report argues that the prison
service needs to “get away from the mindset which automatically
reaches for the prescription pad as a response to a cry for help
and instead to promote adherence to the principle of prescribing
according to therapeutic need”.

During research for her book on women in
prisons, inmates told author Angela Devlin that Valium was “doled
out like Smarties”.³ She also says she saw “zombified”
women doped up on large doses of Largactil (used to manage manic
depression) and suggests that its use was primarily to control them
rather than to help them come to terms with their situation.

To be fair, Devlin says that it is not always
entirely the prisons’ fault – women often arrive at prison with
prescriptions for anti-depressants and tranquillisers from their
own GPs. Women coming into prison are often in “a great deal of
distress”, but according to Devlin most want counselling rather
than drugs.

The Prison Reform Trust wants an audit of drug
prescribing in prison and a protocol developed for prescribing for
women prisoners monitored by the NHS. It also wants increased
access to counselling and psychiatrists as a first port of call,
says Finola Farrant, research and development officer.

“Deprivation of freedom is intrinsically bad
for mental health and imprisonment has the potential to cause
significant mental harm,” she says. “The almost automatic reaching
for medication in prisons may have little to do with the
therapeutic value of treatment and more to do with controlling
those who are frustrated, lonely, isolated and depressed.”

¹ P Burstow, R Stokoe,
Keep Taking the Medicine? Liberal Democrats,
2001

² S Kesteven, Women who
Challenge, Nacro, 2002

³ A Devlin, Invisible
Women: What’s Wrong with Women’s Prisons?, Waterside
Press, 1998

‘I spiralled into two years of medication
dependency…’

In June 1999 Alicia Bentley (not her real
name) was sent to Holloway prison. Distraught at being separated
from her 14-year-old daughter and husband, she was immediately put
on medication – anti-psychotic Melleril and Librium (an
anti-anxiety agent used to relieve anxiety and sometimes for acute
alcohol withdrawal, although she was not an alcoholic) – to calm
her down.

“Outwardly I was numbed, inwardly I was
spiralling into depression, loneliness, isolation, frustration and
the most incredible internal pain. There was no one to help me,”
she says.

“The pain inside became so intense that on
many occasions the only way I could stop this would be to cause
myself physical pain. I would bang my head on a wall or radiator
until my forehead, eyes and cheeks were a mass of bruises.”

She blamed her behaviour on a panic attack,
and was given Valium, Prothiadin, Largactil and Prozac. She soon
became addicted to Valium: “I am not someone with mental health
issues, but I became someone with mental health issues.”

Bentley believes that women are in danger of
becoming mentally ill during their incarceration, and that her
suffering was increased by being put on medication and then taken
off it at a moment’s notice whenever there was a change of nurse or
doctor.

This happened on two occasions: once with
Librium when she suffered panic attacks and became suicidal; and
then with Valium when she collapsed and started hallucinating and
feeling paranoid.

“I went into jail free of medication and with
no history of depression or mental health issues. I then spiralled
downwards into two years of medication dependency along with many
mental health issues that I may never have had to endure.”

Bentley believes that without the intervention
of a counsellor, there was a chance she “may not be here today in
body; but an even stronger danger I may not have been here in
mind”.