May 2, 2025 • 31 mins
This is another conversation from the Complex Needs Conference 2025 and our guest is Adjunct Associate Professor Danny Sullivan, Consultant Forensic and Adult Psychiatrist.
Dr Sullivan gave a keynote at the conference about the prescribing of psychotropic medications, which are namely drugs that influence a person's mood, thoughts, and behavior - for people with complex needs.
He is the Board Director of ACSO Australia and Director of Victoria's Sentencing Advisory Council.
This episode was recorded at the Complex Needs Conference in Melbourne co-hosted in March 2025 by ermha365 and ACSO Australia with support from Swinburne University's Centre for Forensic Behavioural Science and funded by the Victoria State Government's Department of Families, Fairness and Housing.
ermha365 provides mental health and disability support for people in Victoria and the Northern Territory. Find out more about our services at our website.
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Lifeline 13 11 14
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Suicide Callback Service 1300 659 467
ermha365 acknowledges that our work in the community takes place on the Traditional Lands of many Aboriginal and Torres Strait Islander Peoples and therefore respectfully recognise their Elders, past and present, and the ongoing Custodianship of the Land and Water by all Members of these Communities.
We recognise people with lived experience who contribute to GET REAL podcast, and those who love, support and care for them. We recognise their strength, courage and unique perspective as a vital contribution so that we can learn, grow and achieve better outcomes together.
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Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
ermha365 (00:00):
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Welcome to Get Real talking.
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Dr Danny Sullivan (00:35):
Join our hosts, Emily Webb and Carenza
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conversations with specialguests about all things mental
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ermha365 (00:52):
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Emily Webb (01:08):
Welcome to Get Real talking mental health and
disability.
I'm Emily Webb.
We are bringing you anotherconversation from the Complex
Needs Conference and our guestis Adjunct Associate Professor
Danny Sullivan, who is aconsultant, forensic and adult
psychiatrist.
I was pleased to grab some timewith Danny, who gave a keynote
(01:29):
at the conference aboutprescribing psychotropic
medications, which are namelydrugs that influence mood,
thoughts and behaviour forpeople with complex needs.
Danny has a tonne of experiencein forensic mental health and
held senior roles at theVictorian Institute of Forensic
Mental Health or Forensic Careand provides medico-legal and
(01:51):
complex case assessments incriminal, coronial, child
protection and other Australiancases.
Danny is also the boarddirector of AXA Australia, who
co-hosted the Complex NeedsConference with ERMA 365.
In 2024, danny was appointeddirector of Victoria's
Sentencing Advisory Council.
(02:13):
We cover a fair bit in thisconversation, including the
challenges of prescribing forpeople with multiple diagnoses,
the issue of off-labelprescribing, where medications
are used for indications notlicensed by the Therapeutic
Goods Administration, andresources and programs available
for those supporting peoplewith complex needs to get the
(02:35):
right medication.
Dr Danny Sullivan, it's so goodto have some time with you at
the Complex Needs Conference, sowe're recording live and you've
been here for both days.
It's day two, danny.
Can you first of all tell usabout your work?
You're a forensic psychiatrist,where you work, where you've
(02:56):
worked and why you've come tothe conference?
Dr Danny Sullivan (02:59):
Well, forensic psychiatry, emily, is
obviously psychiatry but appliedto people who are in prison or
who have offended or who are atrisk of offending and who have
mental health and related issueslike personality disorder and
substance use are the main two.
I trained in England andAustralia.
I've worked over the last 20years in the public mental
health system.
(03:20):
I work in Victoria.
I do a little bit of work inthe Northern Territory as well.
I work in Victoria.
I do a little bit of work inthe Northern Territory as well.
Most of that work has been inthe community, so assessing and
providing treatment to peoplewho are at risk of offending or
have offended.
Some of that has also been inhospitals, in the secure
hospital in Victoria and also inprisons, in most of the
Victorian prisons.
Emily Webb (03:41):
Well, you're certainly doing pretty tough
work, and you know, in thepublic system, which I always
think is to be commended, butit's not easy.
You're speaking at theconference and we're going to
actually talk a bit about whatyou're covering, just so other
people can hear it.
What's your topic that you'retalking about?
Dr Danny Sullivan (03:57):
well, I chose to talk about the
medication that's used forpeople with complex needs.
So that's not necessarilymedication that's used for
people with complex needs.
So that's not necessarilymedication that's used for a
particular diagnosis.
It's when people are trying totreat a difficult behaviour or
aggression or substance use orother problems.
And, in fact, once I developedthe presentation, I realised
(04:18):
that most of what I was going tobe talking about was the
limited range of medications forwhich there is effective
evidence and also the ways inwhich prescribing those
medicines can be reallyproblematic.
Emily Webb (04:31):
I find it really interesting to know about who
can prescribe and who can't.
I mean generally, I thinkpeople understand that doctors
prescribe medication.
Psychiatrists are the onlypeople who can prescribe the
kind of medication for, I guess,mental health conditions.
Is that correct?
Just so people listening whomay not know about this can
(04:52):
understand.
Dr Danny Sullivan (04:54):
No, plenty of GPs can prescribe those
medications too, andincreasingly nurse practitioners
.
But I suppose when it comes tocomplicated medications, high
doses, people with very seriousproblems, many prescribers would
become anxious and would liketo have a psychiatrist just
having oversight of theprescribing, giving advice,
(05:14):
checking in that the dosages andthe indications were correct.
The use of medication incomplex needs, unfortunately, is
often driven by crisis.
It occurs in the emergencydepartment, it occurs when
someone's behaviour isdestructive of property or is
damaging to people, and usuallywhen the person is being
(05:34):
assessed they're not in the bestof moods, they don't
particularly give a good accountof themselves.
So I'd describe that as veryreactive prescribing rather than
.
So I'd describe that as veryreactive prescribing rather than
prescribing which is consideredand thoughtful and in which
there's a discussion aboutwhat's to be done and there's
some input from the person.
Emily Webb (05:53):
So, with the medications that you're talking
about and their uses, I guess,for complex needs, what are we
talking about when we're sayingcomplex needs?
We've got a lot of people atthis conference and complexity
is the name of the game here,and it's mental health
conditions, it's disability, butit's a lot of other things like
(06:14):
barriers to you know, livingthe kind of lives they want.
But in your role as apsychiatrist, what kind of
conditions, or I don't know ifthat's the right word what are
you?
Dr Danny Sullivan (06:29):
prescribing for.
Well, we talk about complexneeds as involving usually a
mental health diagnosis or apersonality disorder.
That can be intellectualdisability or acquired brain
injury.
Often there's complicationswith substance use as well as
that, I think with complex needswe're often talking about
people whose needs aren't met byone service, so sometimes
(06:52):
they're described as boundaryspanners or intersectional.
So we're talking about, Isuppose, people whose contact
with various services isunfulfilling and often
challenging.
They can be argumentative, notturn up to appointments, not be
eligible for services because ofthe range of diagnosis.
They have To give an example.
(07:12):
I mean, if you attend a serviceand you're aggressive and
finger-pointing and threatening,I reckon the clinicians who are
going service and you'reaggressive and finger-pointing
and threatening, I reckon theclinicians who are going to see
you will find any reason theycan to determine that you should
go to another service becauseyou know, in frank terms, they
don't like you.
So in this case we're talkingabout the medications that are
prescribed to people who havemultiple diagnoses, and they're
(07:35):
medications which aren'tnecessarily for their primary
mental health problem, butthey're medication which is at
some level intended to assistwith the behaviours that they
present with and which causeproblems.
Emily Webb (07:47):
So with your presentation, why are you
talking about this, what are youwanting the people in the room
to understand, and how did youget to this place where you're
like?
I want to talk about this.
Dr Danny Sullivan (08:02):
Well, it's interesting.
At this Complex NeedsConference, by my estimation
there's only one otherpsychiatrist out of a large
number of people attending.
I figured that a lot of peoplewould talk about interesting
services and approaches tocomplex needs that were at the
service level and I wondered howmy talk could be slightly
different, and that's why Iseized upon the idea of talking
about medication.
So even though many of thepeople here are not prescribers,
they will have a passingacquaintance with lots of
(08:24):
complicated medications.
They will often have clientswhose drug charts are full of
medications and which might becausing problems.
So I suppose I wanted to openpeople's eyes up to thinking
about what to do aboutprescribing or when to prescribe
or not to prescribe.
Although I started off reallywanting to get a grip on the
(08:46):
contemporary landscape, I foundmyself increasingly focusing
upon the limitations of evidenceand the problems with
prescribing and what we can doabout it, and the problems with
prescribing and what we can doabout it.
Emily Webb (09:01):
So what have you found are the limitations in the
evidence and, I guess, theeffectiveness of these drugs?
From your experience as apsychiatrist, you've been doing
this for many years, right?
Dr Danny Sullivan (09:10):
Yeah, well, in Australia the Pharmaceutical
Benefit Scheme is the subsidisedmedications which are provided.
They're overseen by theTherapeutic Goods Administration
.
That government, federalgovernment body assesses
medications to determine ifthey're safe and effective.
It publishes information aboutthem.
It does a health technologyassessment, which is really to
(09:32):
determine whether there issufficient evidence to justify
paying for the medication,because of course, the
pharmaceutical benefit schemesubsidises expensive medications
so that consumers don't have topay the full cost, like they
would in, say, the United States.
And finally, it monitorsmedications once they've been
introduced to the market tocheck that they're not causing
(09:53):
unforeseen adverse effects orother problems.
Emily Webb (09:57):
And the kind of medications that you are talking
about.
What are some of the names ofthem that people might have
heard of?
Dr Danny Sullivan (10:05):
Well, they tend to be what we call
psychotropic medications,medications that affect mental
health.
So they're anti-psychoticmedications, they're
anti-depressants, they'remedications prescribed for
anxiety, some other types ofmedication Mood stabilizers is
perhaps a good example and onthe pharmaceutical benefits
scheme, every medication has arange of licensed indications.
(10:27):
What that means is that theTherapeutic Goods Administration
, the TGA, has said thismedication shows evidence that
it is effective in the treatmentof something.
I'll give you an example.
A medication called Risperidoneis used for schizophrenia, it's
used for mania in bipolaraffective disorder, but it's
also used for behaviouraldisturbance in people with
(10:49):
dementia.
It's used for behaviouraldisturbance and aggression in
people with intellectualdisability who are children, and
it's used in behaviouraldisturbance in autism spectrum
disorders.
They're licensed indications.
What that means is that thereis published research which
satisfies the TGA that thosemedications are safe and
(11:10):
effective to use.
But there are other medicationswhich are going to be used for
those same indications which arenot licensed.
So if it's not licensed, wecall that off-label prescribing.
Emily Webb (11:20):
So can you prescribe ?
You can prescribe off-labelstuff, but it's going to cost
you more.
Dr Danny Sullivan (11:28):
Well, that's right.
If it's not for the licensedindication, you can't get the
pharmaceutical benefit schemeprice, and that's really
interesting.
Pharmaceutical benefit schemeprice and that's really
interesting.
An antipsychotic medicationmight cost an employed person
around $30.
There might be an added feefrom the pharmacy.
For a person with a healthcarecard it might only cost just
under $4.
(11:49):
But if it's prescribedoff-label, the cost of that per
month can be $200 or $300 permonth.
So that's a very significantcost to the consumer.
So off-label prescribing iswhen a medication is used for an
indication that it's notlicensed for, when it's used at
a different dose, when it'sadministered by a different
method, when it's used for alonger period than it should be,
(12:11):
or if it's used for a personwhose age or gender is not
consistent with the licensing.
Emily Webb (12:18):
And so are you forming the thought or the pitch
in your presentation that thereneeds to be more research for
off-label use, or that the PBS,the TGA, needs to loosen up a
bit Like what conclusions haveyou come to through your
experience and the researchyou've done?
Dr Danny Sullivan (12:37):
Yeah, look, it's a really good point.
I mean, there certainly is aneed for more research, and some
of the people with complexneeds would never be included in
a research study, because whatyou really want is someone who's
got a pure disorder and it'snot confounded or confused by
other things such as substanceuse or other problems.
So with off-label prescribing,we certainly need more evidence
(12:59):
to justify its use, but actuallymost of the findings were that
the processes by which weprescribe off-label and the
indications for which weprescribe may expose the people
who take the medication to notinsignificant risks.
Emily Webb (13:16):
So can you tell me a bit more about that?
Because I guess there's sideeffects for everything, but I do
have a basic understanding thatthere are some drugs that can
be quite effective, but they dohave significant side effects
and that's got to be balanced.
Dr Danny Sullivan (13:30):
Yeah, so we use off-level prescribing when a
standard treatment hasn'timproved the symptoms, but the
guidance is pretty clear.
The Royal Australian and NewZealand College of Psychiatrists
has guidance on how toprescribe and it says, for
instance, that we need to getinformed consent.
So the person we're prescribingfor needs to understand that
this is not a licensedindication and they need to be
able to participate in thedecision-making process and hear
(13:54):
about the risks and benefitsand have the opportunity to ask
questions before they prescribethe medication and in complex
needs, I think often theprescription is done to someone
rather than with them.
When a person doesn't havecapacity to give informed
consent, there needs to be alegal framework, and it could be
that, for instance, they're acompulsory patient under the
Mental Health and Wellbeing Act.
(14:15):
It could be that there's alegal guardian in place, or it
could be that they're a childand their parent is their legal
guardian.
So that's really important.
What's most interesting is thatthere is a requirement,
according to the College ofPsychiatrists, that a
psychiatrist prescribingoff-label seeks a peer review.
What that means is a secondopinion from another
(14:36):
psychiatrist or that theydiscuss it with other
psychiatrists.
They discuss thenon-identifying but specific
details of the case to getguidance in that prescribing and
I think that's actually quiteburdensome and I don't think
it's actually very often done.
Emily Webb (14:51):
So if a psychiatrist is prescribing off-label, how
do they go about it?
Is prescribing off-label, howdo they go about it?
How should they go about it?
Dr Danny Sullivan (14:59):
Well, I mentioned the need to involve
the patient in the discussion,but, moreover, there should be a
really clear definition of whatit is that the prescription is
intended to do, and then thereshould be monitoring of that
medication and of its potentialbenefits to see that in fact, it
does what we hoped it would do.
(15:20):
The patient needs to bereviewed regularly, preferably
by the same psychiatrist, sothat they can monitor the
effectiveness of theprescription.
And for people with complexneeds who are, say, in a
residential facility say someonewith a disability what you'd
hope is that the residentialstaff are collecting data which
can actually inform the decision.
(15:40):
So I'll give you an example.
Let's say we talked about thatmedication, risperidone.
Let's say that someone wantedto prescribe that to reduce
aggressive behaviour in autismspectrum disorder.
You might, for instance, sayhow many incidents of aggressive
behaviour are there per weekover the six months before I
start the prescription and thenover the next three months?
(16:02):
Can I demonstrate a reduction?
And if I change the dose, if,for instance, I increase the
dose, do I see a furtherreduction?
Finally, in addition to that,other observed side effects that
I can expect with risperidonemight occur, and are those
severe enough that, in fact, Ishould stop the prescription
because the side effects areworse than the actual treatment.
Emily Webb (16:25):
So, in effect, yourself psychiatrists do need
some buy-in from people who aresupporting people with complex
needs.
There needs to be educationaround how to, I guess, monitor
how the medication's going andunderstanding what the
medications are.
Dr Danny Sullivan (16:43):
Oh, absolutely.
And particularly many peoplewith complex needs, particularly
those who have a cognitiveimpairment, aren't initiating
the contact with a servicethemselves.
They're looked after, they'rein care, or someone else is
making the appointment, someoneelse is taking them there,
someone else is commenting andproviding information to the
prescriber.
So those people are, bydefinition, more vulnerable.
(17:05):
They have less voice and theyrely upon staff to speak for
them.
What that also means is thatthey rely upon staff to look at
their drug chart and say hang on, there's a lot of medication
here, what is this for?
And to go to the prescriber andsay look, I'm a bit worried
because, for instance, Iobserved that she's always
asleep during the day, or she'sgained 20 kilograms over the
(17:27):
last four months since westarted this medication, or I
noticed that she's havingepileptic seizures more
frequently than she didbeforehand.
That's an example, I suppose,of the role of staff advocating
for and supporting their clients.
Emily Webb (17:43):
In your experience.
Does that happen more oftenthan not, or is it the other way
around?
Dr Danny Sullivan (17:48):
I think staff often feel very
disempowered dealing with themedical profession.
Obviously, they're at adisadvantage in terms of
knowledge and some in themedical profession might not
take to being challenged on aparticular prescription.
But as well as that, I thinkit's difficult when you've got a
person with very complex needs.
(18:09):
It's really hard to access aservice consistently which will
provide them with ongoing careand follow-up.
Often, as I said, you end upwith very reactive,
crisis-driven presentations.
You don't get to see the same,for instance, psychiatrist, at a
regular interval.
Emily Webb (18:26):
So let's talk about the evidence, or the lack of
evidence, for the effectivenessof some of the drugs that are
prescribed for conditions thatcome under the complex needs
banner.
Let's talk about the treatmentof substance use disorder.
Dr Danny Sullivan (18:45):
Okay, well, there's some really strong
evidence.
So, for instance, for opioidslike heroin, we know that
long-acting injectableantipsychotic medications like
buprenorphine are reallyeffective and they reduce the
rate of relapse and they'retolerated well by patients.
That's almost overtaken theprevious sublingual or under the
(19:08):
tongue formulations, or oralmethadone, and it's preferable
to patients because it'sinjected once a week or once a
month and apart from somediscomfort it's a really
effective treatment.
So that reduces not just opioiduse but also risk of death by
overdose.
For cannabis, we don't have anylicensed medications.
There is no evidence of anymedication being effective to
(19:29):
treat cannabis dependence.
For alcohol, we have a coupleof medications that have some
strong evidence naltrexoneperhaps less so for acamprosate,
and there's another medicationcalled disulfiram which can be
used in some cases, but allother treatments don't show any
evidence that if you give themto a person with alcohol
dependence it reduces thelikelihood that they're drinking
(19:51):
at high levels or it enablesthem to stay off the grog.
There's a few medications whichare trialled, but there isn't
actually sufficient evidence yet.
People will have heard of theweight loss drugs like Ozempic
or Wegovi.
I'm sure there's different waysof pronouncing them, but
semaglutide is the is thetechnical name and they're
called glp1 agonists.
They're used for diabetes, sothat the weight loss indication
(20:14):
is a secondary aspect, butthey've also shown in people who
are taking those drugs thatthey lose interest in alcohol,
and people drinking at highlevels now drink less.
There's a few other medicationswhich also show some promise,
but there isn't sufficientevidence to prescribe them yet.
Emily Webb (20:30):
I guess with the use of Ozempic for weight loss it
would probably be pretty hard toget your hands on it.
To maybe try it for alcohol use.
Dr Danny Sullivan (20:40):
Yeah, that's right.
The other issue is, forinstance, for things like
methamphetamine or cocaine.
There's been trials of a wholerange of different medications
but none have shown anyeffectiveness.
When I say trials of a lot ofmedications, maybe 20
medications have been trialedexperimentally.
That is, you randomize peopleto either the medication or to a
placebo and then you monitorover time whether they've still
(21:03):
got methamphetamine or cocainein a urine drug screen and you
see whether the population giventhe drug you think might work
shows a greater proportion ofpeople who are able to cease it.
So no medication has proveneffective in sustaining
abstinence from stimulants.
Emily Webb (21:19):
So you mentioned that there's no drug at the
moment that's shown to beeffective to treat cannabis
misuse, but medicinal cannabisis actually prescribed a lot
more in Australia, so how doesthat work?
Dr Danny Sullivan (21:35):
Well, the Therapeutic Goods Administration
says that there's no evidencefor the use of cannabis for
neuropsychiatric disorders,except a few very rare cases.
So spasticity as a neurologicalcondition, some varieties of
severe chronic pain, a rareepilepsy syndrome, nausea and
(21:55):
vomiting induced by chemotherapy, and maybe for extreme weight
loss in HIV.
So there's a little bit ofevidence for those indications
and it's certainly licensed forthat.
So there's a little bit ofevidence for those indications
and it's certainly licensed forthat.
But the people who are takingit for anxiety, for insomnia,
are not based on any clearevidence base.
Furthermore, the formulationsof medicinal cannabis that are
(22:17):
in the market have very variablequantities of the active
ingredients.
As a result, what that means isyou really can't study it very
effectively.
In particular, we know that forthose who are prone to
developing a psychotic illness,the rate of psychosis increases
fivefold if you're using highpotency cannabis.
So in my practice what I'mseeing are patients who have
(22:40):
very severe schizophrenia, whoare admitted to hospital
numerous times per year, who arevery disabled, and they are
obtaining separately a scriptfor medicinal cannabis which is
directly contraindicated andreally bad for their mental
health.
Emily Webb (22:54):
So how are they obtaining that?
Is it through a practitioner oris it sort of off the books?
Dr Danny Sullivan (23:01):
Well, I think the issue is that a market
has sprung up of people who areprescribing purely cannabis.
You would go to them for acannabis prescription, but it's
not being prescribed as part ofthe normal armamentarium of
drugs by people who areprescribing other things for
mental health as well.
Emily Webb (23:19):
So what about medications that can help with
violent behaviour or harmingoneself?
Is there anything that can beeffective in your experience?
Dr Danny Sullivan (23:32):
Well for people with complex needs.
This is a really big problem,emily.
Firstly, in Australia there isno medication licensed for
aggression or self-harm except,as I mentioned, risperidone, for
a very limited group of people.
There's some evidence formedication you prescribe for
depression.
There's some evidence for otherantipsychotics.
There's some evidence for moodstabilisers and anti-epileptic
(23:55):
drugs, but all of these theevidence is not supported
sufficiently for the medicationto be licensed for it.
So all prescription for that isdescribed as off-label For
people with disability or mentalhealth problems.
In fact it's defined in thelegislation as chemical
restraint.
What that means is not that youcan't prescribe it, but that
(24:16):
you have to report on theprescribing of it.
It has to be documented,reported to government and they
monitor and oversight it.
Emily Webb (24:24):
It all sounds pretty complicated, to be honest, from
my non-medical perspective.
So it must be extremelychallenging to be working in
this space, because you'retrying to help people ultimately
, aren't you?
Dr Danny Sullivan (24:35):
Well, that's right and there's a culture of
perhaps a very large culture inAustralia of off-label
prescribing and it's certainlydriven by optimism that maybe
medication can help people.
But, as I've said, with therestrictions on off-label
prescribing I think it does posequite significant risks to
numbers of patients and also theevidence of a benefit is not
(24:59):
necessarily clear.
So that places a really bigburden on prescribers to be safe
, places a burden upon stafflooking after vulnerable clients
and advocating for them toreally monitor for those issues
and come back.
And of course there's a bit ofa split interest there, because
the staff looking after a personwith complex needs also want to
see a reduction in problembehaviours or a reduction in
(25:22):
issues which led them to seekthe prescription in the first
place problem behaviours or areduction in issues which led
them to seek the prescription inthe first place.
Emily Webb (25:27):
It's complicated, as they say.
It sounds very complicated anda lot of, I guess, red tape
around it.
So what kind of adverseoutcomes, side effects, are you
talking about?
Dr Danny Sullivan (25:39):
Okay.
Well, lots of these medications, particularly ones prescribed
to reduce aggression, are verysedative.
Some of those sedativemedications actually impact upon
your thinking.
They can make you mentallysluggish and a bit dopey.
In elderly people, in peoplewith intellectual disability and
in dementia, that can actuallybe the tipping point between
being independent and beingnon-independent.
(26:01):
They pose a risk of increasingyour likelihood of falls.
For people vulnerable toswallowing problems, they can
actually cause swallowingproblems which in rare cases are
associated with death.
They can cause metabolicproblems like diabetes, high
blood pressure, high cholesterol, significant weight gain.
Some of the medications,particularly for schizophrenia,
(26:23):
which are used for otherpurposes, can cause severe and
often lifelong movementdisorders, and a number of these
medications increase the riskof seizures in those who are
prone to them.
Emily Webb (26:34):
And so, with everything that we've spoken
about and what you're going topresent about and that you've
researched, what do you thinkneeds to happen?
Like, what would you like to bethe Disney magic wand solution?
We know there's not one, butwhere do we need to head?
Dr Danny Sullivan (26:50):
It's an Australia-wide problem of the
culture of prescribing, so weneed to really stick to those
guidelines and sort of.
I suppose, have an increasedlevel of suspicion and concern
about prescribing where there isno licensed indication.
I think we need to do theresearch so actually monitor the
(27:11):
outcomes and develop theevidence base that, in fact,
might convert some of theseuncertain prescriptions into
ones for which there is anevidence base.
But most of all, I think weneed to have a system that
ensures there's provision foradequate follow-up and for
clarity of prescribing.
What do I hope to achieveprescribing this medication?
And for clarity of prescribing?
What do I hope to achieveprescribing this medication?
How will I know if it's beeneffective and when will I choose
to stop it on the basis thatit's ineffective?
(27:32):
As I said earlier, if yourprescribing is crisis driven,
every time there's a crisis, anew medication is added or the
dosage of one is bumped up.
But every time there is nocrisis for a period of a week or
two weeks, that doesn't meanthat the medication is then
(27:53):
ceased or the dosage is reduced.
So what we have is this sort ofcontinual drive to treat
challenging behaviour, which canlead to a person being exposed
to significant numbers ofmedications, high dosages and,
consequently, significantadverse effects.
Emily Webb (28:04):
And for consumers and carers people who care for
people with complex needs, butalso for the person who is
getting prescribed themedication themselves.
What can they do to, I guess,understand more, if that's a
possibility, but advocate forthemselves in a way that is
going to mean that you'reworking with your clinician
(28:26):
rather than just being toldwhat's going to happen?
Dr Danny Sullivan (28:29):
That's an interesting question.
There are a range ofopportunities set up by
government to assist thosesupporting people with complex
needs to get the rightmedication.
So, for instance, the NationalDisability Insurance Scheme
provides for home medicinesreview, which is where a person
on five medications or more andwho has NDIS funding can go to a
(28:51):
pharmacist and have them reviewtheir drug chart and advise on
the possibility of druginteractions, advise on whether
some medications can be reducedor ceased and also advise on the
potential for some drugs tointeract with others ceased and
also advise on the potential forsome drugs to interact with
others In aged care.
There are guidelines on theprescription of psychotropic
medications in aged carefacilities.
(29:12):
All health services which areaccredited by the Australian
Commission on Safety and Qualityin Healthcare now have to
ascribe to a standard which iscalled psychotropic Medicines in
Cognitive Disability orImpairment.
But perhaps the most impressiveinnovation in this comes from
the United Kingdom and it'scalled STOMP, which is Stopping
(29:34):
the Over-Medication of Peoplewith a Learning Disability in
Autistic People.
That didn't translate to a verygood acronym, but STOMP is
really effective and there's anAustralian version called
STOMPOZ, that's S-T-O-M-P-O-Z.
What that is?
It involves a range ofresources for those supporting
people, usually with adisability.
It involves prescribers makinga commitment to reviewing
(29:58):
medications and deprescribingwhere possible, particularly
where there is not strongevidence for the use of a
medication For services thathave signed up to it.
I think it provides a frameworkfor really effective shared
decision-making aroundmedication for people whose
voice is often not heard.
Emily Webb (30:15):
So, danny, this has been a really interesting chat.
How have you been finding theconference so far?
Dr Danny Sullivan (30:21):
It's a really good opportunity for
networking.
The people here are special.
They've chosen to work inreally complicated and difficult
areas.
They're not sort of areas thatearn people lots of money, but
there's a lot of love andthere's a lot of good feeling
about doing healthy things forpeople that John Fain described
yesterday as having been leftbehind, and I think that vibe is
(30:42):
through the whole conference.
I think the presentations arereally top quality.
I think Irma and AXO have donea great job in putting this
together and being supported bygovernment to do so.
Emily Webb (30:53):
Well, danny, thank you so much for your time,
because I know it's limited andwe're really grateful that you
came on and talked about whatyou did, so hopefully we'll
speak to you again.
Dr Danny Sullivan (31:03):
It's been a pleasure.
ermha365 (31:03):
Thanks, emily.
You've been listening to GetReal talking mental health and
disability, brought to you bythe team at Irma 365.
Get Real is produced andpresented by Emily Webb with
Corenza Louis-Smith and specialguests.
Thanks for listening and we'llsee you next time.
Get Real is recorded on the unceded lands of the Boon
, wurrung and Wurundjeri peoplesof the Kulin Nation.
We acknowledge and pay ourrespects to their elders, past
and present.
We also acknowledge that theFirst Peoples of Australia are
the first storytellers, thefirst artists and the first
creators of culture and wecelebrate their enduring
(00:21):
connections to country knowledgeand stories, celebrate their
enduring connections to country.
Knowledge and stories.
Welcome to Get Real talking.
Mental health and disabilitybrought to you by the team at
Irma 365.
Dr Danny Sullivan (00:35):
Join our hosts, Emily Webb and Carenza
Louis-Smith, as we have frankand fearless conversations with
special guests about all thingsmental health and complexity
conversations with specialguests about all things mental
health and complexity.
ermha365 (00:52):
We recognise people with lived experience of mental
ill health and disability, aswell as their families and
carers.
We recognise their strength,courage and unique perspective
as a vital contribution to thispodcast so we can learn, grow
and achieve better outcomestogether.
Emily Webb (01:08):
Welcome to Get Real talking mental health and
disability.
I'm Emily Webb.
We are bringing you anotherconversation from the Complex
Needs Conference and our guestis Adjunct Associate Professor
Danny Sullivan, who is aconsultant, forensic and adult
psychiatrist.
I was pleased to grab some timewith Danny, who gave a keynote
(01:29):
at the conference aboutprescribing psychotropic
medications, which are namelydrugs that influence mood,
thoughts and behaviour forpeople with complex needs.
Danny has a tonne of experiencein forensic mental health and
held senior roles at theVictorian Institute of Forensic
Mental Health or Forensic Careand provides medico-legal and
(01:51):
complex case assessments incriminal, coronial, child
protection and other Australiancases.
Danny is also the boarddirector of AXA Australia, who
co-hosted the Complex NeedsConference with ERMA 365.
In 2024, danny was appointeddirector of Victoria's
Sentencing Advisory Council.
(02:13):
We cover a fair bit in thisconversation, including the
challenges of prescribing forpeople with multiple diagnoses,
the issue of off-labelprescribing, where medications
are used for indications notlicensed by the Therapeutic
Goods Administration, andresources and programs available
for those supporting peoplewith complex needs to get the
(02:35):
right medication.
Dr Danny Sullivan, it's so goodto have some time with you at
the Complex Needs Conference, sowe're recording live and you've
been here for both days.
It's day two, danny.
Can you first of all tell usabout your work?
You're a forensic psychiatrist,where you work, where you've
(02:56):
worked and why you've come tothe conference?
Dr Danny Sullivan (02:59):
Well, forensic psychiatry, emily, is
obviously psychiatry but appliedto people who are in prison or
who have offended or who are atrisk of offending and who have
mental health and related issueslike personality disorder and
substance use are the main two.
I trained in England andAustralia.
I've worked over the last 20years in the public mental
health system.
(03:20):
I work in Victoria.
I do a little bit of work inthe Northern Territory as well.
I work in Victoria.
I do a little bit of work inthe Northern Territory as well.
Most of that work has been inthe community, so assessing and
providing treatment to peoplewho are at risk of offending or
have offended.
Some of that has also been inhospitals, in the secure
hospital in Victoria and also inprisons, in most of the
Victorian prisons.
Emily Webb (03:41):
Well, you're certainly doing pretty tough
work, and you know, in thepublic system, which I always
think is to be commended, butit's not easy.
You're speaking at theconference and we're going to
actually talk a bit about whatyou're covering, just so other
people can hear it.
What's your topic that you'retalking about?
Dr Danny Sullivan (03:57):
well, I chose to talk about the
medication that's used forpeople with complex needs.
So that's not necessarilymedication that's used for
people with complex needs.
So that's not necessarilymedication that's used for a
particular diagnosis.
It's when people are trying totreat a difficult behaviour or
aggression or substance use orother problems.
And, in fact, once I developedthe presentation, I realised
(04:18):
that most of what I was going tobe talking about was the
limited range of medications forwhich there is effective
evidence and also the ways inwhich prescribing those
medicines can be reallyproblematic.
Emily Webb (04:31):
I find it really interesting to know about who
can prescribe and who can't.
I mean generally, I thinkpeople understand that doctors
prescribe medication.
Psychiatrists are the onlypeople who can prescribe the
kind of medication for, I guess,mental health conditions.
Is that correct?
Just so people listening whomay not know about this can
(04:52):
understand.
Dr Danny Sullivan (04:54):
No, plenty of GPs can prescribe those
medications too, andincreasingly nurse practitioners
.
But I suppose when it comes tocomplicated medications, high
doses, people with very seriousproblems, many prescribers would
become anxious and would liketo have a psychiatrist just
having oversight of theprescribing, giving advice,
(05:14):
checking in that the dosages andthe indications were correct.
The use of medication incomplex needs, unfortunately, is
often driven by crisis.
It occurs in the emergencydepartment, it occurs when
someone's behaviour isdestructive of property or is
damaging to people, and usuallywhen the person is being
(05:34):
assessed they're not in the bestof moods, they don't
particularly give a good accountof themselves.
So I'd describe that as veryreactive prescribing rather than
.
So I'd describe that as veryreactive prescribing rather than
prescribing which is consideredand thoughtful and in which
there's a discussion aboutwhat's to be done and there's
some input from the person.
Emily Webb (05:53):
So, with the medications that you're talking
about and their uses, I guess,for complex needs, what are we
talking about when we're sayingcomplex needs?
We've got a lot of people atthis conference and complexity
is the name of the game here,and it's mental health
conditions, it's disability, butit's a lot of other things like
(06:14):
barriers to you know, livingthe kind of lives they want.
But in your role as apsychiatrist, what kind of
conditions, or I don't know ifthat's the right word what are
you?
Dr Danny Sullivan (06:29):
prescribing for.
Well, we talk about complexneeds as involving usually a
mental health diagnosis or apersonality disorder.
That can be intellectualdisability or acquired brain
injury.
Often there's complicationswith substance use as well as
that, I think with complex needswe're often talking about
people whose needs aren't met byone service, so sometimes
(06:52):
they're described as boundaryspanners or intersectional.
So we're talking about, Isuppose, people whose contact
with various services isunfulfilling and often
challenging.
They can be argumentative, notturn up to appointments, not be
eligible for services because ofthe range of diagnosis.
They have To give an example.
(07:12):
I mean, if you attend a serviceand you're aggressive and
finger-pointing and threatening,I reckon the clinicians who are
going service and you'reaggressive and finger-pointing
and threatening, I reckon theclinicians who are going to see
you will find any reason theycan to determine that you should
go to another service becauseyou know, in frank terms, they
don't like you.
So in this case we're talkingabout the medications that are
prescribed to people who havemultiple diagnoses, and they're
(07:35):
medications which aren'tnecessarily for their primary
mental health problem, butthey're medication which is at
some level intended to assistwith the behaviours that they
present with and which causeproblems.
Emily Webb (07:47):
So with your presentation, why are you
talking about this, what are youwanting the people in the room
to understand, and how did youget to this place where you're
like?
I want to talk about this.
Dr Danny Sullivan (08:02):
Well, it's interesting.
At this Complex NeedsConference, by my estimation
there's only one otherpsychiatrist out of a large
number of people attending.
I figured that a lot of peoplewould talk about interesting
services and approaches tocomplex needs that were at the
service level and I wondered howmy talk could be slightly
different, and that's why Iseized upon the idea of talking
about medication.
So even though many of thepeople here are not prescribers,
they will have a passingacquaintance with lots of
(08:24):
complicated medications.
They will often have clientswhose drug charts are full of
medications and which might becausing problems.
So I suppose I wanted to openpeople's eyes up to thinking
about what to do aboutprescribing or when to prescribe
or not to prescribe.
Although I started off reallywanting to get a grip on the
(08:46):
contemporary landscape, I foundmyself increasingly focusing
upon the limitations of evidenceand the problems with
prescribing and what we can doabout it, and the problems with
prescribing and what we can doabout it.
Emily Webb (09:01):
So what have you found are the limitations in the
evidence and, I guess, theeffectiveness of these drugs?
From your experience as apsychiatrist, you've been doing
this for many years, right?
Dr Danny Sullivan (09:10):
Yeah, well, in Australia the Pharmaceutical
Benefit Scheme is the subsidisedmedications which are provided.
They're overseen by theTherapeutic Goods Administration
.
That government, federalgovernment body assesses
medications to determine ifthey're safe and effective.
It publishes information aboutthem.
It does a health technologyassessment, which is really to
(09:32):
determine whether there issufficient evidence to justify
paying for the medication,because of course, the
pharmaceutical benefit schemesubsidises expensive medications
so that consumers don't have topay the full cost, like they
would in, say, the United States.
And finally, it monitorsmedications once they've been
introduced to the market tocheck that they're not causing
(09:53):
unforeseen adverse effects orother problems.
Emily Webb (09:57):
And the kind of medications that you are talking
about.
What are some of the names ofthem that people might have
heard of?
Dr Danny Sullivan (10:05):
Well, they tend to be what we call
psychotropic medications,medications that affect mental
health.
So they're anti-psychoticmedications, they're
anti-depressants, they'remedications prescribed for
anxiety, some other types ofmedication Mood stabilizers is
perhaps a good example and onthe pharmaceutical benefits
scheme, every medication has arange of licensed indications.
(10:27):
What that means is that theTherapeutic Goods Administration
, the TGA, has said thismedication shows evidence that
it is effective in the treatmentof something.
I'll give you an example.
A medication called Risperidoneis used for schizophrenia, it's
used for mania in bipolaraffective disorder, but it's
also used for behaviouraldisturbance in people with
(10:49):
dementia.
It's used for behaviouraldisturbance and aggression in
people with intellectualdisability who are children, and
it's used in behaviouraldisturbance in autism spectrum
disorders.
They're licensed indications.
What that means is that thereis published research which
satisfies the TGA that thosemedications are safe and
(11:10):
effective to use.
But there are other medicationswhich are going to be used for
those same indications which arenot licensed.
So if it's not licensed, wecall that off-label prescribing.
Emily Webb (11:20):
So can you prescribe ?
You can prescribe off-labelstuff, but it's going to cost
you more.
Dr Danny Sullivan (11:28):
Well, that's right.
If it's not for the licensedindication, you can't get the
pharmaceutical benefit schemeprice, and that's really
interesting.
Pharmaceutical benefit schemeprice and that's really
interesting.
An antipsychotic medicationmight cost an employed person
around $30.
There might be an added feefrom the pharmacy.
For a person with a healthcarecard it might only cost just
under $4.
(11:49):
But if it's prescribedoff-label, the cost of that per
month can be $200 or $300 permonth.
So that's a very significantcost to the consumer.
So off-label prescribing iswhen a medication is used for an
indication that it's notlicensed for, when it's used at
a different dose, when it'sadministered by a different
method, when it's used for alonger period than it should be,
(12:11):
or if it's used for a personwhose age or gender is not
consistent with the licensing.
Emily Webb (12:18):
And so are you forming the thought or the pitch
in your presentation that thereneeds to be more research for
off-label use, or that the PBS,the TGA, needs to loosen up a
bit Like what conclusions haveyou come to through your
experience and the researchyou've done?
Dr Danny Sullivan (12:37):
Yeah, look, it's a really good point.
I mean, there certainly is aneed for more research, and some
of the people with complexneeds would never be included in
a research study, because whatyou really want is someone who's
got a pure disorder and it'snot confounded or confused by
other things such as substanceuse or other problems.
So with off-label prescribing,we certainly need more evidence
(12:59):
to justify its use, but actuallymost of the findings were that
the processes by which weprescribe off-label and the
indications for which weprescribe may expose the people
who take the medication to notinsignificant risks.
Emily Webb (13:16):
So can you tell me a bit more about that?
Because I guess there's sideeffects for everything, but I do
have a basic understanding thatthere are some drugs that can
be quite effective, but they dohave significant side effects
and that's got to be balanced.
Dr Danny Sullivan (13:30):
Yeah, so we use off-level prescribing when a
standard treatment hasn'timproved the symptoms, but the
guidance is pretty clear.
The Royal Australian and NewZealand College of Psychiatrists
has guidance on how toprescribe and it says, for
instance, that we need to getinformed consent.
So the person we're prescribingfor needs to understand that
this is not a licensedindication and they need to be
able to participate in thedecision-making process and hear
(13:54):
about the risks and benefitsand have the opportunity to ask
questions before they prescribethe medication and in complex
needs, I think often theprescription is done to someone
rather than with them.
When a person doesn't havecapacity to give informed
consent, there needs to be alegal framework, and it could be
that, for instance, they're acompulsory patient under the
Mental Health and Wellbeing Act.
(14:15):
It could be that there's alegal guardian in place, or it
could be that they're a childand their parent is their legal
guardian.
So that's really important.
What's most interesting is thatthere is a requirement,
according to the College ofPsychiatrists, that a
psychiatrist prescribingoff-label seeks a peer review.
What that means is a secondopinion from another
(14:36):
psychiatrist or that theydiscuss it with other
psychiatrists.
They discuss thenon-identifying but specific
details of the case to getguidance in that prescribing and
I think that's actually quiteburdensome and I don't think
it's actually very often done.
Emily Webb (14:51):
So if a psychiatrist is prescribing off-label, how
do they go about it?
Is prescribing off-label, howdo they go about it?
How should they go about it?
Dr Danny Sullivan (14:59):
Well, I mentioned the need to involve
the patient in the discussion,but, moreover, there should be a
really clear definition of whatit is that the prescription is
intended to do, and then thereshould be monitoring of that
medication and of its potentialbenefits to see that in fact, it
does what we hoped it would do.
(15:20):
The patient needs to bereviewed regularly, preferably
by the same psychiatrist, sothat they can monitor the
effectiveness of theprescription.
And for people with complexneeds who are, say, in a
residential facility say someonewith a disability what you'd
hope is that the residentialstaff are collecting data which
can actually inform the decision.
(15:40):
So I'll give you an example.
Let's say we talked about thatmedication, risperidone.
Let's say that someone wantedto prescribe that to reduce
aggressive behaviour in autismspectrum disorder.
You might, for instance, sayhow many incidents of aggressive
behaviour are there per weekover the six months before I
start the prescription and thenover the next three months?
(16:02):
Can I demonstrate a reduction?
And if I change the dose, if,for instance, I increase the
dose, do I see a furtherreduction?
Finally, in addition to that,other observed side effects that
I can expect with risperidonemight occur, and are those
severe enough that, in fact, Ishould stop the prescription
because the side effects areworse than the actual treatment.
Emily Webb (16:25):
So, in effect, yourself psychiatrists do need
some buy-in from people who aresupporting people with complex
needs.
There needs to be educationaround how to, I guess, monitor
how the medication's going andunderstanding what the
medications are.
Dr Danny Sullivan (16:43):
Oh, absolutely.
And particularly many peoplewith complex needs, particularly
those who have a cognitiveimpairment, aren't initiating
the contact with a servicethemselves.
They're looked after, they'rein care, or someone else is
making the appointment, someoneelse is taking them there,
someone else is commenting andproviding information to the
prescriber.
So those people are, bydefinition, more vulnerable.
(17:05):
They have less voice and theyrely upon staff to speak for
them.
What that also means is thatthey rely upon staff to look at
their drug chart and say hang on, there's a lot of medication
here, what is this for?
And to go to the prescriber andsay look, I'm a bit worried
because, for instance, Iobserved that she's always
asleep during the day, or she'sgained 20 kilograms over the
(17:27):
last four months since westarted this medication, or I
noticed that she's havingepileptic seizures more
frequently than she didbeforehand.
That's an example, I suppose,of the role of staff advocating
for and supporting their clients.
Emily Webb (17:43):
In your experience.
Does that happen more oftenthan not, or is it the other way
around?
Dr Danny Sullivan (17:48):
I think staff often feel very
disempowered dealing with themedical profession.
Obviously, they're at adisadvantage in terms of
knowledge and some in themedical profession might not
take to being challenged on aparticular prescription.
But as well as that, I thinkit's difficult when you've got a
person with very complex needs.
(18:09):
It's really hard to access aservice consistently which will
provide them with ongoing careand follow-up.
Often, as I said, you end upwith very reactive,
crisis-driven presentations.
You don't get to see the same,for instance, psychiatrist, at a
regular interval.
Emily Webb (18:26):
So let's talk about the evidence, or the lack of
evidence, for the effectivenessof some of the drugs that are
prescribed for conditions thatcome under the complex needs
banner.
Let's talk about the treatmentof substance use disorder.
Dr Danny Sullivan (18:45):
Okay, well, there's some really strong
evidence.
So, for instance, for opioidslike heroin, we know that
long-acting injectableantipsychotic medications like
buprenorphine are reallyeffective and they reduce the
rate of relapse and they'retolerated well by patients.
That's almost overtaken theprevious sublingual or under the
(19:08):
tongue formulations, or oralmethadone, and it's preferable
to patients because it'sinjected once a week or once a
month and apart from somediscomfort it's a really
effective treatment.
So that reduces not just opioiduse but also risk of death by
overdose.
For cannabis, we don't have anylicensed medications.
There is no evidence of anymedication being effective to
(19:29):
treat cannabis dependence.
For alcohol, we have a coupleof medications that have some
strong evidence naltrexoneperhaps less so for acamprosate,
and there's another medicationcalled disulfiram which can be
used in some cases, but allother treatments don't show any
evidence that if you give themto a person with alcohol
dependence it reduces thelikelihood that they're drinking
(19:51):
at high levels or it enablesthem to stay off the grog.
There's a few medications whichare trialled, but there isn't
actually sufficient evidence yet.
People will have heard of theweight loss drugs like Ozempic
or Wegovi.
I'm sure there's different waysof pronouncing them, but
semaglutide is the is thetechnical name and they're
called glp1 agonists.
They're used for diabetes, sothat the weight loss indication
(20:14):
is a secondary aspect, butthey've also shown in people who
are taking those drugs thatthey lose interest in alcohol,
and people drinking at highlevels now drink less.
There's a few other medicationswhich also show some promise,
but there isn't sufficientevidence to prescribe them yet.
Emily Webb (20:30):
I guess with the use of Ozempic for weight loss it
would probably be pretty hard toget your hands on it.
To maybe try it for alcohol use.
Dr Danny Sullivan (20:40):
Yeah, that's right.
The other issue is, forinstance, for things like
methamphetamine or cocaine.
There's been trials of a wholerange of different medications
but none have shown anyeffectiveness.
When I say trials of a lot ofmedications, maybe 20
medications have been trialedexperimentally.
That is, you randomize peopleto either the medication or to a
placebo and then you monitorover time whether they've still
(21:03):
got methamphetamine or cocainein a urine drug screen and you
see whether the population giventhe drug you think might work
shows a greater proportion ofpeople who are able to cease it.
So no medication has proveneffective in sustaining
abstinence from stimulants.
Emily Webb (21:19):
So you mentioned that there's no drug at the
moment that's shown to beeffective to treat cannabis
misuse, but medicinal cannabisis actually prescribed a lot
more in Australia, so how doesthat work?
Dr Danny Sullivan (21:35):
Well, the Therapeutic Goods Administration
says that there's no evidencefor the use of cannabis for
neuropsychiatric disorders,except a few very rare cases.
So spasticity as a neurologicalcondition, some varieties of
severe chronic pain, a rareepilepsy syndrome, nausea and
(21:55):
vomiting induced by chemotherapy, and maybe for extreme weight
loss in HIV.
So there's a little bit ofevidence for those indications
and it's certainly licensed forthat.
So there's a little bit ofevidence for those indications
and it's certainly licensed forthat.
But the people who are takingit for anxiety, for insomnia,
are not based on any clearevidence base.
Furthermore, the formulationsof medicinal cannabis that are
(22:17):
in the market have very variablequantities of the active
ingredients.
As a result, what that means isyou really can't study it very
effectively.
In particular, we know that forthose who are prone to
developing a psychotic illness,the rate of psychosis increases
fivefold if you're using highpotency cannabis.
So in my practice what I'mseeing are patients who have
(22:40):
very severe schizophrenia, whoare admitted to hospital
numerous times per year, who arevery disabled, and they are
obtaining separately a scriptfor medicinal cannabis which is
directly contraindicated andreally bad for their mental
health.
Emily Webb (22:54):
So how are they obtaining that?
Is it through a practitioner oris it sort of off the books?
Dr Danny Sullivan (23:01):
Well, I think the issue is that a market
has sprung up of people who areprescribing purely cannabis.
You would go to them for acannabis prescription, but it's
not being prescribed as part ofthe normal armamentarium of
drugs by people who areprescribing other things for
mental health as well.
Emily Webb (23:19):
So what about medications that can help with
violent behaviour or harmingoneself?
Is there anything that can beeffective in your experience?
Dr Danny Sullivan (23:32):
Well for people with complex needs.
This is a really big problem,emily.
Firstly, in Australia there isno medication licensed for
aggression or self-harm except,as I mentioned, risperidone, for
a very limited group of people.
There's some evidence formedication you prescribe for
depression.
There's some evidence for otherantipsychotics.
There's some evidence for moodstabilisers and anti-epileptic
(23:55):
drugs, but all of these theevidence is not supported
sufficiently for the medicationto be licensed for it.
So all prescription for that isdescribed as off-label For
people with disability or mentalhealth problems.
In fact it's defined in thelegislation as chemical
restraint.
What that means is not that youcan't prescribe it, but that
(24:16):
you have to report on theprescribing of it.
It has to be documented,reported to government and they
monitor and oversight it.
Emily Webb (24:24):
It all sounds pretty complicated, to be honest, from
my non-medical perspective.
So it must be extremelychallenging to be working in
this space, because you'retrying to help people ultimately
, aren't you?
Dr Danny Sullivan (24:35):
Well, that's right and there's a culture of
perhaps a very large culture inAustralia of off-label
prescribing and it's certainlydriven by optimism that maybe
medication can help people.
But, as I've said, with therestrictions on off-label
prescribing I think it does posequite significant risks to
numbers of patients and also theevidence of a benefit is not
(24:59):
necessarily clear.
So that places a really bigburden on prescribers to be safe
, places a burden upon stafflooking after vulnerable clients
and advocating for them toreally monitor for those issues
and come back.
And of course there's a bit ofa split interest there, because
the staff looking after a personwith complex needs also want to
see a reduction in problembehaviours or a reduction in
(25:22):
issues which led them to seekthe prescription in the first
place problem behaviours or areduction in issues which led
them to seek the prescription inthe first place.
Emily Webb (25:27):
It's complicated, as they say.
It sounds very complicated anda lot of, I guess, red tape
around it.
So what kind of adverseoutcomes, side effects, are you
talking about?
Dr Danny Sullivan (25:39):
Okay.
Well, lots of these medications, particularly ones prescribed
to reduce aggression, are verysedative.
Some of those sedativemedications actually impact upon
your thinking.
They can make you mentallysluggish and a bit dopey.
In elderly people, in peoplewith intellectual disability and
in dementia, that can actuallybe the tipping point between
being independent and beingnon-independent.
(26:01):
They pose a risk of increasingyour likelihood of falls.
For people vulnerable toswallowing problems, they can
actually cause swallowingproblems which in rare cases are
associated with death.
They can cause metabolicproblems like diabetes, high
blood pressure, high cholesterol, significant weight gain.
Some of the medications,particularly for schizophrenia,
(26:23):
which are used for otherpurposes, can cause severe and
often lifelong movementdisorders, and a number of these
medications increase the riskof seizures in those who are
prone to them.
Emily Webb (26:34):
And so, with everything that we've spoken
about and what you're going topresent about and that you've
researched, what do you thinkneeds to happen?
Like, what would you like to bethe Disney magic wand solution?
We know there's not one, butwhere do we need to head?
Dr Danny Sullivan (26:50):
It's an Australia-wide problem of the
culture of prescribing, so weneed to really stick to those
guidelines and sort of.
I suppose, have an increasedlevel of suspicion and concern
about prescribing where there isno licensed indication.
I think we need to do theresearch so actually monitor the
(27:11):
outcomes and develop theevidence base that, in fact,
might convert some of theseuncertain prescriptions into
ones for which there is anevidence base.
But most of all, I think weneed to have a system that
ensures there's provision foradequate follow-up and for
clarity of prescribing.
What do I hope to achieveprescribing this medication?
And for clarity of prescribing?
What do I hope to achieveprescribing this medication?
How will I know if it's beeneffective and when will I choose
to stop it on the basis thatit's ineffective?
(27:32):
As I said earlier, if yourprescribing is crisis driven,
every time there's a crisis, anew medication is added or the
dosage of one is bumped up.
But every time there is nocrisis for a period of a week or
two weeks, that doesn't meanthat the medication is then
(27:53):
ceased or the dosage is reduced.
So what we have is this sort ofcontinual drive to treat
challenging behaviour, which canlead to a person being exposed
to significant numbers ofmedications, high dosages and,
consequently, significantadverse effects.
Emily Webb (28:04):
And for consumers and carers people who care for
people with complex needs, butalso for the person who is
getting prescribed themedication themselves.
What can they do to, I guess,understand more, if that's a
possibility, but advocate forthemselves in a way that is
going to mean that you'reworking with your clinician
(28:26):
rather than just being toldwhat's going to happen?
Dr Danny Sullivan (28:29):
That's an interesting question.
There are a range ofopportunities set up by
government to assist thosesupporting people with complex
needs to get the rightmedication.
So, for instance, the NationalDisability Insurance Scheme
provides for home medicinesreview, which is where a person
on five medications or more andwho has NDIS funding can go to a
(28:51):
pharmacist and have them reviewtheir drug chart and advise on
the possibility of druginteractions, advise on whether
some medications can be reducedor ceased and also advise on the
potential for some drugs tointeract with others ceased and
also advise on the potential forsome drugs to interact with
others In aged care.
There are guidelines on theprescription of psychotropic
medications in aged carefacilities.
(29:12):
All health services which areaccredited by the Australian
Commission on Safety and Qualityin Healthcare now have to
ascribe to a standard which iscalled psychotropic Medicines in
Cognitive Disability orImpairment.
But perhaps the most impressiveinnovation in this comes from
the United Kingdom and it'scalled STOMP, which is Stopping
(29:34):
the Over-Medication of Peoplewith a Learning Disability in
Autistic People.
That didn't translate to a verygood acronym, but STOMP is
really effective and there's anAustralian version called
STOMPOZ, that's S-T-O-M-P-O-Z.
What that is?
It involves a range ofresources for those supporting
people, usually with adisability.
It involves prescribers makinga commitment to reviewing
(29:58):
medications and deprescribingwhere possible, particularly
where there is not strongevidence for the use of a
medication For services thathave signed up to it.
I think it provides a frameworkfor really effective shared
decision-making aroundmedication for people whose
voice is often not heard.
Emily Webb (30:15):
So, danny, this has been a really interesting chat.
How have you been finding theconference so far?
Dr Danny Sullivan (30:21):
It's a really good opportunity for
networking.
The people here are special.
They've chosen to work inreally complicated and difficult
areas.
They're not sort of areas thatearn people lots of money, but
there's a lot of love andthere's a lot of good feeling
about doing healthy things forpeople that John Fain described
yesterday as having been leftbehind, and I think that vibe is
(30:42):
through the whole conference.
I think the presentations arereally top quality.
I think Irma and AXO have donea great job in putting this
together and being supported bygovernment to do so.
Emily Webb (30:53):
Well, danny, thank you so much for your time,
because I know it's limited andwe're really grateful that you
came on and talked about whatyou did, so hopefully we'll
speak to you again.
Dr Danny Sullivan (31:03):
It's been a pleasure.
ermha365 (31:03):
Thanks, emily.
You've been listening to GetReal talking mental health and
disability, brought to you bythe team at Irma 365.
Get Real is produced andpresented by Emily Webb with
Corenza Louis-Smith and specialguests.
Thanks for listening and we'llsee you next time.
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