Nursing Homes in the US Overmedicate People with Dementia (2018)
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Behavioural problems in dementia are very hard. Male patients in particular can be quite strong and mobile. They can easily hurt staff or other residents. They are also a risk to themselves. The coroner in my state published two cases of patients with dementia that highlight this: one swallowed the napkin on his dinner tray and choked, another got put of the facility and died trying to climb a fence.
The reality is that there are few viable alternatives.
Dr. Scott Alexander writes well here on how we treat the demented: http://slatestarcodex.com/2013/07/17/who-by-very-slow-decay/
"And now every time I hear that phrase I want to scream. 21st century American hospitals do not need to “cultivate a culture of life”. We have enough life. We have life up the wazoo. We have more life than we know what to do with. We have life far beyond the point where it becomes a sick caricature of itself. We prolong life until it becomes a sickness, an abomination, a miserable and pathetic flight from death that saps out and mocks everything that made life desirable in the first place. 21st century American hospitals need to cultivate a culture of life the same way that Newcastle needs to cultivate a culture of coal, the same way a man who is burning to death needs to cultivate a culture of fire."
It is similarly unlikely there will be a test which can predict imminent dementia well enough that you would be happy to euthanise yourself while you still have decision making capacity.
As others have said, what you can do is have some legal document which explains your wishes if you lose capacity to make decisions, where you specify the avoidance of life prolonging therapies, intensive care, resuscitation etc. The other thing which is important is having someone that will take over medical decision making whom you trust will act according to your wishes, in the event you lose decision making capacity. Another aspect of this is making sure friends and family are aware of your wishes. This is a kindness to them as much as anything, so that when the time comes to withhold or withdraw medical treatment, they don't have to ruminate on whether it is the right thing to do.
Alternatively you could argue that they still get out of bed and eat and engage, and perhaps these are signs enough of some desire to live. Anyway, I think there are some philosophical complications which require exploration.
For the most part society doesn't care about your wishes.
I think what it really comes down to incentives. As a society we don't want bullying people into a suicide to be a viable strategy for getting the inheritance money early. Or for getting rid of people in general.
There's still some sentience in middle stage dementia, but by the late stage there's literally no one home any more. It's really not obvious what - never mind who - is being kept alive.
It's certainly not a simple problem. But there are existing systems for legal oversight of care, and of power of attorney over family wealth. It doesn't seem an impossible stretch to extend those to allow early termination in cases of extreme suffering or total and irreversible loss of cognitive function.
We have a neighbour in the very late stages of terminal cancer. He's completely lucid. He wants to go, his family want him to go - this has dragged on for over a year now - and it's hard to see a good moral reason for extending everyone's suffering even further.
The possibility of choosing to legally die is another avenue your consent may be faked.
Indeed! In practice, they're often managed with dangerous restraint techniques, or mentally abusive solitary confinement practices! Consider, for instance, this wonderful coverage of Illinois:
https://features.propublica.org/illinois-seclusion-rooms/sch...
https://www.propublica.org/article/illinois-school-restraint...
The worst that can happen isn't death, you can fall off the fence and break 6 vertebrae and spend the next 3 months screaming in pain on top of everything else.
People don't get euthanised in hospice. Palliative care as a profession is fairly obsessed with not shortening the lives of patients they care for. There are studies for example comparing different analgesic regimens to see if there is a difference in survival.
I'm serious, by they way. Almost everyone on this forum (over the age of 18 in the US) should consider getting a relatively inexpensive living will drawn up with advanced medical directives.
My wife and I are moving to a state that allows assisted suicide after our kids are out of the house. Neither of us want to live like that or be remembered like that.
Best option I think is to start with nothing and end with nothing. The above problem is void then. That fortunate bit in the middle needs to be distributed to your children then if they need it.
https://www.nerdwallet.com/blog/insurance/life/does-life-ins...
Thanks for the concern though :)
This seems very wrong. IMO few things are worse for quality of life than slowly losing your mind.
All people over 75 (and, probably, way earlier) are slowly losing their mind. Early stage dementia isn’t that different from ‘just’ aging in that.
The ethical dilemma with living wills is that they always state a past opinion. It also is well-known from various studies that opinions on when you deem your life worth it shift tremendously over time.
With dementia, locked-in syndrome, etc, that’s a catch-22, as there’s no way to ask you about your opinion, or even to know whether there is someone to have an opinion anymore.
So, that you say “If I get wheelchair-bound/bedridden/don’t know my name anymore, I don’t want to live anymore” now doesn’t imply at all that you will think the same if it were to happen to you.
⇒ If you have a living will, be sure to regularly acknowledge or update it.
Same - but even in places where assisted suicide is legal, it's often not available for cases of dementia. In my jurisdiction you must be terminally ill and of sound mind at the time you request medically assisted death; you can't set something up in advance, can't give power of attorney to another, can't qualify based on dementia alone, and if you happen to have, say, dementia and cancer, probably can't request it because of your dementia specifically.
It's a tough problem to be sure, and I hope it gets well sorted out before I hit old age.
I doubt it gets sorted out in next 50 years. I just hope I’m capable of suicide if the situation arises.
It may be helpful to think of a living will as "health care directives". So that now, while you don't have dementia, you can spell out your wishes and who has the authority to act on said wishes, when you can no longer make decisions.
My grandmother died, as far as we can tell, directly from dementia.
I also want something like a Turing test to determine if I should be kept alive.
The best criteria I've come up with so far is: able to use toilet, able to maintain hygiene, aware of self (name, age), aware of world (rough calendar knowledge, recognize friends and family).
--
We had two family members warehoused in a long term facility who were not allowed to die. As in stopped eating, so were given feeding tubes. Extraordinary efforts to keep them alive. Their DNRs were ineffective. They became vegetables with bank accounts.
Their executor (my mother) got nutty about the whole thing. Her own dementia made her totally irrational, whereas had been very humane just a decade earlier.
And the facility and various care providers were only too happy to keep them alive. (One of the other inmates had been there 11 years. Not a single outside contact. Complete vegetable. How is that right?)
(Were the two victims still lucid, they'd be livid about pointless life extension at great suffering and expense.)
I told my kids to not ever, ever let me end up like that. I've had an amazing run. The end will suck, sure, but no sense getting fussy about it.
Let me pass with some dignity, while I can still say goodbye to everyone properly. Don't waste my money. Don't let me suffer.
You can specify that you want every extraordinary measure that is medically possible in your advanced directives. If you don't specify it, your wishes may not be followed either way.
Another reason for visiting with an elder law firm is that there are serious financial implications when someone ends up in a skilled nursing facility for the rest of their life. Private pay is, not joking, more than $10K per month. If you want to use medical assistance (medicaid) you will have to "spend down" your savings until you qualify.
Elders who want to give their assets/money to their children need to do so 5 years before they enter a facility. If they transfer assets and enter a nursing facility in less than 5 years, the children who received those assets will need to cover the cost until the "spend down" is done. This look-back period used to be 2 years, but because of the "Deficit Reduction Act of 2005" signed by George "Dubya" Bush, it is now 5 years. This is the kind of trap that wipes out the finances of entire middle class families-- how's that for reducing the deficit with cruelty? To avoid this trap, the family needs to handle transfer of assets like property and savings very carefully under the advice of lawyers who specialize in this field.
You could literally be not lucid, be repeatedly resuscitated (when you might otherwise might want to die a natural death), and have that all happening while burning through your entire life savings or financially harming your loved ones if you did not specify this beforehand.
>"...Upon transfer to the ward, the patient was inadvertently given hydromorphone instead of morphine. Shortly thereafter she was found not breathing. Resuscitation was not performed because of a do-not-resuscitate order on her medical record." [1]
... A narcan dose would reverse the above in about 20 seconds, but instead the patient died.
... this is why I asked GP about how these things are drawn up - I have to imagine it is scenario based?
"A 90-year-old woman lived independently, despite a history of stroke, congestive heart failure, emphysema, osteoporosis and hypothyroidism. After a fall in her residence during the winter, she presented to the emergency department of her local hospital where she was given long-acting morphine orally to control pain in her chest wall. With a diagnosis of pneumonia and renal failure, the patient was transferred to a ward, where the morphine was discontinued and hydromorphone was ordered in its place. Unfortunately, the patient received both analgesics. Two days after admission to the ward, she was found unrousable. Narcotic overdose was considered. After a single bolus dose of naloxone intravenously, the patient became alert; however, left alone for a few minutes, she was then found without vital signs. No further attempt at resuscitation was attempted because a do-not-resuscitate order had been previously entered in her chart at her request."
It isn't a simple case of an otherwise healthy person not given narcan because of a DNR. They were very ill, injured, and coded after an inital nalaxone treatment. Honestly, if it were me, I might want to shake the hand of the person that gave accidental overdose. Regardless, that is great link and both cases are very ethically complicated.
You should look into it more yourself, but for example, one might want to withdraw life sustaining treatment (food/water) if they are in a persistent vegetative state for a certain period of time. Based on other circumstances they might want a hard DNR. It is important and people should educate themselves about end of live decisions and options.
edit: I just realized you were referring to case #2. That is also complicated ethically.
I'm curious about two things:
1) are you advocating getting a flat out DNR order in your advanced directives / living will (do not ressus, period)? or just having advanced medical directives which say when you should be a DNR case?
If the former then I think that is a more nuanced discussion than just "good advice", considering you might be facing a reversible drug overdose for instance [2].
2) Do these the law firms typically walk through all the hypothetical scenarios to say under which one you should be DNR? The reversible overdose etc. case is one which I would be interested in vs. long-term vegetative state, etc. - I would understandably want to clarify there.
2) The firm I used had a meeting where the family members sat down and discussed everything with a lawyer. We were able to ask detailed questions and get answers. It was helpful and very worth the expense, because we used that knowledge later on to transfer property "the right way" so that it would stay in the family rather than being used entirely for medical-assistance spend-down.
I mean, sure, think it through, I guess. But it's a weird thing to encourage.
Regardless of the rarity of such occurrences, it’s always good to have clear communication around how you want to be treated in such a terrible situation. If there’s a clear medical opinion that my quality of life could not be restored to a fully functionally independent state, I’d rather just go.
The existence of rare bad outcomes is not a good reason to decline a big class of medical treatments. You would not recommend against vaccination because every once in a while a vaccine kills someone.
You do not need a DNR to have clear communication! That's why I specifically mentioned having advanced medical directives. A DNR is standing blanket order to not perform CPR or other live-saving resuscitation in case your heart stops or you stop breathing for any reason.
A proper DNR specifies the situations in which to not be resuscitated. NJ calls it an instruction directive:
https://www.state.nj.us/health/advancedirective/documents/in...
https://www.state.nj.us/health/advancedirective/ad/forums-fa...
https://familydoctor.org/advance-directives-and-do-not-resus...
An advanced directive is a legal document indicating a person's preferences and transferring legal authority. A DNR is an order to medical personnel for emergency situations. Only the DNR is effectively binding on medical personnel in such situations because they can't be expected to know of all legal documents.
Advanced directives can include DNRs, and will often do so for patients who have a bad prognosis. But healthy people do not normally include DNRs in their advanced directive!
I think young people should consider a living will with advanced medical directives for things like pvs, and older/terminally ill people should consider the impact of DNRs, but not lightly.
I went over my own mother's DNR papers several times, but there was never any chance at nuance with this legal document. I held off signing her DNR until it made sense — the point where a hospital admission could not possibly result in an eventual release. Many life-threatening complications require better judgement than a single page of blindly copy-pasted instructions.
As someone that has gone through this, there is a fine line to walk between doctors operating under their Hippocratic oath, caregivers, and patient wishes. My dad was prescribed meds that weren't helping his quality of life and had really bad side effects mentally and physically through the the mid-stages of dementia.
I imagine a significant number of people diagnosed with dementia likely do not have it. The providers just want people to be docile and lie in bed. Having to monitor and manage people who may get up at odd hours and act in ways we aren't used to requires a lot of other people, which gets expensive.
The worst part is that the combination of over medication and lack of suitable care can lead to someone exhibiting symptoms similar to dementia even if they don't have it.
To be fair, funding likely isn't sufficient for many providers to do a sufficient job monitoring and working with their patients, but that's a separate conversation.
I don't think it's as dire as you imagine. People don't just randomly drive themselves to nursing homes for no reason. Like you and I, few who are capable and willing to live independently would want to be in one.
By the time you end up in a nursing home, the odds are good that you require significant care and are unable to function independently. If that's true and you're in a nursing home and not a hospital or hospice, it's probably because the thing incapacitating you is mental — dementia.
However, if you do have dementia and end up in a nursing home... it sucks. Our culture and medical systems just aren't equipped to compassionately take care of fragile, dying people, who are confused, have trouble eating, shit themselves, etc. Caring for someone with dementia is brutal, heartbreaking work. Most people wouldn't want that job, and there's not enough money to pay well and compensate, so you get short-staffed or unhappy caregivers.
You can have musculoskeletal issues that prevent you from performing everyday activities. You might also have neurological issues that don't affect thinking or speech (e.g. as a result of stroke). I'm unsure if vision problems acquired at old age can confine one to a nursing home: it's harder to learn to compensate (e.g. because you have worse medium-term memory and poorer senses other than sight).
You don't get admitted to a "memory care" facility easily (multiple doctors and psychiatrists have to sign off) and it's expensive once you do (health care only really pays during immediate medical events).
I do know that there are horrors in nursing homes. I also know from personal experience that there are also good ones. But, it, as always, comes down to money.
My mother had to have 3 independent assessments before they would authorize permanent admission. And her Alzheimer's was beyond obvious once you knew what to look for.
A friend of mine wound up in a hospital mental health care facility in California, and within 48 hours had a state appointed patient advocate who immediately started forcing the doctors to justify their assessments. The doctors played some games, but at the end of 10 days, he was released as he should have been since whatever the "episode" was had clearly passed.
The problem with a dementia diagnosis in that context is that someone, probably the patient's family, has to go out of their way to show that the patient actually has something else and find a doctor willing to look into it before any other doctors will even consider the idea that they don't have dementia.
And while the patient has a dementia Dx, they will likely be chemically and physically restrained in a custodial care setting, which tends to further impair their functionality and ability to care for themselves, and that reduction in functionality is often taken as further proof that they are demented.
I have had between 10 and 20 physicians and 3 neurologists tell my family over the past two decades that what my grandmother had was Alzheimer's, Lewy body, and Vascular dementia, and that she would only decline. As it turns out, they were all wrong. They weren't just a little wrong, they were all completely wrong. To myself and my family, it was obvious that they were wrong because she would come back home from the Hospital, SNF, Board & Care, or Day Program and function much better than she did in those custodial settings, but they would only see her as mostly non-functional because the way they treated her significantly worsened her conditions. We had to really dig to figure out what was going on, but most people probably don't have the time and energy to do what we did.
There are also many people who do have different forms of dementia, but even in that population I imagine there are many treatable disorders missed that complicate their dementia.
Ultimately, the elderly are the most medically complex population with the least amount of time left to live, and because of that they tend to be given the least amount of care, and what care they are given tends to be of lesser quality. It's understandable from the point of view of triage, but as a society we should acknowledge that.
For the old folks, why not morphine or heroin? That, I've heard, is at least pleasant. As long as the supply is assured, anyway. Anti-psychotics aren't so much fun.
And if that seems outrageous, please say why.
But the problem is that people with dementia can hurt themselves and each other.
It sounds good, but if you've ever cared for a severely demented person who can no longer safely walk, you will have to make the choice between (a) strapping someone to a bed or (b) paying for 24/7 care (or, to some pro-rated amount, giving up your own time) to ensure that they don't get up, fall, and break something.
Me, I will die before going to a nursing home. And neither my wife nor I have life insurance, so suicide isn't problematic.
In the rare case where a simple, effective drug gets into medical practice, it magically ends up becoming "not recommended" about 20 years after it hits the market when the pharmaceutical company's patent runs out.
MAOIs work much better for depression than SSRIs, for example, yet the clock runs down, a few widely-publicized cases of serotonin syndrome caused by careless ER doctors hit the press, and suddenly anyone prescribing those drugs comes under scrutiny, and we all need to switch to the newly-patented option.
SSRIs tend not to have that side effect and less side effects in general, even though they are definitely less effective.
Additionally, each doctor wants you to try the less-effective drug for months at a time, each revision in the medication requires an expensive and time-consuming follow-up appointment at which point the doctor won't remember anything about you anyway, and SSRIs have their own non-trivial side effect profiles and withdrawal symptoms. It's just not as simple as -- or at least shouldn't be as simple as -- "oh, this one has fewer side effects!"
It's especially bad in the case of SSRIs, because to switch from an SSRI to an MAOI or vice-versa, you have to "wash out" (that is, go unmedicated) for at least two weeks, during which time the person is unlikely to be functional regardless of their natural chemistry because they'll be withdrawing from the old medication.
Meanwhile, the industry replaces pseudophedrine with phenylephrine (placebo whose only reliable effect is increased blood pressure) so that they don't have to admit every effective decongestant is now restricted and pushes the predominantly-ineffective atomoxetine as a replacement for amphetamines.
There are definite benefits to competent medical supervision, if it ever actually happened, but it's so uncommon that we're better off dropping the pretense and just using drugs that work.
I didn’t actually start getting better until I started seeing doctors in private practice who I paid to listen to me.
Pseudoephedrine is still available without a prescription if you want it. I bought some at my local pharmacy last month. The government forced the industry to restrict sales quantities and require customers to show ID because drug dealers were buying it to cook methamphetamine.
This is a claim that demands substantial support - particularly when simple effective drugs are used routinely! - and you've offered none.
I think that Hanlon's razor applies here.
> Never attribute to malice that which can be adequately explained by stupidity.
It's just how the system works. People behave as if they're part of a conspiracy, but they're all just doing what seems best (here, most profitable) for them.
That's somehow worse than conspiracy.
One issue is that new drugs aren't approved based on testing against old drugs, or other treatments. They're just tested against no treatment. It's generally not until much later that comparison studies get done.
The other issue, as you say, is patent protection. Patent protected drugs are heavily promoted. And a huge chunk of that is detailing to physicians.
Generic drugs generally aren't promoted. That's because physicians aren't actually prescribing them. They're prescribing the brand, which pharmacies fill as generic equivalents, unless the prescription says "fill as directed".
So when some new patent protected drug comes out, it tends to displace older drugs. Because the older brand drugs are no longer being promoted.
There are some pretty crazy effects from all the ridiculous players involved in this market with manufacturers plying clients with financial assistance, PBMs extorting manufacturers for rebates and providers over-billing everyone... the beautiful thing is this sunset effect is clear to see even through all that haze.
The US doesn't have that.
As I said, there's a very similar situation in the US about child care and education. And really, it's about everyone who isn't effectively competing for resources.
One might posit that the bias is in the drug being recommended in the first place (by a company that stands to gain from that recommendation and can afford lobbyists.)
> MAOIs work much better for depression than SSRIs, for example, yet the clock runs down, a few widely-publicized cases of serotonin syndrome caused by careless ER doctors hit the press
Or, y'know, caused by people eating cheese. Or drinking. MAOIs aren't not-a-first-line-therapy because they're easy to mis-prescribe; they're not-a-first-line-therapy because they're incompatible with many people's lifestyles.
Treatment regimens are designed such that you prescribe first the thing that's least likely to interfere with the patient's life, however small a chance it has of helping them. Because, if it does help, then it helped with (likely) no negative consequences.
In other words, most first-line treatments are placebos, and that's the whole point. First-line treatments should be placebos. People who can be cured by placebos shouldn't get drugs stronger than placebo; since drugs stronger than placebo necessarily have more side-effects than placebo.
People who aren't cured, come back and get the second-line treatment. And on and on until they get one that works for them.
I won't go into details, but suffice to say, either we got her into the nursing home at the exact right time where she absolutely needed it, or they started over-medicating her right away. Once she stepped foot through those doors, she was never the same again.
Her admittance coincided with the hospitalization and subsequent death of my Grandpa, who was her primary caregiver at the age of 92 (WWII veteran and atomic engineer, btw - smartest guy I ever knew).
Long story short, we started off getting them a two-person room where they were supposed to reunite once my Grandpa was checked out (a room which my Grandpa never made it to). Within a month, we had to move her into a one-person room. She never put two and two together (they were married for 70 years). I was the only person she recognized.
But she was never the same again once she checked in. And it was immediate.
Similarly, withholding meds from people in their 80s because those meds might shorten their life some seems dubious.
Nursing care is expensive. Very expensive. No one wants to pay for it, either because people didn't or couldn't save enough for it prior to needing it, or government can't get the will together to properly fund it (Medicaid/Medicare aside) with taxes. People still end up in homes, caregivers continue to be chronically underpaid, and there's some occasional public concern or outrage over it so society can feel better about the situation. "Thoughts and prayers" over meaningful elder care reform.
My estimate would be that you probably need around 1 person for 5 people or less to do the job some justice. Plus doctors and other personnel. This would be freakishly expensive.
Also, it is as expensive as you assume:
"This report, authorized by the Chairman of the Virginia Senate Committee on Education and Health, studies the provisions of Senate Bill 1125 of the 2001 Session of the General Assembly. Senate Bill 1125 requires Virginia nursing homes to implement minimum nursing staff standards of 5.2 hours per resident day (hprd). For Certified Nursing Assistants (CNAs), the Bill requires minimum ratios of 1:5 residents (day), 1:5 (evening), and 1:10 (night) or a total of 4.0 hprd, and minimum licensed nurse-to-resident ratios of 1:15 (day), 1:20 (evening), and 1:30 (night) or a total of 1.2 hprd. These minimum standards exceed those of all other states as well as those recommended by advocacy and research organizations. The fiscal impact on the Medicaid program is estimated to be an additional $91.2 million from the general fund annually."
It would be nice if we could all live to a ripe age, enjoy many years of retirement maintaining mobility and a lucid mind and then suddenly die in sleep. Unfortunately, it doesn't always turn out that way. Hopefully by the time many of us get to be that age, euthanasia will be a mainstream option.
ps - Sorry for misreading. I completely agree with you about nursing home workers in general, and I'm sorry about your father.
Nursing home workers do a job that is important, few want to do or could do. Most do it for pay. Most do not aspire to the job but end up there for practical reasons
Their job is harder than any of the other jobs you mentioned. Some people maybe do it for the money and others probably out of compassion. But in the end it doesn’t matter. It’s a very tough and thankless job.
My wife has been helping care for a dementia patient who is a really nice guy and easy to live with. He just doesn't remember how to get to the cafeteria or do many activities of daily living.
Other dementia patients are nasty and might try to strangle a caregiver that they don't recognize.
Instead of being calming, they were tuned to broadcast channels where the news channels announced the-world-is-going-to-pieces between loud advertisements.
I'm curious if video games being a more common (plus potentially social) activity will be more common in retirement home-like settings.
Maybe by that time we'll have personal VR setups with internet connections that route around health-care-system influence.
You're right that the ethics of the whole thing aren't clear. But a fair discussion of the ethics of cautiously using these drugs for dementia in willing participants - much less rampant, off-label uses in contexts for which there's no empirical evidence of their effectiveness (no FDA indication for any of these drugs for any dementia) - would include an honest conversation about the historical uses of prescribed psychotropics, and of political and economic power in the mental health professions and medicine more generally. Such a historical look would show that stories like this one are far from an abnormality, and that coercion, to greater or lesser degrees, is the norm. Some proportion of people taking these drugs (for any reason) undoubtedly do so of their own volition, and some of these may even derive a benefit from them. I have no objection to this. But vast numbers of people have no such luck, and are forced to take these drugs for some reason or another.
Many of these people are difficult: they're old and agitated and their dementia's getting worse, or perhaps they're yelling to themselves in the street, half-naked, rambling incoherently and looking fairly menacing, etc. What do the rest of us want with difficult people? We want'em out of our way (in a nursing home, say) and we want'em nice and calm. The drugs in this article do exactly that. No one with enough time in the mental health professions, or in geriatrics, is under any illusions about this.
"They want docile" is exactly right. So any discussion about the ethics involved here should also ask: "what are the ethics of coercing people to calm down with drugs?"
No doubt this does happen, and these cases should be investigated. But as with opiates, locking onto one part of the situation without considering the whole picture can lead to monstrous results.
My mother currently has dementia and my father had it before he died.
The confusion and unhappiness these people suffer from due to their illness should not be ignored. If they're in a nursing home, its even worse. In many cases it's quite humane to numb them up. Especially if they don't have loved ones to help them. There is no cure, there is no getting better. There is only getting worse and certain death. And they instinctively know something is wrong.
My mother is currently on two anti-depressant/anti-anxiety meds to help, and its made things much much better for her. No more worrying and confusion over everything, no more phone calls crying. She just goes about doing normal things without being upset.
I watched my mother in law go through it for many years and I would find it hard to say anyone gave someone "too much" when in reality they had no way of knowing what too much or not enough was without simple trial and error.
Short version: paying CNA more increases lifespan and quality of life for people in retirement homes because they are more motivated and you can hire better staff.
They don't care for these people, they don't have any special ties with them (e.g. like family), and if they could dispose them and keep the money they would. Keeping them sleepy and docile removes them from most of their day, and makes their jobs easier.
I get sick when I see the jokes they make on Big Bang Theory about Penny's job, she's basically a criminal (in many countries literally.)
Far more subjective and anecdotal, but the number of people I know who take prescriptions for anxiety or other ongoing mental health concerns but who have never tried therapy is scary. Treating with drugs is clearly solution #1 for a lot of our culture.
And some folks need the drugs just to talk to someone!
So yeah, drugs is often the go-to. A family doctor is a lot more available than a therapist.
Saying 'therapy not drugs' is all fine and dandy until you consider that for probably 99% of people therapy just isn't an option and may never be.
Were you only asking therapists who would accept your insurance, or did the lack of availability also apply to "out of network" providers?
Most people are not apprised of this when they start a medication -- they're just naively following doctor's orders. Consider that psychiatry is a racket where the conventional understanding is that any psych willing to mess with insurance companies is a hack, that every cash-only doc within 50 miles of a significant population has a 3-month waiting list and is generally choosy about their patient base anyway, and that family practitioners aren't willing to do anything slightly unconventional because the DEA will start breathing down their necks, and we have quite the mess on our hands.
I'd suggest that you don't judge those SAHMs too harshly. It's a tough gig on its own, and throwing in "risk becoming totally non-functional" is usually not something that people can just pencil into their schedule.
We're overmedicated in opiates because of the corrupt drug industry and corporations pushing pills for profit (see: the various articles and stories detailing the rampant corruption behind Purdue) and likely undermedicated in everything else.
https://agedcare.royalcommission.gov.au/Pages/default.aspx
One of the 3 major issues identified in the interim report is:
to respond to the significant over-reliance on chemical restraint in aged care,including through the seventh Community Pharmacy Agreement