“As opposed to the ‘ongoing disability’ or ‘impending doom’ assumptions inherent in the Americanisation and Preventative Psychiatry approaches, the Recovery approach is more optimistic about the capacity for recovery and less reliant on pills. It supports mentally ill patients with housing, educational, employment and psychosocial support – building blocks for a healthy and happy mind that can’t be replaced by drugs.”
Mental health policy in Australia, for so long ignored, is finally getting attention. The Australian and West Australian governments have appointed their first Mental Health Ministers and significant resources are being identified for new and expanded services. In addition sport stars, celebrities and politicians have publicly shared their personal battles with depression, bipolar and a host of other mental health problems – helping to ‘de-stigmatise’ mental illness.
To casual observers it may appear at last we are on track to a happier, mentally healthier tomorrow, however appearances can be misleading. The future direction of mental health in Australia is far from certain.
Just about everybody involved in the debate agrees things need to change, but this is where the consensus ends. There are at least three different directions on offer. For the want of better descriptions, I will call them the ‘Americanisation’, the ‘Preventative Psychiatry’ and the ‘Recovery’ approaches.
Apart from spiraling mental health prescribing rates the most obvious evidence of the Americanisation of Australia’s mental health system is the dominance of the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM) diagnostic model. Often referred to as the ‘Bible of Psychiatry’, the current edition, DSM-IV, outlines the diagnostic criteria of 297 psychiatric disorders.
Like the yellow pages, subsequent editions of the DSM have thickened as new disorders have been added. This expansion has been exploited by aggressive pharmaceutical company marketing, resulting in the ‘medication’ of people who would previously have been regarded as ‘normal’.
With the benefit of hindsight Professor Allen Frances, the Chairman of the Task Force that developed the DSM-IV, regrets aspects of the DSM-IV as having helped to trigger “false epidemics” including “the wild over-diagnosis of attention deficit disorder.”
Professor Frances is particularly worried about the next edition, DSM-5, due for publication in 2013. He contends that further diagnostic expansion driven by the inclusion of pet disorders of enthusiastic researchers will see even more ‘normal’ people made patients and more over-prescribing of psychotropic drugs.
Thankfully there is a significant international revolt, led by Professor Frances, from within the psychiatric and psychological professions, against the further medicalisation of behaviours proposed for DSM-5. This has already caused the American Psychiatric Association to abandon some of its more controversial DSM-5 proposals including ‘Psychosis Risk Disorder’ and the expansion of the already absurdly broad diagnostic criteria for ADHD.
Australia’s most prominent psychiatrist, former Australian of the Year, Professor Patrick McGorry, has also expressed concern about the over-prescription of psychiatric drugs in the US, however he argues the risks aren’t as great here. Unlike the US we don’t allow direct advertising to consumers, however the pharmaceutical industry aggressively market their drugs to the Australian doctors who prescribe them. They also sponsor medical research, conferences, educational opportunities and even patient support groups that ‘raise awareness’ of the disorders their drugs treat. Australia is far from immune from undue pharmaceutical company influence.
Professor McGorry is arguably the world’s most prominent advocate of Preventative Psychiatry. He believes that prior to the onset of psychosis, depression and other serious mental illness there is a ‘prodromal phase’ and that intervening then will help save many the misery of full blown mental illness.
Critics of Preventative Psychiatry, including Professor Frances, contend it simply doesn’t work. They argue you can’t predict with sufficient accuracy, who will go onto become ill and that even when it is accurate, independent evidence indicates that preventative measures don’t work.
Even Professor McGorry acknowledges that the vast majority of people that are identified as being at Ultra High Risk of developing psychosis, his specialist area, never do. Nonetheless, he argues the benefits of predictive intervention massively outweigh the risks of doing nothing.
The belief intervention could prevent psychosis was part of the rationale for the Gillard Government’s 2011 decision to allocate $222.4million for the role out of Early Psychosis Prevention Intervention Centres (EPPICs) across Australia. At the time of the decision it looked very likely that DSM5 would include a ‘Psychosis Risk Disorder’. Now that is not happening, the future of the ‘preventative’ function of EPPICs is uncertain.
Adding to this uncertainty is Preventative Psychiatry’s long and continuing history of unsuccessfully experimenting with psychotropic drugs as a means of ‘immunizing’ people considered at elevated risk of future mental illness. While EPPICs will provide a broad range of psychosocial services and also treat patients who are already psychotic, significant questions remain unanswered.
The final option, the Recovery approach, centres on developing a patient’s own capabilities and resilience. As opposed to the ‘ongoing disability’ or ‘impending doom’ assumptions inherent in the Americanisation and Preventative Psychiatry approaches, the Recovery approach is more optimistic about the capacity for recovery and less reliant on pills. It supports mentally ill patients with housing, educational, employment and psychosocial support – building blocks for a healthy and happy mind that can’t be replaced by drugs.
While the Recovery approach is more optimistic about human resilience, it is more realistic about the limits of psychiatry than either of the other approaches. The Americanisation approach is based on the unrealistic assumption that psychiatric science can accurately identify at least 297 different disorders, and the Preventative Psychiatry approach on the fanciful notion that mental illness can be reliably spotted before it happens.
Unfortunately a significant disadvantage for the Recovery approach is that it offers a pessimistic outlook for the profitability of pharmaceutical companies. If history is any predictor of the future this could prove to be its’ fatal flaw.
The above was originally printed as an opinion piece in the West Australian Newspaper Wednesday 13 June 2012 available at http://au.news.yahoo.com/thewest/opinion/post/-/blog/13939119/mental-health-needs-rethink/
 Prof. Allen Frances, ‘Psychiatrists Propose Revisions to Diagnosis Manual’, PBS Newshour, 10 February 2010. Available at http://www.pbs.org/newshour/bb/health/jan-june10/mentalillness_02-10.html
 Amy Corderoy, About-turn on treatment of the Young,Sydney Morning Herald, February 20, 2012http://www.smh.com.au/national/health/aboutturn-on-treatment-of-the-young-20120219-1th8a.html]
 McGorry P.D. ‘Is early intervention in the major psychiatric disorders justified? Yes’, BMJ 2008;337:a695 http://www.bmj.com/cgi/content/full/337/aug04_1/a695(accessed 3 August 2010)]