Australia Day Question- Why do we slavishly follow the American Psychiatric Association’s (DSMIV) prescription for the Mental Health of children. Are American children doing that well?

The USA is the home of ADHD child drugging with at least 2.7 million children currently taking ADHD ‘medications’.^[1] As American psychologist Dr Leonard Sax points out, given that many of the supposed benefits of medication for ADHD children relate to education, ‘you would expect American children to be racing ahead in their school work’; but as it is, ‘France, Germany, and Japan continue to maintain their traditional lead over the United States in tests of math and reading ability’.^[2] Similarly, if ADHD drugs worked, measures of social functioning like juvenile crime rates would be lower in countries with high prescribing rates like the US. Clearly America’s ‘medicated’ children are not doing so well.

Australia should hardly be using America as the ‘model’ for enhancing the welfare of children. However, the reliance of Australian psychiatric practice on imported American Psychiatric Association (APA) diagnostic criteria, over which the Australian medical profession has no control, leaves Australian consumers, particularly children, vulnerable to the same forces that make America the home of indiscriminate psychiatric drugging.

In 2008 it was revealed that more than half the psychiatrists that developed the Diagnostic and Statistical Manual of Mental Disorders DSM-IV received drug company funds.^[3] Thankfully there has been some recent recognition of the problem from the top level of the APA. In the same year, then APA President, Dr Steven S. Sharfstein, wrote a groundbreaking commentary piece on the relationship between psychiatry and the pharmaceutical industry entitled;

‘Big Pharma and American Psychiatry: the Good, the Bad, and the Ugly’

There is widespread concern of the over-medicalization of mental disorders and the overuse of medications. Financial incentives and managed care have contributed to the notion of a ‘quick fix’ by taking a pill and reducing the emphasis on psychotherapy and psychosocial treatments. There is much evidence that there is less psychotherapy provided by psychiatrists than 10 years ago. This is true despite the strong evidence base that many psychotherapies are effective used alone or in combination with medications…

 One of the charges against psychiatry that was discussed in the resultant media coverage (of anti-psychiatry remarks by Tom Cruise) is that many patients are being prescribed the wrong drugs or drugs they don’t need. These charges are true, but it is not psychiatry’s fault—it is the fault of the broken health care system that the United States appears to be willing to endure…In a time of economic constraint, a ‘pill and an appointment’ has dominated treatment. We must work hard to end this situation and get involved in advocacy to reform our health care system from the bottom up.

There are examples of the ‘ugly’ practices that undermine the credibility of our profession. Drug company representatives will be the first to say that it is the doctors who request the fancy dinners, cruises, tickets to athletic events, and so on. But can we really be surprised that several states have passed laws to force disclosure of these gifts? So-called ‘preceptorships’ are another example of the ‘ugly’; that is, drug companies who pay physicians to allow company reps to sit in on patient sessions allegedly to learn more about care for patients and then advise the doctor on appropriate prescribing. Drug company representatives bearing gifts are frequent visitors to psychiatrists’ offices and consulting rooms. We should have the wisdom and distance to call these gifts what they are—kickbacks and bribes.^[4]

Despite Dr Sharfstien’s refreshing honesty, if we continue to blindly follow the lead of the American Psychiatric Association we can be confident that more trouble will follow. The psychiatrist who led the effort to update DSM-IV (in 1994), Dr Allen Frances, now regrets broadening the diagnostic criteria for a range of childhood disorders including autism; juvenile bipolar disorder, and ADHD. Dr Frances has warned of similar problems when DSM-V replaces DSM-IV in 2013. After reviewing the early draft of DSMV he predicted further ‘false epidemics’ and ‘unnecessary, expensive and often horrible treatments for conditions that really are made up by the people doing the manual (DSM-V)’.^[5]

The good news is we can avoid many of these problems. There is absolutely no need for Australia to continue to slavishly follow the lead of the APA as there is a better, although far from perfect, alternative. Chapter five of the International Clarification of Diseases 10 (ICD-10) is the criterion for mental health disorders published by the World Health Organization and used predominantly in Europe. It is largely overlooked in Australia.

The eighteen diagnostic criteria for hyperkinetic disorder outlined in ICD-10 are virtually identical to those for ADHD in DSM-IV. There are, however, two subtle but important distinctions. First, for a diagnosis of hyperkinetic disorder, an individual is required to display at least six of nine of the inattentive and three of five of the hyperactive and one of four of the impulsive behaviours. For a DSM-IV diagnosis of ADHD, six of nine of the inattentive or six of nine of the hyperactive/impulsive are sufficient. Second, unlike ADHD, hyperkinetic disorder is not diagnosed if another condition that may explain the behaviour is diagnosed.

While many of the criticisms of subjectivity of assessment of behaviours are common to both the DSM-IV and ICD-10, in practice far fewer children are diagnosed using ICD-10. Despite the fact that Australia is a member of the World Health Organization and obviously not the American Psychiatric Association, DSM-IV is the predominant criteria used in Australia. As a consequence, the rate of psychostimulant use per head in the US and Western Australia (using DSM-IV) between 1994 and 2000 was approximately ten times the UK rate (predominantly using ICD-10).^[6]

This is not only true for ADHD, DSM-IV generally contains looser, less rigorous diagnostic criteria than ICD-10. A 2005 study compared diagnosis rates for a range of childhood psychiatric disorders using the diagnostic criteria in DSM-IV and the equivalent disorder in ICD-10. For the majority of disorders, including ADHD, rates of diagnosis were higher using DSM-IV.^[7]

That is not to say that the ICD10 should be our final destination or that many of the same corrupting commercial influences don’t have an effect on the World Health Organisation’s ICD development processes. But it is an easily obtainable improvement and at least Australia is a member of the World Health Organisation with some capacity to influence its processes.

Perhaps Australia Day is an opportunity to reflect on whether we should continue to cede sovereignty of the mental health and wellbeing of our children to American Psychiatric Association and therefore indirectly to the pharmaceutical industry.