The following is an edited excerpt from a speech Martin Whitely MLA made in the Western Australian Legislative Assembly on Wednesday 25 May 2011
Mental Health was a centrepiece of the federal budget, with an additional $2.2 billion being identified over five years for mental health initiatives, of which $419.7 million was split between the Early Psychosis Prevention and Intervention Centre (EPPIC), and Headspace. An additional $2.2 billion for mental health is a good thing and to the extent that people such as Professor Patrick McGorry, Professor Ian Hickie and Professor John Mendoza, have contributed to putting mental health on the agenda, they deserve praise. However, I am concerned that the devil is in the detail. My criticism is not about extra funding but about the lack of an evidence base for the decisions that have been made.
Politics not science drove the Gillard Government’s mental health response.
I suggest that this response was a political response to a political problem, not a public policy response based on thorough analysis of the evidence. I criticise not only the Gillard government but also the Abbott opposition, the independents and, indeed, the media. They have all allowed the mental health debate to be dominated by a tiny group—Patrick McGorry, Ian Hickie and John Mendoza.
I am not suggesting that those people do not have valuable contributions to make. However, I am saying that they are not the independent mental health spokespersons that they are portrayed to be in the media; they are players with vested interests. That has been missed by the media, the opposition, the federal government and even the independents in federal Parliament. Those three gentlemen are fantastic advocates and great political lobbyists, but I am not convinced that they have been asked enough tough questions about the programs they advocate for and control—particularly EPPIC and Headspace. I am concerned about the potential for off-label prescribing in expanded EPPIC and Headspace services, and the potential for this to do enormous harm to young people in Australia.
Before I talk about that, I will talk about the political process involved and highlight how unusual it was. The Minister for Mental Health and Ageing has the National Advisory Council on Mental Health to give him advice on strategic directions for mental health. The Minister for Mental Health and Ageing took the extraordinary step of sidelining the National Advisory Council and set up the Mental Health Expert Working Group. Three members of that group—Professor McGorry, Professor Ian Hickie and Monsignor David Cappo—left that group and produced their own $3.5 billion five-year blueprint for mental health under the banner of the Independent Mental Health Reform Group. It is interesting that both Professors McGorry and Hickie have extensive and longstanding commercial ties to the pharmaceutical industry, so I have some questions about the use of the term “independent”.
Extra EPPIC and Headspace funding may see increased ‘off label’ prescribing of SSRI Antidepressants to young people and more youth suicides.
The blueprint they came up with identified $226 million for Headspace, which ended up getting $197.3 million and $910 million for Early Psychosis Prevention and Intervention Centres, which received $222.4 million. The EPPIC funding is supposed to be matched by state governments. I suggest that state governments need to have a good think about whether they do that.
I am very concerned that we will see through Headspace and EPPIC an increase in the off-label prescription of selective serotonin reuptake inhibitor (SSRI) antidepressants, despite the clinical trial evidence that is accepted by the Therapeutic Goods Administration and the US Food and Drug Administration that using SSRI antidepressants leads to a significant increase in the prospects of young people under the age of 24 years being suicidal—an increase of 80 per cent. Regardless both Headspace and EPPIC advocate the use of SSRI antidepressants for all young people with moderate to severe depression.
This document titled, “Using SSRI Antidepressants to Treat Depression in Young People: What are the Issues and What is the Evidence?” was produced by Headspace in 2009 and has five authors, including Patrick McGorry. It concludes by stating —In cases of moderate to severe depression, SSRI medication may be considered within the context of comprehensive management of the patient, which includes regular careful monitoring for the emergence of suicidal ideation or behaviour.
Yet the body of the paper builds a compelling case for not using SSRI antidepressants. It acknowledges that the only SSRI that has positive outcomes in clinical trials is fluoxetine and that even those benefits seem to disappear the longer one looks at the evidence. The paper also highlights the fact that clinical trials indicate that compared to taking a placebo, SSRI antidepressants increase the probability of a young person being suicidal by 80 per cent.
One has to bear this in mind against the political process that was used to sell the need for expansions of Headspace services. It was done against the background of candlelight vigils that were coordinated through Get Up! to highlight concerns about youth suicide and create momentum for increased funding to youth-oriented mental health services. However, the very services that the federal government is funding prescribe against TGA and FDA recommendations and against the (suicidal behaviour) black box warnings that exist for SSRI antidepressants.
Therefore I am very concerned that if this issue of SSRI antidepressant ‘off label’ prescribing is not addressed at both Headspace and EPPIC, we may see an increase in the number of candles at the next vigil.
Patrick McGorry on EPPIC - Contradictory and Confusing
My concerns about EPPIC are less straightforward. EPPIC is very much Professor McGorry’s baby and is based on the principle that early intervention can prevent later psychosis—the philosophy that a stitch in time saves nine. I support the philosophy of early intervention. Members who have listened to my speeches in the past will be bleeding from the ears hearing me plead for the need for early intervention so that we can identify kids’ real health, education and social needs. My concern is not that we do not need early intervention but what that early intervention will be.
At my invitation, Professor McGorry replied to my latest blog. We also had an exchange on The World Today program on ABC radio on 12 May in which I outlined my concerns, and on 20 May Professor McGorry responded. As I said, we are halfway through what I believe is going to be a constructive and cordial exchange. (we are meeting in late June)
However, I want to put on record my prime issue so there is absolutely no ambiguity about it. What we need from Professor McGorry, on behalf of EPPIC, is a very clear unambiguous statement about the circumstances under which antipsychotics will be prescribed at EPPIC, and we need a very clear statement about the future of Psychosis Risk Syndrome. I will not beat around the bush. To date, what Professor McGorry has said and written is confusing for those who follow it closely. It is confusing for one very clear reason: he has contradicted himself too often.
Specifically, I want to begin with the issue of psychosis risk syndrome, otherwise known as attenuated psychotic syndrome. Dr Allen Frances, the psychiatrist who led the redevelopment of DSMIV, the bible of psychiatry, had some very unflattering things to say about psychosis risk syndrome. He said —“Psychosis Risk Syndrome” stands out as the most ill-conceived and potentially harmful …(Of all the proposals for insertion into DSM5) — The whole concept of early intervention rests on three fundamental [flawed] pillars … 1) it would misidentify many teenagers who are not really at risk for psychosis; 2) the treatment they would most often receive (atypical antipsychotic medication) has no proven efficacy; but, 3) it does have definite dangerous complications.”  They are the words of the man who led the redevelopment of DSMIV. These are not the words of someone at the fringe of psychiatry. These are words from the very heart of psychiatry.
When I was on The World Today on 12 May I said that Professor McGorry is a leading international proponent of Psychosis Risk Syndrome a new psychiatric disorder for inclusion in the next edition of DSM5. On the long version of the audio version on The World Today website, Professor McGorry said — Contrary to Mr Whitely’s statements, I haven’t been pushing for it —(That is, psychosis risk syndrome) — to be included in DSM5. Now that hasn’t been my position…But it’s a new area of work. It’s only been studied for the last 15 years or so, so you know we haven’t got all the answers … I’m certainly not saying that it should go into DSM5.
So on two occasions in that interview he said that he was not advocating it should go into DSM5. That is just plain wrong. I have an article that was published in Psychiatry update a year ago entitled “DSMV ‘risk syndrome’: a good start, should go further”.  It begins by stating — The proposal for DSMV to include a ‘risk syndrome’ reflecting an increased likelihood of mental illness is welcome but does not go far enough, according to Orygen Youth Health’s director Professor Patrick McGorry.
That is somebody else paraphrasing his words, so I went to the original source document, which is an article available in the Science Digest under “Schizophrenia Research”. It is written by Professor McGorry and the opening sentence states — The proposal to consider including the concept of the risk syndrome in the forthcoming revision of the DSM classification is innovative and timely. It has not come out of left field, however, and is based upon a series of conceptual and empirical foundations built over the past 15 years.
That is absolutely clear-cut. I could build a case in greater detail but Professor McGorry has clearly advocated the inclusion of psychosis risk syndrome, otherwise known as attenuated psychosis syndrome in DSM5. (Note; Far from rejecting the notion of Psychosis Risk Syndrome McGorry argues for the recognition of yet another disorder, General Distress Syndrome, for those with even less acute, ill-defined symptoms ).
In the same interview, Professor McGorry said — Medication should never be the first line of treatment in young people, we should always try to find psychological and simpler ways of treating youth mental health issues, that is where I agree with him (Martin Whitely) but where I part company is where he tried to I suppose confuse the issue by, I suppose, denying any value to these medications. They clearly do have value, the anti-psychotic medications, in people with clearcut psychosis.
I have never been critical of the on-label prescription of antipsychotics to people who have had a psychotic break. Professor McGorry is quite wrong in characterising me as saying that. But that is not of any great consequence because, after all, it just relates to me being misrepresented.
Another misrepresentation is of greater consequence because he contadicted EPPIC’s position when he said that — Medication should never be the first line of treatment in young people, we should always try to find psychological and simpler ways of treating people with youth mental health issues. EPPIC guidelines (at least in regard to the use of antidepressants in young people) clearly identified that all those presenting with a depressive episode of at least moderate severity should be commenced on an antidepressant. It does not even narrow it down to Fluoxetine, the one selective serotonin reuptake inhibitor identified as having some positive effects. It just says “antidepressant”.
That is not the only misrepresentation. Professor McGorry also claimed, in response to my blog, that EPPIC followed the beyondblue guidelines with regard to the use of SSRI’s. That is not true. The beyondblue guidelines are far more cautious in its recommendations about the use of SSRIs or antidepressants. Professor McGorry is simply wrong to say that EPPIC follows the Beyondblue guidelines for the use of antidepressants.
I have a number of other concerns. (Especially the EPPIC guideline that states ‘All individuals with an ‘at risk’ mental state, e.g. siblings of EPPIC clients, will be referred to PACE clinic for assessment. ) Unfortunately, I will run out of time but a major concern is with the use of antipsychotics in non-psychotic teenagers by EPPIC. EPPIC’s target audience is young people between the ages of 15 to 24 years. Professor McGorry and EPPIC have to answer the following very simple question: under what circumstances, if any, will EPPIC either recommend or prescribe antipsychotics to patients who have not experienced psychosis?
EPPIC and Professor McGorry need to make their position clear because at the moment it is not clear. I mistakenly thought it was made clear in a previous blog that I had written when a spokesperson for Professor McGorry, Matthew Hamilton, made some quite promising statements that indicated that they were no longer proposing the use of antipsychotics for psychosis risk syndrome. Since then, we have seen some ambiguous and contradictory statements by Professor McGorry that have left that door open. We need to have a very clear answer from Professor McGorry on behalf of EPPIC as to when, if ever, antipsychotics will be used by those who have never been psychotic.
Clarrity at least is required, but in my opinion EPPIC and Headspace need to abandon prescribing antidepressants altogether to under 18′s and rule out the use of antipsychotics in non-psychotic young people. If they stick to ‘on label’ prescribing, we can be confident that the extra $419.7 M for EPPIC and Headspace will do more good than harm. This requires a change from experimental, hypothesis based, psychiatry to an evidence based, ’first do no harm’ mindset.
Update – Some progress has been made on the issues identified above see http://speedupsitstill.com/australian-16-june-2011
Coming Blogs – Mental health screening for three year olds and the budget cuts to psychology services: Are these a recipe for more dumbed down, psychiatric labelling and prescribing?
I ran out of time in the speech to outline all of my concerns with the mental health response in the 20011/12 federal budget. I am alarmed at the proposals for mental health screening of three year olds and despair at the cuts to support for psychological services, in order to fund GP mental health visits. Both of these measures have the potential to further promote the increasingly dominant dumbed down, ‘label and prescribe’ approach to mental health, however these are topics for another speech and blog.
Minds at Risk: Choosing the Right Path for Adolescent Mental Health, Lisa Pryor, The Monthly July 2011 http://www.themonthly.com.au/choosing-right-path-adolescent-mental-health-minds-risk-lisa-pryor-3470
 Professor McGorry was the former President and is the current Treasurer (http://www.iepa.org.au/ContentPage.aspx?pageID=40) of the “International Early Psychosis Association” which is funded by antipsychotic manufacturers Astra Zeneca, Lilly and Janssen-Cilag (http://www.iepa.org.au/2010/) McGorry is currently Director of Clinical Services at Orygen Youth Health Clinical Program and Executive Director of the Orygen Youth Health Research Centre. Orygen Youth Health receives support from AstraZeneca, Bristol Myer Squibb, Eli Lilly, and Janssen-Cilag. Orygen Youth Health, Research Centre – Other Funding http://rc.oyh.org.au/ResearchCentreStructure/otherfunding (accessed 3 August 2010) McGorry individually has received unrestricted grants from Janssen-Cilag, Eli Lilly, Bristol Myer Squibb, Astra-Zeneca, Pfizer, and Novartis and has acted as a paid consultant or speaker for most of these companies 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)
Professor Hickie and colleagues created the ‘SPHERE: A National Depression Project’ (http://sydney.edu.au/bmri/about/Hickie_CV.pdf). As was reported in The Australian Pfizer work in conjunction with SPHERE through a company called Lifeblood who are paid to review SPHERE. Through the use of SPHERE Pfizer have restored Zoloft to the number one antidepressant in Australia. (http://www.theaustralian.com.au/news/health-science/gp-jaunts-boosted-drug-sales/story-e6frg8y6-1225890003658). Professor Hickey received the following grants totalling $411,00 from pharmaceutical companies: $10,000 from Roche Pharmaceuticals (1992); $30,000 from Bristol-Myers Squibb (1997); $40,000 from Bristol-Myers Squibb (1998-1999); $250,000 from Pfizer Australia (2009); $81,000 from Pfizer Australia (n.d.) Cited in Ian Hickie, Curriculum Vitae, last updated 23 August 2009 http://sydney.edu.au/bmri/about/Hickie_CV.pdf (accessed 3 August 2010)
Professor Mendoza was co-author of the “Not for Service” report which was issued in 2005. Apart from the Commonwealth Govt, the report was funded by unrestricted grants from AstraZeneca, Bristol-Myers Squibb, Eli Lilly Australia, GlaxoSmithKline, Medicines Australia, Pfizer Australia and Wyeth. (Not For Service: Experiences of Injustice and Despair in Mental Health Care in Australia, Mental Health Council of Australia, Canberra, 2005 http://www.hreoc.gov.au/disability_rights/notforservice/documents/NFS_Finaldoc.pdf (3 August 2010)). He is also a principle of ConNetica Consulting Pty Ltd, whilst they have very broad purposes such as providing a review, survey and planning service to government and not for profit organizations, including those involved in mental health. It currently lists Eli Lilly as one of its private sector clients (ConNetica Consulting, About Us http://connetica.com.au/about_us (accessed 3 August 2010))
 Advisory Group to Guide Mental Health Reforms (23 December 2010), Pro Bono News Advisory Group to Guide Mental Health Reforms (accessed 26 April 2011)
 Including, Connecting, Contributing: A Blueprint to Transform Mental Health and Social Participation in Australia, March 2011. Prepared by the Independent Mental Health Reform Group: Monsignor David Cappo, Professor Patrick McGorry, Professor Ian Hickie, Sebastian Rosenberg, John Moran, Matthew Hamilton A Blueprint to Transform Mental Health and Social Participation in Australia (accessed 26 April 2011)
 Hammad T.A. (16 August 2004). Review and evaluation of clinical data. Relationship between psychiatric drugs and pediatric suicidal behavior, Food and Drug Administration. pp. 42; 115. FDA Review and evaluation of clinical data (accessed 29 May 2008)
 Evidence Summary: Using SSRI Antidepressants to Treat Depression in Young People: What are the Issues and What is the Evidence? Headspace, Evidence Summary Writers Dr Sarah Hetrick, Dr Rosemary Purcell, Clinical Consultants Prof Patrick McGorry, Prof Alison Yung, Dr Andrew Chanen Headspace Evidence Summary (accessed 28 May 2011)
 Frances, A. (2010) DSM5 ‘Psychosis risk syndrome’—Far too risky, Psychology Today Psychosis risk syndrome—Far too risky
 The World Today – Professor McGorry hits back at critics, 20 May 2011 www.abc.net.au/worldtoday/content/2011/s3222359.htm (accessed 28 May 2011)
 Available at http://www.psychiatryupdate.com.au/news/DSM-V-risk-syndrome-a-good-start-should-go-further accessed 28 May 2011
 EPPIC guidelines state that all clients experiencing ‘a depressive episode of at least moderate severity should be commenced on an antidepressant.’ http://www.eppic.org.au/eppic-clinical-guidelines (accessed 28 May 2011)
 In comparison to the EPPIC Guidelines which say that all clients experiencing ‘a depressive episode of at least moderate severity should be commenced on an antidepressant.’ the beyondblue clinical practice guidelines (page 55) state: ‘If symptoms are severe, or if symptoms are moderate to severe and psychological therapy has not been effective, is not available or is refused, prescription of the selective serotonin reuptake inhibitor (SSRI) antidepressant fluoxetine should be considered for reducing depression symptoms in the short term.’ http://beyondblue.org.au/index.aspx?link_id=6.1247 accessed 28 May 2011
 http://www.eppic.org.au/eppic-clinical-guidelines (accessed 28 May 2011)
 In December 2010 Professor McGorry wrote ‘Antipsychotic medications should not be considered unless there is a clear-cut and sustained progression to frank psychotic disorder meeting full DSM 4 criteria.’ He then immediately invalidated this statement by writing, ‘The only exception to the previous statement is where there has been a definite failure to respond to the first and second line interventions described above AND there is worsening and continuing disability, or significant risk of self-harm, suicide or harm to others arising directly from the mental disorder itself and its symptoms. In this situation, a trial of low dose antipsychotic medication for 6 weeks in the first instance may be appropriate, with careful monitoring for adverse events.’ The term mental disorder itself is interesting as he is referring Psychosis Risk Syndrome which is not officially recognised as a legitimate psychiatric disorder and hopefully never will be. See http://speedupsitstill.com/reply-patrick-mcgorry-early-intervention-psychosis#more-1075
Tags: Allen Frances, attenuated psychosis syndrome, David Cappo, DSM5, EPPIC, headspace, Ian Hickie, Independent Mental Health Reform Group, John Mendoza, Julia Gillard, Mental Health Expert Working Group, Patrick McGorry, Psychosis Risk Disorder, SSRI antidepressant 'off label' prescribing, Tony Abbott