Encouraged by its Managing Director Mark Scott, the ABC has promoted Professors Patrick McGorry and Ian Hickie as independent mental health experts and unquestioningly backed their plans for reforming mental health. However both have significant ties to the pharmaceutical industry[1] and there has been prominent international criticism of their methods – and in Hickie’s case his integrity – which has been substantially ignored by the ABC.

As highlighted by Time magazine in 2006, McGorry has a long and controversial history of promoting the use of life shortening antipsychotics[2] as a means of immunising against schizophrenia in mildly distressed young people.[3] In 2011 McGorry’s plans for the national roll out of his Early Psychosis Prevention and Intervention Centres (EPPIC) prompted influential American psychiatrist Professor Allen Frances to write; ‘McGorry’s intentions are clearly noble, but so were Don Quixote’s. The kindly knight’s delusional good intentions and misguided interventions wreaked havoc and confusion at every turn’.

Frances warned that Australia is in danger of following McGorry blindly down ‘an unknown path that is fraught with dangers’.[4] Domestic critics include Australian professors of psychiatry George Patton, Jon Jureidini, David Castle, and Vaughan Carr, who described McGorry’s claims of the cost effectiveness of his EPPIC model as ‘a utopian fantasy’ based on ‘published evidence that is not credible’.[5] [6] [7] [8]

While critics of McGorry are generally complementary about his motives, the same is not true for Australia’s ‘depression guru’ Hickie. He has been criticised on numerous occasions for allegedly promoting inappropriate antidepressant prescribing and exaggerating the benefits of antidepressants in suicide reduction.[9] [10] [11] Most notably in 2012 the editor of the Lancet, Richard Horton, slammed Hickie for writing an article that Horton concluded exaggerated the benefits of an antidepressant he had been paid to spruik.  Horton tweeted ‘the bias in this paper is very disturbing… it is this kind of complicity that damages any hopes of a positive partnership between medicine and [the pharmaceutical] industry’.[12]

In 2014, driven by Scott, the ABC took the unprecedented step of running a week long Mental As campaign to raise awareness and funds for mental health research.[13] The genesis was a meeting between Scott and McGorry.[14] The ABC ‘worked closely’ with the pharmaceutical industry funded Mental Health Australia in developing the campaign.[15]

Most of the Mental As coverage was uncontroversial and encouraged good mental health habits. However, there was a consistent theme of massive unmet need and promises of safe, effective treatments, including medications, if only troubled Australians sought professional help. The Telethon style coverage concluded with a chorus of circular praise between McGorry, Scott and the ABC.

In April 2015, the ABC’s 7.30 obtained a leaked copy of the National Mental Health Commission report into Australia’s mental health system. Hickie is the only psychiatrist on the Commission whose role it is to ‘provide expert and independent advice to the Government on the performance of our mental health system’.[16] The Commission’s report stated the current system is poorly planned and integrated and is a ‘massive drain on people’s wellbeing’. It urges a ‘radical rethink of responses’ to mentally ill people seeking help and recommends redirecting more than $1 billion in funding from acute hospital care to community-based mental health services.[17]

McGorry and Adjunct Professor John Mendoza (Hickie’s close colleague) were the only two mental health experts interviewed by 730. Mendoza spoke about a recent family tragedy. His nephew was one of two tragic examples of young men suiciding after being turned out of acute mental health services prematurely and without adequate support. The fact that the key recommendation of the report was to strip $1billion out of acute hospital care, which risks many more young men being denied acute care, seems to have been completely lost on the ABC reporters.

On 7.30 McGorry called for ‘evidence based’ suicide prevention strategies and for government to set a national target of a 50% drop in suicides in the ‘next 5 to 10 years’. However, McGorry’s ‘evidence based’ rhetoric on suicide doesn’t match his actions.[18] A 2007 audit of McGorry’s Orygen Youth Mental Health Service found the service ‘prescribed medication to a majority of depressed 15 to 25-year-olds before they had received adequate counselling, despite international guidelines advising against the practice.’[19]

In addition a 2009 evidence summary produced for Headspace and overseen by McGorry concluded SSRI antidepressants could be used by moderately depressed young people.[20] This is despite the fact that SSRIs are not approved for use in under 18-year-olds because their use increases the risks of ‘suicidal ideation and suicidal behavior’ by about 80%.[21] The nearest thing to a rationale offered in the evidence summary was that many young people who are depressed get no treatment and that it is better to do something than nothing.

As an advocate who on a daily basis helps mental health service consumers let down by the mental health system, I agree with the National Mental Health Commission report’s bleak assessment of the current state of care. The reality for most Australians seeking mental health help is a visit to the GP, a script of antidepressants, and a bit of a chat if you lucky. Resources are spread too thinly and there is far too much reliance on quick diagnosis backed up by indiscriminate (frequently off-label) prescribing of drugs that messily interfere with a patient’s biochemistry without addressing their underlying problems. Diagnostic labels and drugs are used as a poor substitute for individualised ‘person centered’ support.  

The need for a radical rethink is obvious but the danger is the recipe for reform offered by Hickie and McGorry will make this very bad situation considerably worse. The fundamental problem is they dangerously overstate what a mental health system can achieve. They argue for a system that targets everyone from the severely psychotic to the moderately depressed and even those perceived to be at mildly elevated risk of future mental illness. According to both the report and McGorry, this represents about 4 million Australian’s in any given year.[22]  

The ‘21^st Century…proven approaches’ that McGorry repeatedly claims are readily available if only government would urgently fund them are substantially based on models of care he has developed.[23]  I believe this is a product of his heartfelt ‘crusader’s desire’ to help millions of Australians, and not simply a cynical attempt to expand his mental health empire but ultimately his motivation doesn’t matter. What matters is that these claims are not supported by robust independent evidence.

Although the ‘stitch in time’ philosophy inherent in his approach is intuitively appealing, independent evidence indicates two fundamental problems. Firstly the predictions of future mental illness in mildly troubled individuals are wildly inaccurate.[24] Secondly the preventive measures they employ have very modest sustained benefits.[25]  

McGorry and Hickie not only massively overstate the benefits of their own pet interventions; they also massively overstate the capacity of government to help. Government can’t stop people becoming depressed. Government can’t address the concerns of the socially anxious. What government can do is foster a tolerant and inclusive society, and do their best to ensure housing, employment and educational opportunity – the social determinants of mental health.  

The first priority for Australia’s mental health system must be properly addressing the needs of the acutely unwell by supporting their recovery. A secondary focus can be prevention through programs like Act- Belong-Commit that promote resilience and encourage moderately distressed people to seek help from family and expand friendship networks.

However, despite their overblown claims, the brand of preventive psychiatry developed by McGorry, and to a lesser extent Hickie, is potentially very harmful.  Their approach is wasteful of resources and can create a self-fulfilling prophecy of impending serious mental illness and iatrogenic harm from unnecessary treatments.[26]   

McGorry and Hickie are repeating the pattern of over-promising and under-delivering that has caused much of the current mess in mental health. Historically extremely bad psychiatric practices like lobotomies, deep sleep therapy and ADHD child prescribing[27] have all been justified by grossly exaggerated claims of breakthroughs in brain science and treatment technology. Although less dramatic, much of current psychiatric practice risks trading long term welfare of patients for perceived short term benefits, some of which are external to the patient (e.g. increased compliance from agitated geriatric patients).

In contrast cautious psychiatrists realise the limitations of their profession and diagnose and medicate with great care. They resist incentives from industry and the pressure from ‘the system’ and in some cases from patients and carers, to concentrate primarily on short term symptom management.

A major potential driver towards cautious psychiatry is the patient-led psychiatric ‘recovery’ movement. Proponents of recovery contend that many patients are prevented from recovering by being labeled as permanently disabled and by being numbed by ‘medications’ on the assumption that without them they are biochemically imbalanced.

Although McGorry and Hickie have appropriated the language of the recovery movement, in reality their approach is the very antithesis of recovery. They seek to extend the American Psychiatric Association’s permanent disability model by adding new categories of impending disability to individuals perceived to have an elevated risk of being mentally ill.

In addition to promoting the views of McGorry and Hickie, the ABC has selectively ignored important revelations about the safety and efficacy of mental health drugs. Most notably, in late 2014, management at the ABC intervened to prevent a story, already in production, that highlighted significant concerns about the safety and efficacy of antidepressants, from going to air.

We need a vigorous national debate about the future of mental health, but our taxpayer funded national broadcaster is stifling debate and promoting the unchallenged views of a few gurus. It is not that McGorry and Hickie are wrong about everything – they have put mental health on the national political agenda and many of their criticisms of the current system are indisputable. However, just because you can point at a problem doesn’t mean you know the solution, and if you are paid to promote pharmaceuticals you are not independent.

When the ABC picks favorites and ignores contradictory evidence, our national debate dumbs down. Other contradictory voices need to be heard on ‘our’ ABC. Given the current dearth of national political leadership, we need an ABC that elevates debate and deals with big issues without fear or favour.

The future of Australia’s mental health system is a crucial and complex issue. Millions of Australians, either directly, or indirectly as family and friends, have the potential to be either helped or harmed. It requires better coverage than the black and white bumper sticker campaign currently being run at the ABC.

 References

[1] The information below on the commercial ties of Professor’s McGorry and Hickie to the pharmaceutical industry was current in August 2010 and does not list subsequent funding.

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 Hickie 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)

[2] Joukmaa, M.; Heliovaara, M.; Knekt, P.; Aromaa, A.; Raitasalo, R.; & Lehtinen, V. (2006). Schizophrenia, neuroleptic medication and mortality. The British Journal of Psychiatry 188: 122-127 http://bjp.rcpsych.org/content/188/2/122.full (link is external)

[3] Williams, D (18 June 2006) Drugs Before Diagnosis? Time Magazine http://www.time.com/time/magazine/article/0,9171,1205408,00.html(accessed 18 November 2010)

[4] Australia’s Reckless Experiment In Early Intervention – prevention that will do more harm than good by Allen J. Frances, M.D. at http://www.psychologytoday.com/blog/dsm5-in-distress/201105/australias-reckless-experiment-in-early-intervention ↩

[5] Professor George Patton quoted in The Age, ”This paper illustrates how much we need to be looking at these new services (EPPIC) to determine the extent to which we’re following best clinical practice and to ask the questions, are we getting value for money out of these investments, and are we actually seeing better clinical outcomes?” Jill Stark, Youth mental health team too free with drugs: audit, The Sunday Age, July 8, 2012 http://www.theage.com.au/national/youth-mental-health-team-too-free-with-drugs-audit-20120707-21o29.html ↩

[6] http://speedupsitstill.com/patrick-mcgorrys-ultra-high-risk-psychosis-theory-fails-common-sense-test Patrick McGorry’s ‘Ultra High Risk of Psychosis’ training DVD fails the common sense test

[7] David Castle (St Vincents Melbourne) Medical Journal of Australia 21 May 2012- Is it appropriate to treat people at high risk of psychosis before first onset? NO ↩

[8] Carr, Vaughan. (2010, July 10). Letter to the Editor, Mental health funding. The Australian. http://www.theaustralian.com.au/news/opinion/mental-health-funding/story-fn558imw-1225890005936 ↩

Carr V. (8 July 2010) Mentally ill of all ages need services. The Australian. http://www.theaustralian.com.au/news/opinion/mentally-ill-of-all-ages-need-services/story-e6frg6zo-1225889141003 (accessed 30 April 2011)

[9] http://www.theaustralian.com.au/news/health-science/campaign-targets-depression-guru/story-e6frg8y6-1226269135293

[10] Phillips, N., Oldmeadow, M. J., & Krapivensky, N. (2002, February 18). SPHERE: A National Depression Project. Medical Journal of Australia, 176(4), 193-194.

[11] http://www.bmj.com/content/326/7397/1008?tab=responses

[12] For more detail see  Professor Ian Hickie – Visionary Mental Health Reformer or Paid Pharmaceutical Industry Opinion Leader? Available at http://speedupsitstill.com/professor-ian-hickie-visionary-mental-health-reformer-paid-pharmaceutical-industry-opinion-leader

[13] https://twitter.com/mscott/status/532811349391585280 Mental As http://blogs.abc.net.au/nsw/2014/08/mental-as.html http://mhaustralia.org/newsletters-bulletins/mhca-ceos-weekly-update-15-august

http://blogs.abc.net.au/nsw/2014/08/mental-as.html

[14] http://mhaustralia.org/newsletters-bulletins/mhca-ceos-weekly-update-15-august

[15] http://mhaustralia.org/about-us/pharma-collaboration

[16] http://www.health.gov.au/internet/ministers/publishing.nsf/Content/7B43BA089E706CD8CA2579640010F23B/$File/MB223.pdf ↩

[17] http://www.abc.net.au/news/2015-04-14/mental-health-services-report-recommends-funds-redirection/6391028

‘National Mental Health Commission, 2014: The National Review of Mental Health Programmes and Services. Sydney: NMHC Published by: National Mental Health Commission, Sydney.

http://www.abc.net.au/news/2015-04-14/mental-health-services-report-recommends-funds-redirection/6391028

[18] Jill Stark, Youth mental health team too free with drugs: audit, The Sunday Age, July 8, 2012 http://www.theage.com.au/national/youth-mental-health-team-too-free-with-drugs-audit-20120707-21o29.html ↩

[19] Jill Stark, Youth mental health team too free with drugs: audit, The Sunday Age, July 8, 2012http://www.theage.com.au/national/youth-mental-health-team-too-free-with-drugs-audit-20120707-21o29.html ↩

[20] 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 http://www.headspace.org.au/core/Handlers/MediaHandler.ashx?mediaId=4896 (accessed 26 April 2011) ↩

[21] 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 http://www.headspace.org.au/core/Handlers/MediaHandler.ashx?mediaId=4896 (accessed 26 April 2011) ↩

[22] ABC (11 March 2010) Mental health system in crisis: McGorry, Lateline, Australian Broadcasting Corporation. Reporter: Tony Jones http://www.abc.net.au/lateline/content/2010/s2843609.htm (accessed 26 April 2011) ↩

And ‘National Mental Health Commission, 2014: The National Review of Mental Health Programmes and Services. Sydney: NMHC Published by: National Mental Health Commission, Sydney.

http://www.abc.net.au/news/2015-04-14/mental-health-services-report-recommends-funds-redirection/6391028

[23] Address to the National Press Club Canberra by Prof. Patrick McGorry July 7, 2010 ↩

[24] Professor David Castle Medical Journal of Australia 21 May 2012 Is it appropriate to treat people at high-risk of psychosis before first onset — No Available at https://www.mja.com.au/journal/2012/196/9/it-appropriate-treat-people-high-risk-psychosis-first-onset-no ↩

[25] Marshall M, Rathbone J. Early intervention for psychosis. Cochrane Database of Systematic Reviews 2011, Issue 6. Art. No.: CD004718. DOI: 10.1002/14651858.CD004718.pub3 June 15, 2011 http://summaries.cochrane.org/CD004718/early-intervention-for-psychosis

[26] Whitely M and Raven M, 2012. The risk that DSM-5 will result in a misallocation of scarce resources, Current Psychiatry Reviews, Bentham Science. http://www.eurekaselect.com/103772/article

[27] Whitely M, ‘Chapter 9 – ADHD: How a Lie ‘Medicated’ Often Enough Became the Truth’ in Ewen Speed, Joanna Moncrieff and Mark Rapley, eds., De-Medicalizing Misery II: Society, Politics and the Mental Health Industry, Palgrave Macmillan (2014).

PDF of full thesis available at Martin Whitely PhD Thesis Copy – ADHD and Regulatory Capture in Australia PDF

On Friday 24 July 2006 the Royal Australasian College of Physicians (RACP) issued a press release calling for “legal defences in Australia for the use of corporal punishment (to) be amended … (so) that all forms of corporal punishment are unlawful” (see Child health experts call for change on how we discipline our children).  Predictably the call attracted extensive media coverage and generated impassioned polarised talkback radio.

The RACP’s release stated “research is increasingly showing that physical punishment may be harmful and children who receive physical punishment are at increased risk for a range of adverse outcomes both in childhood and as adults…These include mental health problems such as depression, anxiety, aggressive or antisocial behaviour, substance use problems and abuse of their own children or spouse…While many children will not experience negative outcomes as a result of moderate or reasonable physical punishment, why put your child’s future health and emotional wellbeing at risk?”

I don’t intend to enter the contentious ‘smacking debate’, except to say that there is a significant difference between a light smack on your child’s backside designed to bring their attention to their poor behaviour and inflicting significant pain with a belt or other ‘weapon’.  I am however struck by the contrast between the RACP’s anti-smacking stance and its promotion of the use of amphetamines to alter the behaviour of children, even pre-schoolers. The RACP took the lead role in producing and is continuing to promote discredited draft national ADHD treatment guidelines that relied on discredited and commercially corrupted research to promote the first line use of stimulants to treat ADHD.

The guidelines have never been endorsed by the National Health and Medical Research Council (NHMRC) who paid the RACP $135,000 to develop them.  The reason they were not endorsed according to the NHMRC is that “in July 2011 Harvard Medical School and Massachusetts General Hospital sanctioned Professor Biederman and Drs. Spencer and Wilens (whose work is heavily cited throughout the Draft Guidelines) for failing to report their industry sponsored activities and subsequently violating their organisations’ conflict of interest policies.” (http://www.nhmrc.gov.au/guidelines/publications/ch54 accessed 26 July 2013)  Biederman, Spencer and Wilens received millions in undisclosed drug company payments (see World leading ADHD ‘expert’ Harvard Professor Joseph Biederman sanctioned over hidden drug company money ).

However, these were not the only conflict of interest issues to dog the RACP ADHD guidelines process.  Most of the members of the RACP committee who developed the guidelines had commercial ties to ADHD drug manufacturers that were only disclosed through ‘Freedom of Information’ processes and the RACP itself has received sponsorship from the same companies. (see One year on from the release of the corrupted National ADHD Guidelines ).

Nonetheless the RACP website continues to promote the discredited guidelines stating “the RACP has conducted a thorough and careful process to develop the updated draft Guidelines and believes that these Guidelines will assist in improving the assessment, treatment and care of people with ADHD in Australia.” (http://www.racp.edu.au/index.cfm?objectid=393DD54A-04C5-85AC-B35FE82BA4849595 accessed 26 July 2013)

Regardless of the merits of their anti-smacking stance, the RACP would have more credibility when expressing concern about parenting and child welfare if they got their own house in order.

By Martin Whitely

DSM-5, the newest edition of the American Psychiatric Association’s ‘Bible of Psychiatry’ will be officially released in May 2013 and is already available for presale.  However, this edition of the DSM may not prove as profitable for the American Psychiatric Association (APA) as there is a growing international chorus of voices, many from within mainstream psychiatry, calling for a boycott of the DSM5.

The most prominent critic of DSM5 is Professor Allen Frances who led the development of the current edition DSMIV.  Professor Frances has identified many DSM5 changes that will likely add to ‘the history of psychiatry (which) is littered with fad diagnoses that in retrospect did far more harm than good’.[1]

The DSM5 changes Professor Frances is concerned about include:

1. Disruptive Mood Dysregulation Disorder: DSM 5 will turn temper tantrums into a mental disorder… We have no idea whatever how this untested new diagnosis will play out in real life practice settings, but my fear is that it will exacerbate, not relieve, the already excessive and inappropriate use of medication in young children…
2. Normal grief will become Major Depressive Disorder, thus medicalizing and trivializing our expectable and necessary emotional reactions to the loss of a loved one and substituting pills and superficial medical rituals for the deep consolations of family, friends, religion, and the resiliency that comes with time and the acceptance of the limitations of life.
3. The everyday forgetting characteristic of old age will now be misdiagnosed as Minor Neurocognitive Disorder, creating a huge false positive population of people who are not at special risk for dementia…
4. DSM 5 will likely trigger a fad of Adult Attention Deficit Disorder leading to widespread misuse of stimulant drugs for performance enhancement and recreation and contributing to the already large illegal secondary market in diverted prescription drugs.
5. Excessive eating 12 times in 3 months is no longer just a manifestation of gluttony and the easy availability of really great tasting food. DSM 5 has instead turned it into a psychiatric illness called Binge Eating Disorder…
6. First time substance abusers will be lumped in definitionally in with hard core addicts despite their very different treatment needs and prognosis and the stigma this will cause.
7. DSM 5 has created a slippery slope by introducing the concept of Behavioral Addictions that eventually can spread to make a mental disorder of everything we like to do a lot.  Watch out for careless overdiagnosis of internet and sex addiction and the development of lucrative treatment programs to exploit these new markets.
8. DSM 5 obscures the already fuzzy boundary been Generalized Anxiety Disorder and the worries of everyday life.  Small changes in definition can create millions of anxious new ‘patients’ and expand the already widespread practice of inappropriately prescribing addicting anti-anxiety medications.
9. DSM 5 has opened the gate even further to the already existing problem of misdiagnosis of PTSD in forensic settings.[2]
10. DSM 5 includes a proposal for ‘Somatic Symptom Disorder’ (SSD). This new diagnosis will encourage ‘a quick jump to the erroneous conclusion that someone’s physical symptoms are ‘all in the head’ and mislabel as mental disorders ‘the normal emotional reactions that people understandably have in response to a medical illness’.[3]

Professor Frances concerns can’t be dismissed as the architect of the old edition protecting his work from revision. While criticizing the proposals in DSM5, Professor Frances has identified that the DSMIV process he led inadvertently helped ‘trigger three false epidemics. One for Autistic Disorder… another for the childhood diagnosis of Bi-Polar Disorder and the third for the wild over-diagnosis of Attention Deficit Disorder.’[4] Of course Professor Frances was not solely responsible for the development of the DSMIV diagnostic criteria for ADHD or for other disorders. They were developed by sub-committees of the APA however, as the overall leader of the DSMIV development process he has accepted his share of responsibility for the problems DSMIV helped create.

International Boycotts of DSM5

Internationally there are several alternative online petitions calling for a boycott of DSM5. The most prominent titled ‘Is the DSM5 safe? – Now is the time for mental health professionals and consumers to respond to the problems of the DSM5’ is available at http://dsm5response.com/. Another is titled ‘BOYCOTT DSM5 – Do No Harm’ is primarily aimed at American clinicians and is available at http://boycott5committee.com/.

This second petition has attracted some criticism because it ends with the statement; ‘If we find ourselves obliged to employ diagnostic codes, we agree to disregard the new DSM and utilize the codes listed in the ICD-9 and the next edition of ICD, when the latter is implemented in October, 2014.’ Some DSM5 critics see this as an endorsement of the World Health Organisation’s similarly flawed (but in my view not quite as bad) ICD diagnostic system. I don’t agree. I believe the statement in regards to the ICD is practical advice to American clinicians who are required to quote a ‘diagnostic’ code in order to receive payment from Health Insurers.

In his recent blog, DSM 5 Boycotts and Petitions, Professor Frances suggested there is a real danger that fragmentation and internal differences amongst critics may see the boycott against DSM5 being less effective.[5] In an ideal world one coordinated DSM5 Boycott approach would be better, however I am not as concerned as Professor Frances about multiple petitions diluting their effect as long as every petition contains the a simple message to: Boycott DSM5 – Don’t Buy It and Don’t Use It – It is dangerous and scientifically unsound.

This is a battle that can be won. Already in large part because of Professor Frances courageous, persistent and effective leadership some of the worst proposals for DSM5 like Psychosis Risk Disorder rolled back.[6] (But unfortunately not yet dead – see Patrick McGorry’s ‘Ultra High Risk of Psychosis’ training DVD fails the common sense test)

Australian Critics of DSM5

Closer to home prominent Australian and New Zealand critics of the DSM5 from within the psychiatric profession include Professor Jon Jureidini, University of Adelaide, Professor David Castle, University of Melbourne; Associate Professor Tim Carey, Flinders University, Australia; Professor John Read, Professor of Clinical Psychology, University of Auckland; Melissa Raven, Research Fellow, Flinders University.

Even Professor Patrick McGorry has been critical of the DSM5 as setting arbitrary boundaries between diagnostic silos.[7] Professor McGorry argues that ‘Precise definition of the boundary between what is deemed normal and mental disorder with a need for care is difficult. But how crucial or feasible is the creation of such a precise definition? Would a grey area with soft and flexible entry (and exit) and personal choice as key features of a new primary care culture be acceptable?’ While Professor McGorry’s criticisms of DSM5 are valid, the detail of what he proposes as ‘early intervention’ is just as alarming to many within psychiatry concerned about its’ propensity to turn normal human emotions and distress into disease.

Regardless the current immediate battlefront is DSM5. After it is knocked on its’ head then a long overdue national and international debate about the appropriate direction for psychiatric diagnostic systems can begin in earnest.

[1] See American Psychiatric Association approval of DSM-5 is a sad day for Psychiatry- by Prof Allen Frances

[2] See American Psychiatric Association approval of DSM-5 is a sad day for Psychiatry- by Prof Allen Frances

[3] See http://www.psychologytoday.com/blog/dsm5-in-distress/201212/mislabeling-medical-illness-mental-disorder

[4] Dr 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 (accessed 26 February 2010).

[5] See http://www.psychologytoday.com/blog/saving-normal/201302/dsm-5-boycotts-and-petitions

[6] See DSM5 Rollback Begins – Psychosis Risk Disorder gone and the revised proposal for DSM5 ADHD criteria not quite as horrific

[7] Patrick McGorry, Jim van Os. Redeeming diagnosis in psychiatry: timing versus specificity, The Lancet, 26 Jan 2013, Vol 381, pp 343-345. McGorry attacks value of DSM5

This blog was originally Published on December 2, 2012 in DSM5 in Distress at http://www.psychologytoday.com/blog/dsm5-in-distress/201212/dsm-5-is-guide-not-bible-ignore-its-ten-worst-changes

This is the saddest moment in my 45 year career of studying, practicing, and teaching psychiatry. The Board of Trustees of the American Psychiatric Association (APA) has given its final approval to a deeply flawed DSM 5 containing many changes that seem clearly unsafe and scientifically unsound.  My best advice to clinicians, to the press, and to the general public – be skeptical and don’t follow DSM 5 blindly down a road likely to lead to massive over-diagnosis and harmful over-medication.  Just ignore the ten changes that make no sense.

Brief background.  DSM 5 got off to a bad start and was never able to establish sure footing. Its leaders initially articulated a premature and unrealizable goal- to produce a paradigm shift in psychiatry.  Excessive ambition combined with disorganized execution led inevitably to many ill-conceived and risky proposals.

These were vigorously opposed.  More than fifty mental health professional associations petitioned for an outside review of DSM 5 to provide an independent judgment of its supporting evidence and to evaluate the balance between its risks and benefits.  Professional journals, the press, and the public also weighed in- expressing widespread astonishment about decisions that sometimes seemed not only to lack scientific support but also to defy common sense.

DSM 5 has neither been able to self-correct nor willing to heed the advice of outsiders. It has instead created a mostly closed shop- circling the wagons and deaf to the repeated and widespread warnings that it would lead to massive misdiagnosis.  Fortunately, some of its most egregiously risky and unsupportable proposals were eventually dropped under great external pressure (most notably ‘psychosis risk’, mixed anxiety/depression, internet and sex addiction, rape as a mental disorder, ‘hebephilia’, cumbersome personality ratings, and sharply lowered thresholds for many existing disorders).  But APA stubbornly refused to sponsor any independent review and has given final approval to the ten reckless and untested ideas that are summarized below.

The history of psychiatry is littered with fad diagnoses that in retrospect did far more harm than good.  Yesterday’s APA approval makes it likely that DSM 5 will start a half or dozen or more new fads which will be detrimental to the misdiagnosed individuals and costly to our society.

The motives of the people working on DSM 5 have often been questioned.  They have been accused of having a financial conflict of interest because some have (minimal) drug company ties and also because so many of the DSM 5 changes will enhance Pharma profits by adding to our already existing societal overdose of carelessly prescribed psychiatric medicine.  But I know the people working on DSM 5 and know this charge to be both unfair and untrue. Indeed, they have made some very bad decisions, but they did so with pure hearts and not because they wanted to help the drug companies.  Their’s is an intellectual, not financial, conflict of interest that results from the natural tendency of highly specialized experts to over value their pet ideas, to want to expand their own areas of research interest, and to be oblivious to the distortions that occur in translating DSM 5 to real life clinical practice (particularly in primary care where 80% of psychiatric drugs are prescribed).

The APA’s deep dependence on the publishing profits generated by the DSM 5 business enterprise creates a far less pure motivation.  There is an inherent and influential conflict of interest between the DSM 5 public trust and DSM 5 as a best seller.  When its deadlines were consistently missed due to poor planning and disorganized implementation, APA chose quietly to cancel the DSM 5 field testing step that was meant to provide it with a badly needed opportunity for quality control.  The current draft has been approved and is now being rushed prematurely to press with incomplete field testing for one reason only- so that DSM 5 publishing profits can fill the big hole in APA’s projected budget and return dividends on the exorbitant cost of 25 million dollars that has been charged to DSM 5 preparation.

This is no way to prepare or to approve a diagnostic system.  Psychiatric diagnosis has become too important in selecting treatments, determining eligibility for benefits and services, allocating resources, guiding legal judgments, creating stigma, and influencing personal expectations to be left in the hands of an APA that has proven itself incapable of producing a safe, sound, and widely accepted manual.

New diagnoses in psychiatry are more dangerous than new drugs because they influence whether or not millions of people are placed on drugs- often by primary care doctors after brief visits. Before their introduction, new diagnoses deserve the same level of attention to safety that we devote to new drugs. APA is not competent to do this.

So, here is my list of DSM 5’s ten most potentially harmful changes. I would suggest that clinicians not follow these at all (or, at the very least, use them with extreme caution and attention to their risks); that potential patients be deeply skeptical, especially if the proposed diagnosis is being used as a rationale for prescribing medication for you or for your child; and that payers question whether some of these are suitable for reimbursement. My goal is to minimize the harm that may otherwise be done by unnecessary obedience to unwise and arbitrary DSM 5 decisions.

1) Disruptive Mood Dysregulation Disorder: DSM 5 will turn temper tantrums into a mental disorder- a puzzling decision based on the work of only one research group. We have no idea whatever how this untested new diagnosis will play out in real life practice settings, but my fear is that it will exacerbate, not relieve, the already excessive and inappropriate use of medication in young children. During the past two decades, child psychiatry has already provoked three fads- a tripling of Attention Deficit Disorder, a more than twenty-times increase in Autistic Disorder, and a forty-times increase in childhood Bipolar Disorder. The field should have felt chastened by this sorry track record and should engage itself now in the crucial task of educating practitioners and the public about the difficulty of accurately diagnosing children and the risks of over- medicating them. DSM 5 should not be adding a new disorder likely to result in a new fad and even more inappropriate medication use in vulnerable children.

2) Normal grief will become Major Depressive Disorder, thus medicalizing and trivializing our expectable and necessary emotional reactions to the loss of a loved one and substituting pills and superficial medical rituals for the deep consolations of family, friends, religion, and the resiliency that comes with time and the acceptance of the limitations of life.

3) The everyday forgetting characteristic of old age will now be misdiagnosed as Minor Neurocognitive Disorder, creating a huge false positive population of people who are not at special risk for dementia. Since there is no effective treatment for this ‘condition’ (or for dementia), the label provides absolutely no benefit (while creating great anxiety) even for those at true risk for later developing dementia. It is a dead loss for the many who will be mislabeled.

4) DSM 5 will likely trigger a fad of Adult Attention Deficit Disorder leading to widespread misuse of stimulant drugs for performance enhancement and recreation and contributing to the already large illegal secondary market in diverted prescription drugs.

5) Excessive eating 12 times in 3 months is no longer just a manifestation of gluttony and the easy availability of really great tasting food. DSM 5 has instead turned it into a psychiatric illness called Binge Eating Disorder.

6) The changes in the DSM 5 definition of Autism will result in lowered rates- 10% according to estimates by the DSM 5 work group, perhaps 50% according to outside research groups. This reduction can be seen as beneficial in the sense that the diagnosis of Autism will be more accurate and specific- but advocates understandably fear a disruption in needed school services. Here the DSM 5 problem is not so much a bad decision, but the misleading promises that it will have no impact on rates of disorder or of service delivery. School services should be tied more to educational need, less to a controversial psychiatric diagnosis created for clinical (not educational) purposes and whose rate is so sensitive to small changes in definition and assessment.

7) First time substance abusers will be lumped in definitionally in with hard core addicts despite their very different treatment needs and prognosis and the stigma this will cause.

8) DSM 5 has created a slippery slope by introducing the concept of Behavioral Addictions that eventually can spread to make a mental disorder of everything we like to do a lot.  Watch out for careless overdiagnosis of internet and sex addiction and the development of lucrative treatment programs to exploit these new markets.

9) DSM 5 obscures the already fuzzy boundary been Generalized Anxiety Disorder and the worries of everyday life.  Small changes in definition can create millions of anxious new ‘patients’ and expand the already widespread practice of inappropriately prescribing addicting anti-anxiety medications.

10) DSM 5 has opened the gate even further to the already existing problem of misdiagnosis of PTSD in forensic settings.

DSM 5 has dropped its pretension to being a paradigm shift in psychiatric diagnosis and instead (in a dramatic 180 degree turn) now makes the equally misleading claim that it is a conservative document that will have minimal impact on the rates of psychiatric diagnosis and in the consequent provision of inappropriate treatment.  This is an untenable claim that DSM 5 cannot possibly support because, for completely unfathomable reasons, it never took the simple and inexpensive step of actually studying the impact of DSM on rates in real world settings.

Except for autism, all the DSM 5 changes loosen diagnosis and threaten to turn our current diagnostic inflation into diagnostic hyperinflation. Painful experience with previous DSM’s teaches that if anything in the diagnostic system can be misused and turned into a fad, it will be.  Many millions of people with normal grief, gluttony, distractibility, worries, reactions to stress, the temper tantrums of childhood, the forgetting of old age, and ‘behavioral addictions’ will soon be mislabeled as psychiatrically sick and given inappropriate treatment.

People with real psychiatric problems that can be reliably diagnosed and effectively treated are already badly shortchanged. DSM 5 will make this worse by diverting attention and scarce resources away from the really ill and toward people with the everyday problems of life who will be harmed, not helped, when they are mislabeled as mentally ill.

Our patients deserve better, society deserves better, and the mental health professions deserve better. Caring for the mentally ill is a noble and effective profession.  But we have to know our limits and stay within them.

DSM 5 violates the most sacred (and most frequently ignored) tenet in medicine- First Do No Harm!  That is why this is such a sad moment.

Martin Whitely’s comment:  Professor Frances’ comments can’t be dismissed as the architect of the old edition protecting his work from revision. As the overall leader of the DSM-4 development process he has accepted his share of responsibility for the problems DSM-4 helped create.[1. See http://speedupsitstill.com/dr-allen-frances-lead-author-dsmiv-british-psychological-association-lead-chorus-opposition-disease-mongering-proposals-dsm5 ]  However, rather than learn the lessons of inappropriate medicalisation of behavior and over-prescription from DSM-4, the American Psychiatric Association is about to deliver much worse in DSM-5.  Surely now is the time for the Australian psychiatric profession to end its slavish devotion to the broken American model that sees more than one in five US adults on at least one mental health drug.[2. Report: 1 in 5 American Adults Takes Mental Health Drugs. Time Magazine Nov. 16, 2011
http://healthland.time.com/2011/11/16/report-whos-taking-mental-health-drugs-in-america/?hpt=he_c2 ]

In August 2003 in response to concerns about the high number of children prescribed dexamphetamine for ADHD in Western Australia (WA), the state government tightened prescribing controls and introduced the Stimulants Regulatory Scheme. The introduction of the scheme with annual reporting was followed by a large and sustained fall in child patient numbers but a significant increase in the number of WA adults prescribed ADHD stimulants.

The 2011 Annual Report (the eighth annual report) was released on 17 October 2012 and is available at http://www.public.health.wa.gov.au/cproot/4883/2/stimulant-annual-report-2011.pdf

Highlights of the WA Stimulants Regulatory Scheme 2011 Annual Report

Child Prescribing Rates– WA Stimulants Regulatory Scheme 2011 Annual Report contains both good and bad news. The good news is that the 2011 report confirms there has been a massive decline in per-capita prescribing rates for children since the Stimulant Regulatory Scheme was introduced in mid-2003. However, the bad news is that there was a spike in the number of new cases diagnosed in 2011.

Between 2004 (the first year for which figures are available) and 2010 per-capita ADHD child prescribing rates fell from 2.25 % to 1.3%.[1] Federal Government figures[2] indicate the number of children on ADHD medications in WA peaked in 2002 at 2.6%, indicating a 50% fall from the peak. However, in 2011 the rate rose marginally (to 1.34%) for the first time since the system was introduced. This was due to a significant increase in the number of first time child patients from a low of 883 in 2007, to 1628 in 2011.[3] Most of these (824 or 51%) were aged 9 or less.

The bottom line is that although Perth is the world’s only ADHD child drugging hotspot to have seen a massive decline in child prescribing rates, there are signs that this hard won progress is in danger of being undone. To prevent history repeating there needs to be a crackdown on reckless prescribing now.

Adult Prescribing Rates– Adult ADHD per-capita prescribing rates continue to grow. They are generally not carryover patients from childhood, as 80% are diagnosed first as adults.[4] The vast majority of adults get prescribed dexamphetamine (81.3% as opposed to 22.3% for children)[5] and the majority are first diagnosed between 18 and 29.[6] During 2011, 137 patients had their authority to receive psychostimulants withdrawn because they had abused prescription drugs.[7] All of the facts support the contention that this is the tip of the iceberg and that many of Perth’s twenty to thirty somethings are doctor shopping for dexamphetamine. (For more info see Perth’s Dexamphetamine Hangover )

Perth’s New Rogue Prescriber– One clinician (a psychiatrist) was responsible for prescribing to 1473 patients (1346 adults and 127 children) in 2011.[8] The obvious question is how long is this doctor spending with each patient before prescribing them amphetamines? They can’t be doing much more than meeting each patient for a brief consultation and issuing a script!

There is a precedent for this type of prescribing. When the stimulants monitoring system was first introduced it revealed that a single paediatrician prescribed to 2077 children in 17 months from August 2003 to December 2004.[9] This paediatrician was ‘encouraged’ to retire from prescribing and his subsequent retirement was immediately followed by a significant decrease in child prescribing rates.

History appears to be repeating itself although the major difference is this psychiatrist is prescribing primarily dexamphetamine to adults and there is every reason to be concerned that much of this taxpayer subsidised amphetamine is being abused.  At the very least there needs to be a prescribing audit of this practitioner and ideally they need to be encouraged to find an alternate vocation.

Geography- Geraldton with the highest child and second highest adult prescribing rates is the ADHD capital of WA.[10] Geraldton has long had very high ADHD prescribing rates and concerns have long been raised about prescription drug abuse in the Mid-West Port Town. In 2010 a Geraldton mother of seven with a history of abusing a variety of prescription drugs, including dexamphetamine, died from an overdose of prescription methadone. (Refer to  Prescription drug abuse – A large and growing problem with a very simple solution )

The Oceanic Health District (Perth’s City and wealthy western suburbs) has the highest adult rate but an average child prescribing rate. The considerable anecdotal evidence of high rates of diversion of amphetamines in Perth’s Western suburbs is supported by these high adult prescribing rates.

Conclusion- Western Australia’s scheme provides detailed publicly available (although de-identified) information. This information has been vital in highlighting anomalies, especially the prescribing records of rogue prescribers. It is a system worth replicating in other jurisdictions.

Related Media

Cathy O’Leary, The West Australian, More kids prescribed ADHD drugs, October 17, 2012 page 4. http://au.news.yahoo.com/thewest/a/-/breaking/15137786/rise-in-new-adhd-drug-use/

[1] Note: The stimulants regulatory scheme only reports child ADHD prescribing rate for stimulants (1.25% in 2010). Strattera (the brand name for atomoxetine hydrochloride) is a rarely prescribed non-stimulant ADHD medication. When Commonwealth Department of Health and Ageing data on Strattera Pharmaceutical Benefits Scheme prescriptions is included the rate in 2010 is 1.3% of 4 to 17 year olds. WA Stimulants Regulatory Scheme 2011 Annual Report http://www.public.health.wa.gov.au/cproot/4883/2/stimulant-annual-report-2011.pdf and Department of Health and Ageing Pharmaceutical Benefits Scheme figures prescribing of ADHD medications provided to Martin Whitely on request.

[2] Department of Health and Ageing Pharmaceutical Benefits Scheme figures prescribing of ADHD medications provided to Martin Whitely on request.

[3] WA Stimulants Regulatory Scheme 2011 Annual Report Page 63 http://www.public.health.wa.gov.au/cproot/4883/2/stimulant-annual-report-2011.pdf

[4] WA Stimulants Regulatory Scheme 2011 Annual Report Page 41 http://www.public.health.wa.gov.au/cproot/4883/2/stimulant-annual-report-2011.pdf

[5] WA Stimulants Regulatory Scheme 2011 Annual Report Pages 28 and 43. http://www.public.health.wa.gov.au/cproot/4883/2/stimulant-annual-report-2011.pdf

[6] WA Stimulants Regulatory Scheme 2011 Annual Report Pages 41. http://www.public.health.wa.gov.au/cproot/4883/2/stimulant-annual-report-2011.pdf

[7] WA Stimulants Regulatory Scheme 2011 Annual Report Page 19 http://www.public.health.wa.gov.au/cproot/4883/2/stimulant-annual-report-2011.pdf

[8] WA Stimulants Regulatory Scheme 2011 Annual Report Pages 21 and 37 http://www.public.health.wa.gov.au/cproot/4883/2/stimulant-annual-report-2011.pdf

[9] Stimulant Prescribing and Usage Patterns for the Treatment of ADHD in Western Australia  1 August 2003 – 31 December 2004 Western Australian Department of Health page 17  http://www.public.health.wa.gov.au/cproot/3609/2/03-04_Report.pdf

[10] WA Stimulants Regulatory Scheme 2011 Annual Report Pages 27 and 42 http://www.public.health.wa.gov.au/cproot/4883/2/stimulant-annual-report-2011.pdf

A video and transcript of Colbert’s ‘Meducation’ rant is available at http://www.dailykos.com/story/2012/10/11/1143009/-Stephen-Colbert-on-medicating-children-to-improve-their-grades

On October 10 2012 American comedian Stephen Colbert coined the term “meducation” to describe the growing practice of drugging with ADHD amphetamines, American children with mediocre school grades, who do not have a diagnosis of ADHD.The catalyst for the mock right wing political commentator’s endorsement of ADHD drugs as smart pills was a front page article in the New York Times in which peadiatrician Dr Michael Anderson advocated their widespread use to compensate for America’s third rate public education system. Doctor Anderson said “we’ve decided as a society that it’s too expensive to modify the kid’s environment. So we have to modify the kid.” Unlike Colbert, Dr Anderson is not a comedian but unfortunately for some of the children of Ganton Georgia he is their doctor.

In his comedic monologue Colbert argues the child drugging program should be extended beyond amphetamines. “Folks, I believe this is a great fiscally responsible answer, but we can do more.  I mean, we might be cutting arts programs, but one tab of acid, and your kid will be seeing colours you can’t find in a Crayola box.” Colbert’s mock rant concludes with a serious warning; “Now, of course, eventually it may turn out that drugging poor students creates more problems than it solves.  In which case, we’ll have to stop trying to change our children, and think about changing ourselves.”

Despite Dr Anderson’s claims and Colbert’s mock endorsement, ADHD amphetamines are anything but ‘smart drugs’. Unique long term (8 year) Australian research shows that children diagnosed ADHD and ‘ever medicated’ with amphetamines were a staggering 950% more likely to be rated by their teacher as “performing below age-level” than children diagnosed with ADHD and ‘never medicated’. (see http://speedupsitstill.com/2010/02/17/excerpts-from-the-raine-study/ ) And as pointed out by Colbert the USA, the home of ADHD child drugging, lags most comparable developed nations (and a few second world nations) in terms of academic achievement.

The message is pretty clear – if you want to dumb down – speed up!

Excerpt  from ‘Attention Disorder or Not, Pills to Help in School’

by Alan Schwarz New York Times, page 1, October 9, 2012

full text available at http://www.nytimes.com/2012/10/09/health/attention-disorder-or-not-children-prescribed-pills-to-help-in-school.html?pagewanted=1&_r=1&emc=eta1

When (American paediatrician) Dr. Michael Anderson hears about his low-income patients struggling in elementary school, he usually gives them a taste of some powerful medicine: Adderall (a mixture of four amphetamine salts[1. See http://www.rxlist.com/adderall-drug.htm ])…

Although A.D.H.D is the diagnosis Dr. Anderson makes, he calls the disorder “made up” and “an excuse” to prescribe the pills to treat what he considers the children’s true ill — poor academic performance in inadequate schools. “I don’t have a whole lot of choice…We’ve decided as a society that it’s too expensive to modify the kid’s environment. So we have to modify the kid.”…

Dr. Anderson’s instinct, he said, is that of a “social justice thinker” who is “evening the scales a little bit.” He said that the children he sees with academic problems are essentially “mismatched with their environment” — square pegs chafing the round holes of public education…

About 9.5 percent of Americans ages 4 to 17 were judged to have it (ADHD) in 2007, or about 5.4 million children, according to the Centers for Disease Control and Prevention[2. See http://www.cdc.gov/ncbddd/adhd/data.html]…

According to guidelines published last year by the American Academy of Pediatrics, physicians should use one of several behavior rating scales, some of which feature dozens of categories, to make sure that a child not only fits criteria for A.D.H.D., but also has no related condition like dyslexia or oppositional defiant disorder, in which intense anger is directed toward authority figures. However, a 2010 study in the Journal of Attention Disorders suggested that at least 20 percent of doctors said they did not follow this protocol when making their A.D.H.D. diagnoses, with many of them following personal instinct…

Dr. Anderson said (ADHD diagnostic criteria)…were codified only to “make something completely subjective look objective.”…

“This is my whole angst about the thing,” Dr. Anderson said. “We put a label on something that isn’t binary — you have it or you don’t. We won’t just say that there is a student who has problems in school, problems at home, and probably, according to the doctor with agreement of the parents, will try medical treatment.”

He added, “We might not know the long-term effects, but we do know the short-term costs of school failure, which are real. I am looking to the individual person and where they are right now. I am the doctor for the patient, not for society.”

Martin Whitely’s Comment – I am torn between loathing Doctor Anderson for his blatant disregard for the long term welfare of the children he is supposed to be helping; and respecting him for his honest assessment of the unscientific nature of an ADHD diagnosis and the American public education system. However, his justification for using Adderall on children with mediocre or worse grades is built on a very flawed premise; that is the belief that amphetamines are an academic performance enhancer.

“Personalities, rhetoric and charisma are driving the direction of mental health rather than science and evidence.” (Martin Whitely MLA, Parliament of Western Australia, 25 September 2012)

Related Media

Sue Dunlevy, News Limited Sunday papers, 7 October 2012, Doubts cast on youth mental health program. Available at  http://www.news.com.au/national/doubts-cast-on-youth-mental-health-program/story-fndo4eg9-1226489760605

Also see Patrick McGorry’s ‘Ultra High Risk of Psychosis’ training DVD fails the common sense test http://speedupsitstill.com/patrick-mcgorrys-ultra-high-risk-psychosis-theory-fails-common-sense-test

MARTIN WHITELY (Trancript of speech in the Legislative Assembly, Parliament of Western Australia, 25 September 2012): I want to use this opportunity to talk about some very serious concerns I have about the direction of the mental health policy in Australia. My basic contention is that personalities, rhetoric and charisma are driving the direction of mental health rather than science and evidence.

In May 2011, the Gillard government announced that it would spend $2.2 billion on mental health initiatives over five years. The biggest program it announced expenditure on, costing $222.4 million and which would be matched by state governments, was for the rollout of 16 Early Psychosis Prevention and Intervention Centre sites nationally, which would have “the capacity to assist more than 11 000 Australians with, or at risk of developing, psychotic mental illness.”[1]

A month later, amid growing criticisms of the ability to help those at risk of becoming psychotic, Patrick McGorry, the chief architect of EPPIC services, told The Australian “EPPICs do not treat people with psychosis risk but only patients who have had their first psychotic episode…”[2]

That is in direct contravention to what was said in the May 2011 announcement. Since then the Minister for Mental Health and Ageing, Mark Butler, once in December 2011[3] and again in June 2012[4] indicated that EPPICs may not treat those perceived to be at ultra-high risk of becoming psychotic; which is in conflict with what he said in the May 2011 rollout.

Frankly, confusion reigns supreme. I asked a question in the May 2012 estimates process in the Western Australian Parliament about the functions of the planned Western Australian EPPIC services. The response that came back as supplementary information after the estimates process stated “The Early Psychosis Prevention and Intervention Centre (EPPIC) services are for young people with first episode early psychosis and for detecting those with ultra high risk of developing psychosis.”[5]

Members can see the confusion. The initial announcement was that they would be for the purpose of assessing those at ultra-high risk of developing psychosis. Then there was a backdown by both McGorry, the architect of EPPIC, and the mental health minister. Then the state government indicated that that was one of the chief functions.

How could the functions of the most expensive program that is being rolled out nationally be so confused? There are two reasons for this: first, because we have been let down by the politicians in Canberra on all sides—I am one of the rare critics in politics of what is happening—and, second, because we have been let down by the media. They have been inattentive to the detail of what is on offer.

The problem is that the politicians have let a handful of gurus relying on rhetoric, charisma and hype drive the direction of the mental health policy in Australia. They have accepted their overblown claims without scrutiny. The danger is that young Australians will suffer as a result.

Patrick McGorry is undoubtedly the biggest of those gurus. EPPIC is very much his baby. Patrick McGorry has two claims to fame. The first is obviously the fact that in 2010 he was made Australian of the Year. The second is that he is one of the world’s most prominent advocates of preventive psychiatry. The philosophy of preventive psychiatry is basically the idea that a stitch in time saves nine. In other words, if we get in pre-emptively before people become mentally ill, we can help them—we can prevent it.

He uses the language of early intervention when he is really (often talking about prevention and) not talking about early intervention. He is (often) not talking about getting people when they become psychotic; he is talking about getting in there prior to the advent of psychosis. The theory is that we can spot and stop psychosis and a range of mental illnesses before they happen. Intuitively, it seems like a reasonable theory. However, the independent evidence that is available shows that there are two problems with the theory.

First, we cannot predict with any accuracy who will become mentally ill. In the case of psychosis, the accuracy of predictions are somewhere between eight per cent and 36 per cent. Second, even when we do predict those who will go on to become psychotic, the interventions that are on offer simply do not help in the long term. There is little evidence of sustained benefits.

The problem that we are all saddled with is that Patrick McGorry has been unable to accept that his theory does not stand up to the evidence. He has been unable to accept that even when this theory has been rejected internationally. We should be doing a double take on what we are doing in Australia.

We can thank Professor McGorry for putting mental health on the political agenda in the lead-up to the 2010 election. His status as Australian of the Year allowed him to do that, but we cannot continue to blindly follow him where he tells us to go. Frankly, that is just what is happening.

In the lead-up to the 2010 election, as I said, mental health was on the agenda for the first time. Anybody who watched Insight on SBS in July 2010 would have noticed just how deferential the presenters and the politicians were to Patrick McGorry—in particular Peter Dutton on behalf of the Liberal Party and Mark Butler on behalf of the Labor Party. Peter Dutton went the furthest; he said “we’re going to roll out a national scheme based on advice by people like John Mendoza, Pat McGorry, Ian Hickey, David Crosby and others.”[6] He added that “early intervention is proven, without any doubt, to work”. Frankly, that is just complete and utter rubbish. The independent evidence shows us anything but that.

In fact, Patrick McGorry used an address to the National Press Club in the lead-up to the 2010 election to say that we had “twenty-first century solutions” that were just waiting to be implemented if only government would urgently fund these “proven approaches”.[7]

The rhetoric continued after the election. In March 2011 Professor McGorry was the co-author of a blueprint for mental health that significantly said — “EPPIC has the largest international evidence base of any mental health model of care, demonstrating not only their clinical effectiveness but also their financial and social return on investment. This is a mature model simply requiring implementation in Australia.”[8]

Frankly, the hype is not backed up by the evidence. In 2011 the Cochrane Collaboration, which is acknowledged internationally as one of the world’s most rigorous, systematic and comprehensive sources of independent, reliable medical information, found that there was “inconclusive evidence” that early intervention could prevent psychosis and that “there is a question of whether the gains are maintained”.[9] Professor McGorry responded by attacking the Cochrane review, saying it used flawed methodology.[10] As I pointed out, Cochrane is widely regarded as the gold standard for international research. ` Other evidence that the claims are not supported by the facts was provided by a Queensland psychiatric registrar and economist—he has dual training—Andrew Amos, who wrote an article in the June edition of the Australian and New Zealand Journal of Psychiatry entitled “Assessing the cost of early intervention in psychosis: A systemic review”.[11] He wrote about the methodology used in his study, saying that 11 articles were included in the review. He made reference to one that was co-authored by Patrick McGorry, writing, “one small case-control study with evidence of significant bias concluded annual early-intervention costs were one-third of treatment-as-usual costs.”

That is the only one that found positive outcomes. He said there was significant bias in that study. Andrew Amos’s paper concluded “the published literature does not support the contention that early intervention for psychosis reduces costs or achieves cost-effectiveness.”

We have to bear that against Professor McGorry’s claim that EPPIC is supported by “the largest international evidence base of any mental health model of care”.[12] It simply does not stack up.

The problem is that after the 2010 election, there was no independent review process. The mental health minister, Mark Butler, tried in a sense when he set up the Mental Health Expert Working Group, which included a number of mental health practitioners, including Professor McGorry and Ian Hickey, and Monsignor David Cappo, who was the vice-chair. For some unknown reason, those three gentlemen decided to step outside the process and produce their own blueprint for mental health. They termed themselves the Independent Mental Health Reform Group.

Basically, they produced a $3.5 billion, five-year wish list, which was completely devoid of evidence.[13] Mark Butler should have resisted it at that stage but the media pressure was enormous because there is an enormous cheer squad for this group. He should have ordered an independent review of the evidence underlying the claims that were made in that blueprint. Instead, he adopted so much of it, which led to the $2.2 billion announcement and the $222.4 million for EPPIC, being half of the total expenditure when it is supplemented by the states.

Soon after the debate started to change for Professor McGorry. In fact, science started to catch up with some of his claims last year when international debate about the inclusion of Attenuated Psychosis Syndrome (often called Psychosis Risk Syndrome) in DSM5 took place. The basic theory underlying Professor McGorry’s work and the proposed diagnosis of Attenuaed Psychosis Syndrome was that mental illness has a prodromal phase, and in that phase mental illnesses can be predicted, treated and prevented. There was very strong international backlash to that.

As a result of that, we saw a change in the attitude of Professor McGorry to the inclusion of Attenuated Psychosis Syndrome in DSM5. In May 2010 he was quoted in an article in in the Psychiatry Update entitled “DSM5 ‘risk syndrome’: a good start, should go further” as saying “The proposal for DSM5 to include a ‘risk syndrome’ reflecting an increased likelihood of mental illness is welcome but does not go far enough.”[14]

Also, Professor McGorry wrote a piece for Science Digest in 2010, entitled “Schizophrenia Research” in which he stated, “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.”[15]

It is a very strong endorsement saying it was based on 15 years of research. That was Professor McGorry, the great enthusiast for its inclusion in DSM5.

Then the heat started to go on. In June 2011, McGorry the great enthusiast, became McGorry the indifferent, when he wrote a blog on my website at my invitation. He wrote, “Personally, I am not concerned whether it (Attenuated Psychosis Syndrome) enters the DSM5 or not.”[16] So he began backing away from it.

Later, when pushed on the issue, McGorry the great enthusiast, who had become McGorry the indifferent, went on to become McGorry the denier, denying his previous position. He was on the ABC World Today program of 12 May 2011. I had said that Professor McGorry was a leading international proponent of Psychosis Risk Syndrome as a new psychiatric disorder for inclusion in the next edition of DSM5. Professor McGorry responded by saying, “contrary to Mr Whitely’s statements, I haven’t been pushing for it 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.”[17]

So if we take those three positions—the great enthusiast, the indifferent, the denier—and recap, in 2010 he described the proposal to put Attenuated Psychosis Syndrome in the DSM5 as “innovative and timely … has not come out of left field and is based upon a series of conceptual and empirical foundations built over the past 15 years.”

The heat goes on. In 2011 the response becomes, “I haven’t been pushing for it to be included in DSM5. Now that hasn’t been my position.… It’s only been studied for the last 15 years or so, so you know we haven’t got all the answers.”

Frankly, I was aware of the hypocrisy in that statement, but I did not actually make much of it at the time because Professor McGorry and I were engaged in some very productive discourse. I was very encouraged when in February 2012 in the Sydney Morning Herald, in an article entitled “About-turn on treatment of the young”, Professor McGorry acknowledged the widespread international concern, with the inclusion of psychosis risk syndrome in DSM5 and said that he now opposed it.[18] In fact I wrote a blog entitled “Patrick McGorry deserves praise for about-turn on Psychosis Risk Disorder”. I was very encouraged. I was prepared to forgive him the dishonesty and the inconsistency of his position.

It is important to understand why the idea of Psychosis Risk Disorder, Attenuated Psychosis Syndrome, was removed from DSM5. It was removed basically for three reasons, the first being the rate of false positives. It is an accurate diagnosis of between eight per cent In 2012 in the Medical Journal of Australia Professor David Castle a critic of the rollout of EPIC’s stated that the diagnosis was accurate in only 8% of cases. [19] In the same edition of the MJA McGorry’s close colleague Professor Alison Yung identified the conversion rate from UHR to first episode psychosis was 36%.[20] So, the false positive rate it is somewhere between a 64% per cent and a 92%.

The second was the idea that labelling someone as being pre-psychotic could be stigmatising and could be a self-fulfilling prophecy. The third concern was the inappropriate use of antipsychotics in people who had never been psychotic and are unlikely to go on and become psychotic.

As I said, when Professor McGorry seemingly abandoned supporting Psychosis Risk Disorder’s inclusion in DSM5, that was the high point of the trust that had developed between Professor McGorry and me. But I have to say that I now distrust him for two very clear reasons.

One is that he has acknowledged that it is a problem when other people do it but not a problem when he diagnoses it. He wrote in 2010 that “both of these concerns are valid”—the concern about extending the use of antipsychotic medication and the concerns about labelling and stigmatising people —”Both of these concerns are valid, though both can and have been addressed in our work and systems of care in Melbourne.”[21]

Basically he is saying; Look, nobody else is good enough to do it, but we are good enough to do it in our Melbourne-based system.

What really turned me around was when I got access to training DVD produced by Patrick McGorry’s Orygen Youth Health, which actually teaches mental health clinicians how to diagnose and treat Psychosis Risk Syndrome otherwise known as Attenuated Psychosis Syndrome.[22] This DVD is still for sale, even though Attenuated Psychosis Syndrome has been removed from DSM5 and even though Professor McGorry said he did not support its inclusion.

I encourage people to go to my blog and look at an excerpt from that DVD. There is a video blog there and members can look at an excerpt from the training DVD and see if it passes the commonsense test. Jon Jureidini, a professor of psychiatry at University of Adelaide, somebody who I have great respect for, looked at the training DVD and said that it is a great training tool, because it “demonstrates how not to carry out a psychiatric interview and interact with young people”—a damning comment. (see Patrick McGorry’s ‘Ultra High Risk of Psychosis’ training DVD fails the common sense test )

The diagnosis of Attenuated Psychosis Syndrome is a very controversial issue, but more controversial than that has been the role of the use antipsychotics in the treatment of people who are not psychotic, who are considered to be at risk of being psychotic. Again, Professor McGorry has spun his own position.

In 2010 in response to my blog, he wrote, “our clinical guidelines do not (and have never done so in the past) recommend the use of anti-psychotic medication as the first line or standard treatment for this Ultra High Risk group.”[23]

It is true in the sense that final endorsed clinical guidelines have never actually recommended it, but Professor McGorry has produced draft guidelines recommending their use and, for well over a decade, Professor McGorry has experimented with and it appears likely he continues to experiment with the pre-emptive prescription of psychotropics to adolescents.

Three examples of his earlier advocacy were that in 2006 in the Australian and New Zealand Journal of Psychiatry he proposed a clinical staging framework for psychosis and identified “atypical antipsychotic agents” as one of the “potential interventions” for individuals who are at “ultra-high risk” of developing first-episode psychosis.[24] In 2007 in an article in the British Medical Journal that he jointly authored he extolled the potential of pre-psychotic use of pharmacological interventions.[25] Again in the British Medical Journal in 2008, in an article entitled “Is early intervention in the major psychiatric disorders justified?” he wrote — “Early intervention … It should be as central in psychiatry as it is in cancer, diabetes, and cardiovascular disease … Several randomised controlled trials have shown that it is possible to delay the onset of fully fledged psychotic illness in young people at very high risk of early transition with either low dose antipsychotic drugs or cognitive behavioural therapy.”[26]

I easily found three instances when he advocated for it, which is in conflict with his December 2010 claim that he has not been an advocate.

After the pressure from the debate on the inclusion of Attenuated Psychosis Syndrome in DSM–5, Professor McGorry began to adjust his position. In December 2010 he wrote that, “Antipsychotic medications should not be considered unless there is a clear-cut and sustained progression to frank psychotic disorder meeting full DSM 4 criteria.”[27] He outlined that the only exception to the previous statement is when there has been a definite failure to respond to the first and second line interventions. That was written in late 2010 in response to some concerns I had raised with him.

In November 2010 in an article in The Weekend West titled “Mental health guru stumbles into public policy minefield”, a spokesman from Orygen Youth Health said on Professor McGorry’s behalf that antipsychotics are not recommended as a standard treatment and “there has been a substantial amount of research and we do change according to the research.”

All of that kept me happy at the time, as I thought Professor McGorry had realised that the research showed that antipsychotics are not a good way to treat people perceived to be at risk of becoming psychotic. The problem is that he continued to do research on this topic.

A 2011 article referred to the NEURAPRO-Q trial that was being conducted by Professor Patrick McGorry. Thirteen international critics lodged an appeal against the trial, saying that it was unethical because of the potential harms of the use of Seroquel, an antipsychotic, in this nonpsychotic group, the very high false positive rate of misdiagnosis, which I have talked about, and a number of other reasons.

The heat was on and in August 2011, Melbourne’s The Age quoted Professor McGorry as saying that the trial had been abandoned because of “feasibility issues recruiting participants”.[28] It seems he never gave up on his treasured theory. He has acknowledged, we have all this evidence that we should not use antipsychotics in this way, yet he continued to do this trial. I contend that if he cannot prove it in 15 years of trialling antipsychotics on people who are not psychotic and are never likely to become psychotic, why would he continue to do it?

That is not the only evidence. There are more reasons to be concerned that Professor McGorry has still not abandoned his favourite theory, which is that we can use psychotropic medication as a preventive measure and a way of immunising young people against future mental illness.

He has 10 million good reasons not to abandon this research—a grant that was provided to Professor McGorry and others. He is the principal investigator for a National Health and Medical Research Council grant for “Emerging mental disorders in young people: using clinical staging for prediction, prevention and early intervention”.[29] They received a $10 million grant from the NHMRC. He said “this money will allow us to continue our research into the causes of mental illness and help the one in four young people suffering a mental disorder.”[30]

This $10 million trial may include the testing of psychotropic drugs as a preventive measure—in other words, as an attempt to immunise people against getting future mental illness.

So, go back to the claim that Professor McGorry used in the lead-up to the 2010 election. He said that the Early Psychosis Prevention and Intervention Centre has “the largest international evidence base of any mental health model of care”.[31] If that were true, after 15 years of trialling, we would have a mature model and there would not have been these back-downs.

We also need to be concerned about some of the disease mongering that comes out of the mouth of Professor McGorry and his allies. In March 2010 on the ABC’s Lateline program he said, “4 million Australians have mental health problems in any given year… there are 1 million young Australians aged 12 to 25 with a mental disorder in any given year. … And 750,000 of them have no access to mental health care currently.”[32]

I was at an excellent conference in Perth in June, hosted by the Richmond Fellowship of Western Australia. Patrick McGorry cited a New Zealand study, from memory, and claimed that between the ages of 18 and 25 years, 50.1 per cent of people had a psychiatric disorder.[33] This is disease mongering. This is turning normality into disease. People who are ill and need treatment will be denied resources because we spread resources too thin.

It is very upsetting that not only these statements are being made, but also the media is not questioning them. They are letting them go straight through to the keeper as though they are the absolute truth.

Professor McGorry has appropriated the language of early intervention, but in truth he is engaged in preventive psychiatry—preventive being pre-intervening; that is, stepping in and aggressively interfering with people who will probably never go on to be diseased.

In June 2012 in response to an article I wrote in The West Australian, Professor McGorry criticised me for describing him as a proponent of preventive psychiatry, but his own organisation, Orygen Youth Health Research Centre, registered EPPIC as a trademark in 2011. Part of its registration program listed Orygen as providing “education and training services”, including in the “field of youth-specific preventive psychiatry”.[34] They registered it in their trademark and then a year later criticised me for describing him as an advocate of preventive psychiatry.

One of his great debating tricks is to describe people such as me and those who work in the field, such as Jon Jureidini and others, as being proponents of “late intervention”.[35] We are not. We are arguing for early intervention. When people become psychotic or become mentally ill, we should get in there and intervene and help them. It is completely disingenuous of Professor McGorry to paint his opponents as being proponents of late intervention.

There are other things of concern. In July 2012 The Sunday Age in Melbourne published an article on a 2007 Orygen Youth Health antidepressant prescribing audit. The article highlighted the concern that antidepressants were being prescribed at Orygen “to a majority of depressed 15 to 25-year-olds before they had received adequate counselling”. It also found that “75 per cent of those diagnosed with depression were given the drugs too early”.[36]

Orygen’s own “Evidence Summary: Using SSRI Antidepressants to Treat Depression in Young People: What are the Issues and What is the Evidence?”, produced in 2009, builds a very compelling case for not using anti-depressants in young people, but then goes on to conclude that we should use them.[37] The only rationale that is offered—all the evidence is ignored—is that it is better to do something than nothing.

Am I alone? It is a relevant question. I am not an expert; I am a politician. I am probably the only politician who has stood and said, “We need to be concerned about this major investment in mental health in Australia.” I may be alone in politics, but I am not isolated within psychiatry. A range of very prominent psychiatrists are very critical of where we are going.

One of the most revealing things was that Psychiatry Update in October 2011 published a survey of psychiatrists in Australia. It revealed, “Almost 60% of psychiatrists think the Federal Government’s focus on EPPIC is inappropriate.”[38]

Others who have had plenty to say include Professor Allen Frances, the chief author of the DSM–IV, the current edition of the bible of psychiatry. He has been a fierce critic of Professor McGorry, although he is very charitable in what he says about McGorry’s intentions. He said “McGorry’s intentions are clearly noble, but so were Don Quixote’s. The kindly knight’s delusional good intentions and misguided interventions wreaked havoc and confusion at every turn.”[39] Professor Frances goes on to warn that Australia is really in danger of following him blindly down “an unknown path that is fraught with dangers”.

Another who has been critical is Professor George Patton, who told The Age that the Orygen antidepressant prescribing audit revealed how much we needed to look at the evidence base of these programs.[40] Clinical Professor David Castle, a very high profile psychiatrist from Melbourne, is also critical.[41] Professor Vaughan Carr from the University of New South Wales wrote an opinion piece that was very dismissive of Professor McGorry’s claims that this was the most cost-effective treatment. He described his claims as “a utopian fantasy” based on “published evidence that is not credible.”[42] [43]

I have run out of time. The message I want to put out there is that we need to go back to the evidence. I have met Patrick McGorry and I like him. He is a very charismatic individual and I think he is well intentioned, but that is not the point. The point is that we cannot have mental health policy driven by rhetoric; it needs to be driven by evidence.

Note: this transcript has contains endnotes and minor corrections not in the official Hansard record.

[1] National Mental Health Reform Statement by Hon. Nicola Roxon Minister, Hon. Jenny Macklin and the Hon. Mark Butler 10 May 2011 http://www.budget.gov.au/2011-12/content/ministerial_statements/health/download/ms_health.pdf

[2] Sue Dunlevy ‘Schism opens over ills of the mind’ The Australian June 16, 2011. http://www.theaustralian.com.au/news/features/schism-opens-over-ills-of-the-mind/story-e6frg6z6-1226075910650

[3] The Hon Mark Butler MP Minister for Mental Health and Ageing, Media Release 8 December 2011 More Early Psychosis Services for Young Australians. http://www.health.gov.au/internet/ministers/publishing.nsf/Content/B9CCE606D4092CE1CA257960000474FE/$File/MB222.pdf

[4] Mark Butler A bright future for mental health in Australia Ramp Up 8 Jun 2012 http://www.abc.net.au/rampup/articles/2012/06/08/3521451.htm

[5] Western Australian Legislative Assembly Hansard available at http://www.parliament.wa.gov.au/Hansard/hansard.nsf/0/57de02ae107600d148257a220046f171/$FILE/A38%20S1%2020120531%20p636b-639a.pdf

[6] Insight SBS television 27 July 2010 transcript available at http://news.sbs.com.au/insight/episode/index/id/272#transcript

[7] Address to the National Press Club Canberra by Prof. Patrick McGorry July 7, 2010

[8] 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 http://sydney.edu.au/bmri/docs/260311-BLUEPRINT.pdf (accessed 26 April 2011)

[9] “There is emerging, but as yet inconclusive evidence, to suggest that people in the prodrome of psychosis can be helped by some interventions. There is some support for specialised early intervention services, but further trials would be desirable, and there is a question of whether gains are maintained. There is some support for phase-specific treatment focused on employment and family therapy, but again, this needs replicating with larger and longer trials.” Marshall M, Rathbone J. Early intervention for psychosis. Cochrane Database of Systematic Reviews 2011, Issue 6. Art. No.: CD004718. DOI: 10.1002/14651858.CD004718.pub3 June 15, 2011 http://summaries.cochrane.org/CD004718/early-intervention-for-psychosis

[10] Stark, J. 2011, August 21. Drug trial scrapped amid outcry. The Age. http://www.theage.com.au/national/drug-trial-scrapped-amid-outcry-20110820-1j3vy.html

[11] Andrew Amos Australia New Zealand Journal of Psychiatry – Assessing the cost of early intervention in psychosis: A systematic review 13 June 2012 http://anp.sagepub.com/content/46/8/719

[12] 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 http://sydney.edu.au/bmri/docs/260311-BLUEPRINT.pdf (accessed 26 April 2011)

[13] 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 http://sydney.edu.au/bmri/docs/260311-BLUEPRINT.pdf (accessed 26 April 2011)

[14] Available at http://www.psychiatryupdate.com.au/news/DSM-V-risk-syndrome-a-good-start-should-go-further posted 20 May 2010 accessed 28 May 2011

[15] McGorry, P.D. Risk Syndromes, clinical staging and DSM V; New diagnostic infrastructure for early intervention in psychiatry, Schizophr, Res. (2010), doi;10.1016/j.schres.2010.03.016 http://www.ecnp-congress.eu/~/media/Files/ecnp/communication/talk-of-the-month/mcgorry/McGorry%20RIsk%20Syndrome%202010.pdf

[16] Professor Patrick McGorry June 2011 AUSTRALIA’S MENTAL HEALTH REFORM: AN OVERDUE INVESTMENT IN TIMELY INTERVENTION AND SOCIAL INCLUSION June 2011 available at www.speedupsitstill.com

[17] 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)

[18] Amy Corderoy, About-turn on treatment of the Young,Sydney Morning Herald, February 20, 2012 http://www.smh.com.au/national/health/aboutturn-on-treatment-of-the-young-20120219-1th8a.html

[19] Professor David Castle, Medical Journal of Australia 21 May 2012 Is it appropriate to treat people at high-risk of psychosis before first onset — No Available at https://www.mja.com.au/journal/2012/196/9/it-appropriate-treat-people-high-risk-psychosis-first-onset-no http://www.bmj.com/cgi/content/full/337/aug04_1/a695 (accessed 3 August 2010)

[20] Professor Alison Yung, Medical Journal of Australia 21 May 2012 Is it appropriate to treat people at high-risk of psychosis before first onset — Yes Available at https://www.mja.com.au/journal/2012/196/9/it-appropriate-treat-people-high-risk-psychosis-first-onset-yes

[21] In response to my blog titled Australian of the Year Patrick McGorry’s call for early intervention to prevent Psychosis: A Stitch in Time or a Step too Far? (available at http://speedupsitstill.com/patrick-mcgorry-early-intervention-psychosis-stitch-time-stitch-up ) Professor McGorry wrote a blog titled Responding at the earliest opportunity to emerging mental illnesses http://www.patmcgorry.com.au/blog/pmcgorry/responding-earliest-opportunity-emerging-mental-illnesses

[22] Orygen Youth Health Centre, 2009, “Comprehensive Assessment of At Risk Mental State (CAARMS) Training DVD”, The PACE Clinic, Department of Psychiatry, University of Melbourne. see http://www.eppic.org.au/risk-mental-state accessed 3 September 2012

[23] Right of Reply – Patrick McGorry on Early Intervention for Psychosis December 11, 2010 refer http://speedupsitstill.com/reply-patrick-mcgorry-early-intervention-psychosis

[24] McGorry, P., Purcell, R., Hickie, I. B., Yung, A. R., Pantelis, C., & Jackson, H.J. (2006) Clinical staging of psychiatric disorders: a heuristic framework for choosing earlier safer and more effective interventions. Australian and New Zealand Journal of Psychiatry, 40:616-622. Note: A similar article is available online at http://www.mja.com.au/public/issues/187_07_011007/mcg10315_fm.html (accessed 26 April 2011)

[25] Yung, A.R. & McGorry, P.(2007) Prediction of psychosis: setting the stage, British Journal of Psychiatry, 191: s1-s8. http://bjp.rcpsych.org/cgi/content/full/191/51/s1 (accessed 7 December 2010)

[26] McGorry P.D. (2008) Is early intervention in the major psychiatric disorders justified? Yes, BMJ, 337:a695 http://www.bmj.com/cgi/content/full/337/aug04_1/a695 (accessed 3 August 2010)

[27] Right of Reply – Patrick McGorry on Early Intervention for Psychosis December 11, 2010 http://speedupsitstill.com/reply-patrick-mcgorry-early-intervention-psychosis

[28] “Professor McGorry insists the decision to scrap the trial was made in June and is unrelated to the complaint, which he said he was only alerted to just over a week ago. He maintained the trial received ethics approval in July last year but was abandoned due to “feasibility issues” with recruiting participants in European and American sites, which were to form the international arm of the study”.Stark, J. (2011, August 21). Drug trial scrapped amid outcry. The Age. http://www.theage.com.au/national/drug-trial-scrapped-amid-outcry-20110820-1j3vy.html

[29] Refer to http://www.nhmrc.gov.au/grants/research-funding-statistics-and-data/mental-health-0

[30] Professor Patrick McGorry Emerging Mental Disorders in Young People: Using Clinical Staging for Prediction, Prevention and Early Intervention.http://blogs.unimelb.edu.au/musse/?p=417 accessed 27 September 2009

[31] 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 http://sydney.edu.au/bmri/docs/260311-BLUEPRINT.pdf (accessed 26 April 2011)

[32] ABC (11 March 2010) Mental health system in crisis: McGorry, Lateline, Australian Broadcasting Corporation. Reporter: Tony Jones http://www.abc.net.au/lateline/content/2010/s2843609.htm (accessed 26 April 2011)

[33] Professor Patrick McGorry wrote in a blog on 25 May 2011 “A recent New Zealand study has shown between 18 and 24 years that 50 per cent of young people will manifest diagnosable mental disorders, over half the time repeated episodes, which, far from being trivial or “normal”, will significantly affect their social, vocational and economic well-being at age 30.” See http://www.patmcgorry.com.au/blog/pmcgorry/government-has-thrown-black-dog-bone accessed 20 September 2012

[34] Details of the EPPIC trademark is available at http://www.trademarkify.com.au/trademark/1391532?i=EPPIC-ORYGEN_Research_Centre_ACN_ARBN_098_918_686#.T_OeZpEuh8E and the trademark for ‘E EPPIC’ that has been applied for is available at http://www.trademarkify.com.au/trademark/1447441?i=E_EPPIC-ORYGEN_Research_Centre_ACN_Street_MELBOURNE_VIC_3000_AUSTRALIA#.T_OfP5Euh8E

[35] Sweet, M. (17 August 2010) Patrick McGorry defends early intervention on youth mental health, Croakey: the Crikey Health Blog http://blogs.crikey.com.au/croakey/2010/08/17/patrick-mcgorry-defends-early-intervention-on-youth-mental-health/ (accessed 26 April 2011)

[36] Jill Stark, The Sunday Age, Youth mental health team too free with drugs: audit July 8, 2012 http://www.theage.com.au/national/youth-mental-health-team-too-free-with-drugs-audit-20120707-21o29.html

[37] In the U.S.A. a Black Box warning was put on in 2005 after an analysis of clinical trials by the FDA found statistically significant increases in the risks of ‘suicidal ideation and suicidal behavior’ by about 80%, and of agitation and hostility by about 130%. Headspace’s evidence summary also acknowledged that ‘no antidepressants (including any SSRIs) are currently approved by the Therapeutic Goods Administration (TGA) for the treatment of major depression in children and adolescents aged less than 18 years’. In addition the evidence summary acknowledges that research indicates that in terms of managing the symptoms of depression, ‘the only SSRI with consistent evidence of its effectiveness in young people is fluoxetine (Prozac)….The effectiveness of fluoxetine however is modest…Young people on fluoxetine do not appear to be functioning better in their daily lives at the end of the trials.’ Despite this, it concludes by recommending: ‘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’. 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 Copyright © 2009 Orygen Youth Health Research Centre http://www.headspace.org.au/core/Handlers/MediaHandler.ashx?mediaId=4896

[38] 6 October, 2011 Michael Slezak Psychiatry Update EPPIC disagreement over early intervention: poll http://www.psychiatryupdate.com.au/politics-practice-issues/eppic-disagreement-over-early-intervention–poll

[39] Australia’s Reckless Experiment In Early Intervention – prevention that will do more harm than good by Allen J. Frances, M.D. at http://www.psychologytoday.com/blog/dsm5-in-distress/201105/australias-reckless-experiment-in-early-intervention ]

[40] Professor George Patton quoted in the The Age, ”This paper illustrates how much we need to be looking at these new services (EPPIC) to determine the extent to which we’re following best clinical practice and to ask the questions, are we getting value for money out of these investments, and are we actually seeing better clinical outcomes?” Jill Stark, Youth mental health team too free with drugs: audit, The Sunday Age, July 8, 2012 http://www.theage.com.au/national/youth-mental-health-team-too-free-with-drugs-audit-20120707-21o29.html

[41] David Castle (St Vincents Melbourne) Medical Journal of Australia 21 May 2012- Is it appropriate to treat people at high risk of psychosis before first onset? NO

[42] Carr, Vaughan. (2010, July 10). Letter to the Editor, Mental health funding. The Australian. http://www.theaustralian.com.au/news/opinion/mental-health-funding/story-fn558imw-1225890005936

[43] Carr V. (8 July 2010) Mentally ill of all ages need services. The Australian. http://www.theaustralian.com.au/news/opinion/mentally-ill-of-all-ages-need-services/story-e6frg6zo-1225889141003 (accessed 30 April 2011)

By Martin Whitely MLA

The off colour Australian colloquialism ‘you can’t polish a turd but you can cover it in glitter’ is a fitting analogy for the danger of legitimising ADHD as a diagnosable mental illness by developing treatment guidelines. However, treatment guidelines are being developed and the more conservative the treatment guidelines, the fewer children risk damage with the long-term administration of amphetamines.

That is why I welcome the release by the National Health and Medical Research Council (NHMRC) of the Australian ADHD Clinical Practice Points (CPPs) as a small but significant step in the right direction. (The CPPs available at http://www.nhmrc.gov.au/_files_nhmrc/publications/attachments/mh26_adhd_cpp_2012_120903.pdf )

Eventually ADHD will be regarded as an embarrassing footnote of history and society will collectively wonder how anyone ever thought it would be a good idea to give amphetamines to children. But in the meantime improvements like those in the ADHD CPPs, although modest, will hopefully see fewer children diagnosed and drugged.

That said, the CPPs are far from perfect. The statement that, “…stimulants might be considered for this age group (under 7 years)” leaves the door open for drugging very young children.[1] The manufacturers prescribing information for all stimulants state they should not be used in children under 6 years, since safety and efficacy in this age group have not been established.[2] Any clinician ignoring the manufacturers warning is inviting a future law suit for negligence.

The ADHD CPPs were developed as a stop gap replacement for the corrupted NHMRC 2009 Draft Australian Guidelines on Attention Deficit Hyperactivity Disorder which in turn replaced the deeply flawed 1997 NHMRC ADHD Guidelines that were rescinded in 2005.[3] The ADHD CPPs state the 2009 Draft Guidelines were “not approved by NHMRC” as “…undisclosed sponsorship may have affected the findings of a large number of publications (co-authored by Prof Joseph Biederman and Drs Thomas Spencer and Timothy Wilens) relied on for the Draft Guidelines”.(Page 4)

Undue drug company influence went much deeper than simply relying on corrupted research. While I am not suggesting they were individually corrupt; the majority of members of the guidelines development group had ties to ADHD drug manufacturers and were enthusiastic proponents of ADHD child drugging. (For more detail on the corrupted guidelines development process refer to Open book approach a good start for the new National ADHD Guidelines Committee)

It took six years of determined advocacy to expose the connections and prompt the intervention of Mental Health Minister Mark Butler. In contrast to the indifference and incompetence of previously responsible ministers Nicola Roxon and Tony Abbott, Minister Butler established the relatively conflict of interest free[4] and transparent ADHD CPPs development process.

Although the ADHD CPPS are described as being “based on expert consensus” it would probably have been more accurate if they were described as being “based on expert compromise”. This was an inevitable product of a committee which contained members with diametrically opposed views like ADHD sceptic, Professor Jon Jureidini, and ADHD prescribing enthusiast, Professor Michael Kohn. (see Where is the evidence to support ‘ADHD expert’ Prof Kohn’s claim that amphetamines aid brain development? ) As a result in several places the ADHD CPPs are contradictory.

Despite their limitations Mental Health Minister Mark Butler deserves credit for establishing the ADHD CPPs process. There was significant opportunity for public input with approximately 140 submissions spanning the divergent range of views on ADHD and resulting in significant differences between draft and final guidelines.[5]

One of the more notable improvements from the draft was the removal of the statement that “as with any medical intervention, the inability of parents to implement strategies may raise child protection concerns”.[6] This statement attracted widespread media attention and condemnation.[7]  On 23 November 2011 the NHMRC issued a media release denying that a failure to medicate may result in the intervention of child protection authorities.[8] This statement was welcome however it should never have been included in the draft ADHD CPPs in the first place.

Overall the final September 2012 ADHD CPPs represent a significant improvement on the November 2011 draft ADHD CPPs and a vast improvement on the corrupted 2009 Draft Australian Guidelines. Below I have listed both positive and negative features of the final ADHD CPPs.

Positive features of the final ADHD CPPs include the statements that:

• “The clinician should always be mindful of seeking a more meaningful explanation of the child/adolescent’s behaviour than simply labelling it as ADHD because it meets diagnostic criteria.” (Page 14)
• “ADHD is a description rather than an explanation of a pervasive, persistent, disabling pattern of inattentiveness, overactivity and/or impulsivity. A child/adolescent who meets diagnostic criteria for ADHD may not be always best served by making that diagnosis. For example, their behaviour could be understood as a reaction to specific cognitive difficulties or family/environmental circumstances.” (Page 6)
• Comment- A very good statement, however I would argue that a child is never best served by applying a one size fits all label that fails to explain their unique circumstances.

• “All children and adolescents can display active, impulsive and inattentive behaviour as part of normal development. This does not mean that they have a disorder, and important controversies exist about the use of ADHD as a diagnosis for children and adolescents.” (Page 10)
• “Parents/carers must be given information on the diagnosis and management plan, including any potential adverse effects of treatment in order to fully inform them and to have them make a decision regarding the treatment that is offered to their child.” (Page 16)
• Potential “adverse-effects” of stimulants identified in the ADHD CPPs include sleep disturbance, reduced appetite, abdominal pain, headaches, crying spells, repetitive movements, slowed growth (height and weight), restlessness, dizziness, anxiety, irritability cardiovascular effects such as tachycardia, palpitations and minor increases in blood pressure and psychosis or mania.  In addition the ADHD CPPS say where to report side-effects in Australia (to the TGA) and acknowledge that stimulants are Schedule 8 drugs because they can be addictive and are abused.  (Page 20)
• “Children/adolescents on stimulant medication require 3-6 monthly clinical assessment and review to ensure the management strategies remain appropriate and effective. Monitoring should include assessment of side effects and particularly psychological symptoms and plotting of growth parameters, pubertal development, heart rate and blood pressure.” (Page 8)
• “Not all children and adolescents with ADHD will require, or benefit from, pharmacological management.”  (Page 8)
• Comment- A double edged sword but nonetheless an improvement from previous guidelines that promoted the use of ADHD amphetamines as the first line treatment for all children diagnosed with ADHD.

• “Practical supports for families, such as respite care, parenting education and guidance and counselling, may be helpful or even a sufficient intervention perhaps obviating the need for specific treatment and psychological management of the child.” (Page 17)
• “When stimulant treatment is used it should only be continued if there is demonstrated benefit in the absence of unacceptable side effects. “ (Page 8).
• Comment- Again a double edged sword but an improvement from previous guidelines.

• “There is no one single known cause of ADHD….” (Page 10).
• Comment- Would have been more accurate to say there is no one single known cause of the inattentive and/or impulsive behaviours characterised as ADHD

• “….the effect of medication and behavioural or educational interventions on long-term outcomes such as academic and social and emotional outcomes, has not been established…..“ (Page 11) AND “Considering that there is insufficient evidence on the long-term outcomes and long-term adverse effects following use of stimulants, the continuing benefit from, and need for medication should be regularly assessed.” (Page 21)
• Comment- The limited long term evidence available indicates that children diagnosed with ADHD and never medicated do much better than children diagnosed with ADHD and medicated. Therefore the prudent ‘first do no harm’ step would be to never medicate or time limit the use of stimulants by children to a year. For more information on the long term effects of stimulants see One year on from the Raine Study ADHD Medication Review – Will the analysis of this unique long term data source continue and if so can we trust those doing the analysis?

• “….there are no specific treatments to ‘cure’ ADHD…..” (Page 16)
• “In the absence of another diagnosis, neuroleptics (anti-psychotics) have no role in the treatment of ADHD.” (Page 18)On the negative side the ADHD CPPs include the statements that:

• “The risk of not making a diagnosis is that the child/adolescent may not receive appropriate management and care.” (Page 12)
• Comment-This is one of the most disturbing statements in the CPPs. ADHD is a dumbed down label that does nothing to explain a child’s individual circumstances. It prevents understanding and invites a dangerous one size fits all treatment, stimulants, that mask behaviours without addressing any underlying problems. 

• “Regardless of whether the cause is explicable or not these symptoms impact so adversely on the child or adolescent and their family that the symptoms cannot be left untreated.” (Page 11)
• Comment- These first two statements may panic clinicians and parents in premature treatment with unnecessary and potentially dangerous drugs, i.e. amphetamines. The statements are inconsistent with the precautionary first do no harm principal of medicine. Understanding the cause of any problem is essential to identifying appropriate long term solutions.

• “Use of stimulant medications (methylphenidate and dexamphetamine sulphate) can reduce core ADHD symptoms and improve social skills and peer relations in children and adolescents diagnosed with ADHD in the short term (up to 3 years).” (Page 8)
• Comment- I agree that drugs will alter behaviour immediately and in some cases make boisterous, even annoying and in some cases traumatised children more compliant. However, achieving social control and compliance in that manner is a violation of the rights of the child and frequently covers up underlying serious problems including in some cases the traumatic effects of child abuse and neglect.

• “Both medication and combined medication and behavioural treatment have been shown to be more effective in treating ADHD symptoms than psychosocial or behavioural interventions alone.” (Page 19)
• Comment- Again I agree that drugs will alter behaviour immediately, however achieving compliant behaviour in the short term is not an appropriate way to measure child welfare. The only consideration that should matter is the long-term welfare of the child not the convenience of others. The limited long term evidence available indicates that children diagnosed with ADHD and never medicated do much better than children diagnosed with ADHD and medicated.

• “For young children (under 7 years) psychological, environmental and family interventions should, if possible, be trialed and evaluated before initiating pharmacological treatment. If all these other interventions have not been effective then stimulants might be considered for this age group in consultation with the parents or guardians and including when appropriate teachers or other carers.” (Page 9)
• Comment- This is the most concerning recommendation as it leaves the door open for drugging very young children. The manufacturers prescribing information for all stimulants state stimulants should not be used in children under 6 years, since safety and efficacy in this age group have not been established.[9]

• “It is rare that symptoms of ADHD occur in isolation. In the assessment of a child/adolescent with ADHD the specialist clinician should assess for other psychological, social, emotional and behavioural difficulties that might coexist with ADHD (comorbidities).” (Page 11)
• Comment – Psychological, social and emotional difficulties are often the causes of ADHD type behaviours. In these cases ADHD doesn’t coexist, rather the ADHD type behaviours are caused by psychological, social and emotional difficulties.

• “Children/adolescents with ADHD may have other mental health problems, such as depression, which may be associated with an increased risk of suicidal ideation. Conducting a mental health assessment, where indicated, can detect mental health problems and inform appropriate management.” (Page 15)
• Comment – Inviting multiple diagnoses invites poly-pharmacy in the minds of some medical practitioners. Antidepressants are not approved for use in young people as studies show they increase suicidality by approximately 80%.[10]

• “Assessment of response to treatment and periodic review of progress is facilitated by the use of questionnaires from parents/carers, teachers and if possible the child/adolescent using psychometrically sound, evidence-based checklists such as the Conners’ ADHD/DSM-IV Scales (CADS).” (Page 16)
• Comment- Please let’s all stop pretending the diagnosis of ADHD involves scientific testing. These so-called psychometrically sound, evidence-based checklists are no more than loosely defined behavioural tick-lists and are reminiscent of a Dolly Magazine find your perfect boyfriend tick-box questionnaire.

• “Heredity, genetic, neuro-imaging and neuro-psychological studies provide evidence for a biological basis for inattention and impulsiveness.” (Page 10)
• Comment- This is concerning for two reasons. Firstly it overstates the validity of this evidence. Secondly and most significantly even if a biological basis for ” for inattention and impulsiveness” is established this does not make a disease or disorder any more than other genetic variations like height or skin colour. Refer to The ‘Genetic basis of ADHD’ – much ado about nothing

• “Data from 2000 indicates the prevalence rate of ADHD symptoms among 6–17 year-olds in Australia is around 11%.” (Page 11)Related Media
•  Experts alarmed at new ADHD guidelines | News.com.au Sue Dunlevy, News Limited Network, October 03, 2012
• Comment- This is a massive overestimate of the proportion of children who would qualify for a DSMIV diagnosis as when conducting this research there was no assessment for impairment or requirement for children to display sustained ADHD in multiple settings. Nonetheless the garbage research continues to be quoted by the ADHD industry, the NHMRC and even Commonwealth Ministers.[11]

[1] Page 9 of the ADHD CPPs available at http://www.nhmrc.gov.au/_files_nhmrc/publications/attachments/mh26_adhd_cpp_2012_120903.pdf

[2] Ritalin prescribing information says “Ritalin should not be used in children under 6 years, since safety and efficacy in this age group have not been established” see http://www.pharma.us.novartis.com/product/pi/pdf/ritalin_ritalin-sr.pdf   Concerta’s says “safety and efficacy has not been established in children less than six years old or elderly patients greater than 65 years of age” see http://www.concerta.net/sites/default/files/pdf/Prescribing_Info-short.pdf#zoom=56  Dexedrine’s (brand of dexamphetamine) says “Long-term effects of amphetamines in pediatric patients have not been well established. DEXEDRINE is not recommended for use in pediatric patients younger than 6 years of age with Attention Deficit Disorder with Hyperactivity” see http://www.dexedrine.com/docs/dexedrine_PI.pdf

[3] National Health and Medical Research Council, Attention Deficit Hyperactivity Disorder (ADHD), Canberra, 1997. http://www.nhmrc.gov.au/_files_nhmrc/publications/attachments/ch36.pdf

[4] Conflict of Interest details available at http://www.nhmrc.gov.au/guidelines/adhd-conflicts-interest

[5] For details of the effect of the submissions on the final ADHD CPPs see appendix D page 16 available at http://www.nhmrc.gov.au/_files_nhmrc/publications/attachments/mh26_adhd_cpp_appendices_120903_0.pdf

[6] National Health and Medical Research Council, Public Consultation on the Draft Clinical Practice Points on the Diagnosis, Assessment and Management of Attention Deficit Hyperactivity Disorder in Children and Adolescents, Australian Government, November 2011 p15. Available http://consultations.nhmrc.gov.au/open_public_consultations/a-d-h-d

[7] Sue Dunleavy, The Australian medicate ADHD kids or else parents told 21/11/2011 http://www.theaustralian.com.au/national-affairs/medicate-adhd-kids-or-else-parents-told/story-fn59niix-1226200652633

[8] 8. see http://www.nhmrc.gov.au/media/releases/2011/reassuring-parents-new-draft-adhd-clinical-practice-points-do-not-mandate-medica

[9] Ritalin prescribing information says “Ritalin should not be used in children under 6 years, since safety and efficacy in this age group have not been established” see http://www.pharma.us.novartis.com/product/pi/pdf/ritalin_ritalin-sr.pdf   Concerta’s says “safety and efficacy has not been established in children less than six years old or elderly patients greater than 65 years of age” see http://www.concerta.net/sites/default/files/pdf/Prescribing_Info-short.pdf#zoom=56  Dexedrine’s (brand of dexamphetamine) says “Long-term effects of amphetamines in pediatric patients have not been well established. DEXEDRINE is not recommended for use in pediatric patients younger than 6 years of age with Attention Deficit Disorder with Hyperactivity” see http://www.dexedrine.com/docs/dexedrine_PI.pdf

[10] See http://www.fda.gov/Drugs/DrugSafety/InformationbyDrugClass/ucm096273.htm

[11] Draft ADHD Guidelines Released, Joint Media Release, 30 November 2009.  The Hon Nicola Roxon MP, Minister for Health and Ageing, National Health and Medical Research Council, and Royal Australasian College of Physicians.]

]]> http://speedupsitstill.com/2012/10/02/australian-adhd-clinical-practice-points-6-years-frustrated-advocacy-small-step-direction/feed/ 5 http://speedupsitstill.com/2012/09/05/patrick-mcgorrys-ultra-high-risk-psychosis-theory-fails-common-sense-test/ http://speedupsitstill.com/2012/09/05/patrick-mcgorrys-ultra-high-risk-psychosis-theory-fails-common-sense-test/#comments Wed, 05 Sep 2012 03:55:00 +0000 http://speedupsitstill.com/?p=3397
Part One – Is Nick Sick?   (11 minutes)
Part Two – Is Nick Sick?   (9 minutes)

Response to the ‘Is Nick Sick?’ video blog

by Professor Jon Jureidini

“Patrick McGorry’s Orygen Youth Health, CAARMS training video[1] on how to diagnose ‘Attenuated Psychosis’ demonstrates how not to carry out a psychiatric interview and interact with young people.”

As identified by Martin Whitely in his commentary about the CAARMS training DVD, describing Nick as being at ultra-high risk of psychosis (UHR) fails the common-sense test. Even more concerning is that Nick is labelled as having Attenuated Psychosis – in ordinary language, he is already mildly mad.

Professor McGorry justifies diagnosing young people like Nick as being at ‘ultra high risk’ because within the next 12 months they are ‘between two and four hundred times’ more likely to become psychotic than the ‘the general population’.[2]

But we must respect the ordinary everyday language meaning of ultra high risk. If I am labelled as being at ultra-high risk of something, I assume that I will probably be affected. I do not interpret that label as meaning I am simply much more at risk than my peers.

Even Professor McGorry acknowledges that nearly two-thirds of the people identified as being at ultra high risk of developing psychosis, don’t become psychotic.[3] Independent evidence shows the conversion rate is as low as 8%[4] With between 64% and 92% false positives, the true ‘ultra high’ risk is the risk of being incorrectly labelled.

The pay-off for testing for UHR is simply not sufficient to justify the cost. One cost is that Nick is now being taught to see himself as sick. Who knows if this might not even increase this vulnerable young man’s risk of ultimately being diagnosed with full-blown psychosis? And as Martin Whitely points out, it stigmatises him.

But more important to me than stigmatisation is the fact that the UHR label is an unexplanation; it ignores what is going on in Nick’s life. Unexplaining is different from saying ‘I don’t know’ (something we doctors would do well to say more often). Unexplanations distract from the difficult but rewarding task of working with a young person towards finding an explanation for their stress.

Nick makes it pretty easy for the listener. He tells us about being bullied into a trade that he doesn’t want to be in, and he invites the interviewer to explore his relationship with his father. The interviewer doesn’t notice, or chooses to ignore this invitation, instead sticking to a stereotyped list of questions that generate the sterile unexplanation of UHR.

It might be argued that the interviewer would come back to this later. However, in my experience, young people prefer us to show an interest in their difficult and intimate predicaments when they first get the courage to put them into words.

I am grateful to Martin Whitely for putting the CAARMS training video into the public domain because it provides a potential teaching tool for medical students in how not to carry out a psychiatric interview and interact with young people.

For more on this subject see Whitely tells Parliament – It’s time to confront Patrick McGorry’s disease mongering and end the guru-isation of Australian mental health policy

Related Media

Byron Kaye, Medical Observer, McGorry stands firm on ‘flimsy’ accusations 11th Sep 2012 http://www.medicalobserver.com.au/news/mcgorry-stands-firm–on-flimsy-accusations

The following is a transcript of the interview with Nick and the introduction to the CAARMS Training DVD

Associate Professor Alison Yung.:

Hello and welcome to the CAARMS Training DVD. The CAARMS has two functions; First, to assess whether the person meets the ultra-high risk criteria for psychosis or not and second, to assess the range of psycho-pathology which we see typically in people in the prodrome preceding a first episode of psychosis. For this training video we’ll just focus on the first function,  that of assessing the ultra high- risk criteria.

For this function we need only the first four sub-scales of the CAARMS; Unusual thought content, non bizarre ideas, perceptual abnormalities and conceptual disorganization. These four sub-scales assess sub-threshold and threshold versions of positive psychotic symptoms, delusions, hallucinations and formal thought disorder.

You notice that the interviewer assesses both the intensity, frequency and duration of these phenomena.

We’re going to show you four interviews of typical people who present to the Pace clinic.

Also in the DVD there will be slides showing the ratings for each of these people.

By viewing the DVD you’ll see both how the interviewer asks the questions and the responses that we commonly encounter at the clinic.

DVD also contains additional information. We hope that this resource assists you in your work.

INTERVIEW 1.

Narrator: Nick is an 18 year old apprentice electrician in his first year of training. He is self-referred to PACE, encouraged by his sister, after confiding in her that he has been extremely anxious and has had great difficulty sleeping. He has not previously sought help for psychological issues but there is a family history of depression in the maternal aunt and of an unknown psychiatric condition in his mother’s grandmother. Nick is single and lives with his parents and three younger sisters. The family is of Italian origin. Nick did reasonably well at school and completed Year 12. He has a large circle of friends, enjoys playing sports and has had girlfriends in the past but is not in a relationship at the moment. He does not mind if his mother knows about his current problems but does not want his father informed.

Interviewer: Okay Nick, so you’ve told me that um things haven’t been going very for a little while now  since you started work, I just want to ask you some more detailed questions about the sorts of things you’ve been experiencing. So can you tell me, have you had the feeling that something odd is going on that you can’t explain?

Nick: No, not really, no. (shakes head)

Interviewer: No, Have you been feeling puzzled by anything?

Nick: No.

Interviewer:  Do you feel that you have changed in any way, who you are has changed?

Nick: No.

Interviewer: Or that people around you have changed in in some way?

Nick: No, not not really.

Interviewer:    Okay, have you felt that things around you have ahh a special meaning or that people have arranged things especially for you?

Nick: No.

Interviewer: No?

Nick: No.

Interviewer:  People been trying to give you any messages?

Nick: No.

Interviewer:  No? Now sometimes people have the feeling that someone or something outside of themselves are controlling their thoughts or their feelings – wondering if you’re having any experiences like that?

Nick: No, not like that.

Interviewer:  So you haven’t had any feelings or impulses that seem to come from someone else not yourself?

Nick: No.

Interviewer: No?

Nick: No.

Interviewer:  Okay. Do you ever have the feeling that um ideas or thoughts are put into your mind that aren’t yours?

Nick: No.

Interviewer: Okay. And what about the reverse process – having the the feeling that thoughts are being taken out of your head?

Nick: No, that’s never really happened.

Interviewer: Okay. Sometimes people feel that other people can read their minds or hear their thoughts. Does anything like that happen to you?

Nick: No.

Interviewer: No?

Nick: No.

Interviewer:  Can you tell me, has anyone been giving you a hard time or trying to hurt you in any way?

Nick: Well yeah, I suppose that’s that’s been a big thing for me um It’s gotten really bad. I feel like that all the time. Umm, I’ve actually started a new apprenticeship about three months ago ahm, and my dad got me into it because ahh one of his mates is doing doing him – doing him a favour so he is taking me on, umm, and my dad’s an electrician and he wants me to come in and take over the family business so, so I feel that I have to do it but I really don’t want to be there and I really don’t think that I’m really good at being an electrician so, since I started work um I’ve I’ve really felt while I was at work that I was really bad at what I was doing, ahhm and I actually felt – I actually felt at the time, I was starting to feel that the guys at work were thinking um that I’m really bad at what I’m doing and that they’re laughing at me behind my back and talking about me behind my back, so um, I mean the the guys that I work with they’ve all got families and you know they go fishing together so they’re all a close group of friends um whereas I’ve got nothing in common with them. So whenever we go on smoko breaks they all talk with each other, um and I tend to smoke by myself because I’ve got nothing to say to them really and um when during the smoko breaks you know when they’re laughing, ahh when they’re talking sometimes they look over in my direction and I feel that they’re actually talking about me and they’re laughing at me and you know and they think that I’m really bad at what I do, ummm, and I I mean I’ve made quite a few mistakes at work, umm and and I feel that they’re just waiting for me to stuff up because they know they they I just think that they know that I’m going to stuff up.

Interviewer: So has this been going on the whole time you’ve been at work?

Nick: Well it is it was alright when I started, umm, and then a few weeks into it I I really started to get worried because I’d made a few small, small mistakes, I started to think that you know they really were thinking well you know who have we hired here – he doesn’t know what he is doing, um and that actually got really bad about a month ago. Um, we had a really important deadline that we had to meet and we were quite stressed and um everyone was really busy and I was quite anxious because, um it was just a stressful time during that time and it got really bad there where every time I was at work and every minute I was actually just looking over my shoulder and looking at ah the other workers and seeing if they were looking at me and if they were talking about me and I felt that they were waiting for me to stuff up and and um, so so it got bad about a month ago- it’s not as bad now-it’s still, it’s still pretty bad but it’s not as bad as what it was about a month ago.

Interviewer: Ahuh, so in what way is it a bit better now, then it was a month ago?

Nick: Well I suppose back then it was a really stressful period um and everyone was busy at work and I was really stressed  at work so I think it got worse around that time ahh but I suppose now it’s it’s a bit less stressful at work and not so busy so, it’s not as bad  but I still look around and I still feel that as if they’re talking about me as if I’m really bad, they think that I’m really bad at my job.

Interviewer: Uhuh. How does, how do you respond to this? Has it made you do anything differently or?

Nick: Um, well, I’m, I’m always really  nervous about going to work and and I hate going to work now, um, and I I don’t really do anything differently, ah, but, I’m always looking and and listening and and um trying tryna catch them out- trying to catch them talking about me, um.

Interviewer: Do  you -Have you been getting to work every day?

Nick: Well, the past, the past few months I’ve, I’ve taken a few days off. Well I’ve been taking nearly one day off a week um, which has been really good, um.

Interviewer: That’s what I’m wondering  about. What’s it like for you when you’re at home?

Nick: Oh, when I have the days off and and when I’m home I’m fine you know. I don’t think about work and um I don’t worry about what they’re thinking of me and a lot of the times when I get home from work and I think about what’s happened earlier in the day you know, I feel that it’s – you know what I was thinking at the time was pretty, you know ,pretty silly and you know, it was, like they care what I’m doing and how good I am um.

Interviewer: So you can see it differently when you are at home?

Nick: Yeah, when I’m at home I’m I’m less worried about it and and, you know, sometimes I think that what I was thinking was pretty silly at the time but then when I’m at work I’m I get really anxious and worried about it.

Interviewer: Okay so you’re having this really hard time at work and things are okay at home.

Nick: Hmm, yeah.

Interviewer: You had these, this sort of stuff happen to you anywhere else or is it just at work?

Nick: Aww not really anywhere else. There’s there was this time um, it was about a month ago, still during that period.

Interviewer: During that time-

Nick: Yeah there was a couple of times um when I was actually on the train on my way to work and I was really tired and really really stressed and I just didn’t want to go to work, um and I was just standing up on the train and um I saw a couple talking to each other and I saw another guy um start laughing and um I I started to think at the time that um, they were actually talking about me and and they were laughing about me and um I was, I was  starting to to think they thought I was really bad at what I was doing; they, they knew that I was a bad electrician and I was really bad at what I was doing, so I got really anxious and really worried about that and really stressed; um and that that happened for, for two days.

Interviewer: Two days..

Nic: That happened twice. Yeah.

Interviewer:  Yep. And what happened when the journey ended and you got off the train and you were away from those people. Where you still-did you still have those worries?

Nick: Well, I I was really umn stressed getting off the train, um, and then you know, as I was walking to work I was sort of thinking about it a bit and– you know, I was thinking you know, those people don’t even know me and I’ve never met em before and they don’t even know what I do, so you know I was starting to think you know how would they know that I’m bad at what I do, so I started to think that you know maybe what I was thinking was a bit, you know, a bit over the top, a bit stupid, but you know at the time I really was convinced that they were.

Interviewer: It sounds like a really hard time and then you got to work and the worries would have come again.

Nick: Yeah yeah, like, like on those days walking to work I sort of cleared my head a bit and you know thought that it was all pretty stupid and then I got to work and you know, when work started again and the guys came in to work and you know, again, I still started to sort of worry about what they were thinking and yeah.

Interviewer: Okay, so you’re using, um, marijuana with your friends on the weekends.

Nick: Yeah.

Interviewer: How are you feeling when you’re, when you’re stoned with your friends?

Nick: Oh, um it feels pretty good. I mean the reason I do it is is to relax um.

Interviewer: And that’s the effect that it has?

Nick: Yeah, yeah. I don’t, I just do it just to get away from things, and not to think about things or anything like that so.

Interviewer: Some people find that when they use marijuana they get more worried but that doesn’t sound like your experience?

Nick: Ah no, no never, never been worried or nervous or stressed when I’ve been with my mates and smoking so I suppose that’s why I do it with them, just to chill out on the weekends.

Interviewer: Mkay. Have you been feeling that you’re especially important in some way or that you’ve got special powers to do things?

Nick: No. Not really. No that hasn’t happened.

Interviewer: Okay. Now have you been feeling that there’s anything odd going on with your body that you can’t explain?

Nick: No.

Interviewer: Or that your body’s changed in any way?

Nick: No.

Interviewer: No?um, what about feeling guilty or that you deserve punishment. Does that come up for you at all with..

Nick: No. No.

Interviewer: With these things? Okay, fine.

Nick: Some-Sometimes at work I feel that, um, just with,ah with my stuff ups I think that, you know, the boss will, will catch me out and he’ll find me out and um that I will get punished but yeah I don’t actually feel the need that I need to be punished or anything like that.

Interviewer: Are you very religious Nick, have you had any religious experiences?

Nick: Ahh, no, not really.

Interviewer: Okay. And um, do you have a girlfriend?

Nick: Ah, I I used to a couple of years ago but I can’t be bothered looking after one at the moment.

Interviewer: Another area that I need to ask you about is the area of ah perceptions, what you see and hear

Nick: Yeah

Interviewer: And that kind of thing. Um so I’m wondering if you’ve noticed any changes in in your vision, do you, um are things looking different to you?

Nick: NarI needed, I needed glasses. I need to get glasses, um so um things were getting a bit blurry um, but.

Interviewer: So glasses have improved your vision?

Nick: Yeah. Yeah.

Interviewer: In more recent times has there been a change in the way things look to you?

Nick: No

Interviewer: The colours brighter?

Nick: No, no that’s all the same

Interviewer: Anything like that

Nick: Yeah

Interviewer: Um. Okay. And what about um hearing things. Have you been hearing things that other people can’t hear?

Nick: No.

Interviewer: Any changes to the way you perceive sound at all?

Nick: No. No.

Interviewer: Any strange sensations in smell, smelling strange things, or things smelling different?

Nick: No.

Interviewer: And, um, I asked you whether you had any strange sensations on your skin. Whether you’ve um felt things crawling on your skin or underneath your skin?

Nick: No.

Interviewer: Anything like that?

Nick: No. No.

Interviewer: No. And what about your ability to communicate with people Nick? Have you felt like um, you’re able to communicate clearly, that people understand what you’re saying? You’re able –

Nick: Yeah.

Interviewer: to get your message across?

Nick: Yeah, never really had problems with that.

Interviewer: Uhuh.

Nick: No.

Interviewer: Okay. Do you have um trouble finding the correct word to use at all?

Nick: Aw, sometimes, I mean I’m I’m not the best at English so sometimes I, you know I can’t find the right – I’m thinking of the word that I’d use or I heard a couple of days ago and I just can’t think of it at the time, um, I think of it later on sometimes but- so sometimes I find- have trouble finding the right word, but, it doesn’t happen very often.

Interviewer: It doesn’t happen very often, it’s not something that you’re really worried about?

Nick: No.

Interviewer: No?

Nick: No.

Interviewer: Okay.

Nick: I still, they still understand what I’m trying to say.

Interviewer: Yep. Do you ever have the feeling that, um, you go off on tangents and that people don’t follow what you’re on about?

Nick: No.

Interviewer: No? So do you think your activity level has dropped off a bit? Are there things you used to do that you don’t do now?

Nick: Well, I, I mean I always used to go out with my friends. Go out drinking. Go out clubbing and go to the gym with them, um but, since, since work has started I really haven’t been in the mood to do anything like that. So I haven’t been in the mood to go out with them.

Interviewer: So does that mean you’re not going out at all now?

Nick: Oh, sometimes they drag me out like a lot of the times I don’t want to go but sometimes they just drag me out, and when we actually go out I have a great time with them. So it’s like, it’s like nothing.

Interviewer: So you are still able to enjoy yourself at times but-

Nick: Yeah.

Interviewer: But it’s a bit hard to get yourself going?

Nick: Yeah, yeah. I just feel I don’t have the energy and just don’t want to do it anymore.

The DVD is paused. Take each of the 4 subscales and rate the Global Assessment and Frequency and Duration for each. Press Continue and the answers will follow.

UNUSUAL THOUGHT CONTENT – GLOBAL RATING SCALE

Alison Yung: Unusual thought content. Nick receives a zero for unusual thought content as he does not answer positively to any of the questions.

Non-Bizarre ideas. He does rate on the Non-Bizarre ideas sub-scale however because of the experiences he has been having at work lately. He receives a Global score of 5 with his persecutory ideas – feelings that other people know that he is bad at his job. As he has experienced these thoughts about strangers on the train it is highly unlikely that they are true. However these thoughts are not held with delusional conviction as he is able to question these thoughts. Thus the intensity is not as high as a score of 6. These thoughts have resulted in Nick taking some time off work. Hence they have resulted in some change in behavior. They are not very easy for Nick to dismiss which means that the intensity is not as low as a score of 3.

Because these thoughts occur most days when he is at work. and last for more than an hour he rates a frequency and duration score of 4.

Frequency and Duration

Pattern of Symptoms

Level of Distress (In Relation to Symptoms)

Not At All Distressed                                                                                                                  Extremely Distressed

Perceptual Abnormalities – Global Rating Scale

Perceptual Abnormalities – Nick states that he needed glasses. However, he does not report experiencing any perceptual abnormalities so for this sub-scale he rates a zero.

Disorganised Speech – Global Rating Scale

Disorganised speech – Nick reports that he sometimes has trouble finding the correct word at the right time. However people still understand what he is saying so he rates a global score of 2 for disorganized speech. He said that this does not happen very often so he rates a frequency and duration score of 1.

Nick meets the PACE  intake criteria for Group 2, the Attenuated Psychosis group. He also meets the drop in functioning criteria.

Note: Nick is played by an actor, however the interviewer is a doctor employed by Orygen Youth Health

[1] Orygen Youth Health Centre, 2009, “Comprehensive Assessment of At Risk Mental State (CAARMS) Training DVD”, The PACE Clinic, Department of Psychiatry, University of Melbourne. see http://www.eppic.org.au/risk-mental-state accessed 3 September 2012

[2] McGorry P. Right of Reply – Patrick McGorry on Early Intervention for Psychosis. December 11, 2010. http://speedupsitstill.com/reply-patrick-mcgorry-early-intervention-psychosis#more-1075

[3] Professor McGorry wrote “the false positive rate (for UHR) may exceed 50-60%” 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 McGorry’s close colleague Alison Yung identified the conversion rate from UHR to first episode psychosis was 36% in an article in the Medical Journal of Australia titled Is it appropriate to treat people at high-risk of psychosis before first onset — Yes Available at https://www.mja.com.au/journal/2012/196/9/it-appropriate-treat-people-high-risk-psychosis-first-onset-yes

[4] Professor David Castle, Medical Journal of Australia, 21 May 2012, Is it appropriate to treat people at high-risk of psychosis before first onset — No Available at https://www.mja.com.au/journal/2012/196/9/it-appropriate-treat-people-high-risk-psychosis-first-onset-no