Patrick McGorry’s cautious prescribing Rhetoric not matched by Reality

by Martin Whitely

An article in today’s Sunday Age, available at http://www.theage.com.au/national/youth-mental-health-team-too-free-with-drugs-audit-20120707-21o29.html, highlights the results of a prescribing audit of Patrick McGorry’s Orygen Youth Mental Health Service.  It 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.”¹

The audit of 150 patients teated in 2007 found “75 per cent of those diagnosed with depression were given the drugs too early. Clinical guidelines recommend that in most cases antidepressants should only be given to young people after they fail to respond to four to six sessions of psychotherapy, which usually takes about six weeks. However, the audit, carried out by Orygen’s own researchers, found on average patients received the drugs after just 27 days. It also showed that fewer than half were followed up to see whether their symptoms had improved or to check for side effects, which can include an increased risk of suicide.”²

It is commendable that Orygen³ published the results of the audit, however the results make a mockery of Professor Patrick McGorry’s often repeated assertion that drugs are not the first-line treatment in any but the most serious cases. 

In response Professor George Patton, director of adolescent research at the Centre for Adolescent Health at the Royal Children’s Hospital, told The Age, ”This paper illustrates how much we need to be looking at these new services [EPPIC and headspace] 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?” ⁴

At the very least there is an obvious need for an independent scientific review of the EPPIC and headspace programs identified for national rollout and for tight real time program wide auditing of medication practice.

Note: The issues raised in today’s Age article reinforce similar concerns I voiced last year about antidepressant prescribing at Professor McGorry’s other favourite project headspace.  I raised my concerns in the WA State Parliament and on my blog last year titled “Is Patrick McGorry’s and the Independent Mental Health Reform Group’s $3.5b blueprint for Australian mental health the way forward, or a prescription for more ‘psychiatric disorders’, ‘off label’ prescribing and youth suicide?”

An excerpt from that blog is below and the full blog is available at http://speedupsitstill.com/patrick-mcgorry%e2%80%99s-independent-mental-health-reform-group%e2%80%99s-3-5b-blueprint-australian-mental-health-forward-prescription-%e2%80%98psychiatric-disorders%e2%80%99-%e2%80%98off-label )

Why do Headspace and Professor McGorry advocate the ‘off label’ (unapproved) use of SSRI antidepressants in even ‘moderately depressed’ young people, despite FDA and TGA warnings about the increased risk of suicidality?

A 2009 evidence summary produced by Orygen Youth Health for Headspace and overseen by Professor McGorry, titled ‘Using SSRI Antidepressants to Treat Depression in Young People: What are the Issues and What is the Evidence?’, correctly identifies that the US Food and Drug Administration has issued the highest possible ‘black box’ warning that the use of SSRI antidepressants increases the risk of suicidality in people under 24.⁵

The 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%.⁶

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’.⁷

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.’⁸

The body of the evidence summary builds a compelling argument for avoiding the use of SSRIs in young people. Despite this, it concludes by recommending: ‘In cases of (even) 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’.⁹

The nearest thing to a rationale offered in the paper is that many young people who are depressed get no treatment and that it is better to do something than nothing.

Through the use of a variety of mechanisms, including candle-light vigils, Professor McGorry has mobilised well intentioned, vocal supporters including Get Up! to highlight the tragedy of youth suicide to advocate for reform of mental health services for the young.¹⁰

Yet the Headspace evidence summary, which is effectively a guideline for the treatement of young Australians, acknowledges and then ignores the clinical trial evidence and FDA and TGA advice on the relationship between SSRI antidepressants and youth suicidality.

If Australia were, as Professor McGorry frequently advocates, to follow ‘evidence based medicine’ on preventing the tragedy of youth suicide, we would not allow the use of SSRIs by young people. However, if Australia follows Headspace and Professor McGorry’s advice on SSRIs, we risk more, not fewer, candles at the next vigil.

Coming Blogs

Next Week TIME TO END THE “GURU-ISATION” OF AUSTRALIAN MENTAL HEALTH part 1- Early Psychosis and Professor Patrick McGorry

Following Week TIME TO END THE “GURU-ISATION” OF AUSTRALIAN MENTAL HEALTH part 2 – Depression and Professor Ian Hickie