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 ]

“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)

The central characteristics of ‘Disruptive Mood Disregulation Disorder’ proposed for inclusion in DSM5 are childhood “irritability” and “temper outbursts” occurring, ”on average, three or more times per week”.[1] Disruptive Mood Disregulation Disorder represents a disturbing evolution of the absurd and dangerous practice of diagnosing children, even very young children, with ‘Juvenile Bipolar Disorder’.  Although not an official psychiatric disorder Juvenile Bipolar Disorder was enthusiastically and successfully promoted by disgraced Harvard University Professor of Psychiatry, Joseph Biederman.

Biederman, who was also Director of the Johnson & Johnson Centre for Paediatric Psych-Pathology research at Massachusetts Hospital and according to the New York Times is the “the world’s most prominent advocate of diagnosing bipolar disorder in even the youngest children and of using antipsychotic medicines to treat the disease”.[2] He is largely responsible for the enormous growth in US antipsychotic prescribing rates to children including Johnson & Johnson’s very profitable antipsychotic Risperidone (brand name Risperidal).  In April Johnson & Johnson were fined US$1.2Billion by an Arkansas court for making misleading claims about the safety of Risperidal. This followed similar outcomes in other US states.[3]

In 2011, US congressional investigations led by Iowan Senator Charles E. Grassley exposed that Biederman received at least US$1.6m in undisclosed fees from drug-makers from 2000 to 2007 and only revealed a tiny fraction of this income to Harvard University.[4] The New York Times reports “court documents dating over several years that Dr. Biederman wants sealed showed that he told the drug-giant Johnson & Johnson that planned studies of its medicines in children would yield results benefiting the company”.[5]

Taking and not disclosing drug company money and planning beneficial research results is reprehensible behaviour. Harvard University’s decision to effectively give Biederman little more than a rap on the knuckles brings discredit to one of the world’s most prestigious universities.[6] Perhaps Harvard was motivated more by the funding that Biederman and his cronies attract to the university than by the damage they bring to the university’s reputation. Harvard’s failure to take strong ethical action against Biederman has meant that his influence, although waning, is still considerable.

Thankfully Juvenile Bipolar Disorder is not officially recognised as a diagnosable condition in the current DSM (DSMIV). Supporters lobbied to have it included in the DSMIV, however the DSMIV development committee “found scientific support unconvincing and refused to do so”.[7] Regardless, hundreds of thousands, possibly millions, of children have been diagnosed with the unofficial disorder and treated with anti-psychotics like Johnson & Johnson’s Risperidal.[8] These medications “can cause serious complications – major weight gain, obesity, diabetes, cardio vascular disease and possibly shortened life expectancy.  Sudden death has occurred in a few cases where excessive doses and/or multiple drugs were given to very young children.”[9]

The proposal to include Disruptive Mood Disregulation Disorder is in part a reaction to criticisms of the use of anti-psychotics for Juvenile Bipolar Disorder.  The authors of DSM5 are proposing Disruptive Mood Disregulation Disorder as an alternative to the diagnosis of Juvenile Bipolar Disorder, using the rationale that this will help curb anti-psychotic prescribing rates to children.  In effect, they are proposing a “juvenile bipolar light” disorder.

Given the unrestrained enthusiasm for prescribing psychotropics ‘off label’ to children exhibited by many clinicians, particularly paediatricians, the opposite is likely to occur.[10] The inevitable outcome is that more children will be diagnosed and experience tells us the more children diagnosed with a ‘psychiatric disorder’, the more children are subjected to the cheap and convenient practice of speculative ‘off label’ prescribing.

The only sensible course of action for the American Psychiatric Association is to reject out-of-hand the notion of Juvenile Bipolar Disorder or any lighter version thereof including Disruptive Mood Disregulation Disorder.  Failure to do so will drag the American Psychiatric Association into another epidemic of childhood drugging for which, unlike ADHD, they currently bear no responsibility.

[1] For a full description of the proposed diagnostic criteria see http://www.dsm5.org/proposedrevision/pages/proposedrevision.aspx?rid=397

[2] New York Times Topic Page for Professor Joseph Biederman available at http://topics.nytimes.com/topics/reference/timestopics/people/b/joseph_biederman/index.html]

[3] Companies belittled risks of Risperdal, slapped with huge fine, Los Angeles Times 11 April 2012. Michael Muskal available at http://articles.latimes.com/2012/apr/11/nation/la-na-nn-risperdal-arkansas-20120411

[4] New York Times Topic Page for Professor Joseph Biederman available at http://topics.nytimes.com/topics/reference/timestopics/people/b/joseph_biederman/index.html

[5] New York Times Topic Page for Professor Joseph Biederman available at http://topics.nytimes.com/topics/reference/timestopics/people/b/joseph_biederman/index.html

[6] For more detail see http://speedupsitstill.com/world-leading-adhd-%e2%80%98expert%e2%80%99-harvard-professor-joseph-biederman-sanctioned-hidden-drug-company-money-allegations

[7] Dr Allen Frances, Huffington Post, The false epidemic of Childhood Bipolar Disorder available at http://www.huffingtonpost.com/allen-frances/children-bipolar-disorder_b_1213028.html

[8] There are no reliable estimates of child prescribing patient numbers. In the U.S. outpatient office visits for children and adolescents with bipolar disorder increased 40-fold from 20,000 in 1994–95 to 800,000 in 2002–03. http://www.thedailybeast.com/newsweek/2011/06/19/mommy-am-i-really-bipolar.html

[9] Dr Allen Frances, Huffington Post, The false epidemic of Childhood Bipolar Disorder available at http://www.huffingtonpost.com/allen-frances/children-bipolar-disorder_b_1213028.html

[10] A recent study of psychiatrists in Christchurch New Zealand revealed that 96% of them prescribed antipsychotics off label. While it is unlikely that rate is replicated across the globe it is nonetheless an alarming statistic and indicates the practice is very common. M. Slezack, Psychiatry Update, 26 April 2012, 96% of psychiatrists prescribe off-label anti-psychotics  http://www.psychiatryupdate.com.au/latest-news/off-label-anti-psychotics-almost-universally-presc

1- Tends to act without thinking, such as starting tasks without adequate preparation or avoiding reading or listening to instructions. May speak out without considering consequences or make important decisions on the spur of the moment, such as impulsively buying items, suddenly quitting a job, or breaking up with a friend.

2- Is often impatient, as shown by feeling restless when waiting for others and wanting to move faster than others, wanting people to get to the point, speeding while driving, and cutting into traffic to go faster than others.

3- Is uncomfortable doing things slowly and systematically and often rushes through activities or tasks.

4- Finds it difficult to resist temptations or opportunities, even if it means taking risks (A child may grab toys off a store shelf or play with dangerous objects; adults may commit to a relationship after only a brief acquaintance or take a job or enter into a business arrangement without doing due diligence).[2. for full details of the now abandoned DSM5 ADHD proposal refer to http://speedupsitstill.com/dsm-5-proposal-adhd-%e2%80%93-making-lifelong-patients-healthy-people ]

It is good news that these ridiculous additions have been removed along with the extremely worrying proposal to lower the bar for anyone over 16 years so that exhibiting 4 criteria of a subtype instead of 6 could be enough to get a diagnosis of ADHD.  However, the existing 18 diagnostic criteria have been reworded to be equally applicable to adults as well as children, reflecting the ADHD industries persistent and successful efforts to expand the adult market. (The revised proposed criteria are listed at the end of this blog)[3. see http://www.dsm5.org/ProposedRevision/Pages/proposedrevision.aspx?rid=383 ]

Another remaining concern is the proposal for an ADHD category titled Attention Deficit/Hyperactivity Disorder Not Elsewhere Classified must be removed.  This additional category reads: Attention Deficit/Hyperactivity Disorder (ADHD) Not Elsewhere Classified may be coded in cases in which the individuals are below threshold for ADHD or for whom there is insufficient opportunity to verify all criteria. However, ADHD-related symptoms should be associated with impairment, and they are not better explained by any other mental disorder.[4. see http://www.dsm5.org/ProposedRevision/Pages/proposedrevision.aspx?rid=102] The inclusion of this additional category effectively enables clinicians to diagnose and prescribe without even the flimsy protection offered by the already extremely broad DSM4 diagnostic criteria. It cannot be allowed to stand unchallenged.

While the back-downs from the original DSM5 proposals for Psychosis Risk, ADHD and a number of other dubious disorders are welcome they do not begin to go far enough.  Continued pressure through protest and common-sense advocacy must be brought to bear on the American Psychiatric Association (APA).

The APA only responded after significant past users of the DSM, including the British Psychological Association and chapters of the American Psychological Association threatened a boycott of DSM5.[5. refer to http://speedupsitstill.com/sign-on-line-petition-proposed-dsm5 and http://speedupsitstill.com/dr-allen-frances-lead-author-dsmiv-british-psychological-association-lead-chorus-opposition-disease-mongering-proposals-dsm5] This demonstrates that the APA’s DSM development process is driven by politics and money, rather than science and patient welfare. If their proposals were scientifically robust they would have defended them rather than compromising when the going got tough.

The resistance of DSM5 must continue.  Ideally Australia should reject the permanent disability model of mental health embedded in the DSM and develop a model of treating mental illness designed to enhance individual resilience and assist the natural capacity of most mentally ill people to make a full recovery.

Continuing to follow the APA’s lead, will unnecessarily doom many more Australians to a vicious cycle of difficult personal circumstances, behavioural difficulties, dumbed down labelling, inappropriate prescribing and further prescribing to manage adverse side effects.

Nonetheless yesterday’s back-downs are a welcome first step in the right direction.  More than any other individual former DSMIV chairperson, Doctor Allen Frances, deserves credit for leading the ongoing fight against the excesses of DSM5. Doctor Frances’ blog which deals with progress made and the need for continued advocacy is copied below.[6. The original is available at http://www.psychologytoday.com/blog/dsm5-in-distress/201205/wonderful-news-dsm-5-finally-begins-its-belated-and-necessary-retreat ]

Hear Martin Whitely interviewed on Brisbane Radio 4BC about the backdown on ADHD for the proposed DSM5 at http://www.4bc.com.au/blogs/4bc-blog/adhd-and-its-psychosis-listing/20120524-1z6rg.html

Hear the ABC World Today Program interview Patrick McGorry and Martin Whitely regarding the DSM5 Psychosis Risk Disorder backdown at http://www.abc.net.au/worldtoday/content/2012/s3511017.htm

Wonderful News: DSM 5 Finally Begins Its Belated and Necessary Retreat

Perhaps this will be the beginning of real reform.

Published on May 2, 2012 by Allen J. Frances, M.D. in DSM5 in Distress

Sigh of relief. The DSM 5 website announced this morning that two of its most controversial proposals have finally been dropped. We have dodged bullets on Psychosis Risk and Mixed Anxiety Depression. Both are now definitively rejected as official DSM 5 diagnoses and instead are being exiled to the appendix. And one other piece of good news; the criteria set for Attention Deficit/Hyperactivity Disorder has been tightened (not enough, but every little bit helps).

The world is a safer place now that ‘Psychosis Risk’ will not be in DSM 5. Its rejection saves our kids from the risk of unnecessary exposure to antipsychotic drugs (with their side effects of obesity, diabetes, cardiovascular problems, and shortened life expectancy). ‘Psychosis Risk’ was the single worst DSM 5 proposal—we should all be grateful that DSM 5 has finally come to its senses in dropping it.

For the first time in its history, DSM 5 has shown some flexibility and capacity to correct itself. Hopefully, this is just the beginning of what will turn out to be a number of other necessary DSM 5 retreats. Today’s revisions should be just the first step in a systematic program of reform—a prelude to all the other changes needed before DSM 5 can become a safe and scientifically sound document.

The turnabout here can be attributed to the combination of: 1) extensive criticism from experts in the field; 2) public outrage; 3) uniformly negative press coverage and; 4) the abysmal results in DSM 5 field testing. The same factors working together should deep six many of the other risky DSM 5 proposals. This is certainly no time for complacency. Much of the rest of DSM 5 is still a mess. The reliabilities achieved for many of the other disorders are apparently unbelievably low and the writing of the criteria sets is still unacceptably imprecise. The following specific questions need to be answered.

1) Why introduce Disruptive Mood Dysregulation Disorder when it has been studied by only one research team for only six years and risks further encouraging the inappropriate use of antipsychotic drugs for kids with temper tantrums?

2) Why have a diagnosis for Minor Neurocognitive Disorder that will unnecessarily frighten many people who have no more than the memory problems of old age?

3) Why insist on removing the Bereavement exclusion—thus allowing the inappropriate diagnosis of Major Depressive Disorder in people who are experiencing normal grief?

4) Why open the floodgates to even more over-diagnosis and over-medication of Attention Deficit Disorder (by raising the allowed age of onset to 12)?

5) Why dramatically lower the threshold for Generalized Anxiety Disorder when this will confound mental disorder with the anxiety and sadness of everyday life?

6) Why combine substance abuse with substance dependence under the rubric of Addictive Disorders—when this confuses their different treatment needs and creates unnecessary stigma for many young people who will never go on to ‘addiction’?

7) Why include a category for Behavioral Addictions that will open the door to the mislabelling as mental disorder all sorts of normal interests and passions? The DSM 5 suggestion to include ‘internet addiction’ in the Appendix is an ominous first step.

8) Why include wording in the Pedophilia criteria set that will invite further forensic abuse of the already much misused Paraphilia section?

9) Why label as mental disorder the experience of indulging in one binge eating episode a week for three months?

10) Why introduce a system of personality diagnosis so complicated it will never be used and will give dimensional diagnosis an undeserved bad name?

11) Why not delay publication of DSM 5 to allow enough time to complete the previously planned and crucial second stage of field testing that was abruptly cancelled because of the constant administrative delays in completing the first stage? This is the only way to guarantee acceptable reliability. We should not accept ambiguously worded DSM 5 diagnoses whose reliability barely exceeds chance?

12) And most fundamental. Why not allow for an independent scientific review of all the remaining controversial DSM 5 changes. This has been proposed by fifty-one mental health organizations as the only way to guarantee a credible DSM 5?

The public has 6 weeks to comment on the current DSM 5 suggestions. Then there will be a round of final decisions- with everything probably sewn up by mid-fall. This opening chink in the previously impervious DSM 5 armour should spur renewed efforts to get the rest of DSM 5 right.

For more on the latest revisions of the DSM 5 criteria sets, see here.

Take this last opportunity to be heard.

To comment directly to the American Psychiatric Association on their proposals click on http://www.dsm5.org/Pages/Registration.aspx

Related Media

Psychiatry Manual Drafters Back Down on Diagnoses by BENEDICT CAREY in New York Times 8 May 2012

Sue Dunlevy, Medical ‘Bible’ Squabble, The Weekend Australian, 19 May 2012 available at http://www.theaustralian.com.au/news/health-science/medical-bible-squabble/story-e6frg8y6-1226359242372

Below are the (revised) proposed DSM5 diagnostic criteria for ADHD

(see http://www.dsm5.org/ProposedRevision/Pages/proposedrevision.aspx?rid=383 )

AD/HD consists of a pattern of behavior that is present in multiple settings where it gives rise to social, educational or work performance difficulties.

A. Either (A1) and/or (A2).

A1. Inattention: Six (or more) of the following symptoms have persisted for at least 6 months to a degree that is inconsistent with developmental level and that impact directly on social and academic/occupational activities.

a.   Often fails to give close attention to details or makes careless mistakes in schoolwork, at work, or during other activities (e.g., overlooks or misses details, work is inaccurate).

b.   Often has difficulty sustaining attention in tasks or play activities (e.g., has difficulty remaining focused during lectures, conversations, or reading lengthy writings).

c.   Often does not seem to listen when spoken to directly (e.g., mind seems elsewhere, even in the absence of any obvious distraction).

d.   Often does not follow through on instructions and fails to finish schoolwork, chores, or duties in the workplace (e.g., starts tasks but quickly loses focus and is easily sidetracked;  fails to finish schoolwork, household chores, or tasks in the workplace).

e.   Often has difficulty organizing tasks and activities (e.g., difficulty managing sequential tasks; difficulty keeping materials and belongings in order; messy, disorganized, work; poor time management; tends to fail to meet deadlines).

f.    Often avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort (e.g., schoolwork or homework; for older adolescents and adults, preparing reports, completing forms, or reviewing lengthy papers).

g.   Often loses things necessary for tasks or activities (e.g., school materials, pencils, books, tools, wallets, keys, paperwork, eyeglasses, or mobile telephones).

h.   Is often easily distracted by extraneous stimuli (for older adolescents and adults, may include unrelated thoughts).

i.    Is often forgetful in daily activities (e.g., chores, running errands; for older adolescents and adults, returning calls, paying bills, keeping appointments).

A2. Hyperactivity and Impulsivity: Six (or more) of the following symptoms have persisted for at least 6 months to a degree that is inconsistent with developmental level and that impact directly on social and academic/occupational activities.

a.   Often fidgets with or taps hands or feet or squirms in seat.

b.   Often leaves seat in situations when remaining seated is expected (e.g., leaves his or her place in the classroom, office or other workplace, or in other situations that require remaining seated).

c.   Often runs about or climbs in situations where it is inappropriate. (In adolescents or adults, may be limited to feeling restless).

d.   Often unable to play or engage in leisure activities quietly. 

e.   Is often “on the go,” acting as if “driven by a motor” (e.g., is unable or uncomfortable being still for an extended time, as in restaurants, meetings, etc; may be experienced by others as being restless and difficult to keep up with).

f.    Often talks excessively.

g.   Often blurts out an answer before a question has been completed (e.g., completes people’s sentences and “jumps the gun” in conversations, cannot wait for next turn in conversation).

h.   Often has difficulty waiting his or her turn (e.g., while waiting in line).

i.    Often interrupts or intrudes on others (e.g., butts into conversations, games, or activities; may start using other people’s things without asking or receiving permission, adolescents or adults may intrude into or take over what others are doing).

B.   Several inattentive or hyperactive-impulsive symptoms were present prior to age 12.

C.   Criteria for the disorder are met in two or more settings (e.g., at home, school or work, with friends or relatives, or in other activities).

D.   There must be clear evidence that the symptoms interfere with or reduce the quality of social, academic, or occupational functioning.

E.   The symptoms do not occur exclusively during the course of schizophrenia or another psychotic disorder and are not better accounted for by another mental disorder (e.g., mood disorder, anxiety disorder, dissociative disorder, or a personality disorder).

 Specify Based on Current Presentation

Combined Presentation: If both Criterion A1 (Inattention) and Criterion A2 (Hyperactivity-Impulsivity) are met for the past 6 months.

Predominantly Inattentive Presentation: If Criterion A1 (Inattention) is met but Criterion A2 (Hyperactivity-Impulsivity) is not met and 3 or more symptoms from Criterion A2 have been present for the past 6 months.

Inattentive Presentation (Restrictive): If Criterion A1 (Inattention) is met but no more than 2 symptoms from Criterion A2 (Hyperactivity-Impulsivity) have been present for the past 6 months.

Predominantly Hyperactive/Impulsive Presentation: If Criterion A2 (Hyperactivity-Impulsivity) is met and Criterion A1 (Inattention) is not met for the past 6 months. 

Coding note: For individuals (especially adolescents and adults) who currently have symptoms with impairment that no longer meet full criteria, “In Partial Remission” should be specified.

In support of the criticisms of the proposed DSM5 changes to ADHD diagnostic criteria that I made in my in my last blog, Dr Frances wrote: ‘We are already in the midst of a false epidemic of ADD. Rates in kids that were 3-5% when DSM IV was published in 1994 have now jumped to 10%. In part this came from changes in DSM IV, but most of the inflation was caused by a marketing blitz to practitioners that accompanied new on-patent drugs amplified by new regulations that also allowed direct to consumer advertising to parents and teachers. In a sensible world, DSM 5 would now offer much tighter criteria for ADD and much clearer advice on the steps needed in its differential diagnosis……. The DSM 5 child and adolescent work group has perversely gone just the other way. It proposes to make an already far too easy diagnosis much looser. How puzzling and troubling.’ (Full blog by Dr Frances available at http://www.psychologytoday.com/blog/dsm5-in-distress/201108/dsm-5-will-further-inflate-the-add-bubble )

He had previously (February 2010) raised concerns about the DSM5 proposal for ADHD along with 18 other DSM5 proposals including; Psychosis Risk Syndrome, Mixed Anxiety Depressive Disorder, Minor Neurocognitive Disorder, Binge Eating Disorder, Temper Dysfunctional Disorder, Paraphilic Coercive Disorder, Hypersexuality Disorder, Behavioral Addiction Conditions, Addiction Disorder, Autism Spectrum Disorder, Pedohebephilia and medicalising normal grief. (see http://www.psychiatrictimes.com/dsm/content/article/10168/1522341 )

Dr Frances comments can’t be dismissed as the architect of the old edition protecting his work from revision. While criticising the proposals in DSM5, Dr Frances has identified that the DSMIV process he lead 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.’[1. 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).] Of course Dr 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 American Psychiatric Association. However, as the overall leader of the DSMIV development process he has accepted his share of responsibility for the problems DSMIV helped create.

Dr Frances’ criticisms of the draft of DSM5 were recently mirrored by the British Psychological Societies (BPS).[3. The British Psychological Society, ‘Response to the American Psychiatric Association: DSM-5 Development’,  June 2011.  Available at http://psychrights.org/2011/110630BritishPsychologicalAssnResponse2DSM-5.pdf (accessed 15 August 2011)] The BPS responded to an invitation from the American Psychiatric Association to comment on the DSM5 proposals by concluding; ‘The putative diagnoses presented in DSM-V are clearly based largely on social norms, with ‘symptoms’ that all rely on subjective judgements, with little confirmatory physical ‘signs’ or evidence of biological causation. The criteria are not value-free, but rather reflect current normative social expectations. Many researchers have pointed out that psychiatric diagnoses are plagued by problems of reliability, validity, prognostic value, and co-morbidity.’

The BPS and Dr Frances’ criticisms are not calls from the fringes. They are from the very heart of the psychiatric/psychological establishment. They must not be ignored.

This represents significant progress as in 2010 Professor McGorry wrote, ‘The proposal to consider including the concept of the risk syndrome in the forthcoming revision of the DSM classification is innovative and timely.’ He even argued for the recognition of General Distress Syndrome, for those with even less acute, ill-defined symptoms. It is encouraging that he is now ‘ambivalent’ about including Psychosis Risk Syndrome in DSM5. Although I believe it would be much better if he joined his close colleague Professor Alison Yung and his critic Dr Allen Frances in opposing its inclusion.

Of even greater significance is his current position on the use of antipsychotics as a means of preventing first break psychosis. In an email to me received today (16 June 2011) he stated that the use of antipsychotics in those who have never been psychotic should only occur in ‘ethically approved research studies, not in clinical practice’. And he assured me that ‘patients must always be in control of the decisions’ and pointed out that evidence ‘can only come from research’.

I welcome these statements as my key issues have always been; 1- prematurely inventing a new psychiatric disorder (Psychosis Risk Syndrome) and 2- the ‘off label’ use of antipsychotics in young people who have never been psychotic and who by Professor McGorry’s own admission probably never will be (70% to 90% false positive). Professor McGorry and my position are now much closer than they were when our debate began in November 2010. I look forward to meeting him later this month and hopefully finding more common ground.  

For more  information see http://speedupsitstill.com/extra-eppic-headspace-funding-federal-budget-quick-fix-political-problem-evidence 

0r for more on the ongoing debate see http://theconversation.edu.au/early-intervention-for-psychosis-not-just-popping-pills-1859

Update (22/7/2011) – I had a constructive meeting with Professor McGorry in late June. He confirmed the positions outlined above. We are working cooperatively on many of the unresolved issues I have identified in previous blogs. These include 1- the off label prescribing of SSRI Antidepressants to young people at Headspace, EPPIC and Orygen and 2- mechanisms for ensuring clinical consistencyacross all these services and 3- the merits of continued experimentation with antipsychotics as a means of preventing psychosis.

Mental Health was a centrepiece of the federal budget, with an additional $2.2 billion being identified over five years for mental health initiatives, of which $419.7 million was split between the Early Psychosis Prevention and Intervention Centre (EPPIC), and Headspace.^[1] An additional $2.2 billion for mental health is a good thing and to the extent that people such as Professor Patrick McGorry, Professor Ian Hickie and Professor John Mendoza, have contributed to putting mental health on the agenda, they deserve praise. However, I am concerned that the devil is in the detail. My criticism is not about extra funding but about the lack of an evidence base for the decisions that have been made.

Politics not science drove the Gillard Government’s mental health response.

I suggest that this response was a political response to a political problem, not a public policy response based on thorough analysis of the evidence. I criticise not only the Gillard government but also the Abbott opposition, the independents and, indeed, the media. They have all allowed the mental health debate to be dominated by a tiny group—Patrick McGorry, Ian Hickie and John Mendoza.

I am not suggesting that those people do not have valuable contributions to make. However, I am saying that they are not the independent mental health spokespersons that they are portrayed to be in the media; they are players with vested interests.^[2] That has been missed by the media, the opposition, the federal government and even the independents in federal Parliament. Those three gentlemen are fantastic advocates and great political lobbyists, but I am not convinced that they have been asked enough tough questions about the programs they advocate for and control—particularly EPPIC and Headspace. I am concerned about the potential for off-label prescribing in expanded EPPIC and Headspace services, and the potential for this to do enormous harm to young people in Australia.

Before I talk about that, I will talk about the political process involved and highlight how unusual it was. The Minister for Mental Health and Ageing has the National Advisory Council on Mental Health to give him advice on strategic directions for mental health. The Minister for Mental Health and Ageing took the extraordinary step of sidelining the National Advisory Council and set up the Mental Health Expert Working Group.^[3] Three members of that group—Professor McGorry, Professor Ian Hickie and Monsignor David Cappo—left that group and produced their own $3.5 billion five-year blueprint for mental health under the banner of the Independent Mental Health Reform Group.^[4] It is interesting that both Professors McGorry and Hickie have extensive and longstanding commercial ties to the pharmaceutical industry, so I have some questions about the use of the term “independent”.

Extra EPPIC and Headspace funding may see increased ‘off label’ prescribing of SSRI Antidepressants to young people and more youth suicides.

The blueprint they came up with identified $226 million for Headspace, which ended up getting $197.3 million and $910 million for Early Psychosis Prevention and Intervention Centres, which received $222.4 million. The EPPIC funding is supposed to be matched by state governments. I suggest that state governments need to have a good think about whether they do that.

I am very concerned that we will see through Headspace and EPPIC an increase in the off-label prescription of selective serotonin reuptake inhibitor (SSRI) antidepressants, despite the clinical trial evidence that is accepted by the Therapeutic Goods Administration and the US Food and Drug Administration that using SSRI antidepressants leads to a significant increase in the prospects of young people under the age of 24 years being suicidal—an increase of 80 per cent. Regardless both Headspace and EPPIC advocate the use of SSRI antidepressants for all young people with moderate to severe depression.^[5]

This document titled, “Using SSRI Antidepressants to Treat Depression in Young People: What are the Issues and What is the Evidence?”^[6] was produced by Headspace in 2009 and has five authors, including Patrick McGorry. It concludes by stating —In cases of moderate to severe depression, SSRI medication may be considered within the context of comprehensive management of the patient, which includes regular careful monitoring for the emergence of suicidal ideation or behaviour.

Yet the body of the paper builds a compelling case for not using SSRI antidepressants. It acknowledges that the only SSRI that has positive outcomes in clinical trials is fluoxetine and that even those benefits seem to disappear the longer one looks at the evidence. The paper also highlights the fact that clinical trials indicate that compared to taking a placebo, SSRI antidepressants increase the probability of a young person being suicidal by 80 per cent.

One has to bear this in mind against the political process that was used to sell the need for expansions of Headspace services. It was done against the background of candlelight vigils that were coordinated through Get Up! to highlight concerns about youth suicide and create momentum for increased funding to youth-oriented mental health services. However, the very services that the federal government is funding prescribe against TGA and FDA recommendations and against the (suicidal behaviour) black box warnings that exist for SSRI antidepressants.

Therefore I am very concerned that if this issue of SSRI antidepressant ‘off label’ prescribing is not addressed at both Headspace and EPPIC, we may see an increase in the number of candles at the next vigil.

Patrick McGorry on EPPIC – Contradictory and Confusing

My concerns about EPPIC are less straightforward. EPPIC is very much Professor McGorry’s baby and is based on the principle that early intervention can prevent later psychosis—the philosophy that a stitch in time saves nine. I support the philosophy of early intervention. Members who have listened to my speeches in the past will be bleeding from the ears hearing me plead for the need for early intervention so that we can identify kids’ real health, education and social needs. My concern is not that we do not need early intervention but what that early intervention will be.

At my invitation, Professor McGorry replied to my latest blog. We also had an exchange on The World Today program on ABC radio on 12 May in which I outlined my concerns, and on 20 May Professor McGorry responded. As I said, we are halfway through what I believe is going to be a constructive and cordial exchange. (we are meeting in late June)

However, I want to put on record my prime issue so there is absolutely no ambiguity about it. What we need from Professor McGorry, on behalf of EPPIC, is a very clear unambiguous statement about the circumstances under which antipsychotics will be prescribed at EPPIC, and we need a very clear statement about the future of Psychosis Risk Syndrome. I will not beat around the bush. To date, what Professor McGorry has said and written is confusing for those who follow it closely. It is confusing for one very clear reason: he has contradicted himself too often.

Specifically, I want to begin with the issue of psychosis risk syndrome, otherwise known as attenuated psychotic syndrome. Dr Allen Frances, the psychiatrist who led the redevelopment of DSM­IV, the bible of psychiatry, had some very unflattering things to say about psychosis risk syndrome. He said —“Psychosis Risk Syndrome” stands out as the most ill-conceived and potentially harmful …(Of all the proposals for insertion into DSM­5) — The whole concept of early intervention rests on three fundamental [flawed] pillars … 1) it would misidentify many teenagers who are not really at risk for psychosis; 2) the treatment they would most often receive (atypical antipsychotic medication) has no proven efficacy; but, 3) it does have definite dangerous complications.” ^[7] They are the words of the man who led the redevelopment of DSM­IV. These are not the words of someone at the fringe of psychiatry. These are words from the very heart of psychiatry.

When I was on The World Today on 12 May I said that Professor McGorry is a leading international proponent of Psychosis Risk Syndrome a new psychiatric disorder for inclusion in the next edition of DSM­5. On the long version of the audio version on The World Today website, Professor McGorry said — Contrary to Mr Whitely’s statements, I haven’t been pushing for it —(That is, psychosis risk syndrome) — to be included in DSM­5. Now that hasn’t been my position…But it’s a new area of work. It’s only been studied for the last 15 years or so, so you know we haven’t got all the answers … I’m certainly not saying that it should go into DSM­5.^[8]

So on two occasions in that interview he said that he was not advocating it should go into DSM­5. That is just plain wrong. I have an article that was published in Psychiatry update a year ago entitled “DSM­V ‘risk syndrome’: a good start, should go further”. ^[9] It begins by stating — The proposal for DSM­V to include a ‘risk syndrome’ reflecting an increased likelihood of mental illness is welcome but does not go far enough, according to Orygen Youth Health’s director Professor Patrick McGorry.

That is somebody else paraphrasing his words, so I went to the original source document, which is an article available in the Science Digest under “Schizophrenia Research”.^[10] It is written by Professor McGorry and the opening sentence states — The proposal to consider including the concept of the risk syndrome in the forthcoming revision of the DSM classification is innovative and timely. It has not come out of left field, however, and is based upon a series of conceptual and empirical foundations built over the past 15 years.

That is absolutely clear-cut. I could build a case in greater detail but Professor McGorry has clearly advocated the inclusion of psychosis risk syndrome, otherwise known as attenuated psychosis syndrome in DSM­5. (Note; Far from rejecting the notion of Psychosis Risk Syndrome McGorry argues for the recognition of yet another disorder, General Distress Syndrome, for those with even less acute, ill-defined symptoms ).^[11]

In the same interview, Professor McGorry said — Medication should never be the first line of treatment in young people, we should always try to find psychological and simpler ways of treating youth mental health issues, that is where I agree with him (Martin Whitely) but where I part company is where he tried to I suppose confuse the issue by, I suppose, denying any value to these medications. They clearly do have value, the anti-psychotic medications, in people with clear­cut psychosis.

I have never been critical of the on-label prescription of antipsychotics to people who have had a psychotic break. Professor McGorry is quite wrong in characterising me as saying that. But that is not of any great consequence because, after all, it just relates to me being misrepresented.

Another misrepresentation is of greater consequence because he contadicted EPPIC’s position when he said that — Medication should never be the first line of treatment in young people, we should always try to find psychological and simpler ways of treating people with youth mental health issues. EPPIC guidelines (at least in regard to the use of antidepressants in young people) clearly identified that all those presenting with a depressive episode of at least moderate severity should be commenced on an antidepressant.^[12] It does not even narrow it down to Fluoxetine, the one selective serotonin reuptake inhibitor identified as having some positive effects. It just says “antidepressant”.

That is not the only misrepresentation. Professor McGorry also claimed, in response to my blog^[13], that EPPIC followed the beyondblue guidelines with regard to the use of SSRI’s. That is not true. The beyondblue guidelines are far more cautious in its recommendations about the use of SSRIs or antidepressants.^[14] Professor McGorry is simply wrong to say that EPPIC follows the Beyondblue guidelines for the use of antidepressants.

I have a number of other concerns. (Especially the EPPIC guideline that states ‘All individuals with an ‘at risk’ mental state, e.g. siblings of  EPPIC clients, will be referred to PACE clinic for assessment. ^[15]) Unfortunately, I will run out of time but a major concern is with the use of antipsychotics in non-­psychotic teenagers by EPPIC. EPPIC’s target audience is young people between the ages of 15 to 24 years. Professor McGorry and EPPIC have to answer the following very simple question: under what circumstances, if any, will EPPIC either recommend or prescribe antipsychotics to patients who have not experienced psychosis?

EPPIC and Professor McGorry need to make their position clear because at the moment it is not clear. I mistakenly thought it was made clear in a previous blog that I had written when a spokesperson for Professor McGorry, Matthew Hamilton, made some quite promising statements that indicated that they were no longer proposing the use of antipsychotics for psychosis risk syndrome.^[16] Since then, we have seen some ambiguous and contradictory statements by Professor McGorry that have left that door open.^[17] We need to have a very clear answer from Professor McGorry on behalf of EPPIC as to when, if ever, antipsychotics will be used by those who have never been psychotic.

Clarrity at least is required, but in my opinion EPPIC and Headspace need to abandon prescribing antidepressants altogether to under 18’s and rule out the use of antipsychotics in non-psychotic young people. If they stick to ‘on label’ prescribing, we can be confident that the extra $419.7 M for EPPIC and Headspace will do more good than harm. This requires a change from experimental, hypothesis based, psychiatry to an evidence based, ‘first do no harm’ mindset.

Update – Some progress has been made on the issues identified above see http://speedupsitstill.com/australian-16-june-2011

Coming Blogs – Mental health screening for three year olds and the budget cuts to psychology services: Are these a recipe for more dumbed down, psychiatric labelling and prescribing?

I ran out of time in the speech to outline all of my concerns with the mental health response in the 20011/12 federal budget. I am alarmed at the proposals for mental health screening of three year olds and despair at the cuts to support for psychological services, in order to fund GP mental health visits. Both of these measures have the potential to further promote the increasingly dominant dumbed down, ‘label and prescribe’ approach to mental health, however these are topics for another speech and blog.

Related Media

Minds at Risk: Choosing the Right Path for Adolescent Mental Health, Lisa Pryor, The Monthly July 2011 http://www.themonthly.com.au/choosing-right-path-adolescent-mental-health-minds-risk-lisa-pryor-3470

[2] Professor McGorry was the former President and is the current Treasurer (http://www.iepa.org.au/ContentPage.aspx?pageID=40) of the “International Early Psychosis Association” which is funded by antipsychotic manufacturers Astra Zeneca, Lilly and Janssen-Cilag (http://www.iepa.org.au/2010/) McGorry is currently Director of Clinical Services at Orygen Youth Health Clinical Program and Executive Director of the Orygen Youth Health Research Centre. Orygen Youth Health receives support from AstraZeneca, Bristol Myer Squibb, Eli Lilly, and Janssen-Cilag. Orygen Youth Health, Research Centre – Other Funding http://rc.oyh.org.au/ResearchCentreStructure/otherfunding (accessed 3 August 2010) McGorry individually has received unrestricted grants from Janssen-Cilag, Eli Lilly, Bristol Myer Squibb, Astra-Zeneca, Pfizer, and Novartis and has acted as a paid consultant or speaker for most of these companies McGorry P.D. ‘Is early intervention in the major psychiatric disorders justified? Yes’, BMJ 2008;337:a695 http://www.bmj.com/cgi/content/full/337/aug04_1/a695 (accessed 3 August 2010)

Professor Hickie and colleagues created the ‘SPHERE: A National Depression Project’ (http://sydney.edu.au/bmri/about/Hickie_CV.pdf). As was reported in The Australian Pfizer work in conjunction with SPHERE through a company called Lifeblood who are paid to review SPHERE. Through the use of SPHERE Pfizer have restored Zoloft to the number one antidepressant in Australia. (http://www.theaustralian.com.au/news/health-science/gp-jaunts-boosted-drug-sales/story-e6frg8y6-1225890003658). Professor Hickey received the following grants totalling $411,00 from pharmaceutical companies: $10,000 from Roche Pharmaceuticals (1992); $30,000 from Bristol-Myers Squibb (1997); $40,000 from Bristol-Myers Squibb (1998-1999); $250,000 from Pfizer Australia (2009); $81,000 from Pfizer Australia (n.d.) Cited in Ian Hickie, Curriculum Vitae, last updated 23 August 2009 http://sydney.edu.au/bmri/about/Hickie_CV.pdf   (accessed 3 August 2010)

Professor Mendoza was co-author of the “Not for Service” report which was issued in 2005.  Apart from the Commonwealth Govt, the report was funded by unrestricted grants from AstraZeneca, Bristol-Myers Squibb, Eli Lilly Australia, GlaxoSmithKline, Medicines Australia, Pfizer Australia and Wyeth. (Not For Service: Experiences of Injustice and Despair in Mental Health Care in Australia, Mental Health Council of Australia, Canberra, 2005 http://www.hreoc.gov.au/disability_rights/notforservice/documents/NFS_Finaldoc.pdf (3 August 2010)). He is also a principle of ConNetica Consulting Pty Ltd, whilst they have very broad purposes such as providing a review, survey and planning service to government and not for profit organizations, including those involved in mental health. It currently lists Eli Lilly as one of its private sector clients (ConNetica Consulting, About Us http://connetica.com.au/about_us (accessed 3 August 2010))

[3] Advisory Group to Guide Mental Health Reforms (23 December 2010), Pro Bono News Advisory Group to Guide Mental Health Reforms (accessed 26 April 2011)

[4] Including, Connecting, Contributing: A Blueprint to Transform Mental Health and Social Participation in Australia, March 2011. Prepared by the Independent Mental Health Reform Group: Monsignor David Cappo, Professor Patrick McGorry, Professor Ian Hickie, Sebastian Rosenberg, John Moran, Matthew Hamilton A Blueprint to Transform Mental Health and Social Participation in Australia (accessed 26 April 2011)

[5] Hammad T.A. (16 August 2004). Review and evaluation of clinical data. Relationship between psychiatric drugs and pediatric suicidal behavior, Food and Drug Administration. pp. 42; 115. FDA Review and evaluation of clinical data (accessed 29 May 2008)

[6] Evidence Summary: Using SSRI Antidepressants to Treat Depression in Young People: What are the Issues and What is the Evidence? Headspace, Evidence Summary Writers Dr Sarah Hetrick, Dr Rosemary Purcell, Clinical Consultants Prof Patrick McGorry, Prof Alison Yung, Dr Andrew Chanen  Headspace Evidence Summary (accessed 28 May 2011)

[7] Frances, A. (2010) DSM5 ‘Psychosis risk syndrome’—Far too risky, Psychology Today Psychosis risk syndrome—Far too risky

[8] 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)

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

[10] 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

[11] See  http://speedupsitstill.com/patrick-mcgorry-early-intervention-psychosis-stitch-time-stitch-up

[12] EPPIC guidelines state that all clients experiencing ‘a depressive episode of at least moderate severity should be commenced on an antidepressant.’ http://www.eppic.org.au/eppic-clinical-guidelines (accessed 28 May 2011)

[13] 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#more-1530

[14] In comparison to the EPPIC Guidelines which say that all clients experiencing ‘a depressive episode of at least moderate severity should be commenced on an antidepressant.’ the beyondblue clinical practice guidelines (page 55) state: ‘If symptoms are severe, or if symptoms are moderate to severe and psychological therapy has not been effective, is not available or is refused, prescription of the selective serotonin reuptake inhibitor (SSRI) antidepressant fluoxetine should be considered for reducing depression symptoms in the short term.’ http://beyondblue.org.au/index.aspx?link_id=6.1247 accessed 28 May 2011

[15] http://www.eppic.org.au/eppic-clinical-guidelines (accessed 28 May 2011)

[16] See http://speedupsitstill.com/patrick-mcgorry-reverses-support-psychosis-risk-syndrome-drugging

[17] In December 2010 Professor McGorry wrote ‘Antipsychotic medications should not be considered unless there is a clear-cut and sustained progression to frank psychotic disorder meeting full DSM 4 criteria.’ He then immediately invalidated this statement by writing, ‘The only exception to the previous statement is where there has been a definite failure to respond to the first and second line interventions described above AND there is worsening and continuing disability, or significant risk of self-harm, suicide or harm to others arising directly from the mental disorder itself and its symptoms. In this situation, a trial of low dose antipsychotic medication for 6 weeks in the first instance may be appropriate, with careful monitoring for adverse events.’ The term mental disorder itself is interesting as he is referring Psychosis Risk Syndrome which is not officially recognised as a legitimate psychiatric disorder and hopefully never will be. See http://speedupsitstill.com/reply-patrick-mcgorry-early-intervention-psychosis#more-1075