“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)

Response to the ‘Is Nick Sick?’ video blog

by Professor Jon Jureidini

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

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

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

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

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

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

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

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

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

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

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

Related Media

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

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

Associate Professor Alison Yung.:

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

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

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

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

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

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

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

INTERVIEW 1.

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

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

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

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

Nick: No.

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

Nick: No.

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

Nick: No, not not really.

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

Nick: No.

Interviewer: No?

Nick: No.

Interviewer:  People been trying to give you any messages?

Nick: No.

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

Nick: No, not like that.

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

Nick: No.

Interviewer: No?

Nick: No.

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

Nick: No.

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

Nick: No, that’s never really happened.

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

Nick: No.

Interviewer: No?

Nick: No.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Nick: Hmm, yeah.

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

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

Interviewer: During that time-

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

Interviewer: Two days..

Nic: That happened twice. Yeah.

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

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

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

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

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

Nick: Yeah.

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

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

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

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

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

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

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

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

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

Nick: No.

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

Nick: No.

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

Nick: No. No.

Interviewer: With these things? Okay, fine.

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

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

Nick: Ahh, no, not really.

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

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

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

Nick: Yeah

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

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

Interviewer: So glasses have improved your vision?

Nick: Yeah. Yeah.

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

Nick: No

Interviewer: The colours brighter?

Nick: No, no that’s all the same

Interviewer: Anything like that

Nick: Yeah

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

Nick: No.

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

Nick: No. No.

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

Nick: No.

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

Nick: No.

Interviewer: Anything like that?

Nick: No. No.

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

Nick: Yeah.

Interviewer: to get your message across?

Nick: Yeah, never really had problems with that.

Interviewer: Uhuh.

Nick: No.

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

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

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

Nick: No.

Interviewer: No?

Nick: No.

Interviewer: Okay.

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

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

Nick: No.

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

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

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

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

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

Nick: Yeah.

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

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

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

UNUSUAL THOUGHT CONTENT – GLOBAL RATING SCALE

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

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

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

Frequency and Duration

Pattern of Symptoms

Level of Distress (In Relation to Symptoms)

Not At All Distressed                                                                                                                  Extremely Distressed

Perceptual Abnormalities – Global Rating Scale

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

Disorganised Speech – Global Rating Scale

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

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

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

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

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

[3] Professor McGorry wrote “the false positive rate (for UHR) may exceed 50-60%” McGorry P.D. ‘Is early intervention in the major psychiatric disorders justified? Yes’, BMJ 2008;337:a695 http://www.bmj.com/cgi/content/full/337/aug04_1/a695 (accessed 3 August 2010) Professor McGorry’s close colleague Alison Yung identified the conversion rate from UHR to first episode psychosis was 36% in an article in the Medical Journal of Australia titled Is it appropriate to treat people at high-risk of psychosis before first onset — Yes Available at https://www.mja.com.au/journal/2012/196/9/it-appropriate-treat-people-high-risk-psychosis-first-onset-yes

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

It is also, for the first time, an open process. We know from the start who is developing the guidelines and the details of their conflict of interest declaration. (see http://www.nhmrc.gov.au/guidelines/adhd-conflicts-interest ) Gillard Government Mental Health Minister Mark Butler deserves credit for this. Let us hope this creates a precedent for future commonwealth government medical guidelines and advisory committee processes.

Rescinded 2009 draft Guidelines

The new guidelines, due for release in October, will supersede the flawed draft ADHD guidelines developed by the Royal Australian College of Physicians (RACP) at a cost of $135,000. The RACP process begun in 2007 and was dominated by ADHD prescribing enthusiasts and dogged conflict of interest controversies. In November 2009 the commissioning body, the National Health and Medical Research Council (NHMRC), decided that because of the then uncompleted investigation into undisclosed drug company payments to three prominent US researchers, whose work was heavily relied on in the draft guidelines, the process should be halted. [1. NHMRC, ‘Draft Australian Guidelines on ADHD – NHMRC consideration deferred pending outcome of USA investigation’, NHMRC Noticeboard 2009. Available at http://www.nhmrc.gov.au/media/noticeboard/notice09/091130-adhd.htm (accessed 5 January 2010).]  On 2 July 2011 the Boston Globe reported that Harvard Professor’s Biederman, Spencer and Wilens, who were referenced 82, 46 and 32 times respectively in the draft guidelines, had been sanctioned by their employer after investigations into allegations of millions of dollars in hidden pharmaceutical company payments were completed. The most high profile of the three Professor Joseph Biederman is believed to be the worlds’ most frequently quoted researcher supporting the use of psychotropic drugs for ADHD.[2. http://www.esi-topics.com/add/interviews/JosephBiederman.html]

The Biederman (et al) scandal was not the only ‘conflict of interest’ controversy around the Draft National ADHD Guidelines. The guidelines committee was initially chaired by Dr Daryl Efron until his ADHD pharmaceutical company ties were exposed by the Daily Telegraph in April 2007. [3. ADHD guru quits over Ritalin link, Janet Fife-Yeomans, The Daily Telegraph 5 May 2007 http://www.dailytelegraph.com.au/news/sydney-nsw/adhd-guru-quits-over-ritalin-link/story-e6freuzi-1111113472188 ] Freedom of Information processes also revealed the vast majority, at least 70%, but probably 80% ‘of the original (guidelines committee) group members, including doctors, have declared receiving grants and air fares, hotels and overseas trips from companies making drugs to treat the disorder.’ [4. Janet Fife-Yeomans, ‘Guidelines panel linked to drug firms’, The Advertiser, 17 November 2008, Available at http://www.news.com.au/adelaidenow/story/0,22606,24660999-5006301,00.html (accessed 4 October 2009).] (for more detail see http://speedupsitstill.com/gillard-government-continues-turn-blind-eye-drug-company-money)

Flawed 1997 National Guidelines

The 2009 draft guidelines were supposed to replace Australian National ADHD guidelines developed for the NHMRC in 1997. The 1997 guidelines were also developed by clinicians, mostly paediatricians, with ties to the pharmaceutical industry. They encouraged the widespread ‘off label’ prescribing of stimulants and other psychotropic drugs for ‘co-morbid disorders’, without any evidence base except for ‘reasonable theory’ derived from ‘clinical experience’. This helped facilitate the explosion of prescribing rates in the late 1990’s and into the new millennium by providing a justification for reckless, hypothesis-based prescribing by a relatively small number of self-appointed ‘ADHD experts’; primarily paediatricians with limited mental health training.[5. National Health and Medical Research Council, Attention Deficit Hyperactivity Disorder (ADHD), Canberra, 1997, pp. 32-38.]

2011 Committee

In comparison with either the 1997 or 2007 guideline development committees, the 2011 committee is relatively ‘conflict of interest’ free. At last this gives hope for true ‘evidence based – first do no harm’ approach.

The 2011 committee consists of:

Bruce Tonge (Chairperson) – Child and Adolescent Psychiatrist, Head of the Centre for Development Psychiatry at Monash Medical Centre.

Mark Dadds – Professor of Psychology, University of New South Wales.

John Dowden – Director of Therapeutic Guidelines Ltd.

Jon Jureidini – Professor of Psychiatry and Paediatrics, Adelaide University.

Michael Kohn – Paediatrician, Westmead Hospital Sydney.

Nicole Rinehart – Consulting Clinical Psychologist, Associate Professor, School of Psychology & Psychiatry, Monash University.

Margaret Vikingur representing LADS – Volunteer, Learning and Attentional Disorders Society, Perth.

Three others are expected to join the committee:

Vicky Anderson – Paediatric Neuropsychologist, University of Melbourne.

Kim Cornish – Developmental Neuroscientist, School of Psychology and Psychiatry, Monash University.

Professor Helen Milroy – Child and Adolescent Psychiatrist and Professor Aboriginal and Torres Strait Islander Health, University of Western Australia.

While a number of members of the committee have worked with or for pharmaceutical companies, for most these affiliations don’t relate directly to ADHD. However this can’t be said for Sydney’s Westmead Hospital paediatrician, Professor Michael Kohn, and the Perth based pharmaceutical company sponsored Learning and Attentional Disorders Society (LADS) who have a ‘consumer representative’ on the committee. Both Kohn and LADS have significant and direct conflicts of interest and should be excluded from the committee.

Professor Kohn’s quasi-religious faith in Ritalin

Professor Michael Kohn’s 2009 description of an article in Sydney’s Daily Telegraph detailing extreme reactions to ADHD medications reported to the TGA, such as psychotic episodes and suicidal ideation as “BLASPHEMING the use of Ritalin” indicates a near religious fervour for prescribing amphetamines like drugs to children.[7. Medicating our children, Reportage Online, 22 December 2009 http://www.reportageonline.com/2009/12/medicating-our-children/ Kohn’s comment was in response to We’re turning our children psychotic with ADHD medication, Kate Sikora, The Daily Telegraph October 13, 2009. http://www.dailytelegraph.com.au/lifestyle/body-soul/were-turning-our-children-psychotic/story-e6frf01r-1225786025127] This is not an isolated comment from Professor Kohn. (refer Where is the evidence to support ‘ADHD expert’ Prof Kohn’s claim that amphetamines aid brain development? )

Professor Kohn has significant financial connections to ADHD drug manufacturers Eli Lily and Janssen Cilag[7. M. Williams (et al), 2010. An ‘integrative neuroscience’ perspective on ADHD: linking cognition, emotion, brain and genetic measures with implications for clinical support.]  He was a member of Strattera Advisory Board for Elli Lilly and is currently undertaking publicly funded research on Strattera. He has received other financial support from both Janssen Cilag and Eli Lilly and been paid to prepare and deliver educational materials by Janssen Cilag. He has also received research support for ADHD studies from Brain Resource Ltd which has received funding from at least 13 different pharmaceutical companies.

Learning and Attentional Disorders Society (LADS)

LADS is partially funded by drug companies and has a long history of marketing of ADHD as having a biological cause best treated with ‘safe, effective medication’. [8. ‘LADS has accepted limited unrestricted grants from pharmaceutical companies.’ (Including Eli Lilly and Novartis.) See http://www.ladswa.com.au/page.php?id=6 (accessed 26 June 2009).] In 2003, on a Perth community television program Face the Facts, speaking on behalf of LADS, Michelle Toner and psychiatrist Dr Roger Patterson made some noteworthy statements.

Dr Patterson said: Dexamphetamine has the amphetamine name in it and this is what people are starting to worry about because they are giving them to children – or they are taking them themselves…let me dispel that, they are taking a medicinal form of amphetamine…this is not addictive stuff. In fact, I wish it was a little more addictive so that my younger patients would remember to take it rather than having to be reminded by their long-suffering parents.[9. Dr Roger Patterson interviewed on Face the Facts, video recording taken from Channel 31 Perth, 27 January 2003. 25]

Toner’s statements on the same TV program were even more notable. ‘In order to get a high equivalent to what people are taking [as] street speed, you would have to take close to 200 tablets. Children take 1 or 6 tablets a day and it is not addictive at all.’ [6. Michelle Toner interviewed on, Face the Facts, video recording taken from Channel 31 Perth, 27 January 2003. This information is also referred to in Ferguson and Rushworth, ‘ADHD – The Quick Fix’.] Two hundred of the standard 5 milligram dexamphetamine tablets would deliver a dose of 1 gram which would kill most people and a fair proportion of elephants as well. [10. ‘Individual patient response to amphetamines varies widely. While toxic symptoms occasionally occur as an idiosyncrasy at doses as low as 2mg, they are rare with doses of less than 15mg; 30mg can produce severe reactions, yet doses of 400 to 500mg are not necessarily fatal.’ GlaxoSmithKline’s Prescribing Information for Dexedrine (dextroamphetamine sulphate). Available at http://us.gsk.com/products/assets/us_dexedrine.pdf (accessed 26 June 2009).]

Also obviously ignorant of the effects of 1 gram of dexamphetamine, the interviewer went on to ask Toner: ‘Right, but if you do have ADHD and you take the medication, is it successful?’ Toner replied, ‘Oh yes…a lot of people discovered they had ADHD by accident. For example, truckies who needed uppers to keep them awake while they were driving across the Nullarbor suddenly found that they were driving a whole lot better…when they were taking dexies.’ Both Toner and Patterson remain on the professional advisory board of LADS.  [11. http://www.ladswa.com.au/page.php?id=9 ]

LADS have even encouraged the illegal diversion of ADHD amphetamines. In 1998 LADS was warned twice not to recommend the illegal use of a child’s ADHD stimulants by parents if they thought they had adult ADHD.[9. WA Stimulant Committee, Minutes of Meeting held on 4 August, 1998, obtained under Freedom of Information Act 1992] LADS have also publicly endorsed ADHD drugs in press releases prepared by public relations business in order to promote ADHD drugs. [12. Last Say Communications, ADHD – A Day of Calm – Dawn to Dusk: Long Lasting Medication to Provide Relief for Kids with ADHD, Media Release, 27 March 2007.]

LADS’ representative Margaret Vikingur is probably a very well intentioned individual, however, LADS acceptance of drug company money and its history should preclude it from membership of the committee. Failing LADS exclusion a counter-balancing voice from a ‘conflict of interest’ free support group should be included on the committee.

Minister Butler a vast improvement on ‘Roxon’s hypocrisy’ and ‘Do Nothing Abbott’

The above concerns aside, in comparison to the two previous ministers with responsibility for the development of national ADHD guidelines, Nicola Roxon and Tony Abbott, Mental Health Minister Mark Butler has made a good start.

When opposition health spokesperson Roxon called for the public release of conflict of interest declarations but refused to even release the names of guidelines committee members when she became the Health Minister. Her predecessor, Howard Government Health Minister Tony Abbott, was just as bad. He had the opportunity to prevent the problem when the original panel was appointed. He then had an opportunity to fix his original mistake when the conflict of interest issues were first revealed in 2007. Abbott expressed concern and then did next to nothing. (for more detail see http://speedupsitstill.com/gillard-government-continues-turn-blind-eye-drug-company-money )

Minister Butler has delivered an open process and ensured there is a range of views and expertise on the committee. It is hoped that the committee will produce cautious, evidence based, child friendly, rather than drug-company friendly, hypothesis based, guidelines. However it is just the start of the process and only time will tell. I will keep you posted.

Related Media

The Australian – Sue Dunleevy 13 July 2011 Attention deficit disorder guru’s in conflict of interest http://www.theaustralian.com.au/national-affairs/health/attention-deficit-disorder-gurus-in-conflict-of-interest/story-fn59nokw-1226093390142

The Monthly – Gail Bell 2011 The Rush to Diagnose ADHD http://www.themonthly.com.au/rush-diagnose-adhd-prescribing-behaviour-gail-bell-4013

Opinions as to the validity of ‘ADHD’ as a psychiatric disorder vary among the invited participants. Some consider that ‘ADHD’ is a real but rare condition that is mis-diagnosed and over-medicated; others consider ‘ADHD’ a fraud.

However, all participants agree that unnecessarily administering powerful psychotropic drugs to children is a violation of their rights and often results in serious short and long term harm.

Participants are also concerned that:

1. The criteria used to diagnose ‘ADHD’ are all subjectively assessed behaviours and these behaviours, losing things, forgetting, fidgeting, butting in, disliking homework, and playing loudly etc are a ‘normal’ part of childhood.
2. There is nothing ‘ADHD specific’ about the effects of drugs used to treat the ‘disorder’. Although responses vary, most people become temporarily more narrowly focussed and compliant on low dose amphetamines.
3. Drugs do nothing in the long term to address the many and varied causes of ‘ADHD’ type behaviours’.
4. On occasions drugs mask the symptoms of serious conditions (such as abuse or trauma).
5. ‘ADHD’ drugs have well established significant short term risks including cardiovascular and psychiatric problems.
6. ‘ADHD’ stimulants are amphetamines or amphetamine like drugs that are frequently diverted for illicit use.
7. We know little about the long-term effects of ADHD drugs on growing brains. The limited data that exists indicates their long term use provides no long term benefit but may pose significant risks.

Whilst the forum will discuss the important issue of whether ‘ADHD’ is misdiagnosed and overmedicated or a fraud; the major focus will be on developing strategies to reduce the rates of prescribing and supporting appropriate responses that help not harm children.

Those presenting at the Monday Morning (10-1) session include;

Professor Sami Timimi (prominent UK psychiatrist and author)- An International perspective on the science and history of ADHD.

Professor Jon Jureidini (Professor, Disciplines of Psychiatry and Paediatrics, University of Adelaide)- The dangers of non drug treatments for ADHD.

Associate Professor Carolyn Quadrio (Associate Professor in Psychiatry at the University of New South Wales) – Overprescribing to children: a general look at problems with psychotropic medication.

Dr Linda Graham (academic, education researcher, author)– Thinking pedagogically about students ‘with ADHD’.

Dr Bob Jacobs (psychologist and researcher) – ‘ADHD’ as social control:  How lies benefit the powerful at the expense of the powerless (children).

Anthony Dillon (academic and researcher)– On the validity of twin studies used to legitimise the diagnosis of ADHD.

Dr Lois Achimovich (psychiatrist)- A clinician’s reflections on the evolution of psychiatric practice over the last 40 years.

Martin Whitely MLA (politician and author)- On 1- the rise and fall of ADHD child prescribing in WA and 2- long term WA data about the safety and efficacy of stimulants and 3- the Draft National Guidelines for the treatment of ADHD.

When: Monday 7 and Tuesday 8 february 2011

Venue: Health Faculty Queensland University of Technology 44 Musk Avenue Kelvin Grove Brisbane

Events open to Public and Media (all free entry):

Monday 7 Febs 10am – 1pm a series of short presentations followed by an open Q and A.

Tuesday 8 February 7pm to 9pm Public Forum; If not medication then what? (both in Lecture Room Q2.43)

Media Conference: Tuesday 8 February 12 noon (Boardroom Q2.04).

To find out more please email one of the organising committee members listed below.

• Martin Whitely MLA Member of the Legislative Assembly of WA email  [email protected]
• Siyavash Doostkhah Director Youth Affairs Network of Queensland email [email protected]