To casual observers it may appear at last we are on track to a happier, mentally healthier tomorrow, however appearances can be misleading.  The future direction of mental health in Australia is far from certain.

Just about everybody involved in the debate agrees things need to change, but this is where the consensus ends.  There are at least three different directions on offer.  For the want of better descriptions, I will call them the ‘Americanisation’, the ‘Preventative Psychiatry’ and the ‘Recovery’ approaches.

Apart from spiraling mental health prescribing rates the most obvious evidence of the Americanisation of Australia’s mental health system is the dominance of the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM) diagnostic model.  Often referred to as the ‘Bible of Psychiatry’, the current edition, DSM-IV, outlines the diagnostic criteria of 297 psychiatric disorders.

Like the yellow pages, subsequent editions of the DSM have thickened as new disorders have been added.  This expansion has been exploited by aggressive pharmaceutical company marketing, resulting in the ‘medication’ of people who would previously have been regarded as ‘normal’.

With the benefit of hindsight Professor Allen Frances, the Chairman of the Task Force that developed the DSM-IV, regrets aspects of the DSM-IV as having helped to trigger “false epidemics” including “the wild over-diagnosis of attention deficit disorder.”¹

Professor Frances is particularly worried about the next edition, DSM-5, due for publication in 2013.  He contends that further diagnostic expansion driven by the inclusion of pet disorders of enthusiastic researchers will see even more ‘normal’ people made patients and more over-prescribing of psychotropic drugs.

Thankfully there is a significant international revolt, led by Professor Frances, from within the psychiatric and psychological professions, against the further medicalisation of behaviours proposed for DSM-5.  This has already caused the American Psychiatric Association to abandon some of its more controversial DSM-5 proposals including ‘Psychosis Risk Disorder’ and the expansion of the already absurdly broad diagnostic criteria for ADHD.

Australia’s most prominent psychiatrist, former Australian of the Year, Professor Patrick McGorry, has also expressed concern about the over-prescription of psychiatric drugs in the US, however he argues the risks aren’t as great here.²  Unlike the US we don’t allow direct advertising to consumers, however the pharmaceutical industry aggressively market their drugs to the Australian doctors who prescribe them.  They also sponsor medical research, conferences, educational opportunities and even patient support groups that ‘raise awareness’ of the disorders their drugs treat. Australia is far from immune from undue pharmaceutical company influence.

Professor McGorry is arguably the world’s most prominent advocate of Preventative Psychiatry. He believes that prior to the onset of psychosis, depression and other serious mental illness there is a ‘prodromal phase’ and that intervening then will help save many the misery of full blown mental illness.

Critics of Preventative Psychiatry, including Professor Frances, contend it simply doesn’t work. They argue you can’t predict with sufficient accuracy, who will go onto become ill and that even when it is accurate, independent evidence indicates that preventative measures don’t work.

Even Professor McGorry acknowledges that the vast majority of people that are identified as being at Ultra High Risk of developing psychosis, his specialist area, never do.³Nonetheless, he argues the benefits of predictive intervention massively outweigh the risks of doing nothing.

The belief intervention could prevent psychosis was part of the rationale for the Gillard Government’s 2011 decision to allocate $222.4million for the role out of Early Psychosis Prevention Intervention Centres (EPPICs) across Australia.  At the time of the decision it looked very likely that DSM5 would include a ‘Psychosis Risk Disorder’. Now that is not happening, the future of the ‘preventative’ function of EPPICs is uncertain.

Adding to this uncertainty is Preventative Psychiatry’s long and continuing history of unsuccessfully experimenting with psychotropic drugs as a means of ‘immunizing’ people considered at elevated risk of future mental illness.  While EPPICs will provide a broad range of psychosocial services and also treat patients who are already psychotic, significant questions remain unanswered.

The final option, the Recovery approach, centres on developing a patient’s own capabilities and resilience.   As opposed to the ‘ongoing disability’ or ‘impending doom’ assumptions inherent in the Americanisation and  Preventative Psychiatry approaches, the Recovery approach is more optimistic about the capacity for recovery and less reliant on pills.  It supports mentally ill patients with housing, educational, employment and psychosocial support – building blocks for a healthy and happy mind that can’t be replaced by drugs.

While the Recovery approach is more optimistic about human resilience, it is more realistic about the limits of psychiatry than either of the other approaches.  The Americanisation approach is based on the unrealistic assumption that psychiatric science can accurately identify at least 297 different disorders, and the Preventative Psychiatry approach on the fanciful notion that mental illness can be reliably spotted before it happens.

Unfortunately a significant disadvantage for the Recovery approach is that it offers a pessimistic outlook for the profitability of pharmaceutical companies.  If history is any predictor of the future this could prove to be its’ fatal flaw.

Related Media

The above was originally printed as an opinion piece in the West Australian Newspaper Wednesday 13 June 2012 available at http://au.news.yahoo.com/thewest/opinion/post/-/blog/13939119/mental-health-needs-rethink/

In addition most of the dangerous changes proposed for the already absurdly broad ADHD diagnostic criteria have been abandoned.  An additional four alternative ADHD criteria had been identified for inclusion in the DSM5. They were:

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

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

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 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 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

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.