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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

 References

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

[20] Evidence Summary: Using SSRI Antidepressants to Treat Depression in Young People: What are the Issues and What is the Evidence? Headspace, Evidence Summary Writers Dr Sarah Hetrick, Dr Rosemary Purcell, Clinical Consultants Prof Patrick McGorry, Prof Alison Yung, Dr Andrew Chanen http://www.headspace.org.au/core/Handlers/MediaHandler.ashx?mediaId=4896 (accessed 26 April 2011) ↩

[21] Evidence Summary: Using SSRI Antidepressants to Treat Depression in Young People: What are the Issues and What is the Evidence? Headspace, Evidence Summary Writers Dr Sarah Hetrick, Dr Rosemary Purcell, Clinical Consultants Prof Patrick McGorry, Prof Alison Yung, Dr Andrew Chanen http://www.headspace.org.au/core/Handlers/MediaHandler.ashx?mediaId=4896 (accessed 26 April 2011) ↩

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

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

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

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

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

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

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

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

By Martin Whitely

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

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

The DSM5 changes Professor Frances is concerned about include:

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

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

International Boycotts of DSM5

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

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

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

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

Australian Critics of DSM5

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

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

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

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

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

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

[4] Dr Allen Frances, ‘Psychiatrists Propose Revisions to Diagnosis Manual’, PBS Newshour, 10 February 2010. Available at http://www.pbs.org/newshour/bb/health/jan-june10/mentalillness_02-10.html (accessed 26 February 2010).

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

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

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

“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

8 July 2012

An article in today’s Sunday Age, available at http://www.theage.com.au/national/youth-mental-health-team-too-free-with-drugs-audit-20120707-21o29.html, highlights the results of a prescribing audit of Patrick McGorry’s Orygen Youth Mental Health Service.  It found the service “prescribed medication to a majority of depressed 15 to 25-year-olds before they had received adequate counselling, despite international guidelines advising against the practice.”[1]

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

It is commendable that Orygen[3] published the results of the audit, however the results make a mockery of Professor Patrick McGorry’s often repeated assertion that drugs are not the first-line treatment in any but the most serious cases.

In response Professor George Patton, director of adolescent research at the Centre for Adolescent Health at the Royal Children’s Hospital, told The Age, ”This paper illustrates how much we need to be looking at these new services [EPPIC and headspace] to determine the extent to which we’re following best clinical practice and to ask the questions, are we getting value for money out of these investments, and are we actually seeing better clinical outcomes?”[4]

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

Note: The issues raised in today’s Age article reinforce similar concerns I voiced last year about antidepressant prescribing at Professor McGorry’s other favourite project headspace.  I raised my concerns in the WA State Parliament and on my blog last year titled “Is Patrick McGorry’s and the Independent Mental Health Reform Group’s $3.5b blueprint for Australian mental health the way forward, or a prescription for more ‘psychiatric disorders’, ‘off label’ prescribing and youth suicide?” available at http://speedupsitstill.com/patrick-mcgorry%e2%80%99s-independent-mental-health-reform-group%e2%80%99s-3-5b-blueprint-australian-mental-health-forward-prescription-%e2%80%98psychiatric-disorders%e2%80%99-%e2%80%98off-label

[1] 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

[2] 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

[3] Orygen runs a range of youth mental health services, including EPPIC (Early Psychosis Prevention and Intervention Centre), PACE (Personal Assessment and Crisis Evaluation), YMC (Youth Mood Clinic) and HYPE (Helping Young People Early, for people with emerging borderline personality disorder).  In addition, Orygen is a partner in headspace.

[4] 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

Mental health policy in Australia, for so long ignored, is finally getting attention.  The Australian and West Australian governments have appointed their first Mental Health Ministers and significant resources are being identified for new and expanded services.  In addition sport stars, celebrities and politicians have publicly shared their personal battles with depression, bipolar and a host of other mental health problems – helping to ‘de-stigmatise’ mental illness.

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.[3] Nonetheless, 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/

[1] Prof. Allen Frances, ‘Psychiatrists Propose Revisions to Diagnosis Manual’, PBS Newshour, 10 February 2010. Available at http://www.pbs.org/newshour/bb/health/jan-june10/mentalillness_02-10.html

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

[3] 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)]

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

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

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

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

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

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

Dr Frances is a former Chair of the Department of Psychiatry at Duke University. Whilst at Duke he led the American Psychiatric Association Task Force that revised the current edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV). His attack on Australia’s blind acceptance of Professor Patrick McGorry’s model of early intervention comes from the very heart of heart of the psychiatric profession and can’t be ignored. Following Dr Frances’ blog is a response by Professor McGorry.

Australia’s Reckless Experiment In Early Intervention – prevention that will do more harm than good

by Allen J. Frances, M.D. in DSM5 in Distress

Patrick McGorry is a charismatic psychiatrist who has recently gained heroic status. First he was chosen to be Australia’s Man of the Year. Now, he has convinced the Australian government to spend more than $400 million over five years to fund his plan for a nationwide system of Early Psychosis Prevention and Intervention Centres. McGorry is the visionary prophet and pied piper of preventive psychiatry. His goal is to diagnose mental disorders early and treat them expectantly- before they can do their worst damage.

McGorry’s goal is certainly great. But its current achievement is simply impossible and Australia’s plans are patently premature. Early intervention to prevent psychosis requires first that there be an accurate tool to identify who will later become psychotic and who will not. Unfortunately, no such accurate tool exists. The false positive rate in selecting prepsychosis is at least about 60-70% in the very best of hands and may be as high as 90% in general practice. That’s right, folks, nine misidentified non patients for one accurately identified truly prepsychotic patient. Those are totally unacceptable odds.

What are the costs? McGorry does not recommend antipsychotic medications as a routine part of his prevention regimen. But experience teaches us that they will be overused despite having no proven efficacy and posing the risk of massive weight gain (and its consequent array of serious complications). The false positives will also suffer unnecessary stigma and worry and will undergo unnecessary and misdirected treatment. And surely there are many more productive ways to spend $400 million doing a better job of managing the mental health needs of those who have real and treatable psychiatric disorders.

Unfortunately, Mcgorry is a false prophet who’s visions are offered at least a few decades before their time. Australia, led astray by his impractical hopes, is about to embark on a vast and untried public health experiment that will almost surely cause more harm to its children than it prevents. Before embarking on this headlong and reckless rush, the following research steps need to be accomplished:

1) Developing a proven and reliable definition of “Psychosis Risk”

2) Learning how to use it in a way that reduces current outrageously high false positive rates to levels that are tolerable.

3) Demonstrating that the interventions chosen are indeed effective in preventing psychosis.

4) Determining the likely rate of antipsychotic use and how this influences the overall risk/benefit balance sheet of early intervention.

5) Studying the beneficial and harmful impacts of early diagnosis on stigma and self perception.

6) Comparing the marginal utility of a dollar spent trying to prevent an alleged future disorder vs a dollar spent treating an already clearly established one.

This is a research enterprise that will take many groups around the world many decades to complete. But it is an absolutely necessary precondition before spending $400 million on what is likely to be a failure. The Australian experiment will be flying blind on an airplane that is not at all ready to leave the ground. Doing prevention prematurely and poorly will give a good idea an unnecessary bad name.

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. Sad to say, Australia’s well intended impulse to protect its children will paradoxically put them at greater risk. Let’s applaud McGorry’s vision but not blindly follow him down an unknown path fraught with dangers.

AUSTRALIA’S MENTAL HEALTH REFORM: AN OVERDUE INVESTMENT IN TIMELY INTERVENTION AND SOCIAL INCLUSION

 By Professor Patrick McGorry

One has to wonder why Dr. Allen Francis, a retired former academic psychiatrist from the USA, would insert such an idiosyncratic, highly personalised critique of Australia’s Mental Health Reform into the blogosphere. Perhaps the title “DSM V in Distress” gives us a clue. A more accurate title may have been “Dr Allen Francis in Distress over DSM”. Dr. Francis was the chair of the previous (4^th) edition of the American Psychiatric Association’s classification system of mental disorders, the DSM. He is well known to be seriously unhappy with the way his successors are carrying out their task and has taken aim at one of their candidates for inclusion, the subthreshold stage of psychotic illness. In a quixotic adventure of his own, he has had a dramatic tilt at a windmill of quite a different kind; the mental health policy of another country. We have been caught in a reckless crossfire. Flattering to deceive, Dr. Francis seems to be totally unaware of the facts concerning recent progress in Australia. Here is the background to and the essential elements of Australia’s mental health reform package.

The Australian Context and The Facts of the Reforms

Mental health reform was a key element in the Australian Government’s Health and Hospitals Reform Commission, chaired by Dr. Christine Bennett, whose report was handed down in 2009. This process combed through the evidence base and selected 14 areas for action in mental health. Top of this list were new community based services for young people and the scaling up of the EPPIC model for first episode psychosis. Over the course of the next 12 months and through an election campaign, mental health reform received strong and unprecedented support from across the Australian community, all sides of politics and a uniquely cohesive mental health sector. The re-elected Labor government made a commitment to enact this reform in its second term and embarked on a further wave of community consultation. I was asked to join an Expert Working Group on Mental Health to advise the new Minister for Mental Health, the Hon. Mark Butler, along with many other leaders from the mental health and related sectors. The ultimate reform package however was decided upon by the government and has received unprecedented support from the mental health sector and the Australian community. The Mental Health Council of Australia, the peak body representing the sector nationally, is in full support. The reform covers many aspects of mental health care, not only youth and early intervention, and is the result of a national team effort, not naïve charisma, spin doctoring or a national snake oil scheme. To imply such is not only to reveal ignorance of the facts but is patronising and disrespectful to the Australian community, to the Government and indeed all sides of Australian politics, to the mental health sector, and to those most directly affected by mental ill health who desperately depend upon this investment.

Far from charisma-based reform, this is progress driven by unacceptable levels of unmet need and based upon the best available evidence. Its focus is spread across all stages of illness and the total investment adds up to $2.2bn over 5 years. The largest single allocation of over $500m is actually devoted to those with severe and enduring mental illness.

The $400m focused on youth mental health and early psychosis has little to do with prevention and nothing to do with the “psychosis risk” windmill that Dr Francis is attacking. It has everything to do with the fact that young people bear the major burden for onset of mental disorders with 75% of these appearing before the age of 25 years (25% before age 12 and 50% between 12 and 25). Young people also have the highest prevalence of any group yet the worst access to care by far. So it is treatment needs not prevention that is driving this aspect of our national reforms.

Approximately $200m is to be spent on Australia’s highly successful “headspace” initiative. This will mean that young Australians aged between 12 and 25 years will have access to 90 youth-friendly portals or one-stop shops where stigma-free and holistic mental health care will be available. Up to 100,000 young people will eventually benefit. Commenced in 2006 and currently operating successfully in 30 sites, this enhanced primary care model has started to lift the proportion of young people with diagnosable mental and substance use disorders who receive any kind of mental health care from the basement level of 25% (13% for young men). The type of help on offer ranges from information and support through specialised forms of counselling and psychological interventions and access to youth friendly GPs, and in some sites to psychiatrists as needed. All forms of mental ill-health are eligible and the model has no specific connection to psychosis or subthreshold psychosis/psychosis risk.

The $200m allocated to scale up the EPPIC model around Australia is to implement a model of care developed in Melbourne 20 years ago. It was a response to the fact that, even when young people developed clearcut psychotic illness, where the diagnosis of first episode psychosis was in no doubt, long treatment delays, often for years, occurred during which their lives and futures were seriously damaged. Furthermore when they did enter treatment it was provided in facilities geared to the needs of much older adults with severe and disabling illnesses. The result was poor engagement, poor recovery and secondary trauma in many cases. The EPPIC model, or versions thereof, has now been adopted successfully in hundreds of centres around the world, and across the board in several countries, including England, Canada, the Netherlands, and other parts of Western Europe, Asia and even in the State of Oregon in the USA. The International Early Psychosis Association has held 7 large and successful conferences all over the world and the field has generated large volumes of evidence and an international group of experienced experts in early psychosis.

Consequently, there is very good evidence now that EI for first episode psychosis is more humane, effective, and highly cost-effective. So Australia is hardly being reckless in belatedly implementing its own innovation, some 10 years after England and many other parts of the world have done so. This aeroplane took off years ago. Dr. Francis like other critics of early intervention in psychiatry seeks to confuse the treatment of first episode psychosis with efforts to intervene at an earlier stage, the so-called subthreshold stage or the “ultra-high risk” stage. The latter issue has nothing to do with the Australian reforms which are an overdue catch up/scale up effort in relation to EPPIC, and an essential and welcome response to huge levels of unmet need in the case of headspace and youth mental health more broadly. Finally, unlike in the US health care system, these models of care are guided by young people themselves and their families, not dominated by medication, and are heavily influenced and respectful of the value of psychosocial care, which in our system is covered within our system of universal health insurance.

 Psychosis Risk

Turning to the question of psychosis risk and the ultra-high risk (UHR) mental state that Prof Alison Yung and I described and operationalised over 15 years ago, this is an important frontier for mental health care. Personally, I am not concerned whether it enters the DSM V or not, and indeed believe that there may well be a better way via a much broader spectrum clinical staging approach to address the clinical needs of these young people (which I have described elsewhere (McGorry et al 2010)). There may be a better way through this strategy to resolve anxieties about “false positives” since other diagnostic outcomes are included with many advantages, especially in relation to risk benefit considerations. The young people who do meet the current UHR criteria we defined for the ultra-high risk (UHR) mental state are distressed by symptoms of anxiety, depression and low grade or subthreshold psychotic symptoms. Their ability to function at school or work is substantially impaired and they have cognitive impairments. They are seeking and in need of help and treatment and are certainly not “non-patients” by any measure. They also have 200-400 times the risk of the normal population of developing a sustained psychotic disorder. It is true that the around two thirds will not in fact follow this path. These figures are similar to but more pronounced than the level of risk that someone with impaired glucose tolerance possesses for developing frank diabetes. There is no sense that interventions such as information, diet and exercise should be withheld from such people. Why a double standard? Why cannot young people in need of care not be provided with information on the level of risk, the things they can do to reduce the risk and the care they need for their current problems. Especially when this appears to reduce the risk of psychosis? The evidence that my colleagues and I and other groups has assembled through our research clearly shows that antipsychotic medications are not necessary or indicated at this stage and that psychosocial treatments and even fish oil is sufficient as first line. The metanalysis of Preti et al (2010) shows that the transition rates to frank psychosis can be reduced from around 30% to 10% at least in the short term. Our own latest research also shows that the initial level of distress and functional impairment also improves greatly with conservative psychosocial care. These facts are enshrined in international clinical practice guidelines published in 2005. We haven’t changed our approach merely firmed it up with additional research.

It may be true and indeed it is already that untrained and unregulated practitioners in unregulated settings will still inappropriately prescribe for such patients. The best way to prevent this is to allow such patients to enter more specialised youth mental health settings especially where program and guideline fidelity to treatments can be audited. So while the UHR or psychosis risk concept was in no way a driver of the headspace and EPPIC reforms, the concerns that Dr. Francis expresses regarding the potential harms that may befall UHR patients, notably inappropriate medication and stigma will be much less likely. In the USA even without the UHR concept entering the DSMV and in the absence of any stream of care for early psychosis or youth mental health there is widespread inappropriate use of medication in such patients. This stage of illness will be a key focus for ongoing research to better define the range and sequence of interventions that will be safest and most helpful.

 Reform and Its Challenges

As Naomi Oreskes and Eric Conway illustrates in their compelling book “Merchants of Doubt”, evidence-based progress is not only hard won but can be undermined and delayed by the misuse of scientific arguments in support of vested interests of various kinds. She uses the examples of the link between cigarette smoking and cancer and also climate change. While not all resistance to change is so poorly motivated, vested interests and hidden agendas of other kinds can still delay the implementation of evidence based advances. Recognition of the barriers in the path of implementation of new knowledge has led to a whole new area of scientific endeavour known as implementation science and translational research. In Australia, the scaling up of an Australian innovation, early intervention for psychosis, has been delayed by this dynamic. It is not just a matter of reasonable scientific conservatism, since such reactions have not surfaced in relation to other aspects of reform in mental health over the past 20 years. With the Government’s recent budget announcements, we appear to have crossed a Rubicon in Australia, and the challenge is now high fidelity implementation strategies buttressed by rigorous health services research to measure the impact and outcomes of the reform. Early psychosis care with its vital focus on minimising treatment delays for first episode psychosis and guaranteeing holistic biopsychosocial care during the critical years post diagnosis is the best buy in mental health reform. The aeroplane left the ground 15 -20 years ago. EI for first episode psychosis is feasible now, not decades down the track as suggested by Dr. Francis. Far from labelling Australia as reckless, the Director of the National Institute for Mental Health (NIMH) in Washington DC, Dr. Tom Insel, recently stated at a national workshop on mental health research hosted by the NHMRC in Canberra, that Australia was a decade ahead of the US in research, clinical care and reform in early intervention for psychosis and other forms of mental ill-health in young people. We must ensure that the benefits of this progress to hundreds of thousands of Australians are not undermined by merchants of doubt with other agendas.

References:

McGorry PD, Nelson B, Goldstone S, Yung AR. Clinical staging: a heuristic and practical strategy for new research and better health and social outcomes for psychotic and related mood disorders. Can J Psychiatry. 2010;55(8):486-497.

McGorry P. Risk syndromes, clinical staging and DSM V: new diagnostic infrastructure for early intervention in psychiatry and schizophrenia. Schizophrenia Research. 2010; 120: 49 – 53.

Preti A, Cella M. Randomized-controlled trials in people at ultra high risk of psychosis: a review of treatment effectiveness. Schizophrenia Research. 2010;123(1):30-36.

Oreskes N. and Conway E.M. Merchants of Doubt. Bloomsbury Press. NewYork. 2010

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

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

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

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

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

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

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

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

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

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

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

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

Patrick McGorry on EPPIC – Contradictory and Confusing

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Related Media

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

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

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

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

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

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

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

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

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

[8] The World Today – Professor McGorry hits back at critics, 20 May 2011 www.abc.net.au/worldtoday/content/2011/s3222359.htm (accessed 28 May 2011)

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

[10] McGorry, P.D. Risk Syndromes, clinical staging and DSM V; New diagnostic infrastructure for early intervention in psychiatry, Schizophr, Res. (2010), doi;10.1016/j.schres.2010.03.016

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

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

[13] http://speedupsitstill.com/patrick-mcgorry%e2%80%99s-independent-mental-health-reform-group%e2%80%99s-3-5b-blueprint-australian-mental-health-forward-prescription-%e2%80%98psychiatric-disorders%e2%80%99-%e2%80%98off-label#more-1530

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

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

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

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

In December 2010 Minister for Mental Health & Ageing Mark Butler took the extraordinary step of sidelining his own National Advisory Council on Mental Health and appointing Professors McGorry and Hickie as members of a Mental Health Expert Working Group. Minister Butler said ‘that the creation of the new, time limited, specialist group will allow for targeted advice to be provided directly to the Australian Government on how to achieve the most coordinated, cost-effective and lasting reforms for their investment in mental health care.’^[1]

For reasons that are not clear, Professors McGorry and Hickie and fellow member of the Mental Health Expert Working Group, Monsignor David Cappo, subsequently established the Independent Mental Health Reform Group. In March this year the Independent Mental Health Reform Group released its $3.5B blueprint for mental health.^[2]

In the following blog I outline my concerns in relation to the blueprint including the:

• proposal to increase funding to Headspace by $226 million given the advocacy by Professor McGorry and Headspace of ‘off label’ prescribing of SSRI antidepressants to young people. This is despite clinical studies and FDA and TGA advice that the use of SSRI’s increases the risk of suicidal behaviour by young people.
• proposal to increase funding to EPPIC by $910 million given Professor McGorry advocacy of the recognition of Psychosis Risk Syndrome as a diagnosable psychiatric disorder. This is despite the concerns of numerous high profile psychiatrists including his close colleague Professor Alison Yung who questions; ‘ Is the agenda really to use antipsychotics?…the risk is that instead of getting maybe supportive therapy, they get antipsychotics and they will be diagnosed with the risk syndrome.
• lack of publicly accesible evidence of patient outcomes and the cost effectiveness of the mental health ‘best buys’ identified in the blueprint.
• alarmist claim by Professor McGorry that in 2011 four million Australian’s including 1 million young people will have a mental disorder requiring treatment.

Following my blog Professor McGorry takes up my invitation to exercise his right of reply.

So what is in the blueprint?

The blueprint outlines $3.5billion expenditure over 5 years on programs that are identified as mental health ‘best buys’. The most expensive ‘best buy’, at $910m, is for the rollout of 20 new Early Psychosis Prevention Intervention Centres (EPPIC). Australia’s only existing EPPIC clinic is run by Orygen Youth Health, headed up by Professor McGorry.^[3] The blueprint states that EPPIC has ‘the largest international evidence base of any mental health model of care demonstrating not only their clinical effectiveness but also their return on financial and social return on investment.’ Despite this bold claim, there is no evidence in the blueprint of EPPIC’s cost effectiveness or patient outcomes compared with outcomes from other mental health services.

The second priority identified is the expansion of the national Headspace program to 90 service sites, at a cost of $226m. Professors McGorry and Hickie are both Board members of Headspace. Again there is no supporting evidence. The blueprint is completely unreferenced. It is merely a $3.5billion consensus wish list of these ‘independent’ mental health experts, completely devoid of supporting verifiable evidence.

That is not to suggest that Headspace and even EPPIC don’t provide some valuable interventions, and there is undoubtedly some merit in the other programs identified. However, the blueprint falls far short of establishing the case that an extra $3.5 billion of taxpayer’s funds would be best spent on the identified ‘best buys’.

How ‘independent’ is the Independent Mental Health Reform Group that developed the blueprint?

Professor McGorry and several organisations he presides over have received considerable financial support from the pharmaceutical industry. In 2008, McGorry disclosed the sources but not the quantum of pharmaceutical company funds he has received in an article he wrote published by the British Medical Journal. To its’ credit the BMJ is one of the few journals that strictly enforces its’ disclosure policy. It stated McGorry, ‘has received unrestricted research grant support from Janssen- Cilag, Eli Lilly, Bristol Myer Squibb, Astra-Zeneca, Pfizer, and Novartis. He has acted as a paid consultant for, and has received speaker’s fees and travel reimbursement from, all or most of these companies’.^[4] McGorry is currently Director of Clinical Services at Orygen Youth Health Clinical Program and Executive Director of the Orygen Youth Health Research Centre.^[5] Orygen receives support from numerous pharmaceutical companies.^[6] In addition, McGorry is Treasurer and former President of the pharmaceutical industry funded International Early Psychosis Association.

Professor Ian Hickiehas received grants totalling $411,000 from pharmaceutical companies, including $10,000 from Roche Pharmaceuticals (1992); $30,000 from Bristol-Myers Squibb (1997); $40,000 from Bristol-Myers Squibb (1998-1999); $250,000 from Pfizer Australia (2009); and $81,000 from Pfizer Australia (n.d.).^[7]  Whilst it was not disclosed in the blueprint, Hickie does deserve some credit for disclosing in his online CV that he has received this funding from the pharmaceutical industry.

Along with Professors McGorry and Hickie and Monsignor David Cappo, the other members of the ‘independent’ group are Sebastian Rosenberg, John Moran and Matthew Hamilton. Moran and Hamilton both work for Orygen and therefore are subordinates of McGorry. Rosenberg is the former CEO of the Mental Health Council of Australia and is currently Head of the National Mental Health Policy Unit at Hickie’s Brain and Mind Research Institute^[8] and a director of the mental health business ConNetica, whose website lists one of its ‘Private Sector Customers’ as Eli Lilly.^[9]

Neither Professors McGorry nor Hickie nor any other member of the Independent Reform Group disclosed their pharmaceutical company connections in the blueprint. Neither did the blueprint identify which mental health ‘best buys’ are based on service delivery models exclusive to organisations they control. These potential conflicts of interest may have been known by the politicians controlling funding, however, it is apparent the media were either ignorant of, or disinterested in them and happily portray McGorry and Hickie as independent advocates.

Why does Professor McGorry think that 4 million Australians will have a ‘mental disorder’ requiring treatment in 2011, and what treatments does he propose?

In March 2010 when appearing on ABC’s Lateline, Professor McGorry said ‘4 million Australians have mental health problems in any given year. Only one third of them get access to treatment… there are 1 million young Australians aged 12 to 25 with a mental disorder in any given year. It’s the peak period across a lifespan when mental disorders appear. And 750,000 of them have no access to mental health care currently.’^[10][11]

Public critics of Professor McGorry are rare; however, not everyone accepts his alarming claims. Jon Jureidini, Adelaide University Professor of Psychiatry and Paediatrics, accused McGorry of disease-mongering when claiming that 750,000 young Australians were ‘locked out’ of care they ‘desperately’ needed: ‘He’s taken the biggest possible figure you can come up with for people who might have any level of distress or unhappiness, which of course needs to be taken seriously and responded to, but he’s assuming they all require … a mental health intervention…It’s the way politicians operate. You look at figures and put a spin on it that suits your point of view. I don’t think that has a place in scientific conversations about the need for health interventions.’^[12]

Professor McGorry responded to Professor Jureidini’s criticisms, writing: ‘I have never argued that 1 million young Australians have serious mental illness’. However, he added: ‘late intervention philosophy is associated with risk, preventable damage and stigma and for this reason access to appropriate, staged mental health care for young Australians with mild, moderate and serious mental ill-health is overwhelmingly supported by political parties and the health and social sectors (most recently expressed in a letter co-signed by 65 organisations). To argue that young Australians with mild to moderate mental ill-health do not need access to mental health care applies a standard to mental health that would not be acceptable in physical health. Imagine restricting access to health services to only Australians with severe physical ill-health and locking out all those with milder conditions with the admonition that they should just regard their distress as part of the human condition and suck it up!’^[13]

Professor McGorry is of course correct that there appears to be ‘overwhelming’ support by ‘by political parties and the health and social sectors’ for his calls for early intervention; however, this is evidence of political rather than clinical or scientific success. There is undoubtedly unmet and mis-met mental health need, but Professor Jureidini’s legitimate questions remain. In 2011 will more than one in seven Australians (4 million) have a ‘psychiatric disorder’ requiring a ‘mental health intervention’? Would these millions of Australian’s benefit from, or be stigmatised by being labeled ‘psychiatrically disordered’? And even more worryingly, what are these potential interventions and will they do more harm than good?

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

A 2009 evidence summary produced by Orygen Youth Health for Headspace and overseen by Professor McGorry, titled ‘Using SSRI Antidepressants to Treat Depression in Young People: What are the Issues and What is the Evidence?’, correctly identifies that the US Food and Drug Administration has issued the highest possible ‘black box’ warning that the use of SSRI antidepressants increases the risk of suicidality in people under 24.^[14] The warning was put on in 2005 after an analysis of clinical trials by the FDA found statistically significant increases in the risks of ‘suicidal ideation and suicidal behavior’ by about 80%, and of agitation and hostility by about 130%.^[15]

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’.^[16] 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.’^[17]

The body of the evidence summary builds a compelling argument for avoiding the use of SSRIs in young people. Despite this, it concludes by recommending: ‘In cases of (even) moderate to severe depression, SSRI medication may be considered within the context of comprehensive management of the patient, which includes regular careful monitoring for the emergence of suicidal ideation or behaviour’.^[18] The nearest thing to a rationale offered in the paper is that many young people who are depressed get no treatment and that it is better to do something than nothing.

Through the use of a variety of mechanisms, including candle-light vigils, Professor McGorry has mobilised well intentioned, vocal supporters including Get Up! to highlight the tragedy of youth suicide to advocate for reform of mental health services for the young.^[19] Yet the Headspace evidence summary, which is effectively a guideline for the treatement of young Australians, acknowledges and then ignores the clinical trial evidence and FDA and TGA advice on the relationship between SSRI antidepressants and youth suicidality.

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

Why has Professor McGorry experimented with the use of antipsychotics in non-psychotic adolescents, and why does he advocate the recognition of controversial newly invented psychiatric disorders?

Professor McGorry has a long history of advocating or experimenting with the ‘off label’ use of psychotropic drugs for moderate mental ‘illness’ and for hypothesised psychiatric disorders that are not officially recognised. He is a leading international advocate for the inclusion of psychosis risk syndrome, otherwise known as attenuated psychotic symptoms syndrome, in the next edition of the American Psychiatric Association’s clinically dominant Diagnostic and Statistical Manual of Mental Disorders (DSM-V) (the ‘bible’ of psychiatry) due for publication in 2013.

Professor McGorry hypothesises that that there is ‘prodromal phase’ prior to the onset of a first psychotic episode. He acknowledges that ‘the false positive rate may exceed 50-60%’, but nonetheless he led controversial research that trialled the use of the antipsychotic risperidone (Risperdal®) on young people without psychosis who were suspected of being at risk of developing psychotic disorders such as schizophrenia.^[20]

Risperidone is one of the more commonly used ‘atypical’ (newer) antipsychotics and has a range of serious potential side effects including metabolic syndrome, and sudden cardiovascular death.^[21][22] There have been more than 500 voluntary adverse event reports made to the TGA, and these are just the tip of the iceberg as the vast majority of adverse events are never reported.^[23][24]

Professor Allen Frances, the American psychiatrist who led the 1994 revision of the current edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV), is a fierce critic of the hypothesised psychosis risk syndrome. With the benefit of hindsight, Frances regrets aspects of the 1994 revision for having triggered ‘three false epidemics. One for autistic disorder…another for the childhood diagnosis of Bi-Polar disorder and the third for the wild over-diagnosis of Attention Deficit Disorder.’.^[25]

Based on this experience, Professor Frances warns of numerous problems with the drafting of the next edition, DSM-V, recently writing that: ‘Among all the problematic suggestions for DSM-V, the proposal for a “Psychosis Risk Syndrome” stands out as the most ill-conceived and potentially harmful… The whole concept of early intervention rests on three fundamental [flawed] pillars… 1) it would misidentify many teenagers who are not really at risk for psychosis; 2) the treatment they would most often receive (atypical antipsychotic medication) has no proven efficacy; but, 3) it does have definite dangerous complications.”^[26] Frances contends that up to 90% of those diagnosed with psychosis risk syndrome would never go on to develop psychosis, and concludes that the it is ‘the prescription for an iatrogenic [adverse effects resulting from treatment] public health disaster’.^[27]

Even one of Professor McGorry’s closest colleagues at the Orygen Youth Health Research Centre, Professor Alison Yung, has expressed strong opposition to the inclusion of psychosis risk syndrome in DSM-V, questioning; ‘So why the need for a specific risk syndrome diagnosis? Is the agenda really to use antipsychotics? …….I think there are concerns about validity, especially predictive validity, and this relates to potentially stigmatizing and unjustified treatment for some individuals as well as all the negative social effects of diagnosis. I think including the risk syndrome in the DSM-V is premature…….more people seek help, but the risk is that instead of getting maybe supportive therapy, they get antipsychotics and they will be diagnosed with the risk syndrome.’^[28]

Regardless Professor McGorry still advocates for the inclusion of psychosis risk syndrome in DSM-V. However, he recently distanced himself from the use of antipsychotics on patients perceived to be at risk of psychosis. In response to earlier criticism including a blog I authored, he wrote ‘Antipsychotic medications should not be considered unless there is a clear-cut and sustained progression to frank psychotic disorder meeting full DSM 4 criteria’ This appeared to put an end to the debate about whether McGorry currently advocates the use of antipsychotics on the hunch that adolescents will later become psychotic.

However, the statement in his December 2010 blog that ‘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’ has the potential to mislead.^[29] Whilst it is true that Professor McGorry has never produced final endorsed clinical guidelines recommending the use of antipsychotics for his hypothesised ‘ultra high risk group’, the facts are that for well over a decade McGorry experimented with, and advocated, the pre-emptive prescription of antipsychotics to adolescents.

Professor McGorry was the lead author of a 2006 article which, as part of a proposed ‘clinical staging framework for psychosis’, identified ‘atypical antipsychotic agents’, as one of the ‘potential interventions’ for individuals who are at ‘ultra-high risk (10% to 40%)’ of developing first episode psychosis.^[30] Whilst he has recently adjusted the ‘clinical staging framework’, he was still advocating antipsychotics as a potential pre-psychosis intervention at least as late as October 2007.

A 2007 British Medical Journal article jointly authored by Professor McGorry began by quoting a 1994 paper extolling the potential of pre-psychosis pharmacological interventions: ‘The best hope now for the prevention of schizophrenia lies with indicated preventive interventions targeted at individuals manifesting precursor signs and symptoms who have not yet met full criteria for diagnosis. The identification of individuals at this early stage, coupled with the introduction of pharmacological and psychosocial interventions, may prevent the development of the full-blown disorder.’ McGorry’s article’s opening comment followed: ‘Such sentiment underlines the aim of identifying people in the prodromal phase preceding a first psychotic episode.’^[31] The article went on to outline evidence supporting interventions including antipsychotics ‘to delay or even prevent onset of psychosis.’

Furthermore, in 2008, in the British Medical Journal, in an article titled ‘Is early intervention in the major psychiatric disorders justified? Yes’, Professor McGorry wrote: ‘Early intervention covers both early detection and the phase specific treatment of the earlier stages of illness with psychosocial and drug interventions. 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.’^[32]

These are just a few of numerous similar statements which comment favourably or suggest the use of antipsychotics as part of the treatment for adolescents considered to be at ‘ultra high risk’ of developing psychosis. Whether such comments constitute ‘advocacy’ is open to semantic debate. However, Professor McGorry certainly favoured this highly controversial use and continues to advocate for the official recognition of ‘psychosis risk syndrome’ as a psychiatric disorder. Despite being dircetly asked by me Professor McGorry has not ruled out further experimentation with antipsychotics for psychosis prevention, or the use of antipsychotics as a ‘second line treatment’ for ‘subthreshold psychosis’. These are issues that need a clear resolution before there is any increased funding of EPPIC.

Where are other psychiatrists and the Royal Australian & New Zealand College of Psychiatrists in the national mental health debate?

With the notable exception of Professor Jon Jureidini and Professor Vaughan Carr^[33], there has been little public criticism from within the Australian psychiatric profession of Professor McGorry’s plans for the future of Australian mental health. A number of psychiatrists I have spoken to are privately critical of McGorry’s advocacy of ‘off label’ prescribing; however, they are grateful that McGorry’s Australian of the Year status has at last put mental health on the agenda and is likely to result in extra resources.

Whilst I am critical of the unquestioning acceptance of Professors McGorry and Hickie’s claims by politicians and the media, it is not entirely their fault. Mental health is a confusing and mysterious field clouded by personal and commercial agendas and politicians, and the media have not been offered an attractive alternative – mainly because there are few simple solutions for complex problems.

The Australian psychiatric profession needs to start acting like a profession interested in cautious, first-do-no-harm, evidence-based approaches to addressing unmet and mis-met mental health needs. The Royal Australian & New Zealand College of Psychiatrists needs to stop being so timid. The Australian public needs a vigorous debate within the College, the psychiatric profession, the wider medical and therapeutic community and the public to drive the future of Australian mental health.

Isn’t it time to ask Professor McGorry a few tough questions?

I think that unquestioningly following Professor McGorry’s prescription for Australian mental health risks more harm – more ‘psychiatric disorders’, youth suicides and an epidemic of iatrogenic (adverse prescription drug event) suffering – than good. I am particularly concerned that a McGorry endorsed and Headspace driven increase in the ‘off label’ prescription of SSRI antidepressants to children and young people may cost lives. And I think McGorry’s pharmaceutical company ties and obvious conflicts of interest in advocating for well over $1billion increased funding for EPPIC and Headspace need to be understood and considered.

Professor McGorry needs to show that his claim that four million Australians will suffer a mental health disorder warranting treatment this year is not disease-mongering. He needs to detail what these psychiatric disorders are and exactly what appropriate treatments would involve. And McGorry needs to explain why the FDA and TGA are wrong and why giving SSRIs to depressed children and adolescents doesn’t increase their chances of suicidality.

And Professor McGorry needs to explain why he has experimented with antipsychotics on adolescents who had never been, and by his own admission probably never will be, psychotic. McGorry also needs to explain why Professor Allen Frances and even McGorry’s close ally Professor Alison Yung are wrong to be concerned that his push for the recognition of ‘psychosis risk syndrome’ as a new psychiatric disorder may be all about promoting the use of antipsychotics and may lead to an ‘iatrogenic health disaster’.

Perhaps Professor McGorry really does have insights that make him uniquely placed to design Australia’s 21^st century mental health system. However, now that the Gillard Government is on the verge of committing massive resources to aspects of McGorry’s mental health blueprint, it is time the Canberra politicians, the media and the Australian psychiatric profession and other health and welfare professionals got beyond his former ‘Australian of the Year’ status and asked him a few hard questions.

[2] 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)

[3] Orygen Youth Health – Early Psychosis Prevention Intervention Centre website http://www.eppic.org.au/about-us (accessed 26 April 2011)

[4] 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)

[5] McGorry is the former President and the current Treasurer (http://www.iepa.org.au/ContentPage.aspx?pageID=40) of the International Early Psychosis Association which is funded by antipsychotic manufacturers Astra Zeneca, Lilly and Janssen-Cilag (http://www.iepa.org.au/2010/)

[6]McGorry is currently Director of Clinical Services at Orygen Youth Health Clinical Program and Executive Director of the Orygen Youth Health Research Centre. Orygen receives support from AstraZeneca, Bristol Myer Squibb, Eli Lilly, and Janssen-Cilag. Orygen Youth Health, Research Centre – Other Funding http://rc.oyh.org.au/ResearchCentreStructure/otherfunding (accessed 3 August 2010)

[7] Cited in Ian Hickie, Curriculum Vitae, last updated 23 August 2009 http://sydney.edu.au/bmri/about/Hickie_CV.pdf (3 August 2010). In addition Professor Hickie and colleagues created ‘SPHERE: A National Depression Project’ (http://sydney.edu.au/bmri/about/Hickie_CV.pdf). As was reported in The Australian, Pfizer works in conjunction with SPHERE through a company called Lifeblood, which is based at Hickie’s Brain and Mind Research Institute. BMRI staff are paid to review SPHERE. According to Lifeblood, SPHERE ‘assisted in restoring the market share and growth of the Pfizer antidepressant Zoloft, restoring it to the No 1 product in this market’. Davies J. (10 July 2010) GP jaunts ‘boosted’ drug sales, The Australian. http://www.theaustralian.com.au/news/nation/gp-jaunts-boosted-drug-sales/story-e6frg6nf-1225890003658 (accessed 30 April 2011)

[8] Brain and Mind Research Institute website http://sydney.edu.au/bmri/research/mental-health-policy/index.php (accessed 30 April 2011)

[9] ConNetica website http://connetica.com.au/about (accessed 26 April 2011)

[10] 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)

[11] In a presentation on behalf of beyondblue, Professor Ian Hickie claimed the 12 month prevalence of mental disorders for Australia men is 17.4% and woman 18.0%. Responding to the challenge of brain and mind disorders in Australia, Ian Hickie MD FRANZCP Professor of Psychiatry, Brain and Mind Research Institute, University of Sydney& Clinical Advisor, beyondblue: the national depression initiative http://www.gptt.com.au/Exam%20preparation%20CK%20Khong/Mental%20Health/Depression%20adults%20hickie_slides.pdf

[12] Medew, J. (9 August 2010) McGorry ‘misleading the public’, The Age http://www.theage.com.au/national/mcgorry-misleading-the-public-20100808-11qes.html

[13] 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)

[14] Evidence Summary: Using SSRI Antidepressants to Treat Depression in Young People: What are the Issues and What is the Evidence? Headspace, Evidence Summary Writers Dr Sarah Hetrick, Dr Rosemary Purcell, Clinical Consultants Prof Patrick McGorry, Prof Alison Yung, Dr Andrew Chanen http://www.headspace.org.au/core/Handlers/MediaHandler.ashx?mediaId=4896 (accessed 26 April 2011)

[15] Hammad T.A. (16 August 2004). Review and evaluation of clinical data. Relationship between psychiatric drugs and pediatric suicidal behavior, Food and Drug Administration. pp. 42; 115. http://www.fda.gov/OHRMS/DOCKETS/ac/04/briefing/2004-4065b1-10-TAB08-Hammads-Review.pdf (accessed 29 May 2008)

[16] Evidence Summary: Using SSRI Antidepressants to Treat Depression in Young People: What are the Issues and What is the Evidence? Headspace, Evidence Summary Writers Dr Sarah Hetrick, Dr Rosemary Purcell, Clinical Consultants Prof Patrick McGorry, Prof Alison Yung, Dr Andrew Chanen http://www.headspace.org.au/core/Handlers/MediaHandler.ashx?mediaId=4896 (accessed 26 April 2011)

[17] Evidence Summary: Using SSRI Antidepressants to Treat Depression in Young People: What are the Issues and What is the Evidence? Headspace, Evidence Summary Writers Dr Sarah Hetrick, Dr Rosemary Purcell, Clinical Consultants Prof Patrick McGorry, Prof Alison Yung, Dr Andrew Chanen http://www.headspace.org.au/core/Handlers/MediaHandler.ashx?mediaId=4896 (accessed 26 April 2011)

[18] Evidence Summary: Using SSRI Antidepressants to Treat Depression in Young People: What are the Issues and What is the Evidence? Headspace, Evidence Summary Writers Dr Sarah Hetrick, Dr Rosemary Purcell, Clinical Consultants Prof Patrick McGorry, Prof Alison Yung, Dr Andrew Chanen http://www.headspace.org.au/core/Handlers/MediaHandler.ashx?mediaId=4896 (accessed 26 April 2011)

[19] Hagan, K. (29 July 2010) GetUp! calls for urgent reform to mental health policy, The Age http://www.theage.com.au/victoria/getup-calls-for-urgent-reform-to-mental-health-policy-20100728-10w74.html#ixzz1Ka5lGSDj (accessed 26 April 2011)

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

[21] Consumer Medicine Information: Risperidone http://www.racgp.org.au/cmi/jccrispe.pdf (accessed 3 August 2010)

[22] Webb, D. & Raven, M. (6 April 2010) McGorry’s ‘early intervention’ in mental health: a prescription for disaster, Online Opinion http://www.onlineopinion.com.au/view.asp?article=10267 (accessed 18 November 2010)

[23] Adverse events information related to risperidone obtained from the Therapeutic Goods Administration’s Public Case Detail reports

[24] As reporting is voluntary, there is no way of knowing what proportion of actual adverse events gets reported. A 2008 study by Curtin University pharmacologist Con Berbatis indentified that only a tiny fraction (for general practitioners only 2 per cent) of adverse events are reported. (Con Berbatis, (2008), Primary care and Pharmacy: 4. Large contributions to national adverse reaction reporting by pharmacists in Australia, i2P E-Magazine, Issue 72, p. 1)

[25]Frances, A. (2010), in M. Whitely, Speed Up and Sit Still: The Controversies of ADHD Diagnosis and Treatment, p.18. UWA Publishing, Crawley, Western Australia. Also: Frances, A. (8 April 2010) Psychiatric diagnosis gone wild: The “epidemic” of childhood bipolar disorder, Psychiatric Times http://www.psychiatrictimes.com/bipolar-disorder/content/article/10168/1551005 (accessed 30 April 2011)

[26] Frances, A. (2010) DSM5 ‘Psychosis risk syndrome’—Far too risky, Psychology Today http://www.psychologytoday.com/blog/dsm5-in-distress/201003/dsm5-psychosis-risk-syndrome-far-too-risky

[27] Frances, A. (2010) DSM5 ‘Psychosis risk syndrome’—Far too risky, Psychology Today http://www.psychologytoday.com/blog/dsm5-in-distress/201003/dsm5-psychosis-risk-syndrome-far-too-risky

[28] Schizophrenia Research Forum (4 October 2009) Live Discussion: Is the risk syndrome for psychosis risky business http://www.schizophreniaforum.org/for/live/transcript.asp?liveID=68

[29] Refer http://speedupsitstill.com/reply-patrick-mcgorry-early-intervention-psychosis

[30] 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)

[31] 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)

[32] 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)

[33]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)

Right of Reply – Professor Patrick McGorry

Martin Whitely suggests that the Independent Mental Health Reform Group’s Blueprint may be a template for more psychiatric disorders, more off label prescribing and more youth suicide. In support of this improbable claim Mr. Whitely questions the integrity of the authors of the Blueprint, casts doubt about the wisdom of the Australian community’s desire for major mental health reform and suggests that early intervention models headspace and EPPIC may do more harm than good. I therefore welcome the opportunity to respond to each of these themes.

1. Integrity of the Blueprint’s authors

Mr.Whitely raises numerous doubts about the integrity of the authors (and in particular of myself) – in terms of motive, independence and process. Specifically, Mr. Whitely questions what motivated the authors to convene to write the Blueprint in the first place, states that the authors have undisclosed conflicts of interest and suggests that we have made claims without being able to substantiate them with evidence. It is disappointing that Mr. Whitely should impute such bad faith to our group and should have been prompted to do so in the absence of supporting evidence. In terms of the issues of integrity that he raises:

• The motive of the authors was to produce a credible investment action plan to advance mental health reform across the lifespan that could be adopted by Government (and by Opposition and Cross-Bench Parties). We felt that the momentum for mental health reform might temporarily stall in the absence of such a plan. We therefore convened a group to produce the Blueprint document and chose the name Independent Mental Health Reform Group to make it clear that our work reflected only the views of the six authors made no claims of wider representation or linkage to Government and/or other third parties.
• The suggestion that the authors are dishonestly trying to secure over $1b of public funding for projects (specifically headspace and EPPIC) to which they conceal their links is completely at variance with the truth. The target audience for this Blueprint (political leaders and public servants responsible for mental health policy) are unambiguously clear about my leadership role in EPPIC and the participation of Ian Hickie and myself on the headspace board. I have hosted both Julia Gillard and Tony Abbott at EPPIC, as well as Minister for Mental Health Mark Butler and a diverse range of current and past parliamentarians – including a visit last month by members of the House of Representatives Education and Employment Standing Committee. Likewise, officials from the Department of Health and Ageing have also visited our EPPIC service and both Ian Hickie and myself have longstanding relationships with political and public service leaders arising directly from our role with headspace. Furthermore the proposal we have made is that the public in other parts of Australia beyond the EPPIC service I lead should reap the considerable benefits of this model of care.  There is no request or expectation of any personal benefit to me or any of my colleagues flowing from any Federal government decision to scale up the EPPIC model, as other countries have already done in response to my prior support and advocacy.
• Similarly, the implication that the content of the Blueprint may have been inappropriately influenced by the pharmaceutical industry is also false. In my case, Mr. Whitely perversely uses my own declaration of previous pharmaceutical industry funding as supporting evidence for his claim that I am actively concealing this funding. To put this in context, pharmaceutical funding currently plays a very minor roll (less than 5%) in funding Orygen Youth Health Research Centre projects – all of which have been designed and conducted independently of pharmaceutical company input. Furthermore, its unclear which, if any, of the Blueprint’s 30 recommendations would be core commercial concerns of any of the pharmaceutical companies – for example it is notable none of these recommendations call for the MBS listing of any drug.

2. Wisdom of the Australian community’s desire for major mental health reform

Mr. Whitely acknowledges that the Australian public and elected representatives from all sides of politics accept that there is a major need to act on mental health reform. Mr. Whitely appears not to believe that this national consensus for action is the result of tens of thousands Australians sharing their stories of unmet serious mental distress to finally break through to our national conversation. Instead, Mr. Whitely chooses to believe it is more likely the product of a gullible public falling for some clever sophistry. Mr.Whitely appears to believe that the case for mental health reform remains unproven. This is a disappointing approach from an elected representative. The facts are clear that access and quality in mental health care are well below the standards that exist in the rest of health care.  National Mental Health survey data clearly backs this up and it is freely acknowledged by the department of health and ageing and the current government.  Most of his peers and indeed all sides of politics have listened to the Australian community and concluded that it is time to act – it is unclear what new evidence he is waiting for before he joins them. It is notable that he has not chosen not to state in his article his own views about the appropriate level of expenditure on mental health care (an increase? a cut?) or where he feels resources should be directed.

3. Early intervention models headspace and EPPIC

Mr. Whitely only specifically mentions two investment recommendations contained in the Blueprint – the early intervention youth mental health models headspace and EPPIC. It is not clear why he has chosen just these two recommendations or what he thinks about the other 28 recommendations. For the record, the other 28 recommendations include family based interventions for children, social and economic participation supports for middle and older years Australians and a range of measures to improve accountability, innovation and practice across the mental health system.

Mr. Whitely wrongly concludes that because we wrote the Blueprint as an action plan rather than a referenced review of the evidence, that there is no evidence for our recommendations. It is based on the best available scientific evidence.  In fact, we had already supplied much of that evidence to the policy making audience for the Blueprint over the previous months. The National Health and Hospitals Reform Commission chaired by Dr Christine Bennett reviewed all the evidence for the Rudd government and came up with very similar recommendations and carefully referenced their findings.   Mr. Whitely surely is aware of the NHHRC’s unequivocal support for headspace and EPPIC.  For example, cost-effectiveness data for Early Intervention in Psychosis (EPPIC or EPPIC derived models of care) indicate that:

– Health costs are less under EIP than under standard care. The first year health costs through providing the full EPPIC model to young people experiencing a first episode psychosis have been estimated to be $25,955 compared to $36,833 under standard care [1 – updated to 2009 prices]. Over the long term, mean annual costs under the EPPIC model are estimated to drop to approximately 1/3 of those under standard care [2].

– Employment costs are likely to be less under EIP than under standard care. Long term follow up of EPPIC clients indicates they are twice as likely to be currently in employment than people receiving standard mental health care [2].

– Suicide costs are likely to be less under EIP than under standard care. Most suicides associated with schizophrenia are thought to occur near the beginning of the illness [3]. A recent study suggested that the number of suicide attempts amongst this group in areas with EIP teams is one third that in areas without them [4].

– Homicide costs are likely to be less under EIP than under standard care. People with untreated psychosis are estimated to be ten times more likely to engage in acts of homicide than people with treated psychosis [5]. There is a significant association between homicide and the duration of untreated psychosis [6]. A core goal of EIP services is reducing the duration of untreated psychosis.

This cost-effectiveness data for the EPPIC model is significantly enhanced when including studies that focus specifically on clinical outcomes and functional recovery. Up to 85% of young people with vocational interventions achieve functional recovery, levels which are unprecedented. Furthermore, the recent independent evaluation of headspace was extremely positive, showing that  headspace was meeting the goals set of it by the Australian Government.

Mr. Whitely raises concerns about the use of medication in headspace and EPPIC which are also unwarranted. There are acknowledged risks with medications of all kinds in healthcare so the risk benefit ratio always has to be the guide for timing and need for use of such interventions.  In these programs the Centre for Excellence at Orygen Youth Health and headspace guides evidence based practice within these programs and care is strictly tailored to clinical practice guidelines which are published. We follow the International CPGs for early psychosis in EPPIC and beyondblue CPGs for the treatment of depression in young people recently published by beyondblue.  Of course CPGs are guidelines and individual clinicians must make their own decisions in individual cases since every patient is different in some respects. There are also areas where the evidence is incomplete and clinicians need to act on the best available evidence recognising that further evidence is required through further research.

In closing I appreciate the opportunity to respond to Mr Whitely’s communications.

Patrick McGorry

AO MD PhD FRCP FRANZCP

Professor of Youth Mental Health

University of Melbourne  

[2] Mihalopoulos, C., et al., Is early intervention in psychosis cost-effective over the long term? Schizophr Bull, 2009. 35(5): p. 909-918.

[3] Robinson, J., et al., Suicide attempt in first-episode psychosis: a 7.4 year follow-up study. Schizophr Res, 2010. 116(1): p. 1-8.

[4] Melle, I., et al., Early detection of the first episode of schizophrenia and suicidal behavior. Am J Psychiatry, 2006. 163(5): p. 800-804.

[5] Nielssen, O. and M. Large, Rates of homicide during the first episode of psychosis and after treatment: a systematic review and meta-analysis. Schizophr Bull, 2010. 36(4): p. 702-712.

[6] Large M, Nielssen O. Evidence for a relationship between the duration of untreated psychosis and the proportion of psychotic homicides prior to treatment. Social Psychiatry and Psychiatric Epidemiology 2008, 43:37‐44;

The Last Word – Professor McGorry leaves key questions unanswered – by Martin Whitely

I welcome Professor McGorry’s response and to the limited extent that it identifies the evidence base of the recommendations in the blueprint it is useful. I will examine in detail the evidence provided, however, it leaves most of the questions I raised unanswered.

In particular I believe the key questions that must be answered before EPPIC and Headspace are considered for extra funding are:

1 – EPPIC and the ‘off label” use of antipsychotics– Does Professor McGorry now agree with his colleague at EPPIC Prof Alison Yung and oppose the recognition of Psychosis Risk Syndrome in the next edition of the DSM? And if not, what is EPPIC’s position on the recognition of Psychosis Risk Syndrome (PSR)? And under what circumstances, if any, would Professor McGorry and EPPIC recommend the use of antipsychotics for the treatment of patients considered to be at risk of developing psychosis? Has Professor McGorry finished experimenting on young people with the use of antipsychotics for the treatment of Psychosis Risk Syndrome?

2 – HEADSPACE and the ‘off label’ use of SSRI antidepressants– Why do Professor McGorry and Headspace acknowledge and then ignore the clinical trial evidence, and FDA and TGA warnings, on the increased suicidality risk for young people using SSRI antidepressants and advocate the ‘off label’ use of SSRIs by even moderately depressed young people? Won’t this result in more, not less, youth suicide?

In response to specific comments in Professor McGorry’s right of reply I offer the following:

‘Mr. Whitely… casts doubt about the wisdom of the Australian community’s desire for major mental health reform’ and ‘Mr.Whitely appears to believe that the case for mental health reform remains unproven. This is a disappointing approach from an elected representative…It is notable that he has not chosen not to state in his article his own views about the appropriate level of expenditure on mental health care (an increase? a cut?) or where he feels resources should be directed.’

I support a massive injection of funds into mental health but believe there are far too many unanswered questions to support the ‘best buys’ identified in Professor McGorry’s and the Independent Mental Health Reform Group’s $3.5 billion blueprint. I believe as an elected representative it is not my job to go with the flow but rather to ask difficult questions and ensure taxpayers funds are spent on programs that help not harm.

Mr. Whitely perversely uses my own declaration of previous pharmaceutical industry funding as supporting evidence for his claim that I am actively concealing this funding.

I do not suggest that Professor McGorry or any member of the Independent Mental Health Reform Group dishonestly ‘actively conceal’ their potential conflicts of interest. Rather, I am critical of them for not ‘actively disclosing’ potential conflicts of interest particularly when they badged themselves as an ‘independent’ and asked for $3,500,000,000 of taxpayer’s funds to be directed to programs, several of which they have significant influence over. I accept that senior decision makers would be aware at least of Professors McGorry and Hickies connections to EPPIC and Headspace but I am not so sure about the media and the public.  I became aware of Professor McGorry commercial ties to the pharmaceutical industry from a 2008 article in the British Medical Journal (BMJ). As is required by the BMJ Professor McGorry disclosed the sources but not the quantum of pharmaceutical company funding he had received.

In fairness to Professor Ian Hickie, whilst it was not disclosed in the blueprint, he does deserve credit for disclosing online via his CV that he has received $411,000 from various pharmaceutical companies. Whilst this was acknoweledged in my reference I should have acknowledged this self disclosure in the text of my blog when I originally wrote it (and I now have).

‘Mr. Whitely only specifically mentions two investment recommendations contained in the Blueprint – the early intervention youth mental health models headspace and EPPIC…Mr. Whitely raises concerns about the use of medication in headspace and EPPIC which are also unwarranted… We follow the International CPGs for early psychosis in EPPIC and beyondblue CPGs for the treatment of depression in young people recently published by beyondblue.’

As identified at 1 and 2 above I am very concerned that through the expansion of the EPPIC and Headspace networks we risk more ‘off label’ prescribing of antipsychotics and SSRI antidepressants to young people including children. I would be much more comfortable if EPPIC and Headspace followed the advice of the independent regulators i.e. the TGA and the FDA (and even the drug manufacturers) and stuck to recommending and practising ‘on label’ prescribing.