The McGorry-Hickie reform controversy:
Why has mental health become so political?
September 24, 2011
Yesterday one of Australia’s most prominent psychiatrists, Professor Ian Hickie, wrote an op-ed piece in the SMH titled, “Ignore the critics, public need to back fresh start in mental healthcare”. It is part of a growing controversy around the Gillard government’s apparent big boost to mental health funding in this year’s Budget, in particular around the adoption of the Headspace model of youth early intervention and the downsizing of the Better Access psychology scheme…
The tone of Hickie’s article and the controversy from which it emerges can only be understood in terms of a wider crisis of psychiatry, both in Australia and internationally. Anyone following the debates over the American Psychiatric Association’s planned fifth edition of its diagnostic handbook, the DSM-5, will know that the process has been thrown into turmoil by attacks on the secrecy surrounding its development, its attempts to introduce contested new diagnostic categories, the debacle over its new personality disorder model [opposed by almost every leading personality disorder researcher in the US], and the fact that the psychiatrists who led the creation of DSM-III [Robert Spitzer] and DSM-IV [Allen Frances] — hardly fringe radicals — have both publicly attacked the next iteration.
This comes in the wake of even more generalised problems for the profession. In the US there have been controversies related to overdiagnosis and overprescribing of medications. Even George W Bush felt he had to attack the epidemic of ADHD diagnosis and stimulant prescribing in children, and now there is deep concern that the diagnosis of bipolar disorder across all ages is leading to the dangerous overuse of “second generation” antipsychotics. Globally, there have been scandals over the close financial ties between academic psychiatrists and the pharmaceutical industry, with humiliation of thought leaders in the field.Perhaps most devastating of all has been growing evidence that some of the most prescribed medications of all time, the modern antidepressants, may have little more effect than placebo in the treatment of “major depression”, a finding that has not only undermined the cache of drug therapy of mental disorders, but thrown into question the validity of the diagnosis itself. It is in this context that we can understand why data about the growing prevalence of mental disorder diagnoses — often used by advocates like Hickie and McGorry as a reason for boosting funding and services — is being challenged both within and outside psychiatry…
US no model for mental health
by Patrick McGorry and Alison Yung
June 15, 2011
One has to wonder why Allen Frances, a retired academic psychiatrist from the US, would make such a personalised critique of Australia’s mental health reform. Frances was chairman of the previous [fourth] edition of the American Psychiatric Association’s classification system of mental disorders, the DSM. He is unhappy with the way his successors are carrying out their task and has taken aim at one of their candidates for inclusion, the "attenuated psychosis syndrome". In a quixotic adventure, he has had a tilt at a windmill of quite a different kind, the mental health policy of Australia. Yet, the US health system has seriously failed the mentally ill and Frances is not in a strong position to give us advice…
While public questioning of psychiatry probably hasn’t reached the fever pitch of the 1960s and 70s, when powerful anti-psychiatry and mental health reform movements exacerbated the discipline’s own internal contradictions. That crisis was resolved in the 1970s and 80s with the victory of a particular biomedical model of mental disorder that put reliability of diagnosis ahead of pretty much all other considerations. Apparently turning to models found in the rest of medicine, the approach codified in DSM-III was meant to re-establish the scientificity of psychiatry against accusations it was either meaningless or simply a tool of social repression.
Today’s problems represent the spasmodic unravelling of that model, its inability to deliver “scientific” [read: biological reductionist] answers to the questions posed by disturbances of thought and emotion. This is not a problem found in psychiatry alone — the genomic revolution and bloated drug company bottom lines have failed to deliver the kinds of advances they promised also — but it is naturally concentrated in the speciality where social determinants of health and illness operate most obviously…
My take on the Australian controversies is colored by personal opinion. I don’t know what Schizophrenia is any more than anyone else, but I don’t really think that it’s defined by the dramatic symptoms of psychosis. Most cases that I’ve been around long enough to get to know the life story are like the case I mentioned earlier [1. from n equals one…, 2. from n equals one…, 3. from n equals one…] – they have always had something wrong. I doubt that delaying or aborting the psychotic break will alter the overall course that much [a clinical impression, not a pronouncement]. So I see McGorry’s program as a hypothesis, yet to be proved. His research to date certainly does not offer that proof [1. when n=a few…, 2. when n=a few…, 3. when n=a few needs n=a few more…, Dr. Raven’s Analysis]. It’s worth a well designed pilot project to see what happens – but not a country-wide movement. I’d love for them to prove otherwise, but until they do, that ball’s still in their court. So were I an Australian, I’d want to fund a well designed research program for them, but I think I’d keep my main focus on Basic Access for the near-term.