Posted on Sunday 25 September 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…
In a short burst, the Left Flank gives us as good a summary of the current crisis in psychiatry as I’ve  read. It is perhaps the reason that the rest of the world is so interested in the controversy swirling around in Austraia right now. It’s a microcosm of the story throughout the western world.

Outside Australia, the focus was on Dr. McGorry’s scheme for diagnosing an "ultra high risk" group at risk for psychosis. The DSM-5 task force is considering including this group as a new Disorder. Both Dr. Insel of the NIMH and Dr. Kupfer of the DSM-5 group have jumped on this concept of early intervention [class action in the air…]. Dr. Allen Frances [in charge of the DSM-IV revision] opposed this inclusion [DSM-5 in Distress], and in the course of his opposition pointed to the weakness of Dr. McGorry’s evidence and suggested its widespread application is premature. In mid-June, Dr. McGorry lashed back in an op-ed piece:
US no model for mental health
the australian
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…
Inside Australia, the controversy has a different complexion. The program [headspace, EPPIC] backed and administered by Dr. Patrick McGorry and the equally prominent Dr. Ian Hickie was heavily funded by the Australian government by cutting funds to the Better Access program for general mental health care. So the conflict is not only a scientific question about the strength of the early intervention program, it’s about its impact on Australia’s mental health programs in general. In August, Journalist Jill Stark wrote an article in The Sunday Age summarizing the problem and reporting on allegations that Dr. McGorry had used his position as a government adviser to push his pet program [McGorry accused of conflict of interest]. Dr. McGorry reponded angrily [Merchants of doubt do no favours for people with mental illnesses]. In a few weeks, in response to Dr. McGorry withdrawing a controversial clinical trial of Seroquel in these patients, Jill Stark reported that the trial had been withdrawn in response to the criticism [Drug trial scrapped amid outcry], which Dr. McGorry denied [Response to The Sunday Age article of 21st August 2011], with some venom. Dr. Frances weighed in too [Seven Questions For Professor Patrick McGorry]. Yesterday, Dr. Ian Hickie joined the public debate with an opinion piece in the Sydney Morning Herald [Ignore the critics, public need to back fresh start in mental healthcare]. Meanwhile, the Alliance for Better Access has a press release protesting the changing in funding and published an analysis of Dr. McGorry’s proposed new programs. Finally, there are independent reviews of headspace and Better Access.

Whew! I don’t know if I should apologize for all the links in that paragraph or get a medal for collecting them. There’s no shortage of information about the current goings on in mental health policy in Australia – that’s assured. I decided that collecting them in one spot might help anyone who is interested review the story first hand. The battle’s being passionately waged in the halls of the Australian government and in the popular press [a full curriculum on the misuse of the ad hominem and straw man fallacies in public debate]. So, back to the Left Flank commentary:
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…

Right on target again! I leave his conclusions for your perusal here.

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.

As for the Australian controversy as a microcosm or paradigm for us all, it has all the right elements. It was initiated by a  public health argument reminiscent of many we’ve heard before using statistics that are hyped beyond credibility – increasing incidence requiring urgent attention. They propose massive extension of a small, questionable trial instead of further investigation. They attack and demean their critics instead of responding to [or listening to] the criticisms. The decisions that matter come from the halls of power rather than from measured scientific discourse and are uninformed by abysmal track record of massive public mental health initiatives. They’ve failed to notice that expert opinion no longer carries the weight it once did [for good reason]. The rallying cry of evidence-based medicine has caught up with them because their evidence is weak. And a lot of the support they perceive is, in fact, the desperate cry from like-minded colleagues looking for something to keep a waning dream alive. This is not the time to be rolling out something new in psychiatry aiming at a brave new but indeterminate future. It’s a time to hold on to what you’ve got – a time for reflecting on lessons learned.
    September 26, 2011 | 9:14 AM

    I see hundreds of people given a diagnosis of schizophrenia and, in contrast to your experience, they have NOT always had something wrong. Sometimes the diagnosis is not given until years after treatment starts for what initially presents as a quite different condition.

Sorry, the comment form is closed at this time.