Monday, September 26, 2011

"Misrepresentation" is the polite word for it

In the last few months I've done quite a lot of writing about the work and public statements that have been made by two professors whose activities I've become concerned about. One of those professors is the former Australian of the Year and psychiatrist Prof. Patrick McGorry, who has already exercised a lot of influence on federal government policy in the area of mental health service funding, and has recently turned his attention to state governments. McGorry has his critics, and there are a number of points at which the professor and his critics differ. Many objections have been raised to a proposed mental disorder being accepted and diagnosed by the medical-scientific community, the "At risk mental state" also known as "schizophrenia prodrome", "Attenuated Psychotic Symptoms syndrome", "psychosis risk syndrome", "ultra-high risk" and "APS syndrome". Don't you think it's true that suspect things are often renamed? It's a rule that seems to apply to government departments, over-rated 80s pop stars and psychiatric labels. While McGorry's team of psychiatrists apparently do not advocate the inclusion of this frequently-named category into the next revision of the DSM, McGorry's advocacy of the concept is clear in the way that it has already been incorporated into educational material aimed at the general public which has been freely available from a website of one of the mental health services which McGorry leads. McGorry doesn't seem to be the kind of bloke who sits around waiting for the whole world to sign-off on an idea before he puts it into practice. Some of McGorry's critics have argued that if this new concept of a pre-psychotic state is applied in general clinical practice, the result will be many false-positive cases in which the full set of serious problems associated with psychiatric labelling and medication might be imposed on young people who would never have developed a mental disorder anyway. Allen Frances M.D. is a prominent professional who has written critically about this proposed new label.

A point of criticism of McGorry that I have highlighted in my writing has been what I believe is a failure to declare conflicting interests in many published medical journal papers written or co-authored by McGorry. In contrast I have been able to find a few published papers in which McGorry has disclosed a collection of conflicting interests. Why the inconsistency?

An important criticism of McGorry's work is that he has made important misrepresentations in his advocacy about mental health policy, to governments and to the public in general in media appearances. "Misrepresentation" is the polite word for what McGorry has been doing for quite some time. Melissa Raven, an Australian psychiatric epidemiologist, policy analyst and academic and Jon Jureidini, an Australian psychiatrist, head of a department in an Australian hospital and academic have written about misrepresentations that have been made by McGorry and Adjunct Professor John Mendoza. Jureidini and Raven are polite people, so they use polite language, but their arguments are made with clarity. I believe Raven and Jureidini are both members of Healthy Skepticism, an Australia-based organization which has the aim of "improving health by reducing harm from misleading health information".

A recent addition to the debate and controversy which surrounds Prof. McGorry is a review by Melissa Raven of the published research about EPPIC (Early Psychosis Prevention and Intervention Centre), which is a network of centres devoted to the medical treatment of early psychosis in young people. I believe McGorry is a director of EPPIC. The longitudinal study was conducted primarily in the 1990s and has been used successfully in arguments for greatly increased funding for EPPIC centres from the federal government. A number of the points highlighted in Raven's review have left me feeling alarmed and disappointed about the current state of science, psychiatry and politics in Australia.

A major point made by Raven in her article/paper published at the website of the Alliance For Better Access is that the study of EPPIC did not demonstrate that the EPPIC program of early intervention in psychotic illness is superior to standard (late) intervention in the Australian public mental health system, because the standard type and level of intervention was not represented at all in the study, not in the treatment group nor in the control group, because the control group in the study were patients in the precursor of the EPPIC program which offered a specialised early intervention program. The aspect of this matter which I find disturbing is that Professor McGorry has misrepresented the EPPIC study as evidence showing superiority of his early intervention model for psychosis treatment over "...generic late intervention in the standard system". I'm quoting McGorry being interviewed by Tony Jones on the ABC's Lateline last year. Where, I ask, has the EPPIC model ever been trailed against "...generic late intervention in the standard system"? I'd really like to know where I might read of such a study in a peer-reviewed medical journal, and I think Ms Raven would also be interested.

Another aspect of McGorry's representations about the EPPIC study which concerns me is the way he has described the strength of the evidence from the EPPIC study: "The evidence is very, very strong now....". Strong evidence? The EPPIC study was so methodologically weak that it was simply excluded from the 2011 systematic review of early psychosis interventions which was done by the world-famous and highly respected Cochrane Collaboration. I'm not a doctor, but I know a thing or two about the Cochrane Collaboration, and I would have thought that any study that was formally considered and then rejected by that organization in the process of research for one of their reviews should be considered not evidence at all, let alone strong evidence.

My regular readers should know that I'm a jaded old dame who casts a cynical eye over the way that science is conducted, but even I am disappointed that McGorry and co-authors have done that shabby old trick of writing one thing in the abstract of a journal paper, while writing contradictory content in the body of the paper. It seems no accident that the case that is being pushed is found in the paper's abstract, and abstracts which are supposed to faithfully summarize the overall content of scientific papers have a wider readership than the whole papers. McGorry apparently isn't the only highly influential Australian psychiatrist mental health advocate to pull this trick. Melissa Raven has written about a similar meaningful discrepancy between the content of a journal paper's abstract and its main body of text in a comment that she made at the website of The Conversation about a paper published in The Lancet which was co-authored by Professor Ian Hickie of Beyondblue fame. Regardless of how complacent or disappointed you or I might feel about the practice of writing journal paper abstracts that differ in content from the paper, it's wrong, it's misleading and it also isn't the way that science is supposed to be done.

Melissa Raven has found that "Misrepresentations of EPPIC have been a feature of submissions to governments, and in some cases have been incorporated into government policy documents." and she gives examples in her article, which I highly recommend and link to below. Professors McGorry and Hickie have both already had a major influence on federal government mental health policy, and the federal government is reportedly going to spend hundreds of millions of dollars in the next few years on services such as McGorry's EPPIC and Headspace networks. How do you feel about that? If you are one of my Australian readers, you're paying the tab. Feeling depressed? I thought psychiatrists were supposed to make people feel less depressed.

Review of EPPIC research.
by Melissa Raven
Alliance For Better Access.
August 29th 2011.

Tackling depression and poor sleep with one drug.
by Sunanda Creagh
18 May 2011
The Conversation.
[see the full comments]

Misleading claims in the mental health reform debate.
by Melissa Raven and Jon Jureidini
On Line Opinion.
August 9th 2010.

Healthy Skepticism

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