McGorry and co get a run on Radio National

I didn't hear ABC radio presenter Lynn Malcolm ask any tough questions in this program, but perhaps they were edited out, as McGorry did address many of the issues that people have with his plans for psychiatry geared to young people in Australia, funded by the Gillard Government. He also acknowledged that there are areas of active controversy. I think the most interesting thing about this show is how readily McGorry and another professional interviewed admit that some of the most important modes of treatment delivered at their various networks of mental health clinics are not fully researched and are not supported by a complete or even firm evidence base. They are happy to admit that much more research is needed, and the big issue that I have with McGorry and co is that I believe that an evidence base should precede the offering of any medical treatment (outside of the context of a clinical trial), and not follow after the treatments are offered to vulnerable young people, and after huge sums of funding from the federal government have been aggressively solicited for and received. Demonstrating that a medical service does more good than harm should not be just an afterthought to placate the critics. 
Malcolm, Lynne (2012) Young minds, the highs and the lows. All in the Mind. ABC Radio National. June 10th 2012. http://www.abc.net.au/radionational/programs/allinthemind/young-minds2c-the-highs-and-lows/4054982

Need to see a head specialist?

Does one really need to visit a mental health clinic for butterflies in the stomach? A fluttering in the abdomen is anxiety as in a psychiatric disorder? It seems like a bit of an exaggeration to me.

Headspace - Dreaded Butterflies.
by Simon Bronson


http://vimeo.com/41257447

Big news on the psychiatry front when I wasn't looking

I've not had much time for blogging in the last few weeks and I've missed some important developments in the last couple of months regarding the upcoming edition of the "bible of psychiatry", the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). An early-intervention mental health diagnosis that has been championed by Prof Patrick McGorry, who has great influence on the Gillard Government and a high-profile in Australia, has been rejected by the American Psychiatric Association (APA). This supposed disorder which is thought to be a milder early sign of the onset of a psychotic mental illness, typically in teens and young adults, will not be included inthe fifth edition of the world-famous manual of psychiatric diagnosis, but will be relegated to the appendix where disorders requiring more research are placed and forgotten. This controversial condition went by a bewildering range of names: "psychosis risk syndrome" "prodromal symptoms" "prodrome" "high-risk syndrome" "ultra-high-risk syndrome" "at-risk mental state" etc. The ad hoc nomenclature gives the impression that the professor was just making it up as he went along. 

Don't be overly distracted by the rejection of one proposed new mental illness by the APA. The crashing and burning of the prodrome is not really the big news from last month on the subject of modern psychiatry's revision of it's great big guidebook. The big news was that two diagnostic categories in some of the most supposedly common and also some of the most aggressively promoted types of mental illness in Australia, major depressive disorder and generalised anxiety disorder, have been found by psychiatry researchers to be diagnostic categories which cannot be reliably identified, in that there was found to be a major lack of consensus from one doctor to another about who did or did not meet some diagnostic criteria for these types of disorders. What kind of diagnoses are these, which cannot be identified with any certainty or reliability? If modern psychiatry was an emperor, he'd be looking very bare and very embarrassed right now.

Why are these recent developments important to Australians? The Gillard Government has committed a huge sum of money to reforms in mental health services, guided by controversial figures such as Pat McGorry, Ian Hickie and John Mendoza. We don't only have the government spending big on psychiatry and shoving the message down our throats that we all need more of it, we also have some very powerful and influential charities and organizations inflicting very pervasive and long-standing public awareness campaigns about mental illness onto the general public. Two that come to mind are Beyondblue and the Brain and Mind Research Institute, but there is a mental health message promoter lurking around every corner in Australia. Awareness campaigns actively recruit ordinary unqualified, uneducated members of the public as peer-support spreaders of the word that mental illness is everywhere and needs to be treated yesterday. Psychiatry propaganda seeps into ordinary social exchanges and is impossible to avoid. TV news stories hammer the message that we should be uncertain and concerned about the minds of others and our own. Journalists have swung from one extreme to another regarding the reporting of suicide (which is universally assumed to be the result of mental illness). I remember the days when it was a subject banned from news reports based on the belief that reporting might trigger copy-cats. These days suicide is the flavour of the month on current affairs reporting, and journalists jump to label crimes and deaths as suicide, sometimes mistakenly. Because of this tasteless and horrible focus on the morbid and the sordid it is now impossible to sit through the news hour on TV in the company of young children. For many years now Australians who watch late-night commercial television have been assailed by TV commercials for the network of Headspace psychiatric clinics aimed at young people, often with scant or no indication that this is what these clinics actually are. Now I find that there is absolutely no place except home where I can go to escape messages about mental derangement. Even in a public toilet I have psychiatry propaganda about depression and anxiety (the two disorders that can't apparently be reliably diagnosed) shoved in front of my face. We now have full-page illustrated advertisements advocating the identification of mental illness and the use of the services of professional mental health services on the back of dunny doors! They are found in toilets in shopping centres, universities, you name it. ENOUGH!

What's wrong with spreading awareness, you might ask. If the message is a misrepresentation, then it is all bad, and the message is indeed mostly lies. We are told that the treatments work. In fact, there is a load of good evidence that many of the drugs prescribed for depression and other mental illnesses do not act as chemical treaments and have troublesome or dangerous side effects. If they were just sugar pills, that would only be a con, but it's worse than that. An active placebo works because the person taking the drug can feel definite and troublesome side effects, and he/she unconsciously takes this as evidence of the potency of the drug, and this gives rise to a powerful placebo effect (which is a real effect, but not the result of any drug action). These drugs cost patients and the taxpayer dearly, many have serious side effects and many of them basically don't work, and in the process the patient is often unjustifiably convinced that she/he has a defective brain which needs ongoing chemical assistance to work adequately. We are told that modern psychiatry is based on a solid foundation of decades of research evidence that meets the highest scientific standards, but in fact one of the trials which was part of the evidence foundation of the recent DSM revisions had a grand total of nine (9) ill patients as subjects. And they are trying to make you and I feel guilty for not going along with this debacle? Pull the other one, mate!

Aldhous, Peter (2012) Trials highlight worrying flaws in psychiatry 'bible'. New Scientist. 17 May 2012 issue 2865. p.6-7.
http://www.newscientist.com/article/mg21428653.600-trials-highlight-worrying-flaws-in-psychiatry-bible.html

Maxmen, Amy (2012) Psychosis risk syndrome excluded from DSM-5. Nature. May 9th 2012.
http://www.nature.com/news/psychosis-risk-syndrome-excluded-from-dsm-5-1.10610

"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.
http://www.betteraccess.net/index.php/information/iseppicevidencebased

Tackling depression and poor sleep with one drug.
by Sunanda Creagh
18 May 2011
The Conversation.
http://theconversation.edu.au/tackling-depression-and-poor-sleep-with-one-drug-1332
[see the full comments]

Misleading claims in the mental health reform debate.
by Melissa Raven and Jon Jureidini
On Line Opinion.
August 9th 2010.
http://www.onlineopinion.com.au/view.asp?article=10793

Healthy Skepticism
http://www.healthyskepticism.org/global

Headspace psychs Prof. Ian Hickie and Prof. Patrick McGorry under fire today from other professionals

A quote from one of the professionals in this article:

"The McGorry machine is distorting things in Australia. There's people in the UK who look at what's happening in adolescent and youth psychiatry here and think that it's completely mad."

McGorry accused of conflict of interest.
by Jill Stark
Sydney Morning Herald.
August 7th 2011
http://www.smh.com.au/national/mcgorry-accused-of-conflict-of-interest-20110806-1igxd.html

http://m.theage.com.au/national/mcgorry-accused-of-conflict-of-interest-20110806-1igxd.html

Doctors in different headspace on suicide.
by Jill Stark
Sydney Morning Herald.
August 7th 2011
http://www.smh.com.au/nsw/doctors-in-different-headspace-on-suicide-20110806-1igk0.html