"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

McGorry has his critics ....

Ahmed, Tanveer (2010) Mental health claims overblown. Sydney Morning Herald. smh.com.au August 12, 2010.
http://www.smh.com.au/opinion/politics/mental-health-claims-overblown-20100811-11zoj.html

Attard, Monica (2010) Professor Patrick McGorry, 2010 Australian of the Year. Sunday Profile. ABC Radio National. January 31st 2010.
http://www.abc.net.au/rn/sundayprofile/stories/2010/2806382.htm

Dunleavy, Sue (2011) Schism opens over ills of the mind. Australian. June 16th 2011.
http://www.theaustralian.com.au/news/features/schism-opens-over-ills-of-the-mind/story-e6frg6z6-1226075910650

Dunleavy, Sue (2011) US expert slams Patrick McGorry's psychosis model. Australian. June 14, 2011.
http://www.theaustralian.com.au/national-affairs/us-expert-slams-patrick-mcgorrys-psychosis-model/story-fn59niix-1226074544901

Frances, Allen J. (2011) Continuing Controversy On Australia's Mental Health Experiment: Seven questions for Dr McGorry. Psychology Today Blogs. June 13th 2011.
http://www.psychologytoday.com/blog/dsm5-in-distress/201106/continuing-controversy-australias-mental-health-experiment

Frances, Allen J. (2011) Australia's Reckless Experiment In Early Intervention: prevention that will do more harm than good. Psychology Today Blogs. May 31st 2011.
http://www.psychologytoday.com/blog/dsm5-in-distress/201105/australias-reckless-experiment-in-early-intervention

Frances, Allen J. (2010) DSM5 'Psychosis Risk Syndrome'--Far Too Risky. Psychology Today. March 18, 2010.
http://www.psychologytoday.com/blog/dsm5-in-distress/201003/dsm5-psychosis-risk-syndrome-far-too-risky

McGorry's early intervention model slammed. Australian Doctor. June 14th 2011.
http://www.australiandoctor.com.au/thisWeek.asp

Marshall, M. and Rathbone, J. Early intervention for psychosis. The Cochrane Library. Cochrane Database of Systematic Reviews. 2011 Issue 6. page 24.
Art. No.: CD004718. DOI: 10.1002/14651858.CD004718.pub3.
http://onlinelibrary.wiley.com/o/cochrane/clsysrev/articles/CD004718/pdf_fs.html
http://onlinelibrary.wiley.com/o/cochrane/clsysrev/articles/CD004718/frame.html
[see "Other potential sources of bias" in the summary of findings]

Raven, Melissa and Jureidini, Jon (2010) Misleading claims in the mental health reform debate. On Line Opinion. August 9th 2010.
http://www.onlineopinion.com.au/view.asp?article=10793
["...we also believe it matters that high-profile mental health advocates are able to mislead by proclaiming authoritative-sounding statistics that almost no one bothers to check, and that misleading claims are incorporated into health policy. This uncritical acceptance is an impediment to evidence-based policy. Worse, when the inaccuracies of claims are pointed out, there is often reluctance to acknowledge the misinformation and attempt to rectify it, as is the case with GetUp." ]

Speed Up & Sit Still (blog of Martin Whitely MLA)
http://speedupsitstill.com/

Webb, David and Raven, Melissa (2010) McGorry's 'early intervention' in mental health: a prescription for disaster. On Line Opinion. April 6th 2010.
http://www.onlineopinion.com.au/view.asp?article=10267

Weber, David (2011) Mental health centres under attack. ABC News. May 12, 2011.
http://www.abc.net.au/news/stories/2011/05/12/3215323.htm

Weber, David (2011) Professor McGorry hits back at critics. The World Today. ABC Radio National. May 20 2011.
Audio:
http://www.abc.net.au/news/audio/2011/05/20/3222359.htm
Transcript:
http://www.abc.net.au/worldtoday/content/2011/s3222359.htm

Williams, Daniel (2006) Drugs before diagnosis? Time. June 18th 2006.
http://www.time.com/time/magazine/article/0,9171,1205408,00.html

On the front page of today's Australian .....

US expert slams Patrick McGorry's psychosis model
EXCLUSIVE: Sue Dunlevy
The Australian
June 14, 2011.
http://www.theaustralian.com.au/national-affairs/us-expert-slams-patrick-mcgorrys-psychosis-model/story-fn59niix-1226074544901

and there is also this very recent article in an Australian medical professional magazine which apparently includes a critical quote form the former president of the Royal Australian College of Psychiatrists, Louise Newman, but unfortunately is only available for doctors to read:

McGorry's early intervention model slammed.
Australian Doctor.
June 14th 2011.
http://www.australiandoctor.com.au/thisWeek.asp

and there's also these:

"On the face of it, Australia's sudden and massive investment in the EPPIC program seems far excessive and decades premature. EPPIC may indeed work, but it represents a huge and reckless bet seemingly based more on blind faith in one man than on a substantial foundation of research and experience."
- Dr Allen J. Frances

"Clearly pre-emptive/preventive treatment is an important component of the EPPIC model, and potential recipients are being actively recruited."
- Melissa Raven, psychiatric epidemiologist and member of Healthy Skepticism, in comments on the article by Dr Frances in Psychology Today

Continuing Controversy On Australia's Mental Health Experiment: Seven questions for Dr McGorry.
Allen J. Frances
Psychology Today Blogs.
June 13, 2011
http://www.psychologytoday.com/blog/dsm5-in-distress/201106/continuing-controversy-australias-mental-health-experiment
[with most interesting comments from Prof. Henry Jackson and Melissa Raven]

Australia's Reckless Experiment In Early Intervention: prevention that will do more harm than good.
Allen J. Frances
Psychology Today Blogs.
May 31, 2011
http://www.psychologytoday.com/blog/dsm5-in-distress/201105/australias-reckless-experiment-in-early-intervention

Prof. Pat McGorry and the disclosure of conflicts of interest - what a friggin' joke!

I had to laugh out loud today when I noticed the disclosure statement next to an article written by the Australian psychiatrist, former Australian of the Year and influencer of politicians Professor Patrick McGorry about suicide that was published on April 15th 2011 at a website titled The Conversation beta, which looks like something from Australia that has aspirations to seriousness. The blurb next to the disclosure statement says:

"Our goal is to ensure the content is not compromised in any way. We therefore ask all authors to disclose any potential conflicts of interest before publication."

Well, the folks at The Conversation can ask all they like, but the prof only disclosed this much:

"Pat McGorry receives funding from the NHMRC."

I have serious doubts that this statement covered everything. This online article was published in April 2011 only a month after the publication in March 2011 of a piece by Prof. McGorry and another author was published in the medical journal Australian Family Physician, which included this rather fuller disclosure statement:

"Funding and support: Professor McGorry receives funding from the
Colonial Foundation, and from a program grant and a Clinical Centre
Research Excellence Grant from the National Health and Medical
Research Council of Australia. He has also received research grant
support from Janssen Cilag, Eli Lilly, Pfizer, Novartis and Astra Zeneca."

I guess someone might try to pose the question of how long does it take for a medical researcher to live down a professional conflict of interest. I'd say it would have to be a lot longer than a month, and I'm sure that some would say that there is no "use by" date for conflicts of interest.


References

McGorry, Patrick (2011)
The sort of conversation we should be having about suicide. The Conversation (beta). April 15th 2011.
http://theconversation.edu.au/the-sort-of-conversation-we-should-be-having-about-suicide-663

McGorry, Patrick D. and Goldstone, Sherilyn (2011) Is this normal? Assessing mental health in young people. Australian Family Physician. March 2011 Vol 40, (3) 94-97.
http://www.racgp.org.au/afp/201103/41499