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.
In response I wrote this letter to the editor (second one here):
I’m a public hospital psychiatrist who greatly admires Ian Hickie for his tireless efforts in mental health research and advocacy. However, I thought his intemperate spray at opponents of his preferred set of policy and treatment prescriptions — in particular the controversial early intervention model he and Pat McGorry have championed — demeaned his position and the serious debates in question.
I recently attended an international conference where McGorry and other advocates of early intervention spoke, and what came through was how little evidence there was for the “Headspace” model that our government has adopted so enthusiastically. There is also very little evidence for the use of medications in patients thought to be at risk of psychosis.
Professor Hickie uses an old debating trick, rolling a disparate group of critics into one list without seriously addressing any of their concerns. By mentioning Scientologists alongside professional detractors, in one of his four main points, he seems to want to deflect public attention from debates within psychiatry rather than illuminating them.
Professor Hickie is dead right that psychiatrists should devote their time to debating public policy and arguing for social change. But that also means engaging in explanation rather than bombast when criticised. The public (and his colleagues) will thank him for the former and not the latter.
The crisis in psychiatry
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. Is it really true that more than half the population will have an episode of an “illness” called “major depression” in their lifetimes, or is this an artefact of how such an illness is constructed, measured and contextualised? And does this mean that everyone who meets criteria must pop a tablet or go to 12 sessions of cognitive behavioural therapy?
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.
The last decade has seen not only growing critiques of this impasse but attempts to forge new ways of thinking about mental health. Most, however, seek radical changes to the existing framework and not its outright rejection. So, for example, Sydney University philosopher Dominic Murphy argues that psychiatry needs to find its scientific basis in modern cognitive neuroscience. Psychiatrists and historians Edward Shorter and David Healy look back to earlier periods of scientific advance to make a powerful case that older antidepressants and shock therapy were more effective than more recent (and more profitable) drugs. Psychologist Richard Bentall rejects the biomedical and diagnostic focuses of psychiatry in favour of a symptom-based and psychotherapeutic approach.
To his credit, Pat McGorry also bases his advocacy of an early intervention or “staging” model on the reasonable belief that the tools bequeathed by the diagnostic psychiatrists of DSM-III have proven inadequate. Indeed, McGorry very much sees his efforts as part of an attempt to lead a “scientific revolution” in the Kuhnian sense — to replace a failed old paradigm with a new, better one. As it says in McGorry and Hickie’s statement of their new paradigm,
Diagnosis in psychiatry increasingly struggles to fulfil its key purposes, namely, to guide treatment and to predict outcome. The clinical staging model, widely used in clinical medicine yet virtually ignored in psychiatry, is proposed as a more refined form of diagnosis which could restore the utility of diagnosis, promote early intervention and also make more sense of the confusing array of biological research findings in psychiatry by organizing data into a coherent clinicopathological framework.
It is my contention that this simply deepens the contradictions found in the existing model of diagnostic psychiatry rather than overcoming them. Yet the problem is one faced by all of medicine, which seeks to define health and illness without recognising that such definitions are socially constructed. Medicine follows what may be called a positivist research programme, where value judgements about health and illness are naturalised and eternised, rather than being recognised in their social and historical specificity. Drawing on the pioneering work of Peter Sedgwick, I have written about these issues elsewhere — in a review of Bentall’s last book and an analysis of the limits of antipsychiatry.
The problems with early intervention
It is worth looking at some of the more fine-grain problems with McGorry’s importation of “clinical staging” into psychosis (and other conditions — he has also been part of developing such a model in bipolar disorder, and supports efforts around depression and borderline personality).* Simply put, it may both be an inappropriate analogy to draw for psychiatric disorders but it may also suffer from the limits of staging for most physical illnesses.
Staging depends on being able to find markers of the very early phases of an illness process and, through targeted intervention, prevent progression to later, less treatable phases. A classic example is bowel cancer, where screening for and treatment of early cancer (or pre-cancerous cell changes) with colonoscopies in high-risk individuals (e.g. those with a strong family history) may prevent the devastating metastatic form of the illness.
But in psychiatry we don’t have any specific biological (or other) markers to target, and so it’s the “ultra high risk” (UHR) syndrome itself that is being targeted. This actually parallels the rest of medicine where claims made for biomarkers have proven to be overhyped.
There is also no evidence that there are specific symptoms or parts of the UHR syndrome that, if treated, will prevent onset of psychosis. This is reflected in the fact that only 31 percent of UHR patients “convert” to some kind of actual psychotic syndrome by the two-year mark. And it is not clear whether this is a homogenous group — they probably include a mix of diagnoses and not just schizophrenia. Of the remaining 69 percent, a very high proportion continue to function poorly despite not becoming psychotic, suggesting this syndrome is “UHR for poor function” more than specifically “UHR for psychosis”. Importantly, UHR subjects are pretty much all are self-referrals (perhaps with nudging from families) and so they are unlike typical schizophrenic patients in that they display higher levels of insight and engagement.
The population benefit claims being made by McGorry & Hickie are undermined by the fact that Headspace centres are not population interventions but places that self-selected patients seek help around relatively non-specific problems. Hence why there is virtually no evidence base for Headspace — nobody has really defined what it is meant to help and who it is going to be accessed by in any previous trials. Thus there is a real possibility that the initiative will prevent little of the serious mental illness (or even “neurotic” disorders) that are being treated today because it targets a different population — this issue has simply not been clarified. Don’t get me wrong, Headspace may prove to be very beneficial to the young people it treats, but to say it is evidence-based would not be correct.
Even for individuals, there is little clear evidence that targeted interventions for UHR subjects will work to do anything more than delay onset of psychosis, and then not past two years. Ironically, there is evidence that once you have been UHR for two years, there is minimal chance you will convert to frank psychosis anyhow. Certainly the recent Cochrane review has effectively stopped research into the use of antipsychotics in the UHR group, and fish oil needs further testing. Talk of antidepressants being effective is based on retrospective clinical audits, a relatively weak and unreliable form of evidence (and the idea that a non-antipsychotic drugs are effective in preventing psychosis further undermines the claimed specificity of the UHR concept).
McGorry persisted with hopes around medication-based interventions until the recent controversy over ethics approval blew up. Why would he do so? In this he was only following the pattern of mainstream psychiatry, which maintains a narrow focus on intervention equalling some kind of individualised treatment, whether biological or psychological. There’s a reason medicine (the profession) is called medicine (after medications). That focus is shaped by a complex of forces, in particular the growing influence of Big Pharma over the last 30 years.
Finally, even psychosocial interventions for individuals may not be much chop. If medical epidemiology teaches us anything it’s that to change the population incidence and prevalence of many conditions you need population measures. Clean running water and sewage systems prevent many more deaths from illness than all the high-tech medical advances put together. Maybe to decrease the incidence of psychosis we need to look at social and environmental measures.
Politics and psychiatry inseparably linked
None of the above critique is particularly original, nor is it based on anything but the arguments and evidence marshalled by enthusiasts of early intervention (including McGorry himself). So how did McGorry and Hickie gain so much sway over government policy in the first place? Clearly they are tireless and strategic campaigners for their particular solution for the problems they see in mental health service delivery. They have also correctly identified that the current mainstream psychiatric framework is weak and in need of challenge. But there is something about their model that also fits well with current neoliberal governance models, including Gillard’s preferred preventative health and social inclusion agendas.
In essence, early intervention in psychiatry matches the kinds of preventative health models that dominate in Australian public policy: That while there are social determinants of health and illness, governments can only intervene at the individual level, targeting those who are (through their own behaviour) “at risk”. Social policy thus becomes targeted at individuals or families rather than entire populations. The justification is that this is more cost-effective (an unproven assumption, but one fitting well with neoliberalism’s ideological aversion to universal social provision) and that if behaviour change is not then produced governments can more easily blame individuals for their own failings than turn the spotlight on social structures.
I’m not arguing that this is how McGorry and Hickie see it, but why their model may have become so favoured. It is interesting that Hickie has in the past advocated for more market discipline in health care, and that both Hickie and McGorry seem to have argued for dropping the expansion of Medicare-funded psychological services (Better Access) on the basis that its (flawed) universalism was creating a type of middle-class welfare. It is their reflex acceptance of the social status quo that is the problem, perhaps intensified by having to adapt to the health bureaucracies they have been lobbying so intensely.
One of Hickie’s targets yesterday seems to have been a recent piece by the right-wing psychiatrist Tanveer Ahmed that argued for psychiatrists to stop being so noisy about public policy (bizarre given the author’s frequent ideological rants about psychiatric concepts). It is here that I am with Hickie and McGorry in recognising the fundamentally political nature of debates about not only mental health policy, but the very nature of mental health and illness. How human beings individually experience our society cannot be separated from collective projects for social change and (perish the thought) human liberation. Unfortunately, I fear that despite their passionate beliefs, good intentions and political savvy, McGorry and Hickie have delivered a model that mostly serves to suit the public policy needs of a historically transient phase of capitalist development we call neoliberalism.
* It is important to distinguish McGorry’s work on first episode psychosis, which has a firmer evidence base and doesn’t depend on the staging heuristic, from his approach to early intervention strategies (or “indicated prevention” as it is known in preventative health jargon).
Dr_Tad is a public hospital psychiatrist. The views expressed here are entirely his own.