The West

Mental health policy in Australia, for so long ignored, is finally getting attention. The Gillard and Barnett governments have appointed mental health ministers and significant resources are being identified for new and expanded services.

Sport stars, celebrities and politicians have publicly shared their personal battles with depression, bipolar disorder and a host of other problems, helping to destigmatise mental illness.

It may appear at last we are on track to a happier, mentally healthier tomorrow. However, the future direction of mental health in Australia is far from certain.

Just about everybody involved in the debate agrees things need to change but this is where the consensus ends. There are at least three different directions on offer. For the want of better descriptions, I will call them the “Americanisation”, the “preventive psychiatry” and the “recovery” approaches.

Apart from spiralling mental health prescribing rates, the most obvious evidence of the Americanisation of Australia’s mental health system is the dominance of the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders diagnostic model. Often referred to as the “Bible of Psychiatry”, the current edition, DSM-IV, outlines the diagnostic criteria of 297 psychiatric disorders.

Subsequent editions of the DSM have thickened as new disorders have been added. This expansion has been exploited by aggressive pharmaceutical company marketing, resulting in the medication of people who would previously have been regarded as “normal”.

With the benefit of hindsight, Professor Allen Frances, the chairman of the task force that developed the DSM-IV, regrets aspects of it as having helped to trigger “three false epidemics, one for autistic disorder … another for the childhood diagnosis of bipolar disorder and the third for the wild overdiagnosis of attention deficit disorder”.

Professor Frances is particularly worried about the next edition, DSM-5, due for publication next year. He contends that further diagnostic expansion driven by the inclusion of pet disorders of enthusiastic researchers will see even more “normal” people made patients and more overprescribing of psychotropic drugs.

Thankfully, there is a significant international revolt, led by Professor Frances, from within the psychiatric and psychological professions, against the further medicalisation of behaviours proposed for DSM-5. This has already caused the American Psychiatric Association to abandon some of its more controversial DSM-5 proposals including “Psychosis Risk Disorder”.

Australia’s most prominent psychiatrist, former Australian of the Year Professor Patrick McGorry, has also expressed concern about the overprescription of psychiatric drugs in the US. However, he argues the risks aren’t as great here.

Unlike the US, we don’t allow direct advertising to consumers. However, the pharmaceutical industry aggressively markets its drugs to the Australian doctors who prescribe them. They also sponsor medical research, conferences, educational opportunities and even patient support groups that “raise awareness” of the disorders their drugs treat.

Professor McGorry is arguably the world’s most prominent advocate of preventive psychiatry. He believes that before the onset of psychosis, depression and other serious mental illness, there is a “prodromal phase” and that intervening then will help save many the misery of full-blown mental illness.

Critics of preventive psychiatry, including Professor Frances, contend it simply doesn’t work. They argue you can’t predict with enough accuracy who will go on to become ill and that even when it is accurate, independent evidence indicates that preventive measures don’t work.

Even Professor McGorry acknowledges that most of the people identified as being at ultra-high risk of developing psychosis, his specialist area, never do. Nonetheless, he argues the benefits of predictive intervention massively outweigh the risks of doing nothing.

The belief that intervention could prevent psychosis was part of the rationale for the Gillard Government’s decision last year to allocate $222.4 million for the rollout of early psychosis prevention intervention centres across Australia. At the time of the decision it looked likely that DSM-5 would include a Psychosis Risk Disorder. Now that is not happening, the future of the “preventive” function of EPPICs is uncertain.

Adding to this uncertainty is preventive psychiatry’s long and continuing history of unsuccessfully experimenting with psychotropic drugs as a means of “immunising” people considered at elevated risk of future mental illness.

While EPPICs will provide a broad range of psychosocial services and also treat patients who are already psychotic, significant questions remain unanswered.

The final option, the recovery approach, centres on developing a patient’s own capabilities and resilience. As opposed to the “ongoing disability” or “impending doom” assumptions inherent in the Americanisation and preventive psychiatry approaches, the recovery approach is more optimistic about the capacity for recovery and less reliant on pills.

It supports mentally ill patients with housing, educational, employment and psychosocial support — building blocks for a healthy and happy mind that can’t be replaced by drugs.

While the recovery approach is more optimistic about human resilience, it is more realistic about the limits of psychiatry than either of the other approaches.

The Americanisation approach is based on the unrealistic assumption that psychiatric science can accurately identify at least 297 different disorders and the preventive psychiatry approach on the fanciful notion that mental illness can be reliably spotted before it happens.

Unfortunately, a significant disadvantage for the recovery approach is that it offers a pessimistic outlook for the profitability of pharmaceutical companies.

If history is any predictor of the future this could prove to be its fatal flaw.

  • Professors Frances and McGorry are keynote speakers at the Asia South Pacific Mental Health Conference hosted by the Richmond Fellowship in Perth, which ends today.

Martin Whitely is the Labor MLA for Bassendean

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