Many complex and interlocking issues

Peter Parry

As this film raises so many complex interlocking issues, I'm going to highlight a plethora of things in rapid staccato note form - please note this is not a disorder!

By way of disclosure, I have no pharmaceutical company interests to declare. I am a member of Healthy Scepticism www.healthyscepticism.org - an organisation of medical, pharmacy and other health professionals and academics that seeks to counter misleading pharmaceutical industry information. The Evatt Foundation paid my flight.

Generation RX starts on a philosophical note - the dulcet tones of the narrator hint to the mind/brain problem. Then cut to a psychiatry professor: '... the biomedical model is problematic, I don't think anything is going to be strictly biological that is to do with the brain'. That is spot on in my opinion. Prof Derek Silove, is a Sydney based psychiatrist - together with other colleagues particularly in the Faculty of child psychiatry to which I belong - was influential in gaining the release of asylum seeker children from long term detention. Silove's paper, 'Biologism in Psychiatry', was in the Australian and New Zealand Journal of Psychiatry in 1990. I recall reading it in that, my first year of psychiatry training, to quote:

Australian psychiatry should consider the recent ideological shift in the USA to an extreme biological model of mental disorders. There is increasing evidence that proponents of this model are not simply promoting the value of biological research (with which few psychiatrists would quibble), but that the field is at risk of being overwhelmed by a reductionist 'biologism' which assumes an organic causation for all abnormal human behaviour.

Psychiatry, particularly child psychiatry, deals with an incredibly complex bio-psycho-socio-cultural domain. It is not really science - certainly not physics. It is like economics - with multiple ideologies and theories. Our super funds show how economists can get it very wrong. To some extent, mainly in America, some child psychiatrists are getting it very wrong. To quote a paper by Werry (a NZ emeritus professor of child psychiatry) and McClellan (an American child psychiatrist) that was in the Journal of the American Academy of Child & Adolescent Psychiatry in 2003: '... we still suffer faddish waves of unsupportable treatments and idiosyncratic diagnostic practices, caution and humility are indicated when assessing our current standards of care.'

Overmedicating of children in the USA is a scandal. Where polypharmacy (that's more than one medication at the same time) is common and it is only half parodying the situation to say the number of psychotropic drugs seems almost to correlate with age. Newsweek reported on a boy diagnosed with bipolar just after his 2nd birthday and medicated from that time who had had 38 psychotropic drugs by time he was 10.

In Australia it is nowhere near as bad - at least amongst child psychiatrists who in this country have time to make assessments, not rush diagnoses and are by and large exceptionally cautious in medicating - especially pre-pubertal children. Paediatricians are also more conservative than their American counterparts, but have less time to assess/do therapy than us child psychiatrists, so they can come under greater pressure to medicate.

DSM diagnoses like ADHD, Bipolar, Major Depression, Adjustment disorder, and multitude of anxiety disorders cannot take into account the full developmental context of children's lives and, at worst, abbreviate problems to a reductio in absurdio degree. Tomorrow I go to the psychiatry college headquarters in Melbourne to attend a case histories examiners' meeting. The exams stress 'Diagnostic case formulation' over and above 'DSM diagnoses'. Although one has to know how to appropriately apply the DSM diagnostic manual. A DSM diagnosis tells us about the phenomenology, the symptoms a person is suffering. In severe mental illness a DSM diagnosis tells us more about course and prognosis and likely response to medication. A biopsychosocial diagnostic case formulation is about a wholistic understanding of a person's problems and underlying causes both past and present. This often guides therapy much better than a simple DSM diagnostic label.

The Americans don't have Medicare. At the national American psychiatry and child psychiatry conferences this year, I presented a survey showing only 3.5 per cent of ANZ child psychiatrists thought the Americans weren't over-diagnosing so-called paediatric bipolar disorder. Many American colleagues agreed. An email from a Prof Rosenlicht:

medicalizing aberrent behavior is important in America. Medical benefits, including whether or not a patient can be hospitalized, and for how long, and what medications he/she may take are dependent upon the diagnosis.

This "disorder inflation" is common in this country, and driven by several factors. One is certainly the effort to get needed care for ill children.

But another is the great financial benefit to the pharmaceutical industry, which provides most of the CME (Continuing Medical Education)..

At the American child psychiatry conference, many said the private insurers demand a diagnosis, often they are not paid if they say it is a family relationship problem or an 'adjustment disorder'. But they said they are paid if they make a diagnosis like bipolar or major depression. Those diagnoses imply greater need for medication.

Thus perverse incentives and a pharmaceutical domination of CME and research journals and even the DSM diagnostic manual does drive overmedicalisation. But it is not one big conspiracy. It is more something about complex systems and the way society, money and power operate systemically. Other factors are the desire of doctors to do good. Leading professors can rationalise Pharma money for CME talks and research is because they are doing good. After all the Evatt foundation paid for my airline tickets - I think I'm doing good? Particularly in psychiatry we should be aware of unconscious processes and rationalisations!

At the two main ANZ psychiatry conferences this year I presented internal industry documents regarding the manipulation of drug trials. Feedback from my colleagues was of genuine outrage about documents like this email from AstraZeneca's public relations manager about their antipsychotic Seroquel:

... there is growing pressure from outside the industry to provide access to all data resulting from clinical trials conducted by industry. Thus far, we have buried Trials 15, 31, 56, and are now considering COSTAR. The larger issue is how do we face the outside world when they being to criticize us for suppressing data.

Other documents reveal the company knew about serious weight gain problems despite publishing a paper and numerous drug ads saying it was weight neutral. On that basis, I prescribed Seroquel to a few teenagers with psychosis who had weight problems - and the weight problems got worse. These issues then get personal! We are at a critical moment in medical research and education - we don't know what so-called 'evidence' we can trust.

A 2005 paper in Public Library of Science Medicine is entitled: 'Medical journals are an extension of the marketing arm of pharmaceutical companies.' The author? - the former chief editor at the British Medical Journal.

But intensely emotive issues can polarise debates to an unhelpful degree and the pendulum swing from mindless psychiatry to brainless psychiatry. Medications have a benefit/risk ratio. Sometimes benefits outweigh risks. The film focussed on Ritalin and SSRI antidepressants. There was some mention of antipsychotics - in my view the damage done by overuse of antipsychotics is more serious.

Ritalin: Is a performance enhancing drug. The child should be in very serious trouble from ADHD (after other reasons excluded) that's almost miraculously fixed by Ritalin for it to be worth the risk. These little miracles do occur regularly.

SSRIs: When FDA got all data - they do cause suicidality in small percentages. A small percentage equates to large numbers when millions prescribed. But: Youth suicide rates have fallen - with prescribing of SSRIs. This coincides with economic boom, low youth unemployment. In Australia, with stricter gun laws, drop in shooting suicides. With suicide prevention programs, enhanced access to therapy. And with change in youth and school culture, 'dobbing' in a suicidal friend is no longer taboo. Drug trials show placebo effect is strong. Placebo effect stronger with own doctor and you know you're on the real medication. Adult psychiatrist colleagues who prescribe SSRIs and listen carefully to their patients - say SSRIs not really 'antidepressant', rather they act like mood analgesics. The relief of psychic pain may be enough to initiate recovery. The key is to warn teens and parents and start low and go slow with dose! And try non-drug things and fish oil first! The antipsychotics have their place. The Citizens Commission for Human Rights - a Scientology organisation - was listed in the credits. But true mental illness is not a myth and real bipolar disorder and schizophrenia often start in teenage years.

I talk to families of the big picture. We evolved to live slow-paced, but exercise rich, lives as hunter-gatherer tribes by lakes teaming with omega-3 fish, consuming organic nutritious food. Sunlight, vitamin D, circadian rhythms in time with nature, getting 9 to 10 hours sleep. Demand breast-fed by mothers who didn't have another job, parents supported by other adults and older children who were within earshot 24/7. We have no genetic capacity to truly cope with internet and text messages at 3AM on school nights. At the Affective Disorders conference in Brisbane this year the keynote talks were not so much on the latest drug - but on need to reduce early developmental child abuse/neglect and on getting sleep, exercise, relaxation, omega-3's and off junk food.

As I'm now onto the history of the world, I better stop. Thank you.


Dr Peter Parry is a child and adolescent psychiatrist who works in a community Child & Adolescent Mental Health Clinic in Adelaide. A Senior Lecturer with the Dept of Psychiatry at Flinders University, he has published papers on the overdiagnosis of "paediatric bipolar disorder" in the USA and the associated overmedication of children. These are the notes for his comments in the panel discussion following Generation RX on the pharmaceutical industry & health care, screened as part of the Evatt Foundation's Big Pictures program at NSW Parlimant House on 24 November 2009.


Suggested citation
Parry, Peter, 'Many complex and interlocking issues', Evatt Journal, Vol. 9, No. 5, December 2009.<http://evatt.org.au/papers/many-complex-and-interlocking-issues.html>