Dear Prime Minister Scott Morrison and Minister for Health Greg Hunt
(See far below for the response from Minister for Health Greg Hunt)
24 June 2019
Re: Youth suicide and antidepressant use, headspace, Early Psychosis Youth Service (EPYS) and Suicide Prevention Australia
Congratulations on your recent Federal election win, and thank you for making reducing youth suicide one of the primary objectives for your Government. However, as detailed below, I am concerned that elements of your Government’s policy position (Our Plan for youth mental health and suicide prevention[1]) may entrench the well-meaning but failed approaches implemented by the Gillard, Rudd, Abbott and Turnbull Governments.
Summary
In 2004 and 2005 the US Food and Drug Administration (FDA) and our Therapeutic Goods Administration (TGA) issued warnings that antidepressant use was associated with an increased risk (approximately doubled) of suicidality in people aged under 25 years. As detailed in a recent PsychWatch Australia’s blog I co-authored, between 2007 and 2011 headspace, Orygen Youth Health, Professor Patrick McGorry, Professor Ian Hickie and Suicide Prevention Australia, all challenged the warnings and encouraged the use of antidepressants by young Australians as a suicide prevention measure.
Over the last decade Australian psychiatric practice, much of which is conducted by GP’s with little training, has substantially ignored the FDA’s and TGA’s warnings and followed the advice of these local ‘experts’. The result, as I predicted in 2011[2], are that over the last decade:
I take no satisfaction in being proved correct. I am frustrated and angry that the same voices pushing the same failed programs still dominate the national debate about youth suicide prevention, despite their very poor track record. To put it bluntly, I strongly contend that without change, it is likely that antidepressant use and suicide rates among young Australians will continues to increase.
headspace - Expanding headspace is frequently marketed as the recipe for reducing the per-capita rate of youth suicide. However, headspace has been an abject failure in reducing the rate of youth suicide and self-harm among the 12 to 25 year-old Australians it was established to serve.
While I am critical of headspace I agree that the concept of a one-stop shop supporting troubled young people has merit. A reconfigured headspace, better integrated into other services with a less ‘medicalised, diagnose and treat’ and more ‘personalised, listen and support’ focus, could prove valuable. However, I have no confidence in the capacity of the current leadership of headspace to transform the service.
EPYS - In regards to EPYS (Early Psychosis Youth Services) I contend the EPYS model is fundamentally flawed. The driving force behind EPYS is Professor Patrick McGorry’s unshakable belief that young people at ‘Ultra High Risk’ of psychosis can be identified and treated, and thereby prevented from developing psychosis and schizophrenia. Intuitively, it seems like a reasonable ‘stitch in time saves nine’ theory. However, the independent evidence indicates that vast majority of Ultra High Risk diagnosis are false positives, and that the treatments have no sustained benefits. (*I encourage you to watch a twenty minute excerpt from a Orygen Youth Health Service training video on how to diagnose young people at ‘Ultra High Risk’ of becoming psychotic and ask yourself if the Ultra High Risk diagnosis passes the common sense test.)
My concerns are outlined in greater detail below, but in summary we recommend that you adjust your Government’s policy outlined in the document ‘Our Plan for youth mental health and suicide prevention’ so that:
Further government engagement with, and funding of, Suicide Prevention Australia (SPA) is made conditional on SPA providing a detailed explanation of why it offered flawed advice regarding antidepressant use and youth suicide.
Before funding any expansion of headspace there should be a comprehensive independent audit and evaluation of headspace diagnostic and treatment processes (including prescribing practices). The evaluation should identify the long-term outcomes for headspace clients. The audit and evaluation results (de-identified to protect client confidentiality) must be made public to ensure confidence in the process. A clear pathway for addressing problems identified in the audit and ensuring ongoing accountability must be developed before headspace receives further funding.
The government should defund EPYS. Failing this, there should be a comprehensive independent audit similar to that described at 2 above.
Detailed Evidence Supporting My Recommendations
My concerns regarding antidepressant prescribing, youth suicide, headspace and Suicide Prevention Australia are detailed in two recent PsychWatch Australia blogs that received extensive media coverage (e.g. 'Prozac Nation', page 1, Daily Telegraph, 24 April 2019 and Antidepressants use among young Australians has soared, so has the suicide rate, Daily Telegraph, 2 June 2019.)
The first PsychWatch Australia blog - 1 in 8 (over 3 million) Australians are on antidepressants – Why is the Lucky Country so miserable? - published on 24 April 2019, revealed that approximately 1 in 8 (more than 3 million) Australians were prescribed an antidepressant between July 2017 and June 2018. As detailed in the blog, we (co-author Dr Melissa Raven and I) contend that these extraordinarily high and growing antidepressant prescribing numbers are a consequence of a number of factors, including:
The diagnostic definitions of 'normal' and 'depressed' have been effectively outsourced to the American Psychiatric Association, which has inappropriately broadened the definitions of psychiatric disorders, so that previously ‘well’ people are now identified as being ‘mentally ill’.
Most antidepressant prescribing in Australia is done by time-poor GPs with limited mental health training and few other options.[3]
The uncritical promotion by key elements of the Australian media (including the ABC) of claims that mental illness is massively under-diagnosed and under-treated have misled health professionals, policy-makers, and the Australian community.
These factors have contributed to the growing expectation that Australian governments, both state/territory and federal, will provide free (or heavily subsidised) access to mental health services to large and growing numbers of Australians.
From a government perspective, pharmaceutical interventions appear to be the cheapest and quickest way to meet this demand. However, too often this is a false economy. Iatrogenic harm (harm caused by treatment) from psychiatric drugs and the failure to deal with underlying causes of distress can create extra long-term costs to both patients and the health and welfare system.[4] Put simply, too often governments have spent taxpayer’s money, making people sicker, which in turn has created more demand for increased government expenditure.
The second PsychWatch Australia blog - More young Australians suicide/self-harm and use antidepressants while experts dismiss FDA warnings - published on 1 June 2019, raised grave concerns that, despite their good intentions, Australia’s leading suicide prevention organisations and depression experts have given advice about the use of antidepressants that may have contributed to the avoidable deaths of many young Australians.
As stated above “beginning in 2008-09, an increase of approximately 60% in per-capita antidepressant use rates by young Australians (aged 0 to 27) has been associated with a 40% increase in per-capita suicide rates by young Australians (aged 0 to 24)”. Furthermore, research recently published in the BMJ [British Medical Journal] found “a concerning increase in child/adolescent self-poisoning in Australia” that mirrored an increase in mental health prescribing rates, particularly antidepressants. It also found that there was "substantial overlap between the most dispensed psychotropics and medicines most commonly used in self-poisoning episodes”. Specifically, there was an increase in intentional poisonings of 98% (for those aged 5 to 19) from 2006 to 2016 in New South Wales and Victoria, with most of the growth occurring after 2011.[5]
While correlation does not prove causation, these results are consistent with the FDA and TGA warnings and are inconsistent with the advice from Suicide Prevention Australia, Orygen, headspace, and professors McGorry and Hickie. Furthermore, they provide compelling evidence that antidepressants prescribed to children and adolescents are frequently the means of self-harm.
I recognise that in response in media coverage of the second PsychWatch Australia blog Professor McGorry stated that, “antidepressants should not be used as the first line treatment… and there should be an audit to check whether young people using the drugs were first given counselling and cognitive behavioural help”. However, I note that Professor McGorry has a very inconsistent record of statements and actions regarding the use of psychotropic drugs, particularly antidepressants and antipsychotics, by young people.
I also note that a prior audit of the prescribing practices of the Orygen Youth Mental Health Service headed up by Professor McGorry, found that “prescribed medication to a majority of depressed 15 to 25-year-olds before they had received adequate counselling, despite international guidelines advising against the practice”.[6] To the best of our knowledge these are the prescribing audit results that have been made public, for any Orygen or headspace service. Given the level of taxpayer support for these services this is unacceptable.
Concerns with your Government’s policy position outlined in ‘Our Plan for youth mental health and suicide prevention’, relate to:
Suicide Prevention Australia
Expansion of Early Psychosis Youth Services (EPYS)
Expansion of headspace
Suicide Prevention Australia’s role as the peak body providing expert advice on suicide prevention - As detailed in the second PsychWatch Australia blog, Suicide Prevention Australia misrepresented the association between antidepressant use and youth suicide in a 2010 position paper titled Youth Suicide Prevention. Although this misrepresentation was instigated in 2010, the position paper remained available on the SPA website until March of this year. Unless the current board and management of Suicide Prevention Australia acknowledges the organisations past failings and demonstrates a commitment to reform, you should have no confidence in the organisation.
Plans to expand Early Psychosis Youth Services (EPYS) - There are longstanding concerns that the core concept driving the roll-out of EPYS is fundamentally flawed. These concerns will be detailed with up-to-date information in a coming PsychWatch Australia blog (due for publication in July). The genesis of the EPYS model is Professor Patrick McGorry’s belief that young people at ‘Ultra High Risk’ of becoming psychotic can be identified and treated, and thereby prevented from developing psychosis and schizophrenia. Professor McGorry believes that pre-emptive intervention, before people become psychotic, can prevent psychosis. However, the independent evidence that is available indicates that there are three problems with the theory:
The rate of false positives is extremely high. Proponents of the Ultra High Risk diagnosis claim a false positive rate of 64%[7], critics assert it is 92%[8]. Either way the vast majority of young people diagnosed as being at ‘Ultra High Risk’ of psychosis, never become psychotic.
Even in those cases where the predictions are accurate, there is little to no independent evidence that the interventions that are on offer, help, in the long term.
Labelling young people as being at Ultra High Risk of becoming psychotic is stigmatising, and can invite the unwarranted use of antipsychotic medication, with substantial risks of life-shortening metabolic and cardiovascular damage.
(Note: To read more about the reasons for our concerns with EPYS, refer to Time Magazine 2006 - Drugs before Diagnosis and The Australian and New Zealand Journal of Psychiatry 2012 - ‘Prodromal’ diagnosis of psychosis: Ethical problems in research and clinical practice and the PsychWatch Australia pages Guruisation of Australian Mental Health Policy and Orygen Prepsychosis Training Flawed. We will forward up-to-date information on EPYS to you by 31 July 2019.)
Plans to expand headspace - As stated above headspace has been scaled up enormously since it was established in 2006, however there is no evidence that it has improved the mental health of young Australians at a population level.[9] In contrast, as detailed in the second blog, youth suicide and self-harm rates have increased markedly since 2006.
The driver and chief architect of headspace, Professor Patrick McGorry, has frequently asserted that headspace is supported by extensive evidence. However, two external evaluations of headspace conducted in cooperation with headspace, in 2009 and 2015 and one independent assessment conducted in 2015, do not support Professor McGorry’s positive assertion.
The two evaluations conducted with headspace's cooperation both provided very weak evidence to support the effectiveness of headspace, let alone its cost-effectiveness. The first evaluation, by Muir et al (2009), found “there was little tangible evidence of the extent to which services were evidence-based”.[10] The most recent evaluation, by Hilferty et al. (2015), showed high levels of client attrition and raised concerns about poor engagement with Indigenous young people.[11] Media reports have also raised similar concerns.
Furthermore, even the weak evidence of positive outcomes is questionable, because both evaluations had significant methodological limitations. The Muir 2009 evaluation had no control group for comparison.[12] Hilferty et al.’s 2015 evaluation used two comparison groups.[13] The 18-25-year-old comparison group was recruited online from commercial access panels, with a very low response rate (p. 175), and was poorly-matched (p. 16). In addition, the headspace client survey group excluded clients who only attended once (p. 180), and girls/women were over-represented (p. 179).
The other assessment conducted in 2015 by Professor Anthony Jorm, without headspace’s involvement, found “improvements seen in headspace clients are similar to those seen in untreated cases, and it would seem that the services provided may have had little or no effect”.[14] Apart from the weak evidence base, other concerns associated with the rollout of headspace include problems with workforce shortages and its failure to service those most at risk and respond to local conditions.
These are complex issues and I appreciate that my advice challenges dominant voices in the debate about the direction of mental health policy in Australia. However, we must stop ignoring the independent evidence, particularly the FDA and TGA warnings, or accept that more avoidable deaths of young Australians are likely.
If more information is required and please contact me. Once again thanks for your commitment to tackling the scourge of youth suicide. With care, and attention to detail, and a focus on evidence rather than rhetoric, I am confident you can be successful. I look forward to your response which we will publish unedited on the PsychWatch Australia website.
Yours Sincerely
Editor/Publisher
cc. All members of the Australian Parliament
References
[1]Liberal Party of Australia, (2019) ‘Our Plan for youth mental health and suicide prevention’ Available at https://www.liberal.org.au/our-plan-youth-mental-health-and-suicide-prevention (accessed 28 May 2019)
[2] Whitely M, (2011) Hansard Western Australian Parliament [Wednesday, 25 May 2011] p3984d - 3994a http://www.parliament.wa.gov.au/Hansard/hansard.nsf/0/75032653ddacbe7f482578b100299ab4/$FILE/A38+S1+20110525+p3984d-3994a.pdf accessed 11 February 2019
[3] In 2014/15, the vast majority (90.4%) of antidepressant prescribing was done by general practitioners. Psychiatrists were directly responsible for only 6.5%. Australian Institute of Health and Welfare (2016). Mental health services—in brief 2016. Cat. no. HSE 180 Canberra: AIHW (pp. 24-25). Available at https://www.aihw.gov.au/getmedia/681f0689-8360-4116-b1cc-9d2276b65703/20299.pdf.aspx?inline=true (accessed 13 August 2018)
[4] Geoff Waghorn & Chris Lloyd, (2005) The employment of people with mental illness Australian e-Journal for the Advancement of Mental Health, 4(2,* Supplement),
[5] Cairns R, Karanges EA, Wong A, et al. (2019). Trends in self-poisoning and psychotropic drug use in people aged 5-19 years: a population-based retrospective cohort study in Australia. BMJ Open 2019; Available at https://bmjopen.bmj.com/content/9/2/e026001?rss=1 (accessed 15 March 2019)
[6] Jill Stark, Youth mental health team too free with drugs: audit, The Sunday Age, July 8, 2012, Available at
http://www.theage.com.au/national/youth-mental-health-team-too-free-with-drugs-audit-20120707-21o29.html (accessed 6 June 2019)
[7] Professor Alison Yung, Medical Journal of Australia 21 May 2012 Is it appropriate to treat people at high-risk of psychosis before first onset — Yes Available at https://www.mja.com.au/journal/2012/196/9/it-appropriate-treat-people-high-risk-psychosis-first-onset-yes
[8] Professor David Castle, Medical Journal of Australia 21 May 2012 Is it appropriate to treat people at high-risk of psychosis before first onset — No Available at https://www.mja.com.au/journal/2012/196/9/it-appropriate-treat-people-high-risk-psychosis-first-onset-no (accessed 6 June 2019)
[9] Jorm AF. Headspace: The gap between the evidence and the arguments. Australian and New Zealand journal of Psychiatry. 2016;50(3):195-6. https://www.semanticscholar.org/paper/Headspace%3A-The-gap-between-the-evidence-and-the-Jorm/d18f1121e92ed77c253984dc16351a94ce8b0514
[10] Muir K, Powell A, Patulny R, Flaxman S, McDermott S, Oprea I, et al. Headspace Evaluation Report: Independent Evaluation of headspace: the National Youth Mental Health Foundation (SPRC Report 19/19). Sydney: Social Policy Research Centre (SPRC), UNSW, Australia; 2009. P. 125 Available at https://headspace.org.au/assets/Uploads/Corporate/Publications-and-research/final-independent-evaluation-of-headspace-report.pdf (accessed 6 June 2019)
[11] Hilferty F, Cassells R, Muir K, Duncan A, Christensen D, Mitrou F, et al. Is headspace making a difference to young people's lives? Final Report of the independent evaluation of the headspace program. (SPRC Report 08/2015). Sydney: Social Policy Research Centre, UNSW, Australia; 2015. Available at https://headspace.org.au/assets/Uploads/Evaluation-of-headspace-program.pdf (accessed 6 June 2019)
[12] Muir K, Powell A, Patulny R, Flaxman S, McDermott S, Oprea I, et al. Headspace Evaluation Report: Independent Evaluation of headspace: the National Youth Mental Health Foundation (SPRC Report 19/19). Sydney: Social Policy Research Centre (SPRC), UNSW, Australia; 2009. P. 134 Available at https://headspace.org.au/assets/Uploads/Corporate/Publications-and-research/final-independent-evaluation-of-headspace-report.pdf (accessed 6 June 2019)
[13] Hilferty et al.’s 2015 evaluation used two comparison groups. The 18-25-year-old comparison group was recruited online from commercial access panels, with a very low response rate (p. 175), and was poorly-matched (p. 16). In addition, the headspace client survey group excluded clients who only attended once (p. 180), and girls/women were over-represented (p. 179). Hilferty F, Cassells R, Muir K, Duncan A, Christensen D, Mitrou F, et al. Is headspace making a difference to young people's lives? Final Report of the independent evaluation of the headspace program. (SPRC Report 08/2015). Sydney: Social Policy Research Centre, UNSW, Australia; 2015. Available at https://headspace.org.au/assets/Uploads/Evaluation-of-headspace-program.pdf (accessed 6 June 2019)
[14] Jorm AF. How effective are 'headspace' youth mental health services? The Australian and New Zealand journal of psychiatry. 2015;49(10):861-2. P. 862 https://minerva-access.unimelb.edu.au/bitstream/handle/11343/91134/how%20effective%20are.pdf?sequence=3&isAllowed=y
Response from Minister Greg Hunt received 6 August 2019
The remaining page (page 3) of Minister Hunt's letter included only private contact details and an invitation to provide further information. The substantive response is in the first two pages above.
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