Editor’s Note: The following is an edited excerpt from Martin Whitely’s book, Overprescribing Madness: What’s Driving Australia’s Mental Illness Epidemic.
Australia should be a country in which it is relatively easy to be happy and feel safe, affluent, and secure. Its five largest cities are all ranked in the 22 most liveable cities in the world. Australians enjoy abundant sunshine, clean air, sensational beaches and open spaces, great food, longevity, a world-class universal access health-care system, robust democracy, rule of law, political and religious freedom, relative economic equity, and a high standard of living following 28 years of unbroken economic growth before the COVID-19 recession.
Clearly these positives are not enough to make many Australians ‘relaxed and comfortable’. In 2018, over 1 in 6 Australians took at least one mental health-related drug, with roughly 1 in 8 taking an antidepressant. Since then, prescribing rates have continued to rise.
Many take multiple psychotropic medications. For example, many elderly Australians are prescribed antidepressants for anxiety or depression, along with antipsychotics to control agitation. Similarly, children prescribed amphetamines for Attention Deficit Hyperactivity Disorder (ADHD) are sometimes prescribed clonidine, or other downers (depressants) to help them sleep.
The willingness of Australians to take pills, and give them to our children, to ease perceived unhappiness, dysfunction, and distress, is not new. Comparisons of 30 OECD countries in the year 2000, and again in 2015, both found that Australians were the second largest per-capita users of antidepressants. Only tiny Iceland (population 340,000), with its frozen, dark, miserable North Atlantic winters, had a higher per-capita antidepressant prescribing rate in either year. The propensity for using antidepressants is consistent with a 2017 World Health Organization (WHO) publication that reported that Australia was the second most depressed country in the world.
But are things really that miserable in the lucky country? These disturbing statistics have nothing to do with Australians being disproportionately mentally ill. Rather, a combination of slick salesmanship, dishonest and incompetent medical practice (overlooked by timid regulators) and cultural, commercial, and political drivers now see Australians hooked on a cycle of over-diagnosis and over-medication.
Medicalising Misery – At the heart of the problem is how we have come to define mental health and mental illness. Anything that causes us to be sad, stressed, anxious, or even bored is now regarded as a threat to our mental health, and therefore a potential source of mental illness. If you lose your job, are grieving a death or a relationship breakdown, or are experiencing any of life’s inevitable vicissitudes, then it is very human to be deeply unhappy or anxious and some may even fleetingly consider ending it all. But we have come to regard these normal, although troubling, human reactions as compelling evidence of mental illness.
Australia has blindly followed the flawed lead of the American Psychiatric Association, which has progressively medicalised normality. In effect, Australians have outsourced our definitions of mental illness to the USA – a country that spends the most per-capita on mental health but achieves appallingly poor outcomes.
While many Australians decry the effects that Hollywood, Coca-Cola, and McDonald’s have on our culture, most are completely ignorant about the dominant role American psychiatry plays in contemporary Australia. They have no idea that we have let the Americans define sanity and madness for us. This outsourcing has a massive impact on millions of Australians and their families. It is hard to think of a more powerful example of cultural capture.
What is even more disturbing is that this corrosive Americanisation of Australian psychiatric practice is officially endorsed by government. In 2017, the Australian Commonwealth Government and all state and territory governments agreed that mental illness is defined as a ‘clinically diagnosable disorder’ that significantly interferes with a person’s cognitive, emotional, or social abilities. Of course, individual ‘clinically diagnosable disorders’ are defined in the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5).
The main problem with DSM-5 is that normal human suffering and frailty is classified as disease. The complexity of human behaviour is reduced to a tick box list of behaviours, devoid of empathy for individual differences in disposition and circumstance. Misery is medicalised, and claims of massive unmet mental health need become the orthodoxy.
Very high estimates of the prevalence of mental illness are accepted by most Australian decision makers, including governments, who fail to understand the significant flaws that lead to massive overestimation. For example, the Australian Parliamentary website contains a webpage titled, Mental Health in Australia: a quick guide that reports approximately:
- 45% of Australians have experienced a mental disorder in their lifetime, with 20% experiencing a mental disorder in the previous year.
- 14% of young people aged 4 to 17 years experienced a mental disorder in a year.
These – and other even more inflated figures – are used to argue that mental illness is being left unrecognised and untreated with disastrous consequences and that governments must support universal mental health screening in schools and in the workplace.
Alarming figures about the cost to the economy of unrecognised and untreated mental illness are also frequently cited. For example, in October 2019 there was widespread media coverage of a draft Australian Government Productivity Commission report that estimated that as many as one million Australians are going untreated for mental health conditions and these ‘illnesses’ are costing the economy $500 million every day.
This represents well over 10% of Australia’s GDP, yet, despite the astonishing size of the estimated cost, it and similar claims rarely get challenged. Instead, it is assumed that massive economic benefits are available if we just address unmet mental health needs. This analysis and other similar claims are based on two flawed assumptions. The first is that we can accurately identify who needs help (without massive false positives) and the second is that the help available (primarily drugs) fixes the problem.
More is Less – In Australia we have come to believe as an article of faith that spending more on mental health interventions improves outcomes and has economic benefits. However, too often the drugs that are the first-line treatment used to treat psychiatric disorders create new disorders that are managed with other drugs. Often the withdrawal effects from psychiatric drugs are worse than the initial problems they were supposed to treat.
This iatrogenic suffering (harm caused by treatment) is often blamed on the patient’s re-emerging mental illness, and doses are increased and/or new medications are added. The result is that the patient gets locked into a vicious cycle of drugs creating harm, with more drugs added to address that harm; meanwhile, medication sales soar and Big Pharma rakes in iatrogenic profits (profits caused by creating harm).
This suffering is avoidable. Governments, doctors, patients and their families need to resist the sugar rush temptation of relying on pharmaceutical quick fixes for complex mental health and social problems. Ironically, the increasing use of psychotropic drugs temporarily takes the political pressure off governments to provide more resource-intensive but safer, and in the long term more effective and less expensive, interventions.
Governments must recognise the harm caused by the over-prescription of the psychotropic drugs that they often subsidise. Otherwise they will continue to misallocate resources to options that superficially appear to address mental health need at minimal cost.
Non-expert dumbed down psychiatric practice – Another obstacle for achieving safe and effective psychiatric practice is the dominant role that non-expert mental health practitioners, particularly general practitioners, play in the delivery of Australian mental health services. In 2018/19, according to the Australian Government, ‘86.3% of mental health-related prescriptions were prescribed by general practitioners; 7.7% prescribed by psychiatrists; 4.5% prescribed by non-psychiatrist specialists’.
So even if the Australian psychiatric profession miraculously got its act together overnight and only prescribed psychotropic drugs within genuinely evidence-based parameters, this would have minimal effect. Sadly, non-expert, dumbed down, cookbook, DSM-5 based biological psychiatry has become the dominant model of psychiatric care in Australia, and it is going to take a revolution to change that.
There is no doubt that there are new challenges to the mental wellbeing of Australians. We have designed our suburbs, houses and society with too much concern for privacy and too little concern about loneliness. Increasing materialism, the loss of low-skill jobs, and the casualization of the workforce, have also had an impact on our wellbeing. However, there has also been many changes for the better. Prejudices about, sex, race, religion, sexual preferences etc. have diminished, making Australia a much more inclusive society.
The evidence suggests that taking prescription psychotropic drugs in such large and increasing numbers is not helping us face new challenges or embrace new opportunities. Surveys suggest that Australians are relatively content and functional people. However, they also suggest that we are slowly going backwards in terms of happiness, social isolation, rates of psychosis and in international comparisons of numeracy and literacy – the very problems these ‘treatments’ are supposed to address.
Not all the responsibility lies with doctors or the ‘system’. Many patients demand pills. They want a quick fix and are not open to other options. If they are fully informed about the true benefits and risks of treatments (which very often they are not) then that is their choice.
However, parents make these decisions on behalf of their children. Many are attracted by the promise of immediate improvement in behaviours and do not pay proper regard to the long-term effects of medication use. Some even seek out clinicians who will tell them what they want to hear and prescribe the drugs they want for their children.
Much of this prescribing is ‘off label’, i.e. for conditions and/or populations that it has not been approved for, even if this contravenes the manufacturer’s recommendations or product warnings. Off label prescribing occurs so regularly that it has, in many cases, become the norm. It does not necessarily result in adverse outcomes; sometimes patients benefit. But off label prescribing is unregulated and outside safety parameters established through the licencing process.
This should not be acceptable. Psychiatric practice should be based on robust independent evidence. Yet, collectively, Australians seem determined to spend even more on dubious treatments and overhyped programs, sometimes to fix problems in part created by dubious treatments and overhyped programs.
Australia’s home-grown mental illness scientist/salesman – Many of the factors driving this escalating madness are identical to those in other developed nations. However, the influence of some home-grown key thought leaders, who have dominated the debate about the future of service delivery in Australia, should not be underestimated. More salesmen than scientists, these mental health gurus/entrepreneurs have secured hundreds of millions in taxpayer funds for their pet programs. They have massively overpromised and under-delivered, and yet to date they have not been held to account.
Successive Australian Governments have unquestioningly accepted the hype and rhetoric around these programs and failed to thoroughly evaluate their outcomes. Worse still, these Governments have failed to carry out one of their core functions – ensuring that medications are used within robust evidence-based safety and efficacy parameters – in these services and elsewhere.
Big Pharma and their paid associates are incredibly good at gaming the systems of drug regulation and subsidisation. They charm, bamboozle and manipulate hapless politicians and limp regulators by creating the illusion that their products are supported by robust science. They are so good at manipulating research as a marketing tool that we should stop expecting the regulatory system to protect our health and well-being.
We should also stop being shocked by stories of 93-year-olds in nursing homes being drugged into a stupor with life-shortening heavy doses of antipsychotics, or of 7-year-olds given amphetamines, antidepressants, and antipsychotics and wanting to take their own lives. We must change the system, or at least wake up to the fact that evidence-free psychiatric prescribing is normal.
The most damning example of this failure is the wholesale off label prescribing of antidepressants to children and adolescents, despite FDA and TGA warnings that antidepressant use increases suicidality in young people. As detailed in a 2020 article in Frontiers in Psychiatry, Australian child, adolescent, and young adult antidepressant prescribing rates have soared over the last decade, and so has the rate of suicide among young Australians. From July 2017 to June 2018, at least 101,174 Australians aged 0 to 17 years (1.8% of the total number) were prescribed an antidepressant, despite the fact that no antidepressant is approved for the treatment of paediatric depression.
It is highly plausible that this failure of government to ensure evidence-based prescribing has contributed significantly to Australia’s epidemic of youth suicide. Yet our political leaders have continued to seek advice from the same failed suicide prevention gurus who obstinately deny the possibility that antidepressant use maybe part of the problem. If insanity is doing the same thing over and over again and expecting different results, then clearly Australia’s mental health system has gone barking mad.
Politics – Where is the conflict when you actually need it? Unlike the USA, many aspects of Australian public policy benefit from a bipartisan approach (e.g. gun control and universal healthcare). However, Australian mental health policy is suffering from a lack of competition between political parties.
Perhaps this is understandable. For most politicians, mental health is a mysterious issue, and the simple option of subsidising the quick application of diagnostic labels and prescription of pills has superficial appeal. In addition, when charismatic mental health entrepreneurs claim to have 21st century solutions, many politicians clearly think: Who am I to argue? But there are sound reasons why both the Right and the Left should be suspicious of the direction of Australian mental health policy and practice.
Conservatives should be concerned about overreach by Big Government interfering in the lives of citizens by applying a permanent disability model of mental illness that robs us of our individual autonomy and self-reliance. The Left should be concerned about the influence of Big Pharma corrupting our regulatory processes and selling us products that are bad for us and make us sicker and more reliant on their products. The Centre should be concerned about both. But there is effectively no competition of ideas regarding mental health among Australian politicians. The only competition appears to be squabbling about who can give our high-profile mental health entrepreneurs the most money for their pet projects.
Time for our elected leaders to stop following – If we are to achieve better mental health outcomes, our elected leaders need to stop following failed experts. Australians need our nation’s leaders to take the time to consider the independent, robust evidence and not be swayed by those with programs to promote, and empires to build.
Perhaps the bravest thing that politicians need to do is to own up to the limitations of government and the limitations of mental health interventions. They need to challenge the expectation that governments can alleviate, and even prevent, persistent unhappiness, anxiety and distress. Instead they are enabling unrealistic expectations of the capacity of government by engaging in bidding wars for the support of mental health gurus with insatiable appetites for taxpayer’s dollars. Even governments of the Centre Right are buying into the nonsense that it is their job to spend taxpayer’s money achieving the unachievable.
Of course there is a role for government, but good governments know their limits. Good governments foster tolerance and inclusion and help the disadvantaged live dignified lives, with the opportunity for improvement. Good governments also make sure that those with real debilitating mental illness get support that helps them recover, or at least live their best lives. Good governments are concerned about the long-term wellbeing of people, not quick (political or treatment) fixes.
Governments concerned about long-term patient wellbeing need to recognise there are three superficial reasons drugs appear more attractive than psychosocial treatments. First, psychological interventions are often more resource intensive in the short to medium term. Second, drugs usually alter behaviour much faster than non-drug treatments, and trials most often measure improvements in short-term symptom management (often for no longer than a few weeks). Third, the vast majority of psychiatric treatment research is funded by drug companies, with the emphasis on short-term effects rather than lasting benefits and harms. Consequently, pharmaceutical interventions are seriously over-rated and over-utilised.
To address this imbalance, Australian Governments, primarily the Commonwealth Government, but also state governments, should initiate multiple reforms.
Fifteen reforms needed in Australia to improve mental health outcomes
- Public disclosure of safety and efficacy data. Massive reform of our system of regulating medical product safety and efficacy is required. The Australian Government, through the Pharmaceutical Benefits Scheme, has powerful levers to pull. It should make it a condition of licencing and subsidising pharmaceuticals and medical devices that there is full public disclosure of all safety and efficacy data held by product manufacturers (with protections for intellectual property and commercially sensitive costing information). There should be very heavy penalties, including immediate removal from market and massive fines (and possibly jail time for directors), for failing to disclose relevant information. Only product manufacturers who are not confident in the safety of their products would choose to take them off the market rather than expose the truth to public scrutiny.
- Prevent cherry picking of favourable results by requiring pre-registration of all new research that may be later used to support the TGA licencing and PBS subsidisation of pharmaceutical products in Australia. Obviously this system would only work prospectively, and would not enable access to studies already concluded. To address this shortfall, details of all research conducted on a particular drug should be provided to the relevant regulator for consideration and made available for public scrutiny. This would help to address the problem of a narrow base of selective research used to licence and subsidise drugs. Regulators would have access to all related research.
- Freedom of Information Reform. Commonwealth Freedom of Information legislation must be amended to end the entitlement of corporations to rely on privacy provisions originally intended to protect the health records of individuals.
- Make adverse drug event reporting for a specified range of serious reactions (suicidal ideation, strokes, psychosis etc.) mandatory, and regularly publish full details on the TGA website. Voluntary reporting means that only a tiny fraction of adverse events ever get reported. Arguably, reckless prescribers may be less likely to report serious adverse events than cautious prescribers because they may be concerned about acknowledging the consequences of their prescribing practices. The public has a right to know, and policy makers need to know about the frequency of adverse events, so they can make informed decisions about the risk-benefit profile of medications.
- Full public disclosure of pharmaceutical industry funding sources for clinicians, researchers, patient groups, advisory board members and members of committees involved in regulatory and policy development processes is also required. The Commonwealth Government should look at the US Physician Payments Sunshine Act, passed in 2010 and co-sponsored by Republican Senator Chuck Grassley and Democrat Senator Richard Blumenthal. The goal of the Physician Payments Sunshine Act was to increase the transparency of financial relationships between doctors and other health care providers and drug companies. Potential conflicts of interest should be made public. It was not perfect legislation, but at least it was a start.
- Consumer medicine information leaflets. In addition, the Commonwealth Government should also strengthen Consumer Medicine Information (CMI) requirements, so that:
- Every warning currently included in information to prescribers is also on the CMI. (Currently warnings are often only highlighted on information made available to prescribers and are not seen by consumers.)
- It should also be mandatory to include a CMI inside medication packaging.
- A brief summary of the most serious safety warnings is written on the outside packaging of drugs, so consumers are aware of very significant risks.
- Off label prescribing is another massive issue the Commonwealth Government needs to tackle. It should, over time, encourage off label prescribing to become ‘on label’. This could be achieved by gradually restricting the government subsidisation of medications to only those prescribed within the approved guidelines.
- Without further delay, implement real-time electronic monitoring of pharmaceutical dispensing. The Commonwealth and State Governments need to roll-out, without further delay (originally planned for 2012), the Electronic Recording and Reporting of Controlled Drugs (ERRCD) initiative. ERRCD would provide a mandatory, real-time, electronic tool for all pharmacies dispensing Controlled Drugs. Pharmacists would have real-time information from a database about previous dispensing episodes, enabling them to detect doctor shoppers.
- Coordination of Commonwealth and State Government Spending. In total, Australia will spend roughly US$7 billion on mental health services in 2020 (about $300 per Australian). The State governments and the Commonwealth Government will contribute roughly equal proportions, with private health insurance providing the remaining 5%. We can have little confidence we are getting value for money. The Commonwealth and the States need to sort out the mishmash in service delivery. The practice of successive Federal Governments going it alone by directly funding mental health services, without robust supporting evidence, or regard for how these services integrate with state government services, should end. Too often, funding for these services has been based on short-term political considerations and personal relationships with charismatic mental health gurus. This is just not how good public policy is done.
- Replace DSM with ICD. One of the simpler reforms governments could initiate is to restrict financial support (including Medicare co-payments and PBS drug subsidisation) for the treatment of mental health disorders to those diagnosed using the World Health Organization’s (WHO) ICD criteria. While the ICD is far from ideal, research indicates that diagnosis and prescribing rates are usually lower using ICD rather than DSM criteria.
- Protect the human rights of involuntary patients. State governments need to increase the protections for involuntary patients. Involuntary patients have, in the vast majority of cases, not committed any crime. Too many are detained and drugged against their will on a flimsy basis. Yes, it is legitimate to protect the public from dangerously psychotic individuals and self-harming patients; however, too often, patients are detained and drugged on vague grounds (e.g. to protect their reputation).
- Prohibit pharmaceutical company donations to political parties and candidates and compensate if necessary through increased public funding of political parties. Governments are responsible for multi-million-dollar decisions about which drugs get approved and subsidised, and must make these decisions without fear or favour. There is currently only retrospective partial disclosure of political donations. While there is no evidence of direct corruption, there has been very little scrutiny of pharmaceutical company operations by parliamentarians. Although a similar case could be made for a range of industries, the pharmaceutical industry is unique in that it produces mind- and body-altering chemicals that are ingested by children – a particularly vulnerable consumer group. Some of these chemical interventions are lifesaving; many are warranted, but many are harmful (e.g. the use of amphetamines to ‘treat’ ADHD). Government must be free from improper influence by the pharmaceutical industry.
- Address the inequity of resourcing of competing perspectives on controversial mental health and health policy issues by direct government funding of independent non-government pharmaceutical and medical/psychiatric watchdogs. The pharmaceutical industry has demonstrated that it has sufficient resources to effectively organise, lobby, and market to enhance its own economic interests. However, there is no significant counterbalancing economic interest that supports those concerned about the inappropriate and unsafe use of pharmacological interventions. Industry domination of notional consumer support groups further exacerbates the problem by creating the false impression of independent consumer-driven advocacy. Governments could address this imbalance by funding independent non-government watchdogs specifically tasked with critiquing research and clinical practice in the medical/psychiatric and pharmaceutical fields.
- Ensure diverse views are robustly represented in health and mental health policy and regulatory process. In many cases, these types of processes (e.g. treatment guidelines development and drug prescribing oversight processes) are dominated by like-minded, industry friendly ‘experts’ who develop consensus (often unanimous outcomes). These processes should be open and contested, with a range of views competing to influence outcomes. Very often ‘experts’ in a single condition or disorder have significant financial or even intellectual and ideological conflicts of interest. If medical knowledge is required to evaluate evidence of the safety and efficacy of treatments etc., this can generally be done by medical practitioners/researchers who don’t specialise in the condition or disorder.
- Stop schools demanding that students be medicated as a condition of attendance. There are too many disturbing reports of schools suggesting that a child has a psychiatric disorder, particularly ADHD, or, worse still, demanding that a child be ‘medicated’ (i.e. drugged with amphetamine) as a condition of attending school. This is a child rights abuse. It is particularly disturbing because all around the globe many children are drugged because schools and teachers mistake age-related immaturity, among the youngest in class, for a psychiatric disorder i.e. ADHD.
Many of the fifteen suggested reforms would require courageous political leadership, something we have not seen in Australian federal politics for a long time. A significant barrier to these necessary reforms will be the influence of the pharmaceutical industry. Big Pharma’s enormous economic resources and political skills have enabled them to dominate, virtually uncontested, the processes of licencing and subsidising their products in Australia. Without political leadership on these issues, Australians will continue to be denied fully informed consent and be exposed to unnecessary risks.
For their part, doctors, other mental health professionals and policy makers who genuinely want to see better sustained outcomes Australia’s mental health system, need to restrict psychiatric practice to robust evidence-based parameters. This will require the Australian medical and psychiatric professions to acknowledge how little they actually know about the interplay between brain, body, biochemistry and behaviour. This in turn requires far greater respect for just how difficult it is to be a competent, empathetic psychiatrist, who knows both their patients the relevant science.
Psychiatry is an exceptionally difficult and complex profession that must be done by highly skilled specialists. Non-expert practitioners, especially general practitioners without extensive psychiatric and psychopharmacological training, should not be able to initiate psychotropic drug treatments. Most importantly, if a doctor is not capable of helping people withdraw from a mental health drug (usually by tapering), they should not be allowed to prescribe them.
Government and the psychiatric and medical professions and even the media need to lift their game. But ultimately the Madmen marketing us our epidemic of mental illness couldn’t sell their products if consumers were not buying.
If Australians want improved mental wellbeing, the most obvious change that needs to happen is that patients need to stop believing in ‘quick fixes’. Pills may work in the short term, and for a minority of severely ill patients they may be required for extended periods, but very often they do much more harm than good.
Mad in America hosts blogs by a diverse group of writers. These posts are designed to serve as a public forum for a discussion—broadly speaking—of psychiatry and its treatments. The opinions expressed are the writers’ own.