BMJ [British Medical Journal] 2004;329:367 (14 August)
President Bush announced on 26 July that his administration has begun implementing the recommendations of the New Freedom Commission on Mental Health to "improve mental health services and support for people of all ages with mental illness" through comprehensive screening.
The plan states that schools are in a "key position" to screen the "52 million students and six million adults who work at the schools" and includes recommendations for screening preschool children (19 June, p 1458).
Mr Bush's announcement comes after new reports showing that increasing numbers of toddlers and children are being prescribed amphetamines, anti-depressants, and antipsychotic drugs. Concern that widespread screening will only increase the number of young people taking drugs has triggered criticism of the plan.
Dr Daniel Fisher, one of the 22 commissioners responsible for writing the final report for the president, said that widespread screening—at a time when medical education was "geared to the biomedical model and teachers want to get kids fixed"—could result in greater numbers of children being given "a label, a diagnosis, and a medication."
"What troubles me a little bit," said Dr Fisher, "is that mental health will continue to be used as a substitute for addressing the social, cultural, and economic needs of children."
Addressing those needs and heeding the recommendation of the plan to transform the system to one based on fostering recovery and resilience could, he said, "solve many behavioural problems." But, he added, widespread screening before systems are transformed could undermine some very positive elements of the plan, including its focus on care that is driven by patients and on housing support, educational rights, and employment.
Concerns about the increasing number of children taking psychotropic drugs were heightened by a study published in this month's issue of the Archives of Pediatric and Adolescent Medicine ( 2004;158: 753-9)[Abstract/Free Full Text]. The study, by Dr William Cooper and colleagues at Vanderbilt University, Tennessee, found that in 2001 nearly one in every 100 adolescents enrolled in TennCare, a programme for families in Tennessee on low to moderate incomes, became new users of antipsychotic drugs. The six year study followed the 313 454 children enrolled in TennCare in 1996, just under 30% of all children in Tennessee.
Dr Cooper said that he and his colleagues are currently studying nationwide data on the use of antipsychotic drugs among children covered by private insurance. He said that they expect they'll see similar findings nationally, given preliminary results from current research at Vanderbilt and reports from doctors at other institutions.
The Tennessee study found that a minority of children who were prescribed antipsychotic drugs were psychotic. The two main reasons for new prescriptions of antipsychotic drugs were attention deficit hyperactivity disorder (23% of prescriptions) and conduct disorder (20%). Most of the prescriptions were for the newer "atypical" antipsychotics.
"We don't know if these drugs are helpful in conditions like attention deficit hyperactivity disorder," said Dr Cooper. Although the atypical antipsychotics reportedly cause fewer dyskinaesias than the older antipsychotic drugs, they are associated with serious problems, including weight gain (one study showed that 11% of children taking the drugs gained 10% of their body weight in six months), diabetes, fatal ketoacidosis, and potentially lethal cardiac dysrhythmias. "You're just trading one set of side effects for another," said Dr Cooper. "We don't know if the benefits of these drugs outweigh their risks."
President Bush's proclamation on the anniversary of the Americans with Disabilities Act is at www.whitehouse.gov Other related articles in BMJ:
News Bush plans to screen whole US population for mental illness. Jeanne Lenzer BMJ 2004 328: 1458. [Full text]
Where’s the Evidence for Screening, Are Systems in Place for Positive Screens? Laura Newman bmj.com, 13 Aug 2004 [Full text] Number crunching Joan McClusky bmj.com, 16 Aug 2004 [Full text] Psychological testing could promote drugs Laura J. Borst bmj.com, 19 Aug 2004 [Full text]
BMJ [British Medical Journal] 2004;328:1458 (19 June)
Bush plans to screen whole US population for mental illness
A sweeping mental health initiative will be unveiled by President George W Bush in July. The plan promises to integrate mentally ill patients fully into the community by providing "services in the community, rather than institutions," according to a March 2004 progress report entitled New Freedom Initiative. While some praise the plan's goals, others say it protects the profits of drug companies at the expense of the public.
Bush established the New Freedom Commission on Mental Health in April 2002 to conduct a "comprehensive study of the United States mental health service delivery system." The commission issued its recommendations in July 2003. Bush instructed more than 25 federal agencies to develop an implementation plan based on those recommendations.
The president's commission found that "despite their prevalence, mental disorders often go undiagnosed" and recommended comprehensive mental health screening for "consumers of all ages," including preschool children. According to the commission, "Each year, young children are expelled from preschools and childcare facilities for severely disruptive behaviours and emotional disorders." Schools, wrote the commission, are in a "key position" to screen the 52 million students and 6 million adults who work at the schools.
The commission also recommended "Linkage [of screening] with treatment and supports" including "state-of-the-art treatments" using "specific medications for specific conditions." The commission commended the Texas Medication Algorithm Project (TMAP) as a "model" medication treatment plan that "illustrates an evidence-based practice that results in better consumer outcomes."
Dr Darrel Regier, director of research at the American Psychiatric Association (APA), lauded the president's initiative and the Texas project model saying, "What's nice about TMAP is that this is a logical plan based on efficacy data from clinical trials."
He said the association has called for increased funding for implementation of the overall plan.
But the Texas project, which promotes the use of newer, more expensive antidepressants and antipsychotic drugs, sparked off controversy when Allen Jones, an employee of the Pennsylvania Office of the Inspector General, revealed that key officials with influence over the medication plan in his state received money and perks from drug companies with a stake in the medication algorithm (15 May, p1153). He was sacked this week for speaking to the BMJ and the New York Times.
The Texas project started in 1995 as an alliance of individuals from the pharmaceutical industry, the University of Texas, and the mental health and corrections systems of Texas. The project was funded by a Robert Wood Johnson grant—and by several drug companies.
Mr Jones told the BMJ that the same "political/pharmaceutical alliance" that generated the Texas project was behind the recommendations of the New Freedom Commission, which, according to his whistleblower report, were "poised to consolidate the TMAP effort into a comprehensive national policy to treat mental illness with expensive, patented medications of questionable benefit and deadly side effects, and to force private insurers to pick up more of the tab" [Link]((http://psychrights.org/Drugs/AllenJonesTMAPJanuary20.pdf).
Larry D Sasich, research associate with Public Citizen in Washington, DC, told the BMJ that studies in both the United States and Great Britain suggest that "using the older drugs first makes sense. There's nothing in the labeling of the newer atypical antipsychotic drugs that suggests they are superior in efficacy to haloperidol [an older "typical" antipsychotic]. There has to be an enormous amount of unnecessary expenditures for the newer drugs."
Olanzapine (trade name Zyprexa), one of the atypical antipsychotic drugs recommended as a first line drug in the Texas algorithm, grossed $4.28bn (£2.35bn; 3.56bn) worldwide in 2003 and is Eli Lilly's top selling drug. A 2003 New York Times article by Gardiner Harris reported that 70% of olanzapine sales are paid for by government agencies, such as Medicare and Medicaid.
Eli Lilly, manufacturer of olanzapine, has multiple ties to the Bush administration. George Bush Sr was a member of Lilly's board of directors and Bush Jr appointed Lilly's chief executive officer, Sidney Taurel, to a seat on the Homeland Security Council. Lilly made $1.6m in political contributions in 2000—82% of which went to Bush and the Republican Party.
Jones points out that the companies that helped to start up the Texas project have been, and still are, big contributors to the election funds of George W Bush. In addition, some members of the New Freedom Commission have served on advisory boards for these same companies, while others have direct ties to the Texas Medication Algorithm Project.
Bush was the governor of Texas during the development of the Texas project, and, during his 2000 presidential campaign, he boasted of his support for the project and the fact that the legislation he passed expanded Medicaid coverage of psychotropic drugs.
Bush is the clear front runner when it comes to drug company contributions. According to the Center for Responsive Politics (CRP), manufacturers of drugs and health products have contributed $764 274 to the 2004 Bush campaign through their political action committees and employees—far outstripping the $149 400 given to his chief rival, John Kerry, by 26 April.
Drug companies have fared exceedingly well under the Bush administration, according to the centre's spokesperson, Steven Weiss.
The commission's recommendation for increased screening has also been questioned. Robert Whitaker, journalist and author of Mad in America, says that while increased screening "may seem defensible," it could also be seen as "fishing for customers," and that exorbitant spending on new drugs "robs from other forms of care such as job training and shelter programmes."
But Dr Graham Emslie, who helped develop the Texas project, defends screening: "There are good data showing that if you identify kids at an earlier age who are aggressive, you can intervene... and change their trajectory." Related letters in BMJ:
Bush plans to screen whole US population for mental illness: Is road of initiative paved with good intentions? Woody Caan BMJ 2004 329: 292. [Letter] Bush plans to screen whole US population for mental illness: An unlikely public healthcare initiative John R Broomfield BMJ 2004 329: 292. [Letter] Bush plans to screen whole US population for mental illness: Bush's sanity test is revealed Archie W Julien BMJ 2004 329: 292. [Letter] Bush plans to screen whole US population for mental illness: Summary of responses Birte Twisselmann BMJ 2004 329: 292-293. [Letter]
FDA's counsel accused of being too close to drug industry.
BMJ 2004 329: 189. [Full text]
News Bush launches controversial mental health plan. Jeanne Lenzer BMJ 2004 329: 367. [Full text]