BMJ  2004;329:367 (14 August), doi:10.1136/bmj.329.7462.367-a

News

Bush launches controversial mental health plan

New York

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."

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President Bush's proclamation on the anniversary of the Americans with Disabilities Act is at www.whitehouse.gov

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