New Freedom Commission on Mental Health

From the British Medical Journal
http://bmj.bmjjournals.com/cgi/content/full/328/7454/1458

BMJ 2004;328:1458 (19 June), doi:10.1136/bmj.328.7454.1458

Bush plans to screen whole US population for mental illness
Jeanne Lenzer

New York

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
(www.whitehouse.gov/infocus/newfreedom/toc-2004.html). 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"
(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."

Drug companies have contributed three times more to the campaign of
George Bush, seen here campaigning in Florida, than to that of his rival
John Kerry

Credit: GERALD HERBERT/AP

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; {euro}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]

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