Patrick McGorry stops advocating ‘pre-psychosis drugging’ and should now abandon his support for the inclusion of ‘Psychosis Risk Syndrome’ in DSMV

For over a decade Patrick McGorry has expirimented with or advocated the prescription of antipsychotics to adolescents on the hunch that they may later become psychotic. However, in response to last week’s blog a spokesperson for Professor McGorry told the West Australian he does “not recommend this (pre-psychosis drugging) as a standard treatment for clinical care because there are other treatments that are safer, like cognitive behavioural therapy and fish oil….there has been a substantial amount of research and we do change according to the research.” ^[1] (The full article can be read here: Mental health guru stumbles into public policy minefield.)

To the best of my knowledge this is the first time Professor McGorry has publicly declared that he has abandoned his support for the use of antipsychotics to prevent psychosis. His change of position is welcome. However, history tells it will not be enough to prevent a tide of pre-emptive drugging if Psychosis Risk Syndrome is included in DSMV, the next edition of the American Psychiatric Associations handbook of psychiatry.^[2]

Unfortunately it is common practice for psychiatric drugs to be used ‘off label’ for non-approved purposes, without supporting research on the ‘hunch’ of the prescribing clinician. For example across the globe hundreds of thousands of pre-schoolers have been prescribed Ritalin for ADHD despite the fact that the manufacturers warning ‘there is not enough information to recommend its use in children under 6 years old.’^[3]

This is exactly what will happen with anti-psychotics if Psychosis Risk Syndrome is included in DSMV. Over-confident clinicians influenced by drug company hype (and possibly inducements) will prescribe adolescents antipsychotics as ‘bit of extra insurance’ just in case they later become psychotic. It won’t be the majority of potential prescribers who create a problem, but as we learned from the manufactured ADHD epidemic a handful of rogue prescribers can do enormous damage whilst the majority of their colleagues silently look on.

Officially recognising Psychosis Risk Syndrome in the DSMV would give a false legitimacy to the use of anti-psychotics for the treatment of the “disorder”. It would also give legitimacy to  the “disorder” itself. Given that the vast majority (60%-90%) of those diagnosed with Psychosis Risk Disorder would be misdiagnosed ‘false positives’ it is legitimacy it does not deserve. ^[4]

But most importantly it is completely unnecessary to include Psychosis Risk Syndrome in the DSMV. Professor McGorry and fellow psychiatrists do not need a new “disorder” to allow his now preferred treatments, cognitive behaviour therapy and fish oil, to be used for troubled adolescents.

On the positive side, in addition to reversing his support for the use of anti-psyhotics before any psychotic episode, Professor McGorry’s policy advisor, Matthew Hamilton, has also acknowledged that Professor McGorry is now open to considering these non-pharmaceutical treatments as the first line of treatment for adolescents who have experienced a first psychotic episode.

This is more good news. It may encourage clinicians to identify and deal with the causes of first psychosis free from the ‘mist of medication’ and will not prevent the later use of antipsychotics if less chemically invasive treatments are ineffective.

It is also encouraging that Professor McGorry now acknowledges that it is reasonable to hold contrary views on the merit of including ‘Psychosis Risk Syndrome’ in DSMV. This is a significant change from his recent rhetoric of 21^st Century proven solutions. Hopefully it indicates an increasing willingness to base clinical practice on evidence rather than hypothesis.

I suspect that this softening of Professor Mcgorry’s position is in large part due to the 180 degree reversal of support for Psychosis Risk Syndrome by his long term research partner at Orygen Youth Health psychiatrist Dr Alison Yung. In 2009 Dr Yung said; ‘So why the need for a specific risk syndrome diagnosis? Is the agenda really to use antipsychotics?…I think there are concerns about validity, especially predictive validity, and this relates to potentially stigmatizing and unjustified treatment for some individuals as well as all the negative social effects of diagnosis. I think including the risk syndrome in the DSM-V is premature.’^[5]

Dr Yung’s change is significant, but as Australian of the Year and a former president and current treasurer of the International Early Psychosis Association, it is Professor McGorry who has both the ear of government and the international psychiatric profession.

Changing his view on the validity of Psychosis Risk Syndrome being included in DSMV would not be an admission of failure but an act of a truly deserving Australian of the Year. More importantly according to Dr Allen Frances, the American Psychiatrist who led the 1994 revision of the current edition of the DSM (DSM-IV), it would help avoid ‘an iatrogenic [adverse effects resulting from treatment] public health disaster’.^[6]

Note; Concerns about Professor McGorry’s research into pre psychosis treatment were highlighted in the late 1990’s in a book titled Punishing the Patient. The book is now out of print but the author Dr Richard Gosden put he chapter on early psychosis on the web at http://sites.google.com/site/punishingthepatient/early-psychosis It makes interested if detailed reading.

Update 14 may 2011: Despite being dircetly asked by me in early May 2011 Professor McGorry has not ruled out further experimentation with antipsychotics for psychosis prevention. Similarly despite stating antipsychotics should no be used as ‘first line’ treatment for ‘subthreshold psychosis’ he has not ruled out the use of antipsychotics as a ‘second line treatment’ for psychosis risk syndrome.

[2] Psychosis Risk Syndrome is also known as Attenuated Psychotic Symptoms Syndrome.

[3] Ritalin Consumer Medicine Information, http://www.racgp.org.au/cmi/nvcrtlor.pdf

[4] Professor MCGorry acknowledges that ‘the false positive rate may exceed 50-60%’ McGorry P.D. ‘Is early intervention in the major psychiatric disorders justified? Yes’, BMJ 2008;337:a695 http://www.bmj.com/cgi/content/full/337/aug04_1/a695 (accessed 3 August 2010) Psychosis Risk Syndrome critic Dr Alan Frances contends that up to 90% of those diagnosed with PRS would never go onto develop psychosis. Frances, A (2010) DSM5 ‘Psychosis Risk Syndrome’—Far Too Risky Psychology Today http://www.psychologytoday.com/blog/dsm5-in-distress/201003/dsm5-psychosis-risk-syndrome-far-too-risky

[5] Schizophrenia Research Forum, Live Discussion: Is the Risk Syndrome for Psychosis risky Business? http://www.schizophreniaforum.org/for/live/transcript.asp?liveID=68 Posted 4 October 2009

[6] Frances, A (2010) DSM5 ‘Psychosis Risk Syndrome’—Far Too Risky Psychology Today http://www.psychologytoday.com/blog/dsm5-in-distress/201003/dsm5-psychosis-risk-syndrome-far-too-risky