The following is a verbatim copy of a blog by Dr Allen Frances and a response by Professor Patrick McGorry. The original is available at Psychology Today – DSMV In Distress
Dr Frances is a former Chair of the Department of Psychiatry at Duke University. Whilst at Duke he led the American Psychiatric Association Task Force that revised the current edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV). His attack on Australia’s blind acceptance of Professor Patrick McGorry’s model of early intervention comes from the very heart of heart of the psychiatric profession and can’t be ignored. Following Dr Frances’ blog is a response by Professor McGorry.
Australia’s Reckless Experiment In Early Intervention – prevention that will do more harm than good
Patrick McGorry is a charismatic psychiatrist who has recently gained heroic status. First he was chosen to be Australia’s Man of the Year. Now, he has convinced the Australian government to spend more than $400 million over five years to fund his plan for a nationwide system of Early Psychosis Prevention and Intervention Centres. McGorry is the visionary prophet and pied piper of preventive psychiatry. His goal is to diagnose mental disorders early and treat them expectantly- before they can do their worst damage.
McGorry’s goal is certainly great. But its current achievement is simply impossible and Australia’s plans are patently premature. Early intervention to prevent psychosis requires first that there be an accurate tool to identify who will later become psychotic and who will not. Unfortunately, no such accurate tool exists. The false positive rate in selecting prepsychosis is at least about 60-70% in the very best of hands and may be as high as 90% in general practice. That’s right, folks, nine misidentified non patients for one accurately identified truly prepsychotic patient. Those are totally unacceptable odds.
What are the costs? McGorry does not recommend antipsychotic medications as a routine part of his prevention regimen. But experience teaches us that they will be overused despite having no proven efficacy and posing the risk of massive weight gain (and its consequent array of serious complications). The false positives will also suffer unnecessary stigma and worry and will undergo unnecessary and misdirected treatment. And surely there are many more productive ways to spend $400 million doing a better job of managing the mental health needs of those who have real and treatable psychiatric disorders.
Unfortunately, Mcgorry is a false prophet who’s visions are offered at least a few decades before their time. Australia, led astray by his impractical hopes, is about to embark on a vast and untried public health experiment that will almost surely cause more harm to its children than it prevents. Before embarking on this headlong and reckless rush, the following research steps need to be accomplished:
1) Developing a proven and reliable definition of “Psychosis Risk”
2) Learning how to use it in a way that reduces current outrageously high false positive rates to levels that are tolerable.
3) Demonstrating that the interventions chosen are indeed effective in preventing psychosis.
4) Determining the likely rate of antipsychotic use and how this influences the overall risk/benefit balance sheet of early intervention.
5) Studying the beneficial and harmful impacts of early diagnosis on stigma and self perception.
6) Comparing the marginal utility of a dollar spent trying to prevent an alleged future disorder vs a dollar spent treating an already clearly established one.
This is a research enterprise that will take many groups around the world many decades to complete. But it is an absolutely necessary precondition before spending $400 million on what is likely to be a failure. The Australian experiment will be flying blind on an airplane that is not at all ready to leave the ground. Doing prevention prematurely and poorly will give a good idea an unnecessary bad name.
McGorry’s intentions are clearly noble, but so were Don Quixote’s. The kindly knight’s delusional good intentions and misguided interventions wreaked havoc and confusion at every turn. Sad to say, Australia’s well intended impulse to protect its children will paradoxically put them at greater risk. Let’s applaud McGorry’s vision but not blindly follow him down an unknown path fraught with dangers.
AUSTRALIA’S MENTAL HEALTH REFORM: AN OVERDUE INVESTMENT IN TIMELY INTERVENTION AND SOCIAL INCLUSION
By Professor Patrick McGorry
One has to wonder why Dr. Allen Francis, a retired former academic psychiatrist from the USA, would insert such an idiosyncratic, highly personalised critique of Australia’s Mental Health Reform into the blogosphere. Perhaps the title “DSM V in Distress” gives us a clue. A more accurate title may have been “Dr Allen Francis in Distress over DSM”. Dr. Francis was the chair of the previous (4th) edition of the American Psychiatric Association’s classification system of mental disorders, the DSM. He is well known to be seriously unhappy with the way his successors are carrying out their task and has taken aim at one of their candidates for inclusion, the subthreshold stage of psychotic illness. In a quixotic adventure of his own, he has had a dramatic tilt at a windmill of quite a different kind; the mental health policy of another country. We have been caught in a reckless crossfire. Flattering to deceive, Dr. Francis seems to be totally unaware of the facts concerning recent progress in Australia. Here is the background to and the essential elements of Australia’s mental health reform package.
The Australian Context and The Facts of the Reforms
Mental health reform was a key element in the Australian Government’s Health and Hospitals Reform Commission, chaired by Dr. Christine Bennett, whose report was handed down in 2009. This process combed through the evidence base and selected 14 areas for action in mental health. Top of this list were new community based services for young people and the scaling up of the EPPIC model for first episode psychosis. Over the course of the next 12 months and through an election campaign, mental health reform received strong and unprecedented support from across the Australian community, all sides of politics and a uniquely cohesive mental health sector. The re-elected Labor government made a commitment to enact this reform in its second term and embarked on a further wave of community consultation. I was asked to join an Expert Working Group on Mental Health to advise the new Minister for Mental Health, the Hon. Mark Butler, along with many other leaders from the mental health and related sectors. The ultimate reform package however was decided upon by the government and has received unprecedented support from the mental health sector and the Australian community. The Mental Health Council of Australia, the peak body representing the sector nationally, is in full support. The reform covers many aspects of mental health care, not only youth and early intervention, and is the result of a national team effort, not naïve charisma, spin doctoring or a national snake oil scheme. To imply such is not only to reveal ignorance of the facts but is patronising and disrespectful to the Australian community, to the Government and indeed all sides of Australian politics, to the mental health sector, and to those most directly affected by mental ill health who desperately depend upon this investment.
Far from charisma-based reform, this is progress driven by unacceptable levels of unmet need and based upon the best available evidence. Its focus is spread across all stages of illness and the total investment adds up to $2.2bn over 5 years. The largest single allocation of over $500m is actually devoted to those with severe and enduring mental illness.
The $400m focused on youth mental health and early psychosis has little to do with prevention and nothing to do with the “psychosis risk” windmill that Dr Francis is attacking. It has everything to do with the fact that young people bear the major burden for onset of mental disorders with 75% of these appearing before the age of 25 years (25% before age 12 and 50% between 12 and 25). Young people also have the highest prevalence of any group yet the worst access to care by far. So it is treatment needs not prevention that is driving this aspect of our national reforms.
Approximately $200m is to be spent on Australia’s highly successful “headspace” initiative. This will mean that young Australians aged between 12 and 25 years will have access to 90 youth-friendly portals or one-stop shops where stigma-free and holistic mental health care will be available. Up to 100,000 young people will eventually benefit. Commenced in 2006 and currently operating successfully in 30 sites, this enhanced primary care model has started to lift the proportion of young people with diagnosable mental and substance use disorders who receive any kind of mental health care from the basement level of 25% (13% for young men). The type of help on offer ranges from information and support through specialised forms of counselling and psychological interventions and access to youth friendly GPs, and in some sites to psychiatrists as needed. All forms of mental ill-health are eligible and the model has no specific connection to psychosis or subthreshold psychosis/psychosis risk.
The $200m allocated to scale up the EPPIC model around Australia is to implement a model of care developed in Melbourne 20 years ago. It was a response to the fact that, even when young people developed clearcut psychotic illness, where the diagnosis of first episode psychosis was in no doubt, long treatment delays, often for years, occurred during which their lives and futures were seriously damaged. Furthermore when they did enter treatment it was provided in facilities geared to the needs of much older adults with severe and disabling illnesses. The result was poor engagement, poor recovery and secondary trauma in many cases. The EPPIC model, or versions thereof, has now been adopted successfully in hundreds of centres around the world, and across the board in several countries, including England, Canada, the Netherlands, and other parts of Western Europe, Asia and even in the State of Oregon in the USA. The International Early Psychosis Association has held 7 large and successful conferences all over the world and the field has generated large volumes of evidence and an international group of experienced experts in early psychosis.
Consequently, there is very good evidence now that EI for first episode psychosis is more humane, effective, and highly cost-effective. So Australia is hardly being reckless in belatedly implementing its own innovation, some 10 years after England and many other parts of the world have done so. This aeroplane took off years ago. Dr. Francis like other critics of early intervention in psychiatry seeks to confuse the treatment of first episode psychosis with efforts to intervene at an earlier stage, the so-called subthreshold stage or the “ultra-high risk” stage. The latter issue has nothing to do with the Australian reforms which are an overdue catch up/scale up effort in relation to EPPIC, and an essential and welcome response to huge levels of unmet need in the case of headspace and youth mental health more broadly. Finally, unlike in the US health care system, these models of care are guided by young people themselves and their families, not dominated by medication, and are heavily influenced and respectful of the value of psychosocial care, which in our system is covered within our system of universal health insurance.
Turning to the question of psychosis risk and the ultra-high risk (UHR) mental state that Prof Alison Yung and I described and operationalised over 15 years ago, this is an important frontier for mental health care. Personally, I am not concerned whether it enters the DSM V or not, and indeed believe that there may well be a better way via a much broader spectrum clinical staging approach to address the clinical needs of these young people (which I have described elsewhere (McGorry et al 2010)). There may be a better way through this strategy to resolve anxieties about “false positives” since other diagnostic outcomes are included with many advantages, especially in relation to risk benefit considerations. The young people who do meet the current UHR criteria we defined for the ultra-high risk (UHR) mental state are distressed by symptoms of anxiety, depression and low grade or subthreshold psychotic symptoms. Their ability to function at school or work is substantially impaired and they have cognitive impairments. They are seeking and in need of help and treatment and are certainly not “non-patients” by any measure. They also have 200-400 times the risk of the normal population of developing a sustained psychotic disorder. It is true that the around two thirds will not in fact follow this path. These figures are similar to but more pronounced than the level of risk that someone with impaired glucose tolerance possesses for developing frank diabetes. There is no sense that interventions such as information, diet and exercise should be withheld from such people. Why a double standard? Why cannot young people in need of care not be provided with information on the level of risk, the things they can do to reduce the risk and the care they need for their current problems. Especially when this appears to reduce the risk of psychosis? The evidence that my colleagues and I and other groups has assembled through our research clearly shows that antipsychotic medications are not necessary or indicated at this stage and that psychosocial treatments and even fish oil is sufficient as first line. The metanalysis of Preti et al (2010) shows that the transition rates to frank psychosis can be reduced from around 30% to 10% at least in the short term. Our own latest research also shows that the initial level of distress and functional impairment also improves greatly with conservative psychosocial care. These facts are enshrined in international clinical practice guidelines published in 2005. We haven’t changed our approach merely firmed it up with additional research.
It may be true and indeed it is already that untrained and unregulated practitioners in unregulated settings will still inappropriately prescribe for such patients. The best way to prevent this is to allow such patients to enter more specialised youth mental health settings especially where program and guideline fidelity to treatments can be audited. So while the UHR or psychosis risk concept was in no way a driver of the headspace and EPPIC reforms, the concerns that Dr. Francis expresses regarding the potential harms that may befall UHR patients, notably inappropriate medication and stigma will be much less likely. In the USA even without the UHR concept entering the DSMV and in the absence of any stream of care for early psychosis or youth mental health there is widespread inappropriate use of medication in such patients. This stage of illness will be a key focus for ongoing research to better define the range and sequence of interventions that will be safest and most helpful.
Reform and Its Challenges
As Naomi Oreskes and Eric Conway illustrates in their compelling book “Merchants of Doubt”, evidence-based progress is not only hard won but can be undermined and delayed by the misuse of scientific arguments in support of vested interests of various kinds. She uses the examples of the link between cigarette smoking and cancer and also climate change. While not all resistance to change is so poorly motivated, vested interests and hidden agendas of other kinds can still delay the implementation of evidence based advances. Recognition of the barriers in the path of implementation of new knowledge has led to a whole new area of scientific endeavour known as implementation science and translational research. In Australia, the scaling up of an Australian innovation, early intervention for psychosis, has been delayed by this dynamic. It is not just a matter of reasonable scientific conservatism, since such reactions have not surfaced in relation to other aspects of reform in mental health over the past 20 years. With the Government’s recent budget announcements, we appear to have crossed a Rubicon in Australia, and the challenge is now high fidelity implementation strategies buttressed by rigorous health services research to measure the impact and outcomes of the reform. Early psychosis care with its vital focus on minimising treatment delays for first episode psychosis and guaranteeing holistic biopsychosocial care during the critical years post diagnosis is the best buy in mental health reform. The aeroplane left the ground 15 -20 years ago. EI for first episode psychosis is feasible now, not decades down the track as suggested by Dr. Francis. Far from labelling Australia as reckless, the Director of the National Institute for Mental Health (NIMH) in Washington DC, Dr. Tom Insel, recently stated at a national workshop on mental health research hosted by the NHMRC in Canberra, that Australia was a decade ahead of the US in research, clinical care and reform in early intervention for psychosis and other forms of mental ill-health in young people. We must ensure that the benefits of this progress to hundreds of thousands of Australians are not undermined by merchants of doubt with other agendas.
McGorry PD, Nelson B, Goldstone S, Yung AR. Clinical staging: a heuristic and practical strategy for new research and better health and social outcomes for psychotic and related mood disorders. Can J Psychiatry. 2010;55(8):486-497.
McGorry P. Risk syndromes, clinical staging and DSM V: new diagnostic infrastructure for early intervention in psychiatry and schizophrenia. Schizophrenia Research. 2010; 120: 49 – 53.
Preti A, Cella M. Randomized-controlled trials in people at ultra high risk of psychosis: a review of treatment effectiveness. Schizophrenia Research. 2010;123(1):30-36.
Oreskes N. and Conway E.M. Merchants of Doubt. Bloomsbury Press. NewYork. 2010