Australian of the Year Patrick McGorry’s call for early intervention to prevent Psychosis: A Stitch in Time or a Step too Far?

No sensible person would argue against Australian of the Year, psychiatrist Patrick McGorry’s call for early intervention to prevent psychosis; unless of course you know the detail of what Professor McGorry has advocated as early intervention. Put bluntly, Professor McGorry has advocated the use of antipsychotics, with a host of serious potential adverse side effects, on the hunch that adolescents may later become psychotic.

Specifically Professor McGorry is a leading international advocate for the inclusion of Psychosis Risk Syndrome, otherwise known as Attenuated Psychotic Symptoms Syndrome, in the next edition of the clinically dominant Statistical Manual of Mental Disorders (DSM-V) due for publication in 2013. He acknowledges that ‘the false positive rate may exceed 50-60%’ nonetheless has justified the use of pre-psychosis drugs by arguing ‘all those identified are by definition seeking help and need some form of care’.^[1]

Criticism of his views on the use of pre-psychosis drugs have received limited publicity within Australia. However, in 2006 Time Magazine (Drugs before Diagnosis) stated ‘Calm and softly spoken, McGorry has a way of making the experimental use of antipsychotics seem like the only responsible course.’ Time outlined how Professor McGorry trialled the antipsychotic, Risperidone, on subjects without psychosis but that were suspected of being at risk of developing psychotic disorders such as schizophrenia.^[2]

Risperidone (also known as Risperdal) is one of the more commonly used antipsychotics and has a range of serious potential side effects including metabolic syndrome, and sudden cardiovascular death.^{[3] [4]} There have been more than 500 voluntary adverse event reports made to the TGA and these are just the tip of the iceberg as the vast majority of adverse events are never reported. ^{[5] [6]}

The results of Professor McGorry’s Risperidone trial were inconclusive; however Time describes McGorry’s determination to push on ‘full steam ahead – and damn the torpedoes.’^[7] And Professor McGorry did push ahead, but now many of his international colleagues in the psychiatric profession are pushing back.

Dr Allen Frances the American Psychiatrist who led the 1994 revision of the current edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) is a fierce critic of Psychosis Risk Syndrome. With the benefit of hindsight he regrets aspects of the 1994 revision for having triggered ‘three false epidemics. One for autistic disorder… another for the childhood diagnosis of Bi-Polar disorder and the third for the wild over-diagnosis of Attention Deficit Disorder.’^[8] Based on this experience Dr Frances warns of numerous problems with the drafting of the next edition DSM-V, recently writing that;

‘Among all the problematic suggestions for DSM-V, the proposal for a “Psychosis Risk Syndrome” stands out as the most ill-conceived and potentially harmful… The whole concept of early intervention rests on three fundamental [flawed] pillars… 1) it would misidentify many teenagers who are not really at risk for psychosis; 2) the treatment they would most often receive (atypical antipsychotic medication) has no proven efficacy; but, 3) it does have definite dangerous complications.”^[9]

Dr Frances contends that up to 90% of those diagnosed with Psychosis Risk Syndrome would never go onto develop psychosis and concludes it is ‘the prescription for an iatrogenic [adverse effects resulting from treatment] public health disaster’.^[10]

Critics closer to home include Adelaide University Associate Professor, and Head of the Department of Psychological Medicine at the Women’s and Children’s Hospital in Adelaide, Dr Jon Jureidini, who in the August 2010 said that Professor McGorry had falsely claimed that 750,000 young Australians were ‘locked out’ of care they ‘desperately’ needed. ‘He’s taken the biggest possible figure you can come up with for people who might have any level of distress or unhappiness, which of course needs to be taken seriously and responded to, but he’s assuming they all require … a mental health intervention…It’s the way politicians operate. You look at figures and put a spin on it that suits your point of view. I don’t think that has a place in scientific conversations about the need for health interventions.’^[11]

Even one of Professor McGorry’s colleagues at the Orygen Youth Health Research Centre, Alison Yung, recently expressed strong opposition to the inclusion of Psychosis Risk Syndrome in DSM-IV stating;

‘I think the issue of antipsychotics is a crucial one. If someone meeting risk syndrome criteria also has depression and anxiety (the majority do), could they not be treated with psychological therapies such as cognitive behavioral therapy? 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…….more people seek help, but the risk is that instead of getting maybe supportive therapy, they get antipsychotics and they will be diagnosed with the risk syndrome.’^[12]

Perhaps due to his Australian of the year status Professor McGorry is frequently quoted by the Australian media as an independent advocate for mental health reform. However he, and organisations he is influential in, have received support from the pharmaceutical industry.  Along with being treasurer and former president of the pharmaceutical industry funded International Early Psychosis Association,  McGorry is currently Director of Clinical Services at Orygen Youth Health Clinical Program and Executive Director of the Orygen Youth Health Research Centre. Orygen Youth Health Research Centre receives support from numerous pharmaceutical companies.^{[13] [14]} Professor McGorry individually has received unrestricted grants from Janssen-Cilag, Eli Lilly, Bristol Myer Squibb, Astra-Zeneca, Pfizer, and Novartis and has acted as a paid consultant for most of these companies.^[15]

Professor McGorry and his colleagues Professor John Mendoza and Professor Ian Hickie (who also recive support from the pharmaceutical industry) dominated the long overdue debate about mental health policy in the lead up to the August Federal election.^{[16] [17]} Anyone who watched Insight on SBS (27 July 2010) would have noticed how deferential the presenter, politicians and participants were to Patrick McGorry, and to a lesser extent John Mendoza. Their blessing was desperately being sought by Peter Dutton and Mark Butler on behalf of the Coalition and Labor respectively.

Most enamoured of Professor McGorry’s approach was Dutton who stated “Well, we’re going to roll out a national scheme based on advice by people like John Mendoza, Pat McGorry, Ian Hickey, David Crosby and others….early intervention is proven without any doubt to work.”^[18] Mendoza reciprocated Dutton’s admiration describing the Coalition’s approach as “streets ahead. It’s literally comparing an old clunker to a brand new motor vehicle.” Largely due to the advocacy of Professor McGorry and his allies Mental health was unquestionably a net positive for the Coalition in the election.

Professor McGorry is now pressuring the Gillard Government to match the Coalition’s 2010 election commitment of $440m to EPPIC (Early Psychosis Prevention and Intervention Centres)  like those run by Orygen Youth Health which is headed up by McGorry.^[19] These centres aim “to facilitate early identification and treatment of psychosis” and “reduce delays in initial treatment”.^[20] It is undeniable that early intervention in the form of identifying and addressing real problems must be supported. But the majority of Adolescents ‘seeking care’ and diagnosed with Psychosis risk Syndrome would not only suffer their original difficulties but posibly from the unnecessary administration of potentially harmful antipsychotics. Professor McGorry has justified this compromise of the Hippocratic obligation to ‘first do no harm’ by arguing the ‘real danger of lack of care overshadows the theoretical one of premature labelling and overtreatment.’^[21]

Irrespective of these concerns there is no doubt Professor McGorry is a fantastic salesman. He combines excessive pessimism about the widespread prevalence of mental illness and unmet need, with optimistic promises of ‘21^st Century’ solutions (which happen to have been developed by him and his allies) if only government will urgently fund these ‘proven approaches’.^[22]

Mental Health does deserve the national spotlight and we can be grateful that Patrick McGorry’s appointment as Australian of the Year put it on the agenda. But the public are entitled to and informed debate about exactly what is being advocated.

Access to appropriate early intervention in mental health is long overdue, however prescribing antipsychotics to adolescents on the outside chance that they may develop later psychosis, is a bit like killing a fly with a shotgum.