Response to the ‘Is Nick Sick?’ video blog

by Professor Jon Jureidini

“Patrick McGorry’s Orygen Youth Health, CAARMS training video[1] on how to diagnose ‘Attenuated Psychosis’ demonstrates how not to carry out a psychiatric interview and interact with young people.”

As identified by Martin Whitely in his commentary about the CAARMS training DVD, describing Nick as being at ultra-high risk of psychosis (UHR) fails the common-sense test. Even more concerning is that Nick is labelled as having Attenuated Psychosis – in ordinary language, he is already mildly mad.

Professor McGorry justifies diagnosing young people like Nick as being at ‘ultra high risk’ because within the next 12 months they are ‘between two and four hundred times’ more likely to become psychotic than the ‘the general population’.[2]

But we must respect the ordinary everyday language meaning of ultra high risk. If I am labelled as being at ultra-high risk of something, I assume that I will probably be affected. I do not interpret that label as meaning I am simply much more at risk than my peers.

Even Professor McGorry acknowledges that nearly two-thirds of the people identified as being at ultra high risk of developing psychosis, don’t become psychotic.[3] Independent evidence shows the conversion rate is as low as 8%[4] With between 64% and 92% false positives, the true ‘ultra high’ risk is the risk of being incorrectly labelled.

The pay-off for testing for UHR is simply not sufficient to justify the cost. One cost is that Nick is now being taught to see himself as sick. Who knows if this might not even increase this vulnerable young man’s risk of ultimately being diagnosed with full-blown psychosis? And as Martin Whitely points out, it stigmatises him.

But more important to me than stigmatisation is the fact that the UHR label is an unexplanation; it ignores what is going on in Nick’s life. Unexplaining is different from saying ‘I don’t know’ (something we doctors would do well to say more often). Unexplanations distract from the difficult but rewarding task of working with a young person towards finding an explanation for their stress.

Nick makes it pretty easy for the listener. He tells us about being bullied into a trade that he doesn’t want to be in, and he invites the interviewer to explore his relationship with his father. The interviewer doesn’t notice, or chooses to ignore this invitation, instead sticking to a stereotyped list of questions that generate the sterile unexplanation of UHR.

It might be argued that the interviewer would come back to this later. However, in my experience, young people prefer us to show an interest in their difficult and intimate predicaments when they first get the courage to put them into words.

I am grateful to Martin Whitely for putting the CAARMS training video into the public domain because it provides a potential teaching tool for medical students in how not to carry out a psychiatric interview and interact with young people.

For more on this subject see Whitely tells Parliament – It’s time to confront Patrick McGorry’s disease mongering and end the guru-isation of Australian mental health policy

Related Media

Byron Kaye, Medical Observer, McGorry stands firm on ‘flimsy’ accusations 11th Sep 2012 http://www.medicalobserver.com.au/news/mcgorry-stands-firm–on-flimsy-accusations

The following is a transcript of the interview with Nick and the introduction to the CAARMS Training DVD

Associate Professor Alison Yung.:

Hello and welcome to the CAARMS Training DVD. The CAARMS has two functions; First, to assess whether the person meets the ultra-high risk criteria for psychosis or not and second, to assess the range of psycho-pathology which we see typically in people in the prodrome preceding a first episode of psychosis. For this training video we’ll just focus on the first function,  that of assessing the ultra high- risk criteria.

For this function we need only the first four sub-scales of the CAARMS; Unusual thought content, non bizarre ideas, perceptual abnormalities and conceptual disorganization. These four sub-scales assess sub-threshold and threshold versions of positive psychotic symptoms, delusions, hallucinations and formal thought disorder.

You notice that the interviewer assesses both the intensity, frequency and duration of these phenomena.

We’re going to show you four interviews of typical people who present to the Pace clinic.

Also in the DVD there will be slides showing the ratings for each of these people.

By viewing the DVD you’ll see both how the interviewer asks the questions and the responses that we commonly encounter at the clinic.

DVD also contains additional information. We hope that this resource assists you in your work.

INTERVIEW 1.

Narrator: Nick is an 18 year old apprentice electrician in his first year of training. He is self-referred to PACE, encouraged by his sister, after confiding in her that he has been extremely anxious and has had great difficulty sleeping. He has not previously sought help for psychological issues but there is a family history of depression in the maternal aunt and of an unknown psychiatric condition in his mother’s grandmother. Nick is single and lives with his parents and three younger sisters. The family is of Italian origin. Nick did reasonably well at school and completed Year 12. He has a large circle of friends, enjoys playing sports and has had girlfriends in the past but is not in a relationship at the moment. He does not mind if his mother knows about his current problems but does not want his father informed.

Interviewer: Okay Nick, so you’ve told me that um things haven’t been going very for a little while now  since you started work, I just want to ask you some more detailed questions about the sorts of things you’ve been experiencing. So can you tell me, have you had the feeling that something odd is going on that you can’t explain?

Nick: No, not really, no. (shakes head)

Interviewer: No, Have you been feeling puzzled by anything?

Nick: No.

Interviewer:  Do you feel that you have changed in any way, who you are has changed?

Nick: No.

Interviewer: Or that people around you have changed in in some way?

Nick: No, not not really.

Interviewer:    Okay, have you felt that things around you have ahh a special meaning or that people have arranged things especially for you?

Nick: No.

Interviewer: No?

Nick: No.

Interviewer:  People been trying to give you any messages?

Nick: No.

Interviewer:  No? Now sometimes people have the feeling that someone or something outside of themselves are controlling their thoughts or their feelings – wondering if you’re having any experiences like that?

Nick: No, not like that.

Interviewer:  So you haven’t had any feelings or impulses that seem to come from someone else not yourself?

Nick: No.

Interviewer: No?

Nick: No.

Interviewer:  Okay. Do you ever have the feeling that um ideas or thoughts are put into your mind that aren’t yours?

Nick: No.

Interviewer: Okay. And what about the reverse process – having the the feeling that thoughts are being taken out of your head?

Nick: No, that’s never really happened.

Interviewer: Okay. Sometimes people feel that other people can read their minds or hear their thoughts. Does anything like that happen to you?

Nick: No.

Interviewer: No?

Nick: No.

Interviewer:  Can you tell me, has anyone been giving you a hard time or trying to hurt you in any way?

Nick: Well yeah, I suppose that’s that’s been a big thing for me um It’s gotten really bad. I feel like that all the time. Umm, I’ve actually started a new apprenticeship about three months ago ahm, and my dad got me into it because ahh one of his mates is doing doing him – doing him a favour so he is taking me on, umm, and my dad’s an electrician and he wants me to come in and take over the family business so, so I feel that I have to do it but I really don’t want to be there and I really don’t think that I’m really good at being an electrician so, since I started work um I’ve I’ve really felt while I was at work that I was really bad at what I was doing, ahhm and I actually felt – I actually felt at the time, I was starting to feel that the guys at work were thinking um that I’m really bad at what I’m doing and that they’re laughing at me behind my back and talking about me behind my back, so um, I mean the the guys that I work with they’ve all got families and you know they go fishing together so they’re all a close group of friends um whereas I’ve got nothing in common with them. So whenever we go on smoko breaks they all talk with each other, um and I tend to smoke by myself because I’ve got nothing to say to them really and um when during the smoko breaks you know when they’re laughing, ahh when they’re talking sometimes they look over in my direction and I feel that they’re actually talking about me and they’re laughing at me and you know and they think that I’m really bad at what I do, ummm, and I I mean I’ve made quite a few mistakes at work, umm and and I feel that they’re just waiting for me to stuff up because they know they they I just think that they know that I’m going to stuff up.

Interviewer: So has this been going on the whole time you’ve been at work?

Nick: Well it is it was alright when I started, umm, and then a few weeks into it I I really started to get worried because I’d made a few small, small mistakes, I started to think that you know they really were thinking well you know who have we hired here – he doesn’t know what he is doing, um and that actually got really bad about a month ago. Um, we had a really important deadline that we had to meet and we were quite stressed and um everyone was really busy and I was quite anxious because, um it was just a stressful time during that time and it got really bad there where every time I was at work and every minute I was actually just looking over my shoulder and looking at ah the other workers and seeing if they were looking at me and if they were talking about me and I felt that they were waiting for me to stuff up and and um, so so it got bad about a month ago- it’s not as bad now-it’s still, it’s still pretty bad but it’s not as bad as what it was about a month ago.

Interviewer: Ahuh, so in what way is it a bit better now, then it was a month ago?

Nick: Well I suppose back then it was a really stressful period um and everyone was busy at work and I was really stressed  at work so I think it got worse around that time ahh but I suppose now it’s it’s a bit less stressful at work and not so busy so, it’s not as bad  but I still look around and I still feel that as if they’re talking about me as if I’m really bad, they think that I’m really bad at my job.

Interviewer: Uhuh. How does, how do you respond to this? Has it made you do anything differently or?

Nick: Um, well, I’m, I’m always really  nervous about going to work and and I hate going to work now, um, and I I don’t really do anything differently, ah, but, I’m always looking and and listening and and um trying tryna catch them out- trying to catch them talking about me, um.

Interviewer: Do  you -Have you been getting to work every day?

Nick: Well, the past, the past few months I’ve, I’ve taken a few days off. Well I’ve been taking nearly one day off a week um, which has been really good, um.

Interviewer: That’s what I’m wondering  about. What’s it like for you when you’re at home?

Nick: Oh, when I have the days off and and when I’m home I’m fine you know. I don’t think about work and um I don’t worry about what they’re thinking of me and a lot of the times when I get home from work and I think about what’s happened earlier in the day you know, I feel that it’s – you know what I was thinking at the time was pretty, you know ,pretty silly and you know, it was, like they care what I’m doing and how good I am um.

Interviewer: So you can see it differently when you are at home?

Nick: Yeah, when I’m at home I’m I’m less worried about it and and, you know, sometimes I think that what I was thinking was pretty silly at the time but then when I’m at work I’m I get really anxious and worried about it.

Interviewer: Okay so you’re having this really hard time at work and things are okay at home.

Nick: Hmm, yeah.

Interviewer: You had these, this sort of stuff happen to you anywhere else or is it just at work?

Nick: Aww not really anywhere else. There’s there was this time um, it was about a month ago, still during that period.

Interviewer: During that time-

Nick: Yeah there was a couple of times um when I was actually on the train on my way to work and I was really tired and really really stressed and I just didn’t want to go to work, um and I was just standing up on the train and um I saw a couple talking to each other and I saw another guy um start laughing and um I I started to think at the time that um, they were actually talking about me and and they were laughing about me and um I was, I was  starting to to think they thought I was really bad at what I was doing; they, they knew that I was a bad electrician and I was really bad at what I was doing, so I got really anxious and really worried about that and really stressed; um and that that happened for, for two days.

Interviewer: Two days..

Nic: That happened twice. Yeah.

Interviewer:  Yep. And what happened when the journey ended and you got off the train and you were away from those people. Where you still-did you still have those worries?

Nick: Well, I I was really umn stressed getting off the train, um, and then you know, as I was walking to work I was sort of thinking about it a bit and– you know, I was thinking you know, those people don’t even know me and I’ve never met em before and they don’t even know what I do, so you know I was starting to think you know how would they know that I’m bad at what I do, so I started to think that you know maybe what I was thinking was a bit, you know, a bit over the top, a bit stupid, but you know at the time I really was convinced that they were.

Interviewer: It sounds like a really hard time and then you got to work and the worries would have come again.

Nick: Yeah yeah, like, like on those days walking to work I sort of cleared my head a bit and you know thought that it was all pretty stupid and then I got to work and you know, when work started again and the guys came in to work and you know, again, I still started to sort of worry about what they were thinking and yeah.

Interviewer: Okay, so you’re using, um, marijuana with your friends on the weekends.

Nick: Yeah.

Interviewer: How are you feeling when you’re, when you’re stoned with your friends?

Nick: Oh, um it feels pretty good. I mean the reason I do it is is to relax um.

Interviewer: And that’s the effect that it has?

Nick: Yeah, yeah. I don’t, I just do it just to get away from things, and not to think about things or anything like that so.

Interviewer: Some people find that when they use marijuana they get more worried but that doesn’t sound like your experience?

Nick: Ah no, no never, never been worried or nervous or stressed when I’ve been with my mates and smoking so I suppose that’s why I do it with them, just to chill out on the weekends.

Interviewer: Mkay. Have you been feeling that you’re especially important in some way or that you’ve got special powers to do things?

Nick: No. Not really. No that hasn’t happened.

Interviewer: Okay. Now have you been feeling that there’s anything odd going on with your body that you can’t explain?

Nick: No.

Interviewer: Or that your body’s changed in any way?

Nick: No.

Interviewer: No?um, what about feeling guilty or that you deserve punishment. Does that come up for you at all with..

Nick: No. No.

Interviewer: With these things? Okay, fine.

Nick: Some-Sometimes at work I feel that, um, just with,ah with my stuff ups I think that, you know, the boss will, will catch me out and he’ll find me out and um that I will get punished but yeah I don’t actually feel the need that I need to be punished or anything like that.

Interviewer: Are you very religious Nick, have you had any religious experiences?

Nick: Ahh, no, not really.

Interviewer: Okay. And um, do you have a girlfriend?

Nick: Ah, I I used to a couple of years ago but I can’t be bothered looking after one at the moment.

Interviewer: Another area that I need to ask you about is the area of ah perceptions, what you see and hear

Nick: Yeah

Interviewer: And that kind of thing. Um so I’m wondering if you’ve noticed any changes in in your vision, do you, um are things looking different to you?

Nick: NarI needed, I needed glasses. I need to get glasses, um so um things were getting a bit blurry um, but.

Interviewer: So glasses have improved your vision?

Nick: Yeah. Yeah.

Interviewer: In more recent times has there been a change in the way things look to you?

Nick: No

Interviewer: The colours brighter?

Nick: No, no that’s all the same

Interviewer: Anything like that

Nick: Yeah

Interviewer: Um. Okay. And what about um hearing things. Have you been hearing things that other people can’t hear?

Nick: No.

Interviewer: Any changes to the way you perceive sound at all?

Nick: No. No.

Interviewer: Any strange sensations in smell, smelling strange things, or things smelling different?

Nick: No.

Interviewer: And, um, I asked you whether you had any strange sensations on your skin. Whether you’ve um felt things crawling on your skin or underneath your skin?

Nick: No.

Interviewer: Anything like that?

Nick: No. No.

Interviewer: No. And what about your ability to communicate with people Nick? Have you felt like um, you’re able to communicate clearly, that people understand what you’re saying? You’re able –

Nick: Yeah.

Interviewer: to get your message across?

Nick: Yeah, never really had problems with that.

Interviewer: Uhuh.

Nick: No.

Interviewer: Okay. Do you have um trouble finding the correct word to use at all?

Nick: Aw, sometimes, I mean I’m I’m not the best at English so sometimes I, you know I can’t find the right – I’m thinking of the word that I’d use or I heard a couple of days ago and I just can’t think of it at the time, um, I think of it later on sometimes but- so sometimes I find- have trouble finding the right word, but, it doesn’t happen very often.

Interviewer: It doesn’t happen very often, it’s not something that you’re really worried about?

Nick: No.

Interviewer: No?

Nick: No.

Interviewer: Okay.

Nick: I still, they still understand what I’m trying to say.

Interviewer: Yep. Do you ever have the feeling that, um, you go off on tangents and that people don’t follow what you’re on about?

Nick: No.

Interviewer: No? So do you think your activity level has dropped off a bit? Are there things you used to do that you don’t do now?

Nick: Well, I, I mean I always used to go out with my friends. Go out drinking. Go out clubbing and go to the gym with them, um but, since, since work has started I really haven’t been in the mood to do anything like that. So I haven’t been in the mood to go out with them.

Interviewer: So does that mean you’re not going out at all now?

Nick: Oh, sometimes they drag me out like a lot of the times I don’t want to go but sometimes they just drag me out, and when we actually go out I have a great time with them. So it’s like, it’s like nothing.

Interviewer: So you are still able to enjoy yourself at times but-

Nick: Yeah.

Interviewer: But it’s a bit hard to get yourself going?

Nick: Yeah, yeah. I just feel I don’t have the energy and just don’t want to do it anymore.

The DVD is paused. Take each of the 4 subscales and rate the Global Assessment and Frequency and Duration for each. Press Continue and the answers will follow.

UNUSUAL THOUGHT CONTENT – GLOBAL RATING SCALE

Alison Yung: Unusual thought content. Nick receives a zero for unusual thought content as he does not answer positively to any of the questions.

Non-Bizarre ideas. He does rate on the Non-Bizarre ideas sub-scale however because of the experiences he has been having at work lately. He receives a Global score of 5 with his persecutory ideas – feelings that other people know that he is bad at his job. As he has experienced these thoughts about strangers on the train it is highly unlikely that they are true. However these thoughts are not held with delusional conviction as he is able to question these thoughts. Thus the intensity is not as high as a score of 6. These thoughts have resulted in Nick taking some time off work. Hence they have resulted in some change in behavior. They are not very easy for Nick to dismiss which means that the intensity is not as low as a score of 3.

Because these thoughts occur most days when he is at work. and last for more than an hour he rates a frequency and duration score of 4.

Frequency and Duration

Pattern of Symptoms

Level of Distress (In Relation to Symptoms)

Not At All Distressed                                                                                                                  Extremely Distressed

Perceptual Abnormalities – Global Rating Scale

Perceptual Abnormalities – Nick states that he needed glasses. However, he does not report experiencing any perceptual abnormalities so for this sub-scale he rates a zero.

Disorganised Speech – Global Rating Scale

Disorganised speech – Nick reports that he sometimes has trouble finding the correct word at the right time. However people still understand what he is saying so he rates a global score of 2 for disorganized speech. He said that this does not happen very often so he rates a frequency and duration score of 1.

Nick meets the PACE  intake criteria for Group 2, the Attenuated Psychosis group. He also meets the drop in functioning criteria.

Note: Nick is played by an actor, however the interviewer is a doctor employed by Orygen Youth Health

[1] Orygen Youth Health Centre, 2009, “Comprehensive Assessment of At Risk Mental State (CAARMS) Training DVD”, The PACE Clinic, Department of Psychiatry, University of Melbourne. see http://www.eppic.org.au/risk-mental-state accessed 3 September 2012

[2] McGorry P. Right of Reply – Patrick McGorry on Early Intervention for Psychosis. December 11, 2010. http://speedupsitstill.com/reply-patrick-mcgorry-early-intervention-psychosis#more-1075

[3] Professor McGorry wrote “the false positive rate (for UHR) 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) Professor McGorry’s close colleague Alison Yung identified the conversion rate from UHR to first episode psychosis was 36% in an article in the Medical Journal of Australia titled Is it appropriate to treat people at high-risk of psychosis before first onset — Yes Available at https://www.mja.com.au/journal/2012/196/9/it-appropriate-treat-people-high-risk-psychosis-first-onset-yes

[4] Professor David Castle, Medical Journal of Australia, 21 May 2012, Is it appropriate to treat people at high-risk of psychosis before first onset — No Available at https://www.mja.com.au/journal/2012/196/9/it-appropriate-treat-people-high-risk-psychosis-first-onset-no

In December 2010 Minister for Mental Health & Ageing Mark Butler took the extraordinary step of sidelining his own National Advisory Council on Mental Health and appointing Professors McGorry and Hickie as members of a Mental Health Expert Working Group. Minister Butler said ‘that the creation of the new, time limited, specialist group will allow for targeted advice to be provided directly to the Australian Government on how to achieve the most coordinated, cost-effective and lasting reforms for their investment in mental health care.’^[1]

For reasons that are not clear, Professors McGorry and Hickie and fellow member of the Mental Health Expert Working Group, Monsignor David Cappo, subsequently established the Independent Mental Health Reform Group. In March this year the Independent Mental Health Reform Group released its $3.5B blueprint for mental health.^[2]

In the following blog I outline my concerns in relation to the blueprint including the:

• proposal to increase funding to Headspace by $226 million given the advocacy by Professor McGorry and Headspace of ‘off label’ prescribing of SSRI antidepressants to young people. This is despite clinical studies and FDA and TGA advice that the use of SSRI’s increases the risk of suicidal behaviour by young people.
• proposal to increase funding to EPPIC by $910 million given Professor McGorry advocacy of the recognition of Psychosis Risk Syndrome as a diagnosable psychiatric disorder. This is despite the concerns of numerous high profile psychiatrists including his close colleague Professor Alison Yung who questions; ‘ Is the agenda really to use antipsychotics?…the risk is that instead of getting maybe supportive therapy, they get antipsychotics and they will be diagnosed with the risk syndrome.
• lack of publicly accesible evidence of patient outcomes and the cost effectiveness of the mental health ‘best buys’ identified in the blueprint.
• alarmist claim by Professor McGorry that in 2011 four million Australian’s including 1 million young people will have a mental disorder requiring treatment.

Following my blog Professor McGorry takes up my invitation to exercise his right of reply.

So what is in the blueprint?

The blueprint outlines $3.5billion expenditure over 5 years on programs that are identified as mental health ‘best buys’. The most expensive ‘best buy’, at $910m, is for the rollout of 20 new Early Psychosis Prevention Intervention Centres (EPPIC). Australia’s only existing EPPIC clinic is run by Orygen Youth Health, headed up by Professor McGorry.^[3] The blueprint states that EPPIC has ‘the largest international evidence base of any mental health model of care demonstrating not only their clinical effectiveness but also their return on financial and social return on investment.’ Despite this bold claim, there is no evidence in the blueprint of EPPIC’s cost effectiveness or patient outcomes compared with outcomes from other mental health services.

The second priority identified is the expansion of the national Headspace program to 90 service sites, at a cost of $226m. Professors McGorry and Hickie are both Board members of Headspace. Again there is no supporting evidence. The blueprint is completely unreferenced. It is merely a $3.5billion consensus wish list of these ‘independent’ mental health experts, completely devoid of supporting verifiable evidence.

That is not to suggest that Headspace and even EPPIC don’t provide some valuable interventions, and there is undoubtedly some merit in the other programs identified. However, the blueprint falls far short of establishing the case that an extra $3.5 billion of taxpayer’s funds would be best spent on the identified ‘best buys’.

How ‘independent’ is the Independent Mental Health Reform Group that developed the blueprint?

Professor McGorry and several organisations he presides over have received considerable financial support from the pharmaceutical industry. In 2008, McGorry disclosed the sources but not the quantum of pharmaceutical company funds he has received in an article he wrote published by the British Medical Journal. To its’ credit the BMJ is one of the few journals that strictly enforces its’ disclosure policy. It stated McGorry, ‘has received unrestricted research grant support from Janssen- Cilag, Eli Lilly, Bristol Myer Squibb, Astra-Zeneca, Pfizer, and Novartis. He has acted as a paid consultant for, and has received speaker’s fees and travel reimbursement from, all or most of these companies’.^[4] McGorry is currently Director of Clinical Services at Orygen Youth Health Clinical Program and Executive Director of the Orygen Youth Health Research Centre.^[5] Orygen receives support from numerous pharmaceutical companies.^[6] In addition, McGorry is Treasurer and former President of the pharmaceutical industry funded International Early Psychosis Association.

Professor Ian Hickiehas received grants totalling $411,000 from pharmaceutical companies, including $10,000 from Roche Pharmaceuticals (1992); $30,000 from Bristol-Myers Squibb (1997); $40,000 from Bristol-Myers Squibb (1998-1999); $250,000 from Pfizer Australia (2009); and $81,000 from Pfizer Australia (n.d.).^[7]  Whilst it was not disclosed in the blueprint, Hickie does deserve some credit for disclosing in his online CV that he has received this funding from the pharmaceutical industry.

Along with Professors McGorry and Hickie and Monsignor David Cappo, the other members of the ‘independent’ group are Sebastian Rosenberg, John Moran and Matthew Hamilton. Moran and Hamilton both work for Orygen and therefore are subordinates of McGorry. Rosenberg is the former CEO of the Mental Health Council of Australia and is currently Head of the National Mental Health Policy Unit at Hickie’s Brain and Mind Research Institute^[8] and a director of the mental health business ConNetica, whose website lists one of its ‘Private Sector Customers’ as Eli Lilly.^[9]

Neither Professors McGorry nor Hickie nor any other member of the Independent Reform Group disclosed their pharmaceutical company connections in the blueprint. Neither did the blueprint identify which mental health ‘best buys’ are based on service delivery models exclusive to organisations they control. These potential conflicts of interest may have been known by the politicians controlling funding, however, it is apparent the media were either ignorant of, or disinterested in them and happily portray McGorry and Hickie as independent advocates.

Why does Professor McGorry think that 4 million Australians will have a ‘mental disorder’ requiring treatment in 2011, and what treatments does he propose?

In March 2010 when appearing on ABC’s Lateline, Professor McGorry said ‘4 million Australians have mental health problems in any given year. Only one third of them get access to treatment… there are 1 million young Australians aged 12 to 25 with a mental disorder in any given year. It’s the peak period across a lifespan when mental disorders appear. And 750,000 of them have no access to mental health care currently.’^[10][11]

Public critics of Professor McGorry are rare; however, not everyone accepts his alarming claims. Jon Jureidini, Adelaide University Professor of Psychiatry and Paediatrics, accused McGorry of disease-mongering when claiming 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.’^[12]

Professor McGorry responded to Professor Jureidini’s criticisms, writing: ‘I have never argued that 1 million young Australians have serious mental illness’. However, he added: ‘late intervention philosophy is associated with risk, preventable damage and stigma and for this reason access to appropriate, staged mental health care for young Australians with mild, moderate and serious mental ill-health is overwhelmingly supported by political parties and the health and social sectors (most recently expressed in a letter co-signed by 65 organisations). To argue that young Australians with mild to moderate mental ill-health do not need access to mental health care applies a standard to mental health that would not be acceptable in physical health. Imagine restricting access to health services to only Australians with severe physical ill-health and locking out all those with milder conditions with the admonition that they should just regard their distress as part of the human condition and suck it up!’^[13]

Professor McGorry is of course correct that there appears to be ‘overwhelming’ support by ‘by political parties and the health and social sectors’ for his calls for early intervention; however, this is evidence of political rather than clinical or scientific success. There is undoubtedly unmet and mis-met mental health need, but Professor Jureidini’s legitimate questions remain. In 2011 will more than one in seven Australians (4 million) have a ‘psychiatric disorder’ requiring a ‘mental health intervention’? Would these millions of Australian’s benefit from, or be stigmatised by being labeled ‘psychiatrically disordered’? And even more worryingly, what are these potential interventions and will they do more harm than good?

Why do Headspace and Professor McGorry advocate the ‘off label’ (unapproved) use of SSRI antidepressants in even ‘moderately depressed’ young people, despite FDA and TGA warnings about the increased risk of suicidality?

A 2009 evidence summary produced by Orygen Youth Health for Headspace and overseen by Professor McGorry, titled ‘Using SSRI Antidepressants to Treat Depression in Young People: What are the Issues and What is the Evidence?’, correctly identifies that the US Food and Drug Administration has issued the highest possible ‘black box’ warning that the use of SSRI antidepressants increases the risk of suicidality in people under 24.^[14] The warning was put on in 2005 after an analysis of clinical trials by the FDA found statistically significant increases in the risks of ‘suicidal ideation and suicidal behavior’ by about 80%, and of agitation and hostility by about 130%.^[15]

Headspace’s evidence summary also acknowledged that ‘no antidepressants (including any SSRIs) are currently approved by the Therapeutic Goods Administration (TGA) for the treatment of major depression in children and adolescents aged less than 18 years’.^[16] In addition the evidence summary acknowledges that research indicates that in terms of managing the symptoms of depression, ‘the only SSRI with consistent evidence of its effectiveness in young people is fluoxetine (Prozac)….The effectiveness of fluoxetine however is modest…Young people on fluoxetine do not appear to be functioning better in their daily lives at the end of the trials.’^[17]

The body of the evidence summary builds a compelling argument for avoiding the use of SSRIs in young people. Despite this, it concludes by recommending: ‘In cases of (even) moderate to severe depression, SSRI medication may be considered within the context of comprehensive management of the patient, which includes regular careful monitoring for the emergence of suicidal ideation or behaviour’.^[18] The nearest thing to a rationale offered in the paper is that many young people who are depressed get no treatment and that it is better to do something than nothing.

Through the use of a variety of mechanisms, including candle-light vigils, Professor McGorry has mobilised well intentioned, vocal supporters including Get Up! to highlight the tragedy of youth suicide to advocate for reform of mental health services for the young.^[19] Yet the Headspace evidence summary, which is effectively a guideline for the treatement of young Australians, acknowledges and then ignores the clinical trial evidence and FDA and TGA advice on the relationship between SSRI antidepressants and youth suicidality.

If Australia were, as Professor McGorry frequently advocates, to follow ‘evidence based medicine’ on preventing the tragedy of youth suicide, we would not allow the use of SSRIs by young people. However, if Australia follows Headspace and McGorry’s advice on SSRIs, we risk more, not fewer, candles at the next vigil.

Why has Professor McGorry experimented with the use of antipsychotics in non-psychotic adolescents, and why does he advocate the recognition of controversial newly invented psychiatric disorders?

Professor McGorry has a long history of advocating or experimenting with the ‘off label’ use of psychotropic drugs for moderate mental ‘illness’ and for hypothesised psychiatric disorders that are not officially recognised. He 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 American Psychiatric Association’s clinically dominant Diagnostic and Statistical Manual of Mental Disorders (DSM-V) (the ‘bible’ of psychiatry) due for publication in 2013.

Professor McGorry hypothesises that that there is ‘prodromal phase’ prior to the onset of a first psychotic episode. He acknowledges that ‘the false positive rate may exceed 50-60%’, but nonetheless he led controversial research that trialled the use of the antipsychotic risperidone (Risperdal®) on young people without psychosis who were suspected of being at risk of developing psychotic disorders such as schizophrenia.^[20]

Risperidone is one of the more commonly used ‘atypical’ (newer) antipsychotics and has a range of serious potential side effects including metabolic syndrome, and sudden cardiovascular death.^[21][22] 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.^[23][24]

Professor 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 the hypothesised psychosis risk syndrome. With the benefit of hindsight, Frances 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.’.^[25]

Based on this experience, Professor 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.”^[26] Frances contends that up to 90% of those diagnosed with psychosis risk syndrome would never go on to develop psychosis, and concludes that the it is ‘the prescription for an iatrogenic [adverse effects resulting from treatment] public health disaster’.^[27]

Even one of Professor McGorry’s closest colleagues at the Orygen Youth Health Research Centre, Professor Alison Yung, has expressed strong opposition to the inclusion of psychosis risk syndrome in DSM-V, questioning; ‘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.’^[28]

Regardless Professor McGorry still advocates for the inclusion of psychosis risk syndrome in DSM-V. However, he recently distanced himself from the use of antipsychotics on patients perceived to be at risk of psychosis. In response to earlier criticism including a blog I authored, he wrote ‘Antipsychotic medications should not be considered unless there is a clear-cut and sustained progression to frank psychotic disorder meeting full DSM 4 criteria’ This appeared to put an end to the debate about whether McGorry currently advocates the use of antipsychotics on the hunch that adolescents will later become psychotic.

However, the statement in his December 2010 blog that ‘our clinical guidelines do not (and have never done so in the past) recommend the use of anti-psychotic medication as the first line or standard treatment for this Ultra High Risk group’ has the potential to mislead.^[29] Whilst it is true that Professor McGorry has never produced final endorsed clinical guidelines recommending the use of antipsychotics for his hypothesised ‘ultra high risk group’, the facts are that for well over a decade McGorry experimented with, and advocated, the pre-emptive prescription of antipsychotics to adolescents.

Professor McGorry was the lead author of a 2006 article which, as part of a proposed ‘clinical staging framework for psychosis’, identified ‘atypical antipsychotic agents’, as one of the ‘potential interventions’ for individuals who are at ‘ultra-high risk (10% to 40%)’ of developing first episode psychosis.^[30] Whilst he has recently adjusted the ‘clinical staging framework’, he was still advocating antipsychotics as a potential pre-psychosis intervention at least as late as October 2007.

A 2007 British Medical Journal article jointly authored by Professor McGorry began by quoting a 1994 paper extolling the potential of pre-psychosis pharmacological interventions: ‘The best hope now for the prevention of schizophrenia lies with indicated preventive interventions targeted at individuals manifesting precursor signs and symptoms who have not yet met full criteria for diagnosis. The identification of individuals at this early stage, coupled with the introduction of pharmacological and psychosocial interventions, may prevent the development of the full-blown disorder.’ McGorry’s article’s opening comment followed: ‘Such sentiment underlines the aim of identifying people in the prodromal phase preceding a first psychotic episode.’^[31] The article went on to outline evidence supporting interventions including antipsychotics ‘to delay or even prevent onset of psychosis.’

Furthermore, in 2008, in the British Medical Journal, in an article titled ‘Is early intervention in the major psychiatric disorders justified? Yes’, Professor McGorry wrote: ‘Early intervention covers both early detection and the phase specific treatment of the earlier stages of illness with psychosocial and drug interventions. It should be as central in psychiatry as it is in cancer, diabetes, and cardiovascular disease….. Several randomised controlled trials have shown that it is possible to delay the onset of fully fledged psychotic illness in young people at very high risk of early transition with either low dose antipsychotic drugs or cognitive behavioural therapy.’^[32]

These are just a few of numerous similar statements which comment favourably or suggest the use of antipsychotics as part of the treatment for adolescents considered to be at ‘ultra high risk’ of developing psychosis. Whether such comments constitute ‘advocacy’ is open to semantic debate. However, Professor McGorry certainly favoured this highly controversial use and continues to advocate for the official recognition of ‘psychosis risk syndrome’ as a psychiatric disorder. Despite being dircetly asked by me Professor McGorry has not ruled out further experimentation with antipsychotics for psychosis prevention, or the use of antipsychotics as a ‘second line treatment’ for ‘subthreshold psychosis’. These are issues that need a clear resolution before there is any increased funding of EPPIC.

Where are other psychiatrists and the Royal Australian & New Zealand College of Psychiatrists in the national mental health debate?

With the notable exception of Professor Jon Jureidini and Professor Vaughan Carr^[33], there has been little public criticism from within the Australian psychiatric profession of Professor McGorry’s plans for the future of Australian mental health. A number of psychiatrists I have spoken to are privately critical of McGorry’s advocacy of ‘off label’ prescribing; however, they are grateful that McGorry’s Australian of the Year status has at last put mental health on the agenda and is likely to result in extra resources.

Whilst I am critical of the unquestioning acceptance of Professors McGorry and Hickie’s claims by politicians and the media, it is not entirely their fault. Mental health is a confusing and mysterious field clouded by personal and commercial agendas and politicians, and the media have not been offered an attractive alternative – mainly because there are few simple solutions for complex problems.

The Australian psychiatric profession needs to start acting like a profession interested in cautious, first-do-no-harm, evidence-based approaches to addressing unmet and mis-met mental health needs. The Royal Australian & New Zealand College of Psychiatrists needs to stop being so timid. The Australian public needs a vigorous debate within the College, the psychiatric profession, the wider medical and therapeutic community and the public to drive the future of Australian mental health.

Isn’t it time to ask Professor McGorry a few tough questions?

I think that unquestioningly following Professor McGorry’s prescription for Australian mental health risks more harm – more ‘psychiatric disorders’, youth suicides and an epidemic of iatrogenic (adverse prescription drug event) suffering – than good. I am particularly concerned that a McGorry endorsed and Headspace driven increase in the ‘off label’ prescription of SSRI antidepressants to children and young people may cost lives. And I think McGorry’s pharmaceutical company ties and obvious conflicts of interest in advocating for well over $1billion increased funding for EPPIC and Headspace need to be understood and considered.

Professor McGorry needs to show that his claim that four million Australians will suffer a mental health disorder warranting treatment this year is not disease-mongering. He needs to detail what these psychiatric disorders are and exactly what appropriate treatments would involve. And McGorry needs to explain why the FDA and TGA are wrong and why giving SSRIs to depressed children and adolescents doesn’t increase their chances of suicidality.

And Professor McGorry needs to explain why he has experimented with antipsychotics on adolescents who had never been, and by his own admission probably never will be, psychotic. McGorry also needs to explain why Professor Allen Frances and even McGorry’s close ally Professor Alison Yung are wrong to be concerned that his push for the recognition of ‘psychosis risk syndrome’ as a new psychiatric disorder may be all about promoting the use of antipsychotics and may lead to an ‘iatrogenic health disaster’.

Perhaps Professor McGorry really does have insights that make him uniquely placed to design Australia’s 21^st century mental health system. However, now that the Gillard Government is on the verge of committing massive resources to aspects of McGorry’s mental health blueprint, it is time the Canberra politicians, the media and the Australian psychiatric profession and other health and welfare professionals got beyond his former ‘Australian of the Year’ status and asked him a few hard questions.

[2] Including, Connecting, Contributing: A Blueprint to Transform Mental Health and Social Participation in Australia, March 2011. Prepared by the Independent Mental Health Reform Group: Monsignor David Cappo, Professor Patrick McGorry, Professor Ian Hickie, Sebastian Rosenberg, John Moran, Matthew Hamilton http://sydney.edu.au/bmri/docs/260311-BLUEPRINT.pdf (accessed 26 April 2011)

[3] Orygen Youth Health – Early Psychosis Prevention Intervention Centre website http://www.eppic.org.au/about-us (accessed 26 April 2011)

[4] McGorry P.D. (2008) Is early intervention in the major psychiatric disorders justified? Yes, BMJ 337:a695 http://www.bmj.com/cgi/content/full/337/aug04_1/a695 (accessed 3 August 2010)

[5] McGorry is the former President and the current Treasurer (http://www.iepa.org.au/ContentPage.aspx?pageID=40) of the International Early Psychosis Association which is funded by antipsychotic manufacturers Astra Zeneca, Lilly and Janssen-Cilag (http://www.iepa.org.au/2010/)

[6]McGorry is currently Director of Clinical Services at Orygen Youth Health Clinical Program and Executive Director of the Orygen Youth Health Research Centre. Orygen receives support from AstraZeneca, Bristol Myer Squibb, Eli Lilly, and Janssen-Cilag. Orygen Youth Health, Research Centre – Other Funding http://rc.oyh.org.au/ResearchCentreStructure/otherfunding (accessed 3 August 2010)

[7] Cited in Ian Hickie, Curriculum Vitae, last updated 23 August 2009 http://sydney.edu.au/bmri/about/Hickie_CV.pdf (3 August 2010). In addition Professor Hickie and colleagues created ‘SPHERE: A National Depression Project’ (http://sydney.edu.au/bmri/about/Hickie_CV.pdf). As was reported in The Australian, Pfizer works in conjunction with SPHERE through a company called Lifeblood, which is based at Hickie’s Brain and Mind Research Institute. BMRI staff are paid to review SPHERE. According to Lifeblood, SPHERE ‘assisted in restoring the market share and growth of the Pfizer antidepressant Zoloft, restoring it to the No 1 product in this market’. Davies J. (10 July 2010) GP jaunts ‘boosted’ drug sales, The Australian. http://www.theaustralian.com.au/news/nation/gp-jaunts-boosted-drug-sales/story-e6frg6nf-1225890003658 (accessed 30 April 2011)

[8] Brain and Mind Research Institute website http://sydney.edu.au/bmri/research/mental-health-policy/index.php (accessed 30 April 2011)

[9] ConNetica website http://connetica.com.au/about (accessed 26 April 2011)

[10] ABC (11 March 2010) Mental health system in crisis: McGorry, Lateline, Australian Broadcasting Corporation. Reporter: Tony Jones http://www.abc.net.au/lateline/content/2010/s2843609.htm (accessed 26 April 2011)

[11] In a presentation on behalf of beyondblue, Professor Ian Hickie claimed the 12 month prevalence of mental disorders for Australia men is 17.4% and woman 18.0%. Responding to the challenge of brain and mind disorders in Australia, Ian Hickie MD FRANZCP Professor of Psychiatry, Brain and Mind Research Institute, University of Sydney& Clinical Advisor, beyondblue: the national depression initiative http://www.gptt.com.au/Exam%20preparation%20CK%20Khong/Mental%20Health/Depression%20adults%20hickie_slides.pdf

[12] Medew, J. (9 August 2010) McGorry ‘misleading the public’, The Age http://www.theage.com.au/national/mcgorry-misleading-the-public-20100808-11qes.html

[13] Sweet, M. (17 August 2010) Patrick McGorry defends early intervention on youth mental health, Croakey: the Crikey Health Blog http://blogs.crikey.com.au/croakey/2010/08/17/patrick-mcgorry-defends-early-intervention-on-youth-mental-health/ (accessed 26 April 2011)

[14] Evidence Summary: Using SSRI Antidepressants to Treat Depression in Young People: What are the Issues and What is the Evidence? Headspace, Evidence Summary Writers Dr Sarah Hetrick, Dr Rosemary Purcell, Clinical Consultants Prof Patrick McGorry, Prof Alison Yung, Dr Andrew Chanen http://www.headspace.org.au/core/Handlers/MediaHandler.ashx?mediaId=4896 (accessed 26 April 2011)

[15] Hammad T.A. (16 August 2004). Review and evaluation of clinical data. Relationship between psychiatric drugs and pediatric suicidal behavior, Food and Drug Administration. pp. 42; 115. http://www.fda.gov/OHRMS/DOCKETS/ac/04/briefing/2004-4065b1-10-TAB08-Hammads-Review.pdf (accessed 29 May 2008)

[16] Evidence Summary: Using SSRI Antidepressants to Treat Depression in Young People: What are the Issues and What is the Evidence? Headspace, Evidence Summary Writers Dr Sarah Hetrick, Dr Rosemary Purcell, Clinical Consultants Prof Patrick McGorry, Prof Alison Yung, Dr Andrew Chanen http://www.headspace.org.au/core/Handlers/MediaHandler.ashx?mediaId=4896 (accessed 26 April 2011)

[17] Evidence Summary: Using SSRI Antidepressants to Treat Depression in Young People: What are the Issues and What is the Evidence? Headspace, Evidence Summary Writers Dr Sarah Hetrick, Dr Rosemary Purcell, Clinical Consultants Prof Patrick McGorry, Prof Alison Yung, Dr Andrew Chanen http://www.headspace.org.au/core/Handlers/MediaHandler.ashx?mediaId=4896 (accessed 26 April 2011)

[18] Evidence Summary: Using SSRI Antidepressants to Treat Depression in Young People: What are the Issues and What is the Evidence? Headspace, Evidence Summary Writers Dr Sarah Hetrick, Dr Rosemary Purcell, Clinical Consultants Prof Patrick McGorry, Prof Alison Yung, Dr Andrew Chanen http://www.headspace.org.au/core/Handlers/MediaHandler.ashx?mediaId=4896 (accessed 26 April 2011)

[19] Hagan, K. (29 July 2010) GetUp! calls for urgent reform to mental health policy, The Age http://www.theage.com.au/victoria/getup-calls-for-urgent-reform-to-mental-health-policy-20100728-10w74.html#ixzz1Ka5lGSDj (accessed 26 April 2011)

[20] Williams, D. (18 June 2006) Drugs before diagnosis? Time Magazine http://www.time.com/time/magazine/article/0,9171,1205408,00.html (accessed 18 November 2010)  

[21] Consumer Medicine Information: Risperidone http://www.racgp.org.au/cmi/jccrispe.pdf (accessed 3 August 2010)

[22] Webb, D. & Raven, M. (6 April 2010) McGorry’s ‘early intervention’ in mental health: a prescription for disaster, Online Opinion http://www.onlineopinion.com.au/view.asp?article=10267 (accessed 18 November 2010)

[23] Adverse events information related to risperidone obtained from the Therapeutic Goods Administration’s Public Case Detail reports

[24] As reporting is voluntary, there is no way of knowing what proportion of actual adverse events gets reported. A 2008 study by Curtin University pharmacologist Con Berbatis indentified that only a tiny fraction (for general practitioners only 2 per cent) of adverse events are reported. (Con Berbatis, (2008), Primary care and Pharmacy: 4. Large contributions to national adverse reaction reporting by pharmacists in Australia, i2P E-Magazine, Issue 72, p. 1)

[25]Frances, A. (2010), in M. Whitely, Speed Up and Sit Still: The Controversies of ADHD Diagnosis and Treatment, p.18. UWA Publishing, Crawley, Western Australia. Also: Frances, A. (8 April 2010) Psychiatric diagnosis gone wild: The “epidemic” of childhood bipolar disorder, Psychiatric Times http://www.psychiatrictimes.com/bipolar-disorder/content/article/10168/1551005 (accessed 30 April 2011)

[26] 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

[27] 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

[28] Schizophrenia Research Forum (4 October 2009) Live Discussion: Is the risk syndrome for psychosis risky business http://www.schizophreniaforum.org/for/live/transcript.asp?liveID=68

[29] Refer http://speedupsitstill.com/reply-patrick-mcgorry-early-intervention-psychosis

[30] McGorry, P., Purcell, R., Hickie, I. B., Yung, A. R., Pantelis, C., & Jackson, H.J. (2006) Clinical staging of psychiatric disorders: a heuristic framework for choosing earlier safer and more effective interventions. Australian and New Zealand Journal of Psychiatry, 40:616-622. Note: A similar article is available online at http://www.mja.com.au/public/issues/187_07_011007/mcg10315_fm.html (accessed 26 April 2011)

[31] Yung, A.R. & McGorry, P.(2007) Prediction of psychosis: setting the stage, British Journal of Psychiatry, 191: s1-s8.  http://bjp.rcpsych.org/cgi/content/full/191/51/s1  (accessed 7 December 2010)

[32] McGorry P.D. (2008) Is early intervention in the major psychiatric disorders justified? Yes, BMJ, 337:a695 http://www.bmj.com/cgi/content/full/337/aug04_1/a695 (accessed 3 August 2010)

[33]Carr V. (8 July 2010) Mentally ill of all ages need services. The Australian. http://www.theaustralian.com.au/news/opinion/mentally-ill-of-all-ages-need-services/story-e6frg6zo-1225889141003 (accessed 30 April 2011)

Right of Reply – Professor Patrick McGorry

Martin Whitely suggests that the Independent Mental Health Reform Group’s Blueprint may be a template for more psychiatric disorders, more off label prescribing and more youth suicide. In support of this improbable claim Mr. Whitely questions the integrity of the authors of the Blueprint, casts doubt about the wisdom of the Australian community’s desire for major mental health reform and suggests that early intervention models headspace and EPPIC may do more harm than good. I therefore welcome the opportunity to respond to each of these themes.

1. Integrity of the Blueprint’s authors

Mr.Whitely raises numerous doubts about the integrity of the authors (and in particular of myself) – in terms of motive, independence and process. Specifically, Mr. Whitely questions what motivated the authors to convene to write the Blueprint in the first place, states that the authors have undisclosed conflicts of interest and suggests that we have made claims without being able to substantiate them with evidence. It is disappointing that Mr. Whitely should impute such bad faith to our group and should have been prompted to do so in the absence of supporting evidence. In terms of the issues of integrity that he raises:

• The motive of the authors was to produce a credible investment action plan to advance mental health reform across the lifespan that could be adopted by Government (and by Opposition and Cross-Bench Parties). We felt that the momentum for mental health reform might temporarily stall in the absence of such a plan. We therefore convened a group to produce the Blueprint document and chose the name Independent Mental Health Reform Group to make it clear that our work reflected only the views of the six authors made no claims of wider representation or linkage to Government and/or other third parties.
• The suggestion that the authors are dishonestly trying to secure over $1b of public funding for projects (specifically headspace and EPPIC) to which they conceal their links is completely at variance with the truth. The target audience for this Blueprint (political leaders and public servants responsible for mental health policy) are unambiguously clear about my leadership role in EPPIC and the participation of Ian Hickie and myself on the headspace board. I have hosted both Julia Gillard and Tony Abbott at EPPIC, as well as Minister for Mental Health Mark Butler and a diverse range of current and past parliamentarians – including a visit last month by members of the House of Representatives Education and Employment Standing Committee. Likewise, officials from the Department of Health and Ageing have also visited our EPPIC service and both Ian Hickie and myself have longstanding relationships with political and public service leaders arising directly from our role with headspace. Furthermore the proposal we have made is that the public in other parts of Australia beyond the EPPIC service I lead should reap the considerable benefits of this model of care.  There is no request or expectation of any personal benefit to me or any of my colleagues flowing from any Federal government decision to scale up the EPPIC model, as other countries have already done in response to my prior support and advocacy.
• Similarly, the implication that the content of the Blueprint may have been inappropriately influenced by the pharmaceutical industry is also false. In my case, Mr. Whitely perversely uses my own declaration of previous pharmaceutical industry funding as supporting evidence for his claim that I am actively concealing this funding. To put this in context, pharmaceutical funding currently plays a very minor roll (less than 5%) in funding Orygen Youth Health Research Centre projects – all of which have been designed and conducted independently of pharmaceutical company input. Furthermore, its unclear which, if any, of the Blueprint’s 30 recommendations would be core commercial concerns of any of the pharmaceutical companies – for example it is notable none of these recommendations call for the MBS listing of any drug.

2. Wisdom of the Australian community’s desire for major mental health reform

Mr. Whitely acknowledges that the Australian public and elected representatives from all sides of politics accept that there is a major need to act on mental health reform. Mr. Whitely appears not to believe that this national consensus for action is the result of tens of thousands Australians sharing their stories of unmet serious mental distress to finally break through to our national conversation. Instead, Mr. Whitely chooses to believe it is more likely the product of a gullible public falling for some clever sophistry. Mr.Whitely appears to believe that the case for mental health reform remains unproven. This is a disappointing approach from an elected representative. The facts are clear that access and quality in mental health care are well below the standards that exist in the rest of health care.  National Mental Health survey data clearly backs this up and it is freely acknowledged by the department of health and ageing and the current government.  Most of his peers and indeed all sides of politics have listened to the Australian community and concluded that it is time to act – it is unclear what new evidence he is waiting for before he joins them. It is notable that he has not chosen not to state in his article his own views about the appropriate level of expenditure on mental health care (an increase? a cut?) or where he feels resources should be directed.

3. Early intervention models headspace and EPPIC

Mr. Whitely only specifically mentions two investment recommendations contained in the Blueprint – the early intervention youth mental health models headspace and EPPIC. It is not clear why he has chosen just these two recommendations or what he thinks about the other 28 recommendations. For the record, the other 28 recommendations include family based interventions for children, social and economic participation supports for middle and older years Australians and a range of measures to improve accountability, innovation and practice across the mental health system.

Mr. Whitely wrongly concludes that because we wrote the Blueprint as an action plan rather than a referenced review of the evidence, that there is no evidence for our recommendations. It is based on the best available scientific evidence.  In fact, we had already supplied much of that evidence to the policy making audience for the Blueprint over the previous months. The National Health and Hospitals Reform Commission chaired by Dr Christine Bennett reviewed all the evidence for the Rudd government and came up with very similar recommendations and carefully referenced their findings.   Mr. Whitely surely is aware of the NHHRC’s unequivocal support for headspace and EPPIC.  For example, cost-effectiveness data for Early Intervention in Psychosis (EPPIC or EPPIC derived models of care) indicate that:

– Health costs are less under EIP than under standard care. The first year health costs through providing the full EPPIC model to young people experiencing a first episode psychosis have been estimated to be $25,955 compared to $36,833 under standard care [1 – updated to 2009 prices]. Over the long term, mean annual costs under the EPPIC model are estimated to drop to approximately 1/3 of those under standard care [2].

– Employment costs are likely to be less under EIP than under standard care. Long term follow up of EPPIC clients indicates they are twice as likely to be currently in employment than people receiving standard mental health care [2].

– Suicide costs are likely to be less under EIP than under standard care. Most suicides associated with schizophrenia are thought to occur near the beginning of the illness [3]. A recent study suggested that the number of suicide attempts amongst this group in areas with EIP teams is one third that in areas without them [4].

– Homicide costs are likely to be less under EIP than under standard care. People with untreated psychosis are estimated to be ten times more likely to engage in acts of homicide than people with treated psychosis [5]. There is a significant association between homicide and the duration of untreated psychosis [6]. A core goal of EIP services is reducing the duration of untreated psychosis.

This cost-effectiveness data for the EPPIC model is significantly enhanced when including studies that focus specifically on clinical outcomes and functional recovery. Up to 85% of young people with vocational interventions achieve functional recovery, levels which are unprecedented. Furthermore, the recent independent evaluation of headspace was extremely positive, showing that  headspace was meeting the goals set of it by the Australian Government.

Mr. Whitely raises concerns about the use of medication in headspace and EPPIC which are also unwarranted. There are acknowledged risks with medications of all kinds in healthcare so the risk benefit ratio always has to be the guide for timing and need for use of such interventions.  In these programs the Centre for Excellence at Orygen Youth Health and headspace guides evidence based practice within these programs and care is strictly tailored to clinical practice guidelines which are published. We follow the International CPGs for early psychosis in EPPIC and beyondblue CPGs for the treatment of depression in young people recently published by beyondblue.  Of course CPGs are guidelines and individual clinicians must make their own decisions in individual cases since every patient is different in some respects. There are also areas where the evidence is incomplete and clinicians need to act on the best available evidence recognising that further evidence is required through further research.

In closing I appreciate the opportunity to respond to Mr Whitely’s communications.

Patrick McGorry

AO MD PhD FRCP FRANZCP

Professor of Youth Mental Health

University of Melbourne  

[2] Mihalopoulos, C., et al., Is early intervention in psychosis cost-effective over the long term? Schizophr Bull, 2009. 35(5): p. 909-918.

[3] Robinson, J., et al., Suicide attempt in first-episode psychosis: a 7.4 year follow-up study. Schizophr Res, 2010. 116(1): p. 1-8.

[4] Melle, I., et al., Early detection of the first episode of schizophrenia and suicidal behavior. Am J Psychiatry, 2006. 163(5): p. 800-804.

[5] Nielssen, O. and M. Large, Rates of homicide during the first episode of psychosis and after treatment: a systematic review and meta-analysis. Schizophr Bull, 2010. 36(4): p. 702-712.

[6] Large M, Nielssen O. Evidence for a relationship between the duration of untreated psychosis and the proportion of psychotic homicides prior to treatment. Social Psychiatry and Psychiatric Epidemiology 2008, 43:37‐44;

The Last Word – Professor McGorry leaves key questions unanswered – by Martin Whitely

I welcome Professor McGorry’s response and to the limited extent that it identifies the evidence base of the recommendations in the blueprint it is useful. I will examine in detail the evidence provided, however, it leaves most of the questions I raised unanswered.

In particular I believe the key questions that must be answered before EPPIC and Headspace are considered for extra funding are:

1 – EPPIC and the ‘off label” use of antipsychotics– Does Professor McGorry now agree with his colleague at EPPIC Prof Alison Yung and oppose the recognition of Psychosis Risk Syndrome in the next edition of the DSM? And if not, what is EPPIC’s position on the recognition of Psychosis Risk Syndrome (PSR)? And under what circumstances, if any, would Professor McGorry and EPPIC recommend the use of antipsychotics for the treatment of patients considered to be at risk of developing psychosis? Has Professor McGorry finished experimenting on young people with the use of antipsychotics for the treatment of Psychosis Risk Syndrome?

2 – HEADSPACE and the ‘off label’ use of SSRI antidepressants– Why do Professor McGorry and Headspace acknowledge and then ignore the clinical trial evidence, and FDA and TGA warnings, on the increased suicidality risk for young people using SSRI antidepressants and advocate the ‘off label’ use of SSRIs by even moderately depressed young people? Won’t this result in more, not less, youth suicide?

In response to specific comments in Professor McGorry’s right of reply I offer the following:

‘Mr. Whitely… casts doubt about the wisdom of the Australian community’s desire for major mental health reform’ and ‘Mr.Whitely appears to believe that the case for mental health reform remains unproven. This is a disappointing approach from an elected representative…It is notable that he has not chosen not to state in his article his own views about the appropriate level of expenditure on mental health care (an increase? a cut?) or where he feels resources should be directed.’

I support a massive injection of funds into mental health but believe there are far too many unanswered questions to support the ‘best buys’ identified in Professor McGorry’s and the Independent Mental Health Reform Group’s $3.5 billion blueprint. I believe as an elected representative it is not my job to go with the flow but rather to ask difficult questions and ensure taxpayers funds are spent on programs that help not harm.

Mr. Whitely perversely uses my own declaration of previous pharmaceutical industry funding as supporting evidence for his claim that I am actively concealing this funding.

I do not suggest that Professor McGorry or any member of the Independent Mental Health Reform Group dishonestly ‘actively conceal’ their potential conflicts of interest. Rather, I am critical of them for not ‘actively disclosing’ potential conflicts of interest particularly when they badged themselves as an ‘independent’ and asked for $3,500,000,000 of taxpayer’s funds to be directed to programs, several of which they have significant influence over. I accept that senior decision makers would be aware at least of Professors McGorry and Hickies connections to EPPIC and Headspace but I am not so sure about the media and the public.  I became aware of Professor McGorry commercial ties to the pharmaceutical industry from a 2008 article in the British Medical Journal (BMJ). As is required by the BMJ Professor McGorry disclosed the sources but not the quantum of pharmaceutical company funding he had received.

In fairness to Professor Ian Hickie, whilst it was not disclosed in the blueprint, he does deserve credit for disclosing online via his CV that he has received $411,000 from various pharmaceutical companies. Whilst this was acknoweledged in my reference I should have acknowledged this self disclosure in the text of my blog when I originally wrote it (and I now have).

‘Mr. Whitely only specifically mentions two investment recommendations contained in the Blueprint – the early intervention youth mental health models headspace and EPPIC…Mr. Whitely raises concerns about the use of medication in headspace and EPPIC which are also unwarranted… We follow the International CPGs for early psychosis in EPPIC and beyondblue CPGs for the treatment of depression in young people recently published by beyondblue.’

As identified at 1 and 2 above I am very concerned that through the expansion of the EPPIC and Headspace networks we risk more ‘off label’ prescribing of antipsychotics and SSRI antidepressants to young people including children. I would be much more comfortable if EPPIC and Headspace followed the advice of the independent regulators i.e. the TGA and the FDA (and even the drug manufacturers) and stuck to recommending and practising ‘on label’ prescribing.

Next week’s blog details how 2010 Australian of the Year Professor Patrick McGorry and his close colleagues have dominated the long overdue debate about the future of mental health services in Australia. It outlines how their claims of massive unmet need and proven 21^st century solutions have been accepted almost without question by the Gillard Government, the Abbott Opposition, the independents, the media and therefore the public.

In March Professor McGorry and fellow members of the Independent Mental Health Reform Group released their blueprint for the future of Australian mental health. The blueprint, Including, Connecting, Contributing: A Blueprint to Transform Mental Health and Social Participation in Australia, outlines $3.5b expenditure over 5 years on ‘transformational’ programs that are identified as mental health ‘best buys’.^[1] However, serious questions remain unasked, including:

• How ‘independent’ was the Independent Mental Health Reform Group, and why didn’t participants disclose any potential conflicts of interest?
• Why didn’t the blueprint identify that the most expensive ($910 million) ‘best buy’ is based on a service delivery model developed by Orygen Youth Health, which is headed up by Professor McGorry?^[2]
• Why was the supposedly ‘evidence based’ blueprint unreferenced and devoid of supporting verifiable evidence?
• What is the evidence of EPPIC’s outcomes compared to other mental health services and to support the claim in the blueprint that EPPIC has ‘the largest international evidence base of any mental health model of care’ ?
• Why does Professor McGorry believe four million Australians, including one million young people, will need treatment for a psychiatric disorder in 2011? And exactly what are these ‘disorders’ and what should the treatments involve?
• Has Professor McGorry finished experimenting with antipsychotics on adolescents, most of whom he admits would probably never have become psychotic?^[3]
• Why does Professor McGorry continue to advocate for the recognition of ‘Psychosis Risk Syndrome’ as a new psychiatric disorder when even his close colleague, Professor Alison Yung, asks ‘why the need for a specific risk syndrome diagnosis? Is the agenda really to use antipsychotics?’^[4]
• Why do Professor McGorry and Headspace acknowledge and then ignore the clinical trial evidence, and FDA and TGA warnings, on the increased suicidality risk for young people using SSRI antidepressants and advocate the ‘off label’ use of SSRIs by even moderately depressed young people?^[5]
• When Professor McGorry ‘received unrestricted research grant support from Janssen-Cilag, Eli Lilly, Bristol Myer Squibb, Astra-Zeneca, Pfizer, and Novartis’ and ‘acted as a paid consultant for, and…received speaker’s fees and travel reimbursement from, all or most of these companies,‘ how much money did he get from each pharmaceutical company?^[6]

In next week’s blog I detail why I am most concerned with Professor McGorry and Headspace’s recommendation that SSRI antidepressants be used in even moderately depressed young people despite the clinical trial evidence and FDA and TGA warnings on the increased suicidality risk. Through the use of candle-light vigils Professor McGorry has mobilised well intentioned, vocal supporters including Get Up to highlight the tragedy of youth suicide to advocate for reform of mental health services for the young. However, if Australia follows Professor McGorry’s advice we risk there will be more, not fewer, candles at the next vigil.

Perhaps the answers to the questions above would reveal that Professor McGorry really does have insights that make him uniquely placed to design Australia’s 21^st century mental health system. However, it appears that the Gillard Government, at the urging of the Opposition, is on the verge of committing massive resources to Professor McGorry’s mental health blueprint without ever asking these questions. Isn’t it time the Canberra politicians and the media got beyond his former Australian of the Year status and asked him a few challenging questions?

Note: Professor McGorry has been provided with these questions and with early access to the full transcript of next week’s blog and has been offered the unedited right of reply on the day the full blog is published (Wednesday 4 May 2011)

Professor McGorry prepared his blog entry in response to criticism by me (Australian of the Year Patrick McGorry’s call for early intervention to prevent Psychosis: A Stitch in Time or a Step too Far?) and others of his past advocacy of antipsychotics as a measure to prevent psychosis and his support for the inclusion of a Psychosis Risk Syndrome in the next edition of the handbook of psychiatry, DSMV.

Following Professor McGorry’s blog is my response which details his past advocacy of the pre-psychosis use of antipsychotics, welcomes his recent change of heart but challenges him to join with his long term research partner, Dr Alison Yung, and oppose the inclusion of a Psychosis Risk Disorder in DSMV.

Responding at the earliest opportunity to emerging mental illnesses – by Patrick McGorry

6 December 2010 – 11:01am copied with permission from http://www.patmcgorry.com.au/blog/pmcgorry/responding-earliest-opportunity-emerging-mental-illnesses

One of the most important areas in mental health research is exploring how to delay or prevent the onset of severe mental illnesses such as psychotic illness, especially schizophrenia.   Twenty years ago this possibility was out of reach.  Now thanks to Australian-led research it is much closer.  Yet despite the great potential for this emerging field to avert distress, disability and death, it remains poorly understood within the community and recent progress is often actively misrepresented in the media and public discourse.  Such confusion and misrepresentation creates unnecessary public anxiety and risks weakening the imperative to provide safe forms of early intervention for those most in need.  I am writing this piece with the goal of clarifying the issues, the latest evidence and my own views which derive directly from the scientific evidence base and twenty years of clinical experience in this field.

Summary of key points

• Mental ill-health and a need for support, assessment and care, precedes the onset of psychotic symptoms in most people who develop a psychotic illness, especially schizophrenia.
• It is now possible to recognize in advance a set of symptoms which indicate a much greater risk for developing clearcut and severe psychotic illness.
• This enables safer and potentially more effective treatments to be offered prior to the onset of psychosis which aim to firstly respond to the immediate problems, symptoms and functional disability that has already manifested, and to secondly try to reduce the risk of progression to more severe forms of ill-health, particularly but not exclusively psychotic disorder.
• The support and interventions should be offered in a stepwise way, starting with personal support and information, supportive case management and problem-solving, moving onto trials of CBT and omega 3 fatty acids, all of which have a good risk benefit ratio.  Anti-depressants may also be considered if depression is severe and has not responded to CBT.
• Antipsychotic medications should not be considered unless there is a clearcut and sustained progression to frank psychotic disorder meeting full DSM 4 criteria.
• The only exception to the previous statement is where there has been a definite failure to respond to the first and second line interventions described above AND there is worsening and continuing disability, or significant risk of self-harm, suicide or harm to others arising directly from the mental disorder itself and its symptoms. In this situation, a trial of low dose antipsychotic medication for 6 weeks in the first instance may be appropriate, with careful monitoring for adverse events.
• All such care must be offered in stigma-free environments such as primary care or youth mental health settings and not in services designed for the care of the seriously mentally ill.
• Further research is required to define a clearer evidence base to guide stepwise decision making in the treatment of the pre-psychotic stage of early psychosis.

Psychosis can be devastating for individuals, their families and weakens our society.  Emerging in young people on the threshold of productive life, it poses a huge threat to health, career, personal fulfillment and even survival.   As a matter of equity, people who are experiencing psychosis or have a high risk of doing so should enjoy the same access to stigma-free quality care in a timely fashion just as is routinely the case with physical illnesses of comparable severity.

 Just as with heart disease and cancer, every reasonable effort should be made to avert as much distress, discomfort and long term collateral damage from psychosis as is possible. What that means in practice is identifying the earliest opportunities for detection and intervention and the safest and most effective means of preventing and treating emerging psychosis.  Our goal is to modify the impact and course of the illness, that is to preempt the disabling aspects.  Cure probably remains out of reach for most at this stage but substantially better recovery and long periods of freedom from illness are definitely attainable for the majority of people with psychosis.

 Psychosis tends to first emerge in adolescence or early adulthood. Over the last twenty years, it has been demonstrated that early detection, optimum treatment and support for recovery produce much better short and longer term outcomes for young people experiencing their first episode of psychosis.  This evidence also shows that these better outcomes are achieved with lower costs so that precious resources are freed up and can be used to strengthen and expand mental health and social services for other groups of people including those with persistent illness, children and the elderly.

Early detection and specialized care of young people with first episode psychosis and subsequently was initially the main international focus. Yet we have known for a long time that psychotic illness usually builds up over a period of time and is preceded by “prodromal” features, which distress, disable and attract concern and even stigma, yet do not yet manifest clearcut psychotic features such as delusions and hallucinations.  This held out the exciting possibility that we might be able to identify people who were “en route” to psychosis and not only provide care for their current problems but also intervene to reduce the risk of progression to more severe and clearcut psychosis.  

This challenge prompted a key breakthrough, developed originally by my colleague Prof Alison Yung and I in 1994, and elaborated since in many other overseas centres, which has enabled us to identify young people with high levels of risk of developing psychosis within the next year or so.  This was the reliable definition of the “Ultra High Risk” mental state which predicted progression to psychosis surprisingly accurately.  Young people in this “Ultra High Risk” group are already experiencing a range of mental health and social problems, are in need of care and actively seeking help.    They can typically be expected to have between a one in five to a one in two chance of progressing to a first episode of psychosis within 12 months (that is between two and four hundred times the rate within the general population).  They also are at risk of other persistent mental disorders in addition to psychosis.  But in addition to the potential risk, which is significant, they are in immediate need for care for distress and impairment that they are already experiencing.   What that care should consist of is being actively studied and clinical guidelines have been carefully developed based on the evidence and experience accumulated to date.

The Ultra High Risk criteria have been further studied internationally and have been proposed as a new category in the next edition of the DSMV manual, the US based system of diagnosis in psychiatry.  This proposal has been controversial, because of fears of extending antipsychotic medication more widely in the population and fears that labeling people as being at risk (even if already experiencing mental ill-health) may be harmful.   Both of these concerns are valid, though both can and have been addressed in our work and systems of care in Melbourne. 

 One obvious benefit of the ability to engage and monitor young people with a high risk of developing such a serious illness is obviously in reducing treatment delays once the threshold to first episode of psychosis has been reached and thereby to facilitate better outcomes. But aiming higher, can being offered access to care as a member of the Ultra High Risk group benefit a young person by prompting care responses that delay or prevent the onset of a first episode of psychosis?

This important question has been a subject that I and other colleagues, notably Alison Yung, have been researching over the last twenty years. As a result of this and other research – a total of 6 clinical trials now, we can now say that with appropriate intervention, it does appear to be possible to delay the onset of a first episode psychosis amongst members of the Ultra High Risk group. This finding, unimaginable twenty years ago, is highly encouraging as it gives grounds for optimism that further research may establish whether it is also possible to prevent the onset of a first episode psychosis within this group.  Several approaches to treatment that have been studied seem to be able to delay the progress to psychosis as well as alleviate the distressing and disabling symptoms that affect people at this stage of illness.

This week at the Seven^th International Early Psychosis Conference in Amsterdam, we launched the most recent version of the Australian Clinical Guidelines for Early Psychosis. These guidelines, which distill the very latest research evidence, specify that recommended interventions for this Ultra High Risk Group are a combination of Omega-3 fatty acids, Cognitive Behavioral Therapy and supportive counseling as well as, in some cases, medication for other diagnosed conditions that may be present (for example depression) as well as psycho-education for family members.

The guidelines explicitly state that anti-psychotic medication should not be considered as a first line treatment option for the Ultra High Risk group. Only in exceptional circumstances, where there is rapid worsening of psychotic symptoms combined with an elevated risk to the young person or others should consideration be given to the use of low dose anti-psychotic atypical medication. Even then, the use of anti-psychotic medication would normally not be justified.  The rationale for this is that safer treatment options should always be offered before those which carry increased adverse effects and risk.  This is a fundamental principle in medical care: “first do no harm”.  Only if the initial safer option fails should progress to the next level occur according to a “staging model” which we have explicitly developed and described in recent publications.  These guidelines restate and reinforce the earlier international guidelines produced by the IEPA in 2005 which my colleagues and wrote in a collaborative fashion with other international experts.   The evidence that has accumulated since that time strengthens the position taken in 2005 – there has been no reversal of that position.

This last point about the use of anti-psychotic medication within this group is very important as the stated position of myself and my colleagues about this issue is occasionally misreported or misrepresented. There is a clear distinction to be made between research trials and clinical guidelines, a distinction which is sometimes not made clear.   Our group in Melbourne has researched a number of potential interventions to reduce symptoms, disability and risk in the Ultra High Risk group,  including befriending, cognitive behaviour therapy, supportive case-management, family support, omega 3 fatty acids, lithium, anitdepressants and  low doses of anti-psychotic medication. All of this research has been approved by an independent ethics committee and all participants have of course provided fully informed consent to be involved.  This results have demonstrated that such not only supportive care, cognitive behaviour therapy and omega 3 fatty acids, but also low dose anti-psychotic medication may be effective in delaying the onset of first episode psychosis.

However, our clinical guidelines do not (and have never done so in the past) recommend the use of anti-psychotic medication as the first line or standard treatment for this Ultra High Risk group.  This is because other, safer interventions are equally effective in delaying the onset of psychosis and, despite the greatly elevated risk, it is equally true that most of the Ultra High Risk group will not experience a first episode of psychosis, so many could be receiving antipsychotic medications unnecessarily.  The key issue is timing and careful consideration of benefits versus risks in consultation with the patient and their family. The most promising initial combination so far is omega 3 fatty acids combined with cognitive-behavioural case-management; safe and effective as first line care.   We therefore believe that further research would be required before it could be known whether and in what circumstances, low dose anti-psychotic medication may have a role later in the sequence of treatment of the ultra high-risk group.  It may be for some patients, in the era of short duration of untreated psychosis, even when they have crossed the threshold to fully-fledged  psychosis, that antipsychotic medications may able to be avoided if expert psychosocial care is available.   This is something we are also researching.  

In summary we are trying to define the sequence of decision points for every patient based the balance between benefit and risk, not only for the present day but also for the future.  And not only for psychotic illness but for several other dimensions of mental ill-health.   This is a mainstream evidence based approach that is fully supported everywhere else in health care.  We need to see it embedded in mental health care too.

Martin Whitely’s response to Patrick McGorry’s Blog

Some welcome news but there is unfinished business- Psychosis Risk Syndrome and the DSMV

I wholeheartedly agree with Professor McGorry’s that the best way to prevent psychosis is ‘appropriate’ early intervention. However, I and other far more qualified critics have passionately disagreed with Professor McGorry’s past advocacy of antipsychotics as an ‘appropriate’ early intervention.

There is reason to be optimistic in the recent blog (copy above) prepared by Professor Patrick McGorry. His statement that ‘Antipsychotic medications should not be considered unless there is a clear-cut and sustained progression to frank psychotic disorder meeting full DSM 4 criteria’ is welcome. It appears to put an end to the debate about whether Professor McGorry currently advocates the use of antipsychotics on the hunch that adolescents will later become psychotic. While it is of some concern that the text immediately following the above statement leaves the door open to ‘off label’ psychosis risk prescribing, Professor McGorry’s is clearly less enthusiastic than he has been for broadening  the use of antipsychotics.^[1]

However, the statement in his blog that ‘our clinical guidelines do not (and have never done so in the past) recommend the use of anti-psychotic medication as the first line or standard treatment for this Ultra High Risk group’ has the potential to mislead. Casual readers may take this to mean that Professor McGorry and his allies have never advocated the use of antipsychotics in order to prevent psychosis.

As stated in my blog a fortnight ago ‘for over a decade Patrick McGorry has experimented with, or advocated, the prescription of antipsychotics to adolescents on the hunch that they may later become psychotic.’ Professor McGorry was the lead author of a 2006 article which as part of a proposed ‘clinical staging framework for psychosis’ identified ‘atypical antipsychotic agents’, as one of the ‘potential interventions’ for individuals who are at ‘ultra high risk (10% to 40%)’ of developing first episode psychosis.^[2] Whilst he has recently adjusted the ‘clinical staging framework’ he was still advocating antipsychotics as a potential pre-psychosis intervention at least as late as October 2007.^[3]

In addition a 2007 British Medical Journal article jointly authored by Dr Alison Yung and Professor McGorry began by quoting 1994 paper by Mrazek and Haggerty extolling the potential of pre-psychosis pharmacological interventions: ‘The best hope now for the prevention of schizophrenia lies with indicated preventive interventions targeted at individuals manifesting precursor signs and symptoms who have not yet met full criteria for diagnosis. The identification of individuals at this early stage, coupled with the introduction of pharmacological and psychosocial interventions, may prevent the development of the full-blown disorder.’

Dr Yung and Professor McGorry’s opening comment followed; ‘Such sentiment underlines the aim of identifying people in the prodromal phase preceding a first psychotic episode.’^[4] Their article went on to outline evidence supporting interventions including antipsychotics ‘to delay or even prevent onset of psychosis.’

Furthermore, in 2008, in the British Medical Journal, in an article titled ‘Is early intervention in the major psychiatric disorders justified? Yes’ Professor McGorry wrote; ‘Early intervention covers both early detection and the phase specific treatment of the earlier stages of illness with psychosocial and drug interventions. It should be as central in psychiatry as it is in cancer, diabetes, and cardiovascular disease….. Several randomised controlled trials have shown that it is possible to delay the onset of fully fledged psychotic illness in young people at very high risk of early transition with either low dose antipsychotic drugs or cognitive behavioural therapy.’ ^[5]

These are just a few of numerous similar statements which comment favourably or suggest the use of antipsychotics as part of the treatment for adolescents considered to be at ‘ultra high risk’ of developing psychosis.  Whether such comments constitute ‘advocacy’ is open to semantic debate however, Professor McGorry certainly favoured this highly controversial use.

Professor McGorry’s argues in his blog ‘that recent progress is often actively misrepresented in the media and public discourse. Such confusion and misrepresentation creates unnecessary public anxiety and risks weakening the imperative to provide safe forms of early intervention for those most in need.’ If there is confusion it is because Professor McGorry has never, even in his blog, unambiguously acknowledged he did favour the use of antipsychotics pre-psychosis and now (recent progress) he does not.

The closest Professor McGorry comes to acknowledging his previous position in his blog is when he states; ‘the use of anti-psychotic medication within this group is very important as the stated position of myself and my colleagues about this issue is occasionally misreported or misrepresented. There is a clear distinction to be made between research trials and clinical guidelines, a distinction which is sometimes not made clear.’

The articles cited above as evidence of Professor McGorry’s past advocacy of antipsychotics were all editorial pieces in which Professor McGorry summarised research and suggested appropriate treatment responses. They may not have been formally endorsed ‘clinical guidelines’ but to use that restricted criteria to imply that he has not previously advocated the use of antipsychotics is spin more suited to politics, the search for power, than science, the search for truth.

Nonetheless, Professor Mcgorry’s change of position is welcomed, however, there are two outstanding issues that require resolution. Specifically the issue of ‘off label’ pre-psychosis prescribing and the inclusion of Psychosis Risk Syndrome or Attenuated Psychosis Syndrome in DSMV. Professor McGorry leaves the door open to ‘off label’ prescribing and persists with his advocacy for the inclusion of a Psychosis Risk Syndrome in the DSMV.

In contrast his long term research partner Dr Alison Yung, presumably because of her long term exposure to the scientific evidence and the related medico-political processes, has changed her position. She is now suspicious enough to ask ‘So why the need for a specific (psychosis) risk syndrome diagnosis? Is the agenda really to use antipsychotics?’^[6]

I share Dr Yung’s suspicion.

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

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.