I have disagreed strongly with Dr Patrick McGorry, but I also recognize him to be a truly remarkable man and probably the most politically astute psychiatrist who ever lived. How else is there to explain his unprecedented ability to maneuver the Australian government into making a much needed $2.2 billion investment in mental health services? It is no surprise that Dr McGorry earned the incredible distinction of being Australian of the Year.
Dr McGorry’s promotion of primary prevention has been well-intended but is clearly premature and carries with it considerable risks of harmful unintended consequences. Psychiatry simply does not yet have the tools to accurately identify youngsters before they become psychotic. His previous support for “psychosis risk syndrome” and for the preemptive use of antipsychotic medication presented a danger to the many youngsters who would have been misidentified and inappropriately treated with drugs that can cause tremendous weight gain and reduced life expectancy.
So, all the more reason to celebrate Dr McGorry’s recent recanting of his previous positions. Apparently, he is no longer supporting “psychosis risk syndrome” as an official diagnosis in DSM-5 and now recommends that antipsychotic medication only be prescribed as second- or third-line treatment or as part of a research trial. If Dr McGorry exerts his considerable influence in this new direction, the harmful off-label use of antipsychotic medication may be reduced.
Dr McGorry’s reversals certainly represent an important and reassuring step in clarifying the mission and ensuring the safety of the Early Psychosis Prevention and Intervention Centre (EPPIC) program. (For the latest on Dr McGorry’s new positions, see The Australian, June 16, 2011, at http://www.theaustralian.com.au/news/features/schism-opens-over-ills-of-the-mind/story-e6frg6z6-1226075910650 and also his personal communication of the same date to Martin Whiteley at http://www.speedupsitstill.com.)
But 4 important issues still remain unanswered and need to be addressed by Dr McGorry:
1. A correspondent from Australia indicates that the joint Budget Statement on Mental Health Reform by the Minister for Health and Ageing and the Minister for Mental Health and Ageing makes it clear that they are funding clinics that are also for young people at risk of psychosis: “A total of 16 EPPIC sites nationally will have the capacity to assist more than 11,000 young Australians with, or at risk for developing, psychotic mental illness.” Dr McGorry must now translate his unofficial and personal change of heart into a more conservative government policy statement that better expresses the cautious sentiments about primary prevention he now shares with Dr Yung.
2. What guarantees are there that, once in place, the EPPICs will actually adhere closely to Dr McGorry’s now more restricted mission for them? It is notoriously difficult to make a certain diagnosis of schizophrenia in teenagers. The diagnostic distinction between “psychotic” and “pre-psychotic” may seem crystal clear on paper, but it is often extremely fuzzy in real life—particularly when applied to teens who are using drugs and/or who are especially creative or eccentric or having stormy battles with their parents.
How will the EPPIC program avoid the risk of the premature diagnosis of “psychosis” in uncertain situations? If this is not carefully attended to, EPPICs may unwittingly experience mission drift back to primary prevention based on the loose and inaccurate diagnosis of psychosis. Here are possible proposed solutions to promote good diagnostic habits:
• There would be no label of schizophrenia unless there has been a continuation of psychotic symptoms for a significant period after the teenager has stopped taking mind-altering drugs.
• Watchful waiting and stepped diagnosis would be observed for all uncertain cases.
• Standardized interview instruments and rating scales would be used.
• The diagnosis must be made independently by different observers, reevaluated at frequent intervals, and subjected to systematic reliability testing.
Accurate early diagnosis of schizophrenia by EPPICs leads to useful secondary prevention of distress and disability. Inaccurate early diagnosis of schizophrenia by EPPICs will promote the dangers of premature primary prevention—ie, harmful stigma and the initiation of unnecessary antipsychotic medication.
3. Wouldn’t it make more sense to roll out the EPPIC program more slowly, a few centers at a time, rather than going national in one bold stroke? This is a huge and untried endeavor. It is always difficult to go from a blueprint model prepared in a rarified research environment to a workaday program that can be applied by less expert and committed hands in everyday practice. Why not work out the kinks of translation in phases before going national—start with just a few centers and test their feasibility, safety, and efficacy and smoke out unintended consequences? More centers could be added as accumulated experience demonstrates that they deserve to be. If I were a state government official charged with deciding whether to provide matching funds to start an EPPIC program, I would think twice about being first in line.
4. Will the enormous funding for EPPIC divert much needed dollars and personnel away from more proven treatments that could otherwise have been delivered to those more clearly in need? The factors that governments need to consider are not just the possible utility of the EPPIC model in isolation, but also its comparative cost-effectiveness in competition with all the other urgent and currently unmet mental health needs. It is terrific that Dr McGorry was able to convince the Australian government to devote substantial funds to the desperately underserved mentally ill, but it remains to be proved that so many of the “mental health eggs” should be placed in the one, unproven “EPPIC basket.”
Should the EPPIC program fall far short of its promises, as is likely, it will have greatly set back the cause of mental health treatment that Dr McGorry has worked so hard to promote.