Patrick D. Mcgorry, MD, PhD

SPECIAL REPORT: SCHIZOPHRENIA & PSYCHOSIS

Psychotic disorders are potentially serious and enduring, frequently leading to substantial disability and premature death from suicide or comorbid medical illness. These disorders have been seriously 

in health systems worldwide, even in high-income countries, despite the availability of a range of effective therapeutic interventions and models of care.

 The good news is that better medium-term outcomes are now achievable through early diagnosis and comprehensive early-intervention models of care. Moreover, these outcomes can be sustained, if backed up with high-quality ongoing care to maintain and build on a platform of 

 The challenge is to make this evidence-based and cost-effective approach the new standard of care in the US and globally.

Psychosis is best considered as a range of experiences or symptoms that can develop through the intensification of normal beliefs and perceptions to form delusions or hallucinations, or the acquisition of new and abnormal perceptual experiences or delusional ideas. These constitute what are termed the 

 of psychosis; however, there are other dimensions or syndromes associated with psychotic disorders, notably negative symptoms and mood disturbance.

Psychosis may begin with “orphan” or isolated experiences, but more commonly emerges in the context of fluctuating anxiety and depression, subtle subjective and behavioral changes, and subthreshold warning signs. This pattern, which has been carefully operationalized, represents an earlier, less specific stage—even a pluripotential stage––of illness that already justifies a need for care and attracts additional comorbid syndromes and functional impairment (stage 1).

Once positive psychotic symptoms reach full threshold and are sustained, we can say that the stage of first-episode psychosis (FEP) is now present (stage 2), even if this typically occurs more gradually and dimensionally than is implied by the term, which is to a large extent an artefact of treatment systems. People are allowed to deteriorate to such an extent that a crisis is needed before entry to treatment can be achieved. 

is a heterogeneous umbrella term comprising a range of DSM/International Classification of Diseases diagnoses, including schizophrenia, schizoaffective disorder, brief psychotic disorder, and psychotic mood disorders. It can be seen as a gateway to more traditional diagnostic pathways as well as to remission and recovery.

Staging developed in clinical medicine as a strategy to add precision to diagnosis and treatment selection, and also to prognosis and prediction of outcome.

 Initially a purely clinical approach, it evolved––augmented by biopsy, imaging, and biomarkers––to a more sophisticated clinicopathological approach. Staging is a potentially useful strategy in conditions that have a propensity to persist or recur and lead to worsening impairment and/or premature death. Additionally, it is intimately linked to benefit-risk considerations, embedding the principle “first do no harm.”

Staging is valid when treatments offered in early stages of an illness can be shown to result in better outcomes, but they must be safer than treatments offered in late stages, as the benefit-to-risk ratio changes with illness progression. Remission or stabilization as well as progression are possible at each stage, but remission is usually less likely with each advancing stage, reflecting the interplay with prognosis.

Staging provides the optimal framework for early intervention and a preemptive approach to treatment; the goal is to reduce the risks of progression to later stages. This contrasts with the currently popular notion of stepped care, which is reactive, and only escalates treatment after rather than before a deterioration in clinical status. As such, stepped care represents more of a demand-management strategy than a preventive or preemptive clinical approach.

Biomarkers have the potential to sharpen the precision of staging in psychiatry; however, they are likely to span the traditional syndromal boundaries, which conversely contain heterogeneous biological subgroups. This means a transdiagnostic approach is essential for research and future refinement in staging because current categories are flawed. Transdiagnostic approaches acknowledge the fluid and dynamic nature of the onset and early stages of mental ill health, during which micro phenotypes ebb and flow; they either fade or evolve into a more stable syndrome or macro phenotype or, more commonly, syndromes, because comorbidity is very common (

). Staging has to accommodate this comorbidity and, as such, a transdiagnostic approach that transcends current diagnostic silos is required.

The idea of staging had been proposed earlier in common mental disorders.

 With the early intervention paradigm in psychosis, the ideal conditions existed for clinical staging to be formulated. Psychotic and severe mood disorders were utilized as prototypical disorders for which staging might have the greatest utility.

FEP was the fulcrum around which this began, and an evidence-based case was steadily made that the content of treatment for such cases was very different from what was appropriate for later stages of illness. An earlier clinical stage, the at-risk mental state or ultra/clinical high-risk state, was defined as covering the period prior to the threshold for a first episode of psychosis being reached. This period has become an intense focus for research and intervention.

The validity of these stages was supported by their manifestly different treatment needs and ultimately overwhelming 

that at least progression could be delayed, and early trajectories of illness significantly improved.

 Although some critics remained unconvinced, the mindset of the psychosis field moved from deterministic “doomed from the womb” thinking to a more preventive, recovery-oriented approach, strongly endorsed by patients and families.

A key strength of clinical staging is its ability to guide clinical practice, which is informed by several key principles (

of psychosis there is an earlier stage of illness during which positive psychotic symptoms (eg, distress, mood disturbance, functional impairment), are not dominant.

 During this prodromal stage, treatment consists of needs-based psychosocial interventions, influenced by cognitive behavior therapy (CBT), and a focus on treatable comorbid syndromes such as anxiety and depression, alleviating stress, strengthening coping, and minimizing illicit drug use. Because safer options are effective at this stage, antipsychotic medications are not indicated as first- or second-line treatment, and the benefit-to-risk ratio does not support their use.

Patients with FEP respond much better to all treatments if the duration of untreated psychosis (DUP) is reduced to a minimum. There is varying evidence on the exact window of time for optimal response, but delays of even a few weeks may make a significant difference to treatment response.

 This suggests that FEP might be better considered as a stage with substages within it. In fact, with a much shorter DUP now possible with early intervention, it may be possible for a small subgroup of patients to remit without antipsychotic medication if they are provided with intensive psychosocial interventions alone.

 This might be termed stage 2a. The RAISE (Recovery After Initial Schizophrenia Episode) study shows that specialized early psychosis care may only be more effective than standard care if DUP is not prolonged beyond a certain duration.

 This responsive substage could be designated stage 2b.

Within the first episode of psychosis, the staging approach and research evidence indicate that low doses of antipsychotic medications are effective but must be rigorously adhered to if adverse experiences are to be minimized and engagement maximized.

 Shared decision making has a crucial place here. The imperative to prevent weight gain and metabolic consequences means that medications least likely to produce these effects must be first line.

A subgroup of patients who do not respond to treatment with dopamine antagonists and reveal early treatment failure can be reclassified as a further substage of stage 2, or stage 2c. Alternatively, they can be regarded as having rapidly progressed to stage 4, even within the first 6 months post diagnosis. In this case, the benefit-to-harm ratio changes dramatically, and although clozapine has a number of risks, which means that it should not be used as first-line treatment, the evidence mandates its use early in the course of illness with treatment resistance or as illness rapidly progresses to stage 

Psychosocial treatments, notably vocational interventions such as Individual Placement and Support (IPS) and family interventions, must also be adapted to the stage of illness. Used early and throughout treatment, psychosocial interventions are especially effective at stage 2 in line with what is expected in a staging model and early intervention.

Following the first episode (stage 2), patients may enter stages 3 or 4. Stage 3 interventions involve the prevention of relapse with efforts to prevent and treat comorbidity and persistent subthreshold or residual symptoms of psychosis and other associated syndromes. Long-acting injectables can be seen as a preventive strategy. However, a personalized approach with substages and subgroups reflects a heterogeneity within stage 3. Thus, dose reduction and possible discontinuation are possible for a subgroup of patients.

Long-term follow-up studies reveal that late remission occurs in about 16% of cases.

 Current guidelines for the use of medications are understandably conservative, but patient heterogeneity and response to medications need to be further explored. Later-stage patients who appear to have stabilized, but with continuing symptoms and functional impairment, can be offered a different suite of psychosocial interventions. Interventions specifically linked to this stage can greatly improve patients’ quality of life. These may involve meaningful activity including part-time work, strength-based strategies, social engagement within the community to combat loneliness, family support, financial support, and expert medical care to respond to the greatly increased risk of medical illnesses.

A contributing life is possible for most people and a holistic blend of expert psychiatric, medical, and social care is essential for this to occur. The “soft bigotry of low expectations” is a consequence of poorly resourced systems of care and antiquated diagnostic thinking that is blind to the opportunities that new models of care and high-fidelity implementation can deliver. Such approaches depend on congruent mindsets and conceptual frameworks, and a much more educated and supportive wider community.

Dr McGorry is a professor of youth mental health at The University of Melbourne and executive director of Orygen in Melbourne, Australia. He has received past unrestricted grant funding from Janssen-Cilag, AstraZeneca, Eli Lilly, Novartis, and Pfizer, and honoraria for consultancy and teaching from Janssen-Cilag, Eli Lilly, Pfizer, AstraZeneca, Roche, Bristol-Myers Squibb, and Lundbeck. He has received grant funding from the Colonial Foundation, the National Health and Medical Research Council of Australia, NARSAD, the Stanley Foundation, the National Institutes of Health, and the Australian and Victorian governments.

The Lancet Commission on global mental health and sustainable development

 Correll CU, Galling B, Pawar A, et al. Comparison of early intervention services vs treatment as usual for early-phase psychosis: a systematic review, meta-analysis, and meta-regression. 

Malla A, Joober R, Iyer S, et al. Comparing three-year extension of early intervention service to regular care following two years of early intervention service in first-episode psychosis: a randomized single blind clinical trial. 

Yung AR, McGorry PD. The initial prodrome in psychosis: descriptive and qualitative aspects. 

Clinical Staging in Psychiatry: Making Diagnosis Work for Research and Treatment.

Fava GA, Kellner R. Staging: a neglected dimension in psychiatric classification. 

McGorry PD, Hartmann JA, Spooner R, Nelson B. Beyond the “at risk mental state” concept: transitioning to transdiagnostic psychiatry. 

 McGorry PD, Ratheesh A, O’Donoghue B. Early intervention––an implementation challenge for 21st century mental health care. 

Ajnakina O, David AS, Murray RM. ‘At-risk mental state’ clinics for psychosis—an idea whose time has come—and gone! 

Fusar-Poli P, Salazar de Pablo G, Correll CU, et al. Prevention of psychosis: advances in detection, prognosis, and intervention. 

 McGorry PD, Nelson B. Clinical high risk for psychosis––not seeing the trees for the wood. JAMA Psychiatry. Published online March 11, 2020; Epub ahead of print.

Dama M, Shah J, Norman R, et al. Short duration of untreated psychosis enhances negative symptom remission in extended early intervention service for psychosis. 

Francey SM, O’Donoghue B, Nelson B, et al. Psychosocial intervention with or without antipsychotic medication for first-episode psychosis: a randomized noninferiority clinical trial. 

 Kane JM, Robinson DG, Schooler NR, et al. Comprehensive versus usual community care for first-episode psychosis: 2-year outcomes from the NIMH RAISE Early Treatment Program. 

Australian Clinical Guidelines for Early Psychosis––second edition updated. Orygen. 2016. 

www.orygen.org.au/Training/Resources/Psychosis/Clinical-practice-points/Australian-Clinical-Guidelines-for-Early-Psychosis

 Thien K, Bowtell M, Eaton S, et al. Clozapine use in early psychosis. 

Shah P, Iwata Y, Plitman E, et al. The impact of delay in clozapine initiation on treatment outcomes in patients with treatment-resistant schizophrenia: a systematic review. 

Killackey E, Allott K, Jackson HJ, et al. Individual placement and support for vocational recovery in first-episode psychosis: randomised controlled trial. 

Wunderink L, Nieboer RM, Wiersma D, et al. Recovery in remitted first-episode psychosis at 7 years of follow-up of an early dose reduction/discontinuation or maintenance treatment strategy: long-term follow-up of a 2-year randomized clinical trial. JAMA Psychiatry. 2013;70(9):913-920.

Harrison G, Hopper K, Craig T, et al. Recovery from psychotic illness: a 15- and 25-year international follow-up study. 

Articles

Psychotic disorders are potentially serious and enduring and have been seriously neglected in health systems worldwide. The good news is that better medium-term outcomes are now achievable.

Stage-Specific Treatment  of Psychotic Disorders

[Editor's Note: In this commentary, Professor Patrick McGorry responds to Dr Allen Frances' recent blog, 

Seven Questions For Professor Patrick McGorry

. Their exchange appears in the October 2011 issue of Psychiatric Times.] 


Mental health reform is one of the world’s “grand challenges.” Mental, neurological and substance-use (MNS) disorders constitute 13% of the global burden of disease, surpassing both cardiovascular disease and cancer. The Grand Challenges in Global Mental Health initiative recently identified priorities for the next decade.

 The creation of new knowledge and vastly improved and timely access to mental health care are overarching imperatives. One of the six goals agreed is to advance prevention and implementation of early interventions, and of the 25 key research questions identified, “what neuroprotective agents and/or cognitive retraining paradigms can be used during the period of rapid brain development to reduce vulnerability to disorders in adolescence?” is particularly salient.

On the same message, Dr Thomas Insel, Director of the National Institute of Mental Health, who is playing a most influential role globally, has strongly endorsed the need for what he calls “pre-emptive psychiatry.”

 This means a major endeavour to limit through early intervention the collateral psychosocial damage that flows from delayed and inadequate treatment of potential serious mental disorders. While falling short of primary prevention, pre-emptive psychiatry is a strategy for modifying the course of mental disorders. These messages echo the preventively oriented blueprint published by the Institute of Medicine in 1994,

 which strongly supported notions of indicated prevention and early intervention as an achievable goal in serious mental disorders.


In Australia we are re-embracing the grand challenge of mental health reform. Australia has a strong record of innovation in mental health, but a poor one in terms of sustaining reform. We have seen repeated cycles of crisis, a surge of reform and a subsequent return to neglect. Our system has been partially modernised through mainstreaming of mental health within the general health system, however it has not been built to scale within nearly two thirds of those who experience mental ill health annually failing to access care. We spend only 7% of our health budget on mental health care. It needs at least double that amount.

Furthermore, the system has been poorly designed and engineered. Mental disorders are the chronic diseases of the young

 with three quarters of new cases emerging prior to the mid-twenties, two thirds of these between the ages of 12 and 25. Australian National Mental Health Survey data reveals that 12-month prevalence also peaks between 18 and 25 years at 26%, and yet despite that this age group have the worst access to mental health care than any other.

Australia’s Federal government and its eight State and Territory governments committed on August 19th at the meeting of the Council of Australian Governments to a ten year process of reform and investment in mental health care. This has been catalysed by a systematic review of mental health reform options conducted by an independent commission of inquiry, the National Health and Hospital’s Reform Commission, which reported in 2009. All competing views and supporting scientific evidence were objectively considered. Debates on contentious issues were held and resolved.

Mental health policies then passed through a series of filters, including community consultation, parliamentary inquiries and an intense national election period, during which mental health became a major issue. The mental health sector unified and was supported strongly by the Australian community and the mainstream health sector in advocating for a whole of life reform focus, which would seek to transform the failing mental health system. All sides of politics came to recognise, among other priorities, the urgent need to strengthen the disproportionately weak response to young people and to implement evidence-based early intervention services to pre-empt psychosocial damage and disability.

In May this year the Federal government announced an encouraging, though still relatively modest, initial investment in mental health reform to which State governments have now been asked to respond with matching investments. Approximately 25% of this new investment is to be devoted to expanding and strengthening the novel and successful “headspace” program of enhanced primary care for young people aged 12 to 25 years (www.headspace.org.au), and belatedly to make available to thousands of young Australians with psychotic illnesses, the early psychosis prevention and intervention centre (EPPIC) model, developed in Melbourne 20 years ago and now replicated in many hundreds of locations world-wide, including some parts of the USA and Asia, but more systematically in Canada, England, Denmark and the Netherlands. The bulk of the new investment is focused on other stages of life and illness with the largest single amount devoted to integrate and strengthen services for people with severe and enduring mental illness. The alternative government has an even stronger policy commitment to early intervention and young people.

Dr Allen Frances, who does not live in Australia, is understandably unaware of the complex and rigorous processes through which the Australian reform blueprint has had to pass. A fundamental difference between the USA and Australia is that mental health professionals conceive of mental ill health and mental illness in a much more biopsychosocial and holistic manner. Both conceptually and through our universal system of health financing we respect and provide a much stronger level of psychosocial input to patients. We do not equate treatment with the prescription of medication. We do not permit direct marketing of pharmaceutical products to the public.

Under our universal health insurance scheme, Medicare, it is common practice, especially for mild to moderate disorder for people to receive assessment and psychosocial treatment for mental ill health without being prescribed medication. This contrasts starkly with the description of US practice in a recent 

 that revealed that psychiatrists no longer have time to talk to their patients, insurance schemes constraining their role to merely prescribing drugs (See: 

http://www.nytimes.com/2011/03/06/health/policy/06doctors.html?_r=1&scp=2&sq=psychiatry+and+talk+therapy&st=nyt

). Operating within such a different healthcare system, it is perhaps understandable that Dr Frances might struggle to grasp that the real impact of the youth mental health reforms in Australia will be to make psychosocial interventions available to young people with mental ill health to a much greater extent, as both an alternative and complement to medication. A measurable outcome will be less reliance on medication for those accessing care.


One of the greatest paradoxes of the modern world is that while material well being and physical health have dramatically improved, the mental health of young people in transition from childhood to adulthood has been steadily declining, and this from a low base.

 One of the failures of the field so far is not to have appreciated that the timing and pattern of mental ill health impacts so strongly on young people who, on the threshold of adult life, have the most to lose.

 Society as a whole also loses, in terms of reduced human capital, “mental wealth” and productivity in the broadest sense.

A recent New Zealand study estimated that up to half of young people in this transition period will experience at least one diagnosable episode of mental ill health with proportionate negative impact on earning potential, educational outcomes and social integration at age 30.

 The scene for this erosion of life chances is often set in childhood but more commonly it takes the ever changing climate of adolescence and emerging adulthood to release the variety of clinical phenotypes we recognise as clinicians, the incidence of which surges through adolescence and peaks between 18 and 25 years.

What we call “disorders” are experienced first by young people and their families as emotional distress, attempts to cope or deny, behavioural disturbances and all too often collateral damage such as vocational failure, substance abuse, deliberate self harm and offending behaviour. Influenced by stigma and the orthodox view that the health of young people has never been better,

 many people make the mistake of assuming that, because emotional distress and damaging behaviours are common in young people, this is “normal” and largely transient, and to intervene would be unnecessary or even harmful. This is dangerous thinking. It confuses being common with being benign; a serious error with often fatal consequences. Malaria is common in many developing countries but hardly benign.

Young people with the highest incidence and prevalence of mental ill health receive the least help to overcome these threats to their survival, well-being and contribution to others. Young people make up 27% of the world’s population and their health needs have been seriously neglected because they are perceived as healthy.

 In Australia only one in four young people with mental disorders gain access to any form of mental health care and this drops to 13% for young men. So far we have made only desultory efforts to understand what is behind this rising tide of mental ill health and try to turn it back. With the advent of headspace and EPPIC, in Australia that is starting to change.

The role of evidence and health system reform


Dr Frances adopts a posture of censure in attempting to play the evidence based medicine card in his opposition to early intervention in psychosis. As a clinical scientist with a long track record in conducting clinical trials and health services research, and who has always regarded evidence as the best insurance policy against heading too far down a wrong turning, I found his comments puzzling.

David Sackett, the doyen of clinical epidemiology, defines evidence-based medicine (EBM) as that which is applied by individual clinicians to individual patients, and evidence-based health care (EBHC) as that which is applied by public health professionals to groups of patients and populations.

 Evidence-based health policy is more complex and has several determinants only one of which is evidence. Cooper

 notes that only 10% of clinical trials and metanalyses focus on health services and most of these are inconclusive. While it is crucial that we continue to conduct randomised clinical trials, these are rare and challenging to carry out at the health system level. It is plain that if we limit health service design and reform to Cochrane-confirmed approaches, we will have a very sparse and indecisive health system. Even the latest Cochrane review

 on the use of clozapine in schizophrenia was equivocal as to its superiority over other atypical agents. So what should be done? Should we wind up the use of clozapine? We do need some common sense here.

Evidence will never be conclusive and the perfect is truly the enemy of the good. The real question is where does the onus of proof lie? Given the serious and often irreversible personal and social damage wrought by untreated serious mental illness, surely we can assume that late intervention is not a practice we wish to support. The status quo is the least evidence-based option and the outcome for schizophrenia does not seem to have changed in 100 years. The status quo has comprehensively failed, to which countless human stories bear witness, and those who defend it are defending the indefensible. One only needs to ask the consumers and their families. So the real question is, how to promote early intervention and sustained holistic care most effectively and safely?

Taking first episode psychosis first, notwithstanding the latest Cochrane, review,

 in which the authors inappropriately blended individual treatment trials and health services research, systematic reviews are now clearly confirming that early detection and more specialised care over the first two years is effective in improving short term outcome.

 have since shown that the erosion of these gains, which occurs when the patients are discharged to standard adult care, can be prevented if they are offered step-down early psychosis care up to the 5 year point. There are indications that adolescent onset cases may benefit proportionately more from this model of care.

. The crucial TIPS study shows that the beneficial effect of early detection has a long term effect on negative symptoms,

 but because it was quasi-experimental (the best possible design for this research question), it was not able to be considered by the Cochrane reviewers.

While Dr Frances characterises Australia’s decision to belatedly scale up early psychosis services some 20 years after we began our work in Melbourne as “reckless,” in England, and in many other service systems globally, streamed early psychosis services have been in operation across the nation for many years. The early psychosis airplane has been flying internationally for over a decade. Consequently we now have compelling cost-effectiveness data from England, Australia, Sweden and Hong Kong all showing that early intervention for psychosis is excellent value for money, and rather than, as Dr Frances suggests, diverting funds from other seriously ill patients (as if the FEP patients were not) it actually frees up substantial resources for use elsewhere.

The notion that early diagnosis and treatment should be an optional extra is in any case quite bizarre. Reckless even, given that the lives and futures of young people are at stake. Why do we never see oncologists arguing about the relative value of palliative care and early diagnosis, or insisting that we must have perfect palliative care services before we tackle early intervention? Perhaps it is partly due to the historical neglect of mental health care and our own ambivalence about what we have to offer patients. These are stigma-related issues we must confront.


While the provision of care for young people with subthreshold psychotic symptoms (UHR or ultra-high risk) is not the focus of the Australian reforms, the fact that such patients will not be denied help if they seek it has prompted controversy in some quarters and seems to be the main issue that troubles Dr Frances. This seems driven by his fear that they will be more likely to receive antipsychotic medication. In fact the opposite is much more likely to be the case.

The approach to the UHR group is not analagous to screening asymptomatic people to identify those with an increased risk of an illness such as breast screening programs using mammography, routine blood pressure and cholesterol monitoring and prostate screening. The young people involved in the UHR clinical programs and research are already experiencing substantial levels of mental ill health and are by actively seeking help. So the appropriate analogy would be with the woman who discovers a breast lump on self-examination or the man who experiences the onset of chest pain. These clinical situations require assessment, and typically some kind of clinical intervention and follow up.

We know that most cases of first episode psychosis are preceded by an often prolonged period of distress and functional decline so if we wait until frank and florid psychosis is present, much psychosocial damage has been done. Conversely, we know from pooling international data that only about 36% across all studies of those identified by the UHR criteria will progress to severe and sustained psychotic illness, mostly but not exclusively schizophrenia, within around 3 years. However most of the remainder manifest other treatable disorders and their average GAF scores are in the low fifties when they seek help. They have an undeniable need for care and monitoring.

The best available evidence from 5 RCT’s

 shows that any of range of treatments will reduce their risk of psychosis from around 31% to 11%, though probably only for as long as this is being delivered. This intervention has recently also been shown to be cost-effective.

 The clear message so far (and both the Cochrane review and Dr Frances agree that further research is required) is that antipsychotic medications are not supported as first line therapy since there are safer alternatives. This is in line with the fundamental principle articulated by David Sackett that the earlier one intervenes the less risk can be accepted. In other words the risk benefit ratio is the key. This is where the clinical staging model may be useful as a cross-diagnostic solution to the controversy.


The clinical staging model is a form of stepped care which recognises that many of the standard diagnostic entities such as schizophrenia and bipolar disorder are in fact late stage concepts and that by the time people receive these labels and are first treated, they have been suffering often for years and have been functioning poorly.

 So there are earlier clinical stages of illness where treatment is indicated though the symptoms, distress and functional impairment is more diffuse and difficult to categorise. We do need further research to characterise these early clinical phenotypes and ensure that we can distinguish them from normal life experience. The principle of providing care at this point is that it should be as safe as possible and that the benefits outweigh any harmful effects. While there may be harmful effects of both psychological and pharmacological interventions, it is obvious that the first line approaches should be simple and brief, including the provision of information, support and problem-solving. They may be provided in primary care and stigma-free settings or via new technologies such as the internet and mobile technology. More sophisticated psychosocial interventions and drug therapies should only be offered for later and more sustained and severe stages of illness.

This is a heuristic framework, which may be useful in guiding clinical care and biomarker research as well. I believe that the UHR and early psychosis research has been catalytic in illustrating the potential of this staged approach to mental health care. I believe that rather than agonising over the immediate question of whether this concept or some variant thereof should be introduced into DSM V, it would be better to aim for a more radical revision of our diagnostic approach, a process that would clearly take a significant amount of additional research and development.

In the meantime however I believe all people, especially young people, who are experiencing mental ill health, and are distressed and consistently struggling with relationships and vocational development, should have ready and free access to stigma-free care. Naturally this includes those who happen to meet the current criteria for ultra-high risk who are demonstrably in need of care. There is no justification for them to be excluded from access to care under the Australian reforms. Indeed the establishment of new youth mental health services means that these and other patients will come under a stronger system of clinical governance, which can better ensure adherence to evidence-based practice. In this case that means not commencing with antipsychotic medication in the UHR group. Currently at our PACE clinic in Melbourne 27% of the patients referred have already been prescribed antipsychotic medication by primary care physicians and among our first clinical tasks is to cease this medication. The national reforms will mean less, not more, medication in this group.




In providing more background to the issues at stake in Australian mental health reform I hope I have been able to show that these are issues that the mental health field globally needs to consider. I maintain that any young person with emerging mental ill health should be able to access support, expert assessment and safe and effective evidence-informed care in a timely fashion and in stigma-free settings. This is what we are seriously trying to build in Australia. To the relatively small number of critics, both within Australia and overseas, I would simply say what is the alternative that you are proposing? Is it more of the same? Because every day we delay reform, the status quo continues to fail people with mental ill health and their families. The latter are not critical of the early intervention reform focus. Far from it. We must take action. Not in a reckless way, but according to the best available analysis and evidence.

Dr Thomas Insel, having been made fully aware of developments in Australia and being very familiar with the progress in early psychosis research, recently commented in a presentation to Australia’s National Health and Medical Research Council (Australia’s NIH) that Australian ideas and progress were extremely positive and progressive and could form a major plank in the international research agenda. We certainly have a lot more work to do but I believe that if we continue to combine clinical science, a commitment to building evidence and testing the effectiveness of our interventions and models, and ensure that consumers and carers have a strong say in the reform process we have an excellent opportunity to reduce the impact of mental disorders on our society.

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Mental health reform is one of the world’s “grand challenges.” Mental, neurological and substance-use (MNS) disorders constitute 13% of the global burden of disease, surpassing both cardiovascular disease and cancer.

Patrick D. Mcgorry, MD, PhD

Articles

Stage-Specific Treatment of Psychotic Disorders

The Real Questions in Mental Health Reform