1 Boring Old Man

About-turn on treatment of the young
Sydney Morning Herald
by Amy Corderoy
February 20, 2012

Professor McGorry has been part of a team researching pre- and early-psychosis, and his work in the latter helped secure a massive $222.4 million Commonwealth funding injection for Early Psychosis Prevention and Intervention Centres across Australia. They have found symptoms such as having some delusions or disorganised speech and thought can predict psychosis. But he believes young people at risk of psychosis are already over-medicated and inclusion in the manual could worsen the problem. "I think it’s a valid point to be concerned about the harms particularly in places like America," he said. "I think probably I have given a bit more weight to that argument now".

He said 27 per cent of patients in his ultra-high risk clinics had to be taken off anti-psychotic medications prescribed by GPs. Professor McGorry has been heavily criticised for his work in early psychosis by doctors who believe it will lead to overmedication. "I certainly didn’t push for [pre-psychosis] to be included although I got panned as if that was what I was trying to do," he said. ”I just didn’t want 15 years of progress to be lost"…

Professor McGorry said it was his focus on developing staging models in psychiatry, similar to those seen in other areas of medicine such as cancer treatment where an illness is graded from symptoms needing investigation through to stages of the disease varying in seriousness, that had led him to decide the DSM listing was not helpful. "We need a more radical change to the diagnostic approach which allows people to get help when they really need it but also ensures risky treatments that cause harm wont get used."

Treatment centres such as Headspace, which allowed for non-drug treatments such as counselling or employment help, could provide the first step in such a system, without needing a DSM diagnosis to be attached to the people who used them. "It’s quite a legitimate debate, what the boundaries of mental illness are," he said. "We want to provide help, but we don’t want to turn everyone into a brain disease."

All six of the following:
   [a] Characteristic symptoms: at least one of the following in attenuated form with intact reality testing, but of sufficient severity and/or frequency that it is not discounted or ignored;
      [i]   delusions
      [ii]  hallucinations
      [iii] disorganized speech
   [b] Frequency/Currency: symptoms meeting criterion A must be present in the past month and occur at an average frequency of at least once per week in past month 
   [c] Progression: symptoms meeting criterion A must have begun in or significantly worsened in the past year; 
   [d] Distress/Disability/Treatment Seeking:  symptoms meeting criterion A are sufficiently distressing and disabling to the patient and/or parent/guardian to lead them to seek help
   [e] Symptoms meeting criterion A are not better explained by any DSM-5 diagnosis, including substance-related disorder.
   [f] Clinical criteria for any DSM-V psychotic disorder have never been met

And he might do well to call his friend Ian Hickie and pass on a lesson in humility. Hickie’s paranoid campaign against Lancet Editor Richard Horton demanding retraction of "edgy tweets" is sounding increasingly bizarre [how would you retract a tweet anyway?]. From my perspective, the fact that so many people jumped on Hickie’s article about Agomelatine that quickly is a patch of blue in an overcast sky – that publications that bespeak conflict of interest are just not going to be tolerated anymore as they have been in the all too recent past.

^{Allen Frances, the chairman of the task force that created the current DSM and a critic of the proposals for the new manual, proposal to include pre-psychosis, currently called attenuated psychosis, in the manual that inspired his campaign. "It was a very specific moment, it was in May of 2009," he said. "I realised the ark DSM5 was taking would be so far off the mark that it would be irresponsible not to say anything."}

Speaking of humility, now would be a really good time for the DSM-5 Task Force to develop some humility itself. Barreling ahead right now is a really bad idea on any number of counts. If reason were to prevail, they’d take a mid-course correction stop, and rethink their deadlines to make this the middle – not close to the end.