1 Boring Old Man

When I first became interested in the goings-on in Australia, it was introduced to me as the McGorry Controversy. At the time, I didn’t know enough about it to understand that term. As I’ve read more over the months, I’m beginning to see why it was called the McGorry Controversy instead of the EPPIC Controversy or the Australian Controversy, or the Early Intervention in Schizophrenia Controversy. So, for the moment, I want to overstep my own level of expertise try to be clear about just the Controversy itself as it appears to me.

1. early intervention in new cases of Schizophrenia:
   ^{Schizophrenia classically comes in like a lion with a rapid onset of debilitating psychotic symptoms, a hurricane landing on-shore. In this case, early intervention means rapid detection and treatment. That involves antipsychotic medication and psychosocial intervention to hopefully prevent a deterioration into what might be called a chronic schizophrenic life – something that is a real possibility for many cases. I’m all for that myself. The nature and outcome of the psychosocial part is somewhat controversial, but the alternative can be devastating. In Australia, there is controversy about the new funded program because it takes funding away from other proven mental health programs. I think the opponents would like to see something more like a "pilot project" than a massive initiative. While that makes better sense to me, it’s frankly none of my business. I applaud either path. It’s high time that someone take on Schizophrenia aggressively. It’s clear that neither ignoring the illness nor just medicating it gets the job done. Kudos to Australia for rising to the challenge of secondary prevention.}
2. early intervention in the prodromal syndrome that may lead to Schizophrenia:
   
   ^{From the initial description of Schizophrenia, we have known that there is a prodrome – a syndrome that precedes the manifest illness. I’ve known it as "the trema." Dr. McGorry’s group calls it the "Ultra High Risk" group [UHR] and have made attempts to identify it in advance and treat it with variable results. They have made progress in identifying cases that transition to schizophrenia in from 5% to 40% of the time. Interventions to alter the course of that progression have had variable results among various groups. Most "eraly intervention studies" have used antipsychotic medications – exceptions being the UK group and McGorry’s Fish Oil Study. McGorry’s other studies and one study in the US were industry sponsored. So this kind of early intervention is much more controversial that the first kind, which is controversial in its own right, though less so.}
   

• early intervention in new cases of Schizophrenia:
  ^{Most everyone familiar with the course of Schizophrenia would agree that it’s a good idea, and that medication alone is not enough [even people who are anti-medication mostly are anti-chronic-medication]. There’s a controversy here are about the allocation of resources and a controversy as to whether McGorry’s program is yet ready for country wide implementation.}
• early intervention in the prodromal syndrome that may lead to Schizophrenia:
  ^{This is not the primary piece of their program, but is an obvious interest and these patients are included in their initiative. The controversy here is about using antipsychotic medication in these patients. Most of us feel that the the risk-benefit ration justifies treating psychosis with the currently available antipsychotics at least acutely. So one controversy is about using the drugs long-term. A second controversy is about using these drugs in children. Third, since only a fraction of the UHR patients develop Schizophrenia, there’s a controversy about using them to treat these patients since it means exposing the majority of patients to these drugs needlessly. And finally, there’s a controversy about including some version of this UHR group as a category in the diagnostic manual [DSM-5] as a Disorder.}
  

Early intervention for psychosis: not just popping pills
the conversation
by Dr. Alison Yung
16 June 2011

^{A controversy is brewing on the website Psychology Today and subsequently in The Australian newspaper. At the heart of the issue is US psychiatrist Dr Allen Frances’ comments on the Australian Federal Government’s planned mental health reforms in early psychosis. Dr Frances has linked these reforms with another issue that is being hotly debated in the psychiatric literature: whether to create a new diagnosis of “risk syndrome for psychosis” or “attenuated psychosis syndrome” in the next edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM). These two issues have become confused by Dr Frances and many other commentators. Hopefully this piece will allay some of this confusion.}

^{First, the proposed “risk syndrome” diagnosis. This diagnosis is based on work conducted in Melbourne by me, Professor Patrick McGorry and others. We attempted to define criteria to detect people with a high likelihood of developing a first episode of psychosis within a short period (one to two years). If these people are identified, it might be possible to treat them early and prevent the psychotic episode. It’s important to note that “treatment” doesn’t imply antipsychotic medication. It could be counselling, stress management, help with reducing substance use, management of depression and so on.}

^{To cut a long story short, we developed some criteria that picked up people with a 30% to 40% risk of psychosis within a year. But I’ve always said this is a work in progress and we need a greater understanding of risk factors within this group to better understand which treatments are most effective. I’ve never sought to have these criteria formally recognised as a diagnosis.}

^{I’ve contributed to scientific literature opposing the inclusion of psychosis-risk as a DSM diagnosis and have debated this issue in several public forums. On this issue Dr Frances and I are in agreement. We have both written about the issues involved: problems of falsely identifying people who are not truly at risk, stigma, labelling, unnecessary and potentially harmful treatments including medication, to name a few….}

The Real Questions in Mental Health Reform
Psychiatric Times
by Patrick D. McGorry, MD, PhD
October 5, 2011

^{…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 [randomized clinical trials] 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…}

^{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…}