1 Boring Old Man

In my last post, I tried to separate the various controversies in the proposed and funded programs of Dr. Patrick McGorry and his colleagues in Australia [rearranged]:

1. Are these programs sufficiently developed to put into widespread use?
   ^{This part can get confusing to a foreigner like me [though from reading, I think it can confuse anyone]. The main program focus is on early detection and intervention in cases of Schizophrenia [Psychosis]. That includes the use of medication [antipsychotics] and intensive psycho-social program.As part of that program, Dr. McGorry’s group have identified a group of patients who are not psychotic, but have an Ultra High Risk [UHR] to develop psychosis. They include this group in their program. At issue is the use of antipsychotic medications [see 6. below]. But this controversy has to do with whether or not their early intervention in Schizophrenia program is sufficiently developed to implement en masse. While I am personally very sympathetic to the idea of intensive and early intervention in Schizophrenia, I have not reviewed the data on this part of their particular program, have no personal expertise in this area, and so I have nothing useful to say about this controversy.}
2. The funding of Dr. McGorry’s programs are at the expense of other apparently effective mental health programs and many question that downsizing.
   ^{McGorry and colleagues appear to ignore this controversy sticking to 1. His critics seem very upset about these cuts and argue against 1. as a way of opposing them. My hunch is that in Australia this may be the biggest controversy of them all, but it’s being morphed into all of the other debates rather than addressed directly. It seems like a separate related issue to me – collateral damage. It’s a big piece of the dialog. I am not an Australian. I don’t understand their healthcare system. Though I see why people are complaining, I see this controversy as none of my business.}
3. There is a growing controversy about the use of medication in the long term maintenance treatment of Schizophrenia.
   ^{Most of the people who are seen as anti-medications are really anti-chronic-medication in Schizophrenic patients [including the patients who discontinue medications themselves at a high rate]. The spokesman for this movement is currently Robert Whitaker, author of Anatomy of an Epidemic. That argument is well-presented in his book and outside the scope of what is being discussed in the Australia program. It’s part of this controversy only because it too is centered on over-medication. My impression is that McGorry’s group are not generally "over-medicators." I’ve got nothing to say here. I’ve never been an over-medicator either. I await [and support] the formal study of Whitaker’s hypothesis [which I expect will happen]. This controversy isn’t really part of the McGorry Controversies that I can see.}
4. The use of medications in children and adolescents is a huge controversy, particularly the antipsychotics, particularly in the group recently called "Bipolar Kids."
   ^{The Australian program is focused on acute first episode Schizophrenia, a disorder of late adolescence and early adulthood – though it can occur in "children" and "preadolescents." I don’t want to give antipsychotics to kids but it’s hard to imagine not treating a case of an acute schizophrenic decompensation in a youth with antipsychotics. I expect Dr. McGorry’s group would feel the same way. I’ve done it with much worry. If there’s a child psychiatrist around, I refer such patients. It’s a double bind, but I expect most psychiatrists [and parents] in the situation would use the medication [I would hope being as soft as possible and as worried as needs be the whole time]. There is nothing about this question that I see as specific to McGorry’s programs.}
5. The DSM-5 Committee is considering including Dr. McGorry’s Ultra High Risk group as a Disorder.
   ^{I don’t know the whole story behind including this as a Disorder. But since Dr. Insel and friends can’t seem to give a speech without mentioning some version of matters McGorry, I suspect this is part of the attempt to advance their future-think neuroscience agenda. We already have categories [Schizotypal Personality, Schizophrenia – Prodromal or Residual Phase] for such patients. Adding this as a Disorder is not based in solid phenomenology and is an open door for over-medication. Drs. McGorry, Yung, Frances, and 1boringoldman categorically oppose inclusion of this category.}
6. The final controversy is about using antipsychotic medication in treating the Ultra High Risk group – patients who are not psychotic and have only a 5-40% chance of becoming psychotic.
   ^{This is the only one of the controversies I’m weighing in on. It’s the part about treating non-psychotic people with antipsychotics in hopes of preventing or altering the course of those who do become psychotic. I’m not opposed to McGorry including them in his program, treating them with psychotherapy, Fish Oil, etc. But I’m opposed to his using antipsychotics – period. The minute he can legitimately diagnose a psychotic break, treating that patient with antipsychotics is fine with me.}
   

Dr. McGorry’s group has conducted three clinical trials and proposed another [recently withdrawn]. Two trials were industry sponsored trials where the patients were treated with Risperdal. The withdrawn trial was industry sponsored and involved using Seroquel. Their only trial without antipsychotics was the fish oil trial. There have been three other trials: an industry funded trial using Olanzapine; a Danish study with no fixed drug policy – many patients were on antipsychotics; and the British study that was essentially drug-free. [1. when n=a few…, 2. when n=a few…]. So one reason we’re afraid they’re going to use antipsychotics is because that’s what they have done, except in their fish oil study. And so has everyone else except the British group.

^{The second area of recent controversy in Australia is the early psychosis reforms recently funded by the Federal Government, and their relationship to the “risk syndrome” diagnosis. Put simply, there is no relationship. Unfortunately Dr Frances has confused the detection and treatment of people before psychosis [the “risk syndrome” idea] with the Early Psychosis Prevention and Intervention Centre [EPPIC] model, which attracted the Federal Government investment. The EPPIC model treats young people with established psychotic disorders. Individuals enter the EPPIC program if they are within 12 months of onset of a first psychotic episode. EPPIC aims to prevent secondary morbidity and disability… Through evidence-based treatments such as low dose antipsychotics, cognitive therapy, family engagement and attention to recovery issues, such as vocational intervention, EPPIC attempts to minimise these psychosocial problems and prevent further disability. This is the “prevention” part of the EPPIC name… The planned service developments are for evidence-based cost-effective treatment of individuals early in the course of a diagnosed psychotic disorder…}

^{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… 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… 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.}

The only studies that show sustained positive effect from a non-medication intervention in UHR are his preliminary Fish Oil study and the British CBT study. His own most recent study didn’t even show that they could identify the UHR group, much less the effectiveness of interventions. So I [we] hear his response as overstating the effectiveness of the "safer alternatives" and keeping his options open to use antipsychotics later like he has before. Because of his track record with evasion [Seroquel trial, belated publication of negative results] and his generally vague, condescending rhetoric, he’ll just have to live with the fact that I [we] don’t totally trust him [nor do his fellow Australian psychiatrists].

McGorry’s equivocation  matters beyond the boundaries of EPPIC and Australia. It’s the UHR patients that excite people like the NIMH’s Dr. Insel who mentions McGorry’s program repeatedly along with personalized medicine and neuroimaging as the leading edges of neuroscience. In spite of the opposition, Dr. Kupfer’s DSM-5 committee is still considering adding their version of UHR to the manual [in so far as I know]. With no clear statement from Dr. McGorry, he’s colluding with the real possibility of medicating these patients world-wide – "off label." If psychiatrists are using Atypical Antipsychotics to treat Anxiety Disorders [nothing is simple anymore…] and "Bipolar Kids," they’ll use them for people that remotely resemble these UHR patients given half a chance.

^{…at our PACE clinic in Melbourne 27% of the patients referred have already been prescribed antipsychotic medication by primary care physicians.}

^{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.}