DSM5 in Distress

The DSM's impact on mental health practice and research

Australia's Reckless Experiment In Early Intervention

prevention that will do more harm than good

Patrick McGorry is a charismatic psychiatrist who has recently gained heroic status. First he was chosen to be Australia's Man Of The Year. Now, he has convinced the Australian government to spend more than $400 million over five years to fund his plan for a nationwide system of Early Psychosis Prevention and Intervention Centres. McGorry is the visionary prophet and pied piper of preventive psychiatry. His goal is to diagnose mental disorders early and treat them expectantly- before they can do their worst damage.

McGorry's goal is certainly great. But its current achievement is simply impossible and Australia's plans are patently premature. Early intervention to prevent psychosis requires first that there be an accurate tool to identify who will later become psychotic and who will not. Unfortunately, no such accurate tool exists. The false positive rate in selecting prepsychosis is at least about 60-70% in the very best of hands and may be as high as 90% in general practice. That's right, folks, nine misidentified non patients for one accurately identified truly prepsychotic patient. Those are totally unacceptable odds.

What are the costs? McGorry does not recommend antipsychotic medications as a routine part of his prevention regimen. But experience teaches us that they will be overused despite having no proven efficacy and posing the risk of massive weight gain (and its consequent array of serious complications). The false positives will also suffer unnecessary stigma and worry and will undergo unnecessary and misdirected treatment. And surely there are many more productive ways to spend $400 million doing a better job of managing the mental health needs of those who have real and treatable psychiatric disorders.

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Unfortunately, Mcgorry is a false prophet who's visions are offered at least a few decades before their time. Australia, led astray by his impractical hopes, is about to embark on a vast and untried public health experiment that will almost surely cause more harm to its children than it prevents. Before embarking on this headlong and reckless rush, the following research steps need to be accomplished:

1)Developing a proven and reliable definition of "Psychosis Risk"

2)Learning how to use it in a way that reduces current outrageously high false positive rates to levels that are tolerable.

3)Demonstrating that the interventions chosen are indeed effective in preventing psychosis.

4)Determining the likely rate of antipsychotic use and how this influences the overall risk/benefit balance sheet of early intervention.

5)Studying the beneficial and harmful impacts of early diagnosis on stigma and self perception.

6)Comparing the marginal utility of a dollar spent trying to prevent an alleged future disorder vs a dollar spent treating an already clearly established one.

This is a research enterprise that will take many groups around the world many decades to complete. But it is an absolutely necessary precondition before spending $400 million on what is likely to be a failure. The Australian experiment will be flying blind on an airplane that is not at all ready to leave the ground. Doing prevention prematurely and poorly will give a good idea an unnecessary bad name.

McGorry's intentions are clearly noble, but so were Don Quixote's. The kindly knight's delusional good intentions and misguided interventions wreaked havoc and confusion at every turn. Sad to say, Australia's well intended impulse to protect its children will paradoxically put them at greater risk. Let's applaud McGorry's vision but not blindly follow him down an unknown path fraught with dangers.

 

Allen Frances, M.D., was chair of the DSM-IV Task Force and is currently professor emeritus at Duke.

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