DSM5 in Distress

Whose instead of who's. Enjoyed the article, hate to be a grammar Viking, but it must be said!

The situation is measurably worse than this article suggests.

Not only is funding being directed to these programs on the basis of speculation, but the funding used to back these new centres is also being siphoned away from our existing mental health programs that have been shown to work.

Much of the funding ear-marked for this 'vision' is going to be sourced from cut-backs to psychological services that currently exist for people who have high prevalence mental health disorders, like depression and anxiety. The Australian Government intends to reduce the maximum of 18 sessions of psychological treatment that can currently be accessed by those who have a recognised mental health disorder, down to just 10 sessions. Evaluations of the 'Better Access' program demonstrated that the program led to marked reductions in symptom severity for people with moderate to severe distress and did so in a way that outperformed predictions of the cost-effectiveness for this program. Those familiar with evidence-based practice in psychology will know that the consensus is that 15 to 20 sessions is far more realistic for the treatment of conditions such as these than the new proposal that 10 sessions will do. Mental health consumers are protesting that this new policy stigmatises those who reach out for help, implying that if you need more than 10 sessions then something abnormal is going on - when we know that isn't the case at all.

For more information and to sign a petition about this important mental health policy issue, please join our campaign: http://www.tinyurl.com/gopetition12

It is a long way from Australia to Durham, so it is possible that some things have been misunderstood by Allen Frances in his egregious comment about the development of early intervention services in Australia.
The first point to note is that in the 2011 Federal Budget, the Australian Government has made $200 million available for the development of early intervention services not $400 million. The other $200 million would need to come from State Governments which have so far, not committed to providing this. I suspect that beyond creating controversy, Dr Frances has little interest in how Australian Government operates and the relation between State and Federal Governments, particularly in the area of Health. If he is interested, the following website could prove very educational http://australia.gov.au/about-australia/our-government
The second point is that Dr Frances repeats a well-worn tactic of the academically lazy opponents of early intervention. This tactic is to deliberately misrepresent early intervention – which occurs after the onset of psychosis – with prevention in the ultra-high risk population – which occurs before the onset of psychosis. This straw man argument has been soundly refuted in the peer-reviewed literature. To repeat it, one is either advocating on behalf of the scientologists or engaging in half-baked, disingenuous scholarship. The Australian Government is not funding clinics for those in the ultra-high risk group. They are funding clinics for those with first episode psychosis. The Federal Minister for Mental Health made this clear in his speech to the National Press Club following the budget (http://tiny.cc/spyy2).
The third point is that the federal budget allocated nearly $2.2 billion in funding for mental health programs across the lifespan. That is, the money for the early intervention in psychosis part of the budget is 10% of the newly allocated money. There is still a long way to go to get the funding for mental health commensurate with the burden that mental ill health causes to the community, but overall this is a great step in the right direction.
And just a final few points while we are on accuracy. Patrick McGorry was the Australian of the Year in 2010, not ‘Australia’s man of the year’. Again this makes one wonder what knowledge, if any, Dr Frances has of what happens in Australia. And in reference to the pied piper; no-one disputes either that Hamlin had a rat problem, or that the pied piper had the solution. What we recall was that the citizens of Hamlin were too tight-fisted to pay the price. The Australian Government has seen the problem of mental illness, has recognised the solution and is willing to pay the price. After all, we value the presence of all our young people and don’t want them taken away by mental illness.

Dr Frances makes some valid points about the dangers of attempting to detect and intervene in young people possibly at risk of psychotic disorder. This has been my area of research for the last 15 years and I am well aware of the issues involved: problems of falsely identifying people who are not truly prepsychotic, stigma, labeling, unnecessary and potentially harmful treatments including medication, to name a few. For these reasons we have opposed the inclusion of a “Psychosis Risk Syndrome” or Attenuated Psychosis Syndrome” in the DSM-5 (1).

However, as the comment above notes, Dr Frances is confusing the detection and treatment of people before psychosis (the Ultra High Risk strategy) with the Early Psychosis Prevention and Intervention Centre (EPPIC) model. The EPPIC model treats young people with established psychotic disorders. Individuals enter the EPPIC program if they are within the first 12 months of onset of a first episode of psychosis. EPPIC aims to prevent secondary morbidity and disability. Much deterioration associated with psychotic disorders is thought to be due to psychosocial difficulties, including depression and demoralization, fear of relapse, substance use, loss of peer and family networks, and disruption to education or employment. 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 minimize these psychosocial problems and prevent further disability. This is the “prevention” part of the EPPIC name.

Specialized early intervention services, such as EPPIC, have been found to be superior to standard treatment across a range of outcomes. A recent metanalysis showed an advantage for early intervention services over standard treatment during the first 12 months of care (2). This was partly due to the reduction in the duration of untreated psychosis (DUP) through vigorous and sustained community education and mobile detection services (3). Shortening DUP resulted in lower levels of positive symptoms and suicidality at admission (3, 4) and lower levels of negative, depressive and cognitive symptoms at 5-year follow-up (5). The lower DUP group also had higher psychosocial functioning at 5-year follow-up (5).
Additionally, two randomized control trials of specialized early psychosis treatment services compared to standard treatment have been conducted. Advantages of early intervention for up to 2 years post diagnosis were demonstrated (6-8). For example, the Danish OPUS trial (9) found that those accessing EI services had greater rates of independent living and reduced homelessness, improved psychotic symptoms, lower levels of substance abuse, and better global functioning at 2 year follow up. The LEO (Lambeth Early Onset) trial (10) found that individuals treated by a specialist service had lower hospital bed use at 18 months than those receiving care as usual. Unfortunately it seems that when the specialized care was prematurely withdrawn there was a tendency for some, but not all, of these gains to be lost (9). The LEO 5 year follow up (11) study was, as the authors acknowledged, underpowered to find a difference between groups. One of the authors’ conclusions was, nonetheless, that the results could reflect the erosion of initial positive effects due to the withdrawal of specialized interventions and referral to standard adult mental health services. Finally, evidence is emerging that early detection and treatment services for psychosis are at least likely to be cost-effective (12) and may actually be associated with a reduction in health costs (13-15).

In summary, Dr Frances has mistakenly assumed that the proposed national roll out of Early Psychosis services in Australia aim to detect and treat young people before the onset of psychosis. In fact, the planned service developments are for evidence-based cost-effective treatment of individuals early in the course of a diagnosed psychotic disorder. The Australian government is to be applauded for its commitment to improving the health of its people.

References:
1. Yung AR, Nelson B, Thompson AD, Wood SJ. Should a" Risk Syndrome for Psychosis" be included in the DSMV? Schizophrenia Research. 2010;120((1-3)):7-15.
2. Harvey PO, Lepage M, Malla A. Benefits of enriched intervention compared with standard care for patients with recent-onset psychosis: a metaanalytic approach. Canadian journal of psychiatry. 2007 Jul;52(7):464-72.
3. Melle I, Larsen TK, Haahr U, Friis S, Johannessen JO, Opjordsmoen S, et al. Reducing the duration of untreated first-episode psychosis: Effects on clinical presentation. Archives of General Psychiatry. 2004;61(2):143-50.
4. Melle I, Larsen T, Haahr U, Friis S, Johannesen J, Opjordsmoen S, et al. Does early detection improve outcome? A 2-year follow-up Schizophr Res. 2006;86:S24.
5. Larsen TK, Melle I, Auestad B, Haahr U, Joa I, Johannessen JO, et al. Early detection of psychosis: positive effects on 5-year outcome. Psychol Med. 2010;epub ahead of print:doi:10.1017/S0033291710002023.
6. Craig TK, Garety P, Power P, Rahaman N, Colbert S, Fornells-Ambrojo M, et al. The Lambeth Early Onset (LEO) Team: randomised controlled trial of the effectiveness of specialised care for early psychosis. BMJ (Clinical research ed. 2004 Nov 6;329(7474):1067.
7. Garety PA, Craig TK, Dunn G, Fornells-Ambrojo M, Colbert S, Rahaman N, et al. Specialised care for early psychosis: symptoms, social functioning and patient satisfaction: randomised controlled trial. Br J Psychiatry. 2006 Jan;188:37-45.
8. Petersen L, Jeppesen P, Thorup A, Abel MB, Ohlenschlaeger J, Christensen TO, et al. A randomised multicentre trial of integrated versus standard treatment for patients with a first episode of psychotic illness. BMJ Clinical research ed. 2005 Sep 17;331(7517):602.
9. Bertelsen M, Jeppesen P, Petersen L, Thorup A, Ohlenschlaeger J, le Quach P, et al. Five-year follow-up of a randomized multicenter trial of intensive early intervention vs standard treatment for patients with a first episode of psychotic illness: the OPUS trial. Archives of general psychiatry. 2008 Jul;65(7):762-71.
10. Craig TKJ, Garety PA, Power P, Rahaman N, Colbert S, Fornells-Ambrojo M, et al. The Lambeth Early Onset (LEO) Team: randomised controlled trial of the effectiveness of specialised care for early psychosis. British Medical Journal. 2004;329(Nov):1067.
11. Gafoor R, Nitsch D, McCrone P, Craig TKJ, Garety PA, Power P, et al. Effect of early intervention on 5-year outcome in non-affective psychosis. British Journal of Psychiatry. 2010;196 372–6.
12. McCrone P, Craig TKJ, Power P, Garety PA. Cost-effectiveness of an early intervention service for people with psychosis. British Journal of Psychiatry. 2010;196:377-82.
13. Mihalopoulos C, McGorry PD, Carter RC. Is phase-specific, community-oriented treatment of early psychosis an economically viable method of improving outcome? Acta Psychiatr Scand. 1999 Jul;100(1):47-55.
14. Phillips L, Cotton SM, Mihalopoulos C, Shih S, Yung AR, Carter R, et al. Cost implications of specific and non-specific treatment for young persons at ultra high risk of developing a first episode of psychosis. Early Intervention in Psychiatry. 2009;3(1):28-34.
15. Valmaggia LR, McCrone P, Knapp M, Woolley JB, Broome MR, Tabraham P, et al. Economic impact of early intervention in people at
high risk of psychosis. Psychol Med. 2009;39:1617–26.

McGorry makes me ashamed to Australian and ashamed to be a psychiatrist.

One has to wonder why Dr. Allen Francis, a retired former academic psychiatrist from the USA, would insert such an idiosyncratic, highly personalised critique of Australia’s Mental Health Reform into the blogosphere. Perhaps the title “DSM V in Distress” gives us a clue. A more accurate title may have been “Dr Allen Francis in Distress over DSM”. Dr. Francis was the chair of the previous (4th) edition of the American Psychiatric Association’s classification system of mental disorders, the DSM. He is well known to be seriously unhappy with the way his successors are carrying out their task and has taken aim at one of their candidates for inclusion, the subthreshold stage of psychotic illness. In a quixotic adventure of his own, he has had a dramatic tilt at a windmill of quite a different kind; the mental health policy of another country. We have been caught in a reckless crossfire. Flattering to deceive, Dr. Francis seems to be totally unaware of the facts concerning recent progress in Australia. Here is the background to and the essential elements of Australia’s mental health reform package.

The Australian Context and The Facts of the Reforms

Mental health reform was a key element in the Australian Government’s Health and Hospitals Reform Commission, chaired by Dr. Christine Bennett, whose report was handed down in 2009. This process combed through the evidence base and selected 14 areas for action in mental health. Top of this list were new community based services for young people and the scaling up of the EPPIC model for first episode psychosis. Over the course of the next 12 months and through an election campaign, mental health reform received strong and unprecedented support from across the Australian community, all sides of politics and a uniquely cohesive mental health sector. The re-elected Labor government made a commitment to enact this reform in its second term and embarked on a further wave of community consultation. I was asked to join an Expert Working Group on Mental Health to advise the new Minister for Mental Health, the Hon. Mark Butler, along with many other leaders from the mental health and related sectors. The ultimate reform package however was decided upon by the government and has received unprecedented support from the mental health sector and the Australian community. The Mental Health Council of Australia, the peak body representing the sector nationally, is in full support. The reform covers many aspects of mental health care, not only youth and early intervention, and is the result of a national team effort, not naïve charisma, spin doctoring or a national snake oil scheme. To imply such is not only to reveal ignorance of the facts but is patronising and disrespectful to the Australian community, to the Government and indeed all sides of Australian politics, to the mental health sector, and to those most directly affected by mental ill health who desperately depend upon this investment.

Far from charisma-based reform, this is progress driven by unacceptable levels of unmet need and based upon the best available evidence. Its focus is spread across all stages of illness and the total investment adds up to $2.2bn over 5 years. The largest single allocation of over $500m is actually devoted to those with severe and enduring mental illness.

The $400m focused on youth mental health and early psychosis has little to do with prevention and nothing to do with the “psychosis risk” windmill that Dr Francis is attacking. It has everything to do with the fact that young people bear the major burden for onset of mental disorders with 75% of these appearing before the age of 25 years (25% before age 12 and 50% between 12 and 25). Young people also have the highest prevalence of any group yet the worst access to care by far. So it is treatment needs not prevention that is driving this aspect of our national reforms.

Approximately $200m is to be spent on Australia’s highly successful “headspace” initiative. This will mean that young Australians aged between 12 and 25 years will have access to 90 youth-friendly portals or one-stop shops where stigma-free and holistic mental health care will be available. Up to 100,000 young people will eventually benefit. Commenced in 2006 and currently operating successfully in 30 sites, this enhanced primary care model has started to lift the proportion of young people with diagnosable mental and substance use disorders who receive any kind of mental health care from the basement level of 25% (13% for young men). The type of help on offer ranges from information and support through specialised forms of counselling and psychological interventions and access to youth friendly GPs, and in some sites to psychiatrists as needed. All forms of mental ill-health are eligible and the model has no specific connection to psychosis or subthreshold psychosis/psychosis risk.

The $200m allocated to scale up the EPPIC model around Australia is to implement a model of care developed in Melbourne 20 years ago. It was a response to the fact that, even when young people developed clearcut psychotic illness, where the diagnosis of first episode psychosis was in no doubt, long treatment delays, often for years, occurred during which their lives and futures were seriously damaged. Furthermore when they did enter treatment it was provided in facilities geared to the needs of much older adults with severe and disabling illnesses. The result was poor engagement, poor recovery and secondary trauma in many cases. The EPPIC model, or versions thereof, has now been adopted successfully in hundreds of centres around the world, and across the board in several countries, including England, Canada, the Netherlands, and other parts of Western Europe, Asia and even in the State of Oregon in the USA. The International Early Psychosis Association has held 7 large and successful conferences all over the world and the field has generated large volumes of evidence and an international group of experienced experts in early psychosis.
Consequently, there is very good evidence now that EI for first episode psychosis is more humane, effective, and highly cost-effective. So Australia is hardly being reckless in belatedly implementing its own innovation, some 10 years after England and many other parts of the world have done so. This aeroplane took off years ago. Dr. Francis like other critics of early intervention in psychiatry seeks to confuse the treatment of first episode psychosis with efforts to intervene at an earlier stage, the so-called subthreshold stage or the “ultra-high risk” stage. The latter issue has nothing to do with the Australian reforms which are an overdue catch up/scale up effort in relation to EPPIC, and an essential and welcome response to huge levels of unmet need in the case of headspace and youth mental health more broadly. Finally, unlike in the US health care system, these models of care are guided by young people themselves and their families, not dominated by medication, and are heavily influenced and respectful of the value of psychosocial care, which in our system is covered within our system of universal health insurance.

Psychosis Risk

Turning to the question of psychosis risk and the ultra-high risk (UHR) mental state that Prof Alison Yung and I described and operationalised over 15 years ago, this is an important frontier for mental health care. Personally, I am not concerned whether it enters the DSM V or not, and indeed believe that there may well be a better way via a much broader spectrum clinical staging approach to address the clinical needs of these young people (which I have described elsewhere (McGorry et al 2010)). There may be a better way through this strategy to resolve anxieties about “false positives” since other diagnostic outcomes are included with many advantages, especially in relation to risk benefit considerations. The young people who do meet the current UHR criteria we defined for the ultra-high risk (UHR) mental state are distressed by symptoms of anxiety, depression and low grade or subthreshold psychotic symptoms. Their ability to function at school or work is substantially impaired and they have cognitive impairments. They are seeking and in need of help and treatment and are certainly not “non-patients” by any measure. They also have 200-400 times the risk of the normal population of developing a sustained psychotic disorder. It is true that the around two thirds will not in fact follow this path. These figures are similar to but more pronounced than the level of risk that someone with impaired glucose tolerance possesses for developing frank diabetes. There is no sense that interventions such as information, diet and exercise should be withheld from such people. Why a double standard? Why cannot young people in need of care not be provided with information on the level of risk, the things they can do to reduce the risk and the care they need for their current problems. Especially when this appears to reduce the risk of psychosis? The evidence that my colleagues and I and other groups has assembled through our research clearly shows that antipsychotic medications are not necessary or indicated at this stage and that psychosocial treatments and even fish oil is sufficient as first line. The metanalysis of Preti et al (2010) shows that the transition rates to frank psychosis can be reduced from around 30% to 10% at least in the short term. Our own latest research also shows that the initial level of distress and functional impairment also improves greatly with conservative psychosocial care. These facts are enshrined in international clinical practice guidelines published in 2005. We haven’t changed our approach merely firmed it up with additional research.

It may be true and indeed it is already that untrained and unregulated practitioners in unregulated settings will still inappropriately prescribe for such patients. The best way to prevent this is to allow such patients to enter more specialised youth mental health settings especially where program and guideline fidelity to treatments can be audited. So while the UHR or psychosis risk concept was in no way a driver of the headspace and EPPIC reforms, the concerns that Dr. Francis expresses regarding the potential harms that may befall UHR patients, notably inappropriate medication and stigma will be much less likely. In the USA even without the UHR concept entering the DSMV and in the absence of any stream of care for early psychosis or youth mental health there is widespread inappropriate use of medication in such patients. This stage of illness will be a key focus for ongoing research to better define the range and sequence of interventions that will be safest and most helpful.

Reform and Its Challenges
As Naomi Oreskes and Eric Conway illustrates in their compelling book “Merchants of Doubt”, evidence-based progress is not only hard won but can be undermined and delayed by the misuse of scientific arguments in support of vested interests of various kinds. She uses the examples of the link between cigarette smoking and cancer and also climate change. While not all resistance to change is so poorly motivated, vested interests and hidden agendas of other kinds can still delay the implementation of evidence based advances. Recognition of the barriers in the path of implementation of new knowledge has led to a whole new area of scientific endeavour known as implementation science and translational research. In Australia, the scaling up of an Australian innovation, early intervention for psychosis, has been delayed by this dynamic. It is not just a matter of reasonable scientific conservatism, since such reactions have not surfaced in relation to other aspects of reform in mental health over the past 20 years. With the Government’s recent budget announcements, we appear to have crossed a Rubicon in Australia, and the challenge is now high fidelity implementation strategies buttressed by rigorous health services research to measure the impact and outcomes of the reform. Early psychosis care with its vital focus on minimising treatment delays for first episode psychosis and guaranteeing holistic biopsychosocial care during the critical years post diagnosis is the best buy in mental health reform. The aeroplane left the ground 15 -20 years ago. EI for first episode psychosis is feasible now, not decades down the track as suggested by Dr. Francis. Far from labelling Australia as reckless, the Director of the National Institute for Mental Health (NIMH) in Washington DC, Dr. Tom Insel, recently stated at a national workshop on mental health research hosted by the NHMRC in Canberra, that Australia was a decade ahead of the US in research, clinical care and reform in early intervention for psychosis and other forms of mental ill-health in young people. We must ensure that the benefits of this progress to hundreds of thousands of Australians are not undermined by merchants of doubt with other agendas.

References:

McGorry PD, Nelson B, Goldstone S, Yung AR. Clinical staging: a heuristic and practical strategy for new research and better health and social outcomes for psychotic and related mood disorders. Can J Psychiatry. 2010;55(8):486-497.
McGorry P. Risk syndromes, clinical staging and DSM V: new diagnostic infrastructure for early intervention in psychiatry and schizophrenia. Schizophrenia Research. 2010; 120: 49 – 53.
Preti A, Cella M. Randomized-controlled trials in people at ultra high risk of psychosis: a review of treatment effectiveness. Schizophrenia Research. 2010;123(1):30-36.
Oreskes N. and Conway E.M. Merchants of Doubt. Bloomsbury Press. NewYork. 2010

One has to wonder why Dr. Allen Francis, a retired former academic psychiatrist from the USA, would insert such an idiosyncratic, highly personalised critique of Australia’s Mental Health Reform into the blogosphere. Perhaps the title “DSM V in Distress” gives us a clue. A more accurate title may have been “Dr Allen Francis in Distress over DSM”. Dr. Francis was the chair of the previous (4th) edition of the American Psychiatric Association’s classification system of mental disorders, the DSM. He is well known to be seriously unhappy with the way his successors are carrying out their task and has taken aim at one of their candidates for inclusion, the subthreshold stage of psychotic illness. In a quixotic adventure of his own, he has had a dramatic tilt at a windmill of quite a different kind; the mental health policy of another country. We have been caught in a reckless crossfire. Flattering to deceive, Dr. Francis seems to be totally unaware of the facts concerning recent progress in Australia. Here is the background to and the essential elements of Australia’s mental health reform package.

The Australian Context and The Facts of the Reforms

Mental health reform was a key element in the Australian Government’s Health and Hospitals Reform Commission, chaired by Dr. Christine Bennett, whose report was handed down in 2009. This process combed through the evidence base and selected 14 areas for action in mental health. Top of this list were new community based services for young people and the scaling up of the EPPIC model for first episode psychosis. Over the course of the next 12 months and through an election campaign, mental health reform received strong and unprecedented support from across the Australian community, all sides of politics and a uniquely cohesive mental health sector. The re-elected Labor government made a commitment to enact this reform in its second term and embarked on a further wave of community consultation. I was asked to join an Expert Working Group on Mental Health to advise the new Minister for Mental Health, the Hon. Mark Butler, along with many other leaders from the mental health and related sectors. The ultimate reform package however was decided upon by the government and has received unprecedented support from the mental health sector and the Australian community. The Mental Health Council of Australia, the peak body representing the sector nationally, is in full support. The reform covers many aspects of mental health care, not only youth and early intervention, and is the result of a national team effort, not naïve charisma, spin doctoring or a national snake oil scheme. To imply such is not only to reveal ignorance of the facts but is patronising and disrespectful to the Australian community, to the Government and indeed all sides of Australian politics, to the mental health sector, and to those most directly affected by mental ill health who desperately depend upon this investment.

Far from charisma-based reform, this is progress driven by unacceptable levels of unmet need and based upon the best available evidence. Its focus is spread across all stages of illness and the total investment adds up to $2.2bn over 5 years. The largest single allocation of over $500m is actually devoted to those with severe and enduring mental illness.

The $400m focused on youth mental health and early psychosis has little to do with prevention and nothing to do with the “psychosis risk” windmill that Dr Francis is attacking. It has everything to do with the fact that young people bear the major burden for onset of mental disorders with 75% of these appearing before the age of 25 years (25% before age 12 and 50% between 12 and 25). Young people also have the highest prevalence of any group yet the worst access to care by far. So it is treatment needs not prevention that is driving this aspect of our national reforms.

Approximately $200m is to be spent on Australia’s highly successful “headspace” initiative. This will mean that young Australians aged between 12 and 25 years will have access to 90 youth-friendly portals or one-stop shops where stigma-free and holistic mental health care will be available. Up to 100,000 young people will eventually benefit. Commenced in 2006 and currently operating successfully in 30 sites, this enhanced primary care model has started to lift the proportion of young people with diagnosable mental and substance use disorders who receive any kind of mental health care from the basement level of 25% (13% for young men). The type of help on offer ranges from information and support through specialised forms of counselling and psychological interventions and access to youth friendly GPs, and in some sites to psychiatrists as needed. All forms of mental ill-health are eligible and the model has no specific connection to psychosis or subthreshold psychosis/psychosis risk.

The $200m allocated to scale up the EPPIC model around Australia is to implement a model of care developed in Melbourne 20 years ago. It was a response to the fact that, even when young people developed clearcut psychotic illness, where the diagnosis of first episode psychosis was in no doubt, long treatment delays, often for years, occurred during which their lives and futures were seriously damaged. Furthermore when they did enter treatment it was provided in facilities geared to the needs of much older adults with severe and disabling illnesses. The result was poor engagement, poor recovery and secondary trauma in many cases. The EPPIC model, or versions thereof, has now been adopted successfully in hundreds of centres around the world, and across the board in several countries, including England, Canada, the Netherlands, and other parts of Western Europe, Asia and even in the State of Oregon in the USA. The International Early Psychosis Association has held 7 large and successful conferences all over the world and the field has generated large volumes of evidence and an international group of experienced experts in early psychosis.
Consequently, there is very good evidence now that EI for first episode psychosis is more humane, effective, and highly cost-effective. So Australia is hardly being reckless in belatedly implementing its own innovation, some 10 years after England and many other parts of the world have done so. This aeroplane took off years ago. Dr. Francis like other critics of early intervention in psychiatry seeks to confuse the treatment of first episode psychosis with efforts to intervene at an earlier stage, the so-called subthreshold stage or the “ultra-high risk” stage. The latter issue has nothing to do with the Australian reforms which are an overdue catch up/scale up effort in relation to EPPIC, and an essential and welcome response to huge levels of unmet need in the case of headspace and youth mental health more broadly. Finally, unlike in the US health care system, these models of care are guided by young people themselves and their families, not dominated by medication, and are heavily influenced and respectful of the value of psychosocial care, which in our system is covered within our system of universal health insurance.

Psychosis Risk

Turning to the question of psychosis risk and the ultra-high risk (UHR) mental state that Prof Alison Yung and I described and operationalised over 15 years ago, this is an important frontier for mental health care. Personally, I am not concerned whether it enters the DSM V or not, and indeed believe that there may well be a better way via a much broader spectrum clinical staging approach to address the clinical needs of these young people (which I have described elsewhere (McGorry et al 2010)). There may be a better way through this strategy to resolve anxieties about “false positives” since other diagnostic outcomes are included with many advantages, especially in relation to risk benefit considerations. The young people who do meet the current UHR criteria we defined for the ultra-high risk (UHR) mental state are distressed by symptoms of anxiety, depression and low grade or subthreshold psychotic symptoms. Their ability to function at school or work is substantially impaired and they have cognitive impairments. They are seeking and in need of help and treatment and are certainly not “non-patients” by any measure. They also have 200-400 times the risk of the normal population of developing a sustained psychotic disorder. It is true that the around two thirds will not in fact follow this path. These figures are similar to but more pronounced than the level of risk that someone with impaired glucose tolerance possesses for developing frank diabetes. There is no sense that interventions such as information, diet and exercise should be withheld from such people. Why a double standard? Why cannot young people in need of care not be provided with information on the level of risk, the things they can do to reduce the risk and the care they need for their current problems. Especially when this appears to reduce the risk of psychosis? The evidence that my colleagues and I and other groups has assembled through our research clearly shows that antipsychotic medications are not necessary or indicated at this stage and that psychosocial treatments and even fish oil is sufficient as first line. The metanalysis of Preti et al (2010) shows that the transition rates to frank psychosis can be reduced from around 30% to 10% at least in the short term. Our own latest research also shows that the initial level of distress and functional impairment also improves greatly with conservative psychosocial care. These facts are enshrined in international clinical practice guidelines published in 2005. We haven’t changed our approach merely firmed it up with additional research.

It may be true and indeed it is already that untrained and unregulated practitioners in unregulated settings will still inappropriately prescribe for such patients. The best way to prevent this is to allow such patients to enter more specialised youth mental health settings especially where program and guideline fidelity to treatments can be audited. So while the UHR or psychosis risk concept was in no way a driver of the headspace and EPPIC reforms, the concerns that Dr. Francis expresses regarding the potential harms that may befall UHR patients, notably inappropriate medication and stigma will be much less likely. In the USA even without the UHR concept entering the DSMV and in the absence of any stream of care for early psychosis or youth mental health there is widespread inappropriate use of medication in such patients. This stage of illness will be a key focus for ongoing research to better define the range and sequence of interventions that will be safest and most helpful.

Reform and Its Challenges
As Naomi Oreskes and Eric Conway illustrates in their compelling book “Merchants of Doubt”, evidence-based progress is not only hard won but can be undermined and delayed by the misuse of scientific arguments in support of vested interests of various kinds. She uses the examples of the link between cigarette smoking and cancer and also climate change. While not all resistance to change is so poorly motivated, vested interests and hidden agendas of other kinds can still delay the implementation of evidence based advances. Recognition of the barriers in the path of implementation of new knowledge has led to a whole new area of scientific endeavour known as implementation science and translational research. In Australia, the scaling up of an Australian innovation, early intervention for psychosis, has been delayed by this dynamic. It is not just a matter of reasonable scientific conservatism, since such reactions have not surfaced in relation to other aspects of reform in mental health over the past 20 years. With the Government’s recent budget announcements, we appear to have crossed a Rubicon in Australia, and the challenge is now high fidelity implementation strategies buttressed by rigorous health services research to measure the impact and outcomes of the reform. Early psychosis care with its vital focus on minimising treatment delays for first episode psychosis and guaranteeing holistic biopsychosocial care during the critical years post diagnosis is the best buy in mental health reform. The aeroplane left the ground 15 -20 years ago. EI for first episode psychosis is feasible now, not decades down the track as suggested by Dr. Francis. Far from labelling Australia as reckless, the Director of the National Institute for Mental Health (NIMH) in Washington DC, Dr. Tom Insel, recently stated at a national workshop on mental health research hosted by the NHMRC in Canberra, that Australia was a decade ahead of the US in research, clinical care and reform in early intervention for psychosis and other forms of mental ill-health in young people. We must ensure that the benefits of this progress to hundreds of thousands of Australians are not undermined by merchants of doubt with other agendas.

References:

McGorry PD, Nelson B, Goldstone S, Yung AR. Clinical staging: a heuristic and practical strategy for new research and better health and social outcomes for psychotic and related mood disorders. Can J Psychiatry. 2010;55(8):486-497.
McGorry P. Risk syndromes, clinical staging and DSM V: new diagnostic infrastructure for early intervention in psychiatry and schizophrenia. Schizophrenia Research. 2010; 120: 49 – 53.
Preti A, Cella M. Randomized-controlled trials in people at ultra high risk of psychosis: a review of treatment effectiveness. Schizophrenia Research. 2010;123(1):30-36.
Oreskes N. and Conway E.M. Merchants of Doubt. Bloomsbury Press. NewYork. 2010

I would love for someone from EPPIC to explain what "low dose" actually means. I have known two people who have been on FORCED treatment from EPPIC and both were FORCED to take 20 mg of Olanzipine a day. That is the MAXIMUM recommended dose supported by ANY research and you classify this as low dose. The simple fact is that low dose is the latest weapon to try and convince people to take useless medications. Research has clearly demonstrated that the atypicals are no less toxic and no more tolerated than the typical antipsychotics and The Lancet has made very clear that to believe that was simply a marketing propaganda by drug companies. Yet EPPIC continues to advocate that these atypicals are some magical wonder drugs.

I would also like for Patrick McGorry or anyone for that matter to explain how it is that any medication can have antipsychotic properities in it. It is well known that these medications were on the market and in use for 15 YEARS as major tranqullisers BEFORE they labelled them antipsychotics. In order for a drug to have anti psychotic properties, you actually have to have some concept of what psychosis is and what you are wanting to remove. The fact that a person no longer admits to having voices or visions does not mean they are not having them, any more than saying they are means they are.

If you were really interested in preventing and CURING psychosis and preventing young people and for that matter ANYONE from becoming mentally ill and to fully recover, you would look at the Open Dialouge therapy in Western Lapland in Finland, that now has the lowest rates of Schizophrenia anywhere to the point that it is now becoming non existant. They have less than 30% of people with psychosis ever exposed to medication and less than 15% being maintained on it.

As for headspace being some unique and multitreatment service, that is total crap. Headspace policy which is written by McGorry encourages and says that young people as young as 12 should be prescribe anti-depressents against all medical and research advice and support. In fact headspace policy is for any young person with even moderate depression, no matter how young to be given medication and this is actively practiced. There is NO evidence to support such use of medication, infact The Australian Governments Theraputic Goods Administration Guidelines specifically advise against it. All the research shows that there is no clinical benefit for anti-depressents in people under the age of 18, and not even the drug companies have been able to produce such evidence. What it does show is that these drugs while doing nothing to improve the young persons well being do increase the risk of suicide to massive levels and unless the drugs could be proved to cure depression in 100% of young people, even then you would have to question the value of them, given the risks. Headspace offers a total of 12 sessions of counselling and that is reducing to 6 sessions in 2012. Young people who are not fixed in those 12 sessions are told that they are too damaged to ever benefit from counselling or support and are given increased doses of medication and in many cases also prescribed antipsychotics even if they are only depressed. Headspace offers nothing but medication as the first and primary mode of treatment and some very limited couselling services.

NO clinical services are funded via the billions that have been allocated by the government to headspace clinics, that is all funded by other programs, especially medicare, as all the staff bulk bill, be they GP's, Psychologists or the like.

Despite the fact that government legislation allows for people to have up to 18 sessions of psychological treatment in any calander year in exceptional circumstances, headspace policy is that young people are not under ANY circumstances to be offered any more than 12 sessions and anything over 6 is to be discouraged. How that is youth friendly and in line with research I would love to know.

The simple fact is if you wanted to provide young people with access to mental health care there are millions of more cost effective ways it could be done, rather than spending billions of dollars building brand new clinics that do nothing more than dole out medication. We have youth services in every community in Australia and you could easily put a GP in those centre's and have psychologists on staff there. In fact it would be more logical to do that, as it would be a one stop shop for ALL youth services, be they housing, employment, education, training, etc. But no instead they label young people with depression and tell them they need to take medication that will kill for life, even when they are just sad beacuse they broke up with a girl friend or the like. We could easily fund and put psychologists into schools and provide suport to TAFE's and Universities to provide more counselling services. But McGorry is not interested in helping young people, he is more interested in enhancing the interests of his pharmacuetical company friends and being paid by them, by putting the whole population of toxic substances.

If these drugs are as effective as he claims one wonders why he does not simply ask to have them put in the water supply like flouride. Afterll flouride is hardly good for us, but the evidence showed it was better than not using it. The fact is McGorry and his collegues would not be willing to put any of these medications into their bodies.

It also needs to be remembered that McGorry is not and never has been a child or adolescent psychiatrist. He is trained in Adult mental health and is simply trying to force adult mental health treatments onto young people without any regard for how they impact on the developing brain.

There is and always will be a small role to play for medication, but it should not be a first line treatment and people should not be lied to about some brain abnormality, chemical imbalance in the brain, etc, when there never has been any research to support such statements. The simple fact is the ONLY differences shown in brain scans are found AFTER someone has been medicated. You do not diagnose an illness via a pen and paper sitting five feet away from someone and yet that is exactly what psychiatrists do. If you want us to have some respect for what you say, then tell the truth, that is all anyone asks.

http://www.smh.com.au/national/health/aboutturn-on-treatment-of-the-youn...

About-turn on treatment of the young

Amy Corderoy | February 20, 2012

CONCERNS about the overmedication of young people and rigid models of diagnosis have led the architect of early intervention in Australian psychiatry, Patrick McGorry, to abandon the idea pre-psychosis should be listed as a new psychiatric disorder...