DSM5 in Distress

The DSM's impact on mental health practice and research

Continuing Controversy On Australia's Mental Health Experiment

Seven questions for Dr McGorry

 

  My concern about Australia's Early Psychosis Prevention and Intervention Centres ( EPPIC) has stirred up strong opinion on both sides. The best defense of the EPPIC program comes from a distinguished researcher in the field, Dr Alison Yung:

  "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.

  However, 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."

  Many Australian opponents of EPPIC are much less sanguine about its reasonableness and the huge and sudden investment it will require. They worry that the delivery of the EPPIC programs on the ground may depart radically from Dr Yung's vision of their proper goals and methods. What will guarantee that EPPIC practitioners will restrict themselves only to well established first break schizophrenic patients- ie, those who are likely to have a low false positive rate, a clear need for treatment, and a fair chance of benefiting from it. EPPIC's could easily slip into a more ambitious interpretation of their "Prevention" mandate- consciously or unconsciously  extending their efforts to the much more uncertain and hazardous terrain of  "psychosis risk syndrome". Opponents request clear guidelines that will limit centers to patients with accurately diagnosed psychotic episodes. They want to be sure that centers cannot decide on their own that prepsychotic individuals are fair game?

 And the issue gets even tougher when translated to the uncertainties of  actual clinical practice. The boundary between "prepsychotic" and "psychotic" is sometimes very fuzzy and much in the eye of the beholder (especially when youngsters are also abusing mind altering drugs, as they so often do). In order to meet eligibility requirements for services, eager clinicians might even have the perverse incentive of prematurely labeling unclear boundary cases as schizophrenic- thus raising the false positive rate and increasing the risks of stigma and harmful treatment. 

  Opponents also have grave concerns about the speed, scope, size, and massive funding of the EPPIC's. They wonder whether it makes sense to leap fairly blindly to an expensive and unproven national prevention model based only on quite limited outcome findings that are subject to different interpretations and may not generalize at all well to the real world.   Would it not be wiser to lay a stronger foundation of research and experience by scaling up in small, steady steps to determine how well the model survives the translation from research to national policy.

  Opponents also worry that patients clearly in need of mental health services that have proven efficacy will be deprived of them because of the misallocation of an enormous budget to an essentially untried prevention project. If (possibly) first break teenagers get enormous funding, how will this reduce the treatment availability down the road for those with clearly established schizophrenia who definitely need help. Is the unproven prevention tail wagging the proven treatment dog?  

 Dr McGorry is the guiding spirit and moving force behind  the EPPIC agenda. His positions on the diagnosis and treatment of "prepsychotic risk"have evolved over the years. It is crucial that the EPPIC programs be crystal clear on their mission, the limits of their purview, and their methods of implementation. It would therefore be extremely helpful to have Dr McGorry provide explicit answers staking out his current positions on the following seven questions:

1) Does Dr McGorry agree with Dr Yung that "psychosis risk syndrome" is an inappropriate and risky target for EPPIC centers and also that it should not be included in DSM 5?

2) Does Dr McGorry agree with Dr Yung that the “Prevention” part of the EPPIC name refers only to secondary prevention (ie, of disability in those already clearly psychotic) and specifically does not include primary prevention for those merely at some theoretical (and fairly low) risk of becoming psychotic in the future?

3) Does Dr McGorry agree with Dr Yung that it is inappropriate to use
antipsychotic medication in treating youngsters with "psychosis risk
syndrome" because of the high false positive rate of the diagnosis and the
devastating side effects of the drugs? And if yes, will Dr McGorry attempt to ensure that EPPIC rules out the use of antipsychotics in those who do not yet have definite and reliably diagnosed psychotic symptoms? 

4) What concrete safeguards will Dr McGorry build into the day to day clinical practice and quality control of the EPPIC program to prevent the overdiagnosis of "prepsychosis" and of schizophrenia and the overuse of antipsychotic medicine?

5) Does Dr McGorry recognize how difficult it would be to scale up a pilot project into a national endeavor- with the attendant risks of mission and practice drift inherent to any huge and unwieldy program? What administrative and oversight structure does he envision?

6) Can Dr McGorry reassure us that the EPPIC centers will not result in a  misallocation of scarce mental health resources by siphoning off funds that would be otherwise be used for proven treatments delivered to those more in need and/or more likely to benefit?

7) What is Dr McGorry's position on the reduction in psychotherapy benefits that appears to be the first consequence of diverting funds  toward EPPIC and away from the rest of mental health services?  What future diversions does he envision?

   On the face of it, Australia's sudden and massive investment in the EPPIC program seems far excessive and decades premature. EPPIC may indeed work, but it represents a huge and reckless bet seemingly based more on  blind faith in one man than on a substantial foundation of research and experience. EPPIC could easily turn out to be a terrible bet- wildly expensive for the gains that can be realized, diverting resources desperately needed elsewhere, and actually causing clinical harm to a substantial minority of users. Before going national, there should be a gradual and extensive proof of concept phase to see if the program works well in non-research settings. At the very least, this would provide an opportunity to identify and attempt to solve the many kinks in implementation that will undoubtedly emerge. EPPIC should have to prove itself step by step rather than receiving a blank check.  

   EPPIC is Dr McGorry's pet project and he will likely have great influence in its design and implementation. Australia needs to know how much Dr McGorry has revised his previous  strong endorsement of primary prevention and whether he now supports Dr Yung's much more conservative position. And even more to the point, the government should reconsider whether to jump into this enormous experiment all at once. It would be far wiser to take one step at a time building on acquired experience and proof that EPPIC translates reasonably well to the real world. 

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

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