More Questions For Professor McGorry Arrive From Australia

I have previously framed a series of questions inviting Professor McGorry to state clearly his current positions on: the accuracy and suitability of attempting to predict psychosis; the types of preventive interventions that he believes are indicated and those (perhaps antipsychotics) that clearly are not; his reaction to a Cochrane report that questions whether prevention has any scientifically proven benefit; the implications that derive from funding preventive services at the expense of continuity of care; and how he expects his Australian experiment in preventive psychiatry to be led and managed. Professor McGorry has replied, eloquently and at length, but has (as feared) carefully avoided answering any of my quite specific questions.

Perhaps the following message I just received from Dr Tad Tietze will help persuade Professor McGorry to address the questions he has so far avoided. Dr Tietze is a psychiatrist who works within the Australian public system. His clear headed assessments on these and other issues can be accessed at the blog he co-runs, Left Flank (http://left-flank.blogspot.com/).

Dr Tietze writes, "In Australia the controversy over early intervention in psychosis became part of a national policy debate after the Gillard Government dramatically shifted funding priorities towards the “EPPIC” and “Headspace” youth early intervention models put forward by Professors Pat McGorry and Ian Hickie. Formerly staunch critics of the government, the two were invited onto a select expert panel to inform policy, a move seen as bypassing normal advisory channels. Despite the overall increase in mental health funding in May’s Budget being much less than they’d advocated for, they’ve since been full of praise for the hundreds of millions poured into their preferred interventions (Headspace being a government-funded corporate entity on whose Board the two sit).

McGorry bases his early intervention “staging” model on the belief that the DSM classification system has failed. He sees his ideas as part of a “scientific revolution” to introduce a new paradigm in psychiatry, of the sort described by philosopher Thomas Kuhn. But the early intervention model seems to me to simply exacerbate the problems in the existing biomedical approach that dominates psychiatry.

Worryingly, it has become national policy despite having little evidence behind it. Hickie and McGorry have made strong claims as to population health benefits, yet the EPPIC and Headspace centres are not population interventions but places that self-selected patients seek help around relatively non-specific problems.

There is continuing controversy over whether the EPPIC model should include treatment of those at “ultra high-risk” (UHR) of psychosis, despite the lack of evidence for effective interventions and growing concern about risks associated with antipsychotic drugs. McGorry has recently been criticized for pursuing a trial of quetiapine in UHR young people, even after the weight of scientific opinion had shifted against such research. Under pressure, the trial has since been abandoned and McGorry himself ruled out further antipsychotic trials, at least for now.

Interestingly, I saw McGorry speak as part of a panel of early intervention experts at the ECNP conference in Paris last month. Other experts in the field were uniformly much more modest in their claims than he and Hickie have been in public. They admitted that at least 70 percent of the UHR people never transition to psychosis, that there are no proven preventative interventions, and that those who do transition may not even be the same group as those who end up with chronic psychosis.

Adding to the backlash have been Budget cuts - supported by McGorry and Hickie - to the “Better Access” psychology scheme because its popularity was driving up government expenditure. It is clear that in a world of limited resources, paying for prevention reduces funding for treatment.

These controversies led Hickie to write an angry op-ed slamming the critics of early intervention (somehow listing dissenting voices like your own alongside Scientologists!) in the Sydney Morning Herald. In response, I wrote a letter to the editor and expanded it into a blog post looking at the science and politics.

Prior to this McGorry was almost unassailable because of his position as Australian of the Year in 2010, which gave him unparalleled media access to push his views. With some exceptions, leading mental health professionals felt they had to bite their tongues over McGorry’s lack of advocacy for services for chronically ill patients because at least he was putting mental health in the spotlight. Now that the Budget has delivered little for such services, and mental health funding continues to lag overall health expenditure, there has been disappointment and greater questioning of early intervention as a priority.

I am all for innovation, but it would be good if Hickie and McGorry were more willing to admit the lack of evidence for what they have convinced the government to fund - rather than go on the defensive as Hickie did in the Herald. The public debate would be richer for it."

Thank you, Dr Tietze. Very well and truly said. It is past time for Professor McGorry to become less an embattled advocate and more an inclusive and consensus leader, giving just due to the just critiques of his Australian critics and to the diverse mental health needs of Australia.