Minds at risk
Choosing the right path for adolescent mental health
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When the federal budget was announced in May, mental health funding was boosted by $2.2 billion. Health Minister Nicola Roxon described it as “the largest Commonwealth commitment to mental health services in Australia’s history”.
This included $419.7 million over five years for the expansion of two services for young people championed by Melbourne psychiatrist Professor Patrick McGorry. The number of Headspace centres is set to triple to 90. These centres focus on young people aged 12 to 25 with a range of mild to moderate mental health concerns. The rest of the money will go towards a service – pioneered by McGorry – that is dedicated to catching psychotic illnesses early, at a stage where patients are more likely to respond to the treatment, before friendships unravel and jobs are lost, before the condition progresses and there are significant structural changes in the brain. The Early Psychosis Prevention and Intervention Centre (EPPIC) in Melbourne will be replicated across the country, with the federal government contributing $222.4 million towards 12 new centres.
In the public discussion of mental health within Australia the concept of early intervention has received almost universal praise. Last year, Professor McGorry was honoured with the distinction of Australian of the Year for a career devoted to youth mental health with a particular focus on spotting and treating psychosis. What rarely gets mentioned is that at the heart of his research is a controversial syndrome sparking fierce debate around the world.
The most vocal critic of the syndrome originally known as ‘psychosis risk syndrome’ but now rebranded ‘attenuated psychosis syndrome’ is the American psychiatrist Allen Frances, an emeritus professor at Duke University. Dr Frances chaired the task force behind the current edition of the Diagnostic and Statistical Manual of Mental Disorders, the American bible of mental illness that influences psychiatry around the world.
“Australia’s puzzling infatuation with McGorry’s early intervention may lead it to conduct the largest and most reckless public health experiment ever attempted,” he says. “The country seems to be ignoring three crucial facts: there is simply no available way to accurately identify kids who are really at risk of later psychosis, no effective preventive treatment and the potential medications have extremely harmful side effects. Although the goal of prevention is great, its execution is currently impossible and McGorry’s project is decades premature.”
He adds that there should not be “mass experiments on our children” before we have “a firm grasp of possible unintended consequences”. “Let’s celebrate McGorry’s vision but not follow his recommendations until we have proven the tools work and can be sure that applying them is safe. The resources that would be devoted wastefully to this wild goose chase should be allocated where they are really needed and can do great good – to adequately care for those suffering from clear-cut psychiatric problems that have proven effective treatments.”
Psychosis is an umbrella term, encompassing the early stages of a range of psychotic illnesses, including schizophrenia. About 5300 young Australians each year experience psychosis for the first time. Before the condition reaches full flourish and the patient experiences symptoms such as hearing voices and experiencing delusional thoughts of persecution, mind control, even guilt for causing natural disasters, there are hints of what is budding in the brain. These hints include loss of concentration, growing suspicion about the motives of friends and family, withdrawal from these people and hearing sounds in the head that are not quite voices (such as clicks). When EPPIC first opened in 1988 its focus was on treating young people experiencing their first episode of psychosis, which McGorry says “is clear-cut and the treatment is clear-cut”. But they found EPPIC, which targets those aged 15 to 24, was also being referred young people with warning signs of what was to come: “They had a need for clinical care but there was also a sense they might be at risk of psychosis but we didn’t know what extent that risk was at first.”
Research followed, as McGorry and other researchers in Australia and around the world tried to pin down the warning signs so individuals could be treated without delay if it looked like they were headed for psychosis. ‘Psychosis risk syndrome’ was born and has now developed to the point where it is being considered for inclusion as a mental illness in its own right in the next edition of the Diagnostic and Statistical Manual of Mental Disorders.
Additions to and removals from the manual naturally spark interest because of the power such changes have in shaping our very sense of normality and abnormality, health and disease. When homosexuality was erased from its pages during the 1970s, it was a pivotal moment for gay liberation. When adjustments were made to the criteria for attention deficit hyperactivity disorder in the 1990s, these contributed to an epidemic of children being diagnosed with the condition and medicated for it. In the latest review of the tome in preparation for its fifth edition the inclusion of the diagnosis under the newer name attenuated psychosis syndrome has proven to be one of the most controversial proposals.
One of the reasons for concern is the high rate of false positives possible under the diagnostic criteria of the syndrome. Early studies showed that about 40% of individuals who meet the criteria for this syndrome would go on to develop psychosis; more recently, this figure has been revised down to 20%. Critics argue that in the hands of inexpert clinicians the true strike rate may end up being more like 10%.
The doubts have extended across the Atlantic. Last August an editorial in the Journal of Mental Health highlighted the dangers of stigma this diagnosis threatens. “It is a bit like telling ten people with the common cold that they are ‘at risk for pneumonia syndrome’ when only one is likely to get the disorder,” argued Til Wykes, professor of clinical psychology and rehabilitation at King’s College London. She also noted, in the editorial co-written by Felicity Callard, senior research fellow at King’s College London, that the idea early treatment will provide benefits and avert some of the toxic effects of psychotic experience had some validity “but it is not, as yet, based on sound evidence”.
McGorry says he does not mind if the syndrome is included in the manual or not, but he “won’t resile from the fact that we were the ones to [develop] the idea and it has been a major advance in psychiatry”. He points out that even if a minority of those identified with the syndrome go on to develop psychosis, this is still a rate 200 to 400 times greater than in the general population.
Perhaps the most controversial aspect of the debate is whether this new diagnosis will prove a marketing tool for drug companies. Dr Frances’ greatest concern is that the syndrome will be a “new and inviting target” for the prescription of antipsychotic medications, which he says are already overused in children. “These drugs have the frequent and disastrous side effect of inducing a huge weight gain, with all the life-shortening medical complications that follow.”
Last September the New York Times reported on the case of a Louisiana boy who had been prescribed antipsychotics at the age of 18 months to deal with severe temper tantrums. The article cited Food and Drug Administration figures showing more than 500,000 American children and adolescents were taking these powerful medications. It was also noted that poor children were the most likely to be given drugs rather than therapy. A study by Rutgers University found that children from low-income families were four times as likely to receive antipsychotics as their privately insured counterparts.
But what about in Australia? Would our mental health services be as vulnerable to a new diagnosis offering greater opportunities for medicating young people? Martin Whitely believes so. The former high school teacher, who now represents Labor in the West Australian parliament, made a name for himself campaigning against the over-prescription of medication for children suffering attention deficit hyperactivity disorder. He now has his sights on Headspace and EPPIC, as he is concerned about their guidelines, which allow for medicating teenagers with antidepressants. “There is this creep of ever-expanding use of psychotropic medicine on younger and younger children and it doesn’t have a solid evidence base.”
Whitely argues that the services are being expanded dramatically without adequate public scrutiny of methods, and that the media “has been a real cheer squad” for the programs simply because no one is going to campaign against putting mental health on the agenda, or indeed against early intervention. “We’re all time poor, and we don’t have the time to bury down into the detail of things. When you get someone with an incredibly high profile like Patrick McGorry, and let’s be honest a lot of that comes from his Australian of the Year status, politicians and the media tend to go, ‘I’ll trust him and he must know what he’s talking about.’”
He fears that official recognition of attenuated psychosis syndrome could lead to more young people being medicated with antipsychotics, especially in the hands of less experienced doctors. “Because these things are so subjective, if you leave the door slightly ajar, a whole bunch of quacks will rush through and there will be an explosion and soon it will be normal.”
It is a Wednesday afternoon in Hall Ward, an acute psychiatric ward at the Children’s Hospital in Westmead, Sydney. On the door of the ward a notice reads: “STOP. No junk food or soft drink allowed on ward.” Inside a boy is asking for afternoon tea already – and no, he’s not interested in the mandarins sitting on the bench in the games room. The healthy food and the exercise equipment out in the courtyard are there for a reason, to balance out the weight gain from the antipsychotics some of the adolescents here will be placed on.
The clinical director, Dr Lucy Chapman, says she takes children off medication as often as she puts them on it. “I haven’t seen a drug company rep since I’ve worked here. Ever.” She is reluctant to hand out medications or diagnoses to young people at a formative time in their development.
However, she does see a role for antipsychotics in helping some young people with serious mental illness, along with cognitive behavioural therapy and skill building, especially if it keeps them out of hospital. “It’s hard enough being a kid or teenager normally, let alone if you’re being tormented by hearing voices [and] you don’t know where they’re coming from, or [you are sure] that the family you love is against you.” She says it is worth relieving that distress. She also does not believe that general practitioners in Australia hand out psychotropic medication to young people more readily than specialists: “GPs are more worried about prescribing psychotropic medication to children in Australia.”
Arguably, it is the very expansion of mental health services such as Headspace and EPPIC that will mean the fears of Martin Whitely are less likely to be realised, and that young people suffering mental illness in Australia will be protected from the fate of so many adolescents in America. Publicly funded mental health services that allow young people to access a suite of treatments, including therapy, regardless of the wealth of their parents, decrease the likelihood of medication becoming the first, or only, intervention.
Professor McGorry has made it clear, repeatedly, both in his research and in public statements, that he does not believe antipsychotic medication should be used as a first resort for young people at risk of developing psychosis. Instead he leans towards cognitive behavioural therapy, supportive counselling, increased consumption of omega-3 fatty acids, as well as medication in cases where other conditions such as depression may be present.
But there is a caveat. He hints that his position could change with further clinical trials to determine whether, and when, antipsychotic medication is most useful. “We reserve the right, because it is a new area, to study alternative treatments.” And there is no question that antipsychotics are an aspect of treatment at EPPIC.
The future of attenuated psychosis syndrome remains in limbo. In the same month the Australian government confirmed its support for early intervention through its allocations in the federal budget, the American Journal of Psychiatry published an article weighing in on the debate about the inclusion of the diagnosis in the next Diagnostic and Statistical Manual of Mental Disorders, due for publication in May 2013.
Members of the task force itself remain divided. Psychiatrist William Carpenter is in favour: he emphasises the often devastating course psychotic disorders take and asserts that the best of hope minimising damage resides in early detection and intervention. Its inclusion in the manual “can focus attention on this syndrome and stimulate the creative acquisition of new knowledge that may be life altering for afflicted persons,” he writes. “There is little reason to rely on less specific diagnostic categories, such as anxiety and depression, if we can reliably give patients and their families a more informative picture of their situation.”
Another member of the task force, Jim van Os, sits on the other side of the debate. He argues that the best way forward is investment in public health measures for the population as a whole “rather than in attempts to diagnose risk in individuals for what will be a low incidence of future psychosis”. He cites accessible services, diagnostic training for primary care workers and community awareness as important factors in making the pathway to getting help easier.
As debate continues it illuminates questions about psychiatry that go well beyond the science. How hard should psychiatrists work to outfox the pharmaceutical industry? How much should science bend to protect itself from abuse?
On this last question, McGorry is absolutely clear: “We can’t have research constrained by emotional or ideological arguments. My view is if it’s valid, it’s valid.”