Psychology Today – August 18, 2011
by Allen Frances, M.D.
Psychiatry cannot promise more than it can deliver.
The great news is that Professor McGorry has recently renounced the relevance of psychosis risk syndrome in the current practice of clinical psychiatry. He has done so in two separate and dramatic ways: 1) by withdrawing his support for the inclusion of psychosis risk in DSM 5; and 2) by promising not to include it as a target in Australia’s massive new experiment in early intervention. Psychosis risk syndrome is an extremely promising topic for ongoing research, but it is not nearly ready for current clinical application and if introduced prematurely could cause disastrous unintended consequences.
Professor McGorry’s sharp about face on both fronts could well be a wonderful double game changer. He is by far the most powerful psychiatrist in the world and an absolutely brilliant politician. Leveraging his unique stature as 2010 ‘Australian Of The Year,’ McGorry has succeeded in gaining the support of all the major Australian parties in the funding of a large and much needed investment in the country’s mental health. His new caution on psychosis risk will influence others to be less venturesome in prematurely promoting this potentially dangerous diagnostic proposal.
But a dark cloud surrounds the silver lining of having one psychiatrist in a position of almost unopposed influence. Professor McGorry has developed the messianic blind spot that is so common in visionary prophets. His zeal has made him an unreliable evaluator of scientific evidence, allowing him to defend absolutely indefensible positions with the convincing, but inaccurate, force of a true believer. A review of Professor McGorry’s public statements shows his willingness to ignore any evidence contrary to his belief, to change stated views back and forth when he regards this to be necessary or convenient, and to unfairly attack those who point out the fallacies and inconsistencies in his comments. His are the skills of a prophet and rainmaker, not those of a policy maker or a program developer or a sober reviewer of scientific evidence.
The most telling example of the McGorry blind spot was his ready dismissal of a recent Cochrane review that has discredited his extravagant claims for early intervention. This independent, systematic, comprehensive, and rigorous review of the scientific literature concluded there was insufficient scientific evidence to support McGorry’s grand assertions that early intervention programs promote enduring change and can reduce the lifelong burden and cost of illness. Early intervention does seem to be helpful temporarily while it is being provided, but does not seem to have any lasting impact on the course or cost of illness once it is stopped.
So, the Cochrane group lines up on one side and McGorry lines up on the other. Who to believe? The Cochrane group is widely credited for its impartiality and esteemed for its expertise in all aspects of scientific review. Its reports are considered a gold standard, exerting great influence on state of the art, evidence based medical practice throughout the world, particularly in Great Britain. One might expect that Cochrane’s stainless reputation would daunt a person even of Professor McGorry’s extraordinary power and blind conviction. But no. When the Cochrane report disappoints his expectations and fails to nourish his prejudices, McGorry feels no hesitation in attacking it, criticizing its methodology, and dismissing its discouraging conclusions. His rebuttal of the Cochrane group consists only of his personal endorsement of early intervention accompanied by the blithe (but empty) claim that it has strong supporting evidence. As far as McGorry is concerned, Cochrane be damned. Such idiosyncratic evaluation of scientific evidence cannot be trusted as a sensible foundation for mental health policy.
This is part of a pattern, not one isolated and exceptional instance of blind spot. Whenever contradicted, Professor McGorry attacks the motives of the messenger rather than providing any reasoned rebuttal to the message. His skill in the parry/thrust of the political sound bite is matched by an unwillingness to subject his views to anything resembling fact based discussion. When I expressed doubts about Dr McGorry’s excessive claims for his prevention model, he twisted my concerns to suggest that somehow I was defending the traditional US model of care against his innovative Australian model. This silly and totally incorrect attempt at diversion had not the slightest relevance to my two real motivations. Primary is the fear that by ambitiously overselling itself, psychiatry does a disservice to its patients and harm to its core mission and credibility. I believe strongly that scarce mental health resources must be judiciously spent to provide care for those who clearly need them- with continuity that starts with the first episode and lasts until they have either become well enough to do without or are dead. I therefore object to squandering vast resources upfront on those who may not need them using what are premature and still unproven methods. My secondary motivation (now somewhat assuaged by McGorry’s recanting, if he sticks to it) is the fear that the recognition of psychosis risk syndrome as an official diagnosis in DSM 5 and/or as a target in EPPIC programs will result in unnecessary stigma for the misidentified and dangerous off label overprescription of antipsychotic drugs.
McGorry has also tried to stifle his Australian critics- consistently evading their well reasoned and empirically supported arguments with the false innuendo that their motivation is simply to protect turf. His distraction technique employs catchy phrases (“Merchants of doubt do no favours for people with mental illnesses”) and dismissive insults (critics are a ‘cadre’). This so called ‘cadre’ of ‘merchants of doubt’ happen to be highly respected colleagues who are doing precisely what needs to be done- challenging McGorry in an open discussion of his excessive claims and of his idiosyncratic take on the literature. They are trying to protect Australia from blindly making a risky public health bet promoted by a stubborn ‘true believer’ who refuses to engage in meaningful dialog and cannot be unconvinced even by clearest evidence contradicting his personal belief system. It is crucial that scientists and policy makers always be honest and skeptical ‘merchants of doubt’ -not joiners in a parade of the credulous marching blindly off a cliff. McGorry needs to meet opposition with facts and rational debate, not innuendo and insult.
This brings me to my immediate purpose here. Let’s all get off the personal and focus instead on the issues. Below are seven questions that beg for Dr McGorry’s immediate public response. No evasion or questioning of my motivation is called for- just straight answers to simple questions. It will be useful for Professor McGorry to respond for the record now, before Australia’s makes final the terms of its much needed and awaited investment in mental health.
Question 1) Please spell out on what scientific basis you have dismissed the findings of the Cochrane report and indicate why Australia should base policy decisions on your personal interpretation of these data rather than on Cochrane’s more objective and systematic approach?
Question 2) What will be your role in establishing the goals and in directing the implementation of Australia’s early intervention programs and what protections are in place to ensure that opposing voices and interpretations get a fair hearing? Who else will be involved in the governance of these programs and how will they be selected?’
Question 3) Can you now state with certainty that the newly
funded early psychosis intervention programs will be restricted exclusively to those who are already diagnosed with definite psychosis and will definitely not include individuals deemed to be only at some increased risk for future psychosis?
Question 4) Do you now agree that it is inappropriate to prescribe antipsychotic medication for psychosis risk except under the close supervision of an approved research protocol?
Question 5) What protections will be in place to avoid the premature and incorrect differential diagnosis of psychosis? The distinction between prepsychotic and psychotic is much clearer on paper than in practice and psychotic symptoms in teenagers are often transient, caused by substance abuse or mood disorder. Will strict diagnostic requirements, careful differential diagnosis, and quality control guard against incorrect, premature, and stigmatizing diagnoses and also against unnecessary and potentially harmful treatments?
Question 6) Why not roll out the EPPIC programs in gradual steps? This would ensure that the model translates well from the research environment to day to day practice and would provide an opportunity to demonstrate its efficacy and cost effectiveness before disproportionate investments are made in it.
Question 7) How do you justify the funding shortfalls for other necessary continuity of care programs that will likely be caused by the front ending of expenditures for EPPIC (especially given lack of convincing evidence that EPPIC confers enduring benefits or any reduction in future need for, or cost of, services)? Is it worth staking such a large proportion of the mental health budget on such an uncertain roll of the dice?
His track record makes clear that Professor McGorry can not be relied upon as a neutral reviewer of scientific evidence or a neutral advisor on the question of which mental health investments will bring to Australians the highest and safest returns. His countrymen should be very grateful to Professor McGorry for having obtained desperately needed funding for mental health, but should also be cautious in following his lead in determining how to best to allocate it. The mental health situation in Australia is without historic precedent. Never before has the future direction of an entire country’s mental health program depended almost solely on the unopposed opinions and actions of one charismatic psychiatrist and his band of loyal followers. His inordinate power places a huge responsibility on Professor McGorry to exercise responsible and responsive leadership. Direct answers to the questions raised above are needed to ensure that public policy will follow the scientific evidence and not be unduly influenced by the blinkered zeal of one man, however well meaning and highly respected he may be.