McGorry’s mental health minefield
17th Oct 2011 Jodie Thomson all articles by this author
Professor Patrick McGorry is fending off a barrage of bitter and very personal dissent over his approach to mental health.
AT
THE eye of the stormy debate around mental health funding sits one man:
the 2010 Australian of the Year, Professor Patrick McGorry.
While he’s lifted the profile of mental health
among the general public – and been referred to as ‘the most powerful
psychiatrist in the world’ – many of his peers have showered him with
criticism since the 2011–12 federal budget.
That’s when funding was diverted from the GP-led
Better Access program to early intervention youth services, leaving GPs
concerned that there would be a gaping hole in primary care services for
mental health patients.
Professor McGorry, an adviser to the government on
mental health funding and founder of the Early Psychosis Prevention and
Intervention Centres (EPPIC) and headspace programs, has been accused of
bias towards his early intervention models and conflict of interest
over his advisory position to the government.
There is also doubt about the stated benefits of
EPPIC and headspace, which have scored almost a quarter of the $2.2
billion mental health package.
And there’s concern around early intervention
treatment that involves giving antipsychotic medication to young people
merely at risk of psychosis.
“We need to get broader advice to government, we
need the right advisers, who truly understand developmental principles
and a lifespan approach,” says Professor Louise Newman, director of the
Centre for Developmental Psychiatry and Psychology at Monash University.
The criticisms have grown increasingly personal in
recent weeks. Professor McGorry was attacked by a prominent American
psychiatrist, Professor Allen Frances, chair of the DSM-IV Task Force,
who accused him in the Psychiatric Times of having a “messianic blind
spot” and being an “unreliable evaluator of scientific evidence”.
Professor McGorry says these kinds of criticisms
are “false and baseless” and “those making them have not been able to
substantiate them in the face of facts”.
He vehemently refutes suggestions of a conflict of interest over his advisory role with the government.
“It is unclear exactly what improper behaviour I’m being accused of here,” he says.
“It is also unclear what criteria would disqualify
my participation in the expert group due to my involvement in non-profit
youth mental health organisations that would not also disbar all other
members of the expert group on the grounds of their professional or
organisational affiliations.”
The government says Professor McGorry was just one
member of the Mental Health Expert Working Group, which was made up of
experts from a range of health and non-health sectors, plus consumer and
carer representatives.
“While these consultations helped to inform the
development of the government’s record mental health package, decisions
on the specific content... were solely a matter for the government,”
said a spokesperson for Mark Butler, Minister for Mental Health.
With regard to claims of bias over the high
proportion of funding that youth mental health received in the budget,
Professor McGorry said three-quarters of the mental health budget went
to areas other than youth.
“I would also note that when the Independent
National Health and Hospitals Reform Commission considered this issue,
they made early intervention models the first two of their 12 mental
health recommendations.”
Most psychiatrists’ criticisms concern whether the
benefits of the early intervention programs have been overstated. Nearly
two-thirds of pyschiatrists in a recent poll thought the government’s
focus on EPPIC was inappropriate.1
Professor Frances has described it as a “massive
new experiment in early intervention”. Others question Professor
McGorry’s claims that the programs are backed by solid evidence.
“They’ve made a lot of promises and raised a lot of
expectations and these have not been borne out in the studies,” says
Professor David Castle, head of psychiatry at Melbourne’s St Vincent’s
Hospital.
In response, Professor McGorry argues early
intervention programs like these have been used in hundreds of centres
internationally for many years with great success.
“Consequently, there is very good evidence that
early intervention for first-episode psychosis is more humane, effective
and cost-effective.”
Adelaide University Associate Professor Jon
Jureidini says he is concerned the early intervention programs have been
misrepresented.
“I don’t think there’s anything wrong with either
EPPIC or headspace as models, but there are other approaches to youth
mental health, and these two approaches have not been proven to the
extent where they dominate the funding,” Professor Jureidini says.
Concerns about the efficacy of the early
intervention approach are not shared by the Royal Australian and New
Zealand College of Psychiatrists (RANZCP), which has called them
“essential” in a recent Senate submission on mental health funding.
“The government must commit to the full
implementation of a national youth primary care service (headspace or
similar) and a national network of Early Psychosis Prevention and
Intervention Centres,” the RANZCP submission stated.
One controversial issue is whether the EPPIC
treatment model involves giving antipsychotic medication to young people
at risk of psychosis.
A trial by Professor McGorry of antipsychotic drugs on people aged 15–40 who were “at risk” of psychosis was recently cancelled.
“A lot of people are very, very concerned about the
potential for over-labelling, over-medicalising and over-treating
youngsters,” says Professor Castle.
“In America there’s been a 400% increase in bipolar
diagnosis in children, and these kids do not all go on to get bipolar
disorder. There’s a danger this sort of stuff will happen here.”
Professor McGorry, however, has repeatedly stated
that antipsychotic medication will not be used as a first-line treatment
option.
“A key goal of youth mental health models... is to
address the over-medication of people with mental ill health in our
overstretched and under-resourced mental health system,” he wrote
recently on his website.
AMA president and GP Dr Steve Hambleton supports the need for early youth intervention.
“In general we want to intervene early and it
doesn’t necessarily mean early use of medication,” he says. “We don’t
want to label people too early, but services like headspace are
appropriate for young people. We don’t want to put people on medication
up front and Professor McGorry doesn’t want to do that either.”
For many GPs, a crucial issue is whether Professor
McGorry’s influence has seen funding diverted to early intervention
services at the expense of the Better Access program.
“Everyone would applaud his bringing youth mental
health issues to the fore, but we have a right to be very angry about
the diversion of funding,” says Dr Brian Morton, chair of the AMA
Council of General Practice.
While the RANZCP and AMA acknowledge there may have
been problems with evaluating Better Access properly, GPs believe the
cuts will be devastating.
“The mental health cuts are going to disadvantage
patients, in particular those who have more chronic and difficult
issues,” says Perth GP Dr Stephen Wilson.
Professor McGorry describes Better Access as an “excellent program” that has been a “building block for mental health reform”.
“While I personally did not advocate the changes
made in the recent budget – nor did I have prior knowledge of the
changes – now that this has occurred, we need to review what is really
required to provide appropriately skilled care for those with more
complex mental disorders for which Better Access was designed,” he says.
“In the very next federal budget, the federal
government [should] fund a more specialised tier of service which would
draw in clinical psychologists – who are clearly required if the problem
is more serious and persistent – psychiatrists in many cases, and
other disciplines as well, notably social workers and occupational
therapists.”
Some argue the real need is for more independent
analysis of all areas of mental health and a more involved discussion on
which ones have the greatest need.
“I would implore people like Patrick McGorry to understand they are a part of a much bigger system,” says Dr Wilson.
“They need to take a step-back view of policy and realise it’s not just their area of work that needs a lot more funding.”
Professor McGorry says his core recommendation is
that mental health policy should ensure all Australians of all ages have
the same access to quality care for mental ill health, as for physical
ill health.
“Those criticising the decisions of the government
on mental health reform are perfectly entitled to do so, though it would
be good to learn what their alternative plans are, if any, especially
for the million young people with mental ill health,” he says.
Reference
1. Psychiatry Update, 6 October 2011, http://enews.psychiatryupdate.com.au/cgi-bin19/DM/t/nMCS0FVx0FM0j7tF0E7
