Abstract
Professor McGorry, in his response to my debate piece in the Journal, seems to get in a terrible muddle in trying to paddle his canoe upstream (McGorry, 2012). First, he quotes Schopenhauer on truth, counterpoising this against Louis Appleby’s view about early intervention service in the UK: so Professor Appleby is now the purveyor of truth, is he, and if he says it is so, then it is true? It is not that easy. There are plenty of UK psychiatrists who would contest Professor Appleby’s reification of early psychosis services as the ‘jewel in the crown’: what about the fact that the rest of the crown is tarnishing, and if it is allowed to go on the way it is, any ‘jewels’ will fall out as they have no framework left to hold them? Surely a more systemic approach to supporting the whole crown is preferable to polishing single jewels?
Professor McGorry then returns to a favourite theme, essentially that if one is not for early intervention then one is against it: redolent of a certain former US president’s view of the War on Terror. This is simply not the point: the debate is not about not intervening early, it is about how that is done in a way that ensures reach to everyone (including people over 25!) and facilitating continuity of care and delivery of comprehensive care for as long as it is required. The early interventionists need to own up to the fact (and yes this is where facts have not been told) that there is no good evidence that intervening effectively early in the course of illness has any major effect on the longitudinal course, and certainly cannot prevent schizophrenia. They also need to own up to the fact that no one has pitted stand-alone services against integrated services in a scientifically robust trial and found one or the other to be superior. Professor McGorry spends time criticising our service, stating that we did not achieve a reduction in duration of untreated psychosis (DUP). He disingenuously quotes mean rather than median DUP: our 3-month median DUP is respectable. In any event, a reduction of DUP is not readily achieved simply by introducing an early psychosis service (see Lloyd-Evans et al., 2011), another fact often left out of the early intervention rhetoric. Finally, on this point, in the recent study by Norman and colleagues (2012) from Canada, DUP reduction has had a minimal effect on outcomes, explaining only 4% of the variance in positive symptoms.
Professor McGorry’s aside about our service having ‘chosen not to use government funds’ for early psychosis is a totally bizarre assertion. Actually, we set up an early psychosis initiative within our service (an integrated model, accessible to anyone, not simply youth) out of existing funds, as part of what we see as a comprehensive service approach (Petrakis et al., 2011). We have benchmarked very well in terms of service provision in this regard (Petrakis et al., 2010) and believe the integrated model is much preferable to the silo service advocated by Professor McGorry. Maybe all services should be as open in auditing their models as we have been, and make public the positives and negatives. For example, a fact Professor McGorry does not share is that his service has a seclusion rate some sixfold higher than ours: hardly a success for stand-alone, early intervention services!
The cost issue fascinates me. The Melbourne data, on which the assertion that early psychosis services are cost-effective is built, seems to rest mostly on reduced inpatient stays (Mihalapoulos et al., 2009). What is not emphasised is that the data are compared to a historical control group taken from an era with more beds in the system and longer lengths of stay overall. Thus, the supposed cost benefits might have been due to factors entirely unrelated to early psychosis services.
Professor McGorry states that I claimed ‘most psychiatrists are not supportive’ of early intervention services. I never said this. I simply stated I am not alone in my view. The material I quoted to support this assertion was appropriately referenced. As it happens, not only are (some) Australian psychiatrists heretical! (see Pelosi, 2004). Professor McGorry’s further diatribe regarding the use of the Journal to air different academic views is truly extraordinary. I always thought debate was part of what academic life was about and should be welcomed. To suppress such debate is what would truly be unscientific, to use Professor McGorry’s elevated term.
Finally, Professor McGorry says that I am an ‘apologist’ for inadequacies of mainstream mental health services. As it happens, I work every week in such a service and (despite Professor McGorry’s negative aspersions on it) I am proud of the work our clinicians do. Is it perfect? Of course not. Can we do better? Of course we can. Will stand-alone services with a short-term commitment and a silo mentality assist us in getting better? Certainly not. I find particularly offensive Professor McGorry and colleagues’ (2010) blaming of the ‘pessimism’ of mainstream service staff for the fact that all the brilliant work done by his service dissipates when patients are transferred. Even in his current piece, he speaks of mainstream services as ‘desultory’. Surely such rhetoric assists no one.
As I have stated many times, I believe we should build on the gains that have been made in terms of mental health service delivery, and seek to do so in a considered and evidence-based manner so that the whole system benefits. Adding silo early psychosis services is like putting a state-of-the-art carburettor into an engine that needs an overhaul, then blaming the rest of the engine for the fact that the car does not drive faster.