The prodromal psychosis debate

To the Editor

Professor Jorm’s (2012) challenge to Professor McGorry’s (2012) rejection of criticism of research on medication for youth ‘at-risk’ of psychosis joins an increasingly unattractive debate. McGorry’s affronted response to sometimes venomous criticism shows what slippery conceptual ground psychiatry treads. When ‘truth’ and ‘reality’ enter the argument we should know we are in trouble.

All participants in the debate retail different concepts of psychosis. Whatever the concept of ‘psychosis’ might be, it is actually no use for understanding, treatment, service design or point-scoring. For McGorry, psychosis now looks less like a target for intervention than a target for the rocks thrown by some of his critics, locally and most prominently, Professor Castle (2012a, 2012b). Castle, eschewing irony, ignores that many of his criticisms could apply to his own views. The certainty he finds in the ‘well established … epidemiology of psychosis …’ offers little reassurance for me given the twofold variation in his own figures and a tenfold variation in older measures (Torrey, 1987). Even strict criteria have to be interpreted in application and set no boundaries to diagnoses that are contingent upon time and place and the needs of the person making the diagnosis. Epidemiological certainties can be hollow since diagnosis does not indicate a firm clinical picture nor predicts a response to treatment or need for care. ‘[T]he treatment evidence rests on diagnosis …’, says Castle; so the evidence is as uncertain as the diagnosis. (And in this argument, selection and interpretation of evidence can support any contention.) While Castle raises valid criticisms and problems, his remark ‘whether they actually need treatment’ suggests that services rationed by diagnosis will send people away, even if their ‘help-seeking behaviour’ was for severe or even lethal problems. Ask the relatives of suicides who had been sent away by services.

Professor Jorm’s challenge at least is not tendentious, but it does rest on the idea that the diagnosis justifies, decides and guides antipsychotic treatment in the way that identifying a bacterium justifies, decides and guides antibiotics. (That misleading analogy of ‘antipsychotic’ and ‘antibiotic’ is embedded in the language of psychiatry.) Psychotropic medicines modify symptoms and behaviours; they are not specific cures for some specific process of ‘psychosis’. The harms done by medicines are visited on ‘psychotic’ and ‘non-psychotic’ alike. Treatments (psychological and physical) are justified if, and only if, their benefits outweigh their harms. Jorm’s challenge to researchers to take the medicine themselves provocatively highlights the harms but it is specious – in that case there are no benefits to be balanced against those harms.

Patients come to specialist services with symptoms. Very often they come already taking these medicines ‘off-label’ prescribed by doctors who are struggling to manage symptoms and risks. I have heard it said that Professor McGorry complained that his service took more people off medicines and from higher doses than he proposed initiating in the trial for which he was so attacked. ‘Off-label’ use runs riot and is not constrained by any evidence. Research on what these medicines do has been stymied and I can understand McGorry’s frustration (but not his tone).