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mental health

Aug 17, 2010

Patrick McGorry defends early intervention on youth mental health

Professor Patrick McGorry has written the article below in response to

Professor Patrick McGorry has written the article below in response to a recent Croakey post by Melissa Raven, a psychiatric epidemiologist and policy analyst, an Adjunct Lecturer in the Department of Public Health at Flinders University, and a member of Healthy Skepticism.

Patrick McGorry writes:

Melissa Raven accepts that official data does indeed show that approximately 750,000 young Australians with mental disorders do not access mental health care, yet continues to falsely characterise my consistent concern that this cohort should receive access to mental health care as misleading the public.

It appears that Raven bases this false claim on her view that only the 170,000 young Australians in this group with severe disorders merit access to mental health care (alarmingly only half of this group do so).

This line of reasoning is not only an example of bad faith on Raven’s behalf (I have never argued that 1 million young Australians have serious mental illness) but also reprises a discredited argument that young people should wait until their mental ill-health becomes serious before accessing care.

This late intervention philosophy is associated with risk, preventable damage and stigma and for this reason access to appropriate, staged mental health care for young Australians with mild, moderate and serious mental ill-health is overwhelmingly supported by political parties and the health and social sectors (most recently expressed in a letter co-signed by 65 organisations).

To argue that young Australians with mild to moderate mental ill-health do not need access to mental health care applies a standard to mental health that would not be acceptable in physical health.

Imagine restricting access to health services to only Australians with severe physical ill-health and locking out all those with milder conditions with the admonition that they should just regard their distress as part of the human condition and suck it up!    

headspace was created as a stigma free model specifically for the group of young Australians with mild to moderate mental ill-health that Raven appears to be suggesting should not have full access to this kind of mental health care. headspace provides information, skilled assessment and linkage to a range of health and social services appropriate to a young person’s need.

As with mild physical ill-health, skilled assessment of mild mental ill-health is most likely to result in a plan that combines changes in routine, diet, exercise and alcohol consumption with some moral support.

Low risk and non-stigmatising care that doesn’t label yet creates the pathway for more specialised interventions if the initial wave of advice and support doesn’t solve the problem.  It would be mischievous to misrepresent this type of 21st Century mental health care as predominantly or exclusively about medication and psychotherapy.  This is nothing more than a straw man that Raven is seeking to set up in order to tear it down.

As with physical health, responses to mental ill-health should always be tailored to need in a stepwise manner to balance risks and benefits.  For this reason, brief interventions provided by health professionals form one part of the headspace model and referral to specialist youth mental health services is confined to headspace clients with the most complex and severe needs.

It is difficult to see what exactly Melissa Raven’s objections are to all young Australians one day having the option of getting information, assessment, support and referral when experiencing mental ill-health. It might be helpful for her to explain this.

Dr Raven and Dr Jureidini also question the link between poor responses to mental ill-health and suicide. Although 90% of people who complete suicide have a diagnosable mental disorder, only a quarter previously accessed mental health care. Accessing care is proven to reduce suicide risk and the period immediately after discharge is one of significant elevated risk for suicide.

In the context of these facts the achievable possibilities for preventing suicide should be clear. Yet, once again Raven is at odds with what commonsense and the facts clearly demand.

It is also perplexing as to why Melissa Raven should characterise the early intervention paradigm represented by linked headspace and EPPIC centres as a “prescription for disaster” and to respond to corrections of her inaccurate claims as “silencing dissent”.

She has been repeatedly provided with the facts on headspace and early intervention but they are inconvenient to her purpose and hence ignored.

Young Australians – and Australians of other ages – deserve a health system that cares for mind and body equally effectively. That means applying the same standards of access to care for mental health as to physical health. Those who believe otherwise should be upfront about this perspective.

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13 thoughts on “Patrick McGorry defends early intervention on youth mental health

  1. ash04

    Examining the Youth Mental Health Care System

    New statistics have found that Young Australians are more likely to commit suicide than to die from an illness or accident (The Australian, 2009). This means that there are more young people choosing to die, than there are young people dying from external causes. These statistics provide a grim reflection of a growing problem which has been termed by Australian of the Year, Patrick McGorry, as an ‘epidemic’ (LIFE, 2010).

    For the first time in history, mental health and suicide have taken their place in the political arena. For the first time in history, Australia is seeing these issues publicly debated within a political context, and becoming key aspects of each party’s political agenda. While this is a reflection of a growing understanding of mental health issues in Australian society, it remains that only a quarter of the one million young people experiencing a mental health issue access help (Orygen Youth Health Research Centre, 2010).

    According to Michelle Blanchard, Director of Research and Policy at the Inspire Foundation, it is economically advantageous for the government to invest in youth mental health services as a form of early intervention (in conversation, September, 2010). An increasing body of research providing evidence that early intervention in mental health is effective supports this assertion. Essentially, accessing professional help for a mental illness in early life increases the chance of rehabilitation and this can relieve future economic burden on government. Professor Alison Yung supported this notion in a presentation on the topic earlier this year at the International Youth Mental Health Conference, 2010 (Orygen Research Centre, 2010).

    Michelle Blanchard (in conversation) of the Inspire Foundation and Matthew Hamilton, Patrick McGorry’s Senior Policy Advisor (Orygen Youth Health Research Centre, 2010) both agree on the importance of e-health services in conjunction with face-to-face support services. Such e-health services include telephone counseling services such as Kids Help Line and Lifeline, online Cognitive Behavioural Therapy programs such as ‘MoodGym’ and ‘E-couch’, websites such as Reachout.com and youthbeyondblue.com, and other such services that offer online counseling and related services.

    As identified by Orygen Youth Health Research Centre (2010) the three focus areas within the youth mental health care system are system capacity, access to care and the social determinants of mental ill health. In particular the system needs to have the capacity and resources to respond adequately to young peoples needs. This includes enhanced investment in creating workforce places, improving skills through training and creating new knowledge through research.

    In terms of access to care, the perspective of Orygen Youth Health (Orygen Youth Health Research Centre, 2010) is that access can be enhanced by creating a national network of ‘Headspace’ centres. Headspace centres are designed to specialize in providing support for young people experiencing mild to moderate mental ill-health. It is recommended that young people experiencing more severe mental ill health issues be referred to specialist services. Orygen Youth Health also asserts the importance of complimenting the national network with e-mental health initiatives. This is particularly beneficial and relevant to rural and remote Australia.

    Orygen Youth Health (2010) also advocates for addressing the social determinants of mental health. Most specifically is the need for more skilled, knowledgeable and confident community responses to mental ill health in young people. This can be developed through public education and mental health literacy campaigns for young Australians, their families and communities.

    As a society, we all have a responsibility to engage in the political and social processes that help to alleviate injustice and inequality. This is applicable to all areas of human life, including the area of mental ill health. Mental ill health is an area of health that has encountered long-term and systematic disadvantage. In an ideal world, mental health will be considered equal to physical health. As quoted by ‘Karen’, “Hopefully, in my lifetime, I will witness the day when being completely open about my mental illness will not be viewed as a matter of courage, but a matter of fact.” (2010).

    References:

    International Youth Mental Health Conference, 2010. http://www.iymhconference.com.au/presentations/ Date accessed: 01/10/2010

    Living is For Everyone (LIFE), 2010 http://www.livingisforeveryone.com.au/Live- chat-with-Jaelea-Skehan—May-2010.html Date accessed: 15/10/2010

    Orygen Youth Health Research Centre, 2010. Supporting the Mental Health of Young Australians. Accessed via: Matthew Hamilton directly.

    The Australian, 2010. http://www.theaustralian.com.au/news/nation/suicide-toll- being-driven-by-copycats/story-e6frg6nf-1225812242812 Date accessed: 15/10/2010

  2. vidavida

    Anybody who supports, in any way shape or form, any such early intervention for mental health is grosely mis-informed and a victim to the mental health marketing madness that see billions of $$$$ in the pockets of Psych-Pharma and their vested interests, and houses of broken dreams for those who fall victim to their diagnosis (un-necessary labelling) and prescriptions… leading to an untold number of side effects, suicides and deaths…
    David you are absolutely on the money… I agree 100%…
    Tully you really have to question the validity of Psych with more deaths from psych drugs world over than the deaths from all wars combined (in the same period of approx 150 years)… That’s not medicine, it’s purely guess work… Would you accept that devastating number of deaths for the treatment of cold and flu, measles, mumps, alzeimers etc… there would be an absolute outcry…

  3. horace

    JAYISOK appears to be guilty of the same mistake as McGorry – he (or she) takes the extreme case as though it is the every case, or the norm. Obviously, there should be mental health care readily available for those who NEED it.

    If someone has no friends, no family, no GP, and a teacher or employer who tells them to ‘suck it up’, then they obviously need help; although it is, unfortunately, doubtful, in the example quoted, whether the person would be pointed in the direction of care even with wall-to-wall mental health care. I mean, with no friends, no family, no GP, no interested teacher or employer, where are they going to discover the necessary help?

    In practice, most people have SOME family, friend(s), GP, counsellor, teacher, or employer who will provide some level of advice or direction, just as was proposed in the earlier post. If these first points of contact do not provide sufficient support or solution, then referral to a higher level of expertise is the obvious next step. Provided, of course, that the next step does NOT automatically involve a dramatic level of administration of prescription drugs.

    Horace

  4. jayisok

    HORACE POSTS: “Professor McGorry is a touch precious in his assertions regarding lack of access to mental health care. If I have a headache, I take a paracetamol; if it worsens, I take a Digesic; if it is ongoing I consult a GP; if it worsens, I see a specialist.
    Given that a large percentage of ‘young people with mental disorders’ are characterised as having a mental disorder solely because of their mishandling of alcohol or other drugs (and surely most of us have been there at some earlier time in our lives); and many other ‘disorders’ are as a result of relationship break-up or similar short-term emotional upsets; surely advice from friends in their peer group should be the ‘paracetamol’; a talk with a family member or friend should be the ‘Digesic’; a consult with their GP should be their ‘consult with a GP’ and so on”

    Suppose for a second that said young person doesn’t have any close family, and/or they have been moved around constantly and have no solid friendships. The ‘headache’ gets worse. Because of this kind of instability and a low socio econmic status said young person doesn’t even have a GP she can go and see. The headache gets even worse. She gets a response like ‘suck it up!’ every time she tries to talk to her teacher or employer about it because they don’t have the scope to be her parent too. People begin to say she is ‘crying out for attention’ instead of giving it to her. She can’t get out of it, she has no power and no money – she is stuck. She stops interacting with people because it hurts her head, she likes being alone anyway – people never listen to her. Everyone is very busy. Soon she is so isolated that she looses grip of her rational mind. She has no one to bounce her ideas off. She feels like a victim and she acts like one – always fighting the system. Eventually the pressure gets to be too much. She snaps and hurts someone, or herself.

    Thousands of children and young people are in unstable living conditions and unstable foster placements each year. Thousands of children and young people are homeless.

    Why on earth would you want to leave it until the problem is too big? We teach our children to think forward, to think of the concequences for things, while we incarcerate these people to the ‘too hard basket’ because we avoided it for so long?

    Good on ya McGorry.

  5. davidwebbo

    Tully,

    Thanks for this quote from McGorry. But a reality check is required.

    The overwhelming dominant influence in mental health “care” today is biomedical – you get a diagnosis and then you get a drug. McGorry is being disengenuous again with his excuses for this. When will he say publicly that the chemical imbalance of the brain explanation for mental illness is a mareketing myth without any scientific evidence to support it? When will he say publicly that mental illness is NOT the same as physical illness, which is another widespread misconception in the community? And why does he constantly talk about dopamine when he talks about psychosis?

    This calamity has come about not because of late intervention or neglect or lack of resources. It is happening because human suffering, in all its many and varied forms, has been excessively medicalised by people like McGorry, whose medical training sees only “illness” that needs to be “diagnosed” and then “treated”.

    If the only tool you have is a hammer, then everything looks like a nail.

    David

  6. VanaheimGroup

    We share David Webb’s concerns. Looking at similar early intervention programs from around the world, early intervention programs lead to increased involuntary treatment of children.

    The best examples are TeenScreen and the Texas Medication Algorithm Project (TMAP), which have well documented cases of involuntary treatment, one example: http://motherjones.com/politics/2005/05/medicating-aliah. TeenScreen started out with all the good intentions of headspace (and similar funding sources).

    Since (McGorry-run) Orygen’s own materials canvas involuntary treatment (www.orygen.org.au/docs/CLINICAL/SupportingaYPwithMI.pdf, http://www.eppic.org.au/acute-care-1), it is surely not unreasonable to expect the appearance of similar outcomes.

    But perhaps Horace is right about the vested interests inherent in a monopoly on early intervention, in which case it is little wonder Melissa’s valid and thoughtful criticisms are being side-lined.

    Surely if McGorry were serious about preserving human rights and helping young people in distress he would be trying to replicate the Soteria House studies rather than Orygen’s current restricted, token efforts (see the tried and tested research here: http://www.moshersoteria.com/soteri.htm vs the approach here: http://rc.oyh.org.au/ResearchAreas/firstepisodepsychosis/stages).

    As an aside, it would also be nice for GetUp to respond to Melissa’s concerns. Or is the deafening silence an indication that they are embarrassed and do not wish to draw attention to their clear errors?

  7. Tully Rosen

    Deja vu David. I believe this conversation between you and Patrick has already occurred.

    http://www.abc.net.au/local/audio/2010/04/09/2868225.htm

    McGorry: “No one sensibly supports a biomedical model these days. It might be happening in practice because of late intervention, neglect and under-resourcing, but no one seriously in the mental health field supports that.”

  8. davidwebbo

    Like Melissa Raven, I too am bothered by Pat McGorry’s one-sided and distorted claims that seem designed to sell his early intervention product rather than stimulate a proper community debate about what kind of mental health system do we really want.

    My expertise is in suicide, as a suicide survivor who went on to complete a PhD on the topic. I frequently see the claim that many people who suicide have a diagnosable mental illness, though McGorry’s 90% is at the top end of these claims. Such assertions are disengenuous when you consider the dubious status of a retrospective psychiatric diagnosis from so-called ‘psychological autopsies’ that these figures are based on – McGorry himself states that most of these people had not accessed mental health services prior to their suicide. For instance, the criteria for diagnosing depression are so loose that anyone who suicides would qualify for a diagnosis, which leaves me wondering who the other 10% are?

    McGorry claims that accessing care is proven to reduce suicide risk but I would like to see the “proof” he refers to as my own research does not indicate this at all. On the contrary, what I see is that our current system of care frequently fails the suicidal person and at times increases the risk of suicide.

    I am also bothered by the “early intervention” product that McGorry wants the community to buy at the cost of several billions of taxpayer dollars. In regard to psychosis, on which McGorry’s international reputation is based, there is much heated debate in the literature about the merits of this approach. McGorry claims he can predict people who are at risk of psychosis in advance of them developing symptoms that would warrant a diagnosis. Given the speculative and problematic nature of psychiatric diagnosis at the best of times, this is a very big claim. McGorry knows this himself when he admits that his early intervention approach would inevitably lead to a high number of “false positives” – i.e. people being diagnosed who would never go on to develop a diagnosable psychosis – usually quoted in the literature as between 60% and 80%. It bothers me greatly that McGorry seems not at all worried about this – and even more that he is not candid about this in the marketing of his product.

    It bothers me again when, on the basis of this early intervention model, McGorry seems quite happy to prescribe potent anti-psychotic medications in the belief that this can prevent the subsequent development of psychosis. The literature is quite clear that this kind of prophylactic use of these medications is experimental and currently without any scientific evidence to support it.

    And it bothers me greatly that he seems unconcerned about the potential risks of these drugs, especially given the very high rates of false positives, when he says, “I’m not saying they’re benign,” says McGorry of the drugs, “but I don’t believe the risk of taking them at [low dose] for six or 12 months is a big deal.” (TIme Magazine, April 9, 2001, NO. 14). I and many others beg to differ, Professor McGorry.

    I have similar reservations about ‘headspace’, although I do support the concept of a non-stigmatising, one-stop shop for all people (not just youth) wishing to access services for a broad range of psychosocial issues. The problem with ‘headspace’ is that it is based on the same medical model as McGorry’s early intervention for psychosis and will also likely lead to a large number of false positive diagnoses of psychiatric disorders.

    We can look to the US to see where this model will take us. Mental health screening is another proposal by McGorry and his ‘headspace’ colleagues that has been accepted by the federal government. In the US mental health screening was heavily promoted by the Bush administration (in partnership with the pharmacuetical industry) but has now become a major controversy. In some states of the US, this screening has led to students being refused entry to school unless they are taking psychiatric medications that neither they nor their parents want them to take. Some families have been forced to move interstate, or sometimes to Canada, in order to escape this kind of psychiatric social control. In Florida, about 30,000 citizens have signed a petition to get rid of this mental health screening from their schools and you can see YouTube video clips of this being debated in the Florida congress.

    So finally, my greatest concern is that all this is coming to Australia with virtually no public debate on whether this is the kind of mental health system we really want. Instead, we have McGorry and his colleagues, such as ‘beyondblue’, selling their particular product to a community that is very concerned about the current mental health crisis, but without disclosing some of the serious hazards of what they are proposing. We need a proper community debate on these issues, not slick marketing.

    David Webb, Melbourne

  9. ravenm

    Prof McGorry, you have twice said on Croakey (and elsewhere) that there are ‘750,000 young Australians currently locked out of the mental health care they and their families desperately need’. Please explain what desperately needing mental health care means. Surely it means having a serious mental illness? If not, what does it mean? Please answer this here on Croakey, since you have made that claim here.
    (The National Survey of Mental Health and Wellbeing estimated that 1 million young Australians had a mental disorder at some point in the previous year, and that 3/4 of them did not access mental health treatment, so you and I are not in dispute about the 750,000 number, but we are in dispute about its interpretation.) Melissa Raven

  10. Tully Rosen

    It is ad hominem attacks like that above which makes it almost worthless to get into these kind of arguments.

    Shooba, Patrick McGorry’s numbers are different, and yes higher, because he actually references a cross-section of available Australian statistics (ABS, AIHW) which Melissa Raven conveniently ignores.

  11. horace

    Professor McGorry is a touch precious in his assertions regarding lack of access to mental health care. If I have a headache, I take a paracetamol; if it worsens, I take a Digesic; if it is ongoing I consult a GP; if it worsens, I see a specialist.

    Given that a large percentage of ‘young people with mental disorders’ are characterised as having a mental disorder solely because of their mishandling of alcohol or other drugs (and surely most of us have been there at some earlier time in our lives); and many other ‘disorders’ are as a result of relationship break-up or similar short-term emotional upsets; surely advice from friends in their peer group should be the ‘paracetamol’; a talk with a family member or friend should be the ‘Digesic’; a consult with their GP should be their ‘consult with a GP’ and so on…

    This would remove many hundreds of thousands from the lists of those supposedly being ‘locked out’ of appropriate treatment.

    It is admirable, from the point of view of building a business, that Professor McGorry has been so successful in having ‘headspace’ and EPPIC as the only acceptable alternatives. Great business if it is one’s own.

    Horace.

  12. Shooba

    There will always be conjecture in regards to mental illness statistics, simply because defining mental illness is so contentious.

    In the first instance, the oft-quoted “chemical imbalance” cannot be clinically defined. Most people know that, so instantly medical illess will not be treated with the same gravity as heart disease or cancer. That’s an unfortunate fact, because most (reasonable) people would accept that mental illness is a real problem for thousands of people in Australia.

    However, in regards to stats like “750,000 people being locked out of the services they desperately need,” such a number includes all people who fall under the increasingly wishy-washy definition of mental illness. Severe depression? Sure. Psychosis? Absolutely. Binge drinking? Most people would draw the line. And rightly so. Giving an alcoholic the tag of “mentally ill” is dangerous on a personal and social level.

    More representative statistics are needed, but for that to happen, Professor McGorry will need to openly state precisely what falls into his definition of ‘mentally ill.’

    Understandably, because he is at the coalface and can see the tragic consequences of inaction on mental health, he will include far more disorders or health matters than the average Australian. But to legislate and build social policy around the extremes is, again, dangerous. We cannot afford to label every international student who is anxious throughout exam period as having a mental illess. I don’t mean financially, I mean that the stigma is too great.

    This debate essentially boils down to responsible use of statistics. I have to agree with Melissa Raven that Professor McGorry appears to inflate figures in the public sphere. This is, as I’ve said, the result of being at in the field and seeing the consequences. However, from a social perspective, we cannot definitively agree that “750,000 people are locked out of services they desperately need” or that such a high proportion of suicides are directly related to early dismissal. Not only does that put unwarranted pressure on government and the health sector, but it creates a culture of victimisation within the community.

  13. Tweets that mention Patrick McGorry defends early intervention on youth mental health – Croakey -- Topsy.com

    […] This post was mentioned on Twitter by TheMHS, Melissa Sweet. Melissa Sweet said: Patrick McGorry responds to critics at Croakey. In support of early intervention in youth mental health problems: http://bit.ly/dhuQKg […]