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“Experience during adolescence predicts very strongly how young people will be doing at age thirty. If you had a certain number of mental health problems during the transition from youth to adulthood, you will have fewer friends, you are more likely to not have completed your education, you will be earning less money – if indeed you have got a job –, you might be on disability support, you might be homeless. And, you might be dead – from suicide.”

Professor Patrick McGorry (Melbourne, Australia), keynote speaker at the ESCAP 2017 congress, is a renowned researcher on early intervention for psychosis and in other aspects of youth mental health. Now he seems to be an activist, against the worldwide discrimination of mental illnesses, and on the barricades to allow 12 to 25 year olds easy access to mental health care.

McGorry: “Yes I have become an activist. I have been around for a long time now, trying to be a good clinician and trying to conduct research. If I take a look now at all the evidence that is on the table now, it is high time we do something with it and bring it to the real world.”
“Imagine if people with cancer or heart disease were told: ‘It’s not serious enough, come back later when it is worse’. We are talking about a massive double standard here between mental illness and somatic illness.”

Neglect of treatment
“There are so many young people out there, who do not get help. The neglect of treatment for these young people does have real consequences. Critics tend to talk about over-diagnosis, but – while some young people do receive a wrong diagnosis and treatment – in fact we are very far away from overtreatment. The contrary is true: we are facing an enormous problem of undertreatment or none at all.”

Step-wise treatment
“What we have to set up is a stage-based system of care, that allows people to get simple care first – just education and support, psychological help or social interventions. If these are insufficient you might consider more complex treatment such as more intensive psychotherapy and, at some point, medication. In a step-wise way with increasing intensity and specificity as required. So you are responding proportionally, and actively guarding against overtreatment. The worldwide risk at the moment is undertreatment. The majority of young people don’t get any help at all. No one is fighting alongside them or working with them, with the common exception of their worried parents.”

Early intervention
Professor McGorry successfully advocated on the early detection, prevention and treatment of psychosis. He started his work on the EPPIC model (Early Psychosis and Intervention Centre) in the eighties of the last century. “We tried fairly early to broaden the diagnostic focus into mood disorders and other areas”, McGorry says. “That took us a long time. In 2001 we had the opportunity to open Orygen, the Australian centre for research, clinical services and advocacy in youth mental health. We thought that our ideas on early psychosis intervention were applicable to all types of syndromes and disorders, which often overlapped anyway. We still had specific structures for treating psychosis, but we left the idea of having separate services for each disorder – honestly, these are just young people that have problems and need help based on their broader needs as well as more specific clinical syndromes. The complicated comorbidities that emerge supported that vision, although in those days psychosis was still seen as something completely different from common disorders like depression, anxiety or other disorders. And we still don’t know quite how to handle these comorbidity problems. Specialist services in the northern hemisphere still have a discrete schizophrenia programme, a depression programme and a bipolar programme. We have a lot less of that right now. In our specialist youth mental health service covering ages 15 to 25, there are streams of care, but there is a lot of commonality in the services that are provided. We do have some specific elements in every so-called ‘diagnostic zone’ or ‘stream’, but we make sure that we tackle comorbidity within any stream. So if a borderline patient also has depression or psychotic symptoms, we address that too. Or if the psychotic patient has a personality disorder or is depressed, we obviously make sure we treat that as well. We don’t just assume it is part of the dominant syndrome and ignore it. What we are treating are not really diseases or disorders – they are syndromes. They come and they go, and they fluctuate. That is why the staging model is important.  Schizophrenia and bipolar are best seen as spectrum disorders and late-stage concepts: it could take you ten years before you get a diagnosis of bipolar and maybe five or ten to get schizophrenia. But you would have had a need for care much earlier than that.”

 

Competition for funding
By the end of the last century, Patrick McGorry’s views on early diagnoses were controversial and heavily criticized – they were supposed to have been “misleading” and his research outcomes were dismissed as “exaggeration”. McGorry: “Early intervention in psychosis has been resisted by a vocal minority of academic psychiatrists in some English-speaking countries, because they had a misplaced fear that somehow the chronic patients with long-term disability are going to miss out if we start focusing on early diagnosis. You never would hear that in cancer, you never would hear the public care specialists say: ‘I am sorry but you can’t get any money for early detection of breast cancer, because we find that the late phase of it must be treated better first...’ But that is what some of our colleagues were essentially saying, and I can even understand it at one level for there is nowhere near enough money in mental health care and there is competition for different areas of funding. So when people see new money being invested in one area, they think: ‘Why can’t we have that money?’ That is naturally how they think. The people though, who never criticized early intervention were the families, the public and the politicians. They could see the logic and the economics of it. And the parallels with physical illness.”

Evidence
“Of course we cannot always cure people, but we can surely change the course of an illness if it is treated early and consistently well. By starting to do it, we actually began to produce the large international body of evidence that it did help. The thing that really nailed it now is the RAISE study in the US, which has replicated what was done in Europe and Australia in the nineties. With a very good methodology, the RAISE outcomes show that you can transform the early course of illnesses if you treat them properly very early especially if treatment delay is kept to a minimum. And it is worthwhile: if you offer early treatment, the person’s life can be preserved, their trajectory, their social world and their prospects can be safeguarded. If you wait for five or ten years, people are in their late twenties and thirties and a critical period of life has passed them by.”

“They pay taxes”
“The sort of outcomes that we can expect are that our patients are more likely to be in education and in employment, they have fewer relapses, and it costs less money to treat them over the longer term because they have better recovery, they pay taxes and they are not on welfare. It is still not a cure per se, but we are bending the curve of outcome. And about the prodromal phase of first-episode psychosis – the people at ultra-high risk – we know that, untreated, this group usually has poor outcomes in a number of ways, not just in terms of transition to psychosis. They also have persistent mood and anxiety disorders, and other problems. Even for these patients we have shown that the outcomes after early treatment are better as well – at least within the first two years.  Also we can reduce the risk of transition to psychosis by fifty per cent.”

 

Headspace
“The need for care of some sort precedes diagnostic clarity in terms of our traditional DSM or ICD systems. So they need some kind of help, and there are large numbers of these young people. We have to provide that care. Crucial to solving the problem of young people with mental health problems not entering the services, is developing a strong primary care system that suits young people. This has been done in Australia, Canada, and Denmark with Headspace, in Ireland with Jigsaw and Headstrong.”
The focus of standard psychiatric care should move from chronic care only, to including this kind of specialized early intervention services, McGorry believes. The Australian Headspace concept offers very accessible, local facilities – ‘soft-entry’ or ‘low-threshold’ as some Europeans say, almost like youth cafés” – where young people can talk to someone about any problem they have, “or only to drink a cup of coffee” – however with real multidisciplinary expertise also available on site. Various health and social care disciplines are represented in these centres that collaborate with schools, labour market agencies, social work and youth work organizations. The Headspace concept aims at eliminating the mismatch between the need for mental health and the lack of entry to it. “We are developing this entry point that avoids that horrible word ‘triage’, which always makes me think of a war time military system: who is worth saving and who is not... That is not something you want to be doing in medicine and health care; you want to respond to people’s genuine needs... So in stead we are offering a place where any young person and their family can come in and at least get some assessment and support. Stigma-free and effective.”

 

Headspace initiatives in Europe

Headspace initiatives in Europe: Headstrong (Ireland), Youthspace (UK), Milestones (EU). Initiatives in Denmark and the Netherlands are on their way. Read the British Journal of Psychiatry special issue on Youth mental health: appropriate service response to emerging evidence.

Read the original ESCAP 2017 abstract and slide presentation by Patrick McGorry.