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Allen Frances

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Predicting Psychosis Risk Is Pretty Risky

Posted: 03/10/2012 1:19 pm

DSM 5 is pursuing an ambitious dream that could turn into a public health nightmare. The intention is admirable. Wouldn't it be great if we could predict who will later become psychotic and intervene early enough to prevent this from happening altogether -- or at least to reduce the severity, duration, and impact. The optimistic hope is to hit two home runs with one preventive swing -- both to alleviate the individual's suffering and simultaneously to save public money by avoiding the need later for expensive treatments.

DSM 5 proposes to pioneer in psychosis prevention by introducing a brand new diagnosis created specifically to trigger interventions. Originally called 'psychosis risk,' it is now repackaged more modestly as 'attenuated psychotic symptoms.' However named or renamed, this is a dangerous idea with little benefit and extremely risky, unintended consequences.

Before 'psychosis risk' can make sense as a new diagnosis, the burden of proof is on DSM 5 to produce positive answers to these three crucial questions: 1) Is there a method of accurately identifying who is truly at risk to become psychotic? 2) Is there an intervention of proven efficacy in preventing psychosis; and 3) Are the treatments safe -- especially since teenagers will be receiving them?

'Psychosis risk' strikes out badly on all three counts: 1) The rate of misdiagnosis would be at least 80-90 percent. This means that as many as nine people would be saddled with an incorrect diagnosis for every accurate hit -- a wild scatter shot approach that is totally unacceptable; 2) The Cochrane group's independent scientific evaluation of the intervention techniques used for 'psychosis risk' finds a lack of evidence to support their efficacy; and 3) in real life, many of the mislabeled 'prepsychotics' will receive unnecessary and potentially very harmful antipsychotic drugs.

As if these three strikes weren't more than enough, 'psychosis risk' carries three additional pieces of heavy baggage. It will tar the mislabeled with unnecessary stigma; reduce their hopes, ambitions, and expectations; and result in a wasting and misallocation of scarce mental health resources.

The stakes are high. Antipsychotic medications have an essential role when used appropriately, but they have a shocking history of being aggressively promoted for inappropriate off-label over-use, particularly in children and teenagers. How else to account for the remarkable revenue generated by this drug class? Originally intended for narrow and quite specific indications, antipsychotics are now the fifth most lucrative money earners for drug companies (at $16 billion a year in the U.S. alone). It is not the intention of its DSM 5 originators that 'psychosis risk' be treated with antipsychotic medication or that drug companies get even richer -- but, once it becomes an official category in DSM 5, they will have no control over drug company marketing or practitioner prescribing. Experience teaches clearly that drug companies will successfully exploit any new diagnosis in their unremitting efforts to boost already swollen sales.

Why is this so dangerous to kids? Antipsychotics can cause enormous weight gain. On average, a 110 pound 12-year-old will gain an amazing 12 pounds in just 12 weeks. We should certainly not be inadvertently adding to our already alarming epidemic of childhood obesity. And with obesity comes the complications of diabetes, heart disease, high blood pressure, and a shortened life expectancy. DSM 5 would embark us on futile and quixotic quest to help prevent psychosis -- and in the process will indirectly create an entirely new threat to the public heath.

It is striking that many (perhaps most) of the leading researchers on 'psychosis risk' have jumped ship and are now opposed to its being included in DSM 5. They worry that the proposal is half-baked, premature and likely to do much more harm than good. This should have been the necessary wake up call for DSM 5 -- if 'psychosis risk' can not even find approval among the experts most committed to it, certainly it is premature to consider its inclusion and unleashing in DSM 5.

And the opposition keeps mounting. Recently two of the most prominent supporters of 'psychosis risk' have gone out of their way to publicly reject it as a DSM 5 entity. Professor Patrick McGorry is the most powerful psychiatrist in the world, a prominent public figure as the 2010 Australian of the Year, a leading researcher on 'psychosis risk,' and the charismatic pied piper of preventive psychiatry. He was originally a strong supporter of 'psychosis risk' but now admits that it encourages over-medication and that its inclusion in DSM 5 could worsen the problem. "I think it's a valid point to be concerned about the harms particularly in places like America... probably I have given a bit more weight to that argument now." Professor McGorry also noted that 27 percent of youngsters seen in his program had to be taken off GP prescribed anti-psychotic drugs.

Dr. Alison Yung, another leading 'psychosis risk' researcher rendered her opinion about its inclusion in DSM 5 in a recent Lancet editorial:

The main concerns relate to the potential high number of false-positive diagnoses of patients who are not actually at risk of psychotic disorder. Additionally, people meeting the criteria might be incorrectly thought of as being in the range of schizophrenic disorders. Most clinicians and general practitioners surveyed incorrectly regarded attenuated psychosis syndrome as a mental disorder related to psychosis and schizophrenia. Possible unintended negative consequences of such a diagnosis include stigma, discrimination, and unnecessary treatment. Some high-risk patients are given antipsychotics (which can have effects on the brain), even though these drugs are not recommended in treatment guidelines.

Diagnostic creep might occur, which could result in lowering of the high-risk threshold and a subsequent reduction in risk of transition to a full-blown psychotic disorder. Paradoxically, the introduction of a high-risk classification could reduce research in psychotic disorders because it might give a false degree of comfort with the DSM definition... On balance, since the high-risk group is heterogeneous in presentation, clinical needs, and outcome, we believe that inclusion of attenuated psychosis syndrome as a new DSM diagnosis would be premature... Moreover, the resources available to fund mental health care would be spread more thinly.

How could such a fatally flawed proposal still be in play as a serious contender for inclusion in DSM 5? It remains a great mystery why DSM 5 has been unable to off-load its worst suggestions despite their obvious risks and in the face of vigorous and almost unanimous opposition of experts in the field, mental health professionals, the press, and the public.

DSM 5 is stubbornly digging in its heals in a futile battle with its users and the public -- a battle it cannot possibly, and should not, win.

Allen Frances is a professor emeritus at Duke University and was the chairman of the DSM-IV task force.

 
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