Quotes of the Day

Experiments, by definition, are a voyage into the unknown. But Melbourne psychiatrist Patrick McGorry conducted one on young people in the late 1990s that was more daring than most. McGorry was tantalized by the idea that psychotic disorders such as schizophrenia have a pre-onset phase, or prodrome, during which careful intervention could prevent them from emerging—and wrecking the lives of sufferers and their loved ones. The theory wasn't McGorry's alone, but he decided to test it in a world-first trial that had psychiatry's skeptics aghast.

The point of contention was that some 30 subjects in McGorry's trial received as part of their treatment regular doses of risperidone, one of a class of drugs known as antipsychotics or neuroleptics, which have been linked to a host of harmful side effects, including movement disorders. Critics were indignant that a potentially dangerous drug was being used on a hunch, and suspected the influence of big pharma and its drive to expand its markets. "This," American mental health lobbyist David Oaks told Time in 2001, "is one of the most bizarre and counterproductive human experiments on young people I know about."

With its small number of participants, the trial was inconclusive, but the results were enough to encourage McGorry. With colleagues at a public mental health clinic linked to the University of Melbourne, he began recruiting in late 2000 for a second, larger trial—whose results are yet to be analyzed—while American researchers embarked on similar experiments of their own. Though the voices of outrage were unrelenting, McGorry had a powerful professional ally in friend Thomas McGlashan, director of Yale University's Psychiatric Institute. But that pillar of support has now gone. Discouraged by the results of his own trial, which failed to show that preemptive drug treatment offered a substantial, measurable benefit, McGlashan told the New York Times recently that he doubts prevention of schizophrenia is possible. "I'm more pessimistic about all this now," he said. "I think more than ever we need to follow a group of [at-risk] adolescents who get no drug treatment to see more clearly what happens and refine our understanding of what the prodrome is."

So where does that leave McGorry? Completely undeterred, it would seem. He argues that McGlashan's "change in attitude" says much less about any flaws in the notion of prevention than it does about "ethical confusion" in American psychiatry. Far from backing off, he says, "We need to think beyond schizophrenia to the issue of access to care for young people with the full spectrum of emerging mental disorders."

Calm and softly spoken, McGorry has a way of making the experimental use of antipsychotics seem like the only responsible course. As executive director of the University of Melbourne–affiliated Orygen Youth Health, he sees patients aged 15 to 24 whose symptoms may include mild paranoia and social impairment. Fish oil and cognitive behavioral therapy (CBT) are sound first-up treatments, he says, but if they don't work it's unacceptable to wait for patients to slide into madness, though it's impossible to predict with certainty which ones will. "You've got to do something," McGorry says, meaning consider adding a neuroleptic drug to the treatment mix. "They've got no friends. They're sitting alone in their bedroom, their lives passing them by. You've got to actively research what's going to help them. The critics have been right to raise issues, but you can't neglect people when they clearly have a disorder, just because we can't technically fit them into our arbitrary system of classification." There were flaws in the design of McGlashan's trial, he says, that account for the negative result.

Contacted by Time, McGlashan calls McGorry a "terrific psychiatrist and a pioneering researcher, [but] we differ in the focus of our greatest enthusiasm"—McGorry's being intervention, his the mechanics of psychosis onset. "There may be gold in the early-intervention hills," McGlashan concedes, "but the data are not plentiful enough and the findings not replicated enough for us to recommend anything more than further research at this point."

As research into preventing psychosis has blossomed in several countries, "it's ground to a halt in the U.S.," says McGorry, president of the International Early Psychosis Association. American health activists "are so confused in their thinking," he says. "They've clouded this issue with the whole business of overmedication of younger children for adhd." But McGorry believes more strongly than ever in what he's doing. Buoyed by the Australian government's recent $A54 million funding of a National Youth Mental Health Foundation, he wants to apply the principle of early diagnosis and treatment to "a range of mental health problems in young people: substance abuse, personality disorders, bipolar—the whole lot, really." Despite the loss of a comrade, the McGorry voyage is a case of full steam ahead—and damn the torpedos.

• Daniel Williams
• An Australian psychiatrist defends medicating troubled adolescents to help prevent schizophrenia