Thanks for this very interesting interview. I hadn’t fully appreciated just how central Patrick McGorry’s work has been in shaping the Australian youth mental health system, and how much his thinking is why this is now mainstream in the UK. Reading this, it becomes clear that many of the principles he helped establish—early intervention, proportionate prescribing, strong psychosocial scaffolding, and a staged, recovery-oriented model—are now simply taken for granted in UK early intervention services. It is a marker of the debt we owe to that intellectual and service-level leadership that his ideas feel like ordinary, humane psychiatry to a UK psychiatrist.
At the same time, when one looks across pre-antipsychotic cohorts, post-antipsychotic outcome data, and prospective developmental studies, a consistent picture emerges. A first psychotic episode is not a neutral event; it tends to mark an inflection point in an already vulnerable developmental trajectory. Across eras and systems, outcomes cluster into familiar bands: a minority achieving full functional recovery, a larger middle group with partial or fluctuating functioning, and a significant subgroup with enduring disability. Those proportions have proved surprisingly stable despite major changes in medication, service models, and social policy.
From that perspective, many of the factors we debate—antipsychotic exposure, substance use, and - while humane and desirable - housing, benefits, or psychosocial input— act as confounders around an underlying developmental distribution. The psychotic episode itself, and the environmental sequelae around it, appear better understood as indicators of an intrinsic neurodevelopmental constraint rather than its primary cause.
Within that frame, the evidence for antipsychotics remains strong where it is most robust: in the reduction of acute positive symptoms and behavioural dysregulation. If it were I or my child, I would absolutely want antipsychotic as early as possible in an acute psychotic episode. In the more impaired subgroup, medication can function as a pragmatic containment tool when other supports are limited, while the long-term trajectory is more strongly determined by underlying cognitive, emotional, and social capacity, with even TD being reported in these groups in the pre-antipsychotic literature.
The harder and still unsettled question is what constitutes the “better” life for this group: long-term institutional care with structure and containment, or community living supported by depot medication and social services. Both models have historical precedents, and neither has delivered "good" outcomes for the most developmentally constrained patients in terms of improvements in functionality. That dilemma remains unresolved, and perhaps speaks to the limits of any purely pharmacological or purely social solution. Evidently either are better than no provision with drift into homelessness and lack of access to all forms of basic care. So while McGorry’s humane, staged, youth-focused model has clearly improved early phases of care, and made us all feel better about being psychiatrists, the deeper epidemiological curve of psychosis outcomes still appears to reflect underlying developmental architecture more than any single treatment or policy lever.
Also, thanks for teaching me the term "neuroleptic threshold". Sounds much better than "stupid threshold", which I used to say.
I've told psychiatrists that I seem to have a "stupid threshold" between 3 and 4 mg of Haldol a day. I'm still smart on 3, but I turn stupid on 4. And they'd nod and go yeah, that's common. Lots of people have a threshold there. Some say body weight seems to play a part, but 3-4 is a common threshold for people around my size.
Anyway, they just rolled with my made-up term "stupid threshold". But I'm gonna say "neuroleptic" from now on.
"The price of not personalizing is unnecessary exposure to metabolic side effects, neurological risks, and the stigma associated with long-term psychiatric medication for a subset of people who could potentially do well with a different therapeutic pathway. "
I wanna add: Part of this price is also more people dropping out of psychiatry completely. Trying to make it as best they can on their own.
Considering the last part, of worsening mental health among the young ... This is all over the western world, right?
There are external factors that have made a HUGE difference to my own "trajectory". I would NOT be where I am today if I hadn't gotten a stable job when I did, because that provided the material circumstances necessary - not sufficient but necessary - for breaking the downward spiral I had been in for a few years (gotten pretty far down at that point). And before that, I would NOT be where I am today if the welfare state hadn't been so strong, still, when I was young.
You could miss out in school and make up for it later. You could drop out and come back and go to uni eventually. There was a lack of housing already, but still waaaaay easier to get a flat and keep it than it is today. You could get temporary jobs and make some money that were far less stressful, and thus easier to manage for a person with bad mental health, than the gig jobs of today.
There have been similar changes in so many countries. People wanna pretend that good mental health is apolitical, of course everyone wants the population to have good mental health, it's not a left-right issue, but oh, it is.
If I had been born with the exact same brain and an equivalent childhood but twenty or thirty years later, I would likely be somewhere near the bottom of the social ladder with pretty serious disabilities.
I just learned of a conference happening at my Alma Mater, William James College, on bridging the gaps in youth mental health care!
“Through interdisciplinary dialogue, attendees will learn concrete strategies to strengthen recruitment pipelines, identity matched mentoring, professional development supports, and retention efforts that promote long term sustainability. The conference will also spotlight collaborative approaches, technical assistance models, and data driven outcomes that demonstrate meaningful progress in increasing access, equity, and culturally responsive care. By convening leaders, educators, students, policymakers, community organizations, and health systems, this conference aims to share evidence-based innovations and inspire actionable steps for strengthening the youth mental health workforce across Massachusetts.” https://web.cvent.com/event/8939722f-b5f7-4459-b877-9d7ad495e17d/summary?environment=P2
Thanks for this very interesting interview. I hadn’t fully appreciated just how central Patrick McGorry’s work has been in shaping the Australian youth mental health system, and how much his thinking is why this is now mainstream in the UK. Reading this, it becomes clear that many of the principles he helped establish—early intervention, proportionate prescribing, strong psychosocial scaffolding, and a staged, recovery-oriented model—are now simply taken for granted in UK early intervention services. It is a marker of the debt we owe to that intellectual and service-level leadership that his ideas feel like ordinary, humane psychiatry to a UK psychiatrist.
At the same time, when one looks across pre-antipsychotic cohorts, post-antipsychotic outcome data, and prospective developmental studies, a consistent picture emerges. A first psychotic episode is not a neutral event; it tends to mark an inflection point in an already vulnerable developmental trajectory. Across eras and systems, outcomes cluster into familiar bands: a minority achieving full functional recovery, a larger middle group with partial or fluctuating functioning, and a significant subgroup with enduring disability. Those proportions have proved surprisingly stable despite major changes in medication, service models, and social policy.
From that perspective, many of the factors we debate—antipsychotic exposure, substance use, and - while humane and desirable - housing, benefits, or psychosocial input— act as confounders around an underlying developmental distribution. The psychotic episode itself, and the environmental sequelae around it, appear better understood as indicators of an intrinsic neurodevelopmental constraint rather than its primary cause.
Within that frame, the evidence for antipsychotics remains strong where it is most robust: in the reduction of acute positive symptoms and behavioural dysregulation. If it were I or my child, I would absolutely want antipsychotic as early as possible in an acute psychotic episode. In the more impaired subgroup, medication can function as a pragmatic containment tool when other supports are limited, while the long-term trajectory is more strongly determined by underlying cognitive, emotional, and social capacity, with even TD being reported in these groups in the pre-antipsychotic literature.
The harder and still unsettled question is what constitutes the “better” life for this group: long-term institutional care with structure and containment, or community living supported by depot medication and social services. Both models have historical precedents, and neither has delivered "good" outcomes for the most developmentally constrained patients in terms of improvements in functionality. That dilemma remains unresolved, and perhaps speaks to the limits of any purely pharmacological or purely social solution. Evidently either are better than no provision with drift into homelessness and lack of access to all forms of basic care. So while McGorry’s humane, staged, youth-focused model has clearly improved early phases of care, and made us all feel better about being psychiatrists, the deeper epidemiological curve of psychosis outcomes still appears to reflect underlying developmental architecture more than any single treatment or policy lever.
Also, thanks for teaching me the term "neuroleptic threshold". Sounds much better than "stupid threshold", which I used to say.
I've told psychiatrists that I seem to have a "stupid threshold" between 3 and 4 mg of Haldol a day. I'm still smart on 3, but I turn stupid on 4. And they'd nod and go yeah, that's common. Lots of people have a threshold there. Some say body weight seems to play a part, but 3-4 is a common threshold for people around my size.
Anyway, they just rolled with my made-up term "stupid threshold". But I'm gonna say "neuroleptic" from now on.
Great read.
"The price of not personalizing is unnecessary exposure to metabolic side effects, neurological risks, and the stigma associated with long-term psychiatric medication for a subset of people who could potentially do well with a different therapeutic pathway. "
I wanna add: Part of this price is also more people dropping out of psychiatry completely. Trying to make it as best they can on their own.
Considering the last part, of worsening mental health among the young ... This is all over the western world, right?
There are external factors that have made a HUGE difference to my own "trajectory". I would NOT be where I am today if I hadn't gotten a stable job when I did, because that provided the material circumstances necessary - not sufficient but necessary - for breaking the downward spiral I had been in for a few years (gotten pretty far down at that point). And before that, I would NOT be where I am today if the welfare state hadn't been so strong, still, when I was young.
You could miss out in school and make up for it later. You could drop out and come back and go to uni eventually. There was a lack of housing already, but still waaaaay easier to get a flat and keep it than it is today. You could get temporary jobs and make some money that were far less stressful, and thus easier to manage for a person with bad mental health, than the gig jobs of today.
There have been similar changes in so many countries. People wanna pretend that good mental health is apolitical, of course everyone wants the population to have good mental health, it's not a left-right issue, but oh, it is.
If I had been born with the exact same brain and an equivalent childhood but twenty or thirty years later, I would likely be somewhere near the bottom of the social ladder with pretty serious disabilities.
Fantastic! Mr McGorry is one of my heroes. His work on clinical staging has been immensely helpful to me.
This was such an excellent conversation! I so appreciate the nuances you and the people you interview bring to conversations in psychiatry.
Very interesting interview with Patrick McGorry. Thanks!
I just learned of a conference happening at my Alma Mater, William James College, on bridging the gaps in youth mental health care!
“Through interdisciplinary dialogue, attendees will learn concrete strategies to strengthen recruitment pipelines, identity matched mentoring, professional development supports, and retention efforts that promote long term sustainability. The conference will also spotlight collaborative approaches, technical assistance models, and data driven outcomes that demonstrate meaningful progress in increasing access, equity, and culturally responsive care. By convening leaders, educators, students, policymakers, community organizations, and health systems, this conference aims to share evidence-based innovations and inspire actionable steps for strengthening the youth mental health workforce across Massachusetts.” https://web.cvent.com/event/8939722f-b5f7-4459-b877-9d7ad495e17d/summary?environment=P2