The Real Questions in Mental Health Reform
The Real Questions in Mental Health Reform
[Editor's Note: In this commentary, Professor Patrick McGorry responds to Dr Allen Frances' recent blog, Seven Questions For Professor Patrick McGorry. Their exchange appears in the October 2011 issue of Psychiatric Times.]
Mental health reform: A global challenge
Mental health reform is one of the world’s “grand challenges.” Mental, neurological and substance-use (MNS) disorders constitute 13% of the global burden of disease, surpassing both cardiovascular disease and cancer. The Grand Challenges in Global Mental Health initiative recently identified priorities for the next decade.1 The creation of new knowledge and vastly improved and timely access to mental health care are overarching imperatives. One of the six goals agreed is to advance prevention and implementation of early interventions, and of the 25 key research questions identified, “what neuroprotective agents and/or cognitive retraining paradigms can be used during the period of rapid brain development to reduce vulnerability to disorders in adolescence?” is particularly salient.
On the same message, Dr Thomas Insel, Director of the National Institute of Mental Health, who is playing a most influential role globally, has strongly endorsed the need for what he calls “pre-emptive psychiatry.”2 This means a major endeavour to limit through early intervention the collateral psychosocial damage that flows from delayed and inadequate treatment of potential serious mental disorders. While falling short of primary prevention, pre-emptive psychiatry is a strategy for modifying the course of mental disorders. These messages echo the preventively oriented blueprint published by the Institute of Medicine in 1994,3 which strongly supported notions of indicated prevention and early intervention as an achievable goal in serious mental disorders.
Australia and mental health reform
In Australia we are re-embracing the grand challenge of mental health reform. Australia has a strong record of innovation in mental health, but a poor one in terms of sustaining reform. We have seen repeated cycles of crisis, a surge of reform and a subsequent return to neglect. Our system has been partially modernised through mainstreaming of mental health within the general health system, however it has not been built to scale within nearly two thirds of those who experience mental ill health annually failing to access care. We spend only 7% of our health budget on mental health care. It needs at least double that amount.
Furthermore, the system has been poorly designed and engineered. Mental disorders are the chronic diseases of the young4 with three quarters of new cases emerging prior to the mid-twenties, two thirds of these between the ages of 12 and 25. Australian National Mental Health Survey data reveals that 12-month prevalence also peaks between 18 and 25 years at 26%, and yet despite that this age group have the worst access to mental health care than any other.5
Australia’s Federal government and its eight State and Territory governments committed on August 19th at the meeting of the Council of Australian Governments to a ten year process of reform and investment in mental health care. This has been catalysed by a systematic review of mental health reform options conducted by an independent commission of inquiry, the National Health and Hospital’s Reform Commission, which reported in 2009. All competing views and supporting scientific evidence were objectively considered. Debates on contentious issues were held and resolved.
Mental health policies then passed through a series of filters, including community consultation, parliamentary inquiries and an intense national election period, during which mental health became a major issue. The mental health sector unified and was supported strongly by the Australian community and the mainstream health sector in advocating for a whole of life reform focus, which would seek to transform the failing mental health system. All sides of politics came to recognise, among other priorities, the urgent need to strengthen the disproportionately weak response to young people and to implement evidence-based early intervention services to pre-empt psychosocial damage and disability.
In May this year the Federal government announced an encouraging, though still relatively modest, initial investment in mental health reform to which State governments have now been asked to respond with matching investments. Approximately 25% of this new investment is to be devoted to expanding and strengthening the novel and successful “headspace” program of enhanced primary care for young people aged 12 to 25 years (www.headspace.org.au), and belatedly to make available to thousands of young Australians with psychotic illnesses, the early psychosis prevention and intervention centre (EPPIC) model, developed in Melbourne 20 years ago and now replicated in many hundreds of locations world-wide, including some parts of the USA and Asia, but more systematically in Canada, England, Denmark and the Netherlands. The bulk of the new investment is focused on other stages of life and illness with the largest single amount devoted to integrate and strengthen services for people with severe and enduring mental illness. The alternative government has an even stronger policy commitment to early intervention and young people.
Dr Allen Frances, who does not live in Australia, is understandably unaware of the complex and rigorous processes through which the Australian reform blueprint has had to pass. A fundamental difference between the USA and Australia is that mental health professionals conceive of mental ill health and mental illness in a much more biopsychosocial and holistic manner. Both conceptually and through our universal system of health financing we respect and provide a much stronger level of psychosocial input to patients. We do not equate treatment with the prescription of medication. We do not permit direct marketing of pharmaceutical products to the public.
Under our universal health insurance scheme, Medicare, it is common practice, especially for mild to moderate disorder for people to receive assessment and psychosocial treatment for mental ill health without being prescribed medication. This contrasts starkly with the description of US practice in a recent New York Times story that revealed that psychiatrists no longer have time to talk to their patients, insurance schemes constraining their role to merely prescribing drugs (See: http://www.nytimes.com/2011/03/06/health/policy/06doctors.html?_r=1&scp=2&sq=psychiatry+and+talk+therapy&st=nyt). Operating within such a different healthcare system, it is perhaps understandable that Dr Frances might struggle to grasp that the real impact of the youth mental health reforms in Australia will be to make psychosocial interventions available to young people with mental ill health to a much greater extent, as both an alternative and complement to medication. A measurable outcome will be less reliance on medication for those accessing care.
Mental health and young people
One of the greatest paradoxes of the modern world is that while material well being and physical health have dramatically improved, the mental health of young people in transition from childhood to adulthood has been steadily declining, and this from a low base.6 One of the failures of the field so far is not to have appreciated that the timing and pattern of mental ill health impacts so strongly on young people who, on the threshold of adult life, have the most to lose.7 Society as a whole also loses, in terms of reduced human capital, “mental wealth” and productivity in the broadest sense.8
A recent New Zealand study estimated that up to half of young people in this transition period will experience at least one diagnosable episode of mental ill health with proportionate negative impact on earning potential, educational outcomes and social integration at age 30.9 The scene for this erosion of life chances is often set in childhood but more commonly it takes the ever changing climate of adolescence and emerging adulthood to release the variety of clinical phenotypes we recognise as clinicians, the incidence of which surges through adolescence and peaks between 18 and 25 years.
What we call “disorders” are experienced first by young people and their families as emotional distress, attempts to cope or deny, behavioural disturbances and all too often collateral damage such as vocational failure, substance abuse, deliberate self harm and offending behaviour. Influenced by stigma and the orthodox view that the health of young people has never been better,6 many people make the mistake of assuming that, because emotional distress and damaging behaviours are common in young people, this is “normal” and largely transient, and to intervene would be unnecessary or even harmful. This is dangerous thinking. It confuses being common with being benign; a serious error with often fatal consequences. Malaria is common in many developing countries but hardly benign.
Young people with the highest incidence and prevalence of mental ill health receive the least help to overcome these threats to their survival, well-being and contribution to others. Young people make up 27% of the world’s population and their health needs have been seriously neglected because they are perceived as healthy.10 In Australia only one in four young people with mental disorders gain access to any form of mental health care and this drops to 13% for young men. So far we have made only desultory efforts to understand what is behind this rising tide of mental ill health and try to turn it back. With the advent of headspace and EPPIC, in Australia that is starting to change.
The role of evidence and health system reform
Dr Frances adopts a posture of censure in attempting to play the evidence based medicine card in his opposition to early intervention in psychosis. As a clinical scientist with a long track record in conducting clinical trials and health services research, and who has always regarded evidence as the best insurance policy against heading too far down a wrong turning, I found his comments puzzling.
David Sackett, the doyen of clinical epidemiology, defines evidence-based medicine (EBM) as that which is applied by individual clinicians to individual patients, and evidence-based health care (EBHC) as that which is applied by public health professionals to groups of patients and populations.7 Evidence-based health policy is more complex and has several determinants only one of which is evidence. Cooper11 notes that only 10% of clinical trials and metanalyses focus on health services and most of these are inconclusive. While it is crucial that we continue to conduct randomised clinical trials, these are rare and challenging to carry out at the health system level. It is plain that if we limit health service design and reform to Cochrane-confirmed approaches, we will have a very sparse and indecisive health system. Even the latest Cochrane review12 on the use of clozapine in schizophrenia was equivocal as to its superiority over other atypical agents. So what should be done? Should we wind up the use of clozapine? We do need some common sense here.
Evidence will never be conclusive and the perfect is truly the enemy of the good. The real question is where does the onus of proof lie? Given the serious and often irreversible personal and social damage wrought by untreated serious mental illness, surely we can assume that late intervention is not a practice we wish to support. The status quo is the least evidence-based option and the outcome for schizophrenia does not seem to have changed in 100 years. The status quo has comprehensively failed, to which countless human stories bear witness, and those who defend it are defending the indefensible. One only needs to ask the consumers and their families. So the real question is, how to promote early intervention and sustained holistic care most effectively and safely?
Taking first episode psychosis first, notwithstanding the latest Cochrane, review,13 in which the authors inappropriately blended individual treatment trials and health services research, systematic reviews are now clearly confirming that early detection and more specialised care over the first two years is effective in improving short term outcome.14 Norman et al15 have since shown that the erosion of these gains, which occurs when the patients are discharged to standard adult care, can be prevented if they are offered step-down early psychosis care up to the 5 year point. There are indications that adolescent onset cases may benefit proportionately more from this model of care.16. The crucial TIPS study shows that the beneficial effect of early detection has a long term effect on negative symptoms,17 but because it was quasi-experimental (the best possible design for this research question), it was not able to be considered by the Cochrane reviewers.
While Dr Frances characterises Australia’s decision to belatedly scale up early psychosis services some 20 years after we began our work in Melbourne as “reckless,” in England, and in many other service systems globally, streamed early psychosis services have been in operation across the nation for many years. The early psychosis airplane has been flying internationally for over a decade. Consequently we now have compelling cost-effectiveness data from England, Australia, Sweden and Hong Kong all showing that early intervention for psychosis is excellent value for money, and rather than, as Dr Frances suggests, diverting funds from other seriously ill patients (as if the FEP patients were not) it actually frees up substantial resources for use elsewhere.
The notion that early diagnosis and treatment should be an optional extra is in any case quite bizarre. Reckless even, given that the lives and futures of young people are at stake. Why do we never see oncologists arguing about the relative value of palliative care and early diagnosis, or insisting that we must have perfect palliative care services before we tackle early intervention? Perhaps it is partly due to the historical neglect of mental health care and our own ambivalence about what we have to offer patients. These are stigma-related issues we must confront.