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Some questions about plans for a “new” model of mental health care

At Croakey last November, Leonie Young, CEO of the national depression initiative, beyondblue, outlined plans to introduce a new model for mental health care into Australia.

She said it was drawn from experience with the UK’s  Improved Access to Psychological Therapies (IAPT), which mainly offers cognitive behaviour therapy, and people who are identified as needing other treatments are referred to mental health professionals for high intensity treatments.

She said the program had shown impressive results, with half of those completing it recovering from depression or anxiety, and the remaining recovering within 10 months. It had allowed about four times as many people to be seen as those who would be seen by traditional face-to-face therapy with similar time and funding.

However, David Pilgrim, Professor of Mental Health Policy at the University of Central Lancashire,  offers an alternative view below. He advises us to be wary of “Poms bearing gifts”.

Tackling human misery requires more than a narrowly clinical response

David Pilgrim writes:

In late November 2010, beyondblue organised a national consultation in Melbourne about promoting the widespread use of psychological therapies.

This was kick started by presentations summarising progress to date in England of the Improving Access to Psychological Therapies scheme (IAPT). This has just presented findings of a pilot trial in Doncaster (a post-industrial, largely white, town in the North of England) and Newham (a racially mixed area of London).

By chance I was on an academic visit to Melbourne at the time and so took the opportunity to attend the event. Knowing a lot about the English mental health policy scene and a little about the Australian one, here I offer some reflections about lessons for both countries to date.

The good news

In developed countries, most government spending on mental health services is directed at controlling risky behaviour in those of working and child rearing age. The very young and the very old lose out by health economic criteria. However, even within that middle adult age band, most (i.e. 95%+) mental health problems are not dealt with by specialist services but are treated in primary care, overwhelmingly with antidepressants.

The IAPT initiative represents a concerted opportunity to respond to these ‘common mental health problems’ by providing a psychological rather than a chemical response to misery.

The argument might simply stop there. After all, who is opposed to helping our fellow citizens who are distressed?

Moreover, if there is an evidence base that a way of responding is cost-effective, then do we have a political not just moral obligation in this regard?

Indeed, IAPT has been about implementing forms of treatment (cognitive behaviour therapy or CBT) which are already of demonstrated efficacy, according to randomised controlled trials. This rationale was at the centre of the group of economists, service managers, psychiatrists and clinical psychologists who drove this initiative in England (the ‘Depression Report’).

The cautions

Here then is some of what Australia can anticipate, given the various critical reactions in England to IAPT.

Western cultures assume that misery is a medical condition and that it should be rectified. Both of these points are challengeable.

Unhappiness is part of oppressed lives, arising from amongst other things: status envy in unequal societies; poor or insecure employment; degraded neighbourhoods; racism; abusive childhoods; bereavement; work place bullying; warfare; and domestic violence. These all predictably make a good number of us unhappy – that is why ‘common mental disorders’ are ‘common’- there is a lot of it about.

Why are these obvious sources of suffering suddenly individual illnesses? Does this medicalisation of misery divert us from social policies to deal with those ‘upstream’ causal factors? By the logic of medicalisation, maybe we should all have CBT (the equivalent of putting Prozac in the drinking water) but could we then miss many political insights about the society we share?

Also, in many Eastern cultures, suffering is simply expected as part of life, and to avoid dealing with its existential realities is an act of bad faith (by turning it into pathology and by making ordinary sufferers, connected in their common humanity, into patients).

In both the UK and Australia, our ethnic mix demands that these cross-cultural differences are respected. If we are now to have a system when the supply side of mental health services offers only one approach (variants of CBT), then what is to be done with the diversity of expectations on the demand side?

The implementation process has also been an opportunity for other insights. For example, why is it that if psychological therapies have an evidence base, they are simply not implemented immediately?

After all antidepressants are not trialled in services in ‘demonstration sites’ before being licensed for general medical use. This shows that drug company pressure shapes political decisions and that a psychological approach (of any sort) has less political leverage with policy makers.

The bid from beyondblue is confirming the same point as the English experience – even though evidence is there already, policy makers want ‘demonstration’ sites. This might be an opportunity as well though to apply this logic equally – in future maybe new drugs (and given their toxic history and poor efficacy, old ones) should also be demonstrated in actual services to work.

Practice based evidence, not just evidence based practice, is a good principle but logically it should be applied across the board.

• A full reference list is available from the author if required. If you would like a copy, please leave a note below.

Comments 6

  1. Captain Planet says:

    Melissa,

    I wonder if you are being deliberately provocative in this article?

    The Diagnostic and Statistical Manual of Mental Disorders (DSM) lists more than 400 different recognised mental illnesses. Almost all of these cause suffering, but your simplistic implication that mental illness is merely normal human suffering, or perfectly natural unhappiness with quite understandable causes, shows a breathtaking ignorance of the complexity and scope of the full range of mental illness.

    Many, many forms of mental illness benefit strongly from Cognitive Behavioural Therapy, or CBT. I can tell you from personal experience that mental illness is drastically under recognised, under treated, misunderstood and stigmatised in Australia and elsewhere, and your attempt to paint mental illness as the unwarranted medicalisation of mere unhappiness is positively destructive.

    CBT offers many patients the hope of actually repairing what is wrong with their mental functioning in the long term, partly or wholly. When you compare this with the “band aid” solution of antidepressants, antipsychotics and mood regulating drugs so often prescribed instead, which do very little except mask the symptoms and make life bearable, CBT gives the chance to return to health instead.

    There is a considerable difference between an individual therapy (Cognitive behavioural therapy, or medication for example) and government funding of an entire treatment delivery mechanism. You ask,

    “if psychological therapies have an evidence base, they are simply not implemented immediately?

    After all antidepressants are not trialled in services in ‘demonstration sites’ before being licensed for general medical use. This shows that drug company pressure shapes political decisions and that a psychological approach (of any sort) has less political leverage with policy makers.”

    The difference is that psychological therapies CAN be implemented immediately, just like medication. It is up to the GP or health professional who recommends, refers or prescribes the therapy or treatment.

    On the other hand, what the UK and Australian governments are talking about is changing the funding model and service delivery itself. If you are going to pour money into a different form of treatment (CBT) you need to check as you go along that it is actually working. Otherwise it’s like cutting funding to Obstetricians and providing and excellent free homeopathy service to expectant mothers. Both options are in fact available but if the state is going to provide one or the other as the preferred method of treatment, you’d better be sure you’re right.

    Certainly drug companies wield undue influence over policymaking, but I believe you are drawing a long bow to make the comparison between the clinical trials and licensing of antidepressants (an individual therapy type), and the manner in which systemic initiatives such as IAPT are implemented. The comparison is not valid.

    Mental illness is a whole lot more complex than someone having a bad day, Melissa. I suggest before you attempt writing about it again, you develop a more in depth understanding of the issue.

  2. Melissa Sweet says:

    Thanks for taking the time to comment Captain Planet. But just a point of clarification – I did not write the article. The author’s details are stated at the top of the post.

  3. Captain Planet says:

    My sincere apologies, Melissa! I missed the “David Pilgrim Writes”.

    Substitute “David” for “Melissa” in my previous comment and my opinion stands, however….

  4. carolinestorm@iinet.net.au says:

    Ms Young, CEO of beyond blue, is impressed by the Improving Access to Psychological Therapies scheme (IAPT). With good reason; by using cognitive behaviour therapy (CBT), a well known, well researched therapy, for clients who are anxious and/or depressed, the scheme claims a 100% recovery rate after 10 months treatment. This rate is obtained after sending clients who are identified as having further needs to MH professionals for “high intensity” treatment. Such ‘high intensity’ selection, of course, can result in any clinic having a high success rate and should not cause too much excitement. Beyondblue has always selected its clients and does not treat the seriously mentally ill.

    It is right to question this “new” model of care, and Professor Pilgrim does so with wisdom and compassion. He sees western culture as believing that “misery is a medical condition and should be rectified”. Misery and distress ARE part of the human condition. So is the fact that the majority of people use their resources to recover from life’s batterings, grief from loss, illness, family, relationship, financial problems, all the universal concerns which disturb our equilibrium. The “medicalisation” of misery is wrong. We have no obligation to help people endure the realities of life, except in personal and charitable ways. Those whose resources are seriously depleted need help and can receive it from such organizations as beyondblue. Our leaders do have ethical and professional duties to fund what care is necessary for the survival of severely ill Australians. They do this for all health services…except the mental health services.

    The question of nomenclature is crucial here. Professor Pat McGorry (Sunday Age, 30/1/11) laid this problem out clearly when he said that at any one time, there are “4.4 million mentally ill” in Australia. The reality is, we have some 3,800,000 people who have problems coping with their lives and some 600,000 people with the devastating and incurable diseases of schizophrenia, bipolar 1 and/or severe affective disorders. Such seriously mentally ill are cited by the World Health Organization as completing 90% of global suicides and by the Mental Health Council of Australia as having only 35% who receive any specialist care.

    We must find names which distinguish these groups, since their conflation is surely depriving the seriously mentally ill. They are catastrophically under-funded, untreated and vulnerable, with a life expectancy of only 55 years. ‘Simple Mental Disorder (SMD)’ and ‘Complex Mental Illness (CMI)’ are examples of how the 4.4 million lumped together as mentally ill could be redefined. The hope is that if such names could be generally used and known, more understanding and less stigma would be the end result. Clearly, a small number of SMD clients may be reclassified as CMI; tragically, the reverse can never occur.

  5. jillian Horton says:

    The need for psychological therapies to be the first line of treatment for depression and anxiety, and medication to be used only if needed, is essential in order to move forward in high quality mental health care. Medication has a role in some cases, but the over use is significantly high in the community. Most people dont want to take medication, or find it not helpful, and often dont get referrals til later in their care.

    What I am however very concerned about is the quick grab at one psychological therapy (CBT) to treat everything and the rest is ignored. How can it be that policy makers or even CEOs of organisations make the decision as to what form of psychological therapy should be used by specialists (or anyone)? Surely the specialist who treats depression and anxiety (eg specialist psychologists) need to be able to assess the person and then discuss with the person, what sort of therapy is required. There is no one shoe fits all. If there is a concern that other less evidenced based therapies may be used, then surely this is more about making sure that people are encouraged to see highly trained professionals, not people with limited skills, or who have done short courses in psychological therapies. Professionals are bound by requirements of ethical care and the use of evidence based therapy.

    On this note, there is a major concern in the community that providing training to people to use CBT is being promoted as sufficient training to assess and treat peoples mental health. Specialist psychologists have 6 years of university training (minimum and often more), PLUS two years of professional supervision, before they are registered as specialists. Are we going to go backward in the need for proper training? If this were to be promoted it would indicate to me that we do not take mental health concerns seriously and we do not recognize the complexity of peoples psychologcal health in the context of their environment and relationships.

    Heres a vote for psychological therapies, but also a vote for proper training and leaving the assessment and therapy choice up to the people who have training to do this.

    Dr. Jillian Horton
    Clinical Psychologist
    Private practice WA
    President of the Australian College of Specialist Psychologists

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