The Margaret Tobin Oration: what does it take to create change in mental health services?

Introduction by Croakey: The Margaret Tobin Award was established in 2003 as a tribute to the memory of mental health reformer Dr Margaret Tobin, and honours special achievement in administrative psychiatry.

Professor Jackie Curtis, executive director of Mindgardens Neuroscience Network, was presented with the 2023 award at the Royal Australian and New Zealand College of Psychiatrists Congress, which is being held in Perth this week on Whadjuk Noongar Boodjar.

Today, she will present the Margaret Tobin Oration, describing her journey of research and advocacy for appropriate physical healthcare for people living with psychosis. An edited version is published below, and we also recommend reading the full oration here.

Also see some #RANZCP2023 tweets, highlighting climate and mental health presentations.

Jackie Curtis writes:

My colleagues and I first developed the Keeping the Body in Mind program at a community mental health clinic in Bondi, in eastern Sydney. What started out as a quality improvement project later ignited into an international movement that has transformed service delivery, with the development of the Healthy Active Lives (HeAL) Declaration, the International physical health in Youth stream (iphYs) and the national Equally Well campaign.

Each of these is now well established, and their momentum means the physical health of people with severe mental ill health is no longer routinely overlooked.

That is truly gratifying and I could frame it as a journey towards a clear goal, proceeding from one achievement to the next.

The truth is less inevitable and much messier. When we started out, there were no signposts and minimal interest – either among our psychiatry colleagues or the specialists in physical health disciplines.

Twenty-two years ago I was a junior consultant psychiatrist working in an early psychosis team, where I watched young people – healthy other than their psychosis – putting on massive amounts of weight. There was one scale in the building and a single blood pressure cuff.

Around this time I attended a talk by Harvard psychiatrist David Henderson, about rapid onset diabetes linked to second-generation anti-psychotic medications. He thought we should measure blood lipids, liver function, weight and waist circumference, but these were just suggestions and had not been evaluated.

So I did a literature review for our team’s journal club. I found four papers, none of them about young people. I then developed a rudimentary metabolic monitoring chart. Our clinicians hand-wrote on the form and took photocopies.

That is how we started screening; the consequences of screening were another matter. Such was the disconnect between physical and mental health care that psychiatry registrars would call me and ask what to do about a patient with blood sugar of 7.5 mmol/l. I would explain that was diabetes, and they needed referral to the diabetes clinic.

My friend and colleague, Professor Phil Ward, suggested we could take the work forward with a retrospective audit of patient files from our early psychosis service. By demonstrating how few included even basic physical measures, we made the case for better surveillance.

Research matters

I was not a researcher and still do not have a PhD, but I now think all clinicians should be involved in research. We should have the intellectual curiosity, and the commitment to our patients, to scrutinise the outcomes we are delivering. We should be in a continuing feedback loop with our own practice, and share our findings – in meetings like this one, and informally with anyone who will listen.

Those were our foundations, and our progress since then has been powered by exceptional people, too numerous to mention them all, and lucky timing. These are just a few:

Andrew Watkins and Catherine Henry, nurses in the early psychosis service, took a diabetes educator course and set up formal metabolic monitoring in 2006, also offering support with diet and exercise. Simon Rosenbaum, an exercise physiologist, arrived in 2010, establishing a gym at the Bondi clinic, and then later, Scott Teasdale a dietitian who developed our nutritional program. Both have gone on to be international leaders in physical activity and nutrition in serious mental illness. Through our people’s professional and personal interests, we were able to create a multi-faceted physical health service alongside psychosis care.

Hannah Myles – in 2008 a third year medical student and now a psychiatrist – transformed the metabolic monitoring form into a polished, professional tool that quickly gained traction in the health system. Hannah demonstrated to me the power of having an extra person to complete things that are otherwise at risk of falling through the cracks, and enabled our first study which found the rate of metabolic syndrome in young people with psychosis was more than double the general population.

In 2010 I got my first grant. I requested $2,000 to present an expert lecture by endocrinologist Prof Katherine Samaras; NSW Health gave me $8,000, to record the presentation and distribute it to clinicians around the state. From there, Katherine, Hannah and I developed what is now the Positive Cardiometabolic Health Algorithm, to step psychiatry trainees through how to protect patients’ physical health. (Since then I have become much better at asking for money.)

Dr David Shiers, then head of the UK’s National Early Intervention in Psychosis development program, as well as a GP and father of an adult daughter living with a psychotic illness, picked up the Algorithm and adapted it to England’s primary care system – the first of many international adaptations. Australian funders took notice, and we found ourselves in a benign funding arms race as the two nations battled to one-up each other.

While I was finalising the first iphYs conference in Sydney in 2011, I received a call from consumer advocate Stephanie Ewart, who asked why there was no-one with lived experience on the program. It was a very good question.

I invited Stephanie to speak at the meeting about her struggle with physical health side effects of treatment, and she brought the house down. I was already tuned in to consumers and open to considering treatments from their perspectives, but until then I had not fully understood the essential role of consumers’ participation in the change process – in research, policy development and service delivery.

Stephanie has gone on to publish research on mental health medication from the consumer perspective, which has made an important contribution to understanding of these issues.

Growing a movement

Each of these developments, small and incremental individually, have coalesced into a movement that is securing real change for some of the most disadvantaged members of our community.

I have learned a lot along the way about mental health service reform, and it seems to me that you need to be powerfully motivated by values, and ready to jump on opportunities – however they may present themselves.

Our achievement in physical healthcare in psychosis was accidental in that we stumbled on something critically important.

But it was also intentional; our guiding principle was a deep focus on consumers, and we refused to accept compromised physical health as just an unfortunate by-product of treatment.

With that in mind I want to share some final calls to action:

• Each of us is individually responsible for the quality of care we give our patients, who still die too early with preventable physical health conditions. This is a human rights scandal and we need to stand with them and put ourselves on the right side of history.
• Public psychiatry is really rewarding and really important. In public clinics, with more disadvantaged patients and over-worked colleagues from multiple disciplines, you really can make a difference.
• Administrative psychiatry, or reform psychiatry, is not different from your day job. You just need to be prepared to go where patients’ experiences and your observations take you.

Thank you for the opportunity to present the Margaret Tobin Oration, and thank you for listening.

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See Croakey’s archive of articles on mental health matters