Abandoning the mentally ill

Australia’s psychologists are an under-utilised resource in our attempts to treat or prevent mental illness and this results in unnecessary suffering and a waste of health resources. The fact they are under-utilised is largely because of short-sighted, ill-informed government and non-government policies.

It is important - from the point of view of the Australian Psychological Society, the peak professional body of psychologists with over 14,500 members - to emphasise that by no means do all psychologists work in the mental health area. Those who do are usually clinical psychologists and are probably the largest and best known sector of our profession.

This perception is a source of frustration to those who work in the areas of health psychology, forensic psychology, industrial and organisational psychology, educational psychology, counselling psychology, sports psychology, or psychological research and teaching. Because mental health issues arise in all areas of life, psychologists in all of these other areas can find themselves drawn into clinical work, but it is not their main focus. For the purposes of this article, the psychologists I refer to will usually be clinical psychologists.

Historically, as in other areas of health, the emphasis has been on the treatment of mental illness after it has developed. Only recently has health research recognised the advantages of preventing illness and health promotion but it is an area which still receives comparatively little funding and consequently less application.

The sad fact is more than a half the Australians with a psychological disorder will receive no treatment - not just bad or inadequate or out-of-date treatment, although there is plenty of that around - but no treatment at all. They will just endure their mental illness, with the attendant adverse effects on those around them and loss of productivity to the community.

Mental illness continues to suffer from its traditional stigma. Those with little direct experience of it often cling to a belief that it represents a lack of willpower, determination or courage and that mentally ill people should just “pull up their socks” and “get on with life”.

It’s definitely easier to raise funds for research into, or treatment of, a physical illness such as cancer, than it is for schizophrenia or depression. Governments know this and it shows in their funding decisions. Simply, there are not adequate resources in the Australian community to effectively meet the needs of people who are mentally ill.

This situation has been worsened by government policies. First was the policy of deinstitutionalisation. This recognised correctly that the grand old psychiatric hospitals were little more than waste bins for mentally ill people, and should be replaced by practices that keep them within the community, as much as possible, and helping them to integrate with normal life. But this can only work if the old institutions are replaced by adequate community support to help mentally ill people adhere to their illness management plans and enjoy good quality of life.

Governments have happily pocketed the savings made by closing the old institutions but failed to spend anything like enough to deliver adequate community support. As a result, many mentally ill people wind up in doss houses, prisons or homeless.

Despite persistent misrepresentations by the media, mentally ill people are no more dangerous than anyone else, except when their illness is active, meaning they have stopped adhering to their treatment plan, often because the necessary support wasn’t available. The Hollywood stereotype of the mentally ill bogeyman does not help.

Second, state governments, the major providers of mental health services, and hence often employers of psychologists, have embarked on a penny-pinching program of converting psychologists’ positions to generic mental health worker positions. Their apparent belief is that anyone with any vaguely relevant training can deliver effective psychological services. The underlying motive is more likely that the cost of employing a two-year TAFE-trained welfare worker is much less than the cost of employing a four or six-year university trained psychologist. There is little, if any, real evaluation of the effectiveness of cheap mental health services, just claims of provision.

The mental illness of depression illustrates many of these points. The WHO has predicted by 2020 depression will be second only to cardiovascular disease as a source of excess mortality, morbity and disease burden to the community. There goes the myth that mental illness isn’t really important.

Last year the National Heart Foundation stated that research now showed depression is as serious a risk factor for heart disease as the traditional risk factors, such as obesity, smoking, lack of exercise or excessive cholesterol. They emphasised that it is a risk factor in its own right, and not only because many people try to manage their depression by smoking, drinking excessively or eating unwisely. That is hopefully the final nail in the coffin of the belief that mental and physical health are separate and unrelated.

Leading health researchers and practitioners acknowledge the most useful approach to understanding and treating illness of all kinds is a biopsychosocial one. Any illness has biological, psychological and social components. To focus on just one or even two of these while ignoring the rest generates inadequate explanations of causality and less than best practice treatments. Yet we are saddled with a health system that is overwhelmingly biomedical in its focus and expenditure, paying scant attention to the psychosocial factors involved.

Evidence-based psychotherapy is at least as effective in the treatment of depression as is evidence-based drug therapy. It does not incur the negative side effects experienced by many people taking anti-depressants and it does not require several weeks to begin to be effective. Conducted properly, following the evidence-based procedures, it can not only alleviate a current bout of depression but make the person less vulnerable to depression in the future: whereas the majority of depressed people helped by anti-depressants will relapse in the future.

Psychotherapy is not a panacea and not 100 per cent effective but it should be as readily available to depressed people as drug therapy is, if only for the sake of cost-effectiveness if not out of humanity. But it isn’t. The Australian Government’s response has been to try to encourage GPs to take training in CBT (cognitive behaviour therapy) for depression and to offer a brief version of CBT through a small number of “long” consultations. This is patently silly. The research demonstrating the effectiveness of CBT for depression involved 12 to 20 one-hour consultations with a highly trained cognitive behavioural therapist, usually a psychologist, sometimes a psychiatrist.

When I run introductory workshops in CBT for GPs they nearly all say that it is wonderful to hear something effective is available for their patients, other than drugs, but they don’t have the time or even the wish to do it. Suggesting a depressed person will be helped by “brief CBT” delivered in a handful of relatively short consultations by a briefly trained GP is as silly as suggesting that psychologists should be allowed to prescribe anti-depressants (or other drugs) in doses smaller than those known to work.

GPs often say they would like to be able to refer their depressed (or anxious or alcoholic or stressed and so on) patients to psychologists but can’t because of the costs to the patient. This reflects the policies of successive federal governments in refusing to include psychologists’ fees in Medicare, despite being given evidence that doing so would most likely reduce the nation’s health costs. Instead of being lifelong consumers of anti-depressants, anti-anxiety drugs, sleeping drugs or other psychoactive medications, many people could be “cured” and cease to be a cost to the health care system.

Only in the past two years has the present government caved in to political pressure - sadly not to reason, logic, or humanity - and included a very restricted set of psychological services in Medicare. The private health funds typically offer miniscule rebates for psychological services, often the same as they offer for “complementary health services” with little or no evidence for efficacy or safety. This policy is obviously based on marketing decisions, not on a genuine concern to provide access for their subscribers to treatments with abundant evidence for efficacy and safety.

That evidence is extensive. A good, accessible starting point to find this is the Cochrane Collaboration. Psychological researchers have made huge progress in developing effective and safe treatments for a wide range of psychological disorders, in adults, children, adolescents and families. It is a shameful reflection on governmental and other policies that most Australians who would benefit from these treatments cannot access them, despite there being a large and growing number of psychologists in the community.

Finally let me address prevention of mental illness and promotion of mental health. It is clearly more humane to prevent people from becoming ill in the first place and to help them to enjoy good mental health and quality of life. However, I have become sceptical of governments’ humanity, so let me instead repeat what we already know about disease prevention and health promotion. It’s much more cost effective. In the long run, it saves money.

Unfortunately, it’s the length of that run that is often the problem in Western democracies, where there is understandable pressure on governments to fund things that get results before the next election. It will require a government of sincere commitment to fund mental illness prevention and mental health promotion programs, because they will necessarily focus on children and the beneficial results will not be seen for some years.

A growing body of research supports the notion that adverse early experiences can instil unhelpful basic thinking patterns which render people vulnerable to developing psychological disorders. Less obvious is the fact that many, if not most, of these adverse experiences are the result of poor parenting skills rather than outright abuse or neglect, although these also do occur.

Australian psychologists at the University of Queensland have developed a clearly effective parenting skills program, the Positive Parenting Program (PPP), which is being widely adopted throughout the world, including major, government-funded trials in the USA. It is ironic that children in Hong Kong are enjoying the benefit of this Australian product while many Australian children do not. Similarly we know the majority of couples who attend marriage preparation or enhancement programs are those who need them least and hence benefit least, while the couples who really need them can’t or won’t access them. We know a lot about making relationships successful. Why aren’t we making better use of that knowledge?

Australia has a large corps of psychologists trained in and often contributing to best practice in mental illness treatment and prevention. It’s long past time that governments and NGOs took a careful look at the evidence for this and started to better utilise our psychological resources.