5.18
One of the greatest obstacles to addressing the
diversity of mental health need is the incapacity of the present health system
to deal with anything other than the most acute levels of need. Dr
Ruth Vine,
Director of Mental Health, Department of Human Services of Victoria, told the
committee:
Public funding is directed towards those most vulnerable, those most
in need, those who may require treatment under the protection of the Mental
Health Act. The recognition that this area has been under increasing demand and
does require expanding services is shown in the growth of the mental health
budget that has occurred.[299]
5.19
The mental health legislation sets out certain
priorities:
One of the challenges for public mental health policy is to
strike a balance, and we have to strike lots of balances. One balance is
between the issues of safety and autonomy, another is between the interests of
the community and the interests of the individual, and another is between the individual’s
immediate safety and their longer term safety. That is why we have mental
health legislation—to try to strike that balance and to try to take into
account the different interests.[300]
5.20
The NMHP interprets this to suggest that the right
'balance' involves prioritisation of care for people with severe mental health
problems but also ensures that ‘appropriate services are readily accessible to
all Australians with menta health problems’. This means that implementation of
early intervention and prevention strategies and other health and community
services, such as housing, employment and income support, are also necessary.[301]
5.21
Under current funding levels, however, most
jurisdictions have adopted the Mental Health-Clinical Care and Prevention
(MH-CCP) model, where state and territory funds aim to address high need,
severe illnesses, leaving the high prevalence disorders, such as anxiety and
depression, to be carried by federal government initiatives. The NSW Government
reported:
In broad terms the MH-CCP model accepts the current division in
which specialist public mental health services operated by States and
Territories provide the vast majority of care for people with severe illness,
and especially those who currently consume 50per cent of state resources,
namely people who are so ill that they must be treated under the involuntary
care provisions of mental health legislation. The other 50 per cent of State
services extend as far towards moderate and mild levels of illness as resources
permit. The “care packages” in the model assume an increasing role for
non-specialist clinical services, especially in primary care, for the high
prevalence by lower severity illnesses. Most of these would be expected to be
provided under Medicare, though generalist community health services would also
be involved, especially in rural and regional areas where – for example –
private psychiatry is either non-existent or extremely scarce.[302]
5.22
In Victoria the result is that, as Dr Vine stated, 'the most in your face' level of need is
prioritised, hence in Victoria the majority of funding goes to adult and youth
services, at 60 to 70 per cent, aged care gets 20 per cent, and child and
adolescent services only nine per cent.[303]
5.23
Medical health professionals argued that the focus
needs revision; delivery models should be front end and preventative, and
address the continuum of need across both high and low-prevalence disorders:
...greater focus on early intervention and illness prevention is
needed across the board, in both low prevalence severe mental health disorders
such as schizophrenia and other psychoses, and in the high prevalence problems
of anxiety and depression.[304]
5.24
Professor Patrick
McGorry of ORYGEN Research Centre agreed:
I am sure you have heard this from a number of submissions but
what we see in mental health care in Australia
is too little, too late. The services that are provided at the state level are
tightly targeted at people with end stage illnesses, severe chronic illnesses
or in very acute, high-risk situations—they may be acutely suicidal, aggressive
or behaviourally disturbed. So the care is reserved, in a sense, at a state level
for that group of patients. The whole concept is to intervene early and prevent
people from getting to that high-conflict stage—where they almost have to force
their way into care—which can be avoided, but the current model of care and
resource levels at a state level are impeding that. There is a resistance to
this mind-set.[305]
5.25
Given the substantial pressures of competing need
within the system, it was argued that the onus is on the federal government to
set up support and funding structures which will train service provision
towards the goal of early intervention and preventative care across the
spectrum of need:
...the failure to specify the priority populations for care has
led to a debate in which the needs of those who were to be given priority under
the National Mental Health Policy have been combined with the much larger
number of people in need of primary care and relatively low levels of
specialist care. This is a long-standing issue in mental health, and for the
same reason: all mental illnesses that warrant a diagnosis are “serious”, but
they are not all equally acute, disabling, or in need of the same kind of
treatment.[306]
Caring for the most vulnerable
5.26
At present the NMHP not only fails to articulate
priorities, it also excludes a number of significant areas of urgent mental
health need from its purview. In the main, those disorders neglected are
complex conditions combining features which fall into disputed territories
between mental health and other health treatment regimes. These people are
arguably the most vulnerable consumers in the community. Failed by demarcated
service regimes, they are falling through the cracks in the mental health
framework.
5.27
As discussed above, psychiatry and psychology have
sought to move away from the distinction between mental and physical aspects of
mental illness, and this is reflected in the definition of mental illness applied
within the NMHP. Unfortunately, the traditional service divisions between
physical, mental and intellectual disability services are not so easily
overcome. This is reflected in the way the NMHP ascribes responsibility for
significant mental health problems to other service systems.
5.28
In particular, dual diagnosis, a growing problem among
youth, is the domain of the drug and alcohol service system, and dementia, on
the rise as the population ages, is primarily the responsibility of aged care
services.[307] The fragmentation of
service delivery for the people with dementia and for those with dual
diagnosis, as discussed here and in other chapters of this report, is therefore
underpinned by this approach, which establishes them as 'non core'
responsibilities for mental health; related, but separate to the mainstream
mental health agenda.
5.29
At the other end of the spectrum, people with
comparatively rare but complex high need disorders, such as intellectual and
developmental disabilities like autism are left outside any identifiable care
framework. The mental health system does not own responsibility for oversight
of targeted assistance, and nor does mainstream health services. [308] In this way there is a lack of impetus and a
lack of flexibility in the system to address the diversity of need in the
holistic way intended by the NMHS. Dementia, dual diagnosis, and autism as
cases in point, are discussed in more detail below.
Dementia and mental illness
5.30
As discussed
in Chapter 15, the mental health of older Australians is not adequately catered
for compared with other groups in the community. Although some developments in psychogeriatric services are occurring at state level, [309] there is a need for a comprehensive
national plan:
Mental health policy is largely focused upon the needs of
relatively robust adults, with more recent attention given to the needs of
children and adolescents. The third National Mental Health Plan acknowledges
the elderly as a priority group, which is welcomed. However, there needs to be
an insertion of the effort and resources required to develop this recognition
into a coherent plan for comprehensive mental health service provision to older
people across the nation.[310]
5.31
The key
policy document for older people, the Public Health Action Plan for an Ageing
Australia (2003), is implemented by the Department of Health and Ageing, with
some assistance from the Department of Families, Community Services and
Indigenous Affairs.[311] However, the
partnership with mental health services needed to produce the comprehensive
approach required is poorly developed:
There appears to be disagreement at National, State and Area
Health Service levels regarding the respective responsibilities of Mental
Health versus Aged Care departments. This is then further exacerbated by
disagreement regarding the respective responsibilities of different levels of
government. The consequence of this is that, even when the need for such
services is acknowledged, at all levels the funding of mental health services
to older people appears to always be something that should be sought ‘from
someone else’. This problem is particularly evident in attempting to develop
services for people with mental health disorders in Residential Aged Care
Facilities; or who have Behavioural and Psychological Symptoms of Dementia
(BPSD). BPSD is a term that has been developed to describe those people with
dementia who develop associated mental health and behavioural disorders.[312]
5.32
The Australian Government acknowledged that people with
dementia and their carers are experiencing serious access problems.[313] Significant government funding was committed to health care in this area:
Existing Australian Government programs that support people with
dementia and their carers currently attract funding of more than $2.6 billion
annually. The government further extended this commitment in the recent budget
by allocating funding of $52.2 million over four years to assist people with
dementia by making dementia a national health priority. This funding will
increase support to people with dementia and their carers through a wide range
of initiatives, including innovative care, assessment, hospitals, workforce,
palliative care and GP initiatives that directly benefit people with dementia
and their families.[314]
5.33
However, without a coherent plan to integrate
approaches across the distinct silos of aged care and mental health services,
people with complex presentations of dementia and mental illness are unlikely
to receive the comprehensive assistance they need:
...if an older Australian develops mental illness this becomes an
impediment to obtaining access to appropriate support services (ongoing or
respite) in the community or within Residential Aged Care. This can be because
services consider (officially or unofficially) that the presence of a mental
illness makes the person ‘outside their scope’; fear that the presence of
mental illness (even depression) may make the person dangerous or inappropriate
for the service; or because no services have been developed for those who do
require services with able to refocus upon people with ongoing mental illness.[315]
5.34
The Office of the Public Advocate Victoria
concluded:
There is little evidence that the projected dramatic increase in
the incidence of dementia ...is matched with preparedness in the mental health
system in terms of infrastructure and expertise. There is potential for a considerable
negative impact upon services already over-stretched and supported
accommodation already in critical under-supply.[316]
Dual diagnosis
5.35
Dual diagnosis is the combination of mental health
disorders with substance abuse. Dual diagnosis has increased most markedly
among young people.[317] At the same
time, self medication among all people with mental health disorders has
increased to the degree that dual diagnosis has become more like the rule,
rather than the exception, among consumers.[318]
As noted above, the NMHP ascribes responsibility for people with dual diagnosis
to drug and alcohol services and the National Drug Strategy provides the
framework of care. In relation to illicit drugs, the overall focus is on
control and regulation of supply, demand reduction strategies, including
abstinence-focussed treatments and harm reduction strategies.[319]
5.36
In recent years the rising incidence of co-mordity, as
it is also termed, has supported a substantial increase in the number of people
with mental illness in gaol. Predominating among these are young men[320] and Indigenous people, a
disproportionate number being women.[321]
Submissions to this inquiry took the view that this trend is a direct
consequence of the failure to adequately respond to the mental health needs of
people with dual diagnosis, combined with an increased focus on law and order
models to control perceived behavioural problems.[322]
5.37
The increased prevalence of dual diagnosis has
highlighted a service gap for this group which has been growing for over twenty
years:
At one time psychiatric illness and the problems of dependence
(inebriation) were regarded as closely related and care was provided in the
same institutions and through similar sets of services. Australian health care
saw these two areas separate several decades ago. That was a positive change at
the time, however, with the increasing recognition of the coexistence of mental
health and substance use problems, this separation needs to be rethought, and
new organisational and professional approaches devised to respond to this area
of serious unmet need more appropriately.[323]
5.38
The Australian Medical Association judged the failure
to integrate services for people with dual diagnosis as an exemplar of the
inefficiencies of the mental health system overall, with its reactive focus on
episodic and acute need:
The separation of some services results in significant
inefficiency eg between mental health, drug and alcohol services, and there is
scope to improve patient outcomes by integrating these services. Existing
funding mechanisms favour defined episodes of care. However the mental health
conditions that generate the highest burden of disease are chronic conditions
and they require longitudinal care. The Commonwealth/State funding arrangements
are dysfunctional, funds are wasted in duplication of administration and policy
formulation while a silo mentality detracts from the continuum of care.[324]
5.39
The committee received evidence from stakeholders and
many personal stories illustrating the limited access that people with dual
diagnosis have to services which can provide assistance. Some state and
territory governments have responded to the extent of unmet need, attempting to
bridge the gaps. The Mental Health
Legal Centre – Victoria reported:
Complex and co-morbid
conditions and drug and alcohol dependence, affects many of our clients. Like
many people with multiple needs this may mean being on the waiting list for a
number of different specialist services, though never being a priority for any,
each service expecting another ‘more appropriate’ service to act. These clients
fall between the gaps between service silos. The Victorian Department of Human
Services was perplexed by the plight of such clients and established new
legislation for some such complex clients. It is envisaged that the complex
care list will provide a range of services to those people deemed to be some of
Victoria’s most difficult clients.[325]
5.40
The extent of the problem of dual diagnosis, and
proposals for a 'whole-of-government' response are discussed in Chapter 14.
Autism—intellectual and developmental disorders
5.41
Between one and three per cent of people in the
community have a developmental or intellectual impairment.[326] Many have coexisting mental health
problems consequent to their disabilities, such as stress, anxiety, depression
and sometimes psychosis.[327] Their
situation exemplifies the very considerable diagnostic and service access
problems for people with complex disorders:
They require constant support and assistance across the
lifespan....yet they are a very diverse group— their needs are often very
individualistic...in the UK and parts of the USA psychiatrists specialise in
the treatment of this group – in Australia, they fall through the gaps in
service provision because they don’t neatly fit into eligibility
criteria...they dont "fit" because of their cross agency, cross-professional
needs....in Australia few psychiatrists have the inclination, the skills or the
expertise to be involved, this is a huge unmet need, clinicians don't know how
to help this group—how to serve their best interests.[328]
5.42
As the Burdekin Report noted, there is 'a huge number
of intellectually disabled people who receive no treatment for their psychiatric
disorder because there is none available'.[329]
At the extreme end of the spectrum, is the situation of those with severe
developmental or intellectual disability; in June 2005, the Senate Community
Affairs Reference Committee reported on the distressing circumstance of
affected young people relegated to aged care facilities.[330]
The gravity of their situation and those of people with intellectual
disability and mental health problems more generally, requires more specialised
attention, and should perhaps the focus in a separate inquiry.
5.43
Autism Spectrum Disorder (ASD), including high
functioning Autisms or Aspergers syndrome, is a developmental disability,
although it is also classified as a mental illness under the diagnostic
treatment manual.[331]. Termed
Pervasive Developmental Disorder by the mental health sector, ASD is not
regarded as a treatable condition. Accordingly:
Policy in the mental health sector does not provide the
resources or funding for the clinical treatment that people with autism need.
Nor does any other section of government...existing policy excludes people with
autism from the effects of the National Mental Health Strategy.[332]
5.44
Rather cruelly this exclusion extends to access of
services under the Better Outcomes Initiative. A parent was advised by a mental
health department official:
Can I explain at the outset that the Better Outcomes Initiative
is designed to support GPs in the management of their patients with mental
health conditions. The Initiative was mentioned in the correspondence to you as
being one of the mainstream programs we have in the health portfolio which may
be of interest to families of children with autism. The program itself does not
extend to developmental disabilities and provides treatment which specifically
targets mental health conditions.[333]
5.45
This has serious consequences for the up to one percent
of children who will be diagnosed with (ASD) before leaving school.[334] Effectively, children with Autism
cannot access early intervention and preventative treatments available to other
children with mental health problems. This is despite recognition of the
effectiveness of these for ASD in the diagnosis reference manual:
The DSM-IV [1], first published in 1994, formally recognised PDD
(or ASD) as a family of clinical conditions, categorising them on Axis I with
the other mental disorders. Internationally, recognition that ASD requires
treatment resulted in improved early intervention and treatment regimes being
provided for people with ASD.[335]
5.46
Autism Aspergers Advocacy Australia asked for urgent
recognition of the validity of recovery-based models of care for children with
autism and for implementation of affordable and evidence-based early
intervention approaches by public health services.[336] A key mechanism is early identification
by screening. Under identification of autism can have profoundly negative
outcomes in adult life. Studies have found, for example, that a significant
number of people diagnosed with schizophrenia or psychosis and unresponsive to
treatment have undiagnosed ASD.[337]
Marginalisation of some disorders – Borderline Personality Disorder
5.47
Borderline Personality Disorder seems to be as much a
recipe for marginalisation as it is a diagnosis:
My daughter is now thirty years old and still no closer to
getting the help or support she as a human being deserves and should be able to
expect.
A few of the diagnoses mentioned by the government authorities
are: psychiatrically ill, post traumatic stress disorder; self harmer;
suicidal; major depression and borderline personality disorder. The most recent
diagnosis I have was that there is nothing wrong with her. Is it any wonder one
can not cope with life? ...
As a mother it has been and is a heart wrenching exercise to see
a loved one go through what my daughter has been through and to hear and see
the cries for help go unnoticed or dismissed as being ‘attention seeking’.
There is barely a patch of unmarked skin on her arms or neck where she has
slashed herself or attempted hanging. ...
Borderline Personality Disorder (BPD) is as I understand, a
difficult thing to diagnose, but it can be done and it can be treated according
to a Psychiatrist in Victoria.
He recommends psycho-therapy and a mild medication for depression and anxiety
which is part of BPD. He also states that many mental health clinicians dismiss
people with BPD as being ‘trouble makers’. What a sad indictment on our
society.[338]
5.48
The evaluation of the second National Mental Health
Plan noted that the role of the mental health system in the treatment of
personality disorders was a particularly poorly understood issue.[339] This remains the case. While
personality disorders clearly fall within the domain of mental illness, as
defined in the DSM-IVR and ICD-10, those experiencing these disorders find it
particularly difficult to access services. The Victorian Office of the Public
Advocate assessed that '[p]eople with personality disorders are often excluded
from the system through clinical judgements'[340]
and recommended that there be '[g]reater acceptance of responsibility by the
mental health sector for the provision of services for people with diagnoses of
personality disorder'.[341]
5.49
Submissions to this inquiry particularly highlighted
the plight of those experiencing Borderline Personality Disorder (BPD).[342] A diagnosis of BPD closes the doors
to already limited mental health services. It leads to social rejection and
isolation. Sufferers are blamed for their illness, regarded as ‘attention
seekers’ and 'trouble makers'. BPD is the diagnosis every patient wants to
avoid.
5.50
The ICD-10 classifies BPD under 'Emotionally unstable
personality disorders', which are characterised by:
...a definite tendency to act impulsively and without
consideration of the consequences; the mood is unpredictable and capricious. There
is a liability to outbursts of emotion and an incapacity to control the
behavioural explosions. There is a tendency to quarrelsome behaviour and to
conflicts with others, especially when impulsive acts are thwarted or censored.[343]
5.51
ICD-10 further notes that BPD is particularly characterised
by 'disturbances in self-image, aims, and internal preferences, by chronic
feelings of emptiness, by intense and unstable interpersonal relationships, and
by a tendency to self-destructive behaviour, including suicide gestures and
attempts'.[344]
5.52
There is a strong link between BPD and experiences of
childhood abuse,[345] but this is too
often ignored in the targeting of service responses:
Many of our clients have childhood abuse and neglect histories.
There appears to be a political blind spot in relation to childhood abuse in
terms both of State policy and everyday practice, the National Mental Health
Strategies are silent about it. People who have early experiences of child
abuse and neglect often end up in the mental health system particularly but not
exclusively with diagnosis of dissociative identity disorder, borderline
personality disorder and other forms of personality disorders; there are many
people who have the diagnosis of psychotic illness who have early experiences
of abuse and neglect.[346]
5.53
The AMA report data that, although a decade old, put
the prevalence of borderline personality disorder at 0.3 per cent of the
population, around the same as schizophrenia (0.4 per cent).[347] However, the likelihood of obtaining
appropriate treatment for BPD is markedly different:
For
example, we know that if you have Borderline Personality Disorder (BPD) somewhere
in your history you’ve probably got a very limited chance of attracting a
service regardless of the seriousness of your pain or functioning. Alternatively, if you’ve managed to
attract a diagnosis of Schizophrenia your chances improve markedly.[348]
5.54
BPD is marginalised within the community and within the
mental health sector. There is a lack of recognition of the disorder as a
mental illness and a lack of service response, let alone specialised treatment
response. Discrimination is evident and studies have reported negative
attitudes and a perceived lack of training amongst clinical staff toward
patients with BPD.[349]
Certain diagnoses seem to have greater and lesser status in the
community and in mental health systems.
This status is often contradictory. It seems that “proper mental
illness” (psychosis) brings some status within mental health systems but is
perhaps most vilified in the community. Alternatively,
‘nasty behaviour traits’ (e.g., Borderline Personality Disorder) does not carry
the same burden as Schizophrenia in society but is a dreaded diagnosis within
mental health services and often leads to clinical neglect and gross and unfair
judgments by many clinicians.[350]
5.55
The marginalisation of BPD has it roots, at least
partly, in the early focus of the Mental Health Strategy on ‘serious’ mental
illness, without a clear concept of how this emphasis would be interpreted for
service delivery:
...since the emergence of the First National Mental Health
Strategy some groups (and I have referred specifically to people labelled as
having Borderline Personality Disorder and people too often not recognised as
having Dissociative Identity Disorder) have been so badly marginalised that it
will take a reversal of policy and a radical retraining and reorientation of
clinicians to overcome the systemic neglect at the State policy and local
level.[351]
5.56
Even the labelling of the disorder is marginalising:
Derogatory labels such as Borderline Personality Disorder must
be examined and new, more respectful, and more accurate terms such as Complex
Post Traumatic Stress Disorder be considered.
Consumers must decide how they would like their distress to be
described.[352]
5.57
Clinicians too encounter the mental health sector's
routine discrimination against people with BPD and are unable to secure
appropriate treatment responses for their patients:
My patient had rapid, severe mood swings and a tendency to
self-harm. She met the criteria for borderline personality disorder. There is
increasing evidence that, rather than a wicked soul, dysfunction of the brain's
limbic system underlies this condition. This dysfunction is often associated
with past emotional trauma. Among my female patients, a history of childhood
sexual abuse is common.
This already disturbed young woman had problems dealing with the
murder of a friend and I sought psychiatric help for her.
She told me that the community mental health service said she
didn't have a mental illness. She was also assessed at a public hospital
psychiatric unit and apparently told that she didn't need a psychiatrist. None
of this surprised me, and I'm not blaming the clinicians who assessed her. Like
most health care problems, the fault does not lie with individuals. They were
merely following their training and, of course, to a degree restrained by the
resources allocated to the public system. There was certainly nothing unique
about the failure to achieve psychiatric support for this woman and I have been
down this same path many times with many patients in many locations.[353]
5.58
There is a clear need for a change in service response
for those experiencing BPD, including the provision of treatments appropriate
for this disorder. As noted elsewhere, a 'one size fits all' response is
inappropriate for 'mental illness', and this is exemplified by the experience
of BPD. For example:
It has been known for many years now that inpatient settings are
terrible places for people with who have Borderline Personality Disorders. Many get “‘re-triggered’
into reliving their abuse experiences and sometimes self harm as a consequence.”
More than any other category of patient these women (usually) do really badly
in hospital. Because of this most
services now have a system where people with Borderline Personality Disorder
are told they will only be admitted very briefly (no more than four days) and
only once every two months for example.
However, the triage system is often too clumsy to pick up people who
have not been hospitalized with psychotic illness as being needy of case
management. Unfortunately many people with this Borderline diagnosis (for
example) lead a terrible life on the streets, cutting themselves regularly,
perhaps picked up for a few days in an acute setting, told that what is happening to them isn’t
serious and sent out to deal with their lives themselves. This happens even
when it is demonstrably shown that they can’t do this on their own.[354]
5.59
Some of the most appropriate treatment responses for
BPD are not available:[355]
Many people who have been diagnosed as having ‘syndromes’ like
BPD or DID which need long term psychotherapy or Dialectical Behavioural
Therapy (DBT) and more intensive interpersonal relationships with therapists
over a longer period of time (rather than medical drugs) are now ‘out of policy
fashion’. Consumers recognise and are very concerned that since the publication
of the First National Mental Health Strategy public systems throughout Australia
have lost a whole generation of psychotherapists.[356] [emphasis in original]
5.60
Ms Merinda
Epstein pointed out that the private sector
is providing some of the best services for people with this disorder:
The
irony is that some consumers who have been literally ejected from the public
system have found very special private psychiatrists with an interest in BPD and DID and who use
psychotherapeutic tools and ‘talking therapies’ either instead of or as an
adjunct to drug therapy. Often, these clinicians are also refugees from the
State system where they found their skills were no longer wanted.[357]
5.61
However, access to the private sector is an issue for
many with mental illness, with few private psychiatrists' bulk billing for
their services. Accessible,
appropriate treatments for those experiencing BPD, and an end to marginalisation
of the disorder within the community and the mental health sector, are urgently
needed.
Need for specialist services for some disorders
5.62
Given the diversity of mental illness, there is a need
for specialist services that allow response to distinctive features of
conditions. Whilst not an exhaustive
exploration of the spectrum of mental illnesses, this section examines: eating
disorders; anxiety; obsessive-compulsive disorder; and, post-traumatic stress
disorder.
Eating Disorders
5.63
Eating disorders – grouped into three broad categories
in the DSM-IV; anorexia nervosa, bulimia nervosa and eating disorders not
otherwise specified (eg binge eating disorder) – are a common group of
psychiatric disorders with a spectrum of severity, and can include significant
levels of medical complications.[358]
Anorexia nervosa has the highest rate of mortality of any psychiatric disorder.[359]
5.64
There are many obstacles to obtaining help for the
treatment of eating disorders. The Centre for Eating and Dieting Disorders reported
that generalist and mental health professionals have expressed 'a lack of
knowledge and skills' on eating disorders, which leads to reluctance in their
willingness to work with people presenting with such disorders. The Centre also
highlighted the stigma that results from the misguided and damaging notion that
eating disorders are 'self-induced' and that the consumer is in some way to
blame for their illness, so treatment is denied.[360]
5.65
The inadequacy of services for people with eating
disorders was highlighted in a submission by a person with recurring bouts of
anorexia nervosa. The submitter explained that the only long-term support
available was through a private practitioner. Paying for this support required
the selling of personal assets.[361]
5.66
The Centre for Eating and Dieting Disorders stated that
recovery from eating disorders requires intervention from multiple health care
providers, such as dieticians, psychologists and psychiatrists, as well as from
organisations delivering social support and family therapy.[362] There is a need for more research
into effective treatments for the specific nature of eating disorders and risk
factors, and strategies for better targeting the needs of groups with a high
risk of developing eating disorders, such as children, adolescents and young
women.
5.67
Promoting heightened awareness of the medical
management of eating disorders and treatment is also needed to assist health
care workers to facilitate the diagnosis and referral of patients with eating
disorders. However, this also relies upon an adequate level of specialised
health care services for people with eating disorders in the community,
including an increase in the number of dedicated eating disorder hospital beds
for the management of acute stages of illness.
Anxiety
5.68
Anxiety Disorders – or disorders of fear and stress
show predominantly in the teenage years or earlier. It is estimated that 12.6 percent of the
population suffers from an anxiety disorder,[363]
yet it is very difficult to access help until the person is in such a poor
state of mental health that they may be suicide.
5.69
A person with an anxiety disorder commented on the
enormous difficulties in accessing help for this category of mental illness:
My search for help has been in four states of Australia,
as well as living in London for
three and a half years. It's only since arriving in Perth
in 1985 I've finally managed to obtain proper help.[364]
5.70
A support group for people with anxiety recommended
that a 'mood disorders clinic(s)' be established, offering services that
address the specialised needs of people with anxiety disorders and depression:
... shorten treatment delays and reduce misunderstandings by
practitioners, negative labelling and poor referral systems. This would offer
an alternative service to acute psychiatric services and an opportunity for
early intervention. The service focus should also consider wellness with less
emphasis on purely medical treatment.[365]
Obsessive-Compulsive Disorder (OCD)
5.71
The diversity of mental illness and the suffering faced
when the true nature of the illness is misdiagnosis, was recalled by a
submitter living with OCD which produced obsessions with food and dieting:
At age 19 I was diagnosed by a local GP with anorexia and began
treatment. A specialist physician confirmed the diagnosis and admitted me to
hospital. Whilst in hospital a psychiatrist appeared once and prescribed
pills. For the next 29 years I was
misdiagnosed by nine psychiatrists who did no more than give me medication which
often left me in a zombie state. In and out of various hospitals and not once
given any program or recovery of indeed any hope of recovery, How could there
be – none of them knew what was wrong with me.[366]
5.72
Submitters pointed out the inadequacy of the public
mental health system in providing specialised care for people with a diversity
of mental illnesses, such as OCD:
There is an attitudinal problem from the public mental health
professionals. I was told, "Beggars
can't be Choosers".[367]
It is essential that people with OCD and people with other anxiety
disorders and depression are able to access psychological and medical
treatments that are evidence-based and can be tailored to their particular
symptoms and experienced.[368]
5.73
The Brisbane Obsessive Compulsive Disorder Support
Group has called for vocational, rehabilitation and employment programmes
targeting the specific needs of people with OCD, so as to 'keep (people with
OCD) on track' and better support living in the community.[369]
Post-Traumatic Stress Disorder
5.74
Post-traumatic stress disorder (PTSD) is a common
disorder where a person has experienced abuse or trauma in their life. In
evidence submitted to the inquiry, groups commonly reported to suffer from PTSD
include women subjected to abuse throughout their lives,[370] and care leavers who endured childhoods
of terrible abuse and neglect growing up in institutional care[371]. The committee also heard evidence
of the high incidence of PTSD that occurs following the release from
involuntary treatment for a mental illness of a different nature.
Responding to the diversity of mental illness
5.75
The committee thus heard about an enormous range of
conditions, and about distinct needs for many of them: needs that are not
adequately being met. Generalist and specialist health care providers must
recognise and respond to the full range of mental illnesses, just as we do to
the range of physical illnesses. The key
to achieving this outcome is recognition of the diversity of health
professionals in the management of mental illness, discussed in Chapter 6,
acknowledging the broad-based biopsychosocial model of illness and diversity of
treatment responses required.
Diversity of treatments
A dominant medical model
5.76
The section above focused attention on two aspects of
the mental health framework that impact on the way in which certain illnesses
are responded to in the current system: the priority given to low-prevalence
disorders and the boundaries of the mental health framework, which precludes
certain disorders. This section introduces a third feature, which limits the
kinds of treatments available within the public health system, in turn limiting
consumer access to different and, in some cases, more appropriate forms of
treatment: the dominance of the medical model.
5.77
As the dominant paradigm governing the care and
treatment of mental illness, the medical model emphasises pharmacological
approaches that aim to cure mental disorders that find their genesis in
bio-chemical disturbances. Less attention is given to the prevention of mental
illness, to non-pharmacological treatments and to the psycho-social causes of
mental health disorders:
[The medical model] stresses: individual rather than collective
health; functional fitness rather than welfare; and cure rather than
prevention. The central beliefs of this model saw physiological factors ('genes
and germs') not psychosocial factors as the main causes of illness. It is a
model, which, in policy terms, translates into a prime concern with the
treatment and cure of individuals' ill health, especially in acute sector
settings.[372]
5.78
The medical model underpins the division between high
and low prevalence disorders and, to an extent, the stigma attached to certain
disorders – for example, the idea that depression is 'all in the mind' or that
borderline personality disorder reflects bad behaviour. The psychological and
the behavioural fit less easily into a model that emphasises biological and
specifically, bio-chemical disturbance. This is not to suggest that there is no
bio-chemical basis to some forms of depression and other high-prevalence
disorders, or that there are no psychological or behavioural dimensions to
low-prevalence disorders. Rather, how certain disorders are culturally
characterised and how they are attended to is, in part, influenced by the dominant
paradigm of thought. Those disorders most responsive to medication are embraced
by the model. Other disorders are, to varying degrees, marginalised.
5.79
While the National Mental Health Plan 2003-08 reports a
shift in emphasis from a 'focus only on treatment to consideration of prevention,
early intervention, rehabilitation and recovery'[373] and presents a vision of a 'holistic
approach to improving mental health and well-being',[374] evidence suggests that in practice
this vision is yet to be realised. The Office of the Public Advocate, Victoria,
submitted that:
Proposed new directions in mental health policy reflect a
departure from the dominant medical paradigm, within which mental health care
has hitherto been situated, to a more individualistic and social model of
mental health care. The Public Advocate observes that despite this clear
direction of the previous two NMHPs, and the current NMHP 2003-2008, this
policy is not reflected in the services provided. For example, people in
non-acute phases of mental illness and people with high prevalence disorders
continue to have difficulty accessing the public mental health system.[375]
5.80
This echoed a 2004 report jointly prepared by the Brain
and Mind Research Institute and the Mental Health Council of Australia:
The Australian system is over-reliant on cost-inefficient
specialist care systems and does not support its investment in effective
medications with effective non-pharmacological treatments and recovery
strategies.[376]
5.81
Insane australia
summarised consumer needs for a more diverse set of treatments:
a very common call from consumers is for
greater attention on and access to counselling services, psychotherapies,
psychosocial services, peer support groups, nutritional and so called
‘alternative’ approaches such as natural therapies, yoga and meditation etc.
Resources are unavailable to these much sought after services because the vast
bulk of publicly funding for mental health is consumed by services based on the
medical model – hospital wards, subsidies for doctors fees and the drugs they
prescribe etc.[377]
5.82
Several submitters noted the dominance of the medical
model and raised concerns about its limitations. These limits include: an
over-reliance on pharmacological treatments and correspondingly, limited
investment in, or access to, non-pharmacological treatments; an inadequate mix
of mental health professionals accessible to consumers; and limited support for
research into alternative/complementary forms of treatment.
A poor mix of pharmacological and non-pharmacological treatments
5.83
The dominance of the medical model results in 'a poor
mix of pharmacological vs
non-pharmacological treatments',[378]
with an over-reliance on pharmacological responses to mental health disorders.
The Office of the Public Advocate, Victoria,
drew attention to the dominance of drug treatments noting their 'concern about
the pharmacological focus of the system and the lack of psychosocial
interventions accessible to people in the public mental health system'.[379]
5.84
Dr Horton-Hausknecht
outlined recent research, which argues that medical and biological models are
too frequently applied to psychological disorders, in part influenced by the
interests of powerful pharmaceutical companies:
Dr. John
Read, Director of Clinical Psychology at the
University of Auckland
in NZ, co-authored a book titled “Models of Madness” (2004). This excellent
book, which mostly focuses on schizophrenia but produces research and argument
which apply to all areas of mental health, outlines the problems which occur
when medical and biological psychiatry illness models are applied to
psychological disorders. The book also focuses on the power of the
pharmaceutical companies to manipulate research to promote the biological
models of mental ill health and to promote their medications. He provides good
evidence that the medical model of psychological disorders is not supported in
research and argues for greater use of psychological therapies in the treatment
of mental health problems. [380]
5.85
Dr
Horton-Hausknecht argued that the situation needs to be redressed with non-drug
therapies being used as the 'first line' of treatment – particularly for high
prevalence disorders such as depression and anxiety - and drug treatments being
used as a 'last resort'.[381]
5.86
The Western Australia
Section of the College of Clinical
Psychologists – Australian Psychological Society
pointed to research that argues that medications are over-prescribed by GPs for
'less-serious' mental illnesses, which adds to the costs of medical care. It
was claimed that other forms of treatment could be as effective, or more
effective.[382]
5.87
The Professional Psychotherapy Centre stated that:
A common consequence of the dominance of the medical approach to
mental disorders is the encouragement of the sick role with its emphasis on
medication as the treatment of choice.[383]
5.88
The Mental Health Foundation (ACT) highlighted the
importance of using a range of treatments and services to enable consumers to
manage their illnesses, arguing that a pharmacological response alone was not
enough:
Consumers need access to interventions which are proven to be effective
such as cognitive behavioural therapy not just crisis management.
It is widely acknowledged that it is not good enough, morally or
ethically to solely prescribe medication and hand over a few jargon written
pamphlets. People need to be educated, and guided to seek ways of managing
their own mental health that works for them. We need to empower these
individuals to take control over their own lives, and access a range of
relevant services to heighten their quality of life.[384]
5.89
Controversy around the treatment of
attention-deficit/hyperactivity disorder (ADHD) highlights some of the concerns
regarding the balance of pharmacological and other treatments. The committee
heard evidence on this in Western Australia,
where prescription rates for ADHD medications are higher than in other parts of
the country. The committee does not want to weigh into a clinical debate about
the treatment of ADHD, and it also acknowledges the work of others in this
area, including the NHMRC,[385] the
Western Australian Legislative Council[386]
and the federal parliamentary Library.[387]
5.90
Concern centres on the dominant use of pharmaceutical
treatments for a behavioural disorder, rather than 'simultaneous medication
use, behaviour management, family counselling and support, educational
management, and specific developmental issues.'[388]
5.91
Drug-Free Attention Deficit Support Inc (DFADS) argued...
Medicare payments are structured to encourage quick diagnosis
and treatment after brief consultations. This pressure for quick diagnosis and
treatment results in ADHD being diagnosed as a catchall condition with the
underlying cause ignored...
Dexamphetamine is the only treatment option supported by the
Commonwealth Government for ADHD. Dexamphetamine in low doses has an almost
universal effect of temporarily sharpening focus and concentration.
The combined effect is that the pressure for quick diagnosis
encourages the diagnosis of ADHD that is then treated with subsidised
Dexamphetamine...[389]
5.92
The Learning & Attentional Disorders Society of WA
(LADS) had a different view from DFADS, arguing that ADHD was if anything
under-diagnosed and that medication was an important part of an effective
treatment strategy. The two groups appeared to differ about the extent to which
ADHD was a primary medical condition as well as the number of cases in which it
should be thought to be a medical condition at all.
5.93
However, the committee notes that the most obvious
point the groups had in common was a consensus around a lack of effective
non-pharmacological treatment options. LADS supported a multi-faceted approach
to treatment including medication as just one element. However, as they
themselves pointed out, 'due to a lack of funding and resources, the
multi-modal treatment stipulated in [WA Department of Health] policy is seldom
accessible to families with AD/HD'.[390]
These concerns, together with evidence of high and rising rates of
prescription, strongly suggest that medication is becoming a dominant treatment
option at the expense of other approaches.
An inadequate mix of mental health professionals
5.94
The dominance of the medical model manifests in the
limited range of mental health professionals financially accessible to
consumers. Unsurprisingly, with their ability to prescribe medications, GPs and
psychiatrists are heavily represented in financially-accessible services.
Psychologists, counsellors and psychotherapists play a distinctly secondary
role. Submitters argued that a greater mix of health professionals and,
correspondingly, a greater mix of treatments are required to adequately meet
the needs of consumers. At the heart of these concerns is ongoing anxiety about
the practice of psychiatry.
The practice of psychiatry
5.95
The Royal Australian and New Zealand College of
Psychiatrists (RANZCP) submitted that psychiatrists are trained to bring an
integrated biopsychosocial approach to mental health problems, which includes
treatment with medication (the biological component), psychological therapies,
and social interventions:
Psychiatrists are medical practitioners with a recognised
specialist qualification in psychiatry. By virtue of their specialist training
they bring a comprehensive and integrated biopsychosocial and cultural approach
to the diagnosis, assessment, treatment and prevention of psychiatric disorder
and mental health problems. Psychiatrists are uniquely placed to integrate
aspects of biological health and illness, psychological issues and the
individual’s social context.[391]
5.96
However, this holistic approach was not the prevailing
experience of consumers or of other organisations. The practice of psychiatry
came in for criticism during the course of the inquiry, primarily in relation
to its reliance on a medical model of treatment of mental illness.[392] Some witnesses indicated that
psychiatrists took an approach where they made an assessment of a patient,
formed a diagnosis, and decided on a treatment. This process often happened too
quickly, and the treatment determined was often medication and/or confinement.
This approach was taken without treating the
patient with respect and without taking into account the patient's perspective
or broader needs.[393]
5.97
Mrs Pearl Bruhn, a submitter with personal experience
of the mental health system, expressed frustration with the perfunctory
treatment sometimes received:
Psychiatrists, if you are lucky enough to see one, and not just
a medical officer, spend only 15 minutes with each patient, with time only to
discuss medication. There is no time to deal with the many other worries a
patient is likely to have.[394]
5.98
Other personal experiences provided to the committee
were similar:
...psychiatrists knew that mania was a possible side effect of
many anti-depressant drugs but they weren’t apparently on the alert for it, and
they apparently did not know how to recognise it, or what questions to ask.
Even after I crashed, they had no idea how to deal with the aftermath, or how
to deal with the devastation caused except to write more prescriptions.[395]
5.99
Evidence of negative consumer experience echoed the
findings of the Mental Health Council of Australia's Not for Service report:
In short, the available evidence suggests that persons with
mental illness still struggle on a daily basis to access appropriate health
care or be treated with respect or dignity when they do enter our health care
systems.[396]
5.100
The Mental Health
Foundation ACT was also critical, noting the propensity towards pharmacological
solutions with little attention to the therapist-client interface:
Professionals, especially medical people, still hold power and
authority in our society. Psychiatrists are mainly educated in the medical
model of prescribing medication, but are not necessarily clued into the importance
of the relationship between themselves and their client, although this is
changing.[397]
5.101
Even some doctors found that aspects of the organisation
of the health system could be contributing to these kinds of problems and
argued that there was a focus on 'biological therapies'. The committee
frequently heard how the pressure in public hospitals, and emergency
departments in particular, contributed to what was seen as unsatisfactory
psychiatric treatment:
Many trainees are now forced to work on crowded, busy acute
adult inpatient units, where the disorders are generally restricted to three or
four diagnoses. The patients are chronic and almost impossible to treat and the
focus is mainly on the biological therapies.[398]
5.102
Obviously not all consumer experiences with psychiatric
treatment are negative. The committee heard from a consumer advocate, Mr
John Olsen, a
person with schizophrenia, who described himself as 'one of the lucky ones' for
whom medication worked. He told the committee of his gratitude to a
psychiatrist (in a prison setting) who coerced him into taking medication, and
established him on the road to a stable life.[399]
Others referred to the positive experience of finding a 'wonderful
psychiatrist' whose care greatly assisted them or family for whom they cared.[400] Nevertheless, rapidly rising levels
of pharmaceutical prescriptions and persistent, widespread complaints about a lack
of other therapy options suggest that such positive experiences are not as
common as they should be.
5.103
The RANZCP responded to criticisms of psychiatry by
saying that they were supportive of consumer and carer involvement when
planning treatment. Dr Freidin
of the RANZCP stated that:
In the clinical setting, the more information you can get about
someone’s social circumstances and social network and the involvement of their
carers and their families and their own views, quite simply the better able you
are to plan with them what needs to be done and then to implement a plan that
will be successful and acceptable to them.[401]
5.104
Dr Freidin
went on to say that in some stressful circumstances, involvement of the
consumer was difficult:
We are also aware, though, that practically, in stressed,
under-resourced services, when people do start having to act fast to make
decisions more quickly than ideally they should—for a host of reasons—one of
the things that slips by the wayside is the time that should be taken
to consult in detail with family and with the patient before deciding on an
ongoing management plan. It is a little easier in private practice because one
is a bit more able to control the pace of things.[402]
5.105
The committee recognises that the stresses under which
psychiatrists are working, particularly in settings such as public hospital
emergency departments, can contribute to poor care outcomes, such as the use of
medication ahead of other therapeutic options. These stresses have been
outlined in Chapter 4, and are discussed further in Chapter 8. However, these
stresses do not account for the under-use of psychologists in the health care
system (particularly public health care) compared to psychiatrists.
A greater role for psychologists
5.106
As discussed in Chapter 6, psychologists are under-employed
in both the public and private sectors of the mental health system. The
Australian Psychological Society submitted:
Psychologists are significantly under-utilised in the provision
of mental health services due to limited federal/state funding for allied
health in the public sector, and by affordable, government-supported access in
the private sector.[403]
5.107
At the same time, evidence to this inquiry also suggests
there is an unmet need for the kinds of treatments that psychologists can
offer. The Australian Psychological Society argued that there is currently only
limited use of evidence-based[404]
psychological interventions despite their effectiveness in treating a range of
mental health disorders. Cognitive behavioural therapy (CBT) was highlighted as
a 'best practice' treatment for depression, anxiety, panic disorder and
alcohol/drug use, and as a contributing therapy for schizophrenia:
CBT is a more effective (and cost-efficient) treatment for Major
Depressive Disorder than anti-depressant medication (Selective Serotonin
Reuptake Inhibitors [SSRIs]) in most cases, especially for youth. In anxiety,
CBT is the most cost-effective treatment available for panic disorder and
generalised anxiety disorder when compared with pharmacological interventions.
Significant developments have occurred in the use of cognitive behavioural
strategies for patients with schizophrenia. These interventions have been shown
to have a significant impact on symptoms, behavioural responses and relapse
incidence.[405]
5.108
An increased role for psychologists could achieve a
greater balance between pharmacological and non-pharmacological therapies. For
example, beyondblue argued that
treatments such as cognitive behaviour therapy should be more accessible to
consumers.[406] The failure of the
health care system to respond to such evidence or to facilitate a diversity of
treatment options reflects a narrow medical model which marginalises
psychologists and the therapies they offer.
Psychotherapists and Counsellors
5.109
A number of submissions expressed support for greater
consumer access to counselling and psychotherapy services and highlighted the
benefits of talking therapies.
5.110
The Psychotherapy and Counselling Federation of
Australia (PACFA) outlined the form of treatment offered by psychotherapists and
counsellors explaining that:
Counsellors and psychotherapists work within a clearly
contracted, principled and collaborative relationship to enable their clients
to explore and resolve a wide range of personal and relational issues.[407]
5.111
In distinction to psychiatrists and psychologists, the
training of psychotherapists and counsellors places a far greater emphasis on
interpersonal communication, clinical skills and experiential learning, with
the therapeutic relationship forming the core of the clinical encounter. In
turn, distinctions can be drawn between counselling, which tends to focus on
'specific problems' or 'changes in life adjustment', and psychotherapy, which
generally involves intensive, long-term work on 'deeper issues' and/or with more
'deeply disturbed clients'. Both
psychotherapists and counsellors receive clinical supervision, which supports
the health professional and provides a quality assurance mechanism for
consumers by ensuring 'competent and ethical practice'. [408]
5.112
PACFA submitted that counsellors and psychotherapists
are under-utilised in current models of care. They argued that government
resources need to be allocated across a broad range of services and a wider mix
of health professionals.[409]
5.113
PACFA explained that the existing policy framework also
limits the role of counsellors and psychotherapists in the non-government
sector and consumer access to private services:
Current government policy provides barriers to employment of
well trained counsellors and psychotherapists within the non-government sector
and access of clients to private providers. The most important barrier is that
the current GST legislation does not recognise counsellors and psychotherapists
as approved providers of counselling services. The GST legislation provides for
GST-exemption on counselling services provided by several other health
professions such as psychiatry, psychology and social work, many of whom would
not meet the minimum requirements for specialist training in counselling or
psychotherapy, as defined by PACFA. This situation is inequitable. Government
policy should provide the same funding to the various health professional
groups who can provide counselling services.[410]
5.114
PACFA made a specific recommendation:
We recommend that Psychotherapists and Counsellors who are
eligible for registration on the PACFA national Register for Psychotherapists
and Counsellors be recognised in the GST legislation as a recognised provider
of counselling services.[411]
5.115
The Australian Mental Health
Consumer Network (AMHCN) argued in favour of bolstering resources for
therapeutic 'talking therapies'. In particular, the AMHCN expressed concern
that mental health problems arising from childhood abuse and neglect required
early intervention, but that resources in the public health system for
providing psychotherapeutic treatment were inadequate:
AMHCN hears frequently from members with histories of child
abuse and neglect. Many consumers come from childhood backgrounds that were
psychologically dangerous and damaging. This calls not only on interventions to
protect children but also on supporting psychotherapeutic interventions early –
before harmful adult mental health patterns are fully established. At the
present time there is almost no psychotherapy available in public mental health
systems in this country. Since the First National Mental Health
Plan 1993-1998 pushed priorities away from ‘talking therapies’ there has been
no investment in developing the capacity of mental health services to respond
to people with abuse and neglect histories.[412]
Other forms of care and treatment
5.116
While more and more resources are poured into
pharmacological treatments and pharmaceutical research, talk therapies remain
relatively hard to access, while other possible approaches to care are largely
neglected.
Support groups and consumer-driven recovery approaches
5.117
Several submitters highlighted the importance of
support groups in the management of mental illness. The evidence presented by
the community-based organisation, GROW, exemplified these views.
5.118
GROW is a voluntary, non-government mental health
organisation that operates 'mutual support groups' and provides training and social
activities. GROW explained that at the support groups:
individuals who are experiencing the trauma of mental illness or
seek to prevent mental illness, come together to support each other with the
aid of GROW’s 12 step Program (referred to by some Psychologists as “ lay
person’s cognitive behavioural therapy”). Here members are able to share their difficulties,
find commonality and learn to recover from their illnesses with the sustained
assistance of a caring and sharing community environment.[413]
5.119
GROW argued that mutual support groups provide a
valuable, complementary role in the prevention and recovery stages of mental
illness. Based on self-conducted and independent research, GROW submitted that
the support groups:
-
Significantly reduce the need for
hospitalisation
-
Decreased the incidence of suicidal thoughts
-
Improve quality of life for consumers
-
Facilitate development of life management and
social skills[414]
5.120
A recent study on GROW support groups undertaken by
Lizzie Finn and Dr Brian Bishop, School of Psychology, Curtin University,
Western Australia, confirmed GROW's claims. The researchers argued for the
recognition of the value of mutual help groups:
It is important for health professionals to realise the very
real benefits which mutual help groups can offer, and to see them as being
complementary to mainstream mental health services. Mutual help groups can be
integrated with therapy where relevant. For some people, particularly those
with the more severe diagnoses, mutual help can be a vital ingredient for
maintenance within community and reduction of the risk of relapse.[415]
5.121
In a study undertaken by the Albury-Wodonga Anxiety and
Depression Support Group, La Trobe University and the Anxiety Recovery Centre, Victoria,
the need for 'more support to support groups' was identified. This included
increased funding and improved referral sources – for example, through
educating GPs about referral to the support group.[416]
5.122
The need for more support of support groups was
reiterated by Patricia Minnar,
Coordinator of the Brisbane Obsessive Compulsive Disorder Support Group
(BOCDSG). She argued that the lack of substantial recurrent funding was inhibiting
the capacity of this state-wide support group.[417]
5.123
The Centre for Psychiatric Nursing Research and
Practice (CPNRP) highlighted the importance of recovery centres outside of
acute hospital care settings, and consumer driven recovery approaches:
The Soteria houses set up by Dr
Loren Mosher
are an example of a recovery centre without forced treatments. There are other
recovery centres in Europe and The US, where outcomes
are at the least comparable, usually better, than for standard acute hospital
care. As the current rhetoric moves toward the language of recovery, it is
critical that it is consumers who define this most individual and personal
journey. We need the resources to develop and articulate our own deepening and
sophisticated thinking about what works best for us, in terms of service
provision, and in terms of our own well being and self care. Nobody else can do
that for us, and no service or government can be confident of success without
that knowledge, and without then directing resources to it. [418]
5.124
The CPNRP noted that consumer support services in Australia
are significantly under-resourced and therefore under-developed in contrast to
services in New Zealand,
the United Kingdom,
Europe and the United
States:
We know that peer support and peer operated services work. ... Australia
lags far behind New Zealand,
the United Kingdom,
Europe and the United
States when it comes to resourcing consumer
operated peer support and recovery services, so that it is not surprising to
find there are almost no such services in the whole of the country, and therefore
almost no current evaluative data. In fact, the money spent on consumer
initiated projects and services is negligible. This is a serious gap, when we
already know that these types of services work. If our National mental health
plans are to be more than mere rhetoric, proper resources must be devoted to
consumer initiated projects and services.[419]
5.125
The Centre recommended:
That funding be allocated to develop peer support programs, and
consumer operated services in each state and territory, and that consumers
define recovery and what approaches/resources should be used to facilitate
recovery.[420]
5.126
Noting that support groups should be encouraged, Professor
Gavin Andrews
argued that these services should complement rather than stand in for
professional treatment. In particular, he emphasised that consumer groups
should not be expected to fill the current service-gap. Rather, this should be
met by evidence-based therapies.[421] He
explained:
During the sixties we had consumer groups taking responsibility
for the treatment of people with early psychosis. This experiment failed –
people with psychosis did need medication. There is professional knowledge, and
for all disorders evidenced-based care is better than compassionate care. The
age of moral treatment of the insane as the only therapy is past. Treatment
should be expert and moral.[422]
5.127
It was clear from evidence received that support groups
play a vital role in the management and recovery of mental illness. If adequately
resourced and managed, support groups can contribute significantly to improving
the quality of life of consumers. In this way, they play an important,
complementary role to professional therapies. Further, support groups can also
ease the pressure on the broader public health system by reducing consumer need
for hospitalisation. The committee encourages increased Government investment
in support groups. At the same time, the committee believes that improved
consumer access to appropriate forms of professional treatment is also vital.
Support groups should operate as a complementary and not replacement form of
care.
Nutrition-based
approaches
5.128
The committee received evidence on other, dietary-based
approaches to the treatment of mental illnesses.
5.129
Bio-Balance Health Association argued that 'the focus
on biological causes and pharmaceutical solutions' has inhibited the
development of 'more refined approaches' that draw on recent scientific
advances in the understanding of the biochemistry of brain functioning.[423]
5.130
Bio-Balance was set up in 1998 to:
promote, support and assist recovery from mental, behavioural
and learning disorders through the identification of biochemical imbalances and
treatment of such imbalances by complementary nutritional techniques.[424]
5.131
Bio-Balance submitted that there are limits to
medication therapy, which they described as a 'blunt instrument':
The powerful antipsychotic, antidepressant and other
psychoactive pharmaceutical medications currently used to treat mental
illnesses produce some beneficial effects in most cases, but these benefits are
usually partial in nature and the medications can often result in unwanted
changes in behaviour and various other ‘side-effects’ which can be so intolerable
as to undermine patient compliance with the prescribed medication.[425]
5.132
Bio-Balance put forward a complementary form of
treatment: biochemical treatment. They explained that:
It is now clearly understood that schizophrenia, bipolar
disorder, depression and other mental disorders are primarily caused by
imbalances in brain neurotransmitters, the raw materials of which are amino
acids, vitamins, minerals and other nutrients. The step-by-step processes by
which these neurotransmitters are produced in the brain and how neurotransmitters
function are also well understood.
5.133
In order to remedy these biochemical imbalances
Bio-Balance explained that the prescription of 'appropriate nutrients in
appropriate dosages' can complement, and in some cases reduce the need for,
psychiatric medication therapy.[426]
5.134
Bio-Balance concluded:
Given the limited effectiveness of present ‘mainstream’
psychiatric medications and the serious and widespread implications of these
limitations for patient, family and community outlined above, any treatment
which offers the potential for improvement towards recovery for a significant
proportion of people with mental illness warrants serious consideration.[427]
5.135
Mr Douglas
McIver, a consumer, submitted a personal
account of his success with an alternative treatment – orthomolecular medicine
- which enabled him to manage schizophrenia without the use of medication:
I was diagnosed with schizophrenia in early 1973 and prescribed
psychiatric medication for 10 and half years. I had various side effects from
my medication. Following research by my wife, Jan,
I decided to use an intervention strategy which was a biochemical model
endeavouring to reduce the symptoms of mental illness. It involved the effects
of foods and chemicals on my health, and required fasting, single food
challenges, allergy and sensitivity testing, dietary control, the use of
micronutrients, and minimising exposure to toxic chemicals. And, certainly,
exercise! The intervention was more than, but included, ‘megavitamin therapy'.[428]
5.136
Mr McIver
argued that the current paradigm, with its focus on pharmacological treatments,
inhibits a full examination of other measures:
Medical research is stuck in the biochemical approach of the
drug treatment paradigm. While this continues, safe and effective treatment
regimes using nutrient and food and chemical avoidance regimes are not being
fully investigated. The present system seems more interested in proving such treatments
do not work than finding out how they do work when they work.[429]
5.137
He envisaged a much greater role for medical
accrediting bodies and government in seriously investigating orthomolecular
medicine and other alternative/complementary treatments:
I believe that medical accrediting bodies have a responsibility
to give more priority to examining the positive claims that are made about the
nutritional and environmental medicine issues in conjunction with advocates.
And I feel that Governments can assist the process in various ways and that it
is their interests to do so. ... All that can be done should be done to encourage
the medical accrediting bodies, medical researchers and Governments to more
proactively assess its inclusion within the Medicare protocols and the NMHS.[430]
5.138
The committee is not advocating any particular approach
to treatment of mental illness. It is aware that different treatments have
their advocates and their detractors. Some treatments may only work for some
people. Some complementary treatments may be effective on their own, while
others may assist when used in conjunction with conventional therapies.[431] Some may not be effective at all.
5.139
The committee agrees with the general sentiment
expressed by Mr McIver
that more attention may need to be paid to researching and disseminating a
broad range of therapeutic approaches to different mental illnesses. The
committee shares the opinion of the Senate Standing Committee on Community
Affairs, in its inquiry into services and treatment options for persons with
cancer, that this may involve some broadening of research in the field of
medicine. That committee recommended:
the National Health and Medical Research Council provide a
dedicated funding stream for research into complementary therapies and
medicines, to be allocated on a competitive basis.[432]
5.140
The Mental Health Committee notes that the NHMRC
essentially rejected this recommendation, arguing that
funding of research into complementary therapies and medicines,
like the funding of other health and medical research, must be on the basis of
excellence as assessed by peer review.
Any funding for research outside of existing schemes, such as Project
Grants, would need to be based on identified need and met from external sources.[433]
5.141
While there can be debate about what mechanisms are
best to fund a broader research base, the underlying concern remains that
research is currently not as broad as it could be, and this appears to
marginalised those therapies that do not fit easily with the dominant medical
model. The committee hopes that the current dominance of both pharmacological
treatment and pharmacological research will be corrected through a range of
measures, including some recommended in other chapters of this report. It can
also see a case for a broad-based review of the current state of research in
the area of mental health. This will help a transition toward a more balanced
approach to care.
A balanced approach to care
5.142
Dr Di
Nicolantonio argued that the medical model was
fundamentally flawed and suggested a 'new paradigm' of care:
Set up a completely new paradigm for the treatment of so called
mental illness. There are just too many competing ideologies at the moment.
This is understandable given that mental illness and its treatment is a
relatively new academic construct. Organic brain diseases such as dementia,
mental retardation and schizophrenia will probably always remain within the province
of the medical profession. Psychosis is in a bit of grey area. However, for
states such as depression, anxiety, eating disorders, borderline personality
disorders and addictions, the “patient” should be placed in the primary care of
a psychologist or (better still) a psychoanalyst. A consultant psychiatrist
would also be assigned to act in a liaison capacity only.[434]
5.143
Similarly the Australian Mental Health Consumer Network
(AMHCN) submitted that the range of services available to consumers can no longer
afford to be constrained by the medical model:
[T]he variety and scope of available services [should] no longer
be limited by institutional traditions or medical model understandings of what
constitutes a health intervention.[435]
5.144
These views were reaffirmed by GROW:
The belief that assumes the majority of problems experienced by
mental health consumers are solved solely via medication and/or hospitalization
needs to be challenged. In nearly all forms of mental illness medication/hospitalisation
is not sufficient for recovery.[436]
5.145
Dr Horton-Hausknecht
recommended that:
Non-drug therapies should be supported and promoted as the first
line of therapy for mental health problems such as depression and anxiety, with
medications used as a last resort – not the other way around. [437]
5.146
Research shows that non-pharmacological interventions
can be effective across a range of illnesses. While it is clear that a pharmacological
approach is appropriate and, indeed, imperative for certain illnesses under
certain conditions, the dominance of pharmacological intervention does not
appear to be justified. In economic terms, it has been argued that the
efficiency of the system could be greatly enhanced through a mix of therapies
and models of care:
[I]t has been estimated that the efficiency of the system
(specifically when dealing with persons with common disorders such as
depression or anxiety) could be doubled by improving the balance between
primary and specialist care providers and the use of medications or
psychological therapies.[438]
5.147
The research highlights an over-reliance on medications
for immediate and long-term care and inadequate attention to early intervention,
the use of non-pharmacological treatments and specialised recovery programs. The
flow-on effects are great. For example, the research states that the numbers of
people with enduring mental illness able to return to work or other forms of
social participation in Australia is half that of people in other OECD
countries.[439] As a result, it is
argued that increased expenditure should be directed towards remedying this
situation.[440]
5.148
The committee is concerned that the dominance of the
medical model may colour assessments of alternative/complementary forms of
treatment and inhibit research into these areas. As discussed in Chapter 8, it
is clear that the system still emphasises cure and crisis management and not prevention
and early intervention, with care concentrated in the hospital system.
5.149
Evidence to the inquiry suggests there would be both
economic and therapeutic benefits to diversifying treatments. The form this
would take is two-fold:
-
supporting consumer access to psychologists and
other non-medical practitioners through the public health system, and Medicare
access to private sector health professionals
-
investment in research on other treatments
Conclusion
5.150
The committee was disappointed to hear that there is a considerable
disjunction between the aspirations of the National Mental Health Plan to
provide a 'holistic approach' to mental health care in Australia
and the actual range of treatments available to consumers. The committee
recognises the necessity of pharmacological interventions and supports ongoing
research to improve and refine pharmacological options available to consumers.
However, it is clear that a better balance between pharmacological and
non-pharmacological treatments is urgently required.
5.151
Within the current paradigm consumers have limited
choice in the kinds of treatments available to them – unless they can afford
the luxury of choice. The form of treatment offered is determined by the
prevailing approach rather than the treatment being tailored to meet the
specific needs of the consumer. This problem is exacerbated by the tendency to
view mental illnesses as a homogeneous group.
5.152
In some cases, access to treatment is extremely restricted.
The current (inadequately resourced) system concentrates on low-prevalence
disorders and acute and crisis cases. At the same time, the system and many health
professionals appear to be ill-equipped to manage certain illnesses such as obsessive-compulsive
disorder and some of the personality disorders.
5.153
The dominance of the medical model and the consequent
dominance of psychiatric treatment have resulted in these limits. While the committee
recognises that consumer experience of psychiatric treatment has in many cases
been positive, evidence to this inquiry suggests an unacceptable level of
dissatisfaction with the current paradigm of care. Further, positive
experiences conveyed to the committee highlight the expertise, compassion and
receptiveness of individual
psychiatrists rather reflecting a systemic attitude or approach to psychiatric treatment.
5.154
The committee believes that all consumers should
receive appropriate forms of support in a timely manner. To this end, the committee
supports the diversifications of treatments available in the mental health
system. This will require:
-
An increased role for psychologists,
psychotherapists and counsellors in the mental health system
-
Improved access of consumers to these health professionals
through a) more positions for these health professionals in the public sector
and b) Medicare funded access to these health professionals
-
Investment in research of alternative treatments
5.155
Whilst the committee appreciates that public resources
are invariably limited and must be targeted accordingly, the under-resourcing
of mental health in Australia
and the resulting focus on low-prevalence disorders and crisis intervention
produces false economies. This is compounded by the dominance of the medical
model and an over-reliance on pharmacological approaches. Evidence suggests
that the diversification and appropriate targeting of treatments could, in
fact, produce savings as well as enhancing the mental health and well-being of
consumers.
Navigation: Previous Page | Contents | Next Page