The Real Questions in Mental Health Reform

[Editor's Note: In this commentary, Professor Patrick McGorry responds to Dr Allen Frances' recent blog, Seven Questions For Professor Patrick McGorry. Their exchange appears in the October 2011 issue of Psychiatric Times.]

Mental health reform: A global challenge
Mental health reform is one of the world’s “grand challenges.” Mental, neurological and substance-use (MNS) disorders constitute 13% of the global burden of disease, surpassing both cardiovascular disease and cancer. The Grand Challenges in Global Mental Health initiative recently identified priorities for the next decade.¹ The creation of new knowledge and vastly improved and timely access to mental health care are overarching imperatives. One of the six goals agreed is to advance prevention and implementation of early interventions, and of the 25 key research questions identified, “what neuroprotective agents and/or cognitive retraining paradigms can be used during the period of rapid brain development to reduce vulnerability to disorders in adolescence?” is particularly salient.

On the same message, Dr Thomas Insel, Director of the National Institute of Mental Health, who is playing a most influential role globally, has strongly endorsed the need for what he calls “pre-emptive psychiatry.”² This means a major endeavour to limit through early intervention the collateral psychosocial damage that flows from delayed and inadequate treatment of potential serious mental disorders. While falling short of primary prevention, pre-emptive psychiatry is a strategy for modifying the course of mental disorders. These messages echo the preventively oriented blueprint published by the Institute of Medicine in 1994,³ which strongly supported notions of indicated prevention and early intervention as an achievable goal in serious mental disorders.

Australia and mental health reform
In Australia we are re-embracing the grand challenge of mental health reform. Australia has a strong record of innovation in mental health, but a poor one in terms of sustaining reform. We have seen repeated cycles of crisis, a surge of reform and a subsequent return to neglect. Our system has been partially modernised through mainstreaming of mental health within the general health system, however it has not been built to scale within nearly two thirds of those who experience mental ill health annually failing to access care. We spend only 7% of our health budget on mental health care. It needs at least double that amount.

Furthermore, the system has been poorly designed and engineered. Mental disorders are the chronic diseases of the young⁴ with three quarters of new cases emerging prior to the mid-twenties, two thirds of these between the ages of 12 and 25. Australian National Mental Health Survey data reveals that 12-month prevalence also peaks between 18 and 25 years at 26%, and yet despite that this age group have the worst access to mental health care than any other.⁵

Australia’s Federal government and its eight State and Territory governments committed on August 19th at the meeting of the Council of Australian Governments to a ten year process of reform and investment in mental health care. This has been catalysed by a systematic review of mental health reform options conducted by an independent commission of inquiry, the National Health and Hospital’s Reform Commission, which reported in 2009. All competing views and supporting scientific evidence were objectively considered. Debates on contentious issues were held and resolved.

Mental health policies then passed through a series of filters, including community consultation, parliamentary inquiries and an intense national election period, during which mental health became a major issue. The mental health sector unified and was supported strongly by the Australian community and the mainstream health sector in advocating for a whole of life reform focus, which would seek to transform the failing mental health system. All sides of politics came to recognise, among other priorities, the urgent need to strengthen the disproportionately weak response to young people and to implement evidence-based early intervention services to pre-empt psychosocial damage and disability.

In May this year the Federal government announced an encouraging, though still relatively modest, initial investment in mental health reform to which State governments have now been asked to respond with matching investments. Approximately 25% of this new investment is to be devoted to expanding and strengthening the novel and successful “headspace” program of enhanced primary care for young people aged 12 to 25 years (www.headspace.org.au), and belatedly to make available to thousands of young Australians with psychotic illnesses, the early psychosis prevention and intervention centre (EPPIC) model, developed in Melbourne 20 years ago and now replicated in many hundreds of locations world-wide, including some parts of the USA and Asia, but more systematically in Canada, England, Denmark and the Netherlands. The bulk of the new investment is focused on other stages of life and illness with the largest single amount devoted to integrate and strengthen services for people with severe and enduring mental illness. The alternative government has an even stronger policy commitment to early intervention and young people.

Dr Allen Frances, who does not live in Australia, is understandably unaware of the complex and rigorous processes through which the Australian reform blueprint has had to pass. A fundamental difference between the USA and Australia is that mental health professionals conceive of mental ill health and mental illness in a much more biopsychosocial and holistic manner. Both conceptually and through our universal system of health financing we respect and provide a much stronger level of psychosocial input to patients. We do not equate treatment with the prescription of medication. We do not permit direct marketing of pharmaceutical products to the public.

Under our universal health insurance scheme, Medicare, it is common practice, especially for mild to moderate disorder for people to receive assessment and psychosocial treatment for mental ill health without being prescribed medication. This contrasts starkly with the description of US practice in a recent New York Times story that revealed that psychiatrists no longer have time to talk to their patients, insurance schemes constraining their role to merely prescribing drugs (See: http://www.nytimes.com/2011/03/06/health/policy/06doctors.html?_r=1&scp=2&sq=psychiatry+and+talk+therapy&st=nyt). Operating within such a different healthcare system, it is perhaps understandable that Dr Frances might struggle to grasp that the real impact of the youth mental health reforms in Australia will be to make psychosocial interventions available to young people with mental ill health to a much greater extent, as both an alternative and complement to medication. A measurable outcome will be less reliance on medication for those accessing care.

Mental health and young people
One of the greatest paradoxes of the modern world is that while material well being and physical health have dramatically improved, the mental health of young people in transition from childhood to adulthood has been steadily declining, and this from a low base.⁶ One of the failures of the field so far is not to have appreciated that the timing and pattern of mental ill health impacts so strongly on young people who, on the threshold of adult life, have the most to lose.⁷ Society as a whole also loses, in terms of reduced human capital, “mental wealth” and productivity in the broadest sense.⁸

A recent New Zealand study estimated that up to half of young people in this transition period will experience at least one diagnosable episode of mental ill health with proportionate negative impact on earning potential, educational outcomes and social integration at age 30.⁹ The scene for this erosion of life chances is often set in childhood but more commonly it takes the ever changing climate of adolescence and emerging adulthood to release the variety of clinical phenotypes we recognise as clinicians, the incidence of which surges through adolescence and peaks between 18 and 25 years.

What we call “disorders” are experienced first by young people and their families as emotional distress, attempts to cope or deny, behavioural disturbances and all too often collateral damage such as vocational failure, substance abuse, deliberate self harm and offending behaviour. Influenced by stigma and the orthodox view that the health of young people has never been better,⁶ many people make the mistake of assuming that, because emotional distress and damaging behaviours are common in young people, this is “normal” and largely transient, and to intervene would be unnecessary or even harmful. This is dangerous thinking. It confuses being common with being benign; a serious error with often fatal consequences. Malaria is common in many developing countries but hardly benign.

Young people with the highest incidence and prevalence of mental ill health receive the least help to overcome these threats to their survival, well-being and contribution to others. Young people make up 27% of the world’s population and their health needs have been seriously neglected because they are perceived as healthy.¹⁰ In Australia only one in four young people with mental disorders gain access to any form of mental health care and this drops to 13% for young men. So far we have made only desultory efforts to understand what is behind this rising tide of mental ill health and try to turn it back. With the advent of headspace and EPPIC, in Australia that is starting to change.

The role of evidence and health system reform
Dr Frances adopts a posture of censure in attempting to play the evidence based medicine card in his opposition to early intervention in psychosis. As a clinical scientist with a long track record in conducting clinical trials and health services research, and who has always regarded evidence as the best insurance policy against heading too far down a wrong turning, I found his comments puzzling.

David Sackett, the doyen of clinical epidemiology, defines evidence-based medicine (EBM) as that which is applied by individual clinicians to individual patients, and evidence-based health care (EBHC) as that which is applied by public health professionals to groups of patients and populations.⁷ Evidence-based health policy is more complex and has several determinants only one of which is evidence. Cooper¹¹ notes that only 10% of clinical trials and metanalyses focus on health services and most of these are inconclusive. While it is crucial that we continue to conduct randomised clinical trials, these are rare and challenging to carry out at the health system level. It is plain that if we limit health service design and reform to Cochrane-confirmed approaches, we will have a very sparse and indecisive health system. Even the latest Cochrane review¹² on the use of clozapine in schizophrenia was equivocal as to its superiority over other atypical agents. So what should be done? Should we wind up the use of clozapine? We do need some common sense here.

Evidence will never be conclusive and the perfect is truly the enemy of the good. The real question is where does the onus of proof lie? Given the serious and often irreversible personal and social damage wrought by untreated serious mental illness, surely we can assume that late intervention is not a practice we wish to support. The status quo is the least evidence-based option and the outcome for schizophrenia does not seem to have changed in 100 years. The status quo has comprehensively failed, to which countless human stories bear witness, and those who defend it are defending the indefensible. One only needs to ask the consumers and their families. So the real question is, how to promote early intervention and sustained holistic care most effectively and safely?

Taking first episode psychosis first, notwithstanding the latest Cochrane, review,¹³ in which the authors inappropriately blended individual treatment trials and health services research, systematic reviews are now clearly confirming that early detection and more specialised care over the first two years is effective in improving short term outcome.¹⁴ Norman et al¹⁵ have since shown that the erosion of these gains, which occurs when the patients are discharged to standard adult care, can be prevented if they are offered step-down early psychosis care up to the 5 year point. There are indications that adolescent onset cases may benefit proportionately more from this model of care.¹⁶. The crucial TIPS study shows that the beneficial effect of early detection has a long term effect on negative symptoms,¹⁷ but because it was quasi-experimental (the best possible design for this research question), it was not able to be considered by the Cochrane reviewers.

While Dr Frances characterises Australia’s decision to belatedly scale up early psychosis services some 20 years after we began our work in Melbourne as “reckless,” in England, and in many other service systems globally, streamed early psychosis services have been in operation across the nation for many years. The early psychosis airplane has been flying internationally for over a decade. Consequently we now have compelling cost-effectiveness data from England, Australia, Sweden and Hong Kong all showing that early intervention for psychosis is excellent value for money, and rather than, as Dr Frances suggests, diverting funds from other seriously ill patients (as if the FEP patients were not) it actually frees up substantial resources for use elsewhere.

The notion that early diagnosis and treatment should be an optional extra is in any case quite bizarre. Reckless even, given that the lives and futures of young people are at stake. Why do we never see oncologists arguing about the relative value of palliative care and early diagnosis, or insisting that we must have perfect palliative care services before we tackle early intervention? Perhaps it is partly due to the historical neglect of mental health care and our own ambivalence about what we have to offer patients. These are stigma-related issues we must confront.

The UHR controversy
While the provision of care for young people with subthreshold psychotic symptoms (UHR or ultra-high risk) is not the focus of the Australian reforms, the fact that such patients will not be denied help if they seek it has prompted controversy in some quarters and seems to be the main issue that troubles Dr Frances. This seems driven by his fear that they will be more likely to receive antipsychotic medication. In fact the opposite is much more likely to be the case.

The approach to the UHR group is not analagous to screening asymptomatic people to identify those with an increased risk of an illness such as breast screening programs using mammography, routine blood pressure and cholesterol monitoring and prostate screening. The young people involved in the UHR clinical programs and research are already experiencing substantial levels of mental ill health and are by actively seeking help. So the appropriate analogy would be with the woman who discovers a breast lump on self-examination or the man who experiences the onset of chest pain. These clinical situations require assessment, and typically some kind of clinical intervention and follow up.

We know that most cases of first episode psychosis are preceded by an often prolonged period of distress and functional decline so if we wait until frank and florid psychosis is present, much psychosocial damage has been done. Conversely, we know from pooling international data that only about 36% across all studies of those identified by the UHR criteria will progress to severe and sustained psychotic illness, mostly but not exclusively schizophrenia, within around 3 years. However most of the remainder manifest other treatable disorders and their average GAF scores are in the low fifties when they seek help. They have an undeniable need for care and monitoring.

The best available evidence from 5 RCT’s¹⁸ shows that any of range of treatments will reduce their risk of psychosis from around 31% to 11%, though probably only for as long as this is being delivered. This intervention has recently also been shown to be cost-effective.¹⁹ The clear message so far (and both the Cochrane review and Dr Frances agree that further research is required) is that antipsychotic medications are not supported as first line therapy since there are safer alternatives. This is in line with the fundamental principle articulated by David Sackett that the earlier one intervenes the less risk can be accepted. In other words the risk benefit ratio is the key. This is where the clinical staging model may be useful as a cross-diagnostic solution to the controversy.

The clinical staging model
The clinical staging model is a form of stepped care which recognises that many of the standard diagnostic entities such as schizophrenia and bipolar disorder are in fact late stage concepts and that by the time people receive these labels and are first treated, they have been suffering often for years and have been functioning poorly.^20,21 So there are earlier clinical stages of illness where treatment is indicated though the symptoms, distress and functional impairment is more diffuse and difficult to categorise. We do need further research to characterise these early clinical phenotypes and ensure that we can distinguish them from normal life experience. The principle of providing care at this point is that it should be as safe as possible and that the benefits outweigh any harmful effects. While there may be harmful effects of both psychological and pharmacological interventions, it is obvious that the first line approaches should be simple and brief, including the provision of information, support and problem-solving. They may be provided in primary care and stigma-free settings or via new technologies such as the internet and mobile technology. More sophisticated psychosocial interventions and drug therapies should only be offered for later and more sustained and severe stages of illness.

This is a heuristic framework, which may be useful in guiding clinical care and biomarker research as well. I believe that the UHR and early psychosis research has been catalytic in illustrating the potential of this staged approach to mental health care. I believe that rather than agonising over the immediate question of whether this concept or some variant thereof should be introduced into DSM V, it would be better to aim for a more radical revision of our diagnostic approach, a process that would clearly take a significant amount of additional research and development.

In the meantime however I believe all people, especially young people, who are experiencing mental ill health, and are distressed and consistently struggling with relationships and vocational development, should have ready and free access to stigma-free care. Naturally this includes those who happen to meet the current criteria for ultra-high risk who are demonstrably in need of care. There is no justification for them to be excluded from access to care under the Australian reforms. Indeed the establishment of new youth mental health services means that these and other patients will come under a stronger system of clinical governance, which can better ensure adherence to evidence-based practice. In this case that means not commencing with antipsychotic medication in the UHR group. Currently at our PACE clinic in Melbourne 27% of the patients referred have already been prescribed antipsychotic medication by primary care physicians and among our first clinical tasks is to cease this medication. The national reforms will mean less, not more, medication in this group.

Conclusion
In providing more background to the issues at stake in Australian mental health reform I hope I have been able to show that these are issues that the mental health field globally needs to consider. I maintain that any young person with emerging mental ill health should be able to access support, expert assessment and safe and effective evidence-informed care in a timely fashion and in stigma-free settings. This is what we are seriously trying to build in Australia. To the relatively small number of critics, both within Australia and overseas, I would simply say what is the alternative that you are proposing? Is it more of the same? Because every day we delay reform, the status quo continues to fail people with mental ill health and their families. The latter are not critical of the early intervention reform focus. Far from it. We must take action. Not in a reckless way, but according to the best available analysis and evidence.

Dr Thomas Insel, having been made fully aware of developments in Australia and being very familiar with the progress in early psychosis research, recently commented in a presentation to Australia’s National Health and Medical Research Council (Australia’s NIH) that Australian ideas and progress were extremely positive and progressive and could form a major plank in the international research agenda. We certainly have a lot more work to do but I believe that if we continue to combine clinical science, a commitment to building evidence and testing the effectiveness of our interventions and models, and ensure that consumers and carers have a strong say in the reform process we have an excellent opportunity to reduce the impact of mental disorders on our society.

References:

References:1. Collins PY, Patel V, Joestl SS, et al. Grand challenges in global mental health. Nature. 2011;475:27-30.
2. Insel TR. The arrival of pre-emptive psychiatry. Early Interv Psychiatry. 2007;1:5-6.
3. Mrazek PJ, Haggerty RJ. Reducing the Risks for Mental Disorder: Frontiers for Preventive Intervention Research. Washington DC: National Academy Press; 1994
4. Insel TR, Fenton WS. Psychiatric epidemiology: it's not just about counting anymore. Arch Gen Psychiatry. 2005;62:590-592.
5. Australian Bureau of Statistics. National survey of mental health and wellbeing: summary of results. Canberra, Australian Bureau of Statistics. (2008).
6. Eckersley RM. Never better-or getting worse? The health and wellbeing of young Australians. Canberra, Australia21. (2008). Available at: www.australia21.org.au/pdf/Youth%20Health%20Text%2008.pdf. Accessed September 20, 2011.
7. Sackett DL, Tugwell P, Guyatt GH. Clinical Epidemiology: A Basic Science for Clinical Medicine. London: Little Brown & Company; 1991.
8. Beddington J, Cooper CL, Field J, et al. The mental wealth of nations. Nature. 2008;455:1057-1060.
9. Gibb SJ, Fergusson DM, Horwood LJ. Burden of psychiatric disorder in young adulthood and life outcomes at age 30. Br J Psychiatry. 2010;197:122-127.
10. Gore FM, Bloem PJ, Patton GC, et al. Global burden of disease in young people aged 10-24 years: a systematic analysis. Lancet. 2011;377:2093-2102.
11. Cooper B. Evidence-based mental health policy: a critical appraisal. Br J Psychiatry. 2003;183:105-113.
12. Asenjo Lobos C, Komossa K, Rummel-Kluge C, et al. Clozapine versus other atypical antipsychotics for schizophrenia. Cochrane Database Syst Rev. 2010(11): CD006633.
13. Marshall M, Rathbone J. Early intervention for psychosis. Cochrane Database Syst Rev. 2011(6):CD004718.
14. Bird V, Premkumar P, Kendall T, et al. Early intervention services, cognitive-behavioural therapy and family intervention in early psychosis: systematic review. Br J Psychiatry. 2010;197:350-356.
15. Norman RM, Manchanda R, Malla AK, et al. Symptom and functional outcomes for a 5 year early intervention program for psychoses. Schizophr Res. 2011;129:111-115.
16. Amminger GP, Henry LP, Harrigan SM, et al. Outcome in early-onset schizophrenia revisited: Findings from the Early Psychosis Prevention and Intervention Centre long-term follow-up study. Schizophr Res. 2011;131:112-119.
17. Melle I, Larsen TK, Friss S, et al. Early detection of first psychosis: TIPS sample five year outcomes. Schizophr Bull. 2009;35(Suppl 1):330.
18. Preti A, Cella M. Randomized-controlled trials in people at ultra high risk of psychosis: a review of treatment effectiveness. Schizophr Res. 2010;123:30-36.
19. Mihalopoulos C, Harris M, Henry L, et al. Is early intervention in psychosis cost-effective over the long term? Schizophr Bull. 2009; 35:909-918.
20. McGorry PD, Hickie IB, Yung AR, et al. Clinical staging of psychiatric disorders: a heuristic framework for choosing earlier, safer and more effective interventions. Aust N Z J Psychiatry. 2006;40:616-622.
21. McGorry PD, Purcell R, Hickie IB, et al. Clinical staging: a heuristic model for psychiatry and youth mental health. MedJ Aust. 2007;187(7 Suppl):S40-S42.