More access for some but not others: Is it better?

Abstract

Australian & New Zealand Journal of Psychiatry, 53(11) A substantial increase in community access to mental health treatment has been proposed in both Australia and New Zealand. Articles led by two of the Australian and New Zealand Journal of Psychiatry’s (ANZJP) associate editors (Tony Jorm and Roger Mulder) have highlighted the lack of supporting evidence for these expanded mental health services. Jorm’s (2018) controversial article about the failure of the Better Access scheme to have any impact on population mental health was published in this journal last year. Similarly, in New Zealand, Mulder et al. (2017) reported that increased provision of psychiatric treatment over the last decade has not been associated with reduced prevalence of mental disorder. Rosenberg and Hickie (this issue) discuss the growth of Australian community mental health services proposed in a recent Medicare review. The original Better Outcomes Program aimed to provide psychological interventions to the most socio-economically and geographically disadvantaged people. This goal seems to have been lost, and despite the change in name to the Better Access Program, the improved access seems to be located in socio-demographically advantaged regions. These same authors note that the current cost of Better Access is AU$28 million/week, and they model three different scenarios for the proposed expansion. They offer a number of recommendations to make the programme fit for purpose, including greater use of digital technologies, and better team-based care for people with complex psychiatric disorders. Scott (this issue) comments on the New Zealand He Ara Oranga report, which concludes that Big Psychiatry should be replaced by Big Community. Big Psychiatry has been criticised for having a colonising world view and a legacy of paternalism and human rights breaches. In contrast, Big Community will have a strong commitment to partnership, recovery, spirituality and human rights and will aim to address the needs of the 20% of the population expressing mental distress in any one year (Allison et al., 2019). While welcoming greater access to treatment, Scott is concerned that increasing the access target from the current 3.7% to 20% is unrealistic and could put further pressure on service provision for those with severe mental illness. She points out that the introduction of Big Community services in New Zealand provides an opportunity to build in careful evaluation. Such evaluation, missing from Better Access in Australia, would enable new services to evolve to optimise effectiveness and impact. The non-governmental organisation (NGO) sector gets some attention in this month’s ANZJP. Looi et al. (this issue) describe ‘Headspace-like Behemoths’. These are monstrous creatures that swallow resources. Looi et al. (this issue) ask whether large NGOs such as Headspace and Beyond Blue address gaps in existing services, or rather drain resources from public mental health services. As with Better Access (Rosenberg and Hickie, this issue; Jorm, 2018), Looi highlights the lack of evaluation of these services. That said, there is also a lack of detailed information about treatments and outcomes from public mental health services. The expansions of Better Access, Big Community and the NGOs are based on the assumption that more treatment, applied to more of the population, has to be a good thing. However, any potent treatment that has positive effects is also liable to negative or adverse effects. Meadows et al. (2019) wrote previously in this journal that reliance on psychiatric treatment can lead to a reduction in spontaneous self-help activity. This may paradoxically increase the prevalence of psychiatric disorders, especially in disadvantaged areas where limited treatment is available. In addition, medicalisation of life problems beyond the bounds of evidence-based treatment may cause clinical problems, such as medication side effects, or reliance on treatment when selfhelp strategies would have worked better. Self-identification as a person with ‘mental health issues’ who lacks resilience and requires professional More access for some but not others: Is it better?