Abstract
Samuel Johnson remarked that we more frequently require to be reminded than informed. Fortunately, the paper by Carr et al., (2012) does both. It reviews results of a survey which can inform policy and service development in the mental health field in Australia and draws conclusions about areas in which the field generally needs to develop, refine and evaluate interventions. It also reminds us that a good deal of the information we already have is not being fully used.
As an outsider who has never been to Australia, I have long been impressed by the calibre of research and debate concerning the delivery of psychiatric care that comes from that continent (Andrews et al., 2004; Jorm, 2011; Meadows and Bobevski, 2011). I sense that there may well be political undercurrents in the authors’ description of competing lobby groups and piecemeal and fragmented reforms, but whatever the challenges and frustrations there have been in using systematically gathered information to improve care for those with serious mental illness, it is noteworthy that mental health issues and in particular efforts at an informed analysis of these issues appears to have been a priority for relevant governments in Australia.
Many years ago, when carrying out focus groups on the needs of clients, I vividly remember one participant summarizing their needs as, ‘a decent place to live, a job, a relationship and self-respect’. These align quite well with several of the challenges and priorities identified by respondents to the survey described in this paper. The authors make important points with regard to meeting these challenges. They remind us to look beyond the reduction of symptoms as an objective, to improve coordination between different types of services and to be flexible in providing services on the basis of the widely varying needs and circumstances of clients.
I have great sympathy with the suggestions made by the authors for the need for future research to better inform us on effective approaches to meeting these challenges. The needs for studies related to improving physical health, the risk to benefit ratio of various pharmacological options and addressing substance abuse/dependence comorbidity are particularly acute.
What strikes me particularly, however, is that many interventions that do have empirical support and compelling clinical rationales are not provided. For instance, the evidence for the benefits of psychosocial interventions (such as family psychoeducation and social skills interventions) is strong, but rates at which they are delivered are indeed ‘unsatisfactorily low’. The less than optimal implementation of evidence-based interventions is by no means unique to Australia (Hall, 2004; Hogan, 2010). Even those of us who work within programs with both clinical service and research mandates can sometimes be struck by the limited impact of our own research findings on our service delivery. How can we diminish the gap between research findings and clinical practice?
The monitoring of services and outcomes on a population basis, as exemplified by this paper, is likely to be of help in focusing more attention on the challenges that need to be addressed by the development, refining and evaluation of interventions using controlled research methods such as randomized clinical trials. However, there is also a need to better address the issue of why what has been demonstrated to be effective often is not being delivered. I would be among the last to deny that limited resources can interfere with delivery of effective interventions, but that seems unlikely to be the full explanation.
The essence of research is answering a question or testing a prediction through careful, replicable observations. Some types of research require expertise and facilities that are beyond the resources of many clinical programs. On the other hand, fundamental questions related to clinical and social accountability should be addressed by information in most clinical programmes. Questions such as what are the needs of our clients, what services are we providing, to how many are we providing these services, what are their impacts and how well are we meeting our clients’ objectives are fundamental. Surely professionals cannot doubt the importance of collecting information relevant to each of these issues. When such information is collected and examined, they almost inevitably lead to the question, ‘How can we do better?’. In that context, the motive for careful analysis and evidence-based change becomes intrinsic for service programs as opposed to being seen as an imposition from outside (Hodges, 2011; Rush and Ogborne, 1991).
In addition to the need for more accountability for the effectiveness of clinical and social services; we have to recognize their limitations, particularly when addressing issues related to social circumstances and exclusion such as employment and accommodation. Consistent with the observations of Carr et al., (2012) the many forms of social exclusion are likely to be significant contributors to the dysphoria, anxiety and reduced self-esteem that accompany psychotic disorders (Birchwood et al., 2007; Davidson et al., 2001). Developing and evaluating interventions for individuals with psychotic disorders designed to reduce the impact of community-based exclusion are important, but social interventions to reduce the likelihood of such exclusion are also important and challenging (Corrigan, 2012).
See Review by Carr et al., 2012, 46(8): 708–718