The need for specialist services for serious and recurrent mood disorders

The WHO predicts that by the year 2030 unipolar depressive disorders will rank as the principal cause of disease burden among high-income countries (Mathers and Loncar, 2006). In Australia, 10% of the total burden of disease in 2003 was accounted for by depression and anxiety in women; double that of men (4.8%). Between 1990 and 2010, depression has jumped from 15th to 11th as a cause of global disability-adjusted life years (DALYs) (Murray et al., 2013). It is highly prevalent, with 6% of the population meeting criteria for depression or dysthymia at any time and 20% of those with major depressive disorder having a prolonged illness course, with symptoms persisting for more than 2 years (Reavley et al., 2011). It is equally highly recurrent, with 30% of individuals experiencing a relapse within 3 months of recovery and 50% experiencing a further episode within 2 years, in the absence of continuation or maintenance treatment (Gordon et al., 2011). Bipolar disorder is frequently under-diagnosed, and is also highly recurrent, costly and disabling; it is one of the most important causes of disability at ages 15 to 44, with 35% of the total cost attributable to hospital care. Suicide rates in bipolar I disorder is elevated to 30 times the general population rate (Malhi and Berk, 2011; Page et al., 2011). Germane to primary care, both depression and bipolar disorders are additionally highly comorbid with a range of mental and medical disorders (Magalhães et al., 2012). Critically, a significant component of the burden of disability of mood disorders is avertable with optimal care, although a large component is not avertable (Andrews et al., 2004). Depression is a predominant cause of work-related disability (both absenteeism and presenteeism), and even sub-threshold depression is a major driver of disability pension awards (Knudsen et al., 2010; McKeith and Scott, 2008). Additionally, the most efficient interventions for depression are highly cost-effective, with each averted DALY costing less than a year of average per capita income (Chisholm, 2005).

It has been suggested that the clinical focus on the management of discrete episodes of major depressive disorder and other mood disorders is outdated and that there is a need to treat depression as a ‘life course’ disorder using models of chronic disease management, as promoted for medical problems such as diabetes (Scott, 2006; Wagner et al., 1998). Services oriented to chronic disease management for depression are, however, marked by their paucity. While there are pockets of high-quality care, there are clinically significant obstacles to the delivery of a more uniform high-quality model of care for mood disorders.

The current funding model, which sees the care of those with a ‘serious mental illness’ as being primarily a state responsibility, leaving the high-prevalence disorders in the federal domain has significant and well recognised sequelae for effective continuity of care. It does not support intensive or long-term interventions for those with anxiety or depression by specialised experts in the public system. The additional preoccupation with risk assessment in the triage process, and the reliance on risk assessment within the public services to determine access to care, filters individuals with expressed aggression or suicide into the system, and leaves many with potentially treatable mood disorders outside of the public system unless critical safety issues are present. Most academics are in the public (state) system, which has a primary focus on psychotic disorders rather than mood and anxiety disorders. Indeed, the paucity of expertise in mood and particular anxiety disorders leaves Australia in divergence to most major Western countries. The counterpoint of this anomaly, which is that the ‘high prevalence’ disorders are amongst the greatest contributors to burden of disease in adults, is stark.

The federal model of care for mood disorders, with the emphasis on primary care, is appropriate given their frequency; however this leads to a number of service consequences. Funding is focused on primary care, with the GP as the centre of the system. The better access system has clearly had a substantial beneficial impact on access to care (Hickie et al., 2011; Jorm, 2011). However, we know from studies such as the STAR*D study, that despite optimal treatment, a distressingly large number of individuals will not respond to therapy. About two-thirds of people respond to any specific trial of treatment, and a third of people who are treated have a placebo response to non-specific factors of care. The substantial proportion of individuals who fail to respond to primary care, or whose disorders relapse (as they do) after non-specific (placebo) response, points to a significant unmet need insofar as non-responders often do not get access to additional help or expertise, and thus remain symptomatic and frequently disabled.

There are important characteristics of the current system. Firstly, being located in the federal domain, and delegated out to individual practitioners, there is little coordination of treatment, training and education, and as a consequence capacity generation is not a principal focus (Scott et al., 2002). As care is principally primary care based, the complexity of mood disorders is underplayed in order to produce algorithms and models that are easy to convey and utilise. Pragmatically, this results in a reductionist model of care that utilises SSRI antidepressants and CBT for the vast majority of the instances of care. While understandable and appropriate for primary care, this neglects the reality that mood disorders are highly heterogeneous and complex conditions, in which outcomes depend critically on subtle diagnostic and treatment decisions.

There are a confusing plethora of potential therapies (Malhi et al., 2009). Psychological treatments for depression range from watchful waiting, bibliotherapy, exercise and dietary interventions, through to more specific interventions such as interpersonal therapies, cognitive and cognitive-behavioural therapies, including the ‘third wave’ cognitive therapies such as mindfulness, dialectical behaviour therapy and acceptance and commitment therapy. Social issues such as housing, employment, poverty and family violence contribute substantially to the genesis of mood and related disorders, and tailored interventions need to be integrated into appropriate therapy models. These can extend beyond traditional social services to include community programmes targeted at young mothers at high risk of depression and/or struggling with parenting, providing early secondary intervention for the parent and potentially delivering primary prevention of problems in their children (McKeith and Scott, 2008). Pharmacological therapies include a wide variety of medications, including antidepressant agents, mood stabilisers, antipsychotics and thyroid hormones, amongst others. Physical treatments include ECT, TMS, phototherapy, psychosurgery and deep-brain stimulation (Dinan and Quigley, 2011; Lawrence et al., 2011; Pasco et al., 2011). Both medical and social dimensions need to be integrated. It needs to be stressed that medical treatment, which requires the model we speak of, and community support, lifestyle intervention and disability support are both needed – one is not a substitute for the other. A plethora of clinical factors including symptom profiles, comorbid personality, substance use or physical disorders, medical factors, duration of illness, patterns of recurrence, severity, suicidality, presence of psychotic symptoms and the presence or absence of episodes of mania or hypomania and patient preferences influences clinicians’ decisions regarding these diverse options.

Additionally, mood disorders are diagnostically heterogeneous, and in each individual, different permutations of developmental, parental, stress, personality, vulnerability, resilience, lifestyle, support, substance use, medical, genetic and similar factors are present (Boyce and Harris, 2011). While it is overtly clear that treatment needs to be individualised such that these factors are addressed in order to optimise therapy, assessment of these factors is complex, and primary care models of treatment need to be simplified and streamlined to make them feasible and pragmatic. As a consequence, many individuals fail to respond to appropriate primary care, and access to secondary facilities is restricted and not uniform. Tertiary facilities are only present in very few locations.

In order to improve standards of care, access to treatment and upskilling of practitioners, there is a clear place for a more coordinated approach to mood disorder management that is also sensitive to the needs of a modern primary care service and its patients. Considerable political effort has been directed at addressing the improvement and integration of primary care and the primary care/specialist care divide in all health, not just mental health. The National Health and Hospital Commission Reform Report ‘A Healthier Future for All Australians’ (National Health and Hospitals Reform Commission, 2009) and the National Health Reform Agreement (Council of Australian Governments, 2011) acknowledge the difficulties caused by divided responsibilities between federal and state governments. A number of recent Commonwealth initiatives are positive efforts to bridge the divide between primary care and specialist care including the Mental Health Nurse Initiative, the Partners in Recovery program, which is about to be rolled out to each region in Australia and state-based funding of primary mental health teams at least in Victoria. There is also an attempt via the National Disability Insurance Scheme to support a collaborative approach between agencies and people with severe disability due to mental illness. One of the consequences of the diversity of these schemes, and a factor that the creation of any new service will have to manage, is for it to be structured in a manner that motivates providers to collaborate effectively with one another, which is what the Reform Plan attempts to achieve.

But more needs to be done and we suggest the following. Firstly, more intrinsic support for primary care is needed, but more comprehensive and specific mood disorder specialist services should be developed that buttress treatment in primary care and that are responsive to that approach. There are many models of mood disorder services, which range from hands-off consultative practice models with emphasis on capacity generation and upskilling, to hands-on and more intensive tertiary models in which the unit takes on the active care of the individual for a variable length of time (Lewis et al., 2004; Parker, 2000). Given the high prevalence of these disorders, the paucity of available clinicians, the high costs of tertiary models of care and a service structure in many countries in which collaborative and integrative care models are normative, the most pragmatic models tend to be closer to the former than the latter (Djernes et al., 2011). We would argue that in order to attain the greatest reach, generate and upskill capacity in primary care and other public or NGO care partners, the former model is the most applicable. In this model of care, an emphasis on thorough assessment, potentially aided by internet assessment tools, allied with a thorough case formulation and management plan, communicated in a bidirectional manner with the primary care practitioner or clinical referral source, is used. A follow-up reassessment visit is useful to monitor progress, and to modify the therapeutic plan, which will be delivered in a primary care setting. Both the initial and follow-up assessments are supported by current billing codes; this provides a funding template around which services could be developed. A process of upskilling the clinicians in this program would need to precede its roll-out, and a secondary upskilling of general practitioners would follow. Flexibility and tailoring services, rather than a cookie cutter approach to service, would be optimal. For example, pure mood disorder services may be appropriate for larger metropolitan centres with substantive population densities, whereas services that have a broader remit may be more appropriate to regional centres.

One type of integrative care model combines cutting edge clinical practice and assessment with clinician education and community promotion and awareness. There is a direct connection between academic clinicians, educators and community teams. These links capitalise on the multidisciplinary strengths of the players, and iterative feedback is possible. Clinicians are not simply research informed, they are actively involved in novel treatment or intervention research, initiating new trials for treatments, new assessment tools to categorise illness or new systems to deliver treatments. These same clinicians work with education teams within the same institution to develop educational content for peers. Educators develop guidelines and provide the expertise to deliver this new knowledge, using best practice educational methods, to general practitioners and health professionals. Within the same organisation, community experts work within traditional and technology-enabled settings to engage and inform all stakeholders. Integrative care models, such as the one above, develop reputations in one or more fields – such as neurostimulation, post and prenatal, psychiatric assessment, web-delivered early intervention, and so on. The critical feature of these models is that translation is direct from clinic, to education, to the community, and happens seamlessly within the one care model.

Collaborative care models have been developed from chronic care models that have been shown to improve the quality of community-based depression management (Katon, 2012). Collaborative care is designed as a multicomponent healthcare intervention, delivered at a system-level intervention. It links primary care providers, patients and mental health specialists using specialised managers, providing case management support to primary care providers, who additionally receive decision and consultation support from mental health specialists, such as psychiatrists and psychologists. The aims of this model of care are designed to improve the quality of routine screening and the accuracy of the diagnosis of depressive disorders, to increase the use of evidence-based treatment protocols among practitioners and to improve clinical and community support to facilitate the patient’s ownership and engagement in self-management strategies such as goal setting (Thota et al., 2012).

Investment into a new set of integrative care model centres for mood disorders is a cost-effective model, which has the capacity to improve the quality of care and outcomes in the community (Mihalopoulos et al., 2011; Parker et al., 2000). As mood disorders are the largest burden of disability in adults, driven by both the receding tide of communicable and other medical disorders, and the worrying epidemiological finding that the prevalence of depression may be increasing in the community, we need to begin to invest in clinical integrative care models that are able to facilitate translation of the body of knowledge that exists regarding effective management into the broader community (Allen and Jackson, 2011).