Abstract
Psychiatric services around the globe are in a constant state of flux. Sometimes changes are deliberate and often these occur on the well-meaning whims of clinicians or managers who have based their preconceptions on what they consider to be ‘a good way to deliver services’. Alternatively, change simply occurs by accident because of changes in local resources such as staffing or physical resources such as buildings. More often than not, there is minimal evaluation either of the baseline situation or the effects of such changes. Amongst staff, some believe things are better whilst others believe they are worse. Notably, patients are rarely consulted. It is therefore encouraging to note that this month’s ANZJP includes the evaluation and discussion of important service issues.
Large amounts of time and money have been spent in Australia in setting up the Access to Allied Psychological Services (ATAPS) programme and then the enhanced Indigenous ATAPS programme. At inception, the collection of a minimum web-based data set was introduced. This included pre- and post-intervention scores on standard treatment outcome measures, so, theoretically, there could have been an evaluation of outcome on clinically relevant rating scales. This month, Reifels et al. (this issue) have published the first evaluation of these services with regards to accessibility for Indigenous Australians. A doubling in Indigenous service volume following the introduction of the Indigenous ATAPS service is heartening and outcome data suggest positive treatment gains. However, areas for further scrutiny include the finding of double the number of unattended sessions amongst Indigenous clients compared with non-Indigenous clients. Also, only 3.5% of patients had pre- and post-outcome scores illustrating the fact that it is sometimes difficult to collect meaningful data in routine clinical practice.
Another way to evaluate practice or service delivery is to define aspects of practice or outcome which are undesirable and to examine current practice against this. While not necessarily so in every case, antipsychotic polypharmacy (concurrent use of more than one antipsychotic) should be avoided where possible. The issue is examined in a cross-sectional study from China (Li et al., this issue). Not only was this impressive study very large, including 4239 patients with schizophrenia in 45 mental health centres across China, but it was a repeat of a similar survey done in 2002 and 2006. The results show that antipsychotic polypharmacy, which occurred in a third of cases (34%), increased from approximately a quarter (26%) in the two previous surveys. The authors conclude that this is an issue which has serious implications for the services involved (and no doubt the patients affected) and that it requires further examination. A similar Australian survey showed a rate of antipsychotic polypharmacy of 28% in people with schizophrenia (Morgan, 2012).
In another paper examining the current state of services, Howlett et al. (this issue) use the relatively novel technique of linking data sets to examine the ‘ambulatory mental health service profile’ of people with an intellectual disability (ID). Using these data sets they were able to evaluate both the recorded mental health profile and service use characteristics of people with intellectual disability – which is an important baseline evaluation to be used in the planning of improved services for this group. Comparison with studies specifically examining the prevalence of mental disorders in people with ID suggests that, in mental health services, there is a relative under representation of people with ID, which may reflect difficulty in accessing services and provides an area for possible intervention.
In their Debate article, Wand et al. discuss issues regarding the provision of consultation-liaison services (Wand et al., this issue). In this article they particularly discuss the issue of evaluating intangible aspects of services; for instance, the effects of educating and upskilling of general health professionals in mental health issues. Their article also resonates with two further debates in the Journal. The first tackles the perceived crisis in academic psychiatry. As Wand et al. point out, The UK Shape of Training Review emphasised the need for trainee psychiatrists to have more general medical training, especially given the aging population and increasing burden of physical co-morbidity. One suggestion is that psychiatrists should undertake clinical attachments, for instance on neurology wards. On the other hand, Lewis et al., in their Editorial (this issue) in response to Henderson et al. (2015), point to the greater research training in clinical psychology which they believe has had a major positive impact on recruitment of clinical psychologists into research careers. They suggest, amongst other things, that the requirement for significant research be brought back into psychiatric training. Clearly it will be difficult to balance the divergent calls for increased clinical and competency-based training and increased research training without extending the overall time spent in training as a psychiatrist. It is likely that the intransigence between these competing contingencies will be the subject of debate in future volumes of the Journal and deservingly so.
Finally, readers will have noticed that ‘patients’ or participants in research are referred to in a number of different ways in the articles this month. In Sara et al. (this issue), the term used is ‘people with psychosis’ in Li et al. (this issue) ‘schizophrenia patients’, Reifels et al. (this issue) use ‘clients’, Sunderland et al. (this issue) ‘old age Australian’ or ‘older Australians’ and Wand et al. (this issue) refer to ‘patients’ but do make brief reference to ‘service user “experts”’. Starcevic (this issue) discusses the report of the Australian Health Ministers Advisory Council (A national framework for recovery-oriented mental health services: Policy and theory), which suggests that these terms be replaced, with terms such as ‘experts by psychotic experience’ or ‘Australian experts by old age and psychiatric experience’. Starcevic, however, argues strongly against such terms, which he believes actually trivialise suffering and romanticise mental illness. Another point of contention – and another opportunity for debate and discussion? Evidently, it’s not only service delivery that we have to re-examine but also how we deliver our messages and, indeed, to whom.