Are we there yet?

In these days of seemingly unending health funding difficulties, issues of service delivery are of more importance than ever, especially in defining target populations, and the effective and efficient means of providing services. There are several papers in this issue of the Australian and New Zealand Journal of Psychiatry (ANZJP) that delve into these important issues. First of all, what should the target population be? In recent years, there has been increased focus on youth mental health alongside the promulgation of early intervention, but there is little mention of children. It is therefore refreshing to see Sawyer and colleagues (in this issue) debate the need to improve Child and Adolescent Mental health Services (CAMHS), and point out that 14% of children have a mental disorder and that, as is often stated, 50% of mental disorders have their onset before 14 years old. Improvements that could be made to CAMHS include making research use of data routinely collected within clinical practice with emphasis on measuring outcomes, and making use of pragmatic trials to evaluate interventions (as has been done in oncology) so as to ensure that evidence-based interventions are implemented with high fidelity.

Another ‘population’ of concern are men; we know there are shortfalls in service utilization among men, with them being less likely to consult health professionals for mental health problems and 40% less likely to consult general practitioners (GPs). There have been a number of initiatives in Australia to attempt to address this and there appear to be signs of success as shown in a study by Harris and colleagues (this issue). These researchers employed a variety of data sets to estimate changes in the percentage of males and females using mental health services in 2006–2007 and 2011–2012. The results offer some encouragement, with an overall increase in treated prevalence from 32% to 40% for males and 45.1–54.6% for females – a growth of service utilization of 25% for males and 21.1% for females. Specialized private services doubled for both genders, but a bit less so for males, most likely the result of the Access to Allied Psychological Service (ATAPS) and Better Outcomes for Mental Health programmes.

Yet another major concern has been the unmet need created by common mental health problems in the general community. Internet-based interventions, in particular Internet cognitive behaviour therapy (iCBT), for the common mental disorders are perhaps one novel way in which this unmet need can be tackled, especially in rural and remote areas. Batterham and colleagues (in this issue) review where we are in developing e-mental health services for depression. There is now good evidence of effectiveness and there have been 20 randomized controlled trials (RCTs) of iCBT for depression with good effect sizes (mean = 0.94), and the effects sizes of other programmes also being found to be effective. Put simply, they are cost efficient and can lead to substantial health gains. Batterham’s team point out that there are different approaches in delivering Internet interventions:

1. An ‘open access’, unguided model in which the consumer registers and completes the programme alone, with the programme supported by government or grants from other funding bodies. This approach has led to the development of the mindhealthconnect website (www.mindhealthconnect.org.au/) that provides a common access point to free and paid services – a particularly useful resource for all clinicians.

2. A health service supported model in which programmes are offered directly through traditional health services (with variable support from clinicians).

3. A private ownership model in which users (sometimes requiring a medical referral) pay the company directly. An advantage of this approach is that the private company will have the funds to reinvest, develop and improve the programme.

4. Finally, a clinically guided referral model. In this approach, the consumer is guided through the programme by a clinician (or receives motivational reminders by SMS, email, etc). Such an approach may lead to larger symptom reduction, but requires greater resourcing.

While there are a number of e-mental health programmes, there is still some resistance to their uptake by clinicians because of lack of awareness, resistance to change and a degree of scepticism, and by consumers but for different reasons; for example, stigma and low mental health literacy among others. To be able to make full use of e-mental health interventions, Batterham et al. propose that programmes require some system of accreditation and endorsement, education and training of health professionals and more stable funding.

There is a caveat in all of this. While on the surface e-mental health services seem to be an ideal solution to service gaps, not all people have access to the Internet, as observed in a debate article by Farooq and colleagues (this issue). They point out that many of those who would benefit from e-mental health services do not have broadband access, and are thereby ‘digitally excluded’. Even if they have access, they may not have sufficient computer literacy to effectively use e-mental health programmes or, if suffering from a psychotic disorder, may be suspicious of computers and mobile phones altogether. It is therefore essential that we advocate for ‘digital inclusion’ of patients with mental illness, especially in socially disadvantaged areas.

Another important target population that has been featured in ANZJP in recent issues is those at risk of suicide. Suicide is not unique to depression as is commonly thought. Hence it is necessary to know about suicide risk in various psychiatric conditions. A seminal report from the International Society for Bipolar Disorders Task Force on Suicide provides us with an updated review (and meta analysis) of suicide in bipolar disorder, and notes that the overall risk in bipolar disorder is 0.164/100 person-years. This is lower than previously thought, but still 10 times higher than the rate in the general population. Suicide attempts, however, are common with 23.8% of patients with bipolar I disorder attempting suicide, and close to 20% of bipolar II patients. The ratio of attempts to completed suicide is 13:1 compared with 20–30:1 in the general population.

Their review confirmed the protective effects of lithium against suicide, but whether this anti-suicidal property is greater than that with other mood stabilizers remains to be established; the key thing seems to be that patients have their mood stabilized as the rates of suicide among patients on anticonvulsant mood stabilizers was similar to that among patients being maintained on lithium. High risk times for suicide are during and following inpatient admissions.

While we are all aware of this risk, perhaps we have not been so aware of the high rates of suicidality among persons with chronic pain (a condition found in close to one-third of the population). Campbell and colleagues (this issue) examine this using data from the 2007 National Survey of Mental Health and Wellbeing (NSMHWB), identifying those in the sample with chronic pain (arthritis, migraine and back/neck pain) and examining lifetime, and past year, suicidality. The rates of suicidality were highest for chronic back/neck pain (28%), followed by arthritis (15.6%) and then migraine. Those with chronic pain had 2.3 times the odds of lifetime suicidal behaviour and double the odds of reporting 12-month suicidal thoughts. This should be something for us to keep in mind when assessing suicide risk, perhaps asking about co-morbid chronic pain.

A quick jaunt through these many challenging issues can be somewhat disheartening and prompt the oft-asked question ‘are we there yet?’ The answer is clearly no, but we are forever inching closer and I hope that by perusing this issue of ANZJP, you will at least see that we are heading in the correct direction.