Improving the impact of treatments and services

In an article that appeared in the journal last year, Mulder et al. (2017) asked ‘Why has increased provision of psychiatric treatment not reduced the prevalence of mental disorder?’. This is a question of great concern for the mental health sector, given that we have treatments that are effective in randomized controlled trials, but these do not seem to produce the expected gains in practice. A number of contributions in this month’s issue give some clues as to why we are in this situation and what needs to be done to improve it.

One possible factor is a lack of quality of services – what has been termed the ‘quality gap’ (Jorm, 2015). This is seen in the data reported by Sawyer and colleagues (this issue) on service use from the 2013–2014 Australian Child and Adolescent Survey of Mental Health and Wellbeing. They found that, while over half the children with a mental disorder had attended a health professional during the previous 12 months, the most common number of visits was 2–4, which would generally be too few to allow implementation of evidence-based treatment. The authors suggest that the low quality of treatment services may be a reason that the prevalence of child mental disorders is not decreasing in Australia and other industrialized countries.

The quality gap is also seen in the article by Page and colleagues (this issue). They describe a decision support tool based on a dynamic simulation model to identify the combination of suicide prevention activities that is most likely to reduce suicide attempts and deaths in a specific catchment area of Sydney. Two interventions that are predicted to produce the most gains are ‘providing assertive aftercare and follow-up among those who have presented to services after a suicide attempt’ and ‘preventing disengagement from mental health services among those who have had mental health service contact’. The fact that these gaps exist in a country with an advanced health care system shows how much is missing from what we are currently offering to people at risk of suicide.

More evidence for what is possible in treatment comes from the meta-analysis by Oud and colleagues (this issue) on specialized psychotherapies for people with borderline personality disorder. This review finds that specialized therapies produce greater gains than non-specialized approaches, with a medium effect size. However, these gains involved a minimum of 52 weeks of treatment, with some trials extending over more than 100 weeks. The question then arises as to how many people with borderline personality disorder actually receive this amount of treatment. In Australia, where psychological therapies are covered by the national health insurance scheme, Medicare, the maximum number of services allowed falls far short of this ideal, so that the quality gap is built into the funding mechanism.

In addition to overcoming the quality gap, producing improvements in the prevalence of mental disorders requires the development of new and better treatments. Unfortunately, in the area of psychiatric medications, there have been no real advances for decades. To achieve these advances requires a better understanding of the causes of mental disorders. The article by Morris and colleagues (this issue) introduces the concepts of ‘leaky brain’ and ‘leaky gut’, which involve novel mechanisms for the pathogenesis of mental disorders and suggest potential new therapeutic approaches, such as melatonin, statins, probiotics and prebiotics, and N-acetylcysteine. While these concepts are a long way from current practice, they point us in exciting new directions.

Taken together, these varied contributions support advocacy for better services, the need for more research effort to develop new and more effective treatments, and, perhaps most importantly, for greater attention to the quality of implementation of what we already know works.