The He Ara Oranga Report: What’s wrong with ‘Big Psychiatry’ in New Zealand?

The portrayal of psychiatry in the recent He Ara Oranga (HAO) Report into New Zealand’s mental health and addiction services raises significant concerns for the profession as a whole. This once-in-a-generation report recommends a decisive shift away from what is termed ‘Big Psychiatry’ towards a new sector called ‘Big Community’ (New Zealand Government, 2018: 97). Big Psychiatry is characterised as a medically led system where ‘most resources are used for psychiatric treatments, clinics and hospitals’ (p. 36). Big Psychiatry is criticised as having a colonising worldview, together with a legacy of paternalism and human rights breaches. In response to this depiction of psychiatry, the HAO Report recommends creating Big Community where ‘resources are used for a broad menu of comprehensive community-based responses’ (p. 36) that embrace multiple worldviews, and respond to people at risk with compassion and support. Big Community is praised as having a strong commitment to partnership, recovery, spirituality and human rights.

The rhetoric of the HAO Report follows from the mid-20th century reform movement that campaigned for the closure of psychiatric hospitals. This reform has dominated mental health policymaking in English-speaking countries for the last 60 years. As a result, New Zealand, Australia, Canada, Ireland, the United Kingdom and the United States have far lower numbers of hospital-based psychiatric beds than most other high-income countries. Tyrer et al. (2017) have suggested that bed numbers have fallen below a critical threshold in English-speaking countries and that ‘More experiments in community care will never be effective if the bed base is too low’ (p. 363). This prediction brings into question the HAO Report’s overall strategy.

Moving from Big Psychiatry to Big Community would have been appropriate national policy during the early phases of deinstitutionalisation in New Zealand, when significant numbers of patients lived in mental hospitals. It is inappropriate in contemporary New Zealand, which already has a largely deinstitutionalised mental health system. After the early 2000s, community services became the largest part of New Zealand’s mental health system, and by 2016, most patients (91%) were treated exclusively by community mental health services with only 9% receiving inpatient care, according to the Office of the Director of Mental Health. The HAO Report also proposes changes to the Mental Health Act (MHA) that could have the unintended consequence of further reducing access to inpatient psychiatric care, due to raising the threshold for compulsory treatment. If the proportion of patients receiving inpatient care is further reduced, the potential for adverse outcomes needs to be closely monitored, as there is a risk of undertreating severe mental illness, as currently happens in many parts of the United States, which led the way on psychiatric bed reductions in the English-speaking countries.

It is important for policymakers to note that New Zealand already has ‘Small Psychiatry’ by international standards. In 2016, New Zealand was ranked 32nd out of 36 member countries in the Organisation for Economic Cooperation and Development (OECD) for numbers of hospital-based psychiatric beds; New Zealand reported 31 beds per 100,000 population (in general hospitals and standalone psychiatric hospitals), which was far below the OECD average (69 beds per 100,000 population). New Zealand also reported far fewer mental health beds than comparable high-income countries in data collected by the World Health Organization (WHO). New Zealand reported having 38 mental health beds per 100,000 population (in general hospitals, psychiatric hospitals and residential care), compared with a median of 71 beds per 100,000 population for all high-income countries and 93 beds per 100,000 population for European countries.

There are clear signs that New Zealand’s Small Psychiatry sector is struggling. The HAO Report paints a gloomy picture of New Zealand’s psychiatric services with high thresholds for entry, long waiting lists, a hard-to-navigate system, variable treatment quality and shabby inpatient units, adding up to ‘a system failing to meet the needs of many people’ (New Zealand Government, 2018: 10), ‘Too many people are treated with a lack of dignity, respect and empathy’ (New Zealand Government, 2018: 11) and ‘Maori are subject to much greater use of compulsory treatment and seclusion’ (New Zealand Government, 2018: 11). Staff attraction and retention is also proving difficult, especially in ageing and overcrowded inpatient units with high levels of violence towards staff (www.radionz.co.nz/news/national/377603/safety-concerns-at-hillmorton-hospital-it-s-a-terrifying-workplace-former-psychiatrist, 6 December 2018).

Patients using New Zealand’s psychiatric services have far higher suicide rates (136 per 100,000 population aged 10–64 years) than the rest of the population (6 per 100,000 population), according to the Office of the Director of Mental Health. In fact, nearly half of those who die by suicide in New Zealand have accessed either psychiatric or addiction services in the year prior to their death. While patients attending psychiatric services are at higher risk of suicide around the world, these figures are still a cause for concern. If access to inpatient care is further reduced through changes to the MHA, it might further increase suicide rates among patients with severe mental illness.

Rather than investing more in the struggling Small Psychiatry sector, however, the HAO Report recommends creating a Big Community sector with a far larger target population. Currently, psychiatric services target the 3% of the population affected by severe mental illness, but the Big Community policy would expand the focus to the 20% of the population reporting mental distress in any given year. The HAO Report recommends more public funding for psychological therapies, primary mental healthcare and programmes run by non-government organisations.

The Big Community proposals were derived from programmes developed in other English-speaking countries; the HAO Report notes as examples the Improving Access to Psychological Therapies (IAPT) programme in the United Kingdom and the Medicare-funded scheme for Better Access to Mental Health Care in Australia. The HAO Report cites two key articles on these responses to ‘a rising tide of mental distress and addiction’ affecting people in English-speaking countries (Jorm et al., 2017; Mulder et al., 2017). Yet, the HAO Report fails to fully engage with the findings of these researchers, which cast doubt on the idea of expanding publicly funded services to 20% of the population. While the clinical outcomes of IAPT have been moderately positive, there is limited empirical evidence that such costly service expansions have reduced psychological distress at the population level (Jorm et al., 2017). If funded by the New Zealand Government, it would be important to assess whether Big Community initiatives reduce the prevalence of psychological distress and suicide. Long-term research would be required, as the benefits might not accrue for many years, and could be confounded by population cohort effects.

The HAO Report also implies that the Big Community initiatives would reduce the demand for frontline mental health and addiction services; however, there is limited evidence for this effect (Mulder at al., 2017). In the previous decade, Australia has invested in primary mental healthcare, early intervention, clinical psychology, pharmaceuticals and community mental health services, which neither prevented a steep rise in hospital emergency department presentations and inpatient admissions nor reduced Australia’s suicide rate (Allison et al., 2018). There are valuable opportunities for New Zealand’s policymakers to learn from Australia’s disappointing experience with such Big Community proposals.

The rising tide of psychological distress and suicide in many English-speaking countries is probably mostly socially determined and hence is not amenable to simple mental health interventions. The HAO Report summarises the social determinants of poor mental health in New Zealand as ‘poverty, lack of affordable housing, unemployment and low-paid work, abuse and neglect, family violence and other trauma, loneliness and social isolation (especially in the elderly and rural populations) and, for Maori, deprivation and cultural alienation’ (New Zealand Government, 2018: 8). It is evident that short courses of cognitive behavioural therapy or antidepressant medication will be unable to fully address these major social adversities. If cultural and social problems are causing the rise of psychological distress in New Zealand, solutions surely need to be sought at the societal level, in addition to the level of individual psychology. The New Zealand Government should explore policies that address the social determinants of poor mental health, an approach that could be termed ‘Big Social’.

In conclusion, New Zealand’s national mental health policy should focus on those patients who have the highest needs and should not be based on the anti-psychiatry rhetoric of a bygone era. With its Big Community proposals, the HAO Report risks a shift away from core psychiatric practice with severe mental illness towards treating other forms of behavioural disturbance and personal distress. This expansion is likely to result in more and more individuals receiving drugs and psychotherapies without any measurable improvement in New Zealand’s population mental health or suicide rate. Shifting the emphasis back to resourcing existing psychiatric and addiction services adequately to better treat patients with severe mental illness would be a more rewarding strategy. It is these patients whom we need to prioritise, rather than continuing an expansion into areas where our expertise is unproven.