Some reflections on He Ara Oranga (HAO): Report of the government inquiry into mental health and addiction

One of the major conclusions of He Ara Oranga (HAO) is that New Zealand (NZ) has for too long been solely focused on providing mental health services for the proportion of the population with the most serious mental disorders. The inquiry argues that this almost exclusive focus on specialist services for the severe group leaves not only much untreated psychological distress but also adds to pressure on specialist services through lost opportunities for early intervention. I think that is a reasonable argument but I share some of the concerns expressed by Allison et al. (2019) that the recommended major expansion of treatment to those in the mild–moderate spectrum could threaten service delivery to the group with severe mental health needs.

Although HAO emphasises that the expansion of community services should not be at the expense of current specialist services, it concludes that specialist services do not themselves need expansion, with the exception of addiction services. This conclusion is based on the fact that current per-annum access to mental health specialist services has reached 3.7% of the population nationally, exceeding the target of 3%. But that 3% target dates back to the late 1990s and was never based on NZ data. In 2003/4, the Ministry of Health funded Te Rau Hinengaro: the NZ Mental Health Survey to provide such data. The survey found 4.7% of population to have severe mental disorders in the prior 12 months. Nonetheless, the target of 3% has remained enshrined in policy documents to this day. These figures are all only estimates, but they do suggest that 3% was too conservative a target for specialist services in NZ and that there is likely still a shortfall in service coverage for the most severely unwell (and this is with the conservative assumption that there has been no increase in mental disorder prevalence in the intervening 15 years). So there is a legitimate concern that the HAO recommendation to expand the access target to encompass all of those in the mild–moderate spectrum could put further pressure on service provision for those with severe mental disorders. Moreover, although in principle I welcome the prospect of expanded access to treatment, recommending an increase in the access target from 3.7% to 20% seems unrealistic given that it has taken 15 years to increase access from below 2% to the present 3.7%. Combining the 4.7% with severe needs with the estimated 9.4% with moderate needs for an expanded access target of around 14% would seem ambitious enough, given workforce and financial constraints.

Allison et al. (2019) and others (Jorm, 2018) query the merit of expanded access given the absence of evidence in Australia of reduced distress at the population level following recent major increases in the availability of mental health treatments. There are encouraging data from other countries. A recent evaluation of the English Improving Access to Psychological Therapies (IAPT) programme found that over 50% of individuals treated recover and around two-thirds show a reliable improvement (Clark, 2018). Although it is unclear whether this programme has decreased mental disorder prevalence, the ability to access psychological therapies does seem to have been beneficial for the majority of those seen as part of the IAPT each year. NZ is in the fortunate position of having the experience of these other countries to learn from. It will be critically important to ensure that new service provision in this country is carefully evaluated in terms of quality, quantity, uptake and outcomes.

I do not share Allison et al.’s scepticism about the effectiveness of expanded mental health treatments given the sociocultural determinants of mental ill-health. The effects of social (and other) stressors are filtered through individual psychology and neurobiology, and mental health interventions work at the individual level. Socioeconomic disadvantage impacts mental health not only through the objective difficulties associated with poverty, unsafe environments and unemployment, but also through the perception of lower relative position on the socioeconomic hierarchy. In a cross-national dataset (including NZ data), we found that subjective judgement of relative socioeconomic position was strongly inversely associated with mental disorders independent of objective socioeconomic status and that the association was stronger in high-income countries than in low-income countries (Scott et al., 2014). Invidious social comparisons in the context of high income inequality may be one contributing factor to recent findings that high-income Western countries have, on average, higher prevalence of mental disorders than low-income countries (Scott et al., 2018). Hence, reducing the population-level risk factors of socioeconomic inequalities and child poverty is hugely important. It is significant and heartening that this mental health inquiry has, for the first time in the history of such inquiries in this country, explicitly addressed social determinants and considered prevention as well as treatment. I hope that the Government response will allow some of the vision described in HAO to be realised.