Reducing the quality gap in mental health services

I have previously argued in the pages of the Australian & New Zealand Journal of Psychiatry (ANZJP) that there is a major ‘quality gap’ in mental health services in Australia, given that a substantial proportion of people receiving services do not receive an adequate standard of treatment (Jorm, 2015). This gap is not unique to Australia and has been shown to occur in other high-income countries with well-developed health systems. The claim that there is a quality gap is unlikely to be controversial to readers of this journal. However, what is more contentious is what to do to overcome it.

One of the responses that governments have made to the quality gap is to appoint commissions of inquiry into mental health services. Australia has had many inquiries in the past, including two running at the present time. One of these is the Royal Commission into Victoria’s Mental Health System. In this month’s issue, we present two debate pieces on the work of the Royal Commission.

The first, by Allison et al. (this issue), concerns the role of early intervention for psychosis services targeted at young people. The state of Victoria has been a world leader in the development of such services, and they have often been promoted as having the potential to prevent chronic psychosis and to save money in the long term. However, Allison and colleagues argue that, while such services are beneficial for the time they are being received, they do not have a long-term preventive effect and do not reduce the need for services later in life. Hence, there is a need for good quality psychosis services across the lifespan, which is a goal that Australia is far off reaching. Allison et al. correctly call for the Royal Commission to investigate whether the current balance of services is optimal.

The second piece on the Royal Commission, by Nicola Reavley (this issue), speaks to how we should promote the need for service improvement to the public. The public hearings held by the Commission have led to reporting in the media of ‘bad news’ stories about services, which may be atypical of what most people receive and are in some instances from the distant past. Although such ‘bad news’ may be useful in motivating service improvement, there is a danger that they may also increase stigma and dissuade people with mental disorders from seeking help that could benefit them. While stigma is generally seen as attaching to people with mental disorders, it can equally attach to the services that treat and support them.

Continuing with this theme, a letter by Allison, once again with a slightly different set of colleagues (this issue), points out that while carrying out service reform, we also have to be mindful of unintended consequences in other parts of the health system. A service modelling study on suicide prevention by Atkinson et al. (2019) had indicated that psychiatric inpatient beds in Western Sydney could be safely cut by 15% without increasing suicides. Allison et al. argue that such cuts could lead to the undesirable effect of increased emergency department (ED) attendances. They also point out that psychiatric inpatient treatment has potential benefits beyond suicide prevention. Their letter points to the need to consider the whole-of-system and whole-person implications of service reform.

This month’s issue also reports two studies describing the quality of current services. The study of van Spijker et al. (this issue) describes the profile of mental health service provision in various rural and remote areas of Australia. The fact that people in rural and remote areas often have poorer service provision is well known, but these researchers present a method for describing and mapping mental health services in a standardized way, which reveals considerable inequity in the composition of services between rural and remote areas.

The other study on quality, by Ellis et al. (this issue), describes how well paediatric depression and anxiety are treated when judged by the standard of clinical practice guidelines. The report card is mixed. Adherence to guidelines is very high for prescription medications, but lower for some other areas, such as ensuring an emergency safety plan for children with depression, informing parents about the risks and benefits of prescribed anxiety medication and assessing for other causes. The greatest need for improvement in quality was with treatment by general practitioners (GPs). Despite the shortcomings identified, these findings give a more optimistic view of quality than those published earlier this year from Sawyer et al. (2019), which found that only 12% of children and adolescents with a mental disorder had enough contact with health professionals to allow provision of minimally adequate treatment.

While closing the quality gap requires greater human resourcing of services, there is also scope for contributions from technological innovations. Many of these never manage to have a major practical impact, but some do. An example is the field of e-therapy, which has become increasingly prominent in recent years as a first step in treatment of people with milder mental health problems. A new horizon in this area is the application of artificial intelligence to benefit mental health. Fonseka et al. (this issue) review the potential contribution of artificial intelligence to suicide risk prediction and management of suicidal behaviours. Their review offers no shovel-ready solutions, but is a space to watch.

Related to quality of treatment, this month also sees a continuation of the discussion from a previous issue about the need to know more about the practical application of repetitive transcranial magnetic stimulation (rTMS) in the treatment of depression. Fitzgerald (this issue) and Pridmore (this issue) have responded to an earlier question posed by Malhi and colleagues that raised concerns regarding the positioning of rTMS in the treatment of depression and highlighted their points by discussing a case in which rTMS was administered for long periods of time and followed the use of electroconvulsive therapy (ECT).

The quality gap in mental health care is a major concern, not only for Australia, but globally, and is likely to be a recurring issue for the journal. When it fades from our pages, it will be a welcome sign that the gap has been closed.