More access for some but not others: Is it better?

A substantial increase in community access to mental health treatment has been proposed in both Australia and New Zealand. Articles led by two of the Australian and New Zealand Journal of Psychiatry’s (ANZJP) associate editors (Tony Jorm and Roger Mulder) have highlighted the lack of supporting evidence for these expanded mental health services. Jorm’s (2018) controversial article about the failure of the Better Access scheme to have any impact on population mental health was published in this journal last year. Similarly, in New Zealand, Mulder et al. (2017) reported that increased provision of psychiatric treatment over the last decade has not been associated with reduced prevalence of mental disorder.

Rosenberg and Hickie (this issue) discuss the growth of Australian community mental health services proposed in a recent Medicare review. The original Better Outcomes Program aimed to provide psychological interventions to the most socio-economically and geographically disadvantaged people. This goal seems to have been lost, and despite the change in name to the Better Access Program, the improved access seems to be located in socio-demographically advantaged regions. These same authors note that the current cost of Better Access is AU$28 million/week, and they model three different scenarios for the proposed expansion. They offer a number of recommendations to make the programme fit for purpose, including greater use of digital technologies, and better team-based care for people with complex psychiatric disorders.

Scott (this issue) comments on the New Zealand He Ara Oranga report, which concludes that Big Psychiatry should be replaced by Big Community. Big Psychiatry has been criticised for having a colonising world view and a legacy of paternalism and human rights breaches. In contrast, Big Community will have a strong commitment to partnership, recovery, spirituality and human rights and will aim to address the needs of the 20% of the population expressing mental distress in any one year (Allison et al., 2019). While welcoming greater access to treatment, Scott is concerned that increasing the access target from the current 3.7% to 20% is unrealistic and could put further pressure on service provision for those with severe mental illness. She points out that the introduction of Big Community services in New Zealand provides an opportunity to build in careful evaluation. Such evaluation, missing from Better Access in Australia, would enable new services to evolve to optimise effectiveness and impact.

The non-governmental organisation (NGO) sector gets some attention in this month’s ANZJP. Looi et al. (this issue) describe ‘Headspace-like Behemoths’. These are monstrous creatures that swallow resources. Looi et al. (this issue) ask whether large NGOs such as Headspace and Beyond Blue address gaps in existing services, or rather drain resources from public mental health services. As with Better Access (Rosenberg and Hickie, this issue; Jorm, 2018), Looi highlights the lack of evaluation of these services. That said, there is also a lack of detailed information about treatments and outcomes from public mental health services.

The expansions of Better Access, Big Community and the NGOs are based on the assumption that more treatment, applied to more of the population, has to be a good thing. However, any potent treatment that has positive effects is also liable to negative or adverse effects. Meadows et al. (2019) wrote previously in this journal that reliance on psychiatric treatment can lead to a reduction in spontaneous self-help activity. This may paradoxically increase the prevalence of psychiatric disorders, especially in disadvantaged areas where limited treatment is available. In addition, medicalisation of life problems beyond the bounds of evidence-based treatment may cause clinical problems, such as medication side effects, or reliance on treatment when self-help strategies would have worked better. Self-identification as a person with ‘mental health issues’ who lacks resilience and requires professional help to negotiate life’s obstacles may be unnecessary and unhelpful.

Agustini and Berk (this issue) describe Plan S (Science Europe, www.scienceeurope.org/our-priorities/open-access; accessed 24 September 2019), which requires scientists and researchers who benefit from state-funded research organisations and institutions to publish their work in open repositories or open-access journals. This sounds great for third-world researchers and clinicians, members of the general community and the many other people who do not have access to medical and scientific journals. It could be argued that the current system locks scientific knowledge behind a wall policed by libraries and publishers and only certain elites have access. The taxpayers have paid for the NHMRC, the Universities and the hospitals – so maybe they should be able to browse the resulting research. The authors go on to point out that it is not that simple. Paying for publication in reputable open-access journals is expensive; for example, publishing an original article in Frontiers in Psychiatry costs US$2950 (www.frontiersin.org/about/publishing-fees; accessed 24 September 2019). Plan S states that Open Access publication fees are covered by the funders or universities, not by individual researchers, but sometimes clinical researchers do not have funders or universities to pick up the tab.

The world of open-access journals is complex. There are many predatory journals, which exist to take money from aspiring authors. Beall’s list, compiled by librarian Jeffrey Beall from the University of Colorado, provided a helpful guide to these journals. The list has not been updated since January 2017; it is unclear whether Beall’s University, legal or personal threats, or some other issues was responsible. A new list has been created at https://predatoryjournals.com/journals/ – the site is maintained by an independent group who wish to remain anonymous.

Conversely, it has been suggested that the existence of predatory journals is a sign of a developing market, and a market in scientific publishing is a good thing. But Agustini and Berk (this issue) disagree, arguing that the wide availability of poor science and pseudoscience in social media and pop culture, and the rapid propagation of falsehoods and speculative claims, means that we need quality science with solid methodology and rigorous peer review.

The importance of social determinants in causing and perpetuating mental illness is acknowledged in the above articles discussing community mental health. Morgan et al. (this issue) have identified non-obstetric environmental stressors associated with the risk of later psychotic illness. Modifiable risk factors impacting on the trajectory to psychosis included being indigenous, having a single mother, disrupted parenting due to hospitalisation of a parent or the child before age 10 years, childhood abuse and living in socio-economically disadvantaged areas with elevated rates of violent crime. Jorm has previously suggested that improving social determinants in the broader community, as well as improving the quality of treatment, might be effective in improving population mental health; Morgan et al. (this issue) have identified some of the social determinants that are relevant to psychosis (and most likely other disorders associated with adverse childhood experiences).

Turning to neurobiology, Ryan et al. (this issue) build on the finding that anti-N-methyl-d-aspartate receptor encephalitis is a previously unrecognised cause of psychosis and can be misdiagnosed as schizophrenia. They explore the possibility that antibodies targeting other neurotransmitters, such as muscarinic acetylcholine receptors, might also produce a clinical phenotype of schizophrenia. Ryan et al. (this issue) describe evidence pointing to muscarinic pathology in schizophrenia and advocate for future research investigating levels of anti-muscarinic acetylcholine receptor antibodies in people with first-episode psychosis (FEP).

Tackling this same patient population, Forbes et al. (this issue) examine the clinical utility of structural neuroimaging (computed tomography [CT] or magnetic resonance imaging [MRI]) in FEP. They propose that in people with FEP, routine imaging should only be ordered in those who have neurological or cognitive impairment. In this review, only 10 of 2312 subjects (0.4%) had abnormalities that could have been causally related to psychosis. The best predictor of abnormality was older age in individuals with FEP.

Our RANZCP Guidelines for Schizophrenia and Related Disorders sit neatly on the fence, stating that ‘a comprehensive assessment including physical health screening is essential. Expert opinion is divided about whether an MRI scan of the brain is necessary for all people with FEP’. However, missing a treatable tumour is a nightmare for all concerned. The headline ‘Brain Tumour Misdiagnosed as Mental Illness’ in the Otago Daily Times, 23 September 2019 (www.odt.co.nz/star-news/star-national/brain-tumour-misdiagnosed-mental-illness; accessed 24 September 2019), leads a story about a New Zealand man who had 6 years of unnecessary psychiatric treatment before finally having a CT scan, which revealed a frontal midline meningioma. Many unnecessary scans are likely ordered to avoid this scenario.

The iHOPE-20 study (O’Keeffe et al., this issue) is indeed hopeful – it is good news for people with FEP. iHOPE reports 20-year follow-up of people initially seen with FEP. There were 171 people in the original cohort; 20 (11%) had died and 80 people agreed to follow-up. Of these, 65% were in remission, 35.2% had full functional recovery and 53.7% believed they had recovered, according to their personal definition. Predictors of good outcome included short duration of untreated psychosis, better social adjustment at age 5–11 years and some baseline factors – being older, living with others, being in full-time employment, a non-affective diagnosis and (rather counter-intuitively) a lower Global Assessment of Function (GAF) score.

Is Internet gaming disorder a thing? A vigorous argument about whether Internet gaming disorder should be categorised as a mental disorder continues in successive editions of the ANZJP. In this issue, King et al. argue the positive case, refuting papers in recent editions of the journal which take the contrary view. Interestingly, in each successive article, the authors say less about Internet gaming disorder and spend more time deconstructing their opponents’ arguments.

Bayes et al. (this issue) ask if we are getting ahead of ourselves with ketamine? The World Health Organization (WHO) estimates that more than 300 million people are living with depression, an increase of more than 18% between 2005 and 2015. Ketamine is a new treatment, with a novel mechanism of action, and might help to reduce this global burden. Intranasal ketamine has been approved by the Food and Drug Administration (FDA), is available as a clinical treatment in the United States and most likely will be able to be prescribed in Australia and New Zealand in the next few years. Clinical trials of an oral formulation of ketamine are under way.

These authors go on to discuss the challenges of using emerging treatments with a limited evidence base. The RANZCP clinical memorandum (www.ranzcp.org/practice-education/guidelines-and-resources-for-practice; accessed 24 September 2019) states that ketamine is not recommended to treat depression, as further research is needed. Nevertheless, the clinical memorandum does provide advice for clinicians who decide to use ketamine off-label outside research trial conditions. Appropriate review, properly informed consent, and awareness of efficacy, safety and required monitoring are essential. Bayes et al. (this issue) provide a useful template for clinicians considering using ketamine, to ensure their practice is safe and ethical.

Finally, Maylea (this issue) quotes the Victorian Department of Health (2009) statement that ‘Any sexual activity in an adult acute impatient unit is incompatible with the acute treatment environment and is unacceptable’. Undaunted, Maylea (this issue) addresses the complexities of consent to sexual activity involving inpatients, incorporating hu-man rights law, mental health law, criminal law and the law of tort governing the duty of care.

November’s ANZJP includes debates, commentaries and opinions along with research papers. Looi and Keightley (2019) have suggested that psychiatrists should take on more participatory leadership roles. As we move towards 2020, perhaps the analysis and opinions expressed in these pages will increasingly translate into engagement, influence and action, for the benefit of our patients and the wider community.