The value of early intervention in creating the new mental health system: Response to Allison et al

It is not enough to succeed. Others must fail.

Gore Vidal

In announcing the Victorian Royal Commission, the Victorian Premier became the first Australian leader to acknowledge the nationwide (and global) problem that the State-funded public mental health system is ‘broken’ and that mainstreaming of mental health care has failed the severely mentally ill. The Commission has heard moving and often shocking testimonies from patients and families about the ubiquitous neglect and trauma, and the increasingly toxic culture of care. These derive from system design flaws, complacency among policy makers, learned helplessness among the clinical leadership, progressive erosion of funding and morale, and work practices that often lack compassion. Such problems must be overcome to grasp the once-in-a-generation opportunity provided by the Royal Commission.

Allison and colleagues (2019) contend that youth mental health has been ‘generously funded’, that this funding is at the expense of adult mental health, and that early intervention is of minimal value for psychotic disorders. Their combative critique is factually incorrect, unnecessarily divisive and denies the value of a fundamental, evidence-rich building block for new and innovative mental health systems. Most tellingly, the authors do not offer any solutions to the problems that they raise. As highlighted by their own critique, it is self-evident that funding ‘more of the same’ will not suffice.

Mental health reform is not a ‘zero-sum game’

The authors wrongly portray the problem as a ‘zero sum game’, in which benefits in one area of mental health must be at the expense of another. This inevitably pits the value of adult psychiatry against that of early intervention and youth mental health. It is evident that substantial investment is urgently needed in adult mental health and this has been the goal of sustained advocacy led by some of us. The failures of the adult mental health system have largely driven the decision to hold the Royal Commission. Yet, the authors offer neither reflection upon these failures nor solutions. We, including our leading international co-authors, advocate for a united call for increased funding, system redesign and culture change for mental health services across the lifespan.

Mental health requires adequate investment: no area has achieved this

It is misleading to assert that youth mental health has been ‘generously funded’ by the Victorian government. Benchmarking the inadequate funding for youth in Victoria against underdeveloped youth mental health services in other jurisdictions is used to imply that youth mental health is well resourced in Victoria. Such services are either nascent or non-existent across the states and territories. Spending ‘twice the national per capita average’ is misleading, as absolute funding is low in all jurisdictions.

The claim that youth service funding is at the expense of adult services is demonstrably erroneous. The authors have conspicuously failed to report that the great bulk of State resources are already devoted to adult mental health care, with per capita expenditure in Victoria for young people (AUD$53) being less than one-third of that for adults (AUD$180) (https://tinyurl.com/y5gc35ry). Their argument misses the key point, that both State adult and youth mental health are ‘poor cousins’ of physical health expenditure, with youth being the poorer of the two.

The assertion that ‘Victoria’s reform of mental health services for young people was stopped midway …’ omits that, while a decision was made to restructure services in 2009, the required funding never materialised. The Victorian Auditor-General’s 2019 report on Child and Youth Mental Health Services (www.audit.vic.gov.au) describes a seriously flawed and underfunded system, directly contradicting the authors’ proposition of generous funding. The authors appear to conflate State funding with Federal Government investment in the headspace platform in order to create the illusion that State youth mental health has received funding at the expense of adult mental health care.

Denial and misrepresentation of evidence

The success of early intervention for psychosis helps to make the case for reform and greater investment in adult mental health. Cochrane Level 1 evidence shows the benefits of early intervention, both for those at risk of psychosis and for those with early but established illness. For example, meta-analytical evidence shows that it is possible to reduce the risk for developing psychotic disorder in those at high risk for up to 4 years, with a low number needed to treat (NNT) (Van der Gaag et al., 2013). Following psychotic disorder onset, early intervention improves outcomes across the early years of illness (Correll et al., 2018). These novel approaches were developed in Victoria and have been emulated across the globe. Similar achievements, such as recent evidence in the New England Journal of Medicine showing delayed onset of Type 1 Diabetes by around 2 years, are celebrated, not minimised.

The authors have also negatively and selectively interpreted the evidence supporting specialised early psychosis programmes. The claim that youth mental health services solely exist to reduce service requirements in midlife is false and appears to be based on the erroneous and obsolete belief that schizophrenia is an inevitably deteriorating illness. In fact, there is a tendency for recovery in most (not all) patients over the medium term, even in the face of poor-quality treatment, as shown by more recent FEP (first-episode psychosis) studies (see AESOP study). The primary aim of FEP services is to provide timely, developmentally appropriate and high-quality care to those in need.

The authors quote long-term follow-up studies showing that many, but not all, of the gains of early psychosis care are lost when treatment is withdrawn or patients are referred to traditional adult services. Most medical fields (e.g. cancer) would interpret such findings to warrant extended expert care to build and sustain these hard-won gains. Indeed, ‘extension studies’, adding another 1–3 years of FEP services, have shown this to be true (Malla et al., 2017). The evidence indicates that many patients need up to 5 years of care and some need very long-term care. Relapse rates following specialised FEP services are 38% at 24 months (vs 49% for treatment as usual) and 54% at more than 10 years (vs 76% for treatment as usual) (Fusar-Poli et al., 2017). This suggests longer lasting benefits associated with early intervention for at least one in four individuals with psychosis. In addition, reducing treatment delay enhances remission (when combined with extended early intervention) and doubles recovery rates at 10-year follow-up (see TIPS study). Indeed, these data suggest that progress made during early intervention might not be maintained because of the poor quality of care that patients receive once they enter the adult system. This is an issue of service culture reform, not just funding, unaddressed by the authors.

Conclusion

‘Bending the curve’ (modifying the course of disease) is a valued goal in medicine, which has seen the lives of cancer and HIV patients, among others, extended and their quality of life improved. This is achievable in psychiatry if the Victorian-led, Cochrane Level 1 evidence of early remissions and better outcomes of early intervention services are implemented and then built upon during the later stages of illness. The gains achieved through early intervention should actually be used to add weight to the authors’ case for a better and stronger adult mental health system to sustain and build upon these outcomes.

We support a united call for reform and adequate investment to ensure quality of care in the Victorian adult mental health system. Allison and colleagues’ critique fails to support this, merely reprising discredited, divisive and unsubstantiated or misleading arguments that are ultimately harmful to those who use and work in the mental health system. These arguments risk nourishing and perpetuating a culture that holds back reforms that will ultimately improve mental health service delivery. The Victorian Royal Commission offers the opportunity to transcend false dichotomies between areas of equal priority, making it possible to offer comprehensive mental health care across the lifespan.