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People & Ideas

Dec 4, 2012

U-turn: time for a new model of mental health care

Why does mental health reform focus on palliative, as opposed to preventive, health care treatment? Emily Rose says we need a new model of care.

The federal government knows its approach to mental health should focus on promoting sound mental health and preventing problems — not just what amounts to palliative care. So why are the changes so slow in coming, and how can we learn to take a more visionary approach to mental health reform?

Twelve years ago, the government prioritised promotion and prevention principles in addressing mental health. The government identified a number of areas in need of repair, including better access to services in rural and remote communities, improved detection and treatment of psychosis, and enhanced mental health literacy in the general community.

Fast forward to 2012 and the mental health system remains badly broken. Despite the federal government injecting $2.2 billion into mental health reform, the rate of Australians estimated to have a mental illness has risen progressively since 1995. Over $6.3 billion dollars was spent on mental health-related services in 2009-2010, an expenditure that has increased annually by an average 4.5% per Australian between 2005-06 and 2009-10.

The National Mental Health Commission’s first report card, launched on November 27, contained a mixed bag of cheers and jeers for mental health and suicide prevention. “Shocked”, “saddened” and “appalled” were words used by chairman of the National Mental Health Commission Allan Fels on the statistics related to physical illness and early death among people with a mental health difficulty.

The Minister for Mental Health, Mark Butler, called the report card a challenge to government, service providers, professionals and the broader community “to better support those living with and recovering from mental illness to live a contributing life. There is more road ahead of us than there is behind us,” Butler said.

But where are we going? Although a number of factors were named as contributors to mental health difficulties, such as poor physical health, unemployment and a lack of social inclusion, the report offered no roadmap for what a good mental health service should look like.

Perhaps most glaringly, the report failed to offer a framework for quality preventive measures that take into account socioeconomic, educational and environmental factors. Greens mental health spokesperson Senator Penny Wright is in favour of policies that lead to preventive mental health care.

But why does mental health reform focus on palliative, as opposed to preventive, health care treatment? To answer this, it’s necessary to look back at where we’ve been.

A century ago, healthcare was focused on preventing or curing acute, infectious diseases. “The great public health success stories of the past century are largely stories of prevention,” says a paper released by the National Institute of Mental Health, Cure Therapeutics and Strategic Prevention: Raising the Bar for Mental Health Research. “From sanitation to vaccines to smoking cessation to the use of statins, we have proven much more successful at pre-empting disease than curing it.”

Modern health care is dominated by treatment of chronic illnesses, many of which are now rare. Mental illness is the conspicuous exception.

Whereas before mental illnesses were considered individual weaknesses or spiritual diseases, now the medical model of mental illness reigns supreme. Ask people about the causes of mental illness, and most will invariably name “chemical imbalance”, “brain disease” or “genetic factors”.

“As a society we are moving ever closer towards an exclusively medicalised vision of mental illness,” says Dr. Mark Dombeck, director of Mental Health Net from 1999 to 2011. Mental illness and mental health coexist on different spectrums from each other, with the presence of one indicating the absence of the other. This dichotomy implies treatment is necessary only when symptoms are present, and preventive measures are secondary in terms of importance.

Dr. Dombeck describes a system that excels at crisis management and biological manipulation, yet neglects to situate the individual within a framework of social and physical environments, an essential component of preventive treatment. Treatment is overwhelmingly symptom-based and crisis-driven, rather than preventive.

Research suggests stigma surrounding certain mental illnesses has increased steadily over time, and that using the term “brain disease” does not reduce this stigma.

One study found that describing mental problems in medicalised terms may result in harsher treatment towards an individual. Researcher Sheila Mehta has this to say about the findings: “The biomedical narrative about an illness like schizophrenia carries with it the subtle assumption that a brain made ill through biomedical or genetic abnormalities is more thoroughly broken and permanently abnormal than one made ill though life events.”

What is striking here is not just the influence that this biomedical narrative has had on treatment, but the idea that our current paradigm of care could be contributing to poorer outcomes in mental health.

The unspoken question is complex and controversial, and answers differ markedly according to who is consulted.

What is apparent is that promotion, prevention and early intervention are essential components of quality mental health care. Last year’s budget for mental health reform included Early Psychosis Prevention Intervention Centres (EPICC), designed to identify and treat mental illness in young people. Expected to open next year, these centres are one of many promising initiatives rolled out by mental health reform.

But where is the promotion of mental health for the general population? What about preventive care for at-risk populations who do not display mental health difficulties? Mental health care is not just relevant for the 12% enabled access to mental health services in the new year. As Fels succinctly put it, “mental health is everyone’s business”.

Treating symptoms after they appear is at best a reactionary response, at worst a Band-Aid solution creating a bottleneck that taxes an overwrought system. Where will it end?

Let’s call for a new model of care, one that encompasses society instead of segregating individuals, balances palliative treatment with that of preventive measures, and points towards a sustainable, effective model of care.

*Emily Rose has a masters in psychology and has worked as a counsellor

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2 thoughts on “U-turn: time for a new model of mental health care

  1. Shaniq'ua Shardonn'ay

    As a person with 14 years experience of mental illness – and a psychology degree I got in my 20s before the illness struck, my question is – which preventative measures are there that actually show some solid evidence that they work? And I’m asking for some studies that show causation rather than just correlation.
    Unfortunately most of what is reported in the media seem to be correlation studies, and psychological treatments seem to follow suit – ‘sleep hygiene’ being one treatment which I found particularly torturous.
    Counselling has it’s place but I think I’ll stick with medication and hospitalisation over some of the rubbish that is pedalled as preventative care.

  2. Jessica Stewart

    Thank you for these words. The limitations of the system are etched on my family’s hearts. We’ve been running uphill in sand trying to overcome its gaps and neglect which ended in the death of my brother earlier this year.

    Our system failed him by not linking him back to his family and his community. It treated him as a bag of chemicals, prescribing him drugs that sometimes actively worked against each other. It failed to see him as a human being with multiple conditions. His paltry pyschological care was weak and he saw no merit in it.

    As you say, the roadmap for a good mental health service must look at physical health, employment and social inclusion, all elements faced by my brother.

    Preventive measures are essential and must work in tandem with intensive treatment, post-trauma. After a suicide attempt, labelled by the doctors as ‘serious’, my brother was released after just 36 hours. Would they have released a heart condition patient?

    For the next seven years, we played a game of watching, waiting, and supporting but we were shut out of his care, despite him living with my parents. The ‘privacy’ of an obviously sick man was deemed more important than using all care, all resources at hand to make him better. He was given neither care in a hospital setting, nor assistance at home.

    In contrast, a friend whose father was hospitalised in Denmark after a suicide attempt was kept in care for seven months while he recovered, exercising, eating well, given different therapies, including some medication but also intensive ‘talk therapy’. After four months, he was allowed to make weekend visits to his family. He is still alive, while my brother is dead.

    We need to do better.