how best to help…

Posted on Thursday 22 September 2011

In the US, we’ve been so focused on psychopharmacology in the last three decades that one wonders what psychiatrists even thought about before Prozac came along in 1987. One of those things actually had roots in early psychopharmacology era – the Community Mental Health Movement. Prior to the 1950s and the coming of Lithium [1949] and Thorazine [1951], the treatment of mental illness had been largely custodial. Dramatic treatments may have helped some patients, but not enough to empty the large State Hospitals where many of the chronically ill lived. By the 1960s, the new medications were being widely used to treat psychotic patients. The combination of often deplorable condition and high costs in the State Hospitals, the arrival of effective treatments, the problem of "institutionalization," and dominant social forces resulted in legislation that funded "deinstitutionalization" and the movement of large numbers of chronic patients into the community to be cared for by Community Mental Health Centers. The watchword was treatment in the "least restrictive environment." The hospitals are empty, but problems of funding cuts and the refractory illnesses created new problems with a large sub-population of chronic patients living marginally, among the ranks of the homeless, or chronically incarcerated. Community programs now vary widely from place to place depending on State funding patterns. Word-wide the same variability of care prevails…

Recently, attention has been drawn to Australia by the controversy surrounding the use of neuroleptic medications to treat the "ultra high risk" group defined by Dr. Patrick MCGorry, because the majority of people in that group will not develop psychosis – so that piece of the issue is a risk/benefit argument. It affected us in the US because it fuels the controversy over including a Psychosis Risk Disorder category in our coming DSM-5, opposed by many as premature, stigmatizing, and a potential conduit for inappropriate medication. The whole topic came to the fore after the recent massive funding of Dr. McGorry’s EPPIC program in Australia:
    The Early Psychosis Prevention and Intervention Centre [EPPIC] is an integrated and comprehensive psychiatric service aimed at addressing the needs of people aged 15-24 with emerging psychotic disorders in the western and north-western regions of Melbourne. EPPIC is a specialist clinical program of Orygen Youth Health [OYH] which is itself a component service of NorthWestern Mental Health and Melbourne Health.
Dr. Allen Frances, who headed the DSM-IV revision, weighed in as part of his campaign against the process of revision of the DSM [DSM-5 in Distress]. Besides the objection to the Psychosis Risk Disorder, Dr. Frances opined that the massive funding of the EPPIC program was premature – feeling that the efficacy of the program was not yet proven. Many of us agree, fearing a fate similar to our Community Mental Health Movement of 40 years ago [above]. Dr. McGorry defended his program [and questioned Dr. Frances’ right to weigh in, given the sorry state of mental health care in the US]. In Australia, there is opposition to Dr. McGorry’s program on another front, something of a hydraulic argument – if one thing goes up, another thing goes down [funding EPPIC at the expense of existing, functioning programs]. A group called THE ALLIANCE FOR BETTER ACCESS has mounted a campaign against EPPIC. Here’s their argument in the form of a Press Release:

A large group of mental health consumers and professionals calling themselves the "Alliance for Better Access" have issued a formal response to an article that appeared in The Sunday Age newspaper (Drug trial scrapped amid outcry 21/8), calling on the federal government to base mental health reform on the best evidence available. They are asking the government not to cut psychological services in the Better Access program. Earlier this year, the federal budget boosted support for early intervention programs, which was partially funded by cutting mental health services in a program called "Better Access to Mental Health Care". As the Sunday Age highlights, international mental health experts have questioned the benefits of early intervention programs for those "at risk" of psychosis. Ben Mullings, a psychologist who has worked in the Better Access program since its inception says, “If these cuts to psychological services go ahead, the level of treatment available for people with depression and anxiety will fall below basic minimal standards. These guidelines are well-established right across the scientific research in our field”

The "Alliance for Better Access" have argued that mental health funding needs to go to programs that are backed by extensive research and independent evaluation. They point out that cutting the Better Access program to fund other services that are not well-established in the research, is not an informed way to make decisions. Given that the Better Access program is based on decades of psychological research, the group is calling on the federal government to leave the program intact. With depression predicted by the World Health Organization to be one of the world’s leading health concerns by 2020, treatment of depression needs to be affordable and easily accessible to the general population.

Darren Stones, a mental health consumer, says “Scaling back Better Access will make it next to impossible for the average Australian to reach out for help. How are we supposed to afford psychological services if Medicare won‟t provide enough support?” Like many people involved in the "Alliance for Better Access", he has criticised the cuts to services from 18 sessions down to just 10 sessions per year, on the basis that it will restrict access for those people who are most in need of psychological care.

The response from the "Alliance for Better Access" is not opposed to programs that target young people or psychosis, but rather, it calls on any changes to the system to be based on the best evidence about programs accessible to the general public across all age groups. Spokesperson for the group, Ben Mullings, says “We want to see government funding aimed at improving and enhancing the current system, instead of dismantling our existing programs that have years of research showing they are effective.” In the coming week the Alliance for Better Access will publish an article on its website outlining the extensive scientific evidence that underpins the Better Access program. This website also contains stories of real people who will be affected by these cuts to services.
If you’re following this story, you’ll be even more interested in Melissa Raven’s review of the EPPIC research [Review of the EPPIC research]. I reviewed it from afar earlier [1. when n=a few, 2. when n=a few, 3. when n=a few needs n=a few more], but her analysis is much more informed and extensively referenced.

I recently commented that I was reminiscing about the crisis in psychiatry in the days when I first came on the scene [like old men often do…]:
    I really think the current crisis was caused by an unusually maladaptive solution to the last crisis – the one that was swirling around in the 1970s when I was in training. I didn’t see it clearly back then [as is often the case in hurricane], but it seems clearer now. If things go true to form, I’ll probably soon be blathering about my view of those days, like old men often do…
I can see I’m doing that without actively trying – Szasz, Crisis Theory, the collapse of the Community Mental Health movement, the confusion about and within psychoanalysis, the question of integrity in academic medicine, the radical DSM revisions, the rise of psychopharmacology – all of those things were churning back then. If I’d thrown in Managed Care and competition among mental health disciplines, I would have close to a full complement of the forces at work during those tumultuous times. In those days, I was unaware of how tumultuous the times really were. The tumult of my own day to day experience with the unfamiliar illnesses like psychosis and severe personality disorders was about all I could handle. I was already an Internist well schooled in the ways of emergency medical situations, but the drama and intensity of the psychiatric version has a way of driving into one’s soul in a much more powerful way. I had little energy left to consider broadly the state of psychiatry as a specialty. Looking back, it was a crisis of major import, in every dimension. By the time I was up to speed on things, the war was over, so to speak.

But back to the dilemma in Australia. There are three elements in the story. Dr. McGorry, who is fighting for EPPIC, an early intervention program in Schizophrenia. THE ALLIANCE FOR BETTER ACCESS who are fighting to maintain mental health services for Australians on Medicade. And the government of Australia involved in providing funding to both programs. While I agree that EPPIC seems premature, that’s an opinion from afar. My main complaint was medicating unafflicted people with potentially toxic drugs. But I do envy and respect Australia for having a problem at this level, figuring out how best to help Australians with Mental Health issues. Right now, I’m not sure anyone in the US government is even thinking about how best to help Americans with Mental Health issues
    September 23, 2011 | 7:06 AM

    I think it would be very interesting if at some point you chose to share more of your experience with severe personality disorders. Not from some DSM perspective, but a real world experience as to how those disorders present, what you believe to be causes (biologic? temperament? maladaptive responses to life?) and what you found to help.

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