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NOW is the time for the mental health sector to “change its paradigm”, say Victorian experts welcoming the recent boost in funding.
Professor Suresh Sundram, Head of the Department of Psychiatry, School of Clinical Sciences at Monash University, told InSight+ that the current funding boost and drive for reform was an ideal opportunity for the mental health sector.
“Let me be controversial here,” he said. “[Psychiatry has focused on] a generic, symptomatic palliation of patients and their symptoms and their issues.
“We need a paradigm which is able to put psychiatry in the same ballpark as many other areas of medicine.”
Professor Sundram said palliation was no longer acceptable treatment for many cancers, with the community demanding that cancers are aggressively treated and cured.
“It’s now time for the community to demand the same of psychiatry and mental health,” he said. “It would be fantastic if the Royal Commission [into Victoria’s Mental Health System] began that process, but then it is up to government and the sector to be able to transform current practice.”
In addition to the 2020 funding boost for the Victorian mental health system, further investment was expected to be announced with the release of the Royal Commission into Victoria’s Mental Health System (RCVMHS) final report. The report will be tabled on 2 March, 2021, ahead of an historic joint sitting of the Victorian Parliament.
Professor Patrick McGorry, Professor of Youth Mental Health at the University of Melbourne and Executive Director of Orygen, said now was the time to put the sector on a “wartime footing”.
“People’s lives and futures are depending on this. We are in the midst of dealing with a shadow pandemic of mental ill-health overwhelming and already broken system, so we can’t afford to just say ‘let’s plan carefully, let’s take our time and get it right’,” Professor McGorry told InSight+.
“That is not the way we approached COVID-19, and it’s not the way we have approached other major crises or emergencies in public health. And the worsening plight of the mentally ill has been revealed by the Royal Commission as a cumulative disaster, compounded now by the shadow pandemic which has added another substantial layer of unmet need.”
He said a “revolution” was needed to ensure that evidence-based care was delivered.
“It is going to take a military-style, can-do attitude to make it happen,” he said.
In transforming the mental health system, Professor McGorry said the sector had to set its sights on the areas in which it was possible to make the most difference.
“I have argued for more than 20 years that you can transform the system by focusing on the teenage and young adult group, where all the new cases emerge from,” Professor McGorry said. “Shifting the boundary of youth mental health services from 18 to 25 years and heavily funding this reform is a key step that Australia has successfully begun.”
“If you want to reduce the burden of mental illness, you have to build early intervention into the system so that you are not always chasing your tail.”
Professors McGorry and Sundram were responding to a Perspective, published in the MJA, which welcomed the funding boost but warned of challenges in human resources, leadership and change management capacity and stakeholder engagement.
“Like sudden heavy rain on degraded soils after drought, such an inundation is welcome, but not without its own risks and challenges,” wrote Associate Professor Steven Moylan, Clinical Director at Barwon Health.
“The pace of this [funding] change and the other challenges involved must be managed carefully by system leaders to ensure that the intended reform occurs and results in provision of better care to the community,” he wrote.
In an exclusive InSight+ podcast, Associate Professor Moylan said workforce shortages will slow the process of reform.
“We know there is a relative shortage of psychiatrists to be able to provide the care required for the relative burden of psychiatric illness across the country. That translates also into psychology, into other allied health professions, into nursing professions and into the emerging discipline of lived experience too,” he said.
He suggested that workforce shortages in psychiatry could be partly traced back to medical schools, noting that young medical practitioners were often not encouraged to pursue psychiatry.
“There hasn’t really been a determined effort, in my view, to encourage young medical practitioners to come into psychiatry,” he said. “When I first entered psychiatry, I was one of 29 people in Victoria trying to enter psychiatry training. And there were 32 positions.
“And I can compare and contrast that to my surgeon friends in other areas, which have significantly more demand.”
Professor McGorry acknowledged that workforce shortages would be a significant issue, but again emphasised the need for “wartime” tactics.
“We have been waiting for this to happen for 15–20 years and, of course, workforce shortage is going to be a huge issue, but why don’t we take an almost wartime approach to it?” he asked. “If you are fighting a war, you mobilise, train and equip the army pretty quickly – that is exactly what we must do here. We have done exactly this in responding to the pandemic.”
Psychiatry resident and acting president of the Victorian Association of Psychiatry Trainees, Dr Benjamin Veness said the workforce shortage was one of the most difficult problems to address due to the long lag time between leaving medical school and completing the psychiatry training program, which usually adds up to at least seven years full-time.
“That particular lever can’t be pulled overnight,” he said, noting that the present shortage had been forecast by the federal government in 2016. “The best we can do is to increase the number of training places and make them as attractive as possible, with good job prospects at the end.”
Dr Veness added that it was important to expose medical students and prevocational doctors to a wide range of positive training experiences in psychiatry.
“We don’t just want them to get a taste of an adult inpatient acute psychiatry unit, which is unfortunately all that a lot of people get exposed to,” he said. “That is just such a narrow slice of the work that is done in psychiatry.”
Exposure to work in prisons, community clinics, and drug and alcohol counselling would be helpful in giving young doctors a more accurate sense of the scope of the specialty, Dr Veness said.
He welcomed Victoria’s 2020 announcement that it would implement mandatory terms in psychiatry for Victorian pre-vocational doctors.
“I am hopeful that that might lead to some really positive increases in interest in psychiatry training in Victoria, and there are certainly opportunities for other states and territories to do the same,” Dr Veness said.
All experts interviewed by InSight+ said they were optimistic about the future of mental health care in Victoria and across the nation.
Professor McGorry said the current alignment between the federal and Victorian governments was an important step towards national reform.
“The reason mental health care has been so bad in Australia is because the bulk of the people who need mental health care have fallen between what the federal government will fund – which is basically primary care – and hospitals, which is what the state governments fund. So, there is nothing in the middle; we call it the ‘missing middle’,” Professor McGorry said.
He said that governance changes and the empowerment of the mental health system within the broader health care system was a significant step, so mental health was not “sidelined” in the acute hospital system.
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Psychiatry will never progress in this country until ALL practitioners get training in PSYCHOLOGY as well. The hyper-medicalised paradigm of complex mental health such as schizophrenia – even the narrative of it being an “organic” brain disease/chemical imbalance – needs to be well and truly thrown out. This is evidenced by the highly successful outcomes of approaches like Open Dialogue in Finland, which rely on very little medication but show recovery rates of up to 80%. THERAPY is the key to unravelling psychosis for optimum long-term outcomes – not masking it with highly sedating drugs.
I highly recommend, for example, books like From Breakdown to Breakthrough: Psychoanalytic Treatment of Psychosis By Danielle Knafo, Michael Selzer, as evidence to the efficacy of therapy in assisting people with psychosis – particularly that cohort deemed ‘treatment resistant’.
Psychiatrists need to drop their confirmation bias/textbook thinking, come down off their pedestal and recognise they are only a very small part of the mental health system – which needs to thoroughly incorporate more psychological treatments into it, quickly! This draconian system of Mental Health Tribunals focussed on ‘compliance’ needs to be drastically overhauled too – at least until psychiatrists have better training in trauma! Many of the current practices are actually incredibly re-traumatising – eg, forcing a young man who has a history of sexual abuse turn up to a clinic and have to pull his pants down in front of a male nurse for a fortnightly injection – for a drug which could and was being taken orally… but because he still had ‘symptoms’ – oh it MUST be non-compliance!
Face up to it, psychiatrists – your drugs often don’t work. Many people still hear voices. Always will ( and they probably won’t tell you, psychiatrists… because you’ll just dial up the meds…) Practices to assist people to build relationship with their voices are much more promising and effective. As is therapy to assist people to understand the relationship between their psychosis and past trauma, to understand its meaning and metaphor, and to assist people to gradually realise they no longer need it (the psychotic phenomena) to protect their fragile minds from the unthinkable things that have happened to them!
Oh, and by the way, teach your patients to sing or hum. It quickly stops voices if they are distressing.
I am not surprised psychiatry is not encouraged to young doctors. A person makes it through medicine because they memorised books and adopted orthodox systems of reasoning through persistent study – the wrong skill set for human emotional and social problems. Psychiatry is the only medicine specialty which does not objectively observe and measure the organ it treats. Why? Because it is poorly understood theory built on a rigid set of institutional beliefs and implemented in a extremely subjective nature. From the way they report in the psychiatric wards, anyone could be illustrated as mentally ill. The ‘paradigm’ problem is they scientifically analyse patients as though they are an animal, to try to formulate a consensus that agrees with a groupthink hypothesis. There is no investigative approach like law enforcement to thoroughly understand the story of what happened. An overkill of antipsychotics is enforced with no ‘care’ given to the devastation of the patient’s life. When someone is in a mental crisis you don’t pump them up with drugs to dampen the symptoms as a band-aid over the root problem. The paradigm should be sending patients to a resort surrounded by nature, cognitive behavioural therapy with psychologists/counselors, and a great emphasis on exercise, meditation, diet and relationships.
Time to actively dal with the well known social causes of mental health issues – neglect, bullying, social defeat, trauma and loss! While psychiatry hides behind the emperors new clothing of brain disease there can’t be any improvement in outcomes, no matter how many new trainees there are.
Ignoring the links between a person, their social network (especially family) and treating them as if they are an island is doomed to fail… Sorry. Real mental health care must include all aspects of all the stresses that contribute to their becoming ill. Psychiatrists spending 15 minutes per consultation ($370!) will never replace real care, along with six month wait lists
This article is like so many about mental health. It is full of generalisations such as “change the paradigm”. Change it to what? No detail, here – lots of words. It cannot be fixed by just more money and focussing on youth within the current medical construct . The fundamental problem in terms of mood disorders is the pathologising of emotional discomfort. Nature gave us physical discomfort and pain as part of physiological homeostasis. So too, uncomfortable emotions, however intense, are designed to be integrative if only we learn to gently interrogate the feelings. By pathologising discomfort, the system is creating the loss of resilience that underpins the “crisis’ in mental health and the rising incidence of so-called “mental illness”. The medical model teaches people that discomfort is inherently bad and has to be got rid of. Indiscriminate use of medication reinforces this way of thinking. Our so-called treatments leave patients less equipped to deal with the vicissitudes of life. I have been exclusively providing talking therapy to men, teenage boys and their families for 25 years employing a personal growth approach which teaches and empowers people to manage their own emotional discomfort for a lifetime I see it as me accompanying my patients on a journey of learning about themselves, the meaning of their “pain” (much of it based upon adverse childhood experiences), how others manage theirs and supporting them to grow in wisdom. GPs should be at the centre of teaching these emotional intelligence skills but it also requires that they have done some work on themselves. We must abandon the psychiatry-dominated, tick-a-box diagnostic model related to the mood disorders. This is the paradigm that must be challenged. Very expensive psychiatrist consultations almost always result in yet more medication. The former “major tranquilisers” are now rebadged as “mood stabilisers”. I contend that “depression” is not a “disease” but rather for each patient, the collection of symptoms (“dys-ease”) reflects a soup of uncomfortable feelings. One patient’s metaphorical soup is tomato, another’s minestrone, another’s fish chowder. All they have in common is that they are wet and they are foods. They all look the same in soup bowls and covered in chopped parsley!
Early intervention should go back to antenatal and perinatal care. That is the time when so much transformative work can be done to heal parents, family dysfunction and older children as well as prevent illness (physical, mental and socioeconomic disadvantage ) from developing in the next generation. I would love to see an Oxygen style organisation for perinatal and infant mental health and measure that over the long term. MASSIVE return on investment.
2 weeks ago, 2 son’s of mine, 1 with diagnosed schitzophrenia, who did not like the boundaries, I had put in place, called aged triage with wild, untruths, about myself. A psychologist, from Peter James, bought into my sons’ vindictive, disturbed, and abusive behaviour towards myself. Placed me on an involuntary assessment order, and locked me in an acute mental health ward, until professionals in mental health intervened, whom know me well. He refused to seek corrorabation and the truth about my son’s abusive behaviour. It was a complete abuse of power, within the mental health at Peter James, and I will be scarred from this experience, for some time. The system has to be changed, for mothers suffering elder abuse/ domestic violence, and work colleagues/ other professionals to be consulted, to prevent perpetration of further abuse. What occurred to me, you would think only happens in movies. Carol
Australia needs to follow the example of some countries that recruiters the youth of a certain age to serve the ARMY on the compulsory basis. This will assist in the unemployment, idle time, boredom, drug and alcohol issues and the most importantly, they will learn life and social skills for life…!!
People with mental health get bounced around like a ping pong ball. Ten sessions a year ain’t enough. You go to emergency department, you get valium and get sent home. I personally have PTSD and a variety of mental health issues and suicidal thoughts, but can’t get on disability. Even though they ( Centrelink ) acknowledge I can’t work. I struggle daily to keep going between my sessions. As they say ring Life Line.
If you don’t have early intervention you will drift into psy inpatient care right uo to gereratic care where no interest is ever takein in that range of cases as well so is the young intervention that needs most intervention and also gereratic care which has fallen between the cracks, & eventually fogged off as dementia or old aged illnesses when in fact Bi polar schuzophrenia & schizofeccitive were never treated into the older age bracket, & never follow these clienrs into the older age group bracket. I know. Iv’e been drifting for many years in & out from forensic to normal MH care & in between all this many families have been affected & ruined because of lack if care in those areas too.
Bot all families understand the mental health area & not enough support is giving to family members even families who no longer keeo in touch with their family members with the psychiatric condition. Most of us have never even met our grandchildren, due to fear of passing it onto family members or just not having the knowledge in those fields. I’m heading now towards the end of my life, with no support & the best therapy i found was going to church & getting all my healing from down to earth sermons better than the DSMV 4 0r 5 medical info. Supplied in those?? books.
anonymous has little idea what he/she is talking about. unemployment, homelessness and poverty are very often caused by mental illnesses , not necessarily the other way around. when people are suicidal, or psychotic, or causing severe distress to their families, what services are going to help them other than public mental health services , particularly on weekends or the middle of the night.
and treating mental illness as an illness like other illnesses is hardly a reason for stigma. treating it differently does.
Mental health care in Australia is a disaster. There is too much reliance in public mental health on coercion and medications. The idea that mental illness is an illness like other illnesses increases stigma and reduces a persons sense of agency.
There are many poorly designed inpatient units with bed pressures to discharge people prematurely to a poorly functioning community service.
The current state and federal governments’ unwillingness to adequately address major issues such as education, unemployment, low Centrelink payments, poverty, inadequate social housing, domestic abuse in addition to an inconsistent approach to drug and alcohol problems creates the perfect storm for mental distress. Placing these issues under mental health can compound the problem.
Covid has managed to highlight problems.
There are no easy answers but more psychiatrists is clearly not the solution.
Professor McGorry rightly states that it is the younger age group that must be focused on in fact teenagers and young adults but then goes onto state 18-25year olds . In my long experience as a GP with an interest in adolescent health it is in fact the 16 and 17 year olds in private as well as public practice that fall through the gaps for as they were often seen as too old for paediatric service and too young for adult services ( it may have changed since I retired a couple of years ago but I doubt it )