16th Nov 2010
Fundamental changes are taking place in the area of mental health. Amanda Sheppeard looks at the top five controversies identified by leaders in the field. Amanda Sheppeard all articles by this author
Professor Ian Hickie
Executive director of the Brain and Mind Research Institute, professor of psychiatry at the University of Sydney, and an NHMRC Australian Medical Research Fellow.
Professor Gordon Parker
Executive director of the Black Dog Institute, research director of the Mood Disorders Unit, and Scientia Professor at the University of NSW.
Professor Patrick McGorry
Executive director of Orygen Youth Health, professor of youth mental health at the University of Melbourne, and Australian of the Year.
The Diagnostic and Statistical Manual of Mental Disorders (DSM-5), due for release in 2013, is attracting controversy for its proposed changes to existing diagnostic criteria and the introduction of new ones.
Among the recommendations are new categories for childhood development and learning disorders; eliminating the substance abuse and dependence categories and replacing them with new ‘addiction and related disorders’. A new category of ‘behavioural addictions’ in which gambling will be the sole disorder has also been proposed. A new ‘risk syndromes’ category is under consideration, identifying earlier stages of disorders, such as dementia and psychosis.
Professor Hickie describes the DSM-5 as less important to Australia than the US, where it is linked to mental health care access.
Professor Parker says “recent DSM definitions of differing expressions of depression run the risk of clinical depression being a lifetime risk for most people, a definitional approach that strains credibility”. A key new definition – called mixed anxiety depression or MAD for short – requires just a few symptoms but effectively changes the disorder’s epidemiology.
“This is, mad by name and mad by nature,” he says.
2. Medicalising normal emotions
Mental health and well- being has evolved into a huge industry, with an enormous range of options for patients looking for help, from privately trained ‘counsellors and psychotherapists’ to highly specialised psychiatrists.
It can be confusing for patients to know where to go, how much it will cost and whether they will be able to receive rebates through Medicare or private health insurance.
There is little doubt that therapy has become a trend, but Professor Parker says the perception of what constitutes a depressive illness has also played a major role. Back in the 1950s about five per cent of people had clinical depression at some point in their lifetime, he says.
But today most people are at risk of clinical depression during their lifetime, largely due to the increased spectrum of depressive disorders, he adds.
Professor Parker says there is a tendency to medicalise feelings of sadness and grief and pigeonhole them into a depressive box.
The wide variety of therapy options and service providers compounds the problem, he says, especially as their training varies so greatly.
“If they go to the GP, the treatment would tend to be drugs, for a psychologist it would be CBT [cognitive behavioural therapy], and a counsellor would provide counselling,” he explains.
“The treatment is dictated by the training or the back-ground of the discipline, and this might not necessarily be what the patient needs.”
3. Online mental health
As information technology takes on an increasing presence in our lives, researchers around the world are working to create models for online-based mental health care services.
According to Professor Hickie, Australia is at the forefront of this research, and already has the capability to develop a world-leading model. But there are major hurdles – a lack of government funding or interest in pursuing such a project and questions over how it can be organised, audited, managed and remunerated.
Professor Hickie concedes it is one of the biggest challenges facing psychiatry, but something that should not be ignored.
“This is the sort of thing that should be at the top of the Government’s agenda, but [it] doesn’t have a clue,” he says.
Professor Hickie believes online consultations are the way of the future worldwide, and are particularly suited to remote communities.
Even more importantly, he sees it as a way to reach a huge number of young people who slip through the cracks because they do not access traditional mental health services.
Around 75 per cent of mental disorders start before a person turns 25, he adds, and yet only 25 per cent of those get help.
Those living in rural or remote parts of Australia also face challenges in accessing services.
“These at-risk people use the Internet and more people can be reached this way,” he says.
“It will [also] be transparent and auditable. We just need to set up a site that meets people’s needs.”
4. Early intervention and pre-emptive treatment for psychosis
Until Professor McGorry earned national prominence as the 2010 Australian of the Year, few people had heard about early intervention and pre-emptive treatment for psychosis, let alone the Early Psychosis Prevention and Intervention Centre, which started off in Melbourne and is now servicing the nation.
Early intervention and pre-emptive treatment has had its share of critics, particularly those who disapprove of the use of antipsychotics in young people who have yet to experience a psychosis.
Despite this, Professor McGorry says there is a huge groundswell of support for the concept, as there is in most developed countries. He is passionate about the impact early intervention has on the mental health of at-risk young people.
“Anyone who argues against early intervention is arguing for poor intervention,” he says.
He addresses the other major criticism – that sometimes the identification of an at-risk patient might prove incorrect – with the analogy of mammograms.
“There is a false positive issue, but that is the issuewith breast lumps and cancer.”
The yield of identification is impressive – one in four in many cases. But the real results come from early intervention, which commonly includes CBT, fish oil supplements and traditional counselling.
In rare and serious cases antipsychotics may be used.
Pre-emptive identification is non-invasive and often opens up the channels of communication – a major step in prevention and recovery.
5. Diagnosing child development disorders
It is well accepted that children develop at different rates, but in recent years there has been a growing number of children diagnosed with development disorders such as attention deficit disorder, ADHD, autism spectrum disorder and Asperger’s syndrome.
Professor Hickie is aware of the high numbers but insists they do not necessarily equate to more cases, but increased awareness.
“In childhood it is all about development disorders and learning difficulties and early intervention is the key,” he says.
The main focus for intervention is on the pre-school and primary school years, he adds, but “after that there is nothing and we really should have something for teenagers and young people”.
Professor McGorry is mindful of the issues and potential controversy when it comes to medication and anti-depressants in young people, but adamant they have a role to play when used in conjunction with other therapies.
Professor Hickie agrees. “In nearly all these areas there is a group where medication is appropriate.
“People tend to fall back on medication because it is the only thing subsidised by the Government. We need to address that,” he says.