Clem Bastow has penned an op-ed criticizing Australian of the Year Pat McGorry. Noting the absence of the voices of the mentally ill themselves in public debate, Bastow contends that is only through individuals like McGorry or organizations like BeyondBlue that mental illness gains attention, and that McGorry is remiss in not ‘listening to the voices of the people they are advocating for’ and not using his profile to agitate against cuts to the Better Access program:
Better Access, introduced in 2006, provides rebates to patients for up to 12 individual (18 in exceptional circumstances) and 12 group allied mental health services per calendar year when referred by a general practitioner or psychiatrist. That is regular care that may otherwise be financially out of reach.
According to Medicare, the cuts due in November this year will ”limit allied mental health services to 10 sessions per patient, per calendar year … consistent with the intent of the Better Access initiative to address mild to moderate forms of mental illness”.
”Mild to moderate” forms of mental illness can still be hugely disruptive to a person’s private and working life, however, and schemes such as Better Access can be very helpful.
Bastow’s column does illustrate one point – that McGorry, by virtue of his nomination as Australian of the Year, has become the media go-to person for any story on mental health issues. By way of this, he is indeed seen as speaking for all “stakeholders” (for want of a better term) when there are a variety of viewpoints on the merits of the particular programs he is personally involved in. Lisa Pryor recently pointed out the just how controversial the type of early intervention McGorry advocates for is:
The most vocal critic of the syndrome originally known as ‘psychosis risk syndrome’ but now rebranded ‘attenuated psychosis syndrome’ is the American psychiatrist Allen Frances, an emeritus professor at Duke University. Dr Frances chaired the task force behind the current edition of the Diagnostic and Statistical Manual of Mental Disorders, the American bible of mental illness that influences psychiatry around the world.
“Australia’s puzzling infatuation with McGorry’s early intervention may lead it to conduct the largest and most reckless public health experiment ever attempted,” he says. “The country seems to be ignoring three crucial facts: there is simply no available way to accurately identify kids who are really at risk of later psychosis, no effective preventive treatment and the potential medications have extremely harmful side effects. Although the goal of prevention is great, its execution is currently impossible and McGorry’s project is decades premature.”
It is perhaps unfortunate that the general media rarely distinguishes between a scientist advocating the consensus position of their field, and one personally advocating for a position that remains heavily disputed within it. It is curious that journalists, so eager for controversy that they accept manufactured ones in climate science, pay so little attention to them in other fields. But that is not to completely absolve those who find themselves in the role of “advocate” or “spokespeople” of responsibility to be careful to distinguish when they are speaking for their field, and when they are expressing their personal views.
However, none of that obligates McGorry (or BeyondBlue, for that matter) to advocate for the Better Access Program, even if the recipients of the program have found it helpful.
We live in a world where there are limited resources available to government. There are always worthy programs the Australian government could spend additional resources on. Attempts to persuade Australians that they – or even the companies operating here – should pay more tax have not exactly brought the Rudd-Gillard government a lot of joy. So there have to be tradeoffs.
And if McGorry honestly believes that expenditure on early intervention programs is a much higher priority for funding than the Better Access Program as currently constituted, why should he do or say anything to the contrary? He’d hardly be Robinson Crusoe in this view. Neil Cole described the Better Access program as “the worst form of middle-class welfare I have ever seen”. As Cole notes, the way the program is currently designed – providing only part-payment for services, but with few restrictions on eligibility – means access is determined by ability to pay, not by the seriousness of the mental illness. The recipients of the programs McGorry advocates – still less those that those programs might have helped in the past – are far less able to speak on their own behalf than Bastow is.
Mental health professionals do indeed need to listen “..to the voices of the people they are advocating for”. But that doesn’t oblige them to be simple megaphones for the loudest, most articulate voices amongst their clients.
No, they should wait for an opinion poll and/or talkback radio.
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Ooops, sorry, wrong thread.
I’m not impressed with Neil Coles’s criticisms of the closing the gap scheme – and I’m not even a middle class patient rocking off to a clinical psychologist once a week with only $35.00 per appointment to pay.
Middle class status isn’t a prophylactic against mental illness. It may be that the middle class is over-represented in the patient lists of clinical psychologists and psychiatrists but it doesn’t follow from this that they’re rorting the system. You’d probably find that they’re over-represented in the patient lists of dentists too but that doesn’t mean that middle class people don’t get dental caries.
The problem with the Better Access scheme is that it’s been basically entirely exploited from the almost the day it started — first by the doctors who do SFA and I believe take over half the money and then by the clinical psychologists who (a) feel obliged to charge extra for their services despite getting $160 per hour, which means people that couldn’t afford to pay still can’t; (b) almost always open their clinics in places where people can offord to pay anyway; (c ) have deliberately and almost immediately decided to erect new barriers to entry into the profession so they become like the medical mafia; and (d) have changed their “scope” in terms of what they work in to almost every area, some of which their training teaches them almost nothing about, and some of which would be far better dealt with by other professionals.
Given this, I couldn’t blame the government for cutting back the funding — they should, and they should force the Aus Psych Society to come up with something that really targets the people at need and isn’t so obviously exploitable before they even contemplate giving it back.
Longer term problems are really that every disorder and non-disorder now seems to get turned to a clinical disorder, since the Aus government seems obsessed with clinical psychology at the expensive of everything else. So you have a bunch of people who think that the world can be solved via looking through the DSM, dealing with problems that really have nothing to do with it. Got a relationship problem? Well, why not have CBT and not believe its a problem? ergh.
Why do the clinical psychologists feel “obliged to charge extra for their services”? According to the SMH article on Cole’s criticisms of Better Access, the total fee per patient, per psychologist, is $113 per session ($78 plus $35 gap). Assuming you’re right on the hourly rate that means that under Better Access the gummint is paying for sessions of about 42 minutes – pretty much par for the course in serious psychiatric/psychological servicing.
Your points b, c & d need to be supported with evidence.
Gummo, I don’t know where Cole is getting her figures from, but these are from the APS. The government Medicare rebate for 50 minutes of clinical services is currently $117 (and about $10 less for counselling, although thanks to the difference counselling psychology is going the way of the dodo) so her figures are certainly wrong.
If you want evidence, then (b) was a complaint brought up with the APS by the government who have the data on this (although I doubt the documents are freely available yet so that one will have to wait). You can simpy look up Wikipedia for (c ), where you will find that the previous method of becoming a qualified psychologist is changing and they are now forcing people to get a Master’s degree versus supervised training, for which there are tiny number of training places. Where I work, which I believe has the largest number of students in Australia getting this training, we take about 20 per year. Note the quote from the wiki page about the group that most supports this:”This vocal group of clinical psychologists” who are not surprisingly the group with the most power (by far after all the government changs) in the APS. If you want evidence for (d), well go and ask a clinical psychologist if, for example, they’re willing to do grief counselling, or see what crazy diagnosis they will come up with for a reading problem. My bet is that many will be happy to do either of these. Neither of these areas are clinical areas (the first one is counselling and the second is educational).
Given all the problems with the current system, it’s pretty clear why McGorry won’t support it — I doubt he wants to be associated with the problems it will bring.
Take away the ability for people to access psychological services through medicare (at a length long enough to make any kind of long term beneficial change for people with serious mental illness) and you effectively remove any chance of people to receive treatment without medication. This would be fine if medication worked for every person and every kind of disorder but it doesn’t. Have the Government provided sufficient alternatives for people who can’t afford psychological services out of pocket? No. Is McGorry responsible for advocating for all people with mental illness who can’t speak for themselves? Perhaps not, but if this is the case, he needs to stop implying that he is. When you take on the responsibility of advocacy you also take on the responsibility of either speaking out about what EVERYONE needs (not just the people you are most interested in treating), or else openly admitting to your own limitations. I don’t believe he has done either.
Conrad, you say: “The government Medicare rebate for 50 minutes of clinical services is currently $117 (and about $10 less for counselling, although thanks to the difference counselling psychology is going the way of the dodo) so her figures are certainly wrong.”
Please note that clinical psychologists’ rebate is currently $119.80, and
“generalist” psychogists’ rebate (don’t get me started on what “generalist” means – it is everybody except the “clinicals”, including people with doctorates, 40 years’ experience, whatever…) is currently $81.60, leaving a $38.20 difference, not $10.
This is leading to the closure of many courses in streams other than clinical, to fewer job advertisements for psychologists other than clinical (even when the exact same skills are required), and therefore to a narrowing of the diversity of the field of psychology.
In any case, Conrad, you make a lot of good points.
I might also add that I believe Cole’s comment that Better Access is just ‘welfare for the wealthy’ is totally unfair, unfounded, and angers me to no end. Is the medicare system considered welfare for the wealthy? Are there plans to scrap that for anything more equitable? If not, why target psychologists? Or more specifically, why target the people with a mental illness who need medicare rebates for psychologists to get treatment? Cole’s comments just fuel the stigmatisation of mental illness. People don’t see psychologists for fun, they do it because they need help. I see mine because I have a bad time with a mental illness that has made it difficult to work my entire adult life. I hate my sessions, but they help me function, the same way the thyroid medication I take every morning helps my thyroid work. But unfortunately there’s no pill to fix my head like there is for my thyroid levels. I need a psychologist for that. And he doesn’t exploit the system, he charges me a minimal gap fee because he knows that’s all I can afford. It’s far less than $35. For all we know it’s the rich people paying larger gap fees, and the poor ones paying none, creating an average of $35. There’s way too much bogus information circulating in the media about Better Access for my liking, and at least Bastow’s article offers something to counteract this.
My son used all 18 consults allowed last year and we didn’t pay any gap, so I assume that some psychologists are bulk billing?
Sedmikrasky — I don’t think Cole is arguing that it’s a bad thing to target mental illness, it’s that if you want to spend a billion dollars a year on mental health that you didn’t a couple of years ago, the scheme itself needs to be evaluated. The reason the AMA is up in arms over it is because they’re the worst offendors for ripping it off (why they give GPs any money at all beats me — they don’t receive any money for sending people to any other specialists), and it’s up to the APS to show that billion dollars really does quantatively reduce mental health or mental health problems in the community. If they can’t do that then the scheme needs to be fixed so that it is better targeted.
It’s worthwhile noting that even people who are ardent supporters of mental health issues still think the program should be reformed, e.g., http://www.mja.com.au/public/issues/194_12_200611/ros10581_fm.html . This isn’t surprising because I assume they think that reform is better than the government chopping the program altogether and simply say that there was no evidence that it was working.
I am a recipient of this great service. Have suffered from depression for years. Meds normally work alone, but last year I had an ‘episode’ . Psych visits have made all the difference. I am on dsp and could not afford to visit without this support.
Have to agree that calling it middle class welfare is a stretch and doesn’t help the attempts to de-stigmatise mental health issues.
Conrad: Cole’s argument is based on the idea that treatment for people with more “serious” mental illnesses should be getting more funding than people who see psychologists through Better Access — that the people who see a “psychologist they don’t really need”. This is a complete misrepresentation of the Better Access scheme, which shows only 4% of people accessing it have mild symptoms. The rest have moderate-servere symptoms (I don’t remember the exact figures on that).
Not to mention, the Better Access scheme has been evaluated, and shows pretty good outcomes. People opposed to it (such as Hickie) were opposed to it before its inception, so there is an obvious bias there. You will also notice there is a statement of competing interests on his behalf at the bottom of the article you posted. Other public critics of Better Access are all linked to the same group of people — even Cole. These experts believe there are better ways to spend funding, but it is also biased towards their fields of expertise. We’re not getting both sides (or rather, the many sides) of the story here, but a lot of information in the media from one group of people. This is highly problematic, especially since what they’re saying doesn’t seem to match what people who use Better Access are saying.
This paper here addresses the arguments the critics are putting forward and points out that the data doesn’t back them up: https://senate.aph.gov.au/submissions/comittees/viewdocument.aspx?id=4c6b2275-b116-4eb3-996b-127af392a51d
The rebates to see a GP to do a specific health plan for other physical conditions also exceeds the rebate for them to do a Mental Health Plan, so it’s not true that they are getting more for mental health? I agree with you here though that the current system is not ideal. However I think the changes they’ve made make it even worse. Reducing sessions from 18 to 10 makes the scheme useless for people with severe and/or chronic mental health problems, but nothing has been put in place for such people. They want to prevent people from using it as a long term service, but how on earth does the Government expect to treat people with conditions that need this. They’re just putting them (and I’m one of them) in the too-hard-basket and not offering any alternative. I wouldn’t be so critical of the cutbacks if they’d put something else on the table to help people who need longterm psychological care but they haven’t. They keep saying people who need more than 10 sessions can be referred on to “more appropriate services” but certainly for many of us seeing a psychologist is the most appropriate and cost-effective treatment out there. And many of us are extremely anxious about what is going to happen to us once these cutbacks are in place.
“Not to mention, the Better Access scheme has been evaluated, and shows pretty good outcomes.”
Reading through the report from Anthony Jorm, he even notes that they they still can’t answer the question as to whether population mental health is improving (last paragraph), versus tackle some of the criticism (where he does a fine job). I’ll repeat myself here and say it’s up to the APS to demonstrate this, and that’s the best arguement. Without this, it’s a program likely to get the chop (presumably and especially if the government changes). I should point out here that just saying “what happens to group X if it gets the chop” is not going to save a program, since the standard response is that there are many groups that need services and not getting them, and this is an opportunity cost (with you unfortunately on the losing side if it happens). For example, people die because life savings drugs are too expensive for them to be on the PBS, people are entirely dysfunctional because they can’t afford decent physio, the standard of care for people with serious neurologically caused mental disease is appaling (as is the way we treat people born retarded), people no doubt get depression as children when they have various learning difficulties and can’t do much at school (and then end up unemployed and unemployable as adults), but unless you are next to entirely dysfunctional, no-one is going to pay for that either, etc. .
Conrad, you’re definitely right about the need for an assessment of longterm benefits for this program in Australia, but at the same time the program was originally established on years of evidence-based research into psychological treatment so it’s not without merit.
We’ve also got the same issue with where the savings from Better Access has been shifted to. One of those places is EPPIC, which has no publicly accessible evaluation of its longterm outcomes, and even Patrick McGorry himself has stated that “first-episode-psychosis client group should have access to a longer tenure of care at EPPIC model services rather than be prematurely dis- charged to standard mental health care” http://static.rbi.com.au/common/contentmanagement/AusDoc/pdf/AD_028___AUG26_11.pdf He says this because the current model of care at EPPIC last for 2 years. I don’t know if there is being any effort made to extend this period of care, or if they’re just rolling out the 2 year model that has proven to be ineffective in the longterm anyway. Meaning people will just shift to standard healthcare at the end of it. That is also troubling, as standard mental health care is a disaster.
Similarly headspace has received a lot of funding, but where is the independent evaluation of that program? There are also questions as to what the money is being spent on, since it appears that headspace relies on Better Access anyway to refer young people on for treatment. It doesn’t seem that they are actually putting money directly into treatment. An article in The Age today brought some attention to this: http://www.theage.com.au/national/youth-service-short-of-gps-20110827-1jfqo.html
So if you expect the APS to provide more sturdy evidence of its worth, why not ask the same thing of these new initiatives?
The good thing about Better Access is the dollars are spent directly on services, not admin costs etc. Seems like better value for taxpayer dollars if you ask me.
Of course, I have my own bias in that Better Access works for me. I needed mental health care before Better Access and after, and think after is much better, not to mention much more cost effective. Previously a lot of money was spent on psychiatrists that cost the taxpayer more, took more of my time, and didn’t work nearly as well. Also taxpayer dollars were wasted on psychologists through centrelink that were quite frankly hopeless. Since the introduction of Better Access the taxpayer now pays a lot less for my healthcare that’s for sure.
I see what you’re saying about these problems across all areas of healthcare. I know less about this. However I am particularly concerned at the loss of Better Access because of how many people I’ve heard say it helps keep them out of hospital. In other areas of healthcare hospital is safe, but in mental healthcare many people who are hospitalised are abused in hospital. This is particularly alarming, and a good reason to be fighting for anything that can keep people out of psych wards. The other reason it’s important to provide adequate treatment for depression is that it is one of the largest causes of disability — another cost to the taxpayer. People aren’t going to get off welfare if they aren’t provided adequate treatment options.
Also, as for psychiatric medication, it is widely used and prescribed, available on PBS etc, yet there are virtually no studies proving its longterm efficacy. If anything, studies show the opposite. I would never advocate for their complete removal, because undoubtedly they are of great benefit for some people, I just ask why do psychological treatments need to prove their worth more so than pharmacological treatments? There seems to be a bit of blind faith in psychopharmacology going on.
It may also interest you to know that the Liberal Government is also opposed to the cutbacks to Better Access (at least, if the letters I have been receiving from senators and MPs are anything to go by), so a change in Government may not see the demise of Better Access at all. In fact, the Howard Government were the ones that first introduced it.
Conrad, who appears anything but impartial or balanced in his arguments, appears ready to fall on all of the vested group complaints about Better Access including the criticisms already evaluated and answered. I wonder what opportunity cost is involved in headspace with hundreds of millions of dollars invested yet with only the 2009 independent evaluation which could not actually result in definitive cost or treatment evaluation due to Orygen Health failing to provide financial records or complete datasets per service users. The headspace evaluation did however show that ten headspace centres saw an average of 17 young people per month. 17 per month. This represents a third of headspace centres providing care at the average financial outlay of $8,200 known and cited (full figures were not provided) per client per month. headspace care of young people would also represent less than 5.5% of the mental health care provided by Better Access in this age group in 2009 if all three years of client use were to be considered in that year. For all the talk of opportunity cost we see Better Access, as used by headspace, offers the majority of care across all age groups.
The beneficiaries of the new funding, incidentally the same people involved in Better Access criticisms, ignore the fact that Better Access has been the one program which has made significant in-roads in treatment uptake for hitherto unmet mental health need. This occurs at the same time that both the National Institute of Labour Studies review of Better Access and Department of Health and Ageing post-implementation report point to a lack of mental health workforce availability to meet demand not an ongoing blow-out in program costs.
This blow-out in administration costs could be more appropriately examined in terms of our untested flavour of the month and their conflict of interest including their very close alliance with the huge multi-national health insurance company, BUPA who provide both financial and political patronage to Orygen. Perhaps Orygen “advocacy” of consumers can be understood from Orygen Health and BUPA representatives working with the govt to funnel 75% of new mental health funding to private and allied interests whilst Ian Hickie, Member of the BUPA Australia Medical Board continues to expect to be taken seriously as an independent critic of other programs. Please.
Jumanji,
I think all government programs should be assessed, and that includes headspace. If it’s as bad as you say it is (I don’t know anything about how it is run), it should be closed down, and if Orygen is losing records, then that’s a serious breach of ethics which should have serious consequences. This is of course is an essentially an orthogonal issue to the one here. As for Better Access, it should be evaluated in the same way too. I also agree, for example, with a lot of what Sedmikrasky suggests, which is that it’s pointless running looks-good programs that don’t work due to insufficient funding and the money would be better spent on fewer people where you get better outcomes (which of course means others miss out). I also can’t see why someone isn’t coming up with a fairly definitive and believable cost-benefit analysis. For all I know Better Access saves the government money by keeping people in employment etc. — and this should be fairly easy data to get.
Conrad,
I do not consider the idea of evaluating headspace or other over-stated mental health programs as orthogonal to the current debate at all. This piece is considering the responsibilities of advocacy and my comments speak of fair appraisal across the programs mental health funds are being diverted towards which appear neither to have a sound economic or empirical base. Or more simply as a friend and colleague who is a genuine advocate of mental health would say, the distinction between an advocate for mental health consumers and an activist such as McGorry who is an Executive Director of a private health initiative must be distinguished.
Before I comment further upon Better Access figures, which much is known about if a commentator was genuinely interested, I need to correct a misunderstanding. I did not say that headspace records were missing. I cited that the publicly available headspace evaluation stated that financial records and dataset content was missing. headspace centres failed to keep and assimilate basic statistics relevant to their service users. Again, a commentator upon the mental health advocacy context in Australia may find this illuminating.
The evidence for the cost-benefit breakdown of psychology services in the community is also well documented. See http://eprints.lse.ac.uk/19673/ as just one of numerous examples of this. Notably, the vast majority of Better Access treatment consultations is at a tax payer cost of a smudge over $80 whilst the alternative, ATAPS according to their 2011 ANAO Audit costs in excess of $200 due to administration costs whilst headspace costs are literally incalculable. All need GP referrals to activate. The average cost of Better Access treatment is approximately the equivalent of four weeks Disability Support Pension if we want to reduce all treatment endeavours to the crass monetary reference. Psychological disability is also the fastest growing disability in Australia so we need to consider as a nation which expenditure we would prefer; treatment or growing morbidity costs.
The empirical basis for Better Access is also known http://www.betteraccess.net/index.php/information/evidence-based-reform and the 2010 evaluation of Better Access showed significant improvement of both clinical presentation and consumer satisfaction. These facts seem to be important to some, not all, mental health commentators.
Jumanji,
just pointing to the fact the psychological treatments work if given doesn’t mean a program is worthwhile. If you do this, all some commentators will do is say this is just simply substituting public money with private money, people that don’t need it will use it and that wiill be a waste, etc., as was done in one of the linked articles. I doubt too many people are disputing that treatments have some efficacy and this helps people in the long-term, and as your first article points out, this would save money if you could theoretically reach these people. As it happens I agree that you need longer term treatment for many disorders (as the second article points out), and cutting the number down will affect outcomes, probably quite negatively. However, this is just the standard political dross, where inputs will be treated as outputs (“Great usage of new services means program is good!”), and not measured outputs (“This program caused an additive effect over and above others that exist”). This is even more reason to measure the outputs, not the inputs.
Yes, but to dismantle the scheme to below evidence-based treatment length before the outputs are adequately measured, and to shift the funds to somewhere else that has even less evidence behind it makes zero sense. I would question the agenda of anyone arguing for such a use of public funds.
“Yes, but to dismantle the scheme to below evidence-based treatment length before the outputs are adequately measured, and to shift the funds to somewhere else that has even less evidence behind it makes zero sense. ”
Politics trumps reality once again.
Thanks for the interesting discussion, everyone.
As far as Headspace and the whole early intervention thing, it’s my understanding (and apologies for any layman mistakes in terminology here) that schizophrenia and similar conditions are exceptionally costly diseases, in both the human and financial senses.
That makes any possible preventative treatment very attractive, even if not fully proven (though, of course, there’s always the risk of being counterproductive, I suppose).
As pointed out above the headspace program evaluation, wasn’t able to access records of attendances and throughput let alone outcomes.
The program was implemented nationally at great cost despite no pilots indicating its success.
The first “evaluation” of headspace is a useful text book example of how evaluation is coopted by policy makers to buttress and promote policy not to question or improve practice.
The headspace program has actually depleted some services available for mental health.
There is a simple scenario that has been repeated all over Australia.
All sorts of health and human services agencies and planning bodies have had a raised awareness of mental health issues over the last 5 years. A large majority of areas have had mental health issues high on the priority of planning and service issues.
Mostly where people have thought about it and contacted carers and mental health consumers themselves this has placed long term chronic mental illness as top priority with the services needed to support people out in the community. That is support fo accommodation needs, support for daily living needs and support for employment.
The skills needed are not clinical skills although an ability to work with clinical workers is important.
The next most identified priority has been for adequate acute mental health facilities ( beds) and also pre and post acute, step up step down support and facilities and supported accommodation.
In general nowhere on the list of any sensible planning priorities is drop in referral centres for youth.. Making services available and accessible to youth plus good services for first break youth is a priority.
Along comes headspace and introduces “new” monies for drop in services all over the nation for youth. No consultation with local serves or planners. No recognition of local priorities and existing services.
Being a Federally funded program it pays better than many state services.
So in a local area where there are already some struggling underfunded well positioned and relevant services the headspace recruits from the limited pool of talent.
Mental health worker A who is working full time at community service with GPs and other professionals such as accommodation workers, dentists, is lured by better pay to headspace. Immediately the original service is less one worker, maybe the sole dedicated mental health worker.
The worker, after a 3 month wait for drop in premises, sets up headspace and encouraged previous clients who fit the “youth” profile top drop in. These clients who need help are then referred back to the original service that now has no worker. The headspace agency claims the referral as a statistic and evidence of work.
End result – more money in mental health, headspace empire expands, less work done to help mental health sufferers than before.
Commonwealth evaluation of headspace cant find more than 30 (from memory) ex headspace clients to fill in a basic happy sheet evaluation.
This is only one of the reasons that mental health workers on the ground are less than impressed by the whole McGorry gravy train.
Robert: I think you’ve hit the nail on the head! Preventative treatment IS very attractive, and therefore can easily win over the public. It sounds like the right thing to do and is a great tool for political manipulation. But when you start to look a little closer at the way the money is flowing (as described by Jumanji), and what many people in the field actually see as urgently necessary for mental health reform (as explained by fxh), combined with the fact that the science behind it is still not widely accepted (how can we prevent something we don’t even understand?), the ability for these specific projects advocated for by McGorry to offer what they say they will starts to fall apart at the seams.
I also think people underestimate just how crippling non-psychotic disorders can be, and what a massive expense they are to society (don’t most people on disability welfare suffer from depression?).
Yes preventative is attractive and it’s bolstered by well meaning but naive hippy cliches like the ” ambulance at the bottom of cliff instead of stopping people being thrown over”
Prevention ( I’m not talking early intervention which is different) in mental illness has about as much scientific / evidence base credibility as acupuncture or homeopathy for cancer.
Or less hypbolically and more accur lately , about as much evidence as eating veggies and fibre will prevent bowel cancer.
That’s is lots of theories, some weak correlations and many confounding variables, and no long term evidence or outcomes.
As a psychiatrist, I think the McGorry model is exceptionally problematic. The whole of medicine is dominated by a culture of preventative medicine that has broken qualitatively from its roots in social medicine and developed a neoliberal-style focus on individual risk factors. This is a category error in that it presumes that population health outcomes can be addressed through tight targeting of individuals at risk, rather than populations. McGorry’s service has had decent results in its clinics for many years, but there is no proof that the incidence of schizophrenia and bipolar disorder have changed the in health sector he services.
The “causes” of severe mental illnesses such as schizophrenia and bipolar disorder (the “Type I” variant, not the controversial softer diagnoses, which are of questionable validity) remain quite opaque, and all we really know are epidemiological associations (many of them profoundly social, but the nature of the connection still not adequately theorised). Dreams of finding genetic “causes” have proven to be no more than a Holy Grail, but millions are spent on seeking them because they fit the individual pathology model that dominates medicine.
I do think, however, that McGorry is really just in the right place at the right time, and not the cause of the problem. Government is obsessed with addressing social problems at the individual level rather than with social solutions, and so his model appeals. It’s kind of the preventative variant of the sickening “social inclusion” agenda run by Gillard — the idea that we will help individuals overcome their exclusion and if they don’t then it’s their own fault.
If you listen to McGorry’s speeches, he is at heart a small-l liberal, committed to an individual-centred view of the world and not social change. No wonder he appeals to politicians and state bureaucrats of the modern era.
On Better Access, the scheme was always problematic because of its subsidised fee-for-service structure; but how is this different from Medicare for GPs and specialists, which most people on LP support? Like Medicare it has the problems of the gap deterring use by poorer people and the relative concentration of providers in wealthier parts of the country. But a real reform would involve the hiring of thousands of psychologists (on decent wages) by state community mental health teams — far more efficient and with rationing less likely to be controlled by ability to pay. But, gee, that would be too much like a National Health Service. Perish the thought.