Tackling the mental health crisis in the time of Covid 19; prescribing the same remedy over and over again?

The Productivity Commission’s inquiry into mental health is recommending the same policies which have been advocated for the better part of 30 years. There is nothing to suggest that continuing to pursue them will produce the improvements that the Commonwealth government seeks.

The insight questionably attributed to Einstein that “doing the same thing over and over again but expecting different results is a sign of madness” is peculiarly apposite to the inquiry of the Productivity Commission into mental health. Judging by its two volume interim report, the Commission is proposing just that. The final report is still to be released by the Commonwealth government.

Its interim report acknowledges that co-occurrence of substance dependency and other mental health issues is the expectation rather than the exception, that such people display the most complex needs, most difficult and costly to address and even that “for effective treatment there should be an alignment between mental health and alcohol and drug policies”, yet made clear that it regards consideration of drug policy as beyond its terms of reference.

It is proposing a combination of measures to address the interplay of drugs and mental health. These are reviewed below. All are worthy but none are new. They have been recommended for the better part of 30 years in a succession of mental health plans. There is nothing to suggest that continuing to pursue them will produce the improvements that the Commonwealth government seeks.

It was in November 2018 that the Treasurer charged the Commission with how to “improve mental health and economic participation and productivity”. The economic and social costs as well as the burden of ill-health were motivating the Government. If only because substance dependency is a recognised mental health condition it was therefore surprising that the Commission largely dismissed the well-documented role of drug policy as a compounder and driver of mental health problems.

The coercion of the criminal law that underpins drug policy leads to prisons being crammed (two thirds or more) with people suffering from co-occurring substance dependency and other mental health conditions to the extent that prisons have become modern day mental health institutions. They house the nation’s most marginalised with the most complex of mental health needs.

While it is acknowledged that “secure hospital care is three to four times the cost of incarcerating the same individual in prison”, research points out that taking into account “mental wellbeing and a reduction in future recidivism” and the “high societal costs of crime”, treating people in “secure hospitals” is superior.

This is without taking into account the extent that subjecting people who use drugs to the coercive procedures of the criminal law actually foments and aggravates mental health conditions. In short, don’t spoil the ship for a penny’s worth of tar. The 2019 research concluded that “in addition to the clinical need and the humanitarian argument, offenders with psychosis should be treated in secure hospitals to reduce future recidivism.”

One would have expected that this high correlation between substance and other mental health conditions would have moved the Commission to consider the extent that drug policy contributes to both the intractable complexity of mental ill-health and the burgeoning prison population that clearly compounds mental health problems.

The following paragraphs summarise the measures that the Commission recommends to address the complex issues of co-occurrence. None is a significant advance on what was laid down in previous mental health plans and national drug strategies.

Alignment of mental health and drug policies delegated to clinicians

Significantly, as stated earlier, the Commission acknowledges the interplay of mental health and drug policy but this acknowledgement was left hanging. The Commission delegates to the clinicians an impossible balancing act between, on the one hand, ministering to people as patients in dire need of respectful care and treatment and, on the other, processing them as criminals to be coerced to change their ways.

Care coordination

The Commissions calls for a “fundamental reform to care coordination services for people with the most complex needs” embracing “clear and seamless” care pathways with “single care plans for people receiving care from multiple providers” (overview p. 3).

Obvious, you might say. Indeed this has been obvious to the framers of a succession of national mental health plans tracing back to the first in 1993 which identified as a priority area “linking mental health services with other sectors”. Substance use comorbidity has been a specific focus since the Second National Mental Health Plan of 2001 and the National Comorbidity Project launched the previous year. The project brought together the National Drug Strategic Framework and that second plan report (vol. 1, p. 325).

The Commission acknowledges that the mental health system should not be “relying simply on the goodwill of committed staff.” In essence, the solution to the faults of the mental health system “that fails far too many people” is delegated to “key players” who “should work together” (overview p. 7). The role of governments is no more than to incentivise for these key players – to provide a governance and funding structure. Nowhere is there an examination of how drug policy impedes care coordination.

A stepped model of care

The Commission made a big play of its stepped model of care plan involving the tailoring of mental health services to the different intensity of needs of consumers. The model helped identify the gaps in service provision like “low intensity clinician-supported on-line treatment and self-help resources, ensuring this is consistently available when people need it, regardless of the time of day, their locality, or the locality choices of providers” (overview p. 3). This too has been around for years with the Commission itself acknowledging that “Stepped care has been adopted nationally in Australia, and while its use is widely accepted, its implementation has proved challenging” (vol. 1, p.17). Why the challenges?

Reducing stigma and marginalisation

The Commission acknowledges that stigma and marginalisation “directed at both those people with mental illness and those who support them” as one of several key factors driving poor outcomes in Australia’s mental health system” (overview 2019 p.6). The stigma around drug use boosts the stigma around mental ill-health.

The Fourth mental health plan called for “Effort to remove barriers which lead to social exclusion such as stigma, negative public attitudes and discrimination in health and community settings.”

Addressing psychosocial factors

The Commission’s valuable insight that psychosocial factors must be addressed if the burden of mental ill-health is to be reduced is also not new. The 2009 – 2014 Mental Health Plan called for “integrated programs between mental health support services” to address “a range of psychosocial factors if the burden of mental ill-health is to be reduced.”

The exposure of mental health consumers to the coercive processes of the criminal law is a key driver of these factors in the life of those with the most complex needs. The criminalisation of drug use and possession for personal use generates and accentuates stigma. Those who abuse substances are termed “unclean”. They are the modern day lepers driven from supports of family, friends and work to associate with deviant peer groups.

Prisons are about the most damaging place for people with mental health problems to be. To quote Professor Paul Mullen, former clinical director of the Victorian Institute of Forensic Health and a professor of forensic psychiatry at Monash University:

“Mental disorders and intellectual limitations are frequently constructed by staff and prisoners alike as a sign of vulnerability and vulnerable is not a safe label to wear in prison. Those who do seek mental health treatment are at risk of being seen by staff as attempting to evade the rigours of prison, and by fellow prisoners as weak and unacceptably alien. Prisons and jails are intended to be punishing and they provide hard and unforgiving environments which often amplify distress and disorder.”

In contrast, the official Australian Commission on Safety and Quality Health Care prescribes person centred care as care “that is respectful of, responsive to, preferences, needs and values of the individual patient.”  That care “involves seeking out, and understanding what is important to the patient, fostering trust, establishing mutual respect and working together to share decisions and plan care.”

Nothing could be more at odds with those principles than seeking to coerce people to overcome a substance dependency (itself a mental health condition) and, if they don’t, consigning them to the harsh mercies of the justice system.

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