Still raving about Better Access

From: //blog.artdoxa.com

This blog post is actually a very long comment on the blog by Jacinta Patterson titled "Argument by anecdote in mental health". The anecdote that Better Access money was being wasted on the over-concerned rich and not on the disadvantaged and genuinely mentally ill, seemed to be the main reason put forward in the press, explaining the cuts to Australia's mental health budget for 2011- 2013.

Aha- this post (referred to above) is still getting responses! I dropped in when it was first posted, but my comment doesn't seem to have got through! As a Better Access client and a former mental health researcher trained in public health, I can find many ways of examining the whole scheme!

It's difficult, firstly, to examine Better Access without the stats from the rest of the outpatient mental health sector. As someone said above, many people, mainly with schizophrenia or manic depressive disorder [these names make it clearer as far as I'm concerned; I know the controversy], are covered by Headspace and  community mental health clinics [which are hospital outreach disguised]. The NEW cases of psychoses, or those at high risk [pro-dromal; the people who were to receive medications if they seemed on the edge of real psychosis], hopefully benefited from Better Access, but I can't see how I can tease them out of the figures from the govt. I would assume that plenty of these people would not recognise they needed help, just as always happened in the past- the only way I imagine they got into Better Access would be if their GP was alert enough when seeing them for another complaint. How alert are GPs usually? Don't know- no figures. There's no epidemiological data from the past on this and I don't know anyone collecting it, so we can't judge.

Anguish at work- needs help

The figures suggest many new clients for mental health care under Better Access and the sudden proliferation of various therapist groups in the community suggests the same- there are community nurse mental health counsellors, psychology-trained, social-work-trained, [I don't know any] occupational therapy-trained plus more, putting up shingles. Most have few empty slots in their calendars, so someone is filling them. My guess is that new clients who couldn't afford private care before are cashing in on the Medicare scheme to get help they've needed for a long time. I know hardly anyone besides myself who has seen a psychiatrist for more than one session under Better Access and I think that is because psychiatrists won't take merely the Medicare rebate as full payment. Mine agreed to it beforehand, because I asked specifically and because I knew her before she qualified. However, her receptionist didn't know this and when I had received 2 sessions and handed her the rebate cheque for the first one she asked: "How would you like to pay the rest; cheque or credit card?". I told her I had no income, no insurance and no benefits, so she was going to have to accept Medicare or take me to court! My shrink cleared it up with her!

USA, ER visits for mental illness increased

I would suggest that psychiatrists have kept on seeing the same sort of clients they always saw- those referred through hospitals and other professionals, mainly privately insured [the uninsured wait to see their psychiatrist in hospital outpatient clinics every week and get the same doctors as they had privately], a slight leaning towards upper income, definitely more city/suburban people and hardly a trace of indigenous Aussies. However, at outpatient clinics there have continued to be stacks of lower-income clients, young people avoiding parental scrutiny and indigenous and other-cultural-group clients. Because there are virtually no psychiatric emergency "drop-in" centres, the poor old Emergency departments of public hospitals have copped the majority of psychotic, alcoholic and suicidal people, usually in terrible emotional states and which the emergency doctors, nurses, police and ambulance personnel are least trained to handle. Better Access could do with setting up a few Psych Emergency Facilities at least on the outskirts of  major towns. I don't think the community is going to suddenly get better at detecting mentally ill relatives and friends before they reach crisis point- they've never seen psychosis etc before, it's scary and they hope it will go away if they ignore it. Maybe the NEW Headspace places can change the culture of stigma and disdain of help-seeking by young men, but I'd like to see it happen before I'd have much hope.

In bed crying? Get help via Better Access

I'm a bit confused about why the change from 10 to 18 sessions in Better Access had to be made and announced because the clients from last year are going to have to see SOMEONE sooner or later. If clients who are still in need of care go back to their previous therapist, which most of us would prefer to do [and that would be therapeutically beneficial], are they suddenly going to say "Bugger off or pay me twice as much?" I can't see it happening except where psychiatrists have hard-hearted receptionists! I'd like to hear from some people about their experiences, since there's NEVER going to be a statistic on this!

As for GPs getting less money for the first consultation under Better Access- I can't work out how the huge amount extra was justified in the first place. The GP gives you a batch of questionnaires to fill in while he/she sees another person, then asks a few brief questions face-to-face, adds up the simplest depression/anxiety scores, gives feedback and may write a standard referral on the computer if you seem to need care elsewhere. Otherwise, if the GP is doing the counseling themselves, people just make regular appointments as they would for anything. I can't imagine that many GPs deduce much themselves from this 1st appointment, even those with special mental health training- mine didn't, that's for sure. Apart from questionnaires, the GP does have some documents to complete proposing a treatment plan, etc, but it's not clear how an ordinary GP could predict what is going to happen with a mental health case anyway- psychiatrists find it hard enough. In my book, the cut in Medicare rebate is justified- doctors just got used to it. Couldn't they feel good about contributing to Public Health with these sessions, rather than through some dubious primary care "health promotion" program? The cuts for ongoing counseling I'm not sure about- halving the rebate seems harsh.

ER will always get self-harm clients

As for the $1.4 billion: Why won't this much be NEEDED for mental health in the future and blow out lesser budgets? You can't hope to "cure" many people, and for the ones fixed up enough to go it alone, another new one will walk in the door & use the Medicare dollars.

Have a look at what happened in California after their mental health budget was slashed. DO we want that in Australia? :
http://disabilityrightsgalaxy.com/2011/10/01/the-system-is-broken/

The USA has even more problems with mentally ill people reporting to ER than we do in Australia:
http://www.msnbc.msn.com/id/25520178/ns/health-mental_health/t/some-psych-patients-wait-days-hospital-ers/
http://vtdigger.org/2011/11/09/frustration-over-upheaval-in-states-mental-health-system-mounts/

Wrong place for mental health care- too tense & anxious

Why self-harm now?: http://thelinc.co.uk/2010/03/self-harm-the-cause-the-facts-the-support/

Moving ahead: http://www.bipolarlifestyles.com/tag/hospitalization/

China adopts Western obesity.

In PubMed, I came across this interesting article about body weight trends in China:

Emerging disparities in overweight by educational attainment in Chinese adults (1989-2006). from the International Journal of Obesity [London]

It appeared to be a great naturalistic study of the effect of increasing capitalism on body weight. Since China dropped strict communism and allowed individual financial enterprise, there has been a gradual division of their society into the more and less educated and the more and less well-off. Some scholars from California analysed the China Health & Nutrition Survey data and discovered that well-educated Chinese women have become slimmer and well-educated Chinese men have become much larger than their less educated fellows.

I haven't delved into the methodology to see were the sample came from and how severe the differences in education or income, but it is an interesting result for the Chinese to follow the Western pattern, rather than that of a society where bodily bulk means power and money, eg. in some African groups & formerly in the Pacific Islands.
From Robert Lindsay's blog, this photo of a Western, Caucasoid, Chinese man:

We seem to accept in Australia that people from lower SES groups become more obese than their high-SES neighbours due to eating too many high-fat, high carbohydrate foods and not enough fruit, vegetables and lean meat (protein). Would the same mechanism have emerged in China or does their different dietary tradition insulate them from this effect? Perhaps the Chinese have adopted Western-style meals and fatty take-aways as the norm these days (it didn't seem to be the norm when I visited a few years ago, but youngsters obviously relished their KFC and McDonalds when they had enough money for them)?

These possibilities need to be explored before accepting that the Chinese change in the distribution of obesity is due to Westernisation of the diet. There is also the racial mixture of the people in the study sample to consider. In the East of China, especially the giant cities of Beijing & Shanghai, most people are the larger-boned Han Chinese, but in the West most are more Caucasoid with finer bones and fairer hair. The diets tend to be different as well, with higher fat, more protein in the East and less variety, less fat and less food overall in the West.

From Fotopedia, a Han Chinese child:

However, we still haven't explained why rich women are thin and rich men are fat (on average, compared with other SES groups). Is there more to it than diet and psychology?

Out damned paradigm!

I have decided that whatever double blind crossover placebo-controlled# trials can do for sorting out the good treatment from the bad, they're completely beyond the pale* in mental health!
My starting points are roughly these:
1. Taking major depression as an example:
a) every case has individual real-life occurrences as contributing factors: maybe being totally neglected emotionally as a child, or having a string of teenage relationships ending in "betrayal".
b) every case happens to a different brain

c) every case has a certain set of present/absent, good/bad liver enzymes
d) whatever the age, size or shape of the person, they have a different "felt response" to the same dose of a drug
e) everyone has different ways of reasoning
f) we all afford differential salience to "stimuli" such as words, happenings, situations and other people's moods.
g) if interpersonal therapy happens, each person will have a different first impression (therapist AND client), which will influence the course of the relationship;
h) therapists all have different interpretations and ways of implementing different therapies (their "style")
i)different client vs. therapist personality combinations either work or don't work in particular therapies, no matter what the therapist thinks about their own "objectivity" in the interaction.
j) clients have differing "stickability" in their regularity and timing of visits to a therapist.
k) additional contributors may/may not occur DURING treatment by any mode eg. parent dies, husband leaves etc.
l)many factors contribute to what "dose" of therapy or medication will alter core symptoms, regardless of liver enzymes etc.
m) many people on medication never get a good therapeutic effect because of recommended dosing levels, especially if they are not referred to a specialist after partial response. Specialists can observe the person while pushing the medication to the biological limit and achieve complete remission (or rule out that medication).
n) people have different "feeling criteria" of when they are "OK" again after an amount of treatment- it may be quite different to what a therapist concludes.

Anyway, having committed heresy, I'll slink away to gather some evidence!