Misleading claims in the mental health reform debate
By Melissa Raven and Jon Jureidini
Posted Monday, 9 August 2010
Below is another thoughtful article sent to us by email, now reproduced here in the public interest:
Since Professor Patrick McGorry was appointed 2010 Australian of the Year, mental health has had a remarkably prominent public profile.
GetUp has played a major role, with a campaign promoting McGorry’s call for radical reform, particularly in relation to youth mental health, arguing that early intervention should be the norm. Many Australians have enthusiastically responded, donating money, signing a petition, and sending faxes to politicians.
A further impetus came when Adjunct Professor John Mendoza dramatically resigned as Chair of the National Advisory Council on Mental Health (or, as he terms it, “head advisor to the Rudd Government on mental health”) and joined the GetUp campaign. Mendoza endorses many of McGorry’s demands, including a national rollout of headspace youth mental health centres and the Early Psychosis Prevention and Intervention Centre (EPPIC).
McGorry and Mendoza are adept at capturing media attention, using emotive statistics and feel-good messages as powerful soundbites. However, few people seem to have critically examined their claims, which have been widely accepted at face value.
We have examined several claims, and found them seriously problematic. Not only is there a high degree of spin in the rhetoric but also there is misrepresentation of evidence.
Two claims are analysed here. In each case the evidence cited to justify the claim, although relevant, does not support it, and other evidence challenges the validity of the claim.
Claim: One third of Australian suicide cases had been discharged inappropriately
According to Mendoza, more than a third of Australians who kill themselves had been discharged too early or without care from hospitals. This claim has been publicised by GetUp on its website and in emails from Mendoza about his resignation distributed to GetUp members.
Mendoza has confirmed to one of us (JJ) that the basis is the 2007 New South Wales Tracking Tragedy report. The introduction of that report does refer to “a third of suicides”:
Other systematic reviews of suicide and previous work of this Committee suggest that around a third of suicides may realistically have been preventible [sic] with more optimal care.
However, the report does not support Mendoza’s claim, because it focuses specifically on 113 cases of suicide by people receiving treatment for depression in community mental health settings, not on suicides in the general population. It is tragic that approximately 38 suicides might have been prevented, but this number is hundreds less than one-third of the 1,776 suicides in the NSW population in that period (2003-2005 inclusive). Furthermore, only 14 (12 per cent) of the 113 people had been discharged (figure 1, p34), appropriately or otherwise.
An earlier Tracking Tragedy report revealed there were about 20 suicides annually in NSW within 28 days of discharge. It concluded that “Suicide death on discharge from hospital is a rare event”.
In the period covered in that report (1999-2003), there were approximately 750 suicides annually in NSW. The 20-odd people discharged within 28 days prior to suicide annually constituted only 2.7 per cent of them. Even if all those discharges were inappropriate, Mendoza’s claim would be wrong by a factor of more than ten. However, the report concluded that only “Between one-quarter and one-third of suicide deaths following discharge from hospital could reasonably be prevented”. Taking the higher of those estimates gives approximately 7 out of 750 (less than 1 per cent), making Mendoza’s claim more than 30-fold wrong.
The “other systematic review” cited in the 2007 Tracking Tragedy report is the 2006 report of the National Confidential Inquiry into Suicide and Homicide by People with Mental Illness (in England and Wales). This does not support Mendoza’s claim. Only 27 per cent of suicides had followed any current or recent contact with the mental health system. Twenty per cent of suicides among these patients occurred within three months of discharge (5.4 per cent of total suicides), but only 18-22 per cent of these were judged preventable, representing only about 1 per cent of all suicides in England and Wales.
Unquestionably there is a need to improve discharge planning and follow-up – for many reasons, not just because of the risk of suicide. However, this is not relevant to the majority of suicide cases.
Mendoza has had the unwitting assistance of GetUp in misleading the Australian public. However, when one of us (JJ) explained why Mendoza’s claim is incorrect, GetUp’s response was “we’ll adjust our future communications accordingly”, but inexplicably it “won’t however be removing anything from the website or issuing any correction statements”. GetUp focuses on “giving everyday Australians opportunities to get involved and hold politicians accountable, on important issues”, yet it is unwilling to be held accountable for misleading everyday Australians about mental health, and its website carries information it knows to be incorrect.
Claim: 750,000 young Australians are denied desperately needed mental health services
McGorry has repeatedly claimed there is a hidden waiting-list of 750,000 young Australians who are denied access to much-needed mental health services. His website refers to “the waiting list of 750,000 young Australians currently locked out of the mental health care they and their families desperately need”.
In his submission to the Senate inquiry into COAG health reforms, McGorry explicitly linked the unmet need to insufficient funding for headspace and EPPIC. He made similar claims at a hearing (PDF 442KB). The Senate report (PDF 1.32MB) quoted his testimony uncritically. Others have also echoed his claim uncritically, including Lesley Russell (PDF 93KB) from the Menzies Centre for Health Policy. Furthermore, McGorry’s claim has been implicitly endorsed by the Coalition’s Real Action Plan for Better Mental Health.
McGorry’s 750,000 claim is based on the 2007 National Survey of Mental Health and Wellbeing (NSMHW), which found that 671,000 (26 per cent) 16-24-year-olds experienced a mental disorder in the previous year, and only 23 per cent of them accessed treatment. McGorry’s 750,000 figure, encompassing 12-25-year-olds, the focus of headspace, seems a reasonable estimate of people in that age range with untreated disorders.
However, diagnosis, particularly in surveys, is not the same as treatment need, contrary to the usual interpretation. According to Scott Henderson (an architect of the original NSMHW) and colleagues:
having symptoms, even at case level, is necessary but not sufficient to justify treatment … it is irrational to suggest that one in five adults need treatment for a case-level mental disorder. (p204)
Leading US psychiatric epidemiologists have similarly argued that prevalence rates in surveys do not represent treatment need. Robert Spitzer, a key player in the development of the DSM (Diagnostic and Statistical Manual of Mental Disorder), published a paper with the title: “Diagnosis and need for treatment are not the same”. The main reason is that many cases are not particularly serious. According to Darrel Regier (Vice-Chair of the DSM-V Task Force) and colleagues: “most episodes of mental illness are neither severe nor long-lasting”.
There is a strong bias towards treatment of people who most need it. In the NSMHW, only 17 per cent of young people with disorders (PDF 308KB) had severe disorders, 35 per cent moderate, and 48 per cent mild. Furthermore, 51 per cent of young people with severe disorders accessed treatment. And according to Gavin Andrews (another key player in the NSMHW), many cases of mental disorders are transient but the extent of remission is usually underestimated.
The gap between prevalence and help-seeking in young people is largely due to high rates of substance use disorders (particularly mild cases of harmful alcohol use) with low rates of help-seeking (particularly by young men). The relatively low threshold for diagnosis of harmful alcohol use – which has a high rate of spontaneous remission – inflates the prevalence of mental disorders. This was recently discussed in some detail by one of us (MR).
Undoubtedly some untreated young people would benefit from treatment. However, for many of them, GP services would be more appropriate than specialist services like headspace or EPPIC. Indeed, according to Andrews and colleagues, “in Australia as elsewhere, the GP is the key to treatment for most people with mental disorders”.
So most of the 750,000 are not locked out of treatment, and most do not desperately need it. Most choose not to access treatment, and often that choice is appropriate, because the disorders are mild and transient. 750,000 is a gross over-estimate of treatment need, particularly need for specialist services like headspace and EPPIC.
These are only two of a number of inaccurate claims made by McGorry and Mendoza that inflate the scale of problems in the mental health system and exaggerate the benefits of their brand of solution – central to which is massively increased funding for headspace and EPPIC – which they imply is the only alternative to the status quo.
But does it really matter if some of the claims made by high-profile mental health advocates are inaccurate? The system is in crisis, and radical change is needed. McGorry’s plan, resoundingly seconded by Mendoza and many mental health community groups, has the support of the public and politicians, so shouldn’t we capitalise on the momentum?
That is how many people will respond to our critical analysis of these claims. It is essentially how GetUp has responded.
However, we believe it does matter that people have been misled to believe that more than a third of people who kill themselves have been inappropriately discharged from hospital, because this implies that massive resources should be directed towards psychiatric inpatients, who constitute only a small proportion of people at risk of suicide, and it deflects attention from other at-risk groups such as unemployed and elderly men. Such resourcing would have inevitable opportunity costs in terms of funding of other services.
We believe it does matter that people have been misled to believe there is a huge hidden waiting-list of young Australians desperately in need of mental health treatment, because this implies that even more resources should be directed towards a relatively narrow age-band. It matters even more that it is claimed that the treatment required is headspace/EPPIC treatment, and the claim is used to justify demands for greatly increased funding for those services, which would increase the opportunity costs.
We also believe it matters that the important role of GPs in mental health treatment is being ignored and implicitly denigrated. This is likely to lead to further deskilling and under-resourcing of GPs, reducing their capacity to intervene effectively with young people, many of whom have mild and relatively short-term mental health problems.
We are not entirely alone in criticising McGorry’s campaign for mental health reform centred on specialist early intervention in youth mental health. The Royal Australian and New Zealand College of Psychiatrists’ submission (PDF 157KB) to the National Health and Hospitals Reform Commission expressed concern about “investment in age specific community based services that have neither identified transition points nor evidence to support that age specific services provide better outcomes” and cautioned that “there are no simple solutions to reforming the mental health sector”. However, this seems to have been ignored by the NHHRC: its report (which will profoundly influence Australian health policy for decades) endorsed McGorry’s demand for a national rollout of EPPIC and favourably mentioned headspace.
On a different level, we also believe it matters that high-profile mental health advocates are able to mislead by proclaiming authoritative-sounding statistics that almost no one bothers to check, and that misleading claims are incorporated into health policy. This uncritical acceptance is an impediment to evidence-based policy. Worse, when the inaccuracies of claims are pointed out, there is often reluctance to acknowledge the misinformation and attempt to rectify it, as is the case with GetUp.
McGorry and Mendoza’s mental health reform campaign, which has become a popular bandwagon, exemplifies flawed problem-solving in which participants move too readily to the solution stage without adequate investigation of the problem and without objective analysis of a range of possible solutions. The histories of medicine and health policy are littered with popular but ill-informed bandwagons (PDF 100KB) like this.
We agree that the mental health system needs reform. However, we believe that there is far too much at stake to take the risk of fast-tracking a solution supported by inaccurate claims and populist sentiment. Furthermore, we argue that inaccurate claims are actually part of the problem, because they obscure the real issues, potentially bias resource allocation, with inevitable opportunity costs, and impede the formulation of effective strategies to improve the wellbeing of Australians.
Melissa Raven is a psychiatric epidemiologist and policy analyst, an adjunct lecturer in Public Health at Flinders University, and a member of Healthy Skepticism.
Jon Jureidini is head of the Department of Psychological Medicine, Women’s and Children’s Hospital, Adelaide where he works in Consultation-Liaison psychiatry. He has academic status as Senior Research Fellow, Department of Philosophy, Flinders University and as Associate Professor in the Disciplines of Psychiatry and Paediatrics, University of Adelaide. He is spokesman for Healthy Skepticism Inc, an organisation devoted to countering misleading drug promotion. He is also a member of the Women’s and Children’s Hospital Patient Care Ethics Committee, and a chair of the board of Siblings Australia, an organisation which advocates for the needs of individuals with ill and disabled siblings. Publications in the last two years have addressed prescribing for children, immigration detention, suicide, and child abuse.
More can be found in Category Mental Health.
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