The release of He Ara Oranga, the Report of the Government Inquiry into Mental Health and Addiction (https://mentalhealth.inquiry.govt.nz/assets/Summary-reports/He-Ara-Oranga.pdf) early this month, highlighted a mental health system that is struggling to cope with the escalating number of people with mental health issues. It is encouraging to see that the increasing morbidity associated with mental illness is being recognised and taken seriously in an effort to destigmatise psychiatric symptoms in our community. The Report should play a pivotal role in improving access and services for those struggling with mental health issues and ultimately lead to enhanced outcomes.
New Zealand data are clear that there is a rising number of people suffering from mental health problems; the New Zealand Health Survey identified that the number of adults with a mood disorder went up by 56% from 2006/2007 (10.8%) to 2016/2017 (16.8%). Rates of anxiety disorders went from 4.3% to 10.3%, an increase of 140%. These estimates come from using the K10 questionnaire. Based on these scores, 5% fell in the severe range, 9% moderate and 7% mild. Children are not immune to these problems, with an almost three-fold increase in that same time period in the number with emotional and behavioural problems, from 1.8% to 4.9% (www.health.govt.nz). Overall, these most recent data indicate that about one in five New Zealanders struggle with mental health problems in any given year, rates on par with international statistics; this equates to about 950,000 people based on a population of almost five million.
The most recent figures from Pharmac show that over that same decade of rising mental health problems (2007–2016), rates of prescriptions for antidepressants went up 48% and rates of prescriptions for antipsychotics went up 40% (www.pharmac.govt.nz). However, increasing access to psychiatric medications as well as increased spending has not resulted in improved mental health outcomes.1 The Report acknowledges that “we can’t medicate or treat our way out of the epidemic of mental distress” (page 10).
The Report not only described the serious shortfalls of the current state of the New Zealand mental health system, it also outlined 40 recommendations, including “more options for talk therapies” (recommendation 12) and to increase access to psychotherapy beyond the most severe cases. The report outlined “The lack of available services, especially talk therapies, was blamed for much of the perceived ineffectiveness and inefficiency of the current system” (page 56).
Overseas initiatives, such as the Improving Access to Psychological Therapies programme in the UK and the Medicare-funded scheme for Better Access to Mental Health Care in Australia, that have focused on increasing the number of health professionals available to offer psychological treatments, were cited as evidence that offering talk therapies was a viable and cost-effective way forward.2 However, before investing in more resources, is it realistic to substantially increase the pool of psychologists/therapists in New Zealand sufficiently to meet the growing demand?
There are currently 3,713 psychologists (that number includes clinical, counselling, neuropsychologist, educational psychologists and general scope) on the New Zealand Psychologists Board’s Register but only 3,005 hold a 2018–2019 Annual Practicing Certificate. Of these 3,005, 1,639 are actively registered under the Clinical Scope of practice, the scope of practice usually identified as those professionals who can treat the most severe cases. The number of psychologists to the number of people who could benefit from psychological treatments is 1:312 or one clinical psychologist for every 145 individuals with severe mental health problems (5% of the population).
Assuming a full-time psychologist can see about 80 patients a year (based on a work load of 20 patients a week and 10 sessions per patient), alongside the acknowledgement that a substantial number of psychologists only work part-time, our current workforce of psychologists realistically might see about 200,000 patients/year. These estimates may be optimistic as based on 2016 figures, 169,454 New Zealanders used specialist mental health services.
There are other professionals who can offer evidence-based psychotherapies, such as counsellors and social workers. Indeed, there are 3,000 counsellors registered with the New Zealand Association of Counsellors (about the same as psychologists; however, they typically treat the mild end of the spectrum and are not trained to treat those with serious mental health problems) and about 6,500 registered social workers (most of whom do not work in a therapeutic capacity treating people with psychiatric disorders). Together, they could possibly see another 200,000 individuals/year.
These estimates leave about 550,000 individuals struggling with mental health problems unable to access “talk therapies”. Alan Kazdin calls this unseen group the treatment gap, that is “the discrepancy in the proportion of the population in need of services and the proportion that actually receive them”.3 Most people (the Report estimates it is between 30–50%) with mental health problems do not receive any help at all.
The challenge is that the treatments that predominate in psychological services are intensive, one-to-one, in person and often provided in a specialised clinic setting. To meet the suggestions of the Report to allow for greater access to psychological services beyond the top 3% to all those in need, we realistically need to triple the workforce. Is this an achievable goal?
Consider clinical psychology as an example. New Zealand training programmes graduate around 60 clinical psychologists per year (about 10–12 per training programme). Even if we were able to double the number of clinical psychologists trained each year to meet the needs of the most severe cases (which would be resource intense requiring many more supervisors and teachers, as well as cause substantial logistical challenges for universities and internship placements), it will be over a decade before we can increase the workforce enough to meet the current need of specialists to help with the most severe cases. Further, these calculations assume that all clinical psychologists work full-time in clinical practice, stay in New Zealand, are effective with all patients, and that the population does not grow over that time period. Immigration could potentially assist with a faster growth of the workforce; however, there is a worldwide shortage of clinical psychologists. Similar challenges would be faced with attempts to substantially increase other disciplines.
In addition, even if we trained an adequate pool of therapists to refer patients to, UK data identify that only half of patients referred for talking therapies actually enter into treatment, with the rest either declining or dropping out.4 Māori and Pacific people, those who live rurally, and those in poverty struggle to access individualised therapies. Even if people are seen by a therapist, at best 50% of them recover.2,4 There is substantial room for diversifying treatment options offered to patients.
It is therefore unrealistic to think we can address the escalating mental health crisis by simply training more mental health professionals. This is not to say we should stop efforts to increase the workforce—more professionals offering psychological therapies are definitely required. Rather, we identify that increasing the workforce on its own is unachievable within current resources. Other innovative therapies (that can reach more people with fewer resources) and preventative methods need to be seriously prioritised and implemented. The Report showed less emphasis and recommendations targeted at prevention initiatives and therapies beyond talk therapies.
What are other ways forward? There is robust data showing that the more deprived one is, the greater the prevalence of psychological distress.5 Addressing the poverty gap is a necessary long-term solution for improving the mental health of the community. Alongside improving deprivation should be developing novel delivery of health services to have better reach within communities. As identified in the Report, e-therapies have broader reach than traditional therapies at a lower cost. Researchers at the University of Auckland developed a uniquely New Zealand intervention: a therapeutic computer game for young people (SPARX).6 It also guides users to apply skills learned in the game to real-life situations. It incorporates Māori cultural elements, and research has found it is effective and enjoyable. Programs like this could be a way to reach those with mild-moderate mental health difficulties and those who don’t access psychological treatments for other reasons.
Kazdin3 suggests a number of other avenues of novel delivery including using social media, nudging therapies, interventions in unconventional settings (like hairdressers), lifestyle changes (controlling diet, exercising, meditating), task shifting (expanding the workforce by using more lay individuals), and best-buy interventions (simple interventions that are cheap but can have broad effects such as increasing taxes or reducing access to spaces where one can smoke in order to reduce cigarette consumption). Focus on prevention would also be an aspiring long-term solution, including reducing exposure to adverse childhood experiences.7 With any intervention, it is essential that evaluation is incorporated into implementation.
The evidence is clear that maternal wellbeing during pregnancy, child-parent attachment, and early childhood experiences create the blueprint for our mental health later in life.8 Nutrition, physical activity, sleep quality, and stress management contribute in an ongoing way to wellbeing throughout life. Nutritional interventions, in the form of dietary manipulation, focused treatments on the microbiome, and supplementation with additional nutrients, have gained substantial traction in the last decade with research identifying that nutrition plays an integral role in prevention and treatment of mental health problems.9,10 The focus in the Report on increasing talk therapies shadows the opportunities afforded by many of these other innovative and preventative approaches.