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Lynne Lane explores improvements in New Zealand in recent years in the services and supports available for people with mental illness
Mental wellbeing is a fundamental component of health.
Good mental health enables people to realise their potential, cope with the normal stresses of life, work productively, and contribute to their communities.
For more than two decades, New Zealand has made progress in addressing inadequate mental health services and social support, and abuses of human rights and discrimination against people with mental disorders and psychosocial disabilities.
Internationally, there is increasing concern the impact of mental illness and addictions in the developed world is outstripping that of cardiovascular disease or cancer.
New Zealand primary care is responding to this challenge by developing services to build resilience and support recovery through coordinated models of care that are more cost-effective, are consumer centred, involve family/whanau and reach greater numbers of people.
While mental health matters, there is still further to go to achieve it.
Taking a look at the bigger picture
The WHO estimates mental disorders account for 13 per cent of the global burden of disease, defined as premature death combined with years lived with disability.
Unipolar depression was the third most important cause of disease burden worldwide and is in first place in middle and high-income countries, with the disability component of mental disorders accounting for 33.5 per cent of all years lived with a disability.1
By 2030, depression will be the leading cause of disease burden globally, the WHO predicts.
An Oxford University review estimates the reduction in life expectancy associated with serious mental illnesses is 10 to 20 years, while heavy smoking (20-plus cigarettes per day) causes a reduction of eight to 10 years.2
Research recently published in New Zealand confirmed similar results, with an estimated 20-25 year reduction in life expectancy, much of which is preventable, for people diagnosed with a serious mental illness (New Zealand Doctor, 13 August).3
In 2012, the World Health Assembly identified the need for a coordinated response from health and social sectors at the country level.4 This led to the release of the Comprehensive Mental Health Action Plan 2013-2020.5
The action plan recognises the essential role of mental health in achieving health for all people. It is based on a life-course approach, aims to achieve equity through universal health coverage and stresses the importance of prevention.
The primary care sector in New Zealand is uniquely positioned to respond to this public health crisis as the national agenda for change, as set out in Blueprint II and Rising to the Challenge, which aligned with and, indeed, influenced the global approach.6,7
To follow are some examples of primary care involvement in initiatives to improve mental health outcomes, across the domains in the WHO plan, that have come to my attention as the mental health commissioner.
Leadership and governance
Primary care plays a key role in DHB multi-agency groups established to jointly plan
mental health and addiction service improvements and coordinate the delivery of local support services across multiple agencies.
Over time, the role of these groups is changing from an advisory capacity to planning service developments, coordinating packages of care for individuals, and making funding decisions.
Integrated care in the community
To improve the physical health and wellbeing of people with chronic and severe mental health problems, the primary care sector and specialist services work on shared recovery plans, developed in partnership with the consumer and their family/whanau, that include specific goals for their physical health to be managed in primary care.
Psychiatric liaison services have been established to help primary care develop confidence in supporting people with complex comorbidities.
To increase access for youth, primary mental health services are delivered in school-based services and community-based youth one-stop shops with sexual health and other social services.
To reduce the stigma and other barriers, specialist services and talking therapies are co-located in primary care settings, and some PHOs employ psychiatrists and psychologists directly.
To improve self-care by people with chronic physical and mental health problems, expert patient groups support people to cope better with day-to-day problems, and reduce the need for hospital admissions in high-risk groups.
Strategies to promote health and prevent illness
To support early intervention, a range of screening tools is used prior to a consultation; some are integrated into patient management systems, to identify individuals at risk, or those who could benefit from a brief intervention and/or self-management e-therapies.
Practice nurse training is available to build confidence in the use of these tools.
To build resilience in children, the Mental Health Foundation provides mindfulness training in 20 schools based on the approach validated by Harvard Health.
The same techniques are integrated into e-therapies for wider use.
Primary care also works with the foundation and local government in Christchurch on the "All right" campaign to support post-earthquake recovery and in Auckland to reduce alcohol-related harm.
To increase support for children and families at risk, primary care refers them to parenting support and some PHOs also deliver services based on the whanau ora approach.
Better IT, evidence and research
To provide better coordinated support and to evaluate services, new information systems are in place. Integrated electronic patient records in a number of districts enable shared care and access to online referrals.
PHOs can monitor their populations' clinical improvement based on the support provided. The pilot of "real time electronic feedback" of the experience of service users and their family/whanau in primary care and specialist services provides information to drive service improvements and has the potential to be rolled out nationally.
Many obstacles still to be negotiated
There is an urgent need to improve the health literacy levels in the general population.
Understanding what contributes to mental health and addiction problems and how to recognise them is critical for people to seek appropriate help and to support others.
There are limited publications available to give patients the treatment options available to support recovery, including relevant information on medicines and recommended talking therapies available on-line and face-to-face. Without this information, individuals cannot engage in leading their own recovery.
The prescribing of psychotropic medication continues to increase annually.8 This raises concerns around medicalisation of distress and the safe use of medicines, and requires further consideration.
There is good evidence for the effectiveness of talking therapies, but access to them is not available to everyone who could benefit.
If New Zealand adopted the international movement to ensure "parity of esteem" for people with mental health and addictions problems compared with those with physical health problems, it would ensure access to a full range of effective interventions by those in need.
Finally, while there are many exemplary and innovative services in primary care, they should all undergo evaluation to identify those providing the greatest value.
By replicating initiatives that also meet the local needs, we will continue to make progress towards achieving mental health for all.
Dr Lynne Lane
Mental Health Commissioner
NZ Doctor, 27 August 2014