489173

2013
ANP47610.1177/0004867413489173ANZJP PerspectivesHarris and Boyce

Editorial

Australian & New Zealand Journal of Psychiatry

Why do we not use psychosocial

47(6) 501­–504
DOI: 10.1177/0004867413489173

interventions in the treatment of © The Royal Australian and

New Zealand College of Psychiatrists 2013

schizophrenia?
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Anthony Harris1,2 and Philip Boyce1

The treatment of schizophrenia pre- to bear fruit despite considerable simple intervention such as psychoe-
sents a conundrum. Remark­ably, even effort. If this lack of treatment was ducation reduces the need for read-
though we are aware that the major due to the absence of any effective mission and emergency care (Xia
portion of the disability caused by intervention, this apparent misalign- et al., 2011).
schizophrenia is the result of the neg- ment of treatment focus could be In this edition of the Journal, we
ative and cognitive symptoms (Milev understood. However, there are have four commentaries by leading
et  al., 2005), the principle focus of other evidence-based treatments for clinicians and researchers working
treatment has been to reduce the these symptoms. These psychological with psychological and psychosocial
positive symptoms of the disorder. and psychosocial treatments have, in treatments for schizophrenia. They
Negative and cognitive symptoms some cases, been available for nearly document the improvements obser­
limit the ability of the individual to 40 years but their uptake has been ved in a wide range of symptoms,
form relationships, obtain employ- poor. The recently published SHIP interpersonal functioning and voca-
ment, be financially secure and care study found that only a third (36.5%) tional outcomes with these treat-
for themselves independently. People of people with a psychotic illness had ments. Considerable skill resides in
living with a psychotic illness and participated in any community reha- the mental health sector in the provi-
those who care for them rate these bilitation or day programs over 12 sion of these and other psychosocial
problems as their major challenges for months (Morgan et al., 2011). This is treatments; however, little opportu-
the coming year. Along with poor despite 63% of them having obvious nity is given to many mental health
physical health, these problems rank or severe dysfunction in their ability practitioners to use their experience
ahead of symptomatic treatment and to socialise and 32% of them having and training and provide these essen-
access to specialised services (Morgan severe impairment in their ability to tial treatments in public mental health.
et al., 2011). So, notwithstanding the care for themselves. In that same sur- We offer five possible reasons why
importance of treating negative and vey, people with psychosis scored 1.6 this may be so.
cognitive (both neurocognitive and standard deviations below the gen- First, is the ongoing crisis in the
social cognitive) symptoms, our treat- eral population on general cognitive provision of public mental health ser-
ment strategies are still directed ability. There is still a clear gap vices in Australia. Although this differs
towards the short-term pharmaco- between the disability suffered by in extent from state to state, the out-
logical resolution of positive people with schizophrenia and the come from four national mental health
symptoms. care that is provided to meet that plans have not seen overall funding to
The deficits caused by negative need. the sector increase as a proportion of
symptoms are little changed by stand- The role of psychological and psy- the health budget despite clearly
ard antipsychotic medications, includ- chosocial interventions is not limited
ing clozapine, dashing earlier hopes to the treatment of negative and cog- 1Discipline of Psychiatry, Sydney Medical
that the second-generation antipsy- nitive symptoms. Interventions such School at the Westmead Clinical School,
chotics would alleviate them (Leucht as cognitive behavioural therapy for University of Sydney, Westmead, Australia
2Brain Dynamics Centre, Westmead
et  al., 2009). Similarly, the cognitive psychosis are of benefit in the treat- Millennium Institute and the University of
symptoms of schizophrenia are only ment of so-called ‘treatment resistant’ Sydney, Westmead, Australia
improved marginally by antipsychotic hallucinations or delusions (Jones
medications (Sergi et  al., 2007; et  al., 2010) and family therapy has Corresponding author:
Anthony Harris, Department of Psychiatry,
Woodward et al., 2005). Novel phar- long been acknowledged to be useful Westmead Hospital, PO Box 533,
macological approaches to both nega- in reducing relapse rates in schizo- Wentworthville, NSW 2145, Australia.
tive and cognitive symptoms have yet phrenia (Pharoah et al., 2010). Even a Email: anthony.harris@sydney.edu.au

Australian & New Zealand Journal of Psychiatry, 47(6)

502 ANZJP Perspectives

identified needs (Department of their case manager on a weekly basis received (Hickie et  al., 2011, 2012;
Health and Ageing, 2010). The past 20 than those with a case manager from Pirkis et al., 2011a, 2011b).
years have seen a move from inpatient the public mental health system (64% Finally, there are inadequate funds
to community care and a decrease vs 28%) (Morgan et al., 2011). being provided for research into psy-
of inpatient care in specialist psychiat- Third, it is our impression (and that chological and psychosocial interven-
ric hospitals and key centres for of many clinicians) that there has been tions. Funding for mental health
long-term inpatient rehabilitation a loss of experience in the provision of research in general and severe mental
(Australian Institute of Health and these treatments from our public illness in particular remains low
Welfare, 2010; Whiteford and mental health services. The new despite being made a targeted area of
Buckingham, 2005). While this move cohort of mental health professionals research (Christensen et  al., 2011).
to the community is in accord with who have entered the workforce in Treatment research for low preva-
good quality care in addition to being the past 10 years have come into a lence disorders is dominated by phar-
patient and carer preference, suffi- workplace where acute care and phar- maceutical industry research. Without
cient additional resources have not macotherapy dominate the treatment the funding to conduct well-designed,
been directed towards community approach and they have not been able randomised controlled trials into psy-
mental health. Although it is difficult to develop skills in psychological and chosocial treatments, the evidence
to compare figures, the Australian psychosocial treatments. For most base for them withers and experience
Institute for Health and Welfare new mental health professionals, psy- in developing and establishing these
report that while Australia’s esti- chosocial treatments are a theoretical treatments is lost. This treatment-
mated real growth in health spending possibility but not an everyday reality oriented research needs to be bol-
was 5.3% per annum the average rate in the workings of their own team. stered by field-level research into the
of increase in state and territory spe- Furthermore, experienced staff have effectiveness and proper integration
cialised mental health services was begun to lose skills because of the of such treatments into mental health
only 3.4% per annum, albeit over a same concentration on acute care and services. The recently published
shorter time course (Australian risk management. A return to the use McKeon report on Health and Medical
Institute of Health and Welfare, of psychosocial treatments within this Research in Australia emphasises the
2012a, 2012b). The speed and nature sector will require adequate training dearth of such service-level research
of this transfer to community-based and supervision that will need to be in Australia (McKeon, 2012).
resources has varied widely between supported by services. An interesting finding of the SHIP
states, with some states concentrating Fourth, there has been the removal study was the increased provision of
on residential services (e.g. Victoria) of many psychologists from the public services by NGOs. NGOs provided
whilst others have virtually disre- mental health system, where care is over two-thirds of the psychosocial
garded these important facilities (e.g. directed towards the most seriously treatments to people with chronic
New South Wales). ill and to the private health system psychotic disorders in the community
Second, is the emphasis upon acute where the majority of treatment is in Australia, a significant rise over 10
care at the expense of recovery- directed towards depression and anx- years. This change in the provision of
focused services. A comparison of data iety of lesser severity (Australian mental health services is likely to con-
from 1998 and 2010 suggest that while Institute of Health and Welfare, tinue with the growing use of NGOs
access to rehabilitation services overall 2010). The last 7 years have seen a in this role and the emphasis on the
improved with an increase in the num- massive uptake of the Better Access availability of a plurality of services for
ber of people accessing some sort of scheme with virtually all the increase those with a mental illness (Council of
rehabilitation service, usually from a in Medicare Benefits Schedule (MBS)- Australian Governments, 2009). This
non-government organisation (NGO), subsidised mental health services is a development with the potential to
the proportion accessing rehabilitation being due to this program and being increase the depth and choice of ser-
services provided by the public mental paid to psychologists (Australian vices. The attractions of utilising
health services dropped from 19.1% to Institute of Health and Welfare, NGOs are numerous. It engages a
14.5% (Jablensky et  al., 1999; Morgan 2012a). While this is potentially group in the community who are
et  al., 2011). The threat is that com- addressing a gap in our health system, often deeply interested in improving
munity care without sufficient funding allowing people with depression and services due to their own poor expe-
will cause a churn of inadequately anxiety to access adequate treatment, riences of public mental health.
treated patients seen infrequently in it is unclear whether the changes to Providing services with staff who have
the community by case managers. Medicare that have brought about this a ‘lived’ experience of mental illness
There is some evidence of this with redirection of funds are having the or caring for someone with it gives a
those offered case management by desired effect on the overall burden ready bridge into understanding the
NGOs being much more likely to see of illness or the standard of care situation of those receiving care.

Australian & New Zealand Journal of Psychiatry, 47(6)

Harris and Boyce 503

From the point of view of govern- not being able to find their way through President of the Mental Illness Fellowship
ment, costs are contained as staff our complex system. We hope that of Australia
employed by NGOs frequently have the recently announced mental health
training levels that are less than those care coordinating program ‘Partners in References
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national charities and multinational number of basic changes need to Council of Australian Governments (2009) Fourth
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orative government action in mental health 2009–
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minetworks.org.au/). in the private, public or NGO sector. Not letting the ideal be the enemy of the
The trend of increased NGO activ- We recognise the distance that our good: The case of the Better Access evalu-
ity has some downsides. There is a system has to travel before these ser- ation – Reply. Australian and New Zealand
danger that by making such organisa- vices are available consistently across Journal of Psychiatry 46: 581.
tions dependent upon government Australia, but we need to start the Jablensky A, McGrath J, Herrman H, et  al. (1999)
People living with psychotic illness: An Australian
funding for a large proportion of their process as a matter of urgency. study 1997–98. Canberra: Mental Health
turnover that they may be ‘captured’ Branch, Commonwealth Department of Health
by government and rendered quies- Funding and Aged Care.
cent when it comes to their traditional This research received no specific grant
Jones C, Cormac I, Silveira da Mota Neto JI,
advocacy role in the community. et al. (2004) Cognitive behaviour therapy for
from any funding agency in the public, schizophrenia. Cochrane Database of Systematic
Relatively short-term government commercial, or not-for-profit sectors. Reviews (4): CD000524.
contracts make it difficult for NGOs to Leucht S, Corves C, Arbter D, et  al. (2009)
invest in staff training and service Second-generation versus first-generation
Declaration of interest
development. However, training is antipsychotic drugs for schizophrenia: A
essential if the NGO sector is to take Philip Boyce meta-analysis. Lancet 373: 31–41.
Honoraria for speaking: AstraZeneca, Eli McKeon S (2012) Strategic Review of Health and
up a broader role in psychosocial Medical Research in Australia. Consultation Paper.
Lilly, Janssen, Lundbeck, Servier; advisory
treatment provision, as these treat- Canberra: Department of Health and Ageing.
board membership: AstraZeneca, Eli Lilly,
ments need a high level of skills and Lundbeck; consulting fees: Servier; clinical Milev P, Ho BC, Ardnt S, et al. (2005) Predictive
continued supervision if they are to be trials: Brain Resource Company, Janssen,
values of neurocognition and negative symp-
provided competently. Finally, the pro- toms on functional outcome in schizophrenia:
Servier. A longitudinal first-episode study with 7-year
cess of engaging an increased number follow-up. American Journal of Psychiatry 162:
Anthony Harris
of service providers risks further frag- 495–506.
Honoraria for speaking: AstraZeneca, Eli
menting the provision of long-term Morgan VA, Waterreus A, Jablensky A, et  al.
Lilly, Lundbeck; advisory board membership:
care in the mental health sector. Care Eli Lilly, Janssen, Lundbeck; consulting fees:
(2011) People living with psychotic illness 2010.
is already difficult to access and with- Report on the second Australian national survey.
nil; clinical trials: Brain Resource Company, Canberra: Commonwealth of Australia.
out the development of ways to coor- Hoffman-La Roche, Janssen. AH is also the Pharoah F, Mari JJ, Rathbone J, et al. (2010) Family
dinate services many people with President of the Schizophrenia Fellowship intervention for schizophrenia. Cochrane
severe mental illness run the risk of of New South Wales and the Vice Database of Systematic Reviews (12):CD000088.

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Australian & New Zealand Journal of Psychiatry, 47(6)