Resolving the paradox of increased mental health expenditure and stable prevalence

Abstract

A doubling of Australian expenditure on mental health services over two decades, inflation-adjusted, has reduced prevalence of neither psychological distress nor mental disorders. Low rates of help-seeking, and inadequate and inequitable delivery of effective care may explain this partially, but not fully. Focusing on depressive disorders, drawing initially on ideas from the work of philosopher and socio-cultural critic Ivan Illich, we use evidence-based medicine statistics and simulation modelling approaches to develop testable hypotheses as to how iatrogenic influences on the course of depression may help explain this seeming paradox. Combined psychological treatment and antidepressant medication may be available, and beneficial, for depressed people in socioeconomically advantaged areas. But more Australians with depression live in disadvantaged areas where antidepressant medication provision without formal psychotherapy is more typical; there also are urban/non-urban disparities. Depressed people often engage in self-help strategies consistent with psychological treatments, probably often with some benefit to these people. We propose then, if people are encouraged to rely heavily on antidepressant medication only, and if they consequently reduce spontaneous self-help activity, that the benefits of the antidepressant medication may be more than offset by reductions in beneficial effects as a consequence of reduced self-help activity. While in advantaged areas, more comprehensive service delivery may result in observed prevalence lower than it would be without services, in less well-serviced areas, observed prevalence may be higher than it would otherwise be. Overall, then, we see no change. If the hypotheses receive support from the proposed research, then implications for service prioritisation and delivery could include a case for wider application of recovery-oriented practice. Critically, it would strengthen the case for action to correct inequities in the delivery of psychological treatments for depression in Australia so that combined psychological therapy and antidepressant medication, accessible and administered within an empowering framework, should be a nationally implemented standard.

The antidepressant standoff: why it continues and how to resolve it

“…Response rates (symptom reduction of 50% or more from baseline) in aADM arms exceed those in PLA arms, typically by 10-15%. The largest recent meta-analysis of aAD efficacy by Cipriani et al included 522 trials, published and unpublished, comprising 1 16 477 participants and found that ADs had better response rates than placebo, with ORs ranging between 1.37 and 2.13 and an averaged SMD = 0.30, similar to NNT = 8 (Meadows et al, 2019), comparable with other recent meta-analyses (Cipriani et al, 2018). Although treatment settings were often unclear, most trials did not take place in primary care settings.…”

Can loss of agency and oppositional perturbation associated with antidepressant monotherapy and low-fidelity psychological treatment dilute the benefits of guideline-consistent depression treatment at the population level?

“…Loss of Agency refers to loss of self-efficacy, problem solving, and other self-help activities that normally benefit recovery [9]. Without treatment, depressed people often engage independently in selfhelp strategies, such as exercising, increasing pleasant activities, reducing stress, and meditation [15].…”

“…Nowadays, more than 80% of Selective Serotonin Reuptake Inhibitor (SSRI) prescriptions are written by General practitioners (GP)s, who may have fewer empowering strategies in their armamentarium or time to implement those. People in disadvantaged communities might thus be deprived twice over because they tend to receive more AD-monotherapy and less rigorous PT treatment compared to the more comprehensive service delivery of combined AD and empowering psychotherapy in affluent areas [9].…”

Socio-economic disadvantage and resource distribution for mental health care; a model proposal and example application for Victoria, Australia

“…The target group for specialist mental health services is an estimated 3% of the population, concordant with overall population prevalence of VHK-10 scores at 3.6% [6]. While many factors influence psychological distress, the composite SED construct includes many powerful influences on these rates [11] and so has a strong claim to be included in bed distribution [9] and other resource considerations.…”