Call for stepped-care approach to mental health

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Current models of mental-health care do not adequately cater for comorbidities, Australian experts say

Current models of mental-health care do not adequately cater for the complexity and comorbidities of patients in primary care and need to be reformed, Australian mental health experts say.

As part of the federal government’s mental-health reform agenda, PHNs have been asked to develop and implement a “stepped-care approach” to mental-health service delivery.

This asks doctors to tailor interventions based on whether patients have mild, moderate and severe mental illness.

“In primary care, general practitioners … will need to assign individuals to these broad categories without clear criteria of what exactly constitutes, for instance, a moderate versus a severe illness,” the authors of a recently published editorial said.

Stepped-care models were based on providing low-intensity treatments as an early step and only providing more intensive treatment if the patient failed to respond or the symptoms worsened, the paper’s authors, clinical services director at the Brain and Mind Centre, Shane Cross, and prominent mental-health advocate, Professor Ian Hickie, said.

However, the fluctuating nature of mental illness has meant that many patients are treated with “watchful waiting” as a first step.

Given the boundary between normalcy and disorder was poorly defined, waiting for full-threshold disorders excluded large numbers of people who were functionally impaired, they added.

This caused treatment delays for people in distress, who had often already delayed seeking support, maybe for years, the authors wrote.

“It would be difficult to imagine a cancer service directing consumers with established illness to a watchful-waiting step,” they said.

Other models of mental-health care currently in operation are also flawed.

Commonly these focus on single disorders, such as depression or anxiety, excluding people with more complex needs.

“For example, the term ‘depression’ is applied to a heterogeneous group of patients who have may vastly different treatment needs,” Mr Cross told TMR.

“Comorbidity is the rule, rather than the exception.”

Models of care that focussed on single disorders ignored the complexity of these patients’ needs, arguably resulting in undertreatment, they said.

Instead, a new model of “transdiagnostic” stepped care, developed in the primary care youth service Headspace, should be implemented more widely among adults,.

This new framework emphasises the need to intervene when people have subthreshold disorders and offer interventions increasing in intensity, cost and time as the severity increases.

The spectrum of services ranges from self-managed online interventions, clinician-supported online interventions, group-based psychological interventions, brief face-to-face psychological therapy, longer-term psychological therapy, case management, first- and second-line medication and secondary mental health services.

“Reform of the mental-health system to provide interventions based on severity and need across the lifespan will require clinical models that are specific, flexible and inclusive,” the authors said.

Public Health Res Pract 2017; online 27 April 

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