Direct access to specialists tied to major mental health harms

5 minute read

Remove GPs from the mental health referral pathway at your peril, if you don’t at least double specialist service capacity.

Removing GPs from the mental health care pathway without increasing the service capacity of specialist care leads to poorer outcomes, including longer waiting times, increased emergency department presentations, increased self-harm hospitalisations and increased deaths by suicide, according to new research.

A modelling study by Dr Sebastian Rosenberg, senior lecturer in mental health policy at the Sydney Brain and Mind Centre, and colleagues tested the effect of providing direct access to specialist mental health care for 10-50% of patients.

Removing the need for a referral from GPs and other medical practitioners led to “unexpected effects”, such as substantial increases in mental health-related emergency department presentations, they found.

“One might think that creating this kind of direct access might actually set the platform for better access,” Dr Rosenberg told TMR.

“In fact, what the modelling showed was there were unintended consequences that arose because of removing the GP role,” he said.

“That has implications for waiting times, which then leads people to become frustrated and disengaged. That means people may become lost and choose not to pursue care. It also meant that people were more likely, when they did receive care, they start from a point of higher psychological distress.”

The research team, which included mental health advocate Professor Ian Hickie, found that across a seven-year period, a 10% increase in direct access would lead to almost 2500 more mental health-related emergency department visits.

If this proportion jumped to 50%, the number of visits would rise to almost 12,500. Similarly, self-harm hospitalisations were predicted to rise by 100 cases if 10% more people had direct access, and almost 500 cases if 50% more people did. Deaths by suicide rose by 14 people if 10% more Australians had direct access and 67 people if 50% more did.

“According to our model, these unexpected effects were attributable to direct access causing longer waiting times for appointments with psychologists and other specialist providers, leading to disengagement, psychological distress, and poorer mental health outcomes,” Dr Rosenberg and colleagues wrote.

These harms could be offset if Australia was able to grow its number of available specialised mental health care consultations with psychologists, psychiatrists and mental health allied workers, the researchers wrote.

But the benefits were small.  

“Doubling the annual growth in consultations was projected to prevent 7083 mental health-related ED presentations, 326 hospitalisations with self-harm, and 43 deaths by suicide across seven years,” they predicted.

“Increasing it fivefold would prevent 12,806 ED presentations, 562 hospitalisations, and 78 deaths by suicide, and was forecast to reduce the prevalence of moderate to very high psychological distress in 2028 from 40.24% to 39.48%.”

The best results came when the researchers combined both strategies.

“If direct access to 50% of consultations for people seeking help was combined with a fivefold increase in service capacity growth, the proportions of mental health-related ED presentations averted during 2021–2028 increased from 1.73% (increased capacity alone) to 3.60%, of averted hospitalisations with self-harm from 0.89% to 1.90%, and of averted deaths by suicide from 1.1% to 2.1%,” Dr Rosenberg and colleagues wrote.

“Providing direct access to Medicare-subsidised mental health care improves population mental health outcomes only when combined with large increases in specialist mental health care service capacity.”

Dr Rosenberg told TMR it was likely that that cutting the GP or other “gatekeeping” referrer removed a layer of interim care that might be beneficial before somebody could get an appointment with a psychologist or psychiatrist.

“Some people’s relationships with their GPs are profound and intimate, and they rely on them, not merely for the management and consideration of their mental health issues, of course, but for a plethora of physical issues, which are quite common with people with mental illness. Removing that potentially creates other problems and other issues,” he said.

“The real question for me, which arises from this is, what is it we actually want GPs to do? And how can we facilitate their role in effective, holistic mental health care?

“There would be opportunities, particularly for people with severe and complex mental illnesses or complex sets of illnesses, that we wouldn’t want to lose by simply trying to concentrate this in the mental health system,” he said.

The problem, he contended, was a lack of clarity around the delineation of roles from a policy-making perspective.

“It’s the lack of a model of care that really underpins our concerns about the role of all health professionals. There is a lack of role delineation and a lack of role clarity, which means that if I was a patient, I wouldn’t really know the difference between receiving care from a registered psychologist, a GP, a clinical psychologist or an allied health professional.”

Dr Rosenberg said the bottom line was that you can’t make a better system by changing elements of it in isolation.

“There is no doubt that we need more mental health professionals,” Dr Rosenberg told TMR. “What qualifies as a mental health professional bears some scrutiny and inspection as part of the role delineation.

“We really have to have a broader discussion, not just about the number of people we have, but how they work together, how they’re organised, how what they do is monitored and assessed. And what that implications are for the mental health of individuals as they as they track through their episode of illness.

“What does that mean for what happens to them if they get better? Or if they get worse?

“In my view we don’t have those models of care adequately described.”

MJA 2023, online 17 April

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