By Dr Neil Thomas MAPS, Southern Health and Monash University, Melbourne and Associate Professor John Gleeson MAPS, Department of Psychology, University of Melbourne and Northwest Mental Health, a program of Melbourne Health.
Psychological interventions for individuals with severe and enduring mental health disorders have traditionally been provided by clinical psychologists working in public sector mental health services. However, the recent introduction of Medicare rebates for psychological interventions has led to local discussions amongst senior psychologists in Melbourne via the Heads of Psychology Group about the feasibility and appropriateness of these interventions being provided by independent practitioners. Here we take the opportunity to evaluate this possibility, taking into account the needs of this group of consumers.
Psychological treatment approaches have become well-established in the treatment of severe mental illness. A recent meta-analysis identified 34 randomised controlled trials of cognitive behavioural therapy (CBT) with schizophrenia, and concluded that it is effective in bringing about improvements in overall mental state, the severity of positive psychotic symptoms such as hallucinations and delusions, and comorbid depressive symptoms (Wykes et al., in press). Similarly, in bipolar disorder, a number of trials have found psychological treatments to be effective in reducing the rate of relapse (Beynon et al., 2008). In response to this strong evidence base, major clinical practice guidelines for schizophrenia and bipolar disorder have recommended that psychological treatments are provided on a routine basis (e.g,. Royal Australian and New Zealand College of Psychiatrists, 2004, 2005).
However, although those with the most complex needs are seen by public mental health services, many clients with diagnoses of psychotic or bipolar disorders are managed by private psychiatrists or general practitioners under the Medicare system. Prior to 2006, without corresponding access to rebates for psychological treatment, such clients would be unable to access recommended psychological treatments without paying, a substantial barrier given high levels of unemployment and poverty in this client group. The subsequent introduction of Medicare rebates for psychological treatments has great potential to make evidence-based treatments accessible more broadly and equitably for those with severe mental health problems, as it has already demonstrated for those with high prevalence disorders such as depression.
Medicare rebates are limited to 12 sessions per year (six further sessions are possible only in ‘exceptional circumstances'), so an initial consideration is whether a standard intervention of this length is sufficient in treating more severe and complex problems. Between acute episodes, clients often present with multiple chronic and comorbid problems, the full range of which could not be addressed within such a brief course of therapy. However, interventions focused upon specific areas of need might be possible. For example, a common focus for treatment is managing medication-resistant psychotic symptoms, for which CBT for psychosis is well established. Compared with the total duration of standard CBT for depression and anxiety, this treatment can be lengthy. The engagement and assessment process may span several sessions whilst the therapist attempts to navigate problems including suspiciousness, variable insight, idiosyncratic delusional systems and perceptual experiences, and problems with attention and volition. Cognitive restructuring also tends to progress at a slow and gradual pace, due to the need to avoid jeopardising rapport by challenging delusional material too directly. In randomised controlled trials, courses of CBT for chronic psychosis have usually been between six and nine months (Zimmerman et al., 2005).
Nonetheless, it may be that significant gains can be achieved within 12 sessions. Briefer formats of CBT for psychosis based upon normalisation (Turkington et al., 2002) and coping enhancement approaches (Tarrier et al., 1998) have been found effective; relapse prevention approaches for bipolar disorder also fit within the 12 session format (Beynon et al., 2008); and treatments for comorbid anxiety and depressive symptomatology - highly prevalent in this population - might also be effectively delivered within this timeframe. It therefore seems that whilst the cap of 12 sessions restricts the comprehensiveness of intervention possible, it does have scope to provide treatments which, for some clients at least, would be clinically important.
Another consideration is how well treatment is suited to provision by private Medicare providers. Independently practising psychologists may have had little training or experience in this field of work, and may not have access to supervision in this area. There may also be significant disincentives for independently practising psychologists to extend their practice to encompass people with severe mental health problems, associated with high rates of non-attendance and difficulties with engagement.
Indeed, the feasibility of providing psychological treatment using the Medicare system seems largely dependent upon the ease of engaging an individual client. Treatment for severe mental illness often requires an assertive approach to engaging clients who may be disabled by negative symptoms, paranoid, and lacking insight into the nature of their difficulties. Mental health team-based clinical psychologists, who work alongside case managers or in a case management role, are in a position to actively engage clients, which is less feasible within a private practice referral model. In the public sector, they also have the flexibility to see clients for longer periods when indicated. Even in situations where clients cannot be engaged in formal treatment, team-based psychologists can offer consultation to case managers on minimising the impact of psychotic symptoms and strategies to reduce the risk of relapse. In contrast, the private Medicare system seems suited primarily to those clients who are likely to be readily engaged in formal therapy, attend regularly and benefit from a time-limited focused intervention.
Overall, it appears that Medicare-based service provision may be suited only to a subset, rather than the full range, of clients. Furthermore, there may need to be different models of service delivery for those clients outside the public system, which provide support for the training and supervision needs of therapists, and which promote the prioritisation of this client group.
The first author has piloted one possible model of working in a specialist ‘Voices Clinic' providing psychological treatment for people with auditory hallucinations. Attached to an academic department with local expertise in the psychological treatment of psychosis, this clinic was set up as a specialist service taking referrals throughout Melbourne. Experience in this clinic was that many clients could be engaged in treatment with an independent service, with preliminary outcome data that a 12-session format of intervention could produce significant improvements in symptoms. Other models of working may also be possible, such as psychologists from public mental health services having a proportion of their time dedicated to using their expertise to see Medicare-funded clients.
In informing the development of such initiatives it will be useful to obtain data on the clinical characteristics of clients with severe mental illness outside the public system, a key issue being to determine how many clients in need of psychological treatment would be amenable to Medicare-based service delivery. Indeed, it is unclear how many clients might fall between the two types of provision - not having sufficient case management needs to fall within the remit of public mental health services, yet not able to be engaged or effectively treated within a less flexible, private Medicare-funded system. Research is required to clarify this issue, but in the meantime there appears potential to increase the availability of therapy to at least a proportion of clients with severe mental illness.
|Common treatment targets in severe mental illness|
|Factors in considering appropriateness of clients for private Medicare-funded services|
|Suited to private Medicare system||Requiring public mental health team provision|
Beynon, S., Soares-Weiser, K., Woolacott, N., Duffy, S., & Geddes, J.R. (2008). Psychosocial interventions for the prevention of relapse in bipolar disorder: Systematic review of controlled trials. British Journal of Psychiatry, 192, 5-11.
Royal Australian and New Zealand College of Psychiatrists (2004). Australian and New Zealand clinical practice guidelines for the treatment of bipolar disorder. Australian and New Zealand Journal of Psychiatry, 38, 280-305.
Royal Australian and New Zealand College of Psychiatrists (2005). RANZCP clinical practice guidelines for the treatment of schizophrenia and related disorders. Australian and New Zealand Journal of Psychiatry, 39, 1-30.
Tarrier, N., Yusupoff, L., Kinney, C., McCarthy, E., Gledhill, A., Haddock, G., & Morris, J. (1998). Randomised controlled trial of intensive cognitive behaviour therapy for patients with chronic schizophrenia. British Medical Journal, 317, 303-307.
Turkington, D., Kingdon, D. & Turner, T. (2002). Effectiveness of a brief cognitive-behavioural therapy intervention in the treatment of schizophrenia. British Journal of Psychiatry, 180, 523-527.
Wykes, T., Steel, C., Everitt, B., & Tarrier, N. (in press). Cognitive behavior therapy for schizophrenia: Effect sizes, clinical models and methodological rigor. Schizophrenia Bulletin.
Zimmerman, G., Favrod, J., Trieu, V.H., & Pomini, V. (2005). The effect of cognitive behavioural treatment on the positive symptoms of schizophrenia spectrum disorders: A meta-analysis. Schizophrenia Research, 77, 1-9.