Commentary 2: Scott Henderson

Abstract

For two months of this year, Australia has been visited by one of the most outstanding individuals in contemporary psychiatry. Most of his time was spent in Victoria in Professor Bruce Singh's Department, with briefer visits to Brisbane and Canberra. For David Goldberg, it was his fourth visit to Australia, and the first since he was knighted in 1997 for his services to mental health.

What is the value of Goldberg's “Impressions”? Like the image in a mirror, they can draw attention to some features of our mental health services — and psychiatric research — that we might not be aware of otherwise. Like a Socratic gadfly, they may cause irritation in some quarters. This could be constructive in the long run: they might pos–sibly help to bring about a change in administrative policy. And they might have value to the historian in a hundred years time, just as Eric Cunningham Dax's “From Asylum to Community” has already done for our younger people. The reader should bear in mind that David Goldberg has been visiting foreign countries and writing reports on other people's mental health services for at least 30 years. So he knows what to look for, where strengths or weaknesses in training or in services can usually be found, and what may occasionally make Governments or policy makers change their thinking. That, and a longstanding close association, made it essential for me that he visit our Centre for Mental Health Research at The Australian National University, and go on to talk in depth with senior policy makers in the Commonwealth Department of Health and Aged Care. After all, Mental Health may not always be in the direct sunlight: it has to be kept among the top health priorities for our Federal and State Governments, and a person of Goldberg's calibre can help in that.

Goldberg saw a great deal in Victoria, including considerable exposure to general practitioners there and in Brisbane. What general practitioners do about the mental health component of their practice has been the principal topic of his research since he worked with its pioneer, Michael Shepherd, in Denmark Hill in the 1960s. It is a topic that is now in the forefront of the reforms that are needed in mental health. Clearly, there is much that Goldberg was not able to see in his two months: what mental health services we have in other rural areas; what is available in the real outback and to a large proportion of our Indigenous Peoples; what is available for children, the elderly and people from very different cultures; and how psychiatrists are distributed across the country in relation to the education and economic circumstances of the population around them. But it is doubtful that the conclusions he has come to would have been much altered if he had seen each of these in detail over many months.

In his Conclusions, Goldberg goes straight to some of the central issues for the advancement of psychiatry in Australia during the century ahead. And some of the issues apply just as much to New Zealand. It is in these matters that our College has to be active if its members are to meet the need being expressed by the general public, carers and consumers, and probably most important of all, the nation's general practitioners. My comments are on a selection of these.

The deskilling of salaried psychiatrists. This is true, and is a very serious matter. I know from my own work as a clinician in Canberra that the range of diagnoses some colleagues deal with is stultifyingly narrow: psychoses and a few severe personality disorders, day after day. Administrators must be helped to appreciate how undesirable this is for all concerned, then do something about it. The other side of the deskilling phenomenon is captured in Goldberg's chilling comment: “It may not have been the intention of the Federal Government to prevent Australians without private means from obtaining treatment for non-psychotic conditions from public sector services — but that is what has been achieved” (my italics).

Can working conditions in public psychiatry be improved? Probably yes. Firstly, this will require the availability of outstandingly good personal models — people who have excelled in certain areas of clinical practice, but who are not academic staff. Some countries have such people in considerable numbers, but they are currently rare here. John Cade was one. Australia has many outstanding salaried specialists in, for example, cardiology, endocrinology and gastroenterology, but few in psychiatry. We must ask why this has come to be. Achieving better working conditions will also require that trainee psychiatrists, intending to work at least part-time in the public sector, learn to work with administrators whose education has been even narrower than our own, whose professional mission is to reduce costs, to take over in the dominance hierarchy, and who are not favorably inclined towards doctors in general. Such people do exist in many States or Territories, and all seem to have had a great deal of assertive training. But they are here to stay, as in many other countries, and it is possible to reach a modus vivendi with them. A manageable caseload and continuing professional development in clinical psychiatry will also help. Lastly, salaries are uncompetitive with alternative career choices.

Clinical psychologists vary greatly in the quality of their training in Australia, and in particular in their postgraduate experience in the whole range of mental disorders. But Goldberg is absolutely right that those we have in the public sector are wrongly deployed as so-called case managers. They have specialised training and skills to offer where these are greatly needed They also need to be made much more accessible to general practitioners and their patients. This is simply because they can deliver treatments for which there is solid evidence for effectiveness. General practitioners are themselves very clear that they want to work with clinical psychologists. But most people cannot afford $100 or more per visit, non-reimbursable, to have non-pharmacological treatment of common anxiety disorders, depression and alcohol misuse.

Psychiatrists from other countries. I am glad he has spoken out about this. It is a moral problem, one that I have personally considered at times. Whatever it cost financially and intellectually to train me in Aberdeen and Edinburgh has never been returned in kind to Scotland. Probably Scotland can afford such exports. But India cannot! So should the Australian Government refund India for having trained the psychiatrists who now provide essential mental health services across the country?

Who will do something about our lack of day hospitals and rehabilitation centres? These are indisputable deficiencies. They were one of the most significant findings in the recent national study of people with psychoses by Jablensky et al.[1] Action is needed on this in each State and Territory.

Support for general practitioners. There is universal agreement among Australian general practitioners that they cannot obtain advice or a direct consultation for patients causing them concern — unless they and the patient wait for many weeks. This is not the case in other medical specialties. Goldberg correctly says the only exceptions are when some special relationship exists between a general practitioner and a psychiatrist. The lack of support for our GPs cannot be allowed to continue. It is a matter which I hope the Federal Government will now act to correct, possibly in concert with the National Depression Initiative.

General practitioners need — and many are keen to obtain — training in recognising and treating mental health problems. Goldberg told me it is not true that general practitioners necessarily need 30 to 40 minutes with such patients. With training, it is possible to control the consultation to within 15 minutes. But this is not to be achieved by a talk from an expert over a dinner. It can be acquired only by hands-on training, with video footage of the general practitioner's performance and subsequent discussion with colleagues. Goldberg himself has pioneered the development of teaching methods and packages, but there is every reason for us to develop our own here. We have already sent for the two kits he referenced.

CONCLUSION

These “Impressions” make an important statement. Goldberg points to issues that our Royal College has begun to tackle constructively, to its great credit. My own belief is that there will have to be changes in what psychiatrists choose to do; and there will also have to be changes at the Federal and State levels in how mental health care is given to the Australian public, currently at an annual cost of about $2.2 billion of taxpayers' money. Without some of the changes in areas Goldberg has identified, I predict that peak bodies within the general community, along with our own general practitioners, will tolerate the current situation no longer. This will be one of the consequences of the increasing public visibility of mental health issues in this and so many countries. Lastly, what Goldberg has written about is almost all about services. He has said little about Australian psychiatric research. The current state of research in the huge expanse that Psychiatry now encompasses deserves its own objective critique to help guide research policy and the development of an adequate infrastructure through the National Health and Medical Research Council.

References

1. Jablensky

McGrath

Herrman

. Psychotic disorders in urban areas: an overview of the Study on Low Prevalence Disorders. Australian and New Zealand Journal of Psychiatry 2000; 34: 221–236.