What about primary care mental health services?

Imagine that your doctor has referred you to the local heart outpatients unit for an assessment because your blood pressure and cholesterol levels appear to be dangerously high.  You are assessed, and told that your levels are indeed dangerously high.  However, because of the shortage of resources for heart disease, you are not eligible for any treatment.  Only if you were to have a heart attack or a stroke would you be entitled to treatment.

You might be angry about this.  Indeed, you would be more angry if you discovered that there was a range of National Institute for Health and Clinical Excellence (NICE) approved early interventions that should have been available from your GP to prevent your blood pressure and cholesterol getting dangerously high, but because of a shortage of resources, the GP hadn't made these available.  The GP would no doubt understand your anger, but would point out that as things stand, services are only available via the heart unit, and because all of their resources are taken up dealing with today's heart attacks, preventating future heart attacks is out of the question.

Actually, heart disease patients are informed and assertive.  If they faced such a situation, they would arrange for patients to camp outside the door to the Health Minister's office until such time as the government provided appropriate resources. 

People with depression, on the other hand, tend not to be assertive (low self-esteem and confidence are symptoms of the condition).  The Sainsbury Centre for Mental Health has referred to them as "The Neglected Majority", as they account for the majority of the 1 in 10 people who have mental illness at any time, but receive less than 10% of the resources afforded to mental health.  Indeed, most of the resources devoted to this group are spent on the purchase of antidepressant drugs to carry out what the Independent referred to as "medicalising social problems on a mass scale".  While the £21.5million cost of antidepressants may seem high, it is worth noting that antipsychotic drugs cost nearly as much (£19.8m) to treat far fewer people (antispychotic drugs are more than 400% more expensive than antidepressant drugs).  Furthermore, whereas antidepressants are often the only treatment available to people with depression, the cost of antipsychotic drugs pale into insignificance against the cost of providing labour-intensive support services to the minority of people who need specialist mental health services.  In Wales, most of the mental health spend goes on sustaining a handful of big, antiquated mental hospitals (and the social care for their "revolving door" patients).

Just as nobody is suggesting that we stop providing resources to treat heart attacks, I am not suggestive that we should not provide specialist mental illness services to the 0.6% or so of us that have complex, enduring and severe mental illness.  What I am saying that talking about serving "1 in 4 of the population" while providing 95% of the resources to specialist services and the pharmaceutical industry is an abuse of people with common mental illness like depression.

The last thing we want is "more mental health services".  What we need is different mental health services aimed specifically at the 90% of patients who are (or should be) treated solely in primary care.  Some of these are already approved by NICE, and include books on prescription, exercise on prescription, ecotherapy, CBT, counselling, Mindful CBT, Computerised CBT, guided self-help.  These should be supplemented by third sector support with information, self-management training, housing support, employment support and relationship counselling.  They should also tie into broader health promotional initiatives around exercise, health eating, social engagement, and smoking, alcohol and drug cessation.

But as long as all of the resources are lumped into one pot called "mental health", and as long as GPs have to go cap in hand to psychiatrists to access simple talking therapies, the message is likely to remain, "let them eat Prozac!