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The term “mental health crisis” was originally defined as an emergency that poses a direct and immediate threat to an individual’s emotional wellbeing. The definition has been expanded to refer to problems in community mental health and in mental health services (MHS) as a whole. A mental health crisis has been widely used to describe the state of New Zealand’s mental health. For example, recent headlines include “New Zealand mental health crisis as Covid stretches a struggling system”[[1]] and “New Zealand mental health crisis has worsened under Labour, data shows,”[[2]] suggesting deteriorating mental health in the population and an overwhelmed health system.

This paper sets out to test the veracity of these headlines. First, we will present data on whether rates of mental distress and the use of services are increasing in New Zealand. Second, we will consider the mental health system’s response to evaluate whether it has been effective. Third, we will consider where the limited available resources could most effectively be used.

We conclude that New Zealand’s mental health planning is heading in the wrong direction by directing resources and thus services away from people with serious mental illness who are often affected by social exclusion and deprivation. The current government’s plans, yet to be implemented, will expand psychotherapy to the “middle class,” an approach labelled as the “Big Community.”[[3]] Evidence from both the UK and Australia indicates that such initiatives might not reduce population distress in New Zealand, as intended. Instead of spending on programmes for moderate psychological distress, we suggest that the limited resources available for mental health should be carefully targeted towards those with serious mental illness, using integrated services located in areas with the highest levels of deprivation, which is often determined by ethnic, cultural and historical factors.

Is there a mental health crisis?

Two major approaches have been used to measure mental health (or illness) in New Zealand. The first is to study service use. Publicly available MHS data lag behind the headlines about the ongoing impact of the COVID-19 pandemic. The latest data are from 2017/18 and published in 2021.[[4]] The figures may not be directly comparable to previous reports due to increasing non-government organisations reporting, resulting in some inflation of numbers. Nevertheless, the figures are the most accurate guide available. They show that increasing numbers of New Zealanders have been accessing MHS over the past decade. In 2017/18, 181,924 patients were seen by mental health and addiction services. The rate of increase since 2008/9 in non-Māori is 47% (1,931.5 to 2,840 per 100,000) and in Māori it’s 26% (4,119.7 to 5,201.2 per 100,000), the latter from a higher base rate. Anecdotally, it appears that the rate of increase has continued to rise since these figures were published. There is also significant pressure and significantly increasing demand for acute mental health beds, despite increased service provision in primary care and the community.

The second approach to measure mental health is the use of population surveys. We are fortunate in New Zealand to have the NZ Health Survey, an annual health survey performed in a random general population and which includes measures of mental health. The measure most sensitive to change in psychological distress is assessed using the K10 scale. The survey publishes the percentage with a very high probability of depressive or anxiety disorder, that is, a K10 score of 12 or higher. This percentage has steadily grown from 4.5% in 2011/12to 8.6% in 2017/18 .[[5]] However, the rates now appear to have stabilised at 7.4% in 2019/20. Rates of diagnosed mental disorder, such as major depression and anxiety, have also stabilised over the past four surveys following steady increases between 2011/12 and 2016/17. Rates of hazardous or heavy drinking have also been stable since they were first measured in 2015/16.

A further plausible measure of mental health is the suicide rate. The latest data from the Office of the Chief Coroner reported that 654 people had died by suicide in the year July 2019 to June 2020, which equates to 13 deaths/100,000, a decrease from both the 2017/18 (13.7 deaths/100,000) and 2018/19 (13.9 deaths/100,000) figures.[[6]]

We should also consider the World Happiness Report conducted by Gallup. In this report, New Zealand ranks highly on wellbeing, having come ninth out of 149 countries on overall happiness measures (average life evaluation) in 2020. This is similar to its ranking and overall score between 2017 and 2019, in which New Zealand ranked eighth.[[7]]

So, what has been happening to MHS funding? Like most high-income countries, spending has increased; in New Zealand, mental health funding rose from NZD 1.1 billion in 2008/09 to 1.4 billion in 2015/16. The number of psychiatrists and psychologists almost doubled from 2005 to 2015.[[8]] More people are taking psychotropic medications than ever before. In 2015, PHARMAC data reported that 13.7% of New Zealanders have been dispensed antidepressants and 3.1% antipsychotics. Both rates have increased by more than 50% over the prior decade.[[9]] However, over this same period, psychological distress was worsening rather than improving. It seems that increasing resources was not accompanied by any evidence of improved mental health at a New Zealand-wide level. We can derive some comfort from the fact that most high-income countries report similar findings. A recent review by Jorm et al[[10]] noted that the prevalence of mood and anxiety disorders has not decreased in Australia, Canada, England or the USA, despite substantial increases in the provision of treatment in the four countries.

We therefore have a somewhat mixed picture before the COVID-19 pandemic. The use of MHS appeared to be increasing while the community rates of psychological distress had been levelling off after a major increase in the first half of the last decade. Overall happiness and life satisfaction measures have been stable since the beginning of 2010. It’s hardly good news. But it’s also inaccurate to say there’s a “mental health crisis” in New Zealand. The major crisis, if there is one, may be in gaining access to MHS, which are having to manage increasing numbers of patients. This is consistent with international epidemiological research pointing to a high, but relatively stable, incidence and prevalence of mental disorder, coupled with evidence that more and more people are using MHS and consuming psychotropic medication.[[11]]

Although we may not have a mental health crisis in the traditional sense of increasing rates of psychological distress, mental disorders and suicide, we do have a crisis in the sense that demand for MHS is increasing and that the expansion of those services and treatments is not leading to improvements in mental health at a community level. To add to the confusion, we have experienced a major epidemic in the past year. The impact of COVID-19 on mental health is not yet clear. New Zealand is relatively unique in that the impact and experience of COVID-19 is around a brief strict lockdown and the post-lockdown economic effects rather than the direct effects of the virus. Early evidence suggests a significant proportion of the population was adversely affected by the lockdown—particularly young people.[[12]] However, our experience may be very different from those countries where the direct effect of the virus was much greater.

The He Ara Oranga Report

Partly in response to the perceived mental health crisis, the New Zealand government set up a commission that produced the He Ara Oranga (HAO) Report in 2018.[[3]] The government, in response to the HAO Report, announced a $1.9 billion mental health package in their Wellbeing Budget.[[13]] The report correctly recognised that doing more of the same was not a good strategy, given the evidence discussed above.

The HAO Report suggested two major ways to improve New Zealanders’ mental health. The first, which could be seen as a preventative strategy, is based on individual psychological therapies like Cognitive Behavioural Therapy. This “Big Community” policy seeks to extend psychological treatment to those suffering psychological distress so that around 6.5% of the population (325,000 people per annum) with mild to moderate anxiety and depression will receive an intervention (Wellbeing Budget 2019).

In our view, there are two major flaws in this strategy. The first is how it would be organised and funded. It would be difficult, perhaps impossible, to train sufficient staff to implement such a programme. At the current rate of training psychologists and counsellors, it is estimated that it will be more than a decade before the workforce is sufficient to meet the current need.[[14]] In addition, at present only a small proportion of those diagnosed with a mental disorder actually receive psychological treatment—so why would (or should) less severe individuals be prioritised?

The second flaw is that similar, albeit less ambitious, programmes have been initiated in Australia (Better Access; 4.7% population coverage) and the UK (Improving Access to Psychological Therapies: IAPT; 1.5% population coverage)[[16]] and the results are not encouraging. In Australia, a recent review reported no impact on population mental health outcomes or suicide rates,[[15]] and the introduction of IAPT in the UK has not been associated with a reduced prevalence of common mental disorders (based on the Adult Psychiatry Morbidity Survey). On the contrary, these disorders have continued to increase.[[16]] Given this evidence, we are concerned that there appears to be no systematic plan to assess the efficacy of the proposed psychotherapy programme.[[17]]

The second major strategy in the HAO Report recommends a decisive shift from Big Psychiatry to a new sector called “Big Community.” This sounds good, that is, moving away from a medically led system where “most resources are used for psychiatric treatments, clinics and hospitals”[[3]] and which the HAO Report labelled as having a colonising world view with a legacy of paternalism and human rights breaches. In contrast, the HAO Report praised Big Community as having a strong commitment to partnership, recovery, spirituality and human rights. This is all very well as far as it goes but runs into a major flaw: “big” psychiatry in New Zealand is actually rather small. For the latest available country data between the years 2016 and 2020, New Zealand was ranked 32nd out of 38 OECD countries for the number of hospital psychiatric beds.[[19]] New Zealand reported 32 psychiatric beds per 100,000 population in 2020 while the OECD average was double that at 65.[[19]] Moving resources from struggling, already under-resourced, public MHS into the community appears a dangerous and an inequitable strategy. We appear to have forgotten that the hospital component of a community health is an essential part of good and balanced practice.[[20]] In addition, we do not appear to have well-resourced community facilities. A recent global report notes that New Zealand, as well as having very low bed numbers, also has the lowest number of community care facilities of all countries surveyed.[[21]] Overall, it would have been more accurate for the HAO Report to have used the term “Small Psychiatry,” which would have helped explain the problems facing the public sector.

Possible responses

1. Serious mental illness: The risk  of following the HAO Report is that we may establish widespread inverse care by tailoring health services for the mild and moderately ill and increasingly neglecting the most severely and chronically ill patients, as has occurred in other English-speaking countries, particularly the USA. Rather than focussing on reducing Big Psychiatry, we suggest that the government increases resources for it and tries to raise psychiatry bed numbers from the current 32 beds per 10,000 to at least 50 beds per 100,000 (OECD average is 65 beds per 100,000).[[22,23]] This is where there is the most need and where those who suffer deprivation are likely to seek help.

To better identify, follow-up and assess treatment outcomes among people with serious mental illness, we suggest that New Zealand is an ideal location for a mental health registry. A useful first step would be to link health datasets between primary, secondary and tertiary mental healthcare to enable mental health service researchers to evaluate the cost–benefit of new policies and investments in reducing hospital demand and improving overall mental health related outcomes. A more comprehensive mental health registry would also link social and non-health related datasets (education, unemployment, housing, corrections) with healthcare datasets at the individual level. This would enable a more comprehensive understanding of the likely bi-directional impact between social and non-health-related policy changes and mental health service utilisation (primary, secondary, tertiary) and outcomes (psychological distress, suicide, etc). Careful consideration of privacy issues would need to be part of database setup. A specific example that New Zealand should consider adopting is the national Danish Schizophrenia Registry, which was first established in 2003 and covers all patients diagnosed with schizophrenia who are receiving mental health care in psychiatric hospitals or outpatient clinics.[[24]] The Danish Schizophrenia Registry contains 21 clinical quality measure in relation to the following domains: diagnostic evaluation, antipsychotic treatment including adverse reactions, cardiovascular risk factors including laboratory values, family intervention, psychoeducation, post-discharge mental healthcare, assessment of suicide risk in relation to discharge and assessment of global functioning.[[24]] This registry also links its data with other national non-health related datasets. The Danish Schizophrenia Registry has been an invaluable tool for clinicians, researchers and policymakers helping to understand and improve the quality of care for this important patient cohort.[[24]]

In conjunction with setting up national mental health registries, consideration should also be given to setting up national mental health service evaluation and research units to analyse the effectiveness of government policy changes and investments. We suggest that approximately 2–3% of existing and new investments in mental health should be allocated to mental health service research and registry investment. Such investment will ensure that new programmes are fully evaluated before endorsing and implementing these measures nationwide.

2. Population distress: In terms of New Zealand’s levels of population distress, rather than reducing Big Psychiatry and offering therapy to all, an alternative strategy is to target resources towards individuals who suffer most from mental distress. Increasing international data has allowed more sophisticated ecological studies to show what factors are associated with psychological distress. These factors are consistent and not surprising: lower incomes, poor housing and unemployment (possibly better expressed as “deprivation”), as well as discrimination, neighbourhood safety, gender equality and corruption.[[25]] None of these appear likely to respond to individual counselling.

New Zealand already has in place some important characteristics of mentally health nations, which we generally take for granted. Our quality of government, assessed using measures of freedom and perception of corruption, is high. Education, lifespan and gender equality are reasonable, albeit with obvious room for improvement.[[25]] Income inequality has increased, but while it negatively affects mental health, the effect sizes are small and inconsistent.[[26]] As we noted, New Zealand is highly ranked in the World Happiness Report.

However, we also have a significant section of the population that suffers from deprivation, and this group has much more psychological distress. Thus, we suggest that resources should be directed towards this group. Data from the New Zealand Health Survey show that those in the most deprived decile were around 30 times more likely than those in the least deprived decile to report a K10 score suggesting clinical anxiety and depression.[[27]] The suicide rates for the lowest quintile in 2016 were two to three times higher than the least deprived quintile.[[28]] These groups are also much more likely to use mental health services; the latest Ministry of Health data on mental health service use report that the most deprived quintile in New Zealand is three to nine times more likely to use various MHS.[[29]]

Since relying on healthcare alone to improve mental health outcomes can be expensive and inefficient, we advocate for integration with social services and practical help. We suggest, as have others,[[30]] that areas associated with higher levels of deprivation should receive more targeted focus in terms of resources, prevention and management of serious mental illness. Specific programmes (particularly supported employment, which has a strong evidence base[[31]]) could be resourced and evaluated. Providing quality care and education early in life and strengthening economic support to families is likely to be associated with fewer adverse childhood experiences.[[32]]

E-therapies may be more practical and efficient for population groups who respond to individual psychological therapies. In recent reviews, e-therapy has appeared superior to no treatment or waitlist controls for patients with depression,[[33]] generalised anxiety disorder, panic disorder and social anxiety disorder.[[34]] Although the effect sizes are modest and tend to fade over time,[[35]] this is similarly true for face-to-face therapies. This may be enhanced by using therapist guided e-therapies.

Conclusion

Although characterising New Zealand’s mental health as being in crisis may be overstating the evidence, there seems little doubt that significant changes in the conceptualisation and delivery of MHS are necessary. Based on the evidence, we suggest that the focus should be on deprivation and the severe mental illness. Rather than expand psychotherapy to middle class New Zealand and further reduce resources to those with serious mental illness, we advocate for better resourced MHS integrated with social services, such as supported employment, supported housing and early interventions. In addition, we suggest locating these integrated services in areas with higher levels of deprivation and that they consider ethnic, cultural and historical factors associated with deprivation. We also support specific investment in mental health registries integrated with service evaluation and policy research units, to ensure that new and existing mental health programme investment delivers better public mental health outcomes and also delivers value for money.

Summary

Abstract

Aim

Method

Results

Conclusion

Author Information

Roger T Mulder: Department of Psychological Medicine, University of Otago, Christchurch, CAN, NZ. Tarun Bastiampillai: College of Medicine and Public Health, Flinders University, Adelaide, SA, Aus. Anthony Jorm: School of Population and Global Health, University of Melbourne, VIC, Aus. Stephen Allison: College of Medicine and Public Health, Flinders University, Adelaide, SA, Aus.

Acknowledgements

Correspondence

Prof Roger Mulder, Department of Psychological Medicin, University of Otago, Christchurch; PO Box 4345, Christchurch 8140, New Zealand; +64 3 372 6700

Correspondence Email

roger.mulder@otago.ac.nz

Competing Interests

Nil.

1. Roy EA. New Zealand mental health crisis as Covid stretches a struggling system. The Guardian (International edition). 2020 9 September.

2. McClure T. New Zealand mental health crisis has worsened under Labour, data shows. The Guardian (International edition). 2021 1 April.

3. Government Inquiry into Mental Health and Addiction. He Ara Oranga: Report of the Government Inquiry into Mental Health and Addiction. Wellington, NZ; 2018 November.

4. Ministry of Health. Mental Health and Addiction: Service Use 2017/18 tables. Wellington, NZ: Ministry of Health (Manatū Hauora). 2021.

5. Ministry of Health. New Zealand Health Survey (NZHS). In: Health Mo, editor. Wellington, NZ: Ministry of Health (Manatū Hauora). 2021.

6. Coronial Services of New Zealand. Annual suicide statistics since 2011 Wellington, NZ: Ministry of Justice, New Zeland Government; 2020 [updated 21 August. Available from: https://coronialservices.justice.govt.nz/suicide/annual-suicide-statistics-since-2011/.

7. Helliwell JF, Layard R, Sachs JD, De Neve J-E, Aknin LB, Wang S. World Happiness Report 2021. Report. New York, NY: Sustainable Development Solutions Network; 2021.

8. Mulder RT, Rucklidge J, Wilkinson S. Why has increased provision of psychiatric treatment not reduced the prevalence of mental disorder? Australian and New Zealand Journal of Psychiatry. 2017;51(12):1176-7.

9. Wilkinson S, Mulder RT. Antidepressant prescribing in New Zealand between 2008 and 2015. New Zealand Medical Journal. 2018;131(1485):52-9.

10. Jorm AF, Patten SB, Brugha TS, Mojtabai R. Has increased provision of treatment reduced the prevalence of common mental disorders? Review of the evidence from four countries. World Psychiatry. 2017;16(1):90-9.

11. Beeker T, Mills C, Bhugra D, Te Meerman S, Thoma S, Heinze M, et al. Psychiatrization of Society: A conceptual framework and call for transdisciplinary research. Frontiers in Psychiatry. 2021;12:645556.

12. Every-Palmer S, Jenkins M, Gendall P, Hoek J, Beaglehole B, Bell C, et al. Psychological distress, anxiety, family violence, suicidality, and wellbeing in New Zealand during the COVID-19 lockdown: A cross-sectional study. PLoS One. 2020;15(11):e0241658.

13. Government of New Zealand. The Wellbeing Budget 2019. Wellington, NZ: Government of New Zealand.; 2019.

14. Rucklidge JJ, Darling KA, Mulder RT. Addressing the treatment gap in New Zealand with more therapists - is it practical and will it work? New Zealand Medical Journal. 2018;131(1487):8–11.

15. Jorm AF. Australia's 'Better Access' scheme: Has it had an impact on population mental health? Australian and New Zealand Journal of Psychiatry. 2018;52(11):1057–62.

16. Bastiampillai TJ, Allison S, Harford P, Perry SW, Wong ML. Has the UK Improving Access to Psychological Therapies programme and rising antidepressant use had a public health impact? The Lancet Psychiatry. 2019;6(3):e8-e9.

17. Bastiampillai TJ, Allison S, Castle D, Beaglehole B, Mulder R. New Zealand's big psychotherapy programme requires evaluation [Editorial]. New Zealand Medical Journal. 2019;132(1502):8–10.

18. Allison S, Bastiampillai T, Castle D, Mulder R, Beaglehole B. The He Ara Oranga Report: What's wrong with 'Big Psychiatry' in New Zealand? Australian and New Zealand Journal of Psychiatry. 2019;53(8):724–6.

19. Health Care Resources [Internet]. 2021 [cited 25 August]. Available from: https://stats.oecd.org/index.aspx?DataSetCode=HEALTH_REAC.

20. Thornicroft G, Tansella M. Components of a modern mental health service: a pragmatic balance of community and hospital care: Overview of systematic evidence. Br J Psychiatry. 2004;185(4):283–90.

21. Perera IM. The relationship between hospital and community psychiatry: Complements, not substitutes? Psychiatric Services. 2020;71(9):964-6.

22. Allison S, Bastiampillai T, Licinio J, Fuller DA, Bidargaddi N, Sharfstein SS. When should governments increase the supply of psychiatric beds? Molecular Psychiatry. 2018;23(4):796–800.

23. O'Reilly R, Allison S, Bastiampillai T. Observed outcomes: An approach to calculate the optimum number of psychiatric beds Administration and Policy in Mental Health. 2019;46(4):507–17.

24. Baandrup L, Cerqueira C, Haller L, Korshøj L, Voldsgaard I, Nordentoft M. The Danish Schizophrenia Registry. Clinical Epidemiology. 2016;8:691–5.

25. Jorm AF, Mulder RT. Characteristics of mentally healthy nations. under review.

26. Ribeiro WS, Bauer A, Andrade M, York-Smith M, Pan PM, Pingani L, et al. Income inequality and mental illness-related morbidity and resilience: A systematic review and meta-analysis. The Lancet Psychiatry. 2017;4(7):554–62.

27. Foulds J, Wells JE, Mulder RT. The association between material living standard and psychological distress: Results from a New Zealand population survey. International Journal of Social Psychiatry. 2014;60(8):766-71.

28. Ministry of Health. Suicide Facts: Data tables 1996−2016 Wellington, NZ: Ministry of Health, New Zeland Government; 2019 [updated 10 January 2020. Available from: https://www.health.govt.nz/publication/suicide-facts-data-tables-19962016.

29. Gibb S, Cunningham R. University of Otago Mental Health and Addiction in Aotearoa New Zealand [Commissioned Report for Government Inquiry into Mental Health and Addiction]. Wellington, NZ: EleMent/Otago University; 2018 July.

30. Lee SC, DelPozo-Banos M, Lloyd K, Jones I, Walters J, Owen MJ, et al. Area deprivation, urbanicity, severe mental illness and social drift - A population-based linkage study using routinely collected primary and secondary care data. Schizophrenia Research. 2020;220:130–40.

31. Marshall T, Goldberg RW, Braude L, Dougherty RH, Daniels AS, Ghose SS, et al. Supported employment: Assessing the evidence. Psychiatric Services. 2014;65(1):16–23.

32. Jorm AF, Mulder RT. Prevention of mental disorders requires action on adverse childhood experiences. Australian and New Zealand Journal of Psychiatry. 2018;52(4):316-9.

33. Ho C, Severn M. e-Therapy Interventions for the Treatments of Patients with Depression: A Review of Clinical Effectiveness [CADTH Rapid Response Report: Summary with Critical Appraisal]. Ottawa, ON: Canadian Agency for Drugs and Technologies in Health; 2018 May 18.

34. Young C, Campbell K, Dulong C. Internet-Delivered Cognitive Behavioural Therapy for Major Depression and Anxiety Disorders: A Review of Clinical zEffectiveness [CADTH Rapid Response Report: Summary with Critical Appraisal]. Ottawa, ON: Canadian Agency for Drugs and Technologies in Health; 2018 Sep 5.

35. Simmonds-Buckley M, Bennion MR, Kellett S, Millings A, Hardy GE, Moore RK. Acceptability and Effectiveness of NHS-Recommended e-Therapies for Depression, Anxiety, and Stress: Meta-Analysis. J Med Internet Res. 2020;22(10):e17049.

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The term “mental health crisis” was originally defined as an emergency that poses a direct and immediate threat to an individual’s emotional wellbeing. The definition has been expanded to refer to problems in community mental health and in mental health services (MHS) as a whole. A mental health crisis has been widely used to describe the state of New Zealand’s mental health. For example, recent headlines include “New Zealand mental health crisis as Covid stretches a struggling system”[[1]] and “New Zealand mental health crisis has worsened under Labour, data shows,”[[2]] suggesting deteriorating mental health in the population and an overwhelmed health system.

This paper sets out to test the veracity of these headlines. First, we will present data on whether rates of mental distress and the use of services are increasing in New Zealand. Second, we will consider the mental health system’s response to evaluate whether it has been effective. Third, we will consider where the limited available resources could most effectively be used.

We conclude that New Zealand’s mental health planning is heading in the wrong direction by directing resources and thus services away from people with serious mental illness who are often affected by social exclusion and deprivation. The current government’s plans, yet to be implemented, will expand psychotherapy to the “middle class,” an approach labelled as the “Big Community.”[[3]] Evidence from both the UK and Australia indicates that such initiatives might not reduce population distress in New Zealand, as intended. Instead of spending on programmes for moderate psychological distress, we suggest that the limited resources available for mental health should be carefully targeted towards those with serious mental illness, using integrated services located in areas with the highest levels of deprivation, which is often determined by ethnic, cultural and historical factors.

Is there a mental health crisis?

Two major approaches have been used to measure mental health (or illness) in New Zealand. The first is to study service use. Publicly available MHS data lag behind the headlines about the ongoing impact of the COVID-19 pandemic. The latest data are from 2017/18 and published in 2021.[[4]] The figures may not be directly comparable to previous reports due to increasing non-government organisations reporting, resulting in some inflation of numbers. Nevertheless, the figures are the most accurate guide available. They show that increasing numbers of New Zealanders have been accessing MHS over the past decade. In 2017/18, 181,924 patients were seen by mental health and addiction services. The rate of increase since 2008/9 in non-Māori is 47% (1,931.5 to 2,840 per 100,000) and in Māori it’s 26% (4,119.7 to 5,201.2 per 100,000), the latter from a higher base rate. Anecdotally, it appears that the rate of increase has continued to rise since these figures were published. There is also significant pressure and significantly increasing demand for acute mental health beds, despite increased service provision in primary care and the community.

The second approach to measure mental health is the use of population surveys. We are fortunate in New Zealand to have the NZ Health Survey, an annual health survey performed in a random general population and which includes measures of mental health. The measure most sensitive to change in psychological distress is assessed using the K10 scale. The survey publishes the percentage with a very high probability of depressive or anxiety disorder, that is, a K10 score of 12 or higher. This percentage has steadily grown from 4.5% in 2011/12to 8.6% in 2017/18 .[[5]] However, the rates now appear to have stabilised at 7.4% in 2019/20. Rates of diagnosed mental disorder, such as major depression and anxiety, have also stabilised over the past four surveys following steady increases between 2011/12 and 2016/17. Rates of hazardous or heavy drinking have also been stable since they were first measured in 2015/16.

A further plausible measure of mental health is the suicide rate. The latest data from the Office of the Chief Coroner reported that 654 people had died by suicide in the year July 2019 to June 2020, which equates to 13 deaths/100,000, a decrease from both the 2017/18 (13.7 deaths/100,000) and 2018/19 (13.9 deaths/100,000) figures.[[6]]

We should also consider the World Happiness Report conducted by Gallup. In this report, New Zealand ranks highly on wellbeing, having come ninth out of 149 countries on overall happiness measures (average life evaluation) in 2020. This is similar to its ranking and overall score between 2017 and 2019, in which New Zealand ranked eighth.[[7]]

So, what has been happening to MHS funding? Like most high-income countries, spending has increased; in New Zealand, mental health funding rose from NZD 1.1 billion in 2008/09 to 1.4 billion in 2015/16. The number of psychiatrists and psychologists almost doubled from 2005 to 2015.[[8]] More people are taking psychotropic medications than ever before. In 2015, PHARMAC data reported that 13.7% of New Zealanders have been dispensed antidepressants and 3.1% antipsychotics. Both rates have increased by more than 50% over the prior decade.[[9]] However, over this same period, psychological distress was worsening rather than improving. It seems that increasing resources was not accompanied by any evidence of improved mental health at a New Zealand-wide level. We can derive some comfort from the fact that most high-income countries report similar findings. A recent review by Jorm et al[[10]] noted that the prevalence of mood and anxiety disorders has not decreased in Australia, Canada, England or the USA, despite substantial increases in the provision of treatment in the four countries.

We therefore have a somewhat mixed picture before the COVID-19 pandemic. The use of MHS appeared to be increasing while the community rates of psychological distress had been levelling off after a major increase in the first half of the last decade. Overall happiness and life satisfaction measures have been stable since the beginning of 2010. It’s hardly good news. But it’s also inaccurate to say there’s a “mental health crisis” in New Zealand. The major crisis, if there is one, may be in gaining access to MHS, which are having to manage increasing numbers of patients. This is consistent with international epidemiological research pointing to a high, but relatively stable, incidence and prevalence of mental disorder, coupled with evidence that more and more people are using MHS and consuming psychotropic medication.[[11]]

Although we may not have a mental health crisis in the traditional sense of increasing rates of psychological distress, mental disorders and suicide, we do have a crisis in the sense that demand for MHS is increasing and that the expansion of those services and treatments is not leading to improvements in mental health at a community level. To add to the confusion, we have experienced a major epidemic in the past year. The impact of COVID-19 on mental health is not yet clear. New Zealand is relatively unique in that the impact and experience of COVID-19 is around a brief strict lockdown and the post-lockdown economic effects rather than the direct effects of the virus. Early evidence suggests a significant proportion of the population was adversely affected by the lockdown—particularly young people.[[12]] However, our experience may be very different from those countries where the direct effect of the virus was much greater.

The He Ara Oranga Report

Partly in response to the perceived mental health crisis, the New Zealand government set up a commission that produced the He Ara Oranga (HAO) Report in 2018.[[3]] The government, in response to the HAO Report, announced a $1.9 billion mental health package in their Wellbeing Budget.[[13]] The report correctly recognised that doing more of the same was not a good strategy, given the evidence discussed above.

The HAO Report suggested two major ways to improve New Zealanders’ mental health. The first, which could be seen as a preventative strategy, is based on individual psychological therapies like Cognitive Behavioural Therapy. This “Big Community” policy seeks to extend psychological treatment to those suffering psychological distress so that around 6.5% of the population (325,000 people per annum) with mild to moderate anxiety and depression will receive an intervention (Wellbeing Budget 2019).

In our view, there are two major flaws in this strategy. The first is how it would be organised and funded. It would be difficult, perhaps impossible, to train sufficient staff to implement such a programme. At the current rate of training psychologists and counsellors, it is estimated that it will be more than a decade before the workforce is sufficient to meet the current need.[[14]] In addition, at present only a small proportion of those diagnosed with a mental disorder actually receive psychological treatment—so why would (or should) less severe individuals be prioritised?

The second flaw is that similar, albeit less ambitious, programmes have been initiated in Australia (Better Access; 4.7% population coverage) and the UK (Improving Access to Psychological Therapies: IAPT; 1.5% population coverage)[[16]] and the results are not encouraging. In Australia, a recent review reported no impact on population mental health outcomes or suicide rates,[[15]] and the introduction of IAPT in the UK has not been associated with a reduced prevalence of common mental disorders (based on the Adult Psychiatry Morbidity Survey). On the contrary, these disorders have continued to increase.[[16]] Given this evidence, we are concerned that there appears to be no systematic plan to assess the efficacy of the proposed psychotherapy programme.[[17]]

The second major strategy in the HAO Report recommends a decisive shift from Big Psychiatry to a new sector called “Big Community.” This sounds good, that is, moving away from a medically led system where “most resources are used for psychiatric treatments, clinics and hospitals”[[3]] and which the HAO Report labelled as having a colonising world view with a legacy of paternalism and human rights breaches. In contrast, the HAO Report praised Big Community as having a strong commitment to partnership, recovery, spirituality and human rights. This is all very well as far as it goes but runs into a major flaw: “big” psychiatry in New Zealand is actually rather small. For the latest available country data between the years 2016 and 2020, New Zealand was ranked 32nd out of 38 OECD countries for the number of hospital psychiatric beds.[[19]] New Zealand reported 32 psychiatric beds per 100,000 population in 2020 while the OECD average was double that at 65.[[19]] Moving resources from struggling, already under-resourced, public MHS into the community appears a dangerous and an inequitable strategy. We appear to have forgotten that the hospital component of a community health is an essential part of good and balanced practice.[[20]] In addition, we do not appear to have well-resourced community facilities. A recent global report notes that New Zealand, as well as having very low bed numbers, also has the lowest number of community care facilities of all countries surveyed.[[21]] Overall, it would have been more accurate for the HAO Report to have used the term “Small Psychiatry,” which would have helped explain the problems facing the public sector.

Possible responses

1. Serious mental illness: The risk  of following the HAO Report is that we may establish widespread inverse care by tailoring health services for the mild and moderately ill and increasingly neglecting the most severely and chronically ill patients, as has occurred in other English-speaking countries, particularly the USA. Rather than focussing on reducing Big Psychiatry, we suggest that the government increases resources for it and tries to raise psychiatry bed numbers from the current 32 beds per 10,000 to at least 50 beds per 100,000 (OECD average is 65 beds per 100,000).[[22,23]] This is where there is the most need and where those who suffer deprivation are likely to seek help.

To better identify, follow-up and assess treatment outcomes among people with serious mental illness, we suggest that New Zealand is an ideal location for a mental health registry. A useful first step would be to link health datasets between primary, secondary and tertiary mental healthcare to enable mental health service researchers to evaluate the cost–benefit of new policies and investments in reducing hospital demand and improving overall mental health related outcomes. A more comprehensive mental health registry would also link social and non-health related datasets (education, unemployment, housing, corrections) with healthcare datasets at the individual level. This would enable a more comprehensive understanding of the likely bi-directional impact between social and non-health-related policy changes and mental health service utilisation (primary, secondary, tertiary) and outcomes (psychological distress, suicide, etc). Careful consideration of privacy issues would need to be part of database setup. A specific example that New Zealand should consider adopting is the national Danish Schizophrenia Registry, which was first established in 2003 and covers all patients diagnosed with schizophrenia who are receiving mental health care in psychiatric hospitals or outpatient clinics.[[24]] The Danish Schizophrenia Registry contains 21 clinical quality measure in relation to the following domains: diagnostic evaluation, antipsychotic treatment including adverse reactions, cardiovascular risk factors including laboratory values, family intervention, psychoeducation, post-discharge mental healthcare, assessment of suicide risk in relation to discharge and assessment of global functioning.[[24]] This registry also links its data with other national non-health related datasets. The Danish Schizophrenia Registry has been an invaluable tool for clinicians, researchers and policymakers helping to understand and improve the quality of care for this important patient cohort.[[24]]

In conjunction with setting up national mental health registries, consideration should also be given to setting up national mental health service evaluation and research units to analyse the effectiveness of government policy changes and investments. We suggest that approximately 2–3% of existing and new investments in mental health should be allocated to mental health service research and registry investment. Such investment will ensure that new programmes are fully evaluated before endorsing and implementing these measures nationwide.

2. Population distress: In terms of New Zealand’s levels of population distress, rather than reducing Big Psychiatry and offering therapy to all, an alternative strategy is to target resources towards individuals who suffer most from mental distress. Increasing international data has allowed more sophisticated ecological studies to show what factors are associated with psychological distress. These factors are consistent and not surprising: lower incomes, poor housing and unemployment (possibly better expressed as “deprivation”), as well as discrimination, neighbourhood safety, gender equality and corruption.[[25]] None of these appear likely to respond to individual counselling.

New Zealand already has in place some important characteristics of mentally health nations, which we generally take for granted. Our quality of government, assessed using measures of freedom and perception of corruption, is high. Education, lifespan and gender equality are reasonable, albeit with obvious room for improvement.[[25]] Income inequality has increased, but while it negatively affects mental health, the effect sizes are small and inconsistent.[[26]] As we noted, New Zealand is highly ranked in the World Happiness Report.

However, we also have a significant section of the population that suffers from deprivation, and this group has much more psychological distress. Thus, we suggest that resources should be directed towards this group. Data from the New Zealand Health Survey show that those in the most deprived decile were around 30 times more likely than those in the least deprived decile to report a K10 score suggesting clinical anxiety and depression.[[27]] The suicide rates for the lowest quintile in 2016 were two to three times higher than the least deprived quintile.[[28]] These groups are also much more likely to use mental health services; the latest Ministry of Health data on mental health service use report that the most deprived quintile in New Zealand is three to nine times more likely to use various MHS.[[29]]

Since relying on healthcare alone to improve mental health outcomes can be expensive and inefficient, we advocate for integration with social services and practical help. We suggest, as have others,[[30]] that areas associated with higher levels of deprivation should receive more targeted focus in terms of resources, prevention and management of serious mental illness. Specific programmes (particularly supported employment, which has a strong evidence base[[31]]) could be resourced and evaluated. Providing quality care and education early in life and strengthening economic support to families is likely to be associated with fewer adverse childhood experiences.[[32]]

E-therapies may be more practical and efficient for population groups who respond to individual psychological therapies. In recent reviews, e-therapy has appeared superior to no treatment or waitlist controls for patients with depression,[[33]] generalised anxiety disorder, panic disorder and social anxiety disorder.[[34]] Although the effect sizes are modest and tend to fade over time,[[35]] this is similarly true for face-to-face therapies. This may be enhanced by using therapist guided e-therapies.

Conclusion

Although characterising New Zealand’s mental health as being in crisis may be overstating the evidence, there seems little doubt that significant changes in the conceptualisation and delivery of MHS are necessary. Based on the evidence, we suggest that the focus should be on deprivation and the severe mental illness. Rather than expand psychotherapy to middle class New Zealand and further reduce resources to those with serious mental illness, we advocate for better resourced MHS integrated with social services, such as supported employment, supported housing and early interventions. In addition, we suggest locating these integrated services in areas with higher levels of deprivation and that they consider ethnic, cultural and historical factors associated with deprivation. We also support specific investment in mental health registries integrated with service evaluation and policy research units, to ensure that new and existing mental health programme investment delivers better public mental health outcomes and also delivers value for money.

Summary

Abstract

Aim

Method

Results

Conclusion

Author Information

Roger T Mulder: Department of Psychological Medicine, University of Otago, Christchurch, CAN, NZ. Tarun Bastiampillai: College of Medicine and Public Health, Flinders University, Adelaide, SA, Aus. Anthony Jorm: School of Population and Global Health, University of Melbourne, VIC, Aus. Stephen Allison: College of Medicine and Public Health, Flinders University, Adelaide, SA, Aus.

Acknowledgements

Correspondence

Prof Roger Mulder, Department of Psychological Medicin, University of Otago, Christchurch; PO Box 4345, Christchurch 8140, New Zealand; +64 3 372 6700

Correspondence Email

roger.mulder@otago.ac.nz

Competing Interests

Nil.

1. Roy EA. New Zealand mental health crisis as Covid stretches a struggling system. The Guardian (International edition). 2020 9 September.

2. McClure T. New Zealand mental health crisis has worsened under Labour, data shows. The Guardian (International edition). 2021 1 April.

3. Government Inquiry into Mental Health and Addiction. He Ara Oranga: Report of the Government Inquiry into Mental Health and Addiction. Wellington, NZ; 2018 November.

4. Ministry of Health. Mental Health and Addiction: Service Use 2017/18 tables. Wellington, NZ: Ministry of Health (Manatū Hauora). 2021.

5. Ministry of Health. New Zealand Health Survey (NZHS). In: Health Mo, editor. Wellington, NZ: Ministry of Health (Manatū Hauora). 2021.

6. Coronial Services of New Zealand. Annual suicide statistics since 2011 Wellington, NZ: Ministry of Justice, New Zeland Government; 2020 [updated 21 August. Available from: https://coronialservices.justice.govt.nz/suicide/annual-suicide-statistics-since-2011/.

7. Helliwell JF, Layard R, Sachs JD, De Neve J-E, Aknin LB, Wang S. World Happiness Report 2021. Report. New York, NY: Sustainable Development Solutions Network; 2021.

8. Mulder RT, Rucklidge J, Wilkinson S. Why has increased provision of psychiatric treatment not reduced the prevalence of mental disorder? Australian and New Zealand Journal of Psychiatry. 2017;51(12):1176-7.

9. Wilkinson S, Mulder RT. Antidepressant prescribing in New Zealand between 2008 and 2015. New Zealand Medical Journal. 2018;131(1485):52-9.

10. Jorm AF, Patten SB, Brugha TS, Mojtabai R. Has increased provision of treatment reduced the prevalence of common mental disorders? Review of the evidence from four countries. World Psychiatry. 2017;16(1):90-9.

11. Beeker T, Mills C, Bhugra D, Te Meerman S, Thoma S, Heinze M, et al. Psychiatrization of Society: A conceptual framework and call for transdisciplinary research. Frontiers in Psychiatry. 2021;12:645556.

12. Every-Palmer S, Jenkins M, Gendall P, Hoek J, Beaglehole B, Bell C, et al. Psychological distress, anxiety, family violence, suicidality, and wellbeing in New Zealand during the COVID-19 lockdown: A cross-sectional study. PLoS One. 2020;15(11):e0241658.

13. Government of New Zealand. The Wellbeing Budget 2019. Wellington, NZ: Government of New Zealand.; 2019.

14. Rucklidge JJ, Darling KA, Mulder RT. Addressing the treatment gap in New Zealand with more therapists - is it practical and will it work? New Zealand Medical Journal. 2018;131(1487):8–11.

15. Jorm AF. Australia's 'Better Access' scheme: Has it had an impact on population mental health? Australian and New Zealand Journal of Psychiatry. 2018;52(11):1057–62.

16. Bastiampillai TJ, Allison S, Harford P, Perry SW, Wong ML. Has the UK Improving Access to Psychological Therapies programme and rising antidepressant use had a public health impact? The Lancet Psychiatry. 2019;6(3):e8-e9.

17. Bastiampillai TJ, Allison S, Castle D, Beaglehole B, Mulder R. New Zealand's big psychotherapy programme requires evaluation [Editorial]. New Zealand Medical Journal. 2019;132(1502):8–10.

18. Allison S, Bastiampillai T, Castle D, Mulder R, Beaglehole B. The He Ara Oranga Report: What's wrong with 'Big Psychiatry' in New Zealand? Australian and New Zealand Journal of Psychiatry. 2019;53(8):724–6.

19. Health Care Resources [Internet]. 2021 [cited 25 August]. Available from: https://stats.oecd.org/index.aspx?DataSetCode=HEALTH_REAC.

20. Thornicroft G, Tansella M. Components of a modern mental health service: a pragmatic balance of community and hospital care: Overview of systematic evidence. Br J Psychiatry. 2004;185(4):283–90.

21. Perera IM. The relationship between hospital and community psychiatry: Complements, not substitutes? Psychiatric Services. 2020;71(9):964-6.

22. Allison S, Bastiampillai T, Licinio J, Fuller DA, Bidargaddi N, Sharfstein SS. When should governments increase the supply of psychiatric beds? Molecular Psychiatry. 2018;23(4):796–800.

23. O'Reilly R, Allison S, Bastiampillai T. Observed outcomes: An approach to calculate the optimum number of psychiatric beds Administration and Policy in Mental Health. 2019;46(4):507–17.

24. Baandrup L, Cerqueira C, Haller L, Korshøj L, Voldsgaard I, Nordentoft M. The Danish Schizophrenia Registry. Clinical Epidemiology. 2016;8:691–5.

25. Jorm AF, Mulder RT. Characteristics of mentally healthy nations. under review.

26. Ribeiro WS, Bauer A, Andrade M, York-Smith M, Pan PM, Pingani L, et al. Income inequality and mental illness-related morbidity and resilience: A systematic review and meta-analysis. The Lancet Psychiatry. 2017;4(7):554–62.

27. Foulds J, Wells JE, Mulder RT. The association between material living standard and psychological distress: Results from a New Zealand population survey. International Journal of Social Psychiatry. 2014;60(8):766-71.

28. Ministry of Health. Suicide Facts: Data tables 1996−2016 Wellington, NZ: Ministry of Health, New Zeland Government; 2019 [updated 10 January 2020. Available from: https://www.health.govt.nz/publication/suicide-facts-data-tables-19962016.

29. Gibb S, Cunningham R. University of Otago Mental Health and Addiction in Aotearoa New Zealand [Commissioned Report for Government Inquiry into Mental Health and Addiction]. Wellington, NZ: EleMent/Otago University; 2018 July.

30. Lee SC, DelPozo-Banos M, Lloyd K, Jones I, Walters J, Owen MJ, et al. Area deprivation, urbanicity, severe mental illness and social drift - A population-based linkage study using routinely collected primary and secondary care data. Schizophrenia Research. 2020;220:130–40.

31. Marshall T, Goldberg RW, Braude L, Dougherty RH, Daniels AS, Ghose SS, et al. Supported employment: Assessing the evidence. Psychiatric Services. 2014;65(1):16–23.

32. Jorm AF, Mulder RT. Prevention of mental disorders requires action on adverse childhood experiences. Australian and New Zealand Journal of Psychiatry. 2018;52(4):316-9.

33. Ho C, Severn M. e-Therapy Interventions for the Treatments of Patients with Depression: A Review of Clinical Effectiveness [CADTH Rapid Response Report: Summary with Critical Appraisal]. Ottawa, ON: Canadian Agency for Drugs and Technologies in Health; 2018 May 18.

34. Young C, Campbell K, Dulong C. Internet-Delivered Cognitive Behavioural Therapy for Major Depression and Anxiety Disorders: A Review of Clinical zEffectiveness [CADTH Rapid Response Report: Summary with Critical Appraisal]. Ottawa, ON: Canadian Agency for Drugs and Technologies in Health; 2018 Sep 5.

35. Simmonds-Buckley M, Bennion MR, Kellett S, Millings A, Hardy GE, Moore RK. Acceptability and Effectiveness of NHS-Recommended e-Therapies for Depression, Anxiety, and Stress: Meta-Analysis. J Med Internet Res. 2020;22(10):e17049.

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The term “mental health crisis” was originally defined as an emergency that poses a direct and immediate threat to an individual’s emotional wellbeing. The definition has been expanded to refer to problems in community mental health and in mental health services (MHS) as a whole. A mental health crisis has been widely used to describe the state of New Zealand’s mental health. For example, recent headlines include “New Zealand mental health crisis as Covid stretches a struggling system”[[1]] and “New Zealand mental health crisis has worsened under Labour, data shows,”[[2]] suggesting deteriorating mental health in the population and an overwhelmed health system.

This paper sets out to test the veracity of these headlines. First, we will present data on whether rates of mental distress and the use of services are increasing in New Zealand. Second, we will consider the mental health system’s response to evaluate whether it has been effective. Third, we will consider where the limited available resources could most effectively be used.

We conclude that New Zealand’s mental health planning is heading in the wrong direction by directing resources and thus services away from people with serious mental illness who are often affected by social exclusion and deprivation. The current government’s plans, yet to be implemented, will expand psychotherapy to the “middle class,” an approach labelled as the “Big Community.”[[3]] Evidence from both the UK and Australia indicates that such initiatives might not reduce population distress in New Zealand, as intended. Instead of spending on programmes for moderate psychological distress, we suggest that the limited resources available for mental health should be carefully targeted towards those with serious mental illness, using integrated services located in areas with the highest levels of deprivation, which is often determined by ethnic, cultural and historical factors.

Is there a mental health crisis?

Two major approaches have been used to measure mental health (or illness) in New Zealand. The first is to study service use. Publicly available MHS data lag behind the headlines about the ongoing impact of the COVID-19 pandemic. The latest data are from 2017/18 and published in 2021.[[4]] The figures may not be directly comparable to previous reports due to increasing non-government organisations reporting, resulting in some inflation of numbers. Nevertheless, the figures are the most accurate guide available. They show that increasing numbers of New Zealanders have been accessing MHS over the past decade. In 2017/18, 181,924 patients were seen by mental health and addiction services. The rate of increase since 2008/9 in non-Māori is 47% (1,931.5 to 2,840 per 100,000) and in Māori it’s 26% (4,119.7 to 5,201.2 per 100,000), the latter from a higher base rate. Anecdotally, it appears that the rate of increase has continued to rise since these figures were published. There is also significant pressure and significantly increasing demand for acute mental health beds, despite increased service provision in primary care and the community.

The second approach to measure mental health is the use of population surveys. We are fortunate in New Zealand to have the NZ Health Survey, an annual health survey performed in a random general population and which includes measures of mental health. The measure most sensitive to change in psychological distress is assessed using the K10 scale. The survey publishes the percentage with a very high probability of depressive or anxiety disorder, that is, a K10 score of 12 or higher. This percentage has steadily grown from 4.5% in 2011/12to 8.6% in 2017/18 .[[5]] However, the rates now appear to have stabilised at 7.4% in 2019/20. Rates of diagnosed mental disorder, such as major depression and anxiety, have also stabilised over the past four surveys following steady increases between 2011/12 and 2016/17. Rates of hazardous or heavy drinking have also been stable since they were first measured in 2015/16.

A further plausible measure of mental health is the suicide rate. The latest data from the Office of the Chief Coroner reported that 654 people had died by suicide in the year July 2019 to June 2020, which equates to 13 deaths/100,000, a decrease from both the 2017/18 (13.7 deaths/100,000) and 2018/19 (13.9 deaths/100,000) figures.[[6]]

We should also consider the World Happiness Report conducted by Gallup. In this report, New Zealand ranks highly on wellbeing, having come ninth out of 149 countries on overall happiness measures (average life evaluation) in 2020. This is similar to its ranking and overall score between 2017 and 2019, in which New Zealand ranked eighth.[[7]]

So, what has been happening to MHS funding? Like most high-income countries, spending has increased; in New Zealand, mental health funding rose from NZD 1.1 billion in 2008/09 to 1.4 billion in 2015/16. The number of psychiatrists and psychologists almost doubled from 2005 to 2015.[[8]] More people are taking psychotropic medications than ever before. In 2015, PHARMAC data reported that 13.7% of New Zealanders have been dispensed antidepressants and 3.1% antipsychotics. Both rates have increased by more than 50% over the prior decade.[[9]] However, over this same period, psychological distress was worsening rather than improving. It seems that increasing resources was not accompanied by any evidence of improved mental health at a New Zealand-wide level. We can derive some comfort from the fact that most high-income countries report similar findings. A recent review by Jorm et al[[10]] noted that the prevalence of mood and anxiety disorders has not decreased in Australia, Canada, England or the USA, despite substantial increases in the provision of treatment in the four countries.

We therefore have a somewhat mixed picture before the COVID-19 pandemic. The use of MHS appeared to be increasing while the community rates of psychological distress had been levelling off after a major increase in the first half of the last decade. Overall happiness and life satisfaction measures have been stable since the beginning of 2010. It’s hardly good news. But it’s also inaccurate to say there’s a “mental health crisis” in New Zealand. The major crisis, if there is one, may be in gaining access to MHS, which are having to manage increasing numbers of patients. This is consistent with international epidemiological research pointing to a high, but relatively stable, incidence and prevalence of mental disorder, coupled with evidence that more and more people are using MHS and consuming psychotropic medication.[[11]]

Although we may not have a mental health crisis in the traditional sense of increasing rates of psychological distress, mental disorders and suicide, we do have a crisis in the sense that demand for MHS is increasing and that the expansion of those services and treatments is not leading to improvements in mental health at a community level. To add to the confusion, we have experienced a major epidemic in the past year. The impact of COVID-19 on mental health is not yet clear. New Zealand is relatively unique in that the impact and experience of COVID-19 is around a brief strict lockdown and the post-lockdown economic effects rather than the direct effects of the virus. Early evidence suggests a significant proportion of the population was adversely affected by the lockdown—particularly young people.[[12]] However, our experience may be very different from those countries where the direct effect of the virus was much greater.

The He Ara Oranga Report

Partly in response to the perceived mental health crisis, the New Zealand government set up a commission that produced the He Ara Oranga (HAO) Report in 2018.[[3]] The government, in response to the HAO Report, announced a $1.9 billion mental health package in their Wellbeing Budget.[[13]] The report correctly recognised that doing more of the same was not a good strategy, given the evidence discussed above.

The HAO Report suggested two major ways to improve New Zealanders’ mental health. The first, which could be seen as a preventative strategy, is based on individual psychological therapies like Cognitive Behavioural Therapy. This “Big Community” policy seeks to extend psychological treatment to those suffering psychological distress so that around 6.5% of the population (325,000 people per annum) with mild to moderate anxiety and depression will receive an intervention (Wellbeing Budget 2019).

In our view, there are two major flaws in this strategy. The first is how it would be organised and funded. It would be difficult, perhaps impossible, to train sufficient staff to implement such a programme. At the current rate of training psychologists and counsellors, it is estimated that it will be more than a decade before the workforce is sufficient to meet the current need.[[14]] In addition, at present only a small proportion of those diagnosed with a mental disorder actually receive psychological treatment—so why would (or should) less severe individuals be prioritised?

The second flaw is that similar, albeit less ambitious, programmes have been initiated in Australia (Better Access; 4.7% population coverage) and the UK (Improving Access to Psychological Therapies: IAPT; 1.5% population coverage)[[16]] and the results are not encouraging. In Australia, a recent review reported no impact on population mental health outcomes or suicide rates,[[15]] and the introduction of IAPT in the UK has not been associated with a reduced prevalence of common mental disorders (based on the Adult Psychiatry Morbidity Survey). On the contrary, these disorders have continued to increase.[[16]] Given this evidence, we are concerned that there appears to be no systematic plan to assess the efficacy of the proposed psychotherapy programme.[[17]]

The second major strategy in the HAO Report recommends a decisive shift from Big Psychiatry to a new sector called “Big Community.” This sounds good, that is, moving away from a medically led system where “most resources are used for psychiatric treatments, clinics and hospitals”[[3]] and which the HAO Report labelled as having a colonising world view with a legacy of paternalism and human rights breaches. In contrast, the HAO Report praised Big Community as having a strong commitment to partnership, recovery, spirituality and human rights. This is all very well as far as it goes but runs into a major flaw: “big” psychiatry in New Zealand is actually rather small. For the latest available country data between the years 2016 and 2020, New Zealand was ranked 32nd out of 38 OECD countries for the number of hospital psychiatric beds.[[19]] New Zealand reported 32 psychiatric beds per 100,000 population in 2020 while the OECD average was double that at 65.[[19]] Moving resources from struggling, already under-resourced, public MHS into the community appears a dangerous and an inequitable strategy. We appear to have forgotten that the hospital component of a community health is an essential part of good and balanced practice.[[20]] In addition, we do not appear to have well-resourced community facilities. A recent global report notes that New Zealand, as well as having very low bed numbers, also has the lowest number of community care facilities of all countries surveyed.[[21]] Overall, it would have been more accurate for the HAO Report to have used the term “Small Psychiatry,” which would have helped explain the problems facing the public sector.

Possible responses

1. Serious mental illness: The risk  of following the HAO Report is that we may establish widespread inverse care by tailoring health services for the mild and moderately ill and increasingly neglecting the most severely and chronically ill patients, as has occurred in other English-speaking countries, particularly the USA. Rather than focussing on reducing Big Psychiatry, we suggest that the government increases resources for it and tries to raise psychiatry bed numbers from the current 32 beds per 10,000 to at least 50 beds per 100,000 (OECD average is 65 beds per 100,000).[[22,23]] This is where there is the most need and where those who suffer deprivation are likely to seek help.

To better identify, follow-up and assess treatment outcomes among people with serious mental illness, we suggest that New Zealand is an ideal location for a mental health registry. A useful first step would be to link health datasets between primary, secondary and tertiary mental healthcare to enable mental health service researchers to evaluate the cost–benefit of new policies and investments in reducing hospital demand and improving overall mental health related outcomes. A more comprehensive mental health registry would also link social and non-health related datasets (education, unemployment, housing, corrections) with healthcare datasets at the individual level. This would enable a more comprehensive understanding of the likely bi-directional impact between social and non-health-related policy changes and mental health service utilisation (primary, secondary, tertiary) and outcomes (psychological distress, suicide, etc). Careful consideration of privacy issues would need to be part of database setup. A specific example that New Zealand should consider adopting is the national Danish Schizophrenia Registry, which was first established in 2003 and covers all patients diagnosed with schizophrenia who are receiving mental health care in psychiatric hospitals or outpatient clinics.[[24]] The Danish Schizophrenia Registry contains 21 clinical quality measure in relation to the following domains: diagnostic evaluation, antipsychotic treatment including adverse reactions, cardiovascular risk factors including laboratory values, family intervention, psychoeducation, post-discharge mental healthcare, assessment of suicide risk in relation to discharge and assessment of global functioning.[[24]] This registry also links its data with other national non-health related datasets. The Danish Schizophrenia Registry has been an invaluable tool for clinicians, researchers and policymakers helping to understand and improve the quality of care for this important patient cohort.[[24]]

In conjunction with setting up national mental health registries, consideration should also be given to setting up national mental health service evaluation and research units to analyse the effectiveness of government policy changes and investments. We suggest that approximately 2–3% of existing and new investments in mental health should be allocated to mental health service research and registry investment. Such investment will ensure that new programmes are fully evaluated before endorsing and implementing these measures nationwide.

2. Population distress: In terms of New Zealand’s levels of population distress, rather than reducing Big Psychiatry and offering therapy to all, an alternative strategy is to target resources towards individuals who suffer most from mental distress. Increasing international data has allowed more sophisticated ecological studies to show what factors are associated with psychological distress. These factors are consistent and not surprising: lower incomes, poor housing and unemployment (possibly better expressed as “deprivation”), as well as discrimination, neighbourhood safety, gender equality and corruption.[[25]] None of these appear likely to respond to individual counselling.

New Zealand already has in place some important characteristics of mentally health nations, which we generally take for granted. Our quality of government, assessed using measures of freedom and perception of corruption, is high. Education, lifespan and gender equality are reasonable, albeit with obvious room for improvement.[[25]] Income inequality has increased, but while it negatively affects mental health, the effect sizes are small and inconsistent.[[26]] As we noted, New Zealand is highly ranked in the World Happiness Report.

However, we also have a significant section of the population that suffers from deprivation, and this group has much more psychological distress. Thus, we suggest that resources should be directed towards this group. Data from the New Zealand Health Survey show that those in the most deprived decile were around 30 times more likely than those in the least deprived decile to report a K10 score suggesting clinical anxiety and depression.[[27]] The suicide rates for the lowest quintile in 2016 were two to three times higher than the least deprived quintile.[[28]] These groups are also much more likely to use mental health services; the latest Ministry of Health data on mental health service use report that the most deprived quintile in New Zealand is three to nine times more likely to use various MHS.[[29]]

Since relying on healthcare alone to improve mental health outcomes can be expensive and inefficient, we advocate for integration with social services and practical help. We suggest, as have others,[[30]] that areas associated with higher levels of deprivation should receive more targeted focus in terms of resources, prevention and management of serious mental illness. Specific programmes (particularly supported employment, which has a strong evidence base[[31]]) could be resourced and evaluated. Providing quality care and education early in life and strengthening economic support to families is likely to be associated with fewer adverse childhood experiences.[[32]]

E-therapies may be more practical and efficient for population groups who respond to individual psychological therapies. In recent reviews, e-therapy has appeared superior to no treatment or waitlist controls for patients with depression,[[33]] generalised anxiety disorder, panic disorder and social anxiety disorder.[[34]] Although the effect sizes are modest and tend to fade over time,[[35]] this is similarly true for face-to-face therapies. This may be enhanced by using therapist guided e-therapies.

Conclusion

Although characterising New Zealand’s mental health as being in crisis may be overstating the evidence, there seems little doubt that significant changes in the conceptualisation and delivery of MHS are necessary. Based on the evidence, we suggest that the focus should be on deprivation and the severe mental illness. Rather than expand psychotherapy to middle class New Zealand and further reduce resources to those with serious mental illness, we advocate for better resourced MHS integrated with social services, such as supported employment, supported housing and early interventions. In addition, we suggest locating these integrated services in areas with higher levels of deprivation and that they consider ethnic, cultural and historical factors associated with deprivation. We also support specific investment in mental health registries integrated with service evaluation and policy research units, to ensure that new and existing mental health programme investment delivers better public mental health outcomes and also delivers value for money.

Summary

Abstract

Aim

Method

Results

Conclusion

Author Information

Roger T Mulder: Department of Psychological Medicine, University of Otago, Christchurch, CAN, NZ. Tarun Bastiampillai: College of Medicine and Public Health, Flinders University, Adelaide, SA, Aus. Anthony Jorm: School of Population and Global Health, University of Melbourne, VIC, Aus. Stephen Allison: College of Medicine and Public Health, Flinders University, Adelaide, SA, Aus.

Acknowledgements

Correspondence

Prof Roger Mulder, Department of Psychological Medicin, University of Otago, Christchurch; PO Box 4345, Christchurch 8140, New Zealand; +64 3 372 6700

Correspondence Email

roger.mulder@otago.ac.nz

Competing Interests

Nil.

1. Roy EA. New Zealand mental health crisis as Covid stretches a struggling system. The Guardian (International edition). 2020 9 September.

2. McClure T. New Zealand mental health crisis has worsened under Labour, data shows. The Guardian (International edition). 2021 1 April.

3. Government Inquiry into Mental Health and Addiction. He Ara Oranga: Report of the Government Inquiry into Mental Health and Addiction. Wellington, NZ; 2018 November.

4. Ministry of Health. Mental Health and Addiction: Service Use 2017/18 tables. Wellington, NZ: Ministry of Health (Manatū Hauora). 2021.

5. Ministry of Health. New Zealand Health Survey (NZHS). In: Health Mo, editor. Wellington, NZ: Ministry of Health (Manatū Hauora). 2021.

6. Coronial Services of New Zealand. Annual suicide statistics since 2011 Wellington, NZ: Ministry of Justice, New Zeland Government; 2020 [updated 21 August. Available from: https://coronialservices.justice.govt.nz/suicide/annual-suicide-statistics-since-2011/.

7. Helliwell JF, Layard R, Sachs JD, De Neve J-E, Aknin LB, Wang S. World Happiness Report 2021. Report. New York, NY: Sustainable Development Solutions Network; 2021.

8. Mulder RT, Rucklidge J, Wilkinson S. Why has increased provision of psychiatric treatment not reduced the prevalence of mental disorder? Australian and New Zealand Journal of Psychiatry. 2017;51(12):1176-7.

9. Wilkinson S, Mulder RT. Antidepressant prescribing in New Zealand between 2008 and 2015. New Zealand Medical Journal. 2018;131(1485):52-9.

10. Jorm AF, Patten SB, Brugha TS, Mojtabai R. Has increased provision of treatment reduced the prevalence of common mental disorders? Review of the evidence from four countries. World Psychiatry. 2017;16(1):90-9.

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