It has recently been discussed in the media, that the former president of the World Mental Health Foundation believes our public mental health system is broken and at a crisis point. It is important this is being discussed, but it is not new news to many - NZ public mental health services seem to have been having this kind of discussion since at least 1876, when the Lunacy Department was established to try and raise standards in 'insane asylums'. Just think how things have moved on from there, at least to some extent, for the better. Yet mental health is still the poor cousin in health care, and addiction services are the even poorer cousin - yet often are utilised by those with the most chronic mental health challenges (read: trauma and lack of secure attachment) alongside their substance use difficulties. 

My time working in the public mental health system before moving in the direction of private practice taught me there is an 'ambulance at the bottom of the hill' approach in public mental health (perhaps in our public services in general). This approach, by design, has to wait for severity of symptoms to be "moderate to severe," because services are stretched - time poor and money poor. This could be the equivalent of waiting for a nail stuck through a foot to get infected before trying to take it out, by which time the damage is worse and may require more treatment at greater expense then if it was cared for straight away (not to mention the cost of leaving someone suffering).

A Non-Scientific Theory

Mental health services are poor in both time and money but face an excess of people needing support - in fact almost 50% of the population will experience a psychological problem at some point in their life, it's an epidemic. I have a (possibly non-scientific) theory on the time and money ratio. It is manageable to be either time-poor or money-poor during busy times and still survive - not enough time but plenty of cash? No worries, throw some spare money at it. Not enough money but time to kill? It's OK - you've got the space you need to work out how to do things efficiently with what you've got. Problems arise when there is no-time and no-money - for short bursts this can be overcome through depleting existing reserves, however with chronicity this is unsustainable and something will eventually give. For health care providers, as their energy and emotional reserves expire, something called compassion fatigue can ensue. This is when attempts to care for others without sufficient support, resources, and control, hurts the helper, and may render them 'burnt-out.' At this point the only options are to resign to an attitude of 'what's the point' and maintaining the status quo, or else decide to leave the situation, if that is possible.

In the mental health field not enough money means less staff and less well qualified staff, it also means reduced access to the "big guns" in treatment like residential stays of various kinds, specialised assessment, or specialised treatments.  No money and low staff means high staff turnover, burnout, and a sad lack of continuity of care or quality experience for service users, not to mention increased risk to them and the public - as we have heard sad stories of recently in the media.

Health professionals are generally there because they care and want to help others - yet they drown in never completed paperwork, spend their days managing risk and putting out fires, and can live with a gnawing sense being powerless to effect change in the existing system. A medical model reigns in public mental health, with psychiatric medication being a standard component of treatment and access to talk therapies limited. Those not meeting the 'moderate to severe' criteria are encouraged to access other services in the community, and yet there is now less than ever funding available for them to do so, and few free services remain, especially those with qualified mental health experts. What happens then? The 24/7 crisis line has more crises then it can reasonably attend to and the ambulance is well and truly at the bottom of the cliff. For some people it's too late - NZ lost 569 people to suicide in the year ending May 2015. How many of those came through our system at some point?

Under these circumstances it is entirely understandable to think our public mental health system is broken - assessment for medication for common mental health symptoms are so commonly prescribed in general practice. 1/9 New Zealander's and 1/6 women are prescribed an antidepressant, and zopiclone (a sleeping pill) was the 16th most prescribed drug last year according to Pharmac data, with 540,000 scripts written. People falling into the 'mild-moderate' category of mental ill health will often never get to see a mental health specialist to assess the nature of their difficulties and what might actually be causing and maintaining them. My understanding is that sometimes medication is prescribed because the prescriber simply wishes to help and medication is a cheap and fast "solution". Other times people request a pill themselves, because they want their distress gone and our social norm is now to take medication for a "brain chemical imbalance." But the most common scenario I see in my private practice is a client anxious, stressed, or down asking whether they should take their script or not, because to them something feels off about it. And if anyone has ever looked up the side effects of psychiatric meds or research regarding the long-term efficacy, people have good reason to be questioning being trigger-happy with these medications. 

Nutritional and Lifestyle Solutions

While it's not up to me to decide if someone takes a prescription or not, and no one should stop medication use without talking to their prescriber, my recommendation in response to this question, 'should I take the meds' most of the time is - let's try something else first. On assessment of contributing factors there are usually other solutions required - starting with a compassionate ear. Examples of contributing factors include nutrition and lifestyle excesses (e.g., caffeine or alcohol) or deficiencies (e.g., vitamins and minerals), immediate stressors like a relationship or work problem, a chronic health condition - most commonly a gut health issue or dysregulated stress response from a life of too many competing demands on the body (often termed "allostatic load"), or a mundane sense of lacking purpose and direction. There is no serotonin pill solution for psychological distress caused by multiple coffee's by day, several wines by night, chronic nutrient deficiencies or undetected food intolerances, blood sugar chaos and a stress response out of whack, and working too many hours in a sedentary job spending all day everyday rushing from one place to the next on autopilot, with a deficiency of meaningful connection with others. Is this what it should be like? How did we get here?

Creating Something Better

Wouldn't we have an amazing community if we could start with compassionate enquiry and psychoeducation about the role of nutrition and lifestyle in what shows up as psychological distress. Practical dietary and lifestyle changes that re-align us with our biological and psychological needs are a low risk, cheap, and accessible option at the first onset of a mental health difficulty, or even better as a prevention strategy at the top of the hill. What if either medical or mental health assessments comprehensively covered the role of nutrition and nutritional deficiencies as a foundation? What if lifestyle interventions including sleep, exercise, reducing stressors, and building meaningful community connection were prescribed more frequently, and not just by psychologists. What if we passed down compassion and mindfulness to our next generation through our words but also our actions? What if instead of solely relying on a medical model for severity of symptoms we used a compassionate model of care with a prevention and early intervention focus. There is an ongoing role to play for psychological therapies and probably still a role for psychiatric medications in severe cases. However in my opinion, the reason why our mental health system is broken, if it is, is down to the inadequacy of nutritional and lifestyle early assessment and interventions provided compassionately.