Mental Health Clinics in the 21st Century
Authors: Isaac Marks
Journal: Psychotherapy and Psychosomatics (2009)

Mental health clinics around the world come in a myriad of forms shaped by a host of factors. They might be directed by a psychiatrist, psychologist, nurse or other professional, with further staff from the same or other groups including graduate mental health workers, counsellors and voluntary workers. The clinics may serve populations of particular geographical areas whose total numbers may range from a few tens of thousands to many millions. They may be intended for referrals who are just children, adolescents, students, adults or the elderly, or for people of any age. Clinics may aim to manage referrals who have any kind of problem, or who just have anxiety or depression or both, eating disorders, aggression, forensic problems, psychosis, neuropsychiatric or other physical disorders, learning disabilities, etc. A mental health clinic might accept referrals from any source, including patients themselves, or only from primary or secondary care professionals, or from employees of a single company in the case of employee assistance programmes. Initial assessment might take just a few minutes or last for hours. The clinic might treat by medication and/or one or several psychosocial therapies. It could treat people face-to-face and/or by live phone or videophone interviews, or by voicemail, SMS, E-Mail or Internet or, very recently, computer-aided self-help. Other variables include whether the mental health clinic is free-standing or in a hospital or school or academic or other institution, and whether the director and other staff are professionals who have had varied types and lengths of training and experience, helped perhaps by volunteers of diverse kinds. Each profession has its expertise, but is also a 'conspiracy against the laity' whose rightful needs may not coincide with the equally rightful needs of its patients. Also, of crucial importance is whether the clinic is funded via a government health department, health insurance or health maintenance organisation, employee assistance programme, or a private or other source; whoever pays helps shape the rules. The huge range of influences on mental health clinics makes it hard to find an ideal prescription for how to run them. Context decides the trade-offs of each model of organisation. A common model is a clinic headed by a psychiatrist [1]. This might be best where a major proportion of referrals have a psychosis or a neuropsychiatric problem with frequent comorbid medical problems [2, 3]. For such referrals, a psychiatrist-led structure facilitates an integrated assessment and treatment service if the psychiatrist has expertise in both pharmaco- and psychosocial therapy, and works with staff trained to give the proper range of therapies. The first assessments and periodic reviews of sufferers with psychosis or neuropsychiatric problems, and the reduction of residual problems as far as possible [1], may be best done or closely supervised by a psychiatrist if those are integrated closely with work of the whole team caring for patients in both the clinic and the community [4,5,6]. This is easier said than done. Schizophrenia and bipolar disorder commonly persist for decades. Despite excellent community care by well-integrated teams, many sufferers eventually slip through the net. Vigilance is hard to sustain indefinitely. The range of patients whose first assessment is most cost-effectively done by physicians [1] needs careful analysis. Formal diagnosis, as opposed to problem formulation, is often less tightly tied to treatment than is widely believed. Several kinds of depression respond to 'antidepressant' treatment, whether it is primary or comorbid with other problems. Nor does 'antidepressant' treatment necessarily mean medication – several brief psychotherapies are effective for mild to moderate depression. For anxiety problems too, which treatment works is dictated less by precise diagnosis than by the presence of anxious avoidance, as found in a range of diagnoses. Most kinds of phobic disorder, including panic disorder, obsessive-compulsive disorder, post-traumatic stress disorder and nightmares, all improve well with self-exposure therapy tailored to the particular problem. The efficient guidance of exposure and other cognitive-behaviour therapy (CBT) is governed less by the DSM or ICD diagnostic label than by the exact problems that the patient has within that label. Such therapy can be guided perfectly well by people trained to do it who have no medical or psychology degree, of which more anon. The key is problem- and goal-oriented care, and not diagnosis-oriented care.Also moot is whether psychotropic medication should always be prescribed by a physician. Overprescribing by doctors is a major issue [1]. It stems from drug companies flooding physicians with advertisements for their products, and from physicians regarding medication as superior to psychosocial care. In some places, limited prescribing powers are given to nurses or clinical psychologists who have had brief training to do this. As that practice spreads, those staff too will be targeted by drug company advertising, and find it hard to resist the lure of overprescribing.Where most referrals have anxiety disorders, ample evidence has shown that well-trained nurse therapists (clinical nurse specialists) in England assessed and gave behavior therapy at least as effectively as did longer-trained professionals [7, 8]. Their post-registration full-time training over a year cost considerably less than that of psychologists and psychiatrists. Hundreds have been trained in England to do both first assessment and subsequent therapy, and are held in high regard. However, thousands of such nurse therapists are needed. Moreover, from 2000 onwards, their training had to be modified to meet a new requirement by the UK nursing profession, namely that nurse education should become more academic with less time spent in acquiring the practical clinical skills that are a hallmark of nurse therapists. The role played by nurse-therapists in England is now being played increasingly by case managers coming on stream, who are not nurses but are trained on similar lines part-time over 6 months. Effective nurse therapists and case managers are rare outside the UK, though they could probably enhance the efficiency of mental health clinics anywhere. After all, related kinds of personnel called nurse practitioners or physician's assistants give good care for many types of health problem in countries around the world. With brief targeted training, such staff could ease serious shortfalls in delivering cost-effective mental health care. Long-term success, however, requires skilful management of the political and professional conflicts that arise. These resemble age-old tensions between clinical psychologists and psychiatrists, and between midwives and obstetricians. Hurdles and how to overcome them will differ from one country to another. The present way in which mental health care is delivered gives a raw deal to most sufferers with anxiety or depression. They account for 97% of people with mental health problems [9] and at least 50% of days lost from disability [10], yet attract only a tiny proportion of the total spend on mental health care. UK sufferers are paid the equivalent of about EUR 12 billion for incapacity benefit for chronic unemployment [11]; this vastly exceeds spending on effective psychotherapy [12], which is received by only 1% of sufferers. Similar problems occur globally. To try to remedy these, health service research programmes have appeared in North America, Europe and Australia. UK government policy in this regard attracts international attention. The 'Layard initiative' of the Department of Health [13, 14] hopes to improve the mood and economic productivity of anxiety-depression sufferers by giving them effective psychotherapy in treatment centres. Towards this end, it is committing more than EUR 400 million over 3 years. Its Improving Access to Psychological Treatment programme [15] for anxiety/depression aims to train 3,500 therapists in CBT. Of the EUR 230 million earmarked for this purpose, 60% is to train therapists to give intensive/low-throughput CBT and 40% to give shorter training in low-intensity/high-throughput CBT. Two IAPT (Improving Access to Psychological Therapies) demonstration sites have been set up. One is a specialist mental health clinic in multi-ethnic Newham, London. It gives mainly intensive/low-throughput CBT, delivered predominately by psychologists. The other IAPT site, in uni-ethnic Doncaster, Yorkshire, field-tested a model of stepped care where most referrals for anxiety/depression are offered low-intensity/high-throughput CBT [16,17,18,19,20]. Its model of stepped-care case management is spreading around England, and might especially influence future mental health clinics. It therefore deserves detailed discussion. Stepped care gives the least-intensive help needed to improve a problem, and only steps up to more intensive care either immediately [if at first triage (filter) referrals are deemed to be unlikely to respond to initial low-intensity care] or later (if their problem has failed to improve with initial low-intensity care). Most referrals are likely to improve with low-intensity care, though first assessment does not always detect the few who will probably only respond to more intensive therapy. Trainee case managers give large numbers of anxious or depressed patients low-intensity brief care as a first step. Trainees who are empathic with people are selected. No prior educational level or psychotherapy experience is needed. They have 25 taught and 20 in-service days in a national course that echoes key aspects of nurse-therapy training [21, 22]. CBT therapists train them in a mix of clinical simulation and clinical practice. Trainees learn to do assessment and brief functional- and recovery-oriented CBT for general practitioner (GP), self- and other referrals, and to use a web-based clinical information and supervision system at every session. They give referrals a self-help manual [23], and learn to enhance adherence in the third of their patients who also have doctor-prescribed antidepressant medication. Each case-manager trainee works with up to 20 patients per week. Improvement by case management of clients' anxiety and depression compares well with results elsewhere. Though all Doncaster referrals were assessed face-to-face, mainly in GP surgeries or other community venues, 75% then had case-management sessions by phone from a hub whose call-centre technology enables trainees to see and to input notes and clinical outcome data into a bespoke web-based information system while talking to patients using hands-free headsets. The web system gives case managers and their supervisors automated flags for action triggered by response to and duration of the low-intensity care. The 25% of patients who get face-to-face case management get this mainly in GP surgeries or other community venues. Each case manager works with a geographical group of GP surgeries. An increasing minority of the patients choose to immediately get more intensive (but high-throughput) self-help guided by NICE-approved computer-aided psychotherapy (CP) on the internet together with brief live support by phone. Up to 10% of initial referrals get more intensive/low-throughput CBT from intensively trained therapists, either straight after assessment by a duty manager or later after failure to improve with case management, or are referred elsewhere for specialist treatment of psychosis or other serious mental illness. The case manager model echoes features not only of nurse-therapy programmes but also of employee-assistance programmes delivered by phone, plus a web-based clinical information system. Low-intensity case managers help far more sufferers than high-intensity CBT therapists. This is because mean total per-patient time in initial assessment plus a mean of 4 subsequent sessions (mostly by phone) is under 3 hours – about 30% of the mean total per-patient time in assessment-plus-therapy sessions by high-intensity therapists. Moreover, case-manager training for early stepped care takes only about half the time taken to train therapists to give high-intensity CBT after those therapists have already had previous long professional training. Caveats to such time comparisons reflect dilemmas inherent in health care. Many referrals to case managers may have remitted rapidly anyway had they been left to their own devices without low-intensity help, and perhaps a few may have improved more had high-intensity therapy been the first step in care. A final caution. The encouraging results of case management for Doncaster's population of 300,000 emerged from a partnership between health, employment, business, and voluntary sectors and patient communities. It cost EUR 4.5 million over 3 years. Time will tell how far its success can generalise to other sites blessed with fewer funds, less-committed talent, and different local and national politics. In the long run, health care prototypes tend to dwindle in efficacy as conditions change. A UK example noted earlier is how, 28 years after nurse therapy began, in 2000 the nursing profession altered the rules of nursing education in a way which impeded the clinical training of effective nurse therapists. In Massachusetts, when just a year of extra training enabled dental hygienists to drill and fill teeth at least as well as dentists who had far longer training, this led, not to expansion, but rather to the ending of such training of dental hygienists [24]. In South Africa, a landmark primary health care experiment ran into the desert sand as socio-political conditions changed [25]. Sniping at the Doncaster results [19] warns that long-term success in dissemination requires constant nurturing and adaptation to new circumstances. Lord Layard's persuasion of the UK government to release substantial funds to train therapists for anxiety-depressive disorders is a major achievement that may alter how UK mental health clinics are run in future. It is not without problems. More bang from its bucks might come from spending a higher proportion of training funds on low-intensity high-throughput help as the first step in a stepped-care approach. More robust evidence is needed that CBT helps enough sufferers back to work to reduce payments of incapacity benefits. CBT is just one of the psychotherapies that are 'evidence-based'. In a meta-analysis [26] of 12 randomised controlled trials, at post-treatment and at follow-up, behaviour therapy alone (by rescheduling activities to re-introduce reward and reduce avoidance) improved depressive symptoms with a similar recovery and dropout rate as the full cognitive or cognitive-behaviour therapy recommended in NICE guidelines [27]. Superior outcome was not associated with level of training, suggesting that shorter training might raise the number of effective therapists with limited resources. Interpersonal psychotherapy too improved depression as much as CBT. Most anxiety disorders improve with non-cognitive exposure therapy, and some improve with procedures involving neither cognitive nor exposure therapy. Well-integrated care requires therapists who can deliver a range of effective brief psychotherapies [28] rather than just cleave to a cognitive cult. Last but not least, the Layard initiative pays lip service to, but does not efficiently harness, an early step in care of low-therapist-intensity but high-throughput use of CP [29]. Effective CP systems for anxiety and depression can widen access to psychotherapy at a lower cost [29]. They enable mental health clinics to greatly raise patient throughput by delegating the bulk of therapy tasks to CP-guided intensive self-help. Such CP saves most per-patient therapist time because it only needs very brief live phone or E-mail support. Moreover, supporters of CP users need far less training that that given to therapists, nurse therapists or even case managers, while CP used on the internet at home means the clinic incurs no expense of computers, printers, receptionist time, space and other overheads. An option of CP is being offered by a growing number of mental health and other clinics in Australia, Netherlands, Sweden, UK, USA and elsewhere [29, 30]. It comes in the wake of randomized controlled trials (RCT) showing the value of CBT in people with anxiety, depression, binge eating [31] and other disorders who have limited access to specialist care, want more confidentiality and prefer self-help at home [29]. The swift spread of CP licensing by health authorities caring for over 12 million people in England and Wales was catalysed by the recommendation of NICE [32] for two CP systems that are now on the internet – Beating the Blues for depression and FearFighter for phobia/panic. Funding for CP in clinics around the world comes directly or indirectly from government sources, public or private insurance programs, employee-assistance programs and private patients. Some unsupported CP systems are free, but have a very high dropout rate. Mental health and other clinics face challenges in introducing CP into routine care, despite successful field trials and RCT [29]. Teething problems appear during the post-RCT implementation of any new approach. Efficient execution requires careful attention to detail in conditions that vary hugely across clinics in different countries and across clinics within a single country. For a start, funding rules in several countries create perverse incentives that actually penalise clinics for increasing the number of patients treated effectively at a lower per-patient cost, and/or allow funding only of help given face-to-face, and not by phone or e-mail or CP. Past Finnish rules allowed reimbursement of years of psychoanalysis, but not of short psychotherapy. Inertia may impose long delays before rules change to allow patients, institutions and society as a whole to reap the full benefits of new advances. Referral and screening rules can constrain clinics' efficiency in delivering CP. A London CP clinic found better uptake and outcome by early GP- and self-referrals than by referrals from mental health professionals [33], and developed a quick way to screen (assess) referrals in 15 min or less [34]. However, many primary care trust clinics in England eschew self-referrals and quick screening. Their screening procedure often takes an hour or longer without detecting common panic/phobic problems that improve well with FearFighter. Defensively long screening for CP or other psychotherapy can cause waitlists to build up just for screening, let alone therapy. It partly reflects risk aversion in a culture that blames staff for the rare tragedies of patients killing themselves or someone else, which occur sooner or later in any big-enough population. Staff are not blamed for deaths in people who are waiting to just get onto a waitlist or are not seeking help. Prolonging screening per se does not demonstrably prevent such tragedies more than just asking a few pertinent questions. Suicide risk was better predicted by a computer than a human interview [35]. One is reminded of UK legislation in 1865 (repealed only in 1896) that stifled the spread of self-propelled vehicles by requiring a man with a red flag or lantern to walk 60 yards ahead of such vehicles to warn others of its dangerous approach. Ultracautious 'red-flagging' defeats the ability of CP to speed access to effective help for anxiety and non-suicidal depression. Staff also need reassurance that integrating CP into their work is more likely to enable them to help a larger number of patients effectively than be made redundant. There are best practices that all mental health clinics can strive for anywhere. Best practices may include the following, depending on the population served and the patients referred: (1) speedy access to care in ways that are unlikely to increase risk; (2) offer as first steps in care the least-intensive treatment options likely to help the patient's problem; (3) harness the patient's capacity for self-help as much as possible; (4) deliver treatment with staff who have had the shortest training needed to enable them to treat their patients efficiently; (5) co-ordinate all agents involved in the treatments given or planned over the entire care period, which might last decades for some chronic mental illnesses that respond only partially at best to even the finest current treatments; (6) monitor outcome at intervals, including follow-up, with quick simple measures, and use results to modify treatment where needed; (7) if the patient is not improving in the time expected with the disorder and the treatments given, or is not maintaining gains, review treatment options; (8) record what is done quickly and confidentially in ways that allow all agents involved to retrieve the information easily; (9) harness information technology as much as possible to triage, deliver, track and record therapy and follow-up; (10) when implementing best practice for large numbers of patients, remember that 'the best can be the enemy of the good'. Clinicians, managers and policy makers can shape their own 10 commandments to their own setting. Compromises are inevitable, but are fewer using the kaizen model of the Toyota Corporation of regularly examining goals, problem-solving how best to achieve those, encouraging all staff to suggest ways to do this and monitoring progress. There is no ideal way to organise every mental health clinic for all disorders in all settings. What constitutes cost-effective care from the patient's or family's points of view may differ from those in the eyes of different professional groups, which may in turn diverge from those of various funding organisations. Any clinic's form of organisation may have both good and bad knock-on effects. Which arrangements on balance seem best given local needs and resources can be judged using 10 best-practice principles that transcend most circumstances. Many thanks are due to Giovanni Fava for valuable comments on a draft of this paper, and to Dave Richards for clarifying case-management training and outcome. Isaac Marks has intellectual property rights in the computer-aided self-help system FearFighter.