Mental Health and Addiction Inquiry – Expert Reaction

The Government has released the report from the Mental Health and Addiction Inquiry. 

The Inquiry’s recommendations include suggestions to form a Mental Health and Wellbeing Commission, reform the Mental Health Act, begin considering illegal drug use a health and social issue, and set a target of reducing suicide rates by 20 per cent by 2030.

The SMC asked experts to comment on the Inquiry’s report.

Dr Dougal Sutherland, Clinical Psychologist, Victoria University of Wellington, comments:

“The MH&A Inquiry report signals a change in the culture of mental health services in New Zealand moving away from a medically-driven approach to a more holistic, person-centred approach. Part of this is the strong need for an increase in access to psychological or ‘talking’ therapies. This represents a major challenge for our education and health systems. Currently, there are approximately 60-70 clinical psychologists graduating each year across the whole of the country. There is clearly a need to increase the number of clinical psychologists that are trained but this will require a significant investment into these training courses, many of which are funded at lower levels than a basic undergraduate science degree. But even if numbers of clinical psychologists were doubled there still wouldn’t be enough to reach the 20 per cent of the population who need their services. The inquiry report has signalled the need for the sector to consider a new type of clinician, a Psychological Wellbeing Practitioner, who could deliver evidence-based talking therapies to those with mild mental health problems, potentially under the supervision of a clinical psychologist. At present no such training exists in New Zealand so thoughts must quickly turn to what this training would look like and how it could happen.”

Conflict of interest statement: I am a member of the Psychology Workforce Task Force group which made a submission to the Inquiry and is mentioned on page 114 of the Report.

Professor Devon Polaschek, School of Psychology, Joint Director, Institute of Security and Crime Science, University of Waikato, comments:

“We are all too aware that there are high levels of treatable mental illness in our community. We have long wait lists for help and many people are simply not eligible for specialist help, despite having treatable problems that create considerable personal suffering, stress and distress to those around us, reduce workplace productivity and challenge economic survival.

“It is a relief to see that the need for a ‘people first’ approach has been heard and acted on in this report. For too many years we have been faced with a system that has viewed psychological wellness as if it was desirable rather than essential to both individual health and the health of families, whānau and communities. Imagine if we approached physical health in the same way.

“As an expert on criminal behaviour and family harm, I am delighted to see recognition that those who are caught up in our criminal justice system are also troubled by high rates of mental illness and addiction. Today’s report offers hope that we are recognising the role of mental health and addictions treatment in reducing related societal ills such as family harm and child abuse. Those who work in crisis services for victims of family harm are only too aware of the need for better access to both mental health and addiction services for both perpetrators and victims. It is also time we stopped treating addiction as a moral issue, or in isolation from other mental illness. Many people do not have addictions in isolation from other problems and services need to reflect that reality.

“The inquiry has also recognised the serious shortages we have in recruiting and supporting sufficient trained workers in the sector. Even people who can afford to pay for their own help often wait weeks to see a private psychologist, for instance. And it cannot be disputed that we need more workers to work in services that better meet the needs of Māori and Pacific people.

“The challenge now is implementation. The report is an impressive document. Will it make a difference? Many of the problems it recognises are longstanding. Providing first class mental health services is simply not as exciting as trying out new techniques in cancer treatment or heart surgery. But it is an aim that is just as important. Will we see a commitment from this government and the next that reflects the needs that are recognised in this report and the recommendations it makes?

No conflict of interest declared.

Dr Fiona Hutton, Senior Lecturer in Criminology, Institute of Criminology, Victoria University of Wellington, comments:

“The inquiry is to be commended for its thorough and broad approach to mental health, including focusing on issues related to addiction and the use of alcohol and other drugs. As noted in the report, many of those struggling with addiction are also struggling with mental health issues, which are in turn exacerbated by other social and cultural factors such as poverty and disadvantage. The way we currently respond to those with addiction issues often intensifies the problems related to addiction and mental health. For example, the current ‘war on drugs’ approach is not only ineffective at reducing the supply and demand for illegal drugs, but it worsens the problems related to addiction and mental health for many users. Criminalising those with addictions means they are labelled for life with a drug-related conviction, often making it impossible to find employment, a place in their community, and to move away from using illegal substances. The stigma that is associated with illegal drugs, addiction and criminal convictions also makes it harder for people to ask for help, with stigma exacerbating mental health issues related to addiction.

“Therefore it is excellent to see that this report is taking a realistic approach to illegal drug use, addiction and mental health, by calling for the criminalisation of personal use and social supply to be removed – this would be an excellent step forward in reducing the stress and stigma for people whose drug use is causing them, their families and communities problems. Other countries such as the Czech Republic, the Netherlands and Portugal have very effectively taken this approach, reducing overdoses, and upscaling treatment services. The use of other drugs in Portugal, the Czech Republic and the Netherlands have remained stable since drug law reform in these countries. In the Czech Republic, youth and young adult drug use has declined since 2003, the Netherlands has a lower rate of addiction and problematic drug use (PDU) than most of Western Europe, and have a lower rate of injecting heroin use and overdoses than the US. In Portugal youth drug use as well as PDU has decreased since 2003, and Portugal’s drug use rates remain below the European average and much lower than the US (Drug Policy Alliance, 2017).

“While the New Zealand social and cultural context is not the same as these European countries, there are clearly lessons that we could learn from these highly effective approaches. Treating drug use and addiction as a health and social issue, and removing criminal sanctions for personal use and social supply would be a much needed, more effective way of addressing illegal drug use, mental health and addiction – such change is long overdue.”

No conflict of interest.

Professor Doug Sellman, Professor of Psychiatry and Addiction Medicine, University of Otago, Christchurch, comments:

“This eagerly awaited report has delivered key recommendations to the government regarding the crisis of mental health and addiction in contemporary New Zealand.

“One of the key recommendations is particularly welcomed – that the government takes a bolder approach to the sale and supply of alcohol. This is arguably the easiest and most effective intervention the government could enact in order to improve the well-being of New Zealanders.

“The report points out that the last three governments have been provided with numerous reports documenting a comprehensive range of scientifically based actions to reduce alcohol-related harm, but not taken any substantial action. In particular, the past three governments have virtually ignored the main recommendations of the New Zealand Law Commission’s report of 2010, following the most comprehensive review of the state of alcohol in New Zealand. The Law Commission report advised dismantling advertising and sponsorship of alcohol, increasing the price, reducing accessibility, and raising the purchase age back up to age 20 years.

“He Ara Oranga recommends the present government finally takes action on these matters in order to reduce the enormous amount of harm and array of associated mental health conditions that easily accessible, normalised alcohol use is inflicting on New Zealand families and communities, and which was voiced over and over to the Inquiry Team.”

No conflict of interest declared.

Professor Sunny Collings, Director, Suicide and Mental Health Research Group, University of Otago Wellington; Consultant Psychiatrist, comments:

“Overall the findings from the consultation are not surprising. From where I sit, the single most important theme is that of leadership. Mental health and suicide prevention in New Zealand have suffered badly from a lack of coherent leadership with the ability to influence. This has been a major contributor to where we now find ourselves.

“However it is translated, through institutional structures such as a commission and offices, it is imperative that the new leadership is characterised by a compelling and visionary leadership style, diversity, compassion, and a deep familiarity with the challenges brought by the state of the scientific evidence.”

No conflict of interest declared.

Professor Sally Casswell, Massey University, comments:

“Congratulations to the Mental Health and Addiction Inquiry for highlighting the role of alcohol and the urgent need for a strong government response. As the report says, there have been clear recommendations from the Law Commission in 2010 and all that has been lacking is political will to put these into effect. The Inquiry rightly points to the importance of responding in the same way we have responded to tobacco to ensure alcohol harms are reduced. The Inquiry heard submissions which spoke of the harm linked to the number of liquor outlets, their proximity to schools and location in poorer communities, and the need for restriction on advertising and sponsorship.

“On the issue of other drugs, the Inquiry highlights the enormous problem being created by use of methamphetamine but goes on to recommend decriminalisation of personal use of drugs, referring as so many do, to Portugal’s experience of decriminalisation. Unfortunately Portugal is not New Zealand and we need a more sophisticated discussion of the appropriate response to our extensive problems with drugs like methamphetamine. Of course, it is important to provide better treatment options than currently exist and the Inquiry calls for this. However, it is silent, as are so many advocates in this field, about the supply side of illicit drugs. Supply, as we have seen from alcohol, is a crucially important part of the problem and we need to ensure that supply of all drugs is tightly controlled.”

No conflict of interest.

Professor Max Abbott CNZM, Pro Vice-Chancellor and Dean, Faculty of Health and Environmental Sciences, Co-director, National Institute of Public Health and Mental Health Research; Professor of Psychology and Public Health, Auckland University of Technology, comments:

“The Minister is acknowledged for placing this report in the public domain so quickly. The Inquiry members and support staff are commended for accomplishing a massive undertaking within a short time frame. They have sought the views of multiple stakeholders, listened to them and reflected their views.

“They have identified the huge need, challenges and actions that are required to reduce inequities and improve outcomes across the board. I support all of the many recommendations.

“Shortcomings are few but from my perspective include omission of changes that need to be made in the education and health sectors regarding pre- and post-entry education. Without a significant increase in graduate numbers reflecting the demographics of the population they serve, a changing skill mix and ongoing professional development, the required developments cannot occur.  Similarly, reform needs to be research-informed and evaluated.  This too is not adequately addressed.

“While drug addictions are highlighted behavioural addictions aren’t included. Recent New Zealand research shows the health and social harms associated with gambling disorder alone exceed those of drug abuse and come close to those of major depression.

“The review has identified numerous gaps and the varied and substantial measures needed to address them. It has probably further increased already high expectations for reform. The major challenge is translating all this into reality at ground level. This cannot happen overnight and will require careful prioritising and management. It will require ongoing commitment from future governments. It will need to avoid capture by vested interests including professional and governmental entities that could thwart innovation and significant reform.”

No significant conflicts of interest. But I have an AUT senior management role, and I’m a long time board member and past deputy chair of Waitemata DHB.

Professor Warren Brookbanks LLD, Professor of Criminal Law and Justice Studies, Director of the Centre for Non-Adversarial Justice, AUT Law School, comments:

“This is the first major report on the state of mental health and addiction services in New Zealand for over 20 years. Unlike earlier reports, it is not incident-driven but represents a purposive inquiry into the broad social determinants of mental health and wellbeing in New Zealand. The defined purposes of the Report are to hear the voices of people with lived experience of mental health and addiction challenges, to report on how New Zealand is preventing mental health and addiction problems, and to recommend specific changes to improve New Zealand’s approach to mental health.

“The breadth of the Terms of Reference for the Report has meant that the Inquiry has been able to investigate mental health problems across the full spectrum, from mental distress to enduring psychiatric illness and to a consideration of the full range of social determinants that influence mental health outcomes. In addition, the Inquiry has revealed a ‘striking’ degree of consensus in the community as to the need for change in New Zealand’s mental health services and the need for a new direction that is focused on wellbeing and community.

“To this end, the Report has identified a range of powerful themes that have emerged from consultations with submitters, and which provide the structure for particular chapters in the Report. These include the voices of the people (chapter 2), access and choice (chapter 4), wellbeing promotion and prevention (chapter 7), action on alcohol and drugs (chapter 9), suicide prevention (chapter 10) and Mental Health Act reform (chapter 11). In the final chapter the report recommends the establishment of a new Mental Health and Wellbeing Commission tasked with providing system leadership and implementation support for mental health and addiction and the transformation of the system, and to oversee and monitor the mental health system.

“Of special interest in the Report is the recommendation that the current Mental Health (Compulsory Assessment & Treatment) Act 1992 be repealed and replaced by a legislative model better equipped to reflect international best practice and a new focus on capacity, as opposed to compulsion. This is consistent with developments in other comparable jurisdictions and reflects the growing human rights focus of international documents, in particular, the United Nations Convention on the Rights of Persons with Disabilities.

“However, given the lengthy gestation period that accompanied the enactment of the 1992 statute, it would be naive to think that such a radical change could be effected speedily and in the absence of further widespread consultation and debate. Indeed, given the other priorities identified in the Report it may be that reform of mental health legislation becomes a less urgent concern, particularly in the face of New Zealand’s alarming suicide statistics and the ongoing challenges of substance abuse and addiction. Both of these issues properly command substantial discussion in the report.

“In relation to action on alcohol and other drugs, the Report acknowledges the significant and widespread impacts these substances are having on individuals and whānau, and ultimately on the whole community. The recommended approach to addiction is to view it as a health and social issue requiring care and support for effective management, by providing support, compassion and access to treatment for users.

“However, the Report notes, disturbingly, that current action on reducing the harmful use of alcohol has stalled. As a result, present official policy is not having the hoped-for impacts and is disproportionately impacting Māori and those in socioeconomically deprived areas. However, the challenge from the Report to drink responsibly is to the nation as a whole, given that one in five New Zealanders drink hazardously each year.

“On the vexed issue of suicide prevention the Report notes that an estimated 150,000 people each year think about taking their own lives, while 525 people died by suicide in 2015, as annual suicide rates continue to increase. In response to this grave problem, the Report recommends a long-term commitment to suicide prevention, including the provision of a clear vision and direction that recognises the complexities associated with suicide, culturally appropriate and inclusive bereavement support, responsiveness to Māori and Pacific world views and responsiveness to the needs of at-risk communities.

“However, in recognition that legislative processes that may be necessary to implement key aspects of the Report’s recommendations may take some time, the Report recommends the establishment of a ministerial advisory committee on an interim basis to lead or participate in urgent tasks while the new Health and Wellbeing Commission is being established.

“But in the final analysis what is sought, and recommended in the Report, is a collective and enduring commitment to improved mental health and wellbeing in New Zealand.”

No conflicts of interest.