The medium is the message

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In the marketplace of ideas, topics about mental health can be a bit of a hard-sell. Digital media promises more opportunities for open dialogue and debate, however that depends on what gets published and how engagement with the reader is structured and controlled. When it comes to mental health care, we need to make contrasting positions visible and open up discussions which challenge dominant narratives. If we don’t, then the status quo goes unchecked and the voices of marginalised people are drowned out by those in charge. 

Recently it has seemed as though stories about mental health policy are being hurriedly presented without giving readers much of an opportunity to engage in meaningful dialogue. A few days ago for example, we saw a point and counterpoint article being published on The Conversation. The first piece by Anthony Jorm and Steven Allison raised important concerns about the cost of early intervention programs for psychosis, specifically that “…the Headspace program cost A$318,954 per QALY gained, which is way above” the recognised standard for cost effectiveness. It was followed by a rebuttal piece by Patrick McGorry and his colleagues at Orygen claiming a “substantial return on investment” for these programs. However, the article was light on detail about what the specifics of those returns were and there was no weighted analysis of how those returns measure up against costs. I point out that a price tag of $318,954 is a lot money to improve quality of living for just one year. By way of comparison $1765 is what it costs for Medicare to fund twenty (20) sessions of psychological care in a year. Maybe the QALYs don’t translate year for year, but I’d be willing to wager that we don’t need 180 years of 20 sessions to improve QALYs by one point (i.e., $318,954 worth).

Now normally one would simply go to the comment thread of an article like that and chime into the discussion. In this case, it had been less than two days since those articles were published, yet the comments were closed for both. A notice at the top of the comment thread reads that comments are “open for 72 hours” (three days) but may be closed early if there’s a high risk of breaching their standards. To my eye it didn’t look like much moderation (if any) was needed. I was left puzzled about how to engage. By the time one learns that an article has been published and gets around to reading it, the comments are closed. There didn’t really seem to be much space for a conversation at The Conversation. 

On the same day, Croakey published an article by Sebastian Rosenberg and Ian Hickie criticising the cost of psychological services in the Medicare system. In this case, the comment thread was open so I raised my objections only to find that my comment had been censored. My comment (verbatim here) pointed out that readers should be aware that Hickie and Rosenberg never miss an opportunity to criticize the Better Access program. Ian Hickie for example was doing the rounds on radio to take shots at the idea as far back as March 2006 – long before the program had even launched. For well over a decade, Rosenberg has been publishing alarmist stories (often in Croakey) about the cost per week of including access to psychological care in the Medicare system. This latest article is just another example and more of the same. Further, this article incorrectly claims that those calling for more sessions in Medicare miss the point that people living with some mental health conditions, like eating disorders, may achieve better results with integrative centre-based systems of care. Nobody is making that claim. It’s a straw-man argument.

If we were to list all of the articles ever written criticizing the costs of funding psychotherapy in Medicare, one wonders what proportion were written by or on behalf of these two critics? Having read most of them over the last decade, I would guess that figure is close to 100%. The sheer volume of these hit-pieces gives an appearance that theirs is the dominant public view. Timing of publication is often like clockwork, aimed at influencing political decision making ahead of the federal budget or other key policy decisions. In this way, the opinions of a very small faction dominate public policy here in Australia. Croakey and other media platforms play a role in shaping that state of affairs.

The key issue about the number of sessions of therapy people can access under Medicare is that ten sessions falls well below basic standards of care. We should remember that Hickie and McGorry misled the senate inquiry in 2011 with their suggestions that the Medicare system should be capped at just ten sessions of therapy. It was on their guidance that the program was scaled back, resulting in further fragmentation and public confusion about how to access psychological care. Dr Aaron T. Beck invented cognitive-behaviour therapy (CBT) which is the main brief intervention used in the Medicare scheme. He recently passed away at the ripe old age of 100 years, but thankfully a few years ago he wrote a letter to our politicians here in Australia stating that optimal treatment for depression often requires “up to 24 visits”. The central issue here is about helping people access psychotherapy for long enough to attain good results. Access to basic standards of psychological care via Medicare is a sensible and cost-effective public investment.