Mental health reform: increased resources but limited gains

Improved population-level prevention and service access is needed

The National Mental Health Report1 is the prime vehicle for monitoring the mental health system reform agenda outlined in the Australian Government's National Mental Health Strategy. We consider here what the 2013 report tells us about the progress of that agenda.

First, we know that mental health expenditure, after 18 years of mirroring growth in overall health spending, in the 2010–11 financial year accounted for an increased proportion of health spending within the health sector. The direct-care workforce employed in mental health services increased by 72% between 1992–93 and 2010–11.

Second, the mix of services provided has improved. Inpatient care has moved from stand-alone psychiatric hospitals to psychiatric beds in general hospitals, while state and territory funding of ambulatory care services increased by 291% from 1992–93 to 2010–11. Between 2006–07 and 2010–11, the percentage of the population receiving Medicare-funded primary mental health care services rose from 3.1% to 6.9%, correlating to Medicare Benefits Schedule expenditure on mental health services increasing from $474 million to $852 million.

Encouragingly, gains have also been made in other areas. Rates of use of licit and illicit drugs that contribute to mental illness in young people have decreased. For example, in 2010, 19% of 14–29-year-olds used cannabis, compared with 36% in 1998.1 The suicide rate has also decreased since the introduction of the National Suicide Prevention Strategy in the late 1990s.2 Mental health literacy, particularly in relation to recognising depression and beliefs about treatments, has improved since 1995.3

However, much remains to be done in other areas. The prevalence of mental disorders appears to be unchanged,4,5 although methodological differences between the 1997 and 2007 surveys complicate any comparison. Employment participation rates have either decreased (from 64% to 62% for employment participation among working-age Australians with a mental illness) or remained unchanged (employment and education participation rates for Australians aged 16–30 years with a mental illness). Access to stable housing also remains largely unchanged.

The National Mental Health Strategy aims to reduce both the prevalence and severity of mental illness. Reducing prevalence involves both primary prevention and increasing access to effective services to reduce the duration of illness in those who already have symptoms. It is notable that increases in expenditure have largely focused on clinical services and, while it is encouraging to see the progress in this area, it is likely that the gains have been largely due to population health efforts, despite these having received a comparatively small amount of funding. For example, both the National Drug Strategy and the National Suicide Prevention Strategy have an emphasis on population prevention. beyondblue is also likely to have played a key role in improving mental health literacy related to depression.6 And MindMatters, a mental health and wellbeing framework for secondary schools, and KidsMatter, designed for primary schools, may also have assisted mental health literacy improvements.7

The low level of resource allocation to population mental health initiatives is seen in the section of the National Mental Health Report outlining key actions taken under the Prevention and Early Intervention priority area. The great majority of resources are targeted towards headspace and early psychosis youth centres, which, though valuable, are oriented towards treatment rather than prevention. The lack of attention to population-level mental health promotion and mental illness prevention is striking.

To reduce the prevalence of mental illness, considerably greater federal and state government-funded population health action is needed. This action should consider the developmental origins and risk factors over the life course, beginning with support for families during pregnancy and early childhood and continuing with programs such as online and school-based cognitive behaviour therapy and whole-school-based bullying prevention interventions.8 Mental health promotion in workplaces, the community and the aged care sector is likely to play a key role in preventing mental disorders in adults. Investing in population mental health strategies is cheap compared with the costs of specialist mental health services, but if successful will reduce future demand for these services.