Broken promises and missing steps in mental health reform

We are still seriously failing to resource and integrate mental health into the mainstream of the health care system

Hundreds of stories of inequity and neglect make up the mosaic assembled in the recent national Survey of High Impact Psychosis.5 This is the face of health care apartheid, and every Australian family is at risk of this discriminatory public policy. This issue of the MJA summarises the new Royal Australian and New Zealand College of Psychiatrists clinical guidelines for the treatment of schizophrenia.6 Guidelines honoured more in the breach than the observance.7 Evidence-based health care depends on service systems that are appropriately financed and organised, a prerequisite still not met in Australian mental health care.8

Yet, hard won scientific evidence now shows that if, as with other non-communicable diseases, our mental health system placed a premium on early diagnosis, provided intensive expert care from the onset of illness and sustained that care over the duration of the illness, life expectancy and functional outcomes would be greatly improved. In some ways, Australia has made progress on mental health in the past 20 years. We have substantially increased awareness of depression.9 Successive federal governments have improved access at the primary care level for mild to moderate mental ill-health, invested in innovation for youth mental health and have begun to cover, via non-clinical support, yawning gaps in the care of patients who are seriously mentally ill after deinstitutionalisation.

However, although per capita funding for mental health grew in real terms by about a third in the decade to 2014–15, the main growth was between 2005–6 and 2009–10, and the rate of growth has since slowed markedly.10 State governments, which reaped the financial rewards of the dismantling of the 19th century asylums, have failed to build a modern expert system of care to take their place. This was the explicit promise made to justify the risk of blending mental health with physical health systems — a promise badly broken. Growth in mental health expenditure has slowed to a trickle at state government level, with per capita funding for clinical community mental health care actually falling, despite burgeoning population growth.11 Demand is transferred to a hospital-centric system already too low in beds to cope, and all balance has been lost. This erosion of the state public mental health system has been compounded by diversion of previously ring-fenced mental health funding by acute hospitals and a dangerous decline of leadership, morale and evidence-based practice. This hidden crisis has been finally exposed, after years of complacency and obfuscation, in Victoria — once the envy of the nation, with the highest per capita spending, through the release of the Duckett report.12 Access to specialist mental health care in Victoria is now around 50% that of key comparator states, notably New South Wales, which themselves represent a too low benchmark. This verdict has at least been freely acknowledged by the Victorian government.13

The national failure of clinical community mental health care is compounded by the threat posed by the National Disability Insurance Scheme to patients currently covered by existing non-government organisation-based non-clinical mental health programs. The National Mental Health Commission emphasised the assembly of an expert multidisciplinary system of stepped care committed to early diagnosis, cure and recovery as the priority, and best possible chronic disease management as the next best thing.9 The failure to build such a system in the wake of deinstitutionalisation has resulted in large numbers of Australians with mental ill-health consigned to their childhood bedrooms with exhausted and anxious parents as their case managers, to lonely lives in poor housing, to prisons, to the streets or to a premature grave.14 In the United States, Torrey15 labelled this scenario an “American psychosis”. The disease has well and truly spread to Australia; its symptoms include the unfulfilled potential of hundreds of thousands of Australians with mental ill-health, avertable suicides and escalating duress on our justice and welfare systems.

What tantalises is that things could be transformed with the implementation of existing evidence. Many of the strategies to enhance the mental health system’s capacity to provide appropriate care have been proposed by the National Mental Health Commission.8 We should build on the major achievements of beyondblue (https://www.beyondblue.org.au) in improving knowledge of and reducing stigma for depression, and include the full spectrum of mental ill-health within the mandate “beyondeverything”. However, awareness is not an end in itself, and unlocking unmet needs carries with it the responsibility to provide care. Only 16% of people with depression are receiving even minimally adequate evidence-based care.16 An immediate priority is to invest heavily in expert multidisciplinary community care for the “missing middle” population of patients who are too complex for primary care, and yet are locked out of state mental health care. A seamless graded system of stepped clinical care with an early intervention focus should be constructed as a federal and state joint venture via Primary Health Networks. The regional commissioning model has advantages, but must be tied to clear evidence-based national templates to find the sweet spot between reproducible evidence-based models of care and innovative local adaptation. Sustained expert oversight to reduce the constant threat of implementation failure is required.

Current caps to access to more specialised clinical services through the Better Access initiative are not supported by evidence and should be modified. Imagine if chemotherapy sessions were capped on such an arbitrary basis. New funding to support vocational needs and combat addiction is another urgent priority. A large proportion of those who needlessly die from suicide is from the ranks of those people who have sought or need expert mental health care, but who cannot access it. Any genuine suicide prevention strategy must prioritise the needs of people who are already clearly in immediate danger. We are less clear about what to do about people who have not yet sought help but are in danger too, and this is where trials are appropriate. Nevertheless, we should not confuse the determinants of suicide, and hence we should provide primary prevention with the complementary need to stem the tide through decisive action of a supportive and expert clinical nature.

These measures all require additional investment. However, the timing in the life cycle of the onset and impact of mental disorders means that the economic returns are potentially greater than those attainable in other major non-communicable disease areas. Poorly treated mental disorders have double the impact on global economic output of all cancers.17 This is why the Prime Minister repeatedly refers to the “mental wealth” that will flow from more effective mental health care.18 Nationally, about 40% of annual expenditures consequent on mental ill-health are welfare transfers.8,10 Our increasing understanding about what sectors of our economy bear the major costs of mental ill-health and have the most potential to benefit from effective treatments may help diversify the funding base for mental health reform and inform the development of innovative financing models, such as social impact bonds.

There is also an urgent need for safer and better treatments. Yet, despite being responsible for at least 14% of the burden of disease and 28% of disability, mental health research receives less than 8% of the National Health and Medical Research Council (NHMRC) budget, and a dramatically smaller fraction of corporate, public and philanthropic donations. Not one mental health researcher is currently appointed to any of the major NHMRC committees or the Medical Research Future Fund. More apartheid. There is strong bipartisan support for mental health, but the public hold the key to transformational change. Decisive action will ultimately be fuelled, as with cancer and other non-communicable diseases, by the engine of self-interest. The fact that mental ill-health affects four million Australians every year makes this engine a powerful one.