How can we increase access to mental health care?

Direct access to mental health specialists is not the solution to improving mental health outcomes

The 2020–21 Australian National Study of Mental Health and Wellbeing found that just over one in five Australians had experienced a mental health disorder during the preceding year,1 but just under half these people had consulted a health care professional about mental health.2 Of those who did not report consultations, about 90% did not want information about mental health treatment and services or medication, and almost 80% did not want counselling.3 These findings highlight the challenge of knowing whether we are meeting community mental health needs. Access to Medicare‐subsidised mental health care specialists requires a consultation with a general practitioner to draw up a mental health treatment plan and a referral to a mental health specialist. During 2020–21, general practitioners provided 1521443 Medicare‐subsidised mental health treatment plans.4

In this issue of the MJA, Vacher and colleagues5 report their dynamic systems modelling of the effect of allowing some level of direct access to mental health specialists (10–50% of consultations) by removing the requirement for a referral and a mental health treatment plan. Their model simulated the impact of direct access on the numbers of mental health‐related emergency department presentations, hospitalisations following self‐harm, and deaths by suicide. Their model appears robust, accounting for complex interactions between a number of factors, including the psychosocial effects of the COVID‐19 pandemic. Dynamic systems modelling of complex interactions to inform population‐level health policy reform is a welcome supplement to real‐life experience. Vacher and her colleagues drew on the available evidence and datasets to inform their model, but we note that some parameters and inputs were derived from studies that may not be representative of mental health care in Australia or direct access health care users, such as rates of disengagement caused by waiting times.6

Vacher and colleagues found that as the proportion of people directly accessing professional mental health care increased, the numbers of adverse mental health outcomes also rose, including hospitalisations with self‐harm and deaths by suicide. This unexpected and concerning finding was the consequence of disengagement caused by a projected increase in specialist mental health service waiting times, which in turn increased psychological distress. To address this problem, they modelled increasing mental health care specialist capacity at two to five times the current annual growth rate. The authors modelled several combinations of direct access level and accelerated mental health service capacity growth that improved mental health outcomes; they found that 50% direct access combined with a fivefold increase in annual capacity growth would more than double the benefits of increased capacity alone.5

One cannot assume that direct access would lead to all eligible people taking up the opportunity of self‐referral; in the National Study of Mental Health and Wellbeing, many people with mental health problems who had not consulted health care professionals did not feel the need to do so.3 Paradoxically, we might consequently see neither the increase in harm nor the need for more mental health specialists were direct access introduced in isolation.

A mental health care system that bypasses general practitioners as gatekeepers to specialist care has recently been the subject of debate in Australia.7 A fivefold increase in the annual growth of specialised mental health services capacity would be equivalent to an almost 72% absolute increase over seven years. The practicality and cost‐effectiveness of such a policy was not investigated by Vacher and colleagues. The underlying assumption that the role of the general practitioner is an unnecessary “gatekeeper” is at odds with the facts that multimorbidity is typical for people requiring mental health care8 and that the complex interplay between physical and mental health benefits from a generalist approach.9,10 Direct access is not the answer for reducing the mental health burden. Our attention should instead turn to innovative models of care that include general practitioners, and assist in identifying appropriate care options tailored to individual needs.11

The study by Vacher and colleagues highlights the potential harm of a mental health care system without the requirement for a general practice referral. Their findings are stark and concerning, particularly the increases in deaths by suicide, self‐harm leading to hospitalisation, and mental health‐related emergency department presentations. We therefore recommend models of care that build bridges between general practice and specialist mental health care and draw upon the strengths of each discipline to meet the needs of the whole person.