Mental health

Australian cancer care is among the best provided in the world. Yet, many cancer patients choose to either forgo aspects of conventional treatment or seek unproven complementary therapies. My own recent cancer treatment prompted me to wonder whether these choices may, at least in part, be due to the failure of Western medicine to address the psychological ...

Tanya L Hall BMed, FRANZCP

To the Editor: The latest guidelines for the management of absolute cardiovascular disease (CVD) risk released by the National Vascular Disease Prevention Alliance1 question the utility of conventional risk assessment methods to accurately estimate cardiovascular risk of individuals with depression. Subsequently, these guidelines advocate that individuals assessed for CVD risk be assessed for depression and other psychosocial factors. This appears to be a promising advance, ...

Adrienne E O’Neil

To the Editor: In describing 8 years of experience in managing adolescent gender identity disorder (GID) at a paediatric hospital clinic, Hewitt and colleagues highlight a small group of patients who require momentous life-long clinical decisions made in a timely manner.1 However, the rarity of this condition means that experience in any centre is limited. The authors state that authorisation from the Family Court of Australia is ...

Ann J Conway · Julie C Hamblin · David J Handelsman

To the Editor: I welcome the article by Hewitt and colleagues,1 but their protocol is problematic. Suppression of puberty improves mental health and general functioning, but not body image and dysphoria.2 For this, cross-sex hormones and/or surgery are the only effective treatments.2 Withholding cross-sex hormones until children are 16 years of age may worsen their mental health,3 cause resentment, and encourage self-medication. Increasingly, young transsexual people are ...

Zoë Hyde

In reply: We thank Hyde and Conway and colleagues for their correspondence following our report on treatment for young people with gender identity disorder (GID).1 We follow current international consensus recommendations for management,2,3 but accept that as more research is performed, there may be future adjustments to endorsed protocols. At present, patients can apply to the Family Court of Australia for authorisation of treatment that ...

Jacqueline K Hewitt · Campbell Paul · Louise K Newman

Cunningham’s perspective provides a timely review of the literature relating to the maternal psychological outcomes of holding stillborn babies, which remains controversial. It is unfortunate that some popular media sources reported it incorrectly as saying that seeing and holding stillborn babies may cause harm. The correct conclusion is that the literature is inconclusive. The Australian and New Zealand Stillbirth Alliance strongly supports Cunningham’s ...

Vicki J Flenady · Christine Carroll · Ros M Richardson

To the Editor: Monshat and Castle have summarised the current state of play of mindfulness as an important component of the integrated management of chronic disease. So too medical students experience significant acute and chronic psychological disturbance, which impacts on their professional performance and personal life, as well as increasing their risk of substance misuse and suicidality.2 Strangely, in this respect, students and doctors have much ...

Jonathan P Page

PATIENTS WITH eating disorders are like canaries in the mines warning of some of the ills of Western society. In broader society, we have lost our way with eating. There are mixed messages on desirable weight and eating. We fret about obesity. No wonder a young person with little sense of self-worth stumbles into dieting and develops an eating disorder. The publisher’s website states that “Fast ...

Judith Fleming

GORDON PARKER describes himself as a “contrarian”. He admits that he’s difficult, combative, impatient with received wisdoms in psychiatry that he thinks don’t work, and dogged — even aggressive — in tackling problems, clinical and conceptual. And it’s clear in this intellectual autobiography that these personal qualities, combined with his enormous energy and brilliance, have been central to his enormous contributions to the field. Professor ...

Rebecca E Adams

To the Editor: The report by Scott and colleagues on the “demographic characteristics, diagnostic category, stage of illness, as well as psychosocial and vocational impairment” of 1260 patients presenting to two Sydney headspace centres1 is problematic for several reasons. No convincing data were presented to support the authors’ conclusion that the research demonstrated that “well designed youth ...

Jon N Jureidini

To the Editor: The study of headspace attendees by Scott and colleagues1 illustrates problems common in articles being used for lobbying purposes in the Australian mental health policy arena. These include misrepresentation of evidence, inappropriate medicalisation, and undeclared competing interests. The authors refer to un(der)employment, lack of engagement in study, and receipt of income support as ...

Melissa Raven

In reply: The detailed demographic, diagnostic and disability data we presented1 responds directly to the critics of headspace clinics. Following the initial establishment phase,1 our two centres now provide services to 390 and 411 young people per month, respectively (data from July to September 2011). Each of the 30 established headspace services now assesses an average of 265 clients ...

Ian B Hickie · Daniel F Hermens · Elizabeth M Scott

As the publication date draws closer, concerns grow over the proposed format of the DSM-5The American Psychiatric Association is currently undertaking a major revision of the Diagnostic and statistical manual of mental disorders, and the 5th edition (DSM-5) is due to be published in May 2013. The process of the revision of this publication has ...

Paul B Fitzgerald MB BS, PhD, FRANZCP

Youth mental health expert Alison Yung says safe treatments should be offeredSchizophrenia carries a great personal and economic burden. It begins with a non-psychotic prodromal phase before the onset of characteristic positive symptoms such as delusions and hallucinations. This prodromal phase is therefore a potential target for early intervention. Criteria have been developed to identify the ...

Alison R Yung MD, MPM, FRANZCP

Schizophrenia expert David Castle suggests caution, especially regarding medication useIt has been suggested that one can “predict” schizophrenia at an individual level. Features posited as being part of these so-called ultra-high risk (UHR) criteria1 include risk factors (eg, a family history of schizophrenia), symptoms (eg, attenuated positive psychotic symptoms) and longitudinal trajectory (decline in functioning). ...

David J Castle MD, FRANZCP, FRCPsych

It is now less clear how parents should be advisedIn Australia, stillbirth is defined as the loss of a fetus of at least 20 weeks’ gestation, or 400 g birth weight if gestational age is unknown. Every year in Australia there are 1750 stillbirths.1 Several studies have reported that stillbirth, regardless of how it is managed, can have ...

Kelly A Cunningham BSc, PhD

Most specialised mental health services in Australia are delivered in community settings and one in six services comprise involuntary treatment. Despite a growing demand for community treatment orders (CTOs) worldwide — and comparatively high rates of use in Australia — the clinical, legal and ethical aspects of CTOs remain contentious. This article examines ...

Edwina M Light BA(Comms), GradCertJournalism, GradCertBioethics · Ian H Kerridge MPhil, FRACP, FRCPA · Christopher J Ryan MB BS(Hons), MHL, FRANZCP · Michael D Robertson MB BS(Hons), FRANZCP, PhD

Staff safety is improved by clear procedures for managing abuse and assault. Hopper and colleagues describe a scenario familiar to many hospital clinicians and managers: staff reports of verbal abuse and physical assaults from patients.This is often in an organisational context of scarce reliable data about the phenomenon, an ad-hoc management response and no specific training of staff to manage aggression....

Brett McDermott MD, FRANZCP, CertCAPsy

Despite significant recent public investment in mental health, do we really know what Australia is getting for its money? In response to repeated inquiries revealing a profound crisis in the provision of mental health care services,1 Australia has committed to spending around $8 billion of new money on mental health since 2006. Few would argue that this investment was long overdue, given the significant gap between the funding mental health receives ($5.8 billion2 out of $113 billion of total health expenditure in the 2008–09 financial year3) and the contribution of mental illness to the burden of disease (13%).4 However, proper accountability for this expenditure is crucial. Health care consumers, carers, service providers, funders and taxpayers all have a right to know that funding for mental health is being spent judiciously, is targeted at the areas of greatest need, and is delivering better outcomes for people with mental illness. Establishing this accountability is not easy. The complexity of state and federal Budget announcements (and re-announcements) are the modus operandi of governments and perpetuate an environment characterised by opacity rather than transparency. After decades of underfunding for mental health services, new funding is often simply welcomed without query as to provenance or policy. In this article, we review the recent wave of mental health funding decisions in Australia. While we want to see the level of funding increase, such increases must be evidence-based, effectively delivered and transparently monitored. Recent mental health fundingThe major contribution to recent funding for mental health has been through the Council of Australian Governments (COAG) National Action Plan (NAP) on Mental Health 2006–2011.5 This provided $5.5 billion, comprising $2.2 billion from the Australian Government and $3.3 billion from the states and territories. However, analysis of Medicare Benefits Schedule (MBS) item reports shows that the uncapped growth in the Better Access to Psychiatrists, Psychologists and General Practitioners through the MBS (Better Access) initiative alone accounted for $2.1 billion by September 2011. It is concerning that, for such a sizeable investment, there have only been two NAP progress reports published, the most recent being released in September 2009.6 A subsequent COAG agreement in 2010 included $1.6 billion to be spent on subacute care, with an unspecified proportion to be allocated to mental health. Lastly, there is the federal government’s 2011 Budget announcement of a “record” $2.2 billion investment in mental health, partly funded through changes made to curb government payments under the Better Access initiative. A large proportion of this package was to enable continued funding of existing programs like Better Access, but the Budget also continued the government’s extensive investment in largely untested semi- or non-professional coordination of services (the Personal Helpers and Mentors Program) and “flexible” packages of care. There are as yet no data to assess how this new funding is progressing. In total, this new spending represents a significant public investment in mental health and, as such, deserves scrutiny. COAG National Action Plan fundingThe $5.5 billion committed in the 2006–2011 COAG NAP was allocated across four agreed action areas. However, there were no agreed definitions as to what activities could or should occur within each action area, and jurisdictions had complete autonomy over how money would be spent and reported. Consequently, there were significant variations in the funding allocations between jurisdictions (Box).6 Fully two-thirds of all NAP funding was allocated to Action Area 2 — “integrating and improving the care system” — while only 5% was allocated to Action Area 4 — “increasing workforce capacity”.6 The bulk of Action Area 2 funds went to the Better Access initiative. Supported housing options, community participation and employment (Action Area 3) remained secondary elements of the NAP, accounting for 17% of total funding allocations. In New South Wales, more than half the spending in this area ($58 million) was on one program — the Housing and Accommodation Support Initiative. Victoria pledged to spend about $44 million on growing its psychosocial rehabilitation sector, but over a 5-year period (2006–2011) this would barely cover anticipated price pressures and wage increases, let alone service expansion. Increasing access to mental health care was clearly a key goal of the NAP, but the evidence for progress is equivocal. The second NAP progress report certainly shows substantial service growth over the period 1997–2007, largely accounted for by the growth in Medicare-funded (Better Access) services.7 It reported that the proportion of the Australian population receiving clinical care for mental illness under Medicare rose from 3.1% in 2006–07 to 4.8% in 2007–08.6 However, the same progress report also shows that the proportion of the population accessing state-run mental health services dropped from 1.6% to 1.5%. Further, the National Survey of Mental Health and Wellbeing conducted by the Australian Bureau of Statistics in 2007 showed that treatment rates for people with a mental illness were unchanged since 1997.8 If the spending effort in Action Area 2 has not led to a discernible increase in treatment rates, then what substantive impact is this increased investment in traditional services having on mental health care in Australia? One explanation might be that new funds and new services are struggling to reach new clients. The data for state-run mental health services in the second NAP progress report indicate that this is the case for state and territory services. The current debate regarding the effectiveness and reach of the Better Access initiative is significant in this regard.9,10 There is evidence suggesting that groups who were missing out on care before Better Access are still missing out. In 2008, 68% of people using the Better Access program were using it for the first time. In 2009, this figure had dropped to 57%.11 The NAP progress report does not provide reasons for the variation in spending priorities between jurisdictions. There is no context to explain why Western Australia should allocate nearly a quarter of its funding to Action Area 1, while Queensland spent almost nothing (Box). Similarly, WA spent four times as much as South Australia on Action Area 3, and the Australian Capital Territory allocated 20% of its effort to workforce development, to which Victoria committed less than 1%. It is conceivable that these jurisdictional variations may be based on local service deficiencies and are therefore warranted. However, if this is the case, it is not clear how such deficiencies were identified. The NAP progress report shows a patchwork of jurisdictional investments rather than a coordinated national effort to address the agreed priorities. In the absence of nationally consistent definitions and accounting processes, it is impossible to verify whether jurisdictions really did spend what they reported. 2010 COAG agreement funding for subacute careThe 2010 COAG agreement to spend $1.6 billion on creating 1300 subacute beds, some of which are to be allocated to mental health, is also without transparency and agreed guidelines. In making this commitment to subacute care, COAG echoed the 2009 final report of the National Health and Hospitals Reform Commission, which stated: We recommend that every hospital-based mental health service should be linked with a multi-disciplinary community-based sub-acute service that supports “stepped” prevention and recovery care.12 There has been no progress report on the implementation of the mental health aspect of this agreement, but from public announcements it is possible to once again discern major variations in jurisdictional approaches. Queensland is building community care units, while SA is opting for supported accommodation places with crisis respite support. NSW is allocating all its subacute funding to new beds on hospital campuses. This variation between jurisdictions is not surprising, as there is no agreement on what constitutes subacute mental care. The term “subacute” does not appear anywhere in the National Mental Health Policy 2008 and is mentioned only once in passing in the Fourth National Mental Health Plan. Alternatives to hospital admission for mental health care in Australia are few. An unpublished national snapshot survey of acute psychiatric wards across Australia in 2006 indicated that 43% of all acute beds were occupied by people who could be cared for in other settings if suitable services were available. The investment in subacute care offers critical opportunities to build new services nationwide. However, competing priorities and a lack of consistent implementation may mean this opportunity could be lost. ConclusionDespite these increased investments, mental health’s share of overall health spending is shrinking. For the period 2004–05 to 2008–09, total mental health spending in Australia increased by an average of 4.8% per annum,2 while total health spending rose by more than 5%.3 There have been some 44 inquiries into mental health in Australia since the 1890s — about one every 2 and a half years. Despite these inquiries, and dozens of plans and policies, spending between jurisdictions continues to be uncoordinated, lacking both accountability and a focus on patients’ needs. There is little evidence to show that new mental health investments are driving improved health outcomes. For people with mental illness, the spectrum, capacity and quality of services available depends on where they live, and the quality of care goes largely unassessed. For real accountability, the new National Mental Health Commission must begin with a robust plan to identify and close service gaps based on evidence-based models of care. This should be accompanied by a National Report Card that includes nationally validated data of the experience of care, quality of life, and rates of homelessness, education and employment for people with a mental illness. Without this, no one will know if mental health funding is well targeted or just well meant. Council of Australian Governments (COAG) National Action Plan (NAP) on Mental Health 2006–2011 funding allocations, by action area and jurisdiction6 Action area* Jurisdiction 1: Promotion, prevention and early intervention 2: Integrating and improving the care system 3: Participation in the community and employment† 4: Increasing workforce capacity Total NAP ($ million) Australian Government 164.2 (8.2%) 1329.8 (66.7%) 369.5 (18.5%) 129.9 (6.5%) 1993.4 New South Wales 121.7 (12.4%) 721.6 (73.6%) 113.8 (11.6%) 23.3 (2.4%) 980.3 Victoria 97.7 (15.2%) 432.1 (67.0%) 110.6 (17.2%) 4.4 (0.7%) 644.8 Queensland 16.3 (1.7%) 717.5 (73.0%) 168.4 (17.1%) 76.9 (7.8%) 983.3 Western Australia 106.8 (22.1%) 216 (44.6%) 139.6 (28.9%) 21.5 (4.4%) 483.9 South Australia 47.1 (16.3%) 215.1 (74.6%) 22.1 (7.7%) 4.2 (1.5%) 288.5 Tasmania 2.2 (3.8%) 36.6 (62.4%) 11.3 (19.3%) 8.6 (14.7%) 58.7 Australian Capital Territory 5.1 (12.3%) 20.1 (48.3%) 8.1 (19.5%) 8.3 (20.0%) 41.6 Northern Territory 1.3 (8.6%) 13 (86.1%) 0.8 (5.3%) 0 15.1 Total 562.3 (10.2%) 3701.8 (67.4%) 944.2 (17.2%) 277 (5.1%) 5490.1 * Figures shown for each action area are $ million (percentage of total COAG commitment). Percentages may not sum to 100% because of rounding. † Including accommodation.

Sebastian P Rosenberg MPubAdmin · John Mendoza BEd · Lesley Russell PhD

Putting a team-based intervention approach to the test.

Sandy M Hopper FRACP, FACEM · Franz E Babl MD, FRACP, FACEP · Claire E Stewart PGDipENB, RN · Jia Wei Woo BSc, MB BS

Objective: To assemble what is known about the mental health of Indigenous Australians from community surveys.

Anthony F Jorm PhD, DSc · Sarah J Bourchier BPsych(Hons) · Stefan Cvetkovski MPH · Gavin Stewart BSc(Hons)

Substance misuse and intellectual disability take their toll.

Ernest M Hunter FRANZCP · Bruce D Gynther FRANZCP · Carrick J Anderson MB BS · Leigh-ann L Onnis GradDipPH · Jeffrey R Nelson PhD · Wayne Hall PhD · Bernhard T Baune PhD, MD, FRANZCP · Aaron R Groves FRANZCP