On mental health policy: Do it better, or do it differently?

Mental health inquiries are more frequent than iPhone updates, says one observer, yet the results have been disappointing. Do we need to radically change our assumptions?

The article below is cross-posted from Inside Story.

Jennifer Doggett writes:

Among the commitments premier Daniel Andrews made during the recent Victorian election campaign was a royal commission into mental health in his state. Coming not long after the launch of a Productivity Commission inquiry into the impact of mental health on the economy and productivity, it was a dramatic expression of a wider trend. Separate inquiries were already examining the mental health systems of Western Australia and South Australia.

In any other healthcare field this welter of inquiries might seem excessive. But it’s business as usual for mental health, a sector in which inquiries are “more frequent than iPhone updates,” according to John Mendoza, former chief executive of the Mental Health Council of Australia. Two other experts in this area, Ian Hickie and Sebastian Rosenberg, have identified thirty-two statutory reviews of the mental health sector since 2006.

The reasons for such a high level of scrutiny are complex. But one key motivator is the quest to find out why, despite significant boosts in funding for research, policy-making and services over the past two decades, the statistics reveal that Australians are not enjoying improved mental health.

Unprecedented investment

The past twenty years have seen an unprecedented investment in the mental health sector in Australia. Advocacy and public-awareness efforts have intensified through organisations like Beyond Blue (established 2000). Dedicated research institutes, including the Black Dog Institute (2002) and Sydney University’s Brain and Mind Centre (2003), have linked researchers and health professions to translate research findings into practice. New funding initiatives have included the federal government’s Better Access initiative (2006), which provides more than $1.2 billion each year in Medicare funding for mental health services, including clinical psychology and psychiatry. And new services and programs like Headspace (2006) — which operates more than one hundred youth mental health centres and an online service — have targeted specific at-risk groups.

Meanwhile, new federal and state/territory bodies have been created to oversee mental health policies and programs and provide advice to governments. These include the National Mental Health Commission (2012), the Western Australian Mental Health Commission (2010), the Mental Health Commission of New South Wales (2012), the Queensland Mental Health Commission (2013), the Mental Health Complaints Commissioner Victoria (2014) and the South Australian Mental Health Commission (2015). Providing a framework for these initiatives is a series of national mental health plans dating back to 1993, the latest of which is the Fifth National Mental Health and Suicide Prevention Plan.

The unprecedented investment has dramatically increased consumers’ access to care. Mental health service use, particularly of services provided by psychologists and other allied professionals, has steadily increased. The number of patients receiving Medicare-subsidised mental health services, for example, has doubled in the past eight years, from 1.2 million (or 5.7 per cent of the population) in 2008–09 to 2.4 million (9.8 per cent) in 2016–17. The overall number of Medicare-funded mental health services (as opposed to the number of people receiving these services) has increased from 6.2 million in 2008–09 to 11.1 million services in 2016–17.

Public hospitals and private hospitals have experienced a similar increase in demand, with the overall rate of overnight mental health–related visits increasing by an average of 3.9 per cent in each of the five years to 2016–17. (Data for community-based mental health services is not available for this period.)

Medication uptake has followed a similar trajectory. Since 2000, the rate of antidepressant use in the community has more than doubled, bringing to one in ten the number of Australians taking this form of medication, one of the highest rates in the world. Adolescents and even younger children have followed the same trend; and in 2015 the Department of Health released figures showing that almost 1500 Australian children aged between two and six had been prescribed antidepressants.

Of course, this increase in demand has come at a cost. By 2015–16, government spending on mental health services had reached a record high of more than $9 billion per annum — in addition to the significant contributions being made by private health insurance funds, charities and philanthropic organisations, and through direct payments from consumers.

Going backwards

Despite this significant investment, though, the mental health of Australia’s population hasn’t noticeably improved. On many indicators, in fact, we seem to be going backwards.

Since 2006, when the Better Access initiative commenced and Headspace began operating, the national suicide rate has actually increased, particularly among young people. A 2016 report by Orygen, the National Centre of Excellence in Youth Mental Health, found that youth suicide was the highest it had been for ten years. Suicide is now the leading cause of death among young Australians.

In 1992, to put things in a longer perspective, suicide accounted for 1.9 per cent of total deaths in Australia. That was before the national mental health strategy and the national depression initiative, and when barely anyone had heard of Prozac. Twenty-five years (and five national mental health plans) later, with Medicare payments for mental health services at $22 million a week and almost a tenth of the population taking antidepressants, suicides still make up 1.9 per cent of deaths.

Australia is not the only country that struggles to reduce the incidence of suicide and self-harm, of course. But our performance is worse than that of comparable countries, including Britain, Denmark, Germany and New Zealand. And, at 12.7 deaths per 100,000 in 2017, we significantly exceed the World Health Organization’s global average suicide mortality rate of 10.5 deaths per 100,000.

It’s true that suicide is not the only (and perhaps not the best) indicator of the performance of our mental health system. But it’s hard to find any indictors of improvement over the past two to three decades. The number of “disability adjusted life years” for mental disorders, for example, increased by 37 per cent between 1990 and 2010, and depression now outstrips musculoskeletal and respiratory conditions as the prime cause of non-fatal disability in Australia.

We’ve done particularly poorly at promoting better mental health outcomes among marginalised and disadvantaged groups in the community. Indigenous Australians continue to die by suicide at twice the rate of non-Indigenous Australians, with young Indigenous men taking their own lives at four times the rate of their non-Indigenous peers, and young Indigenous women at five times the rate. Data on the mental health of LGBTQ Australians has not been systematically collected, but some sources indicate that the rate of self-harm in these communities is the highest of any group in Australia.

It’s possible to explain away some of these figures as the short-term effects of policy changes that should deliver better health in the longer term. Increasing community awareness of depression was always likely to result in an increased demand for mental health services, for instance, which will eventually lead to improvements in mental health and a consequent reduction in suicide and self-harm. But there are no signs that these longer-term gains are on the horizon, let alone occurring.

Even without the statistics, it’s clear that something is very wrong with our current system of mental healthcare. As most of those thirty-two inquiries (and counting) have found, people with mental illnesses are frequently treated in ways that would be considered grossly inappropriate and unethical, if not criminal, if they were seeking treatment for a physical problem.

Human rights abuses

Just a small sample of recent stories in the media includes reports of people having to wait hours or days for treatment, being forced to sleep on hospital floors, and being restrained without their consent, isolated in locked rooms and/or shackled to their beds. People “regularly” escape from allegedly secure facilities, and others have died after being kept in custody without access to essential medication.

Healthcare services continue to use outdated and inappropriate practices despite their traumatic impact on patients and a lack of evidence of efficacy. Over a decade ago, for example, a review by the respected Cochrane Collaboration found no evidence to support using seclusion and restraint to control mental health patients. All Australian governments have agreed to reduce and, where possible, eliminate these practices, and yet Ian Hickie and Sebastian Rosenberg recently reported that mental health patients endured seclusion close to 12,000 times and physical or mechanical restraint 13,000 times in 2016–17.

Even more tragically, in the twelve months to June 2016 twenty-eight people committed suicide while in mental health inpatient units. Less frequently, people with mental illnesses have harmed the healthcare providers who are attempting to care for them.

Consumers who have spoken out about their experiences describe their treatment within the health system as more traumatic than their illness. At a recent Australian College for Emergency Medicine summit, Melbourne woman Fiona Nguyen described the shocking treatment she received during a mental health crisis, including having her door broken down by eight police officers who threw her to the ground and handcuffed her before taking her to a hospital emergency department where she had to wait twenty-seven hours for treatment.

Families also report the devastating experience of finding the mental health system grossly inadequate for needs of family members with a mental illness. At the same summit, Debra Sobott from Perth described how she organised family members to provide twenty-four-hour care for her son in order to keep him out of the mental health system after finding him alone in a seclusion room writing “let me die” in his own blood on the wall.

Daniel Fatovich, an emergency physician from the Royal Perth Hospital, sums up the situation by describing hospital staff as “basically heartbroken” by trying to provide mental healthcare unsuccessfully to patients in what he termed “a truly failed system.”

It would be easy to attribute responsibility for these problems to an individual or group of individuals. If a systemic failure can be framed as someone’s fault, we can replace the relevant person and move on to other things.

But it’s hard to find anyone working in mental health who isn’t genuinely committed to making the system work better. In fact, the sector seems to attract more than its share of high-calibre, dedicated and passionate individuals. These include world-leading mental health experts like Ian Hickie and former Australian of the Year Patrick McGorry, who have been tireless advocates for reform. Organisations including Beyond Blue have attracted people with formidable track records in leadership and public policy, such as the current chair, Julia Gillard, and board member Kate Carnell, former ACT chief minister.

The medical profession has also thrown its considerable weight behind this issue. Earlier this year the Australian Medical Association released a comprehensive mental health position statement calling for changes to the current system. Medical colleges have also been advocating better care for people with mental illnesses: the Australasian College for Emergency Medicine’s summit was preceded by the release of a report on the treatment of people with mental health presentations in hospital emergency departments; and the Royal Australian and New Zealand College of Psychiatrists produced a series of reports highlighting poorer health outcomes and higher mortality rates — even for unrelated physical health problems — among people with mental illnesses.

Courageous consumers

Perhaps most important of all, Australia has an impressive community of articulate and courageous mental health consumers who, over the years, have been prepared to speak out about their experiences and provide detailed and insightful suggestions about how the system needs to change. 

Even with this level of commitment and expertise, though, the mental health sector is still lurching from one crisis to the next. The causes clearly run much deeper than any of the individuals involved.

Governments are another natural target for blame. But it’s hard to fault the willingness of successive governments in Australia to engage with mental health professionals and consumers to develop policy frameworks and action plans. Governments have committed a steadily increasing bucket of money over the past two decades, and have made radical changes to major health programs, such as Medicare, to increase access to services. They have established bodies to oversee mental health policies and programs and, when problems within the sector arise, they have initiated and resourced inquiries and reviews.

These efforts have resulted in high-level policy statements and strategic framework goals articulating a laudable vision for the mental health sector. In New South Wales, for example, “high quality, culturally safe, trauma informed services are available to prevent and respond with compassion when and where they are needed,” says the state government. Services there “always assure the autonomy, dignity and individuality of people who experience mental illness.” But these policy goals are not reflected in the care being provided on the ground, as was clear from the images of NSW woman Miriam Merten, walking a hospital’s corridors, ignored by staff, covered in her own faeces, distressed and disoriented, and falling at least twenty-five times before collapsing and dying of a brain injury.

Of course there is a more cynical explanation for the propensity of governments to hold inquiries whenever evidence of failure emerges. While they can certainly be useful in engaging stakeholders and developing new policy directions, inquiries are a handy political tactic when politicians feel under pressure to act but see all the available solutions as politically unpalatable. This is particularly the case given Australia’s short political cycle, which means that the minister responsible for setting up an inquiry is often not around to receive the final report and take responsibility for its implementation.

It’s also true that adoption of the recommendations from the myriad recent inquiries and reviews has been patchy. Rather than acknowledge the clear message from these processes — that a comprehensive, society-wide approach to mental health is vital — governments have tended to treat their recommendations as a pick ’n’ mix by focusing on the easier-to-implement options and ignoring the more challenging.

The lack of a comprehensive approach is particularly relevant for suicide prevention, where the evidence strongly favours multiple interventions working together. The European Alliance Against Depression has shown that suicidal acts can be significantly reduced (in one case a drop of 24 per cent in two years) using a carefully designed four-level approach.

The failure of successive governments to adopt a more comprehensive approach to mental health also means that there are some common findings and recommendations that have been repeatedly ignored or deferred. These include the need to develop a system-wide approach to mental healthcare and to recognise and address the drivers of poor mental health (such as early childhood trauma and drug and alcohol abuse).

Demarcation issues — where responsibility for community mental health services should sit, how the state/territory and federal mental health commissions work together, and where (and how) the National Disability Insurance Scheme, or NDIS, takes in mental illness — also arise repeatedly.

Is there a better way?

Mental health experts have a range of views about what has gone wrong and what needs to be done, and their ideas have common themes.

One theme relates to resourcing. Despite the increased investment, funding and services still fall short of demand. “On just about every objective measure we are underfunding mental health,” says John Mendoza. Others make the point that while mental health funding has increased, it still does not reflect its contribution to the total burden of disease in Australia.

Ellen Marks, general manager of advocacy and inclusion at One Door Mental Health, identifies a specific funding gap in the area of community-based mental healthcare, partly because much of those resources have recently gone into the NDIS. While the NDIS may work for people with physical disabilities, she believes that the loss of the flexibility that came with the previous system of block funding has caused “enormous chaos” in the mental health sector. Her estimate is that another $500 million is needed to support people with mental illnesses who are not covered by the NDIS.

Marks also identifies the gap between hospitals and community-based mental health services. She stresses the need for more after-hours services and argues that emergency departments “are not suitable places to deal with people in a mental health crisis but too often they are the only option, particularly after hours, which is when around half of all mental health presentations occur.”

Another common view among mental health experts is that the available funding is not being used efficiently.

John Mendoza blames a focus on accounting for expenditure rather than assessing what works. Sebastian Rosenberg, senior lecturer in mental health policy at Sydney University’s Brain and Mind Centre, describes Australia’s use of data to inform systemic quality improvement in mental health as “woeful.” He cites a number of programs with proven track records — the mental health nurse incentive program, Partners in Recovery, and Personal Helpers and Mentors — that have been de-funded and questions why we continue to invest $22 million each week in Medicare payments under the Better Access program without evaluating its effectiveness. He has also expressed concern that the government appears to have abandoned plans for a third national survey of mental health, to follow the two conducted by the Australian Bureau of Statistics in 1997 and 2007.

Ellen Marks also highlights the lack of coordination across services and sectors, and the need for consistent and appropriate discharge and follow-up processes for mental health patients after hospitalisation. “Some patients receive adequate support but others may only get one phone call in the week after discharge,” she says. “This is clearly inadequate. No one should leave hospital and kill themselves. No one should be discharged from hospital into homelessness.”

Part of the problem is that while hospitals may have guidelines stating that patients should not be discharged into unstable or unsafe environments, these guidelines are often ignored. One social worker told me how she had seen a mentally ill man discharged six times from the same hospital, even though hospital staff knew that they were sending him back to live out of his van.

Ian Hickie and Sebastian Rosenberg suggest that the first task for any new mental health inquiry should be to identify “high value” targets from the outstanding recommendations of previous inquiries. These would include early intervention, increased support in regional areas and the use of new technologies to increase access to care.

Ellen Marks suggests using hospital emergency presentations as an opportunity to intervene earlier and in a much broader sense than simply treating the symptoms. Such a presentation might be the one and only chance to intervene in domestic violence or a drug and alcohol problem that is likely to get worse if ignored. She would also like to see mental health case managers/navigators appointed to help consumers steer their way through the system and to provide a pivot point for all the services that someone with a mental illness needs. “Basically there needs to be someone managing the care who has visibility of all parts of the system,” she says, “and there’s no one who has that at the moment.”

More wide-ranging ideas include Patrick McGorry’s proposal to “radically reimagine” our approach by creating a series of local “stigma-free, mental health collaborative mental health hubs,” staffed by an “expert multidisciplinary team of GPs, psychiatrists, allied health professionals, addiction specialists and a twenty-four-hour mobile home intensive-care unit.” McGorry argues that each of these hubs would cost around $15 million (less in rural and regional Australia) and that to establish one in each federal electorate would cost less than $2 billion, or one-tenth of the cost of the NDIS.

At the other end of the spectrum is a need for a greater focus on prevention, including comprehensive community-based services to prevent people from reaching a crisis and support them more effectively as they re-enter the community after hospital treatment. As Ellen Marks suggests, “We need a focus on prevention at all levels. Ultimately the majority of support needs to go into preventing crises from occurring, but we also need to make sure we have sufficient services so we can intervene effectively if a crisis occurs.”

Other lessons

These suggestions all make good sense. But perhaps there are other lessons to be learnt from our failure to improve mental health outcomes over the past two decades.

We’ve spent much of that time trying to “normalise” mental illnesses, to reduce the stigma and discrimination that has often been associated with these conditions by presenting them as “just like” physical health problems. In doing so we have assumed that the needs of people with mental health problems can be neatly shoehorned into a system designed around the paradigm of physical illnesses.

But mental illnesses challenge our assumptions about health and about the way we organise the health system in a way that physical illnesses or injuries rarely do. In particular, they challenge the idea that we can address health problems primarily by treating individual problems with the tools of medicine and healthcare — that it’s just a matter of getting the right mix of services to people in order to “fix” the condition.

When this doesn’t work, we need to ask not just “What can we do better?” but also “What can we do differently?” This means posing questions that challenge some of the fundamental principles of our health system.

How does it make sense, for example, to separate our mental health system from our justice system when half of all people in prisons have a mental illness? What would it mean if we treated homelessness and mental illness (or drug and alcohol misuse and mental illness) as two symptoms of the same problem, rather than two discrete problems that happen to coexist?

How do we support the wellbeing of people dealing with the impact of intergenerational trauma who are experiencing interpersonal and institutional racism on a daily basis? How can we incorporate our understanding of the impact of abuse and neglect in early childhood on mental health into a system that is geared towards treating the manifestation of these events years (or even decades) later?

What would it mean for a health system, designed to treat individuals with discrete mental and physical health problems, to reorient itself around new understandings of the health impact of relational and environmental factors, such as family relationships, social inclusion and economic status?

Asking these questions is challenging, not only because the answers may reveal where our previous approaches to mental health have gone wrong, but also because they may uncover some fault-lines within our health system that have implications beyond the mental health sector.

Previous mental health inquiries have only skirted around these issues, constrained by narrow terms of reference and existing concepts of what a mental health sector should look like. If we genuinely want to improve on the outcomes of the past two decades, we need to look beyond what has been tried in the past and accept that this may mean a radical rethinking of our approach both to mental health services and to our system of healthcare more generally.

• This is part of a series of health policy articles for Inside Story by Croakey editors Jennifer Doggett and Melissa Sweet, and is cross-posted here with permission.

PostScript from Croakey: Noting some comments on Twitter that this article did not cover the move towards peer workers in mental health, we recommend readers check out previous related articles:
Celebrating the wide-ranging contributions of mental health consumers and allies
Identifying the barriers and the benefits around consumers taking charge of mental health research.