21 March 2018

Mental health: How far have we really come?

Clinical Mental Health

Take a look at the people around you. Friends, family, work colleagues, strangers in the street.

Chances are they will be engaged in conversation, relaxed, displaying no signs of distress or ill health.

Yet for every five people you see, one of them will be battling a mental disorder.

Whether a mild, moderate or severe condition, their veneer of calm will belie an inner turmoil.

And around half of them will be tackling their demons without professional help.

Contemplate these statistics too. In 2016, 2,866 people took their own life, a slight improvement on the 3,027 in 2015 but still the second highest for 10 years.

It means that today close to eight people in Australia will end their own life. Tomorrow will be the same, and the next day.

To examine those figures more closely, suicide was the leading cause of death among 15-44 year olds in 2016 and the second leading cause among those aged 45-54. These premature deaths robbed the victims of a collective 100,000 years of potential life.

Furthermore, over the course of the next hour, after you’ve read this article, popped out for a sandwich and phoned your loved one, more than seven people will have attempted suicide.

Beyond these stark and shocking facts lie heart-rending tales of desperate people, ruined lives and shattered families. In too many cases, they also illustrate a failure of Australia’s mental health system.

One of Australia’s most prominent and respected mental-health campaigners, Pat McGorry, executive director of Orygen, The National Centre of Excellence in Youth Mental Health and professor of youth mental health at the University of Melbourne, was scornful of the attitude towards suicide and of a system seemingly unable to offer the services people need.

“Nearly 3000 people a year are dying by suicide, twice as many as the road toll, yet suicide deaths don’t seem to be as valued,” he told The Medical Republic. 

“Cancer is fought at all costs whereas suicide deaths are seen as more expendable even though they often effect much younger people.

“When you take into account the people attempting suicide, you have, over a five-year period, hundreds of thousands of people who have reached the point of wanting to die. And the only thing offered to them is a cursory and often quite traumatic experience in an emergency department. They are often discharged back to the conditions that created the problem in the first place.”

A more withering assessment you’d be hard pressed to find. That said, the National Mental Health Commission came pretty close.

In its appraisal of the broader mental health system in late 2014, the Commission concluded there wasn’t actually a system at all, never mind one that worked.

“Instead of a mental health system – which implies a planned, unitary whole – we have a collection of often uncoordinated services that have accumulated spasmodically over time with no clarity of roles and responsibilities or strategic approach that is reflected in practice,” it said. “The current system is resulting in people not receiving the mental health support they need, when and where they need it.”

Even though that damning denouement was delivered more than three years ago, it is, it seems, still as dishearteningly accurate now as it was then.

While a Fifth National Mental Health and Suicide Prevention Plan was endorsed last year by the Council of Australian Governments, it has been branded as little more than political rhetoric and a “machinery of government” with no targets, no focus on outcomes and no financial commitment. The key strategy appeared to be a “sprinkling of magic dust” as one mental health advocate put it.

Yet despite the disjointed and fragmented nature of the system, access to mental-health services has improved.

In short, more people are seeking help.

In the last National Survey of Mental Health and Wellbeing in 2007, 35% of the estimated
3.2 million people with a 12-month mental disorder accessed services in the year prior to the survey.

While no directly comparable data has been produced since, academic research published in the Australian Health Review found that this proportion had climbed to 46% by 2009-10.

The increase was described in the paper as “remarkable by international standards”. One of its authors, Harvey Whiteford, professor of population mental health at the University of Queensland and a global leader in mental health issues, estimated that had now increased to “well over 50%”. It was, he said, creeping towards targets contained in the National Service Planning Framework of treating 67.5% of people with mental health disorders.

“We don’t want 100% accessing treatment, because not everyone needs it,” Professor Whiteford said. “Some mild disorders are transient and are maybe present for a couple of weeks, but then spontaneously remit as other health problems do. So we are getting close to the targets. But there are still some people who clearly should get treatment who don’t.”

But if we have an idea how many people are being treated, less clear is who is being treated. While the target is to reach 100% of severe, 80% of moderate and 50% of mild cases, Professor Whiteford said no modelling had been done to break down the treated population by severity
of condition.

Two reasons are largely behind our rising enthusiasm for professional help. The first is Australia’s relative success in reducing stigma, a problem which has plagued mental health and its sufferers for decades.

Over time – and arguably it has taken too long – we have, as a society, learned to talk openly and honestly about our mental well-being, and the  “shame” attached to certain disorders has dissipated.

Mental health campaigner and professor of psychiatry Ian Hickie, who is co-director of the University of Sydney’s Brain and Mind Centre, told The Medical Republic that Australia was the “gold medal winner” in reducing stigma.

“We are at least 10 years ahead of anywhere else in the world,” he said.

“It’s been such a big issue for older generations but it’s not the same for younger Australians.”

It’s a view echoed by many within the mental health community, including Professor Whiteford who said it was clear from his work globally that Australia is among the world’s leaders in destigmatising mental illness and creating population awareness.

Yet no-one is assuming stigma has been eradicated. Although progress has been made, negativity and misunderstanding persists.

Debra Rickwood, professor of psychology at the University of Canberra and chief scientific officer at the youth mental health program, Headspace, said stigma “remains high”, particularly among young men and in culturally and linguistically diverse backgrounds.

The stigma exists not just in acknowledging, or “admitting” to having a mental-health problem, but in seeking help for the disorder.

“There is still some sense of shame and personal responsibility in that people believe they should be able to sort out these things themselves,” Professor Rickwood explained. “Young people, in particular, want to be independent and to belong and don’t want to be different.”

Mental Health Australia chief executive Frank Quinlan said lauding Australia as world leaders, while not inaccurate, could be “damning us with faint praise”.

Observing there “is much work to do”, he said workplaces, in particular, remained judgmental environments for people tackling mental disorders. While people in their 20s were “more attuned to mental health issues” and comfortable discussing it, Quinlan suggested many would still be reluctant to confide in their bosses, most of whom were likely to be of a generation where mental illness was viewed with scepticism.

“How many of us today would be comfortable disclosing to our employer that we have some mental illness that requires us to episodically take time off work or reduce our work flow in order to manage the condition?” Quinlan said.

“I don’t think enough workplaces are ready to hear that and act on it appropriately.

“You can talk about back pain and get the required action, but it remains a much tougher ask with mental health.”

He added: “I just don’t think we accept or understand that intergenerational change is just that. It takes decades of work. But when today’s younger people are the managers, CEOs and policy makers I am quite optimistic that we will be living in a different world.”

If changing attitudes have at least encouraged more people to seek treatment, the major driver for the increase was the introduction in 2006 of Better Access, the Commonwealth Government initiative offering Medicare-subsidised treatment through GPs, psychologists and psychiatrists.

A report published in February by the Australian Institute of Health and Welfare (AIHW), revealed that 2.4 million, or 9.8% of the population received Medicare-subsidised mental health services in 2015-16, up from 1.2 million, or 5.7% of the population in 2008-09.

A further breakdown found 8.1% of Australians received Medicare-subsidised mental health-specific services from a GP, 2.7% from a psychologist, 2% from a clinical psychologist, 1.6% from a psychiatrist and 0.4% from an allied health professional. Viewed in isolation, such figures give rise for optimism. Giving swathes of the population free, or in the case of psychologists and psychiatrists,  more affordable mental health treatment, has surely been beneficial to the mental health of the nation.

It is, however, a theory that seems at best questionable, at worst horribly misguided.

Aside from the mammoth costs of Better Access – some estimates put it at $15 million a week  –  experts in the field can find little or no evidence to suggest we have improved outcomes as a result of this greater access.

Professor Hickie said it was time to “stop talking about access and talk instead about outcomes”.

“Has demand for services has gone up? Yes. Has it resulted in positive outcomes? No. More people are seeking care, but many people’s experience of care is a poor-quality care that doesn’t meet their needs,” he told The Medical Republic.

“We are not seeing what everyone hoped we would, that being a relationship between increased access and demand and improved population health outcomes.

“My fundamental narrative is that we have traded off access against quality. Politics over the past 20 years has demanded access, and instead of going for a quality program we traded it for a mass program (Better Access) that was of lower quality.  We have static or deteriorating suicide rates, we haven’t seen changes in disability and we have not seen increased participation in the workforce.”

The problem, he argued, was the current fee-for-service model under Medicare did not lend itself to an integrated care program.

“Everyone acts within the parameters of what they are funded to do,” Professor Hickie said.

“The GP is funded to write the plan and to refer you to the psychologist.

“The psychologist is funded for the six or 10 sessions with the patient. Once the Medicare rebate is up their capacity to use the system is up. Does anyone really care about the outcomes? No. Does anyone track the outcomes? No.”

Mental Health Australia, however, has a different take on GPs, suggesting their hands could be tied through a lack of available options.

With the exception of referring patients to psychologists – which remote and rural communities are hard-pressed to find as recently lamented by the Royal Flying Doctor Service – Quinlan observed that doctors were often left with little alternative other than the prescription of drugs, which might not be the most appropriate treatment.

“Where are the programs in the community that GPs can refer to as part of an on-going and comprehensive mental health plan? Where are the mental health nurses?” he asked.

“How many people get access to drugs compared to the numbers who access community-based care? I am not opposed to medications where it is needed, but that should not be a substitute for other appropriate programs that are potentially evidence-based.”

Concern over the provision of suboptimal care is widespread, and shared by Professor McGorry, whose relentless campaigning in the mental-health arena saw him named Australian of the Year in 2010.

Too few people were receiving appropriate care and treatment, he said, citing research published in the Medical Journal of Australia which concluded only 16% of patients with depression or anxiety received even “minimally adequate evidence-based treatment”.

“To some degree there is better access at the primary care level for common mental disorders so someone can see the GP and receive their 10 sessions from a basic psychologist, but no one is ensuring what they get is evidence-based,” Professor McGorry said.

“And if they have more complex or serious disorders access has actually got worse, because the state governments have not been keeping pace with the population in terms of providing more specialised mental health services.”

Another study, conducted by Tony Jorm, a professorial fellow and NHMRC senior principal research fellow at the University of Melbourne’s School of Population and Global Health, found there had been “no improvement” in adult mental health.

The sector was beset by two key problems, he told The Medical Republic, namely a lack of prevention strategies and lack of quality treatment. “We have a very one-sided approach in Australia which is quite different from chronic physical disease where there is prevention and treatment arms,” he said.

“In mental health, we just have a treatment arm, so we are putting all the resources into trying to fix the problems quicker and virtually nothing into stopping the problem in the first place.

“People know about the dangers of sun exposure and tobacco smoke and there is widespread community action. You get into the mental health area and that just doesn’t exist. But it can exist.

“We have sufficient knowledge to do it but it’s just not seen as a priority.”

But how can we prevent the onset of mental disorders at a young age? What public-health campaigns could help turn the tide?

Jorm highlighted two such examples: showing children greater affection, and delaying their introduction to alcohol.

“We know that if children grow up in a home where they are shown more affection it has a protective affect against anxiety disorder and depression in later life,” he said.

“We also know the later an adolescent has their first drink you reduce the chance they will develop an alcohol problem.

“Most people don’t know that. Those basic messages are not out there and that is what is lacking.”

Turning to the “quality gap”, Jorm said people were receiving “watered down treatment” from those in trials with a big increases in the use of antidepressants for people with milder problems “who they are probably not useful for”.

Ensuring the rise in access to treatment is matched by correct and constructive treatment is “the next challenge for the system”, according to Professor Whiteford.

The word “challenge”, along with “crisis”, “disjointed” and “underfunded” are, not unreasonably, thrown around with gay abandon when discussion turns to mental health. Equally as common are comparisons with other illnesses and conditions.

There is an enduring belief within the mental health community that policy-makers do not tackle mental health with quite the same gusto they do other areas of the health system, and that budgets do not reflect either the debilitating nature of mental health disorders, or the system’s shortcomings. That was reflected in Professor McGorry’s assertion that victims of suicide – 80% of whom suffered some form of mental disorder – are regarded as “expendable” compared with those fighting cancer.

He also referred to The Way Back, beyondblue’s volunteer-led support group for people who have attempted suicide.

“It’s a Band-Aid solution,” he said. “Don’t get me wrong, it’s great. But would that be sufficient for someone who has been discharged with chest pains after a mild stroke? When you look at expenditure on mental illness it’s a fraction of what is spent on cancer.”

Quinlan painted the scenario of diabetes diagnosis where a patient would have consultations with specialists, nurses and dieticians.

“There would be clear points of follow up,” he said. “If I go to my GP and they suspect anxiety or depression or some other form of mental illness my treatment pathway is much less defined.”

To create a broader, cohesive voice in the mental health community, Professor McGorry revealed he was reviving Australians for Mental Health, an organisation he described as a “social movement” for the four million Australians affected by mental health issues each year.

A previous attempt foundered, but more robust governance and stronger financing has seemingly given the project a greater chance of success. “It’s been constructed more carefully this time and we are confident we can get it off the ground,” Professor McGorry explained.

“Politicians will only put modest amounts of money and energy into reform unless they see the public is demanding it and expecting it. Governments would not be able to get away with this level of neglect in cancer or heart disease.

“This social movement has been the missing ingredient in the mental health field.”

Wherever you care to look there appears to missing ingredients, community mental health programs being one.

Such programs are being “dismantled” according to Professor McGorry and substituted by the National Disability Insurance Scheme (NDIS) which he said was ill-equipped to deal with the numbers of people requiring help.

Community Mental Health Australia executive director, Amanda Bresnan, warned that many sufferers who currently accessed services would not be eligible under the NDIS partly because the episodic nature of mental disorders did not fit the “permanent and significant” NDIS criteria.

Many people would fall through the cracks, Bresnan said.

“That will happen particularly to those termed hard to reach, those with higher needs, who are maybe homeless or disengaged who are not likely to want or be able to engage with the NDIS system, particularly when they haven’t got support to test their eligibility.”

According to Quinlan however, he is hearing some “welcome recognition” from senior politicians surrounding mental health issues.

But then politicians often say what we want to hear, a fact not lost on the advocacy chief.

“We judge politicians not just by words but ultimately by their spending priorities,” he said.

“We will be looking at this year’s budget to see how the priorities expressed in the budget match the priorities expressed verbally by the Prime Minister and the Health Minister.”

There was, he said, a growing public groundswell demanding action.

“I would like to think the government will be called to account in a world where far too many Australians experience a mental health system that is not fit for purpose.”

For now at least, the creation of an integrated, coherent system remains worryingly and frustratingly absent.