Over the past 25 years mental illness has emerged from the behind the walls of the asylums and is recognised as one of the most serious and growing health challenges facing 21st century society. For some time, there has been a widespread sense of hope that we are at a tipping point, yet this is matched by a fear that genuine progress is merely a mirage. Is momentum real or illusory? Through a confluence of recent developments, it is clear that we have a once in a generation opportunity to embrace transformational change in mental health care and help to catalyse global reform. Will we embrace it?
The landscape of mental health care
In 2018, the Lancet Commission on Global Mental Health published a report in The Lancet that made for sobering reading. Despite increased awareness, there has been minimal or no progress in closing the treatment gap worldwide, which is wide in high income countries and enormous in low to middle income countries. The average expenditure globally on mental health is around 2% of health budgets, and the large majority of people, even in high income countries like Australia, fail to access quality evidence-based care. The burden of disease in Australia explained by mental illness is at least 12%, and would be substantially more if other key contributors, notably suicide and personality disorders, were included. The level of preventable and premature deaths, directly or indirectly, due to untreated or poorly treated mental illness is staggering. Economically, mental illness is the dominant cause of loss of GDP from all non-communicable diseases, yet there is a worldwide policy failure to implement the wide range of effective interventions, and to fund then discovery of new ones.
In Australia, the underspend in direct care, in mental health research and in prevention is substantial, and there is growing frustration that there have been no improvements in outcomes for those experiencing mental illness. Some, overlooking the overall neglect and implementation failure, contend that there has been an increase in real terms in expenditure and insist this should have led to better outcomes. Yet the need for care has been rising inexorably over the past two decades, driven by a surge in population growth, a much greater willingness to seek help due to stigma reduction, and a likely increase in incidence and prevalence. The latter is difficult to confirm because Australia does not seem to consider it necessary to conduct frequent measurement of the incidence and prevalence of mental disorders. However, indirect indicators are the flood of patients with mental illness in emergency departments and more focal surveys, especially in young people.
On the positive side
On the positive side, we have seen the Federal Government build a first tier of primary mental health care under the ‘Better Access’ initiative and through scaling up the headspace platform for young people. While these programs are currently targeted at the 11% of the populationwho experience mild mental disorders and need only short episodes of care, they have also been crucial in improving access to at least somecare or a referral pathway for those with more moderate to serious experiences of mental ill-health.
While these programs have known, remediable weaknesses which involve equity, geography, quality and depth, the notion that somehow the modest funds that have been supporting these innovations (of the total national mental health expenditure, headspace centre funding represents 1-2% and mental health-specific Medicare services represent approximately 12%) should be cannibalised or their funding diverted to more complex cases lacks logic and sells mental health care very short. The mental health field has long been plagued by false dichotomies and binary thinking that is not seen in general health care, because the latter is much more adequately resourced.
There is a solid national consensus that people with moderate to severe stages of mental illness are in dire need of expert sustained care. They have fallen through the gaps in the service system, gaps that have developed through fractured government responses and sustained policy failures.
However, rather than dismiss or detract from the advances made in primary mental health care, we need to view this critical national infrastructure as something that should be built on and facilitate entry and access into more specialised and acute care for anyone who need it. This must be the next wave of reform and investment that Australia needs.
This could include introducing a tiered system of access to sessions through Better Access as recommended in the recent discussion paper from the Mental Health Reference Group of the MBS Review Taskforce. This would enable a greater number of MBS sessions to be activated for individuals assessed as experiencing more moderate to serious and complex mental health issues. There is a strong argument for requiring increased sessions to be linked with team-based collaborative care systems. There is also an opportunity to build the capacity of the headspace national youth mental health platform to provide timely and expert mental health care for young people with early symptoms of moderate to more severe experiences of mental ill-health, through such linked of additional sessions and a boost in other specialised salaried roles.
Jennifer Doggett’s recent article correctly diagnoses the need to address this crisis, however the solutions suggested in her piece presume a zero-sum game, and would do more harm than good. We need to fund the prevention and treatment of mental illness according to its significance as a health and social issue. In cancer and heart disease we have seen impressive reductions in mortality and morbidity in recent times. This has happened because we have implemented prevention to the extent possible; because when we cannot prevent the illness we place a premium on early diagnosis; because if we achieve remission or recovery, we do our utmost to keep the person well; and because when the illness is chronic or terminal, we provide support and palliative care. In mental illness we haven’t invested sufficient funds to do any of these things well, and hence we see internecine arguments which demand we rob (innovative but imperfect) Peter to pay (desperate) Paul. Understandable, perhaps, but doomed. It assumes a quantum leap is not possible.
Is the prospect of redesigning and funding mental ill-health as the #1 health and social challenge faced by Australia and the world a real tipping point or just a mirage? In my 38 years in mental health care there have been many false dawns. Reforms have typically been modest, with “m” words at budget time, in contrast to cancer and the NDIS, where we always see the “b” word.
Planets may be aligning
However, the planets may be aligning. The World Economic Forum (WEF) has decisively embraced mental health as its key global program area for 2019. Indeed, Orygen has a major partnership with the WEF to work to globalise youth mental health reform. The triumvirate of the Prime Minister, the Treasurer and the Health Minister have all spoken post-election in a genuine and committed manner about the need to deal seriously with mental illness, suicide and especially young people. The new shadow health minister, Chris Bowen, is engaged and supportive. We have a national Productivity Commission Inquiry, examining in particular the consequences of the low direct spend on mental health care, and also the way it is spent. We have a Royal Commission in Victoria following the State Government’s honest admission that the mental health system in that state is “broken” and needs major redesign and investment. We need to think big and unite as a mental health field to ensure this opportunity is not squandered. There are too many lives and futures at stake.
Patrick McGorry AO is Professor of Youth Mental Health, University of Melbourne, and Executive Director, Orygen, the National Centre of Excellence in Youth Mental Health