Much of Australia’s mental ill-health could be avoided if rather than focus on the system, we fix societal factors that lead to distress
ental health system reform is focused on providing more services while failing to evaluate whether those services make people better, leaving people cycling in and out of a system that fails to prevent them from getting sicker, former national mental health commissioner Professor Ian Hickie says.
Hickie, a psychiatrist and co-director of health and policy at the University of Sydney’s Brain and Mind Centre, says to prevent suicide and other acute mental health events, healthcare practitioners need to better understand what works, but data around how people fare following psychological, medicinal and hospital treatment is lacking.
“In mental health we are dominated by activity-based funding and data, such as funding psychological sessions or hospital beds, which often has a poor relationship with outcomes,” he says.
“With a hip replacement you might see the outcome, that being the person walking again. With mental health and other chronic diseases, it is more complex. You might spend money on trips to hospitals and psychiatry sessions and yet there is a lack of tracking of individuals through healthcare providers to see what happens to them and if they improve.
“And then, in terms of the activities we are spending on, we are not spending money on the right activities like unemployment support, multidisciplinary teams, and education support. We don’t know whether many of our therapies, like longer-term psychotherapies and hospital beds, really work, yet we are spending on them.”
Stephanie Berick, who lives in Newcastle NSW, has supported her son through the mental health system and suffered from a lack of community support while doing so. Berick, 70 and retired, says her now 33-year-old son was 21 when he was first diagnosed with schizophrenia. Her family were living in Darwin and her son first became unwell but doctors there could not diagnose or help him.
“We were told there was nothing they could do for him so we came back to Newcastle, where he was diagnosed with schizophrenia and began treatment,” Berick says.
Her son remained relatively stable for about four years but then began to deteriorate. He was in and out of hospital over a two-year period until he was placed in a neuropsychiatric ward for eight months.
“He went into the ward a very verbal, alert, engaged person,” Berick says. “His drug intake was increased regularly, he had 22 sessions of electroconvulsive therapy and he became non-verbal, incontinent and almost catatonic. We pulled him out of hospital because we were told that nothing more could be done for him.”
After 12 months of outpatient treatment there was still no improvement. The family’s GP helped them find a new psychiatrist.
“In two years our son has had his drug intake reduced and been put on two antipsychotic drugs that have worked amazingly well,” Berick says. “He is now verbal, interacting with people again and slowly getting his life back again. We have been fortunate to have had a team of people who were behind our son all the way, but the process of dealing with his illness has been fraught.
“When a crisis happens and he was hospitalised his immediate symptoms were treated and he was then released. But ongoing outreach support was not there. His carers and ourselves were the ones who had to try and make life bearable for him. We saw others who were in a much worse situation and were in and out of hospitals as a short-term fix because there are no resources to help them return to society and support them there.
“We saw people being put into a theoretical model of care and then, if they did not fit, they were discarded.”
Hickie says Berick’s story is a common one. “We need to provide more multidisciplinary and more specialised services to people,” Hickie says. “Lots of people with problems give up because they just go back to the GP or emergency department again and again. Then they drop out of the system because it doesn’t help them.
“We see this particularly in disadvantaged areas, like western Sydney, where people give up. Basically, if you haven’t got money, the public hospitals can’t arrange care. So people are discharged out of the public hospital system to no care. They can’t afford out-of-pocket costs in the private sector, and the public health system often takes no responsibility for the ongoing care of those who can’t pay, and that is a huge problem.
“We don’t give up on heart disease or cancer and say ‘you can’t afford the private specialist so you get no care’. But public hospitals have a tendency to de-diagnose people and send them home to their families. Because there is nowhere else to send them.”
Prevention and early intervention
Hickie says that most spending on chronic diseases, like mental illness, is on “middle aged people with established illness”.
More needs to be spent on prevention in childhood, and early intervention in adolescence, he says. This early intervention is crucial, with prevalence of mental disorders in the previous 12 months highest in the 16-24 years age group, generally decreasing for each older group, with the exception of men aged 25-34, who have approximately the same prevalence of mental disorders as the younger age group.
“The issues around prevention are complex,” Hickie says. “No one is saying you can fully prevent personality disorders, eating disorders or schizophrenia. There is no vaccine for them like there is for other diseases. But once people start to get sick, you need to stop them from becoming worse and progressing. And these areas of primary and secondary intervention in mental health are seriously underfunded.”
He says people have few options for mental health support aside from seeing their GP, a psychologist or psychiatrist, or going to hospital.
Hickie believes the commonwealth needs to work with states to boost private sector capacity and get people to work between the public and private sectors.
“You can’t just build one big hospital or one big centre in certain locations,” he says. “What you have to do is bring together effective services in the community. Early intervention for mental health is two to five years of care, and it may involve a psychiatrist, a general practitioner, a mental health nurse, a dietician, a clinical psychologist, an occupational therapist, and these people are often working with an education or employment support agency.
“The outcome is better mental health, better physical health, and the reduction of other risk factors like smoking and other drugs. It means people can get back to school and back to work. But we need to scale these services up, and fund it through the commonwealth government. We’ve discussed the need for this for 30 years.”
In Victoria once the second lockdown started the commonwealth government established 15 of these types of clinics in just six weeks. Hickie says it was promising, but disappointing that it took a pandemic to initiate. These clinics needed to be more widespread, he says.
“Now they haven’t gone the whole hog, they’ve just created the intake part, they haven’t yet created the multi-disciplinary teams yet,” Hickie says. “But once they do you will have between 10 and 20 people, about 10 full-time equivalent people, working together with good technology systems in a multidisciplinary way, sharing information and working with the patient, their family, their school and the welfare system if that’s required.”
Societal health significantly influences mental health
Dr Karen Price, the president of the Royal Australasian College of General Practitioners, says mental health and mental illness are societal and cultural issues, and are not something the medical and health systems alone are responsible for.
She says while certain conditions may not be preventable, for many Australians, their mental health issues are brought on by their environment, with the pandemic an example of that.
The projected cumulative cost of lost productivity associated with psychological distress, hospitalisations and suicide over the period March 2020 to March 2025 is estimated to be $114 billion, which includes $11.3bn in lost productivity among the youth population alone. In addition, over the next five years, the cumulative cost of mental health services is projected to be $51.6bn, which is $874m above what it would have been had the pandemic not occurred, modelling suggests.
In 2020, Australian Prescriber published its annual list of the 10 most commonly taken drugs – based on standard daily doses for every 1,000 people in the population each day – along with a list of the 10 most costly drugs to government, and the 10 most common drugs by prescription counts. The data was collected between July 2019 and June 2020. The antidepressant sertraline – sold under the brand name Zoloft – entered the top 10 for the first time, coming in at number nine.
Cultural wellbeing must be on the agenda
“Wellbeing is the bedrock of who we are,” Karen Price says.
“We need to change the idea that we can put mental health and mental illness into separate boxes. To think that we can just approach mental illness from the disease end is ridiculous.
“We know that unemployment triggers suicide, we know that poor public housing contributes to poor mental health. These are policy issues that are a function of our culture. Mental health is a reflection of our circumstances in many cases. A lot of people like to say mental health is a genetic thing, and yes it is in some cases, but in many cases it is influenced by society and the environment.”
“It’s clear the environment significantly influences mental health, and that means we need community connectedness and support for young people, we need to address intimate partner violence and structural issues of gender-based violence, we need to examine the culture of workplaces and schools,” Price says.
“We can no longer have rigid workplaces, we need flexibility, we need time to exercise, we need to spend time in and have access to green spaces. Wellness and wellbeing must be on our agenda as a culture and as a society, for all people.”
Victoria’s mental health royal commission recognised this need for societal reform. It found communities and workplaces do not adequately support good mental health and wellbeing.
“There is a predominant focus on the ‘mental health system’, meaning that the social factors influencing mental health and wellbeing are not recognised,” the report found.
“This focus also downplays the importance of communities, workplaces and education settings in shaping good mental health and wellbeing. System leaders need to better support these places and settings to support good mental health and wellbeing.”
The federal government says that by the end of the year, it hopes to have come to agreement with the states and territories about how to reform the mental health system nationally. But Hickie says he and other leaders in the field have been calling for some of the reforms still being discussed for decades and the time for talk is over.
“We historically have not spend money on self-care strategies or multidisciplinary care,” Hickie says. “We can’t just treat the first episode of mental illness, we must also provide ongoing support. Governments talk and talk and hold inquiries about this, but the changes to fix it never arrive.”
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