Why hasn’t the mental health of Australians improved?

Given the money Australia has spent on mental health, it’s surprising that population data doesn’t show expected gains. Ben Barnes

Despite two decades of investment in improving mental health services, the mental health of Australians has not improved. This may be because haven’t been spending money on the right approach and need to place greater emphasis on prevention.

In 1997, Australia had its first National Survey of Mental Health and Wellbeing. The survey showed that mental disorders were common, and that many people who were affected did not seek or get professional help.

Other countries were also carrying out similar national mental health surveys at the time to help plan service development. They produced similar findings, leading to concerns about the “treatment gap in mental heath care” as a global problem.

In 2001, the World Health Organization (WHO) proposed a ten-point plan for addressing this treatment gap.

Good reason to act

The rationale behind closing the treatment gap seems unassailable.

There are treatments for mental disorders that are known to work and many people are not getting them. If we could get more of them into treatment, then the mental health of the population should improve.

Australia provides a good test of this approach; since the first survey in 1997, we’ve had major increases in the provision of mental health services.

From 1992 to 2004, real spending on mental health services by the Commonwealth increased by 149% and spending by the states and territories increased by 67%. Prescriptions per capita for antidepressants also increased dramatically, as did the number of psychological services funded by Medicare.

Between 1997 and 2007, there were decreases in the proportion of people with mental disorders who reported that their needs for care were unmet. But when we look at data on the mental health of the population, we can’t find the expected gains.

Data from four mental health surveys that have been repeated at various points in time between 1995 and 2011 show no gains. If anything, there are trends for worsening mental health in some subgroups of the population.

But why?

There are several possibilities for why we haven’t seen any gains. Perhaps there’s been progress, but the steps forward have been too small to detect in our surveys.

Or progress may have been counteracted by other forces such as the global financial crisis, or natural disasters such as the drought – both of which could increase the risk for some types of mental health problems.

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It’s also possible that we’ve seen an increase in the quantity but not the quality of services. There’s some evidence, for instance, that psychotropic medications are not always targeted at the right people. And that the psychological therapies delivered may not be the type research has shown to be effective.

Antidepressants are not effective for milder depressive disorders and some psychologists may only provide supportive counselling rather than evidence-based therapies such as cognitive behavioural therapy.

Another explanation, which I favour, is that Australia has had a one-pronged approach to mental disorders, when a two-pronged approach is required for effective change.

There are basically two ways of decreasing the number of people with mental disorders in the population. One is to reduce the number developing mental disorders (prevention) and the other is to shorten the length of time people have a disorder once it has developed (treatment).

In Australia, as well as other countries, we have put most of our eggs into the treatment basket and very few in the prevention basket. Critics might say that we can’t prevent mental disorders, but I think that on this score, they are wrong.

The other prong

Recently, Australian Rotary Health hosted a national symposium on prevention of mental disorders to review what is known and what needs to be done next.

Experts attending the symposium presented abundant evidence that preventing people from getting a mental illness is possible across their lifespan, from pre-birth to old age.

Prevention can be carried out in many settings, including families, schools, tertiary institutions and workplaces. The potential of the internet to help people stay well needs to be explored, as does the impact of lifestyle factors, such as diet and exercise, on mental well-being.

Prevention requires a focus on the mental health of the population as a whole. By contrast, clinical services tend to focus on people with the more serious and persistent mental disorders.

There is one area in which Australia has applied such a population-health approach – suicide prevention.

In the late 1990s, Australia developed a National Suicide Prevention Strategy in response to the country’s high suicide rate. The focus was on community-based action, rather than improving clinical responses.

It may be a coincidence, but since the beginning of the strategy, Australia has had a steady decline in its suicide rate. Such a decline has not been seen in other comparable countries. There may be an important lesson here.

This is not an argument for reducing mental health services. They are necessary and underfunded for what they do – and they are clearly insufficient.

The next wave of mental health reform in Australia needs to focus on the second prong. We need to extend what has been achieved in suicide and develop a national prevention strategy for better mental health.

We may soon have a new minister for mental health; I hope he or she will seriously consider prevention as a way to garner better mental health for all Australians.

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