ScoMo's $9 billion investment with no coherent strategy
AUSTRALIA spends more than $9 billion on mental health services every year but has no coherent strategy for where the money is going and whether the programs actually work.
Mental health services are such as labyrinth that someone faced with a crisis can be overwhelmed by the sheer volume of counselling numbers they can call for help.
There are at least three hotlines devoted just to men - MensLine Australia, Men's Referral Service and Dads in Distress - alongside more general services such as Lifeline and Beyond Blue, as well as numbers specifically for suicide, grief, domestic violence, children, survivors of childhood trauma and eating disorders.
On top of this, there are at least three inquiries currently looking into Australia's mental health system.
The Productivity Commission will release a draft report into the social and economic benefits of improving mental health on October 31, the National Mental Health Commission (NMHC) is working on a 2030 vision for mental health and suicide prevention, and a Royal Commission into Victoria's Mental Health System is expected to deliver an interim report in late November.
News.com.au is this month raising awareness of good mental health as part of its campaign Let's Make Some Noise. We are highlighting the issue of anxiety and its cost to employers, the community, families and sufferers in support of Beyond Blue.
The proliferation of hotlines and inquiries reflects the fragmented nature of Australia's mental health system, something organisations such as the Australian Medical Association believe needs reform.
"We've got to look at the system as a whole," AMA president Dr Tony Bartone told news.com.au. "Someone has to play a leadership role and caring role for the patient."
Dr Bartone said the system was not up to the challenges, with many parts of the system acting as silos.
"The emergency department is not the place to sort out detailed mental health issues but often that's where people present because there is no support, and they can't get specialist services until they get to that point," he said.
More than 250,000 Australians turn up at emergency departments every year seeking help for mental health conditions.
In its national report for 2019, the NMHC noted "the evidence suggests that emergency departments are not adequately resourced or positioned to be a timely and accessible entry point to the mental health system".
Australia's example is in stark contrast to the experience of Trieste in Italy, which dramatically reformed its mental health system to reduce the number of psychiatric beds and to focus on community-based services. The city's reforms were so successful that, in 2006, the city only needed to provide eight hospital beds for those with mental illness and these were rarely full.
Trieste, which has a population of about 250,000, also reduced its suicide rate by 30 per cent over eight years and eradicated homelessness among those with mental illness.
In 2010, the suicide rate in Italy was 5.1 per 100,000 population, compared to Australia where rates were over 10 and have increased to 12.1 in 2018.
'IT'S TOTALLY UNACCEPTABLE'
Australia's mental health system is complex and fragmented, with roles and responsibilities split between federal and state, public and private, and community and acute services.
This has led to an ad hoc approach, where governments get mixed messages about mental health priorities and people fall through the gaps between services.
Black Dog Institute chief psychiatrist Samuel Harvey said this could be incredibly difficult for those needing help.
"It's hard enough to get an individual to put their hand up when they are suffering but when they do put their hand up, for them to get totally confused about who to see and where to go, is totally unacceptable," Associate Professor Harvey said.
There are many overlapping services and agencies whose responsibilities impact on each other. The federal government has its own primary health networks as well as Headspace centres aimed at helping young people; these sit alongside state public hospitals and local health networks.
Private psychiatrists and non-government operators add a layer on top.
The NMHC noted the system created uncertainty and complexity for both service providers and those navigating the system.
One gap that has appeared is between those who need are not sick enough to access the limited services offered by the state-funded hospital system but need more help than what's offered in the federally funded outpatient system.
"When you look at things like depression and anxiety, a vast majority of people are managed by their GPs," Prof Harvey said.
"There's evidence GPs do a fantastic job at referring them on to services but there is a proportion of people who don't get better at that point, but are not so unwell that they should be seen in an acute hospital system."
Prof Harvey calls these people the "missing middle". For those who have the money they can pay to see a private psychiatrist to fill that gap.
"Those who don't have that disposable income are really stuck," he said.
The NMHC has recommended the Federal Government consider the role of a central government agency to co-ordinate a whole-of-government approach to policy. It has also advocated for a independent body to monitor and evaluate policy outcomes.
This includes analysing how much Australia is spending on mental health and whether this is effective, efficient and informed by evidence.
It also believes analysis should be done to identify the gaps in services across Australia.
WHERE'S THE MONEY GOING?
Australia is estimated to spend more than $9.1 billion in mental health-related services but this figure does not include all spending because gaps in data make it hard to calculate.
For example, the figure does not include spending outside the health system in areas such as disability, education, justice, child protection and employment.
The sheer number of organisations that deliver mental health services has also made it difficult to collect and share data.
This also makes it harder to identify areas of unmet need and to plan and deliver services.
Meanwhile funding for services such as Headspace, which has been expanded to more than 100 centres across Australia and got a $47 million boost this year, have faced questions over whether they are really effective.
The NMHC believes governments need to understand better how much is spent, where the money is going and how well it is working if it wants to ensure the investment is effective and appropriately targeted.
Prof Harvey said mental health services were also underfunded compared to other parts of medicine.
"The World Health Organisation says depression is the single largest contributor to disability in the world," he said.
"I think the funding for mental health services needs to mirror that. It lags behind other areas of medicine in terms of funding."
He said this was obvious when the state of inpatient facilities in hospitals was compared to the facilities for conditions such as cardiovascular disease and cancer.
"In many hospitals in the country, the mental health inpatient unit is hidden in the back of the hospital in a porta-cabin or a small crumbly building. That needs to change," he said.
"We need to recognise where the burden of disease lies and reflect that in what we fund."
PROMISING NEW TREATMENTS
Prof Harvey said there was hope the Productivity Commission's inquiry would produce some ideas for potential solutions to the complexity of the system and its priorities.
There is already hope developing around some promising new treatments and approaches.
"We know that the peak period of onset of mental health problems is during adolescence and early adulthood," Prof Harvey said.
"If we are serious about trying to prevent that happening, it has to involve schools."
The NMHC report noted there was "good evidence" for investing in early intervention initiatives and prevention strategies due to their cost-effectiveness and cost savings.
They can reduce the likelihood of people needing "costly supports, services and systems, including the child protection and justice systems, acute hospital care and social support payments".
The commission noted that so far Australia lacked a co-ordinated approach to the implementation of these strategies, although it had been asked to complete a National Children's Mental Health and Wellbeing Strategy, funded by the Federal Government.
The use of online programs and apps also looks like a promising technology to prevent more minor conditions from developing into serious problems.
Professor Ian Hickie, of Sydney University's Brain and Mind Centre, said effective digital tools were now available and they had the potential to overcome the limitations of traditional treatments.
"People want and need more effective healthcare methods located near where they live, in forms they can afford and are easy to use," Prof Hickie said.
Prof Hickie, who is a founder of digital platform InnoWell and has an equity interest in the program, said it had demonstrated its ability to help health care agencies like Headspace to provide better care for young people.
There's also been increasing recognition of the role workplaces should be playing in supporting and identifying when someone is struggling.
A report launched ahead of World Mental Health Day in October urged corporate Australia to take the lead in addressing Australia's mental health crisis, with mental illness estimated to cost Australia's economy about $60 billion a year.
Some workplaces have already begun providing mental health training to employees and this has been shown to have some remarkable results.
"We were able to show that a single four-hour training session resulted in a more than 18 per cent reduction in work-related sickness absence over six months," Black Dog Institute chief psychiatrist Associate Professor Samuel Harvey said.
With almost half of Australians aged between 16 and 85 expected to experience a common mental illness, such as anxiety or substance use disorder, in their lifetime, how the country tackles this problem has important implications for many in the community.
"I think we've now got evidence that used using certain evidence-based approaches in the workplace can make a big difference," Prof Harvey said.
"That's why it's so frustrating to see programs that don't an evidence base being used."