One in every eight visits to a general practitioner is seeking help with a mental health problem. Even so, fewer than half of the Australians who could benefit from mental health advice, treatment and care visit their doctor. And those who do so are faced with suboptimal treatment options and significant variations in quality.
The problem isn’t confined to a small segment of the population: one in five Australians aged sixteen to eighty-five report having experienced a mental health disorder in the past twelve months. Forty-five per cent of people in that age group will experience a common mental health condition – depression, anxiety or substance misuse, for instance – at some point in their lifetime.
These disorders wreak havoc on people’s lives, affecting their physical health and interfering with their ability to be engaged and productive members of families and communities. While some people have only one period of mental illness and recover fully, others experience recurring illness. In more severe cases, acute episodes can occur more frequently and, without treatment and effective management, leave little room for recovery.
General practitioners and other primary-care workers are the first stop-off for people looking for help, and provide the main gateway to other services through Medicare programs like Better Access and Access to Allied Psychological Services. But busy GPs – often without higher-level training in mental health, sometimes nervous about managing patients with mental health problems, and rarely with enough time to effectively listen and diagnose – can be overwhelmed. The easy solution is a prescription for an antidepressant, and the results include increased healthcare costs, poorer health outcomes and decreased quality of life.
Integrating mental health services (and the associated issue of substance abuse and misuse) into primary care is the most viable way to close the treatment gap, but the training that health professionals receive and the way Medicare reimburses for healthcare services must also reflect this. Currently, programs like Better Access are merely add-ons, mostly used by those who are financially better off, live in urban areas and are more open about their mental health problems.
These problems have long been recognised, and recommendations for change were an important part of the National Mental Health Commission’s 2014 report, Contributing Lives, Thriving Communities: Report of the National Review of Mental Health Programmes and Services. The report pushed for a “stepped care” approach, providing treatment and support to match people’s changing levels of need over time. It saw a major role for Primary Health Networks to plan and purchase services on a regional basis by working with general practitioners to assess the mental health needs of the local population and then commissioning needed services. The underlying assumption was that funding would shift towards primary care.
In response, the federal government established a flexible funding pool to provide funds to Primary Health Networks. But it emphatically ruled out any shifting of funds from acute care, which meant that a range of current programs and activities were disrupted and defunded. A new digital mental health gateway was also proposed, to offer phone and online help in accessing mental health services, although this important element has yet to be created.
As its name suggests, stepped care is designed to deliver and monitor treatments so that the most effective yet least resource-intensive treatment is delivered to patients first, stepping up to intensive and specialist services only as clinically required. The aim is to deliver the right service in the right place at the right time by the right person. And, while the idea of stepped care makes intuitive sense, it’s important to remember that the evidence base for its success in mental health is largely limited to treatment of depression.
The government’s expert advisory group on mental health reform has talked in very general terms about the relevance of self-help resources, psychological and psychiatric services, general practitioners, allied health services and mental health nurses. But stepped care has not been clearly defined for the Australian context. With only a cursory guidance document from the Department of Health, the Primary Health Networks have been left to decide how they might best achieve the desired goals with the resources available in their local areas.
How then can the plans for stepped care be refined and improved?
• Stepped care requires clear definitions of the roles and skills of the healthcare professionals and services involved, including general practitioners, mental health nurses, help lines and e-health services, specialist services, allied health services, residential care and acute care. Ideally, these teams should also include the skills needed to find ways of meeting patients’ needs for social contact and support.
• Case management is important in a system that is still very fragmented and relies on care being monitored and adjusted in response to patients’ needs. This could easily be done by a mental health nurse – if the government hadn’t essentially abolished the Mental Health Nurse Incentive Program, which helped fund mental health nurses in doctors’ offices, by bundling the money that supported this program into the Primary Health Networks’ mental health funding. If patients cannot effectively navigate this new system, it is essentially worthless, so specific funds must be provided to ensure this can happen.
• Recognition must be given to the additional demands stepped care places on general practitioners, especially those in non-urban areas. They will need more training, more continuing education, and more support from specialist mental health professionals and facilities.
• Attention must also be paid to the current maldistribution of the psychiatric workforce. The Australian College of Psychological Medicine has pointed out that private psychiatrists are largely inaccessible because few bulk-bill and most are located in metropolitan areas. There are very few psychiatrists employed in the public sector and most of those are too busy coping with acute crises to be proactive in prevention and early intervention. Most have no time to deal with the high-prevalence disorders such as anxiety, depression, personality disorders and substance abuse.
• Agreement is needed on evidence-based guidelines and standards. This is not about standardisation of care, but about ensuring best practice and quality of care. The standards should include waiting-time targets for community mental health services.
Regardless of which model is in place, the most important issues for mental health relate to the need for multidisciplinary and collaborative care that encompasses counselling, medication and follow-up care. Primary and secondary mental health services must work together, with acute care added in as necessary. That means efficient referrals, shared health records, and support for patients (including navigation help).
Experience from Britain highlights the fact that very little data is available on the operation of stepped care. As always, the devil is in the detail. What is the optimal number of steps and the range of treatments within each step? What proportion of patients should bypass low-intensity treatments and be referred directly to higher-intensity treatments? How are decisions made about stepping up to higher-intensity care? How much should stepped-care systems be responsive to the local context? Importantly, mental healthcare needs significant resourcing and long-term commitments proportional to the magnitude of the burden of disease. The stepped-care approach is essentially about better allocation of scarce resources – it should not be used as an excuse for continuing to restrict these resources.
In 2015, the government commissioned a policy review, Improving the Integration of Mental Health Services in Primary Health Care at the Macro Level, which argued that a stepped-care approach would encourage continuity of care through efficient referral processes, shared electronic records and inter-professional education. It makes no sense to ignore that advice. The current situation for patients with mental health problems and their families would never be tolerated if the illness were cancer or diabetes. New health minister Greg Hunt has described his personal commitment to addressing mental health reforms: tomorrow is not too early to start. •