Evidence-based mental health services reform in Australia: Where to next?

The past decade has seen some long-overdue investment by Australian governments in new mental health services. While no one in the sector would question the need for improvement in services, there has been debate about whether some of the new programs funded are the right ones. In the ANZJP, there has been on-going discussion and debate about three reforms in particular: the Better Access scheme, the Healthy Kids Check and the roll-out of early psychosis services.

Debates over recent reforms

Better Access

The Better Access scheme was introduced in 2006 to improve the treatment of common mental disorders by extending the Medicare Benefits Schedule to cover additional mental health services. The greatest change involved the extension of Medicare coverage to services provided by psychologists and other allied mental health specialists. On introduction, this scheme proved immediately popular with the Australian public, leading to far greater uptake and cost than anticipated. There was criticism of the scheme on a number of grounds, including the cost blow-out, inequity of access and its use by people with milder problems (Jorm, 2011). An evaluation commissioned by the Australian Government was largely favourable, concluding that the Better Access scheme was meeting previously unmet need in people with common mental disorders and producing improvements in symptoms (Pirkis et al., 2011a). However, this evaluation was criticized on methodological grounds (e.g. Allen and Jackson, 2011). The authors countered that their evaluation was the best possible in the circumstances, where a program had already been rolled out nationally (Pirkis et al., 2011b). In 2011, the Australian Government announced cuts to the Better Access scheme, capping the number of sessions of psychological treatment for which reimbursement can be sought.

Healthy Kids Check

The Healthy Kids Check began in 2008 to allow parents to have a ‘structured conversation’ with a health professional about their pre-school child’s development. In 2011, the Australian Government announced that it would be extended to cover ‘social and emotional wellbeing’ and the target age would be lowered from 4 to 3½ years. When this scheme was announced, some contributors to the Journal saw it as a potentially positive development which would allow early intervention (e.g. Kowalenko, 2012). However, others questioned the accuracy of assessments made at this age (Prior, 2012), were concerned that it would lead to over-diagnosis and unnecessary treatment (Frances, 2012), or were critical about the use of a universal rather than a selective screening approach (Levy, 2012). The Healthy Kids Check is currently being evaluated in its first stage of implementation in eight regions. Subject to the findings at this stage, it is scheduled to be expanded nationally in 2014.

Early psychosis services

The most intensive debate has been about early psychosis services. Early intervention for psychosis was pioneered by the Early Psychosis Prevention and Intervention Centre (EPPIC) service in Melbourne in the 1990s. Early intervention services have also developed in several other countries and have been the subject of considerable research. A review of this evidence published in the Journal concluded that there was ‘promising evidence of effectiveness’ (Catts et al., 2010). In 2011, the Australian Government announced funding to expand early intervention for psychosis services nationally. Since that time, there has been considerable controversy about the strength of the evidence base for early intervention. Following a public debate about early intervention held in Melbourne between Alison Yung and David Castle, both sides were invited to contribute pieces to the Journal putting their respective positions. Castle (2012) questioned whether early intervention services produce long-term benefits, why they are available only to young people and why they need to be set up as stand-alone services. Yung (2012) argued in response that there are benefits to treating first-episode patients in specialized early psychosis services rather than in generic mental health services. Other critics have questioned the evidence for the cost effectiveness of early psychosis services (e.g. Jorm, 2013) and have pointed out that the EPPIC program itself has never been evaluated in comparison to standard care, despite impressions to the contrary (Raven, 2013). They have also accused the advocates for early intervention of selectively citing evidence that supports their case (e.g. Amos, 2013). Proponents of early intervention from around the world have responded vigorously, citing the broader international evidence base for this approach (e.g. Mihalopoulos et al., 2012). McGorry (2012) and McGorry and Mihalopoulos (2013) have questioned why this approach is singled out for so much criticism, while the critics ignore other recent mental health service reforms that have not been evaluated at all. In May 2013, 2 years after the Government’s announcement of additional funding, it was announced that the services will be rolled out by headspace, the National Youth Mental Health Foundation, and that the first two services will be in place by July 2013.

What is the fuss about?

It is interesting to note that each of the three reforms that have featured in the Journal and attracted commentary and critique promote a common theme; namely, that of earlier intervention. They involve the earlier detection of problems, the corollary of which is earlier treatment. The two are inevitably iteratively linked: detection of an illness naturally prompts its management, but also the promotion of treatment and treatment services raises awareness of a ‘disorder/problem’ and may enhance the likelihood of diagnosis.

Hence, all three reforms raise common concerns about the risk of inflating the diagnosis of a particular disorder by incorrectly labelling healthy individuals, or those with symptoms of another disorder, and about the risk of administering specific treatments to those who do not require them and for whom they are ill-suited.

These considerations, which centre on the key issue of defining disorders by partitioning them from normalcy and distinguishing them from other disorders, are apt and particularly timely given the recent release of the Diagnostic and Statistical Manual of Mental Disorders (DSM)-5 (Malhi, 2013a, 2013b).

Evidence-based reform: Where to next?

Carr (2012) has called for the discussion of reform to move on from early intervention and to look at ‘the many other challenges to be addressed in policy and service development for the psychoses’. But if we are to move on, then where do we go next? The debates about recent reforms have centred largely around the evidence base, with reforms being initiated on the basis of no evidence or disputed evidence, and evaluations carried out in retrospect after a program has been widely disseminated. On the other hand, there are other interventions that have a substantial evidence base, but which are not being implemented (Killackey et al., 2008). All of this raises the issue of whether a nation can implement a rational evidence-based series of reforms that are widely supported by the mental health sector.

In an effort to promote national discussion about the directions of future reform, the Journal invited three Viewpoints from individuals who have a wide view of mental health services in Australia and who are familiar with the relevant evidence. Each author, or team of authors, was asked to set out what they believe the next reforms should be and to justify their suggestions with supporting evidence. This discussion is particularly timely given that Australia will have a federal election before the end of 2013, with the possibility of a new government and a different Minister for Mental Health.

Promoting recovery and self-efficacy

The first Viewpoint, by Castle (2013), focuses on services for people with severe mental disorders. He argues that the foundations of the current system of care are fundamentally sound, but identifies a number of deficits: the current system does not serve people with cross-sector issues well (e.g. those with dual diagnosis or dual disability); generic case management does not make use of the special skills of particular professions; emergency departments are not always friendly to patients with mental health problems; and linkages with other service providers (including GPs, private providers, employment agencies, educational institutions) are suboptimal. His solution is that services should adopt the perspective of the recovery movement and see the individual as the centre of their care package, with patients empowered to take better control of their own wellness. To achieve this, funding needs to be linked to individual patients and directed at ensuring collaboration amongst service providers and educating staff about this model of care.

Promoting workforce and social participation

Carr and Waghorn (2013) also focus on people with severe mental disorders. They remind us that there has been substantial progress in services for these people over the last 50 years. Even over the past 10 years, progress has been seen between the first and second national surveys of psychosis. However, the 2010 Australian national Survey of High Impact Psychosis (SHIP) also reveals a number of remaining challenges for services (Carr et al., 2012). Carr and Waghorn single out two: high rates of unemployment and high levels of social isolation and loneliness. They cite evidence that effective interventions exist in both of these domains, and discuss the need to identify the barriers to their implementation and suggest ways to overcome these barriers.

Evidence-based service planning

Whiteford and colleagues (2013) note that reform has often been in response to perceived crises, and this has resulted in it being piecemeal and ad hoc rather than systematic. They propose that reform should be based on an analysis of the burden of mental disorders and what will reduce it, and they set out a methodology for doing this. However, this is a long-term approach that will take many years to produce its findings. It suggests that optimal service planning is a long-term enterprise that is perhaps beyond the cycle of a single government. In the interim, they suggest some immediate measures that can be implemented relatively quickly. First, they suggest targeting those disorders that have a high burden of disease and increasing the availability of services for these disorders. Second, they advise that currently available knowledge can be better applied in order to align with the mental health needs of the population. Finally, they advocate for better integration of services within existing systems. These are all useful and doable, but remain a temporary fix. It will be a challenge to transition to a longer-term, more rational approach.

Conclusion

It is clear from these Viewpoints that there are good ideas that are supported by evidence for where we should go next. We hope the next Minister for Mental Health will take note of these ideas, and we invite readers to contribute letters commenting on these Viewpoints, so that we can have an ongoing discussion that may eventually converge on a consensus.