Mental health services research in Australia

Along with other countries Australia has seen enormous changes in mental health services since Governor Macquarie established the first psychiatric hospital in a converted farmhouse at Castle Hill, Sydney, in 1811. These hospitals were the cornerstone of specialist mental health treatment for over 100 years, their relative size remaining constant from around 1900 until the mid-1950s. The introduction of non-hospital treatment for those with severe mental illness was not without controversy despite research demonstrating its benefits. Hoult et al. (1983) have shown that treatment within the community was able to deliver outcomes as good, if not better, than comparably ill patients treated within the hospital setting. Service components highlighted in this early research remain the building blocks of the better community services today, such as 24-hour availability for crisis intervention, assertive continuity of care and support for carers.

As the evidence for community treatment of mental illness strengthened and these models of care became accepted, service structures and standards evolved to describe optimal, integrated inpatient and community-based area mental health services (Rosen et al., 1989). In addition to standards for the operation of services, the need to measure service effectiveness was promoted with clinician and consumer rated outcome measures identified for Australia and incorporated into all state and territory mental health data collection systems (Pirkis et al., 2005) as well as in the private mental health sector. The Australian Mental Health Outcomes and Classification Network (www.amhocn.org/) was established to support the implementation, collection and national reporting of public sector outcome measures.

Although the number of psychiatric beds declined from a peak of 280 beds per 100,000 in the early 1960s to 40 beds per 100,000 by 1992, over 70% of the state and territory governments’ mental health budgets were still spent on inpatient services at this time. The expansion of mental health treatment for the broader population did not commence in earnest until the involvement of the Commonwealth government in the National Mental Health Strategy in 1993. Five-year national mental health plans agreed by Commonwealth, State and Territory health ministers ran concurrently with Commonwealth/State Health Care Agreements; The First Plan (1993–1998) was focused on improving services, primarily those provided within general hospitals and the community, for people with severe mental illness. The efforts of academic leaders such as Beverley Raphael saw the scope of The Second Plan (1998–2003) expand to include mental health promotion, illness prevention and early intervention; this evidence base was informed by emerging research on risk factors and from child and adult surveys of the wider population. The epidemiological studies demonstrated the high prevalence and significant disability from mental disorders; most people with these disorders were not treated at all and those who were often received the intervention in primary care. Researchers and groups such as the Mental Health Council of Australia and SANE Australia used the survey findings, plus data on suicide rates, homelessness, unemployment and lost productivity, to advocate for increased investment in community mental health services.

The ambitious attempt to encompass the policy priorities of the first two Plans in The Third National Mental Health Plan (2003–2008) however meant available resources were diluted and implementation struggled to gain traction. In part as a result of this attempt, there was increasing disillusionment among stakeholders with health department led national reform. In response, the Council of Australian Governments (the Prime Minster, state premiers and territory chief ministers) in 2006 endorsed a whole of government National Action Plan on Mental Health (2006–2011) in which the Commonwealth expanded coverage for psychological treatment of common mental disorders within the national health insurance–funded Medicare system. This initiative was shown to increase the population treatment rate for mental disorders in Australia from 37% in 2006–2007 to 46% 3 years later, in 2009–2010. However, population mental health prevention and early intervention programs have been much slower to embed into services, including even high-profile initiatives such as the those for first-episode psychosis (McGorry and Yung, 2003). Other initiatives that have been less reliant on incorporation into mainstream services, such as headspace, the National Youth Mental Health Foundation and mental health first aid developed by Tony Jorm and colleagues, have been more widely adopted within Australia and internationally.

Increasing knowledge of the epidemiological need across the Australian population, combined with the clinical evidence for interventions at differing levels of need, allowed researchers and planners to bring the development of a comprehensive service planning framework based on a stepped care approach to planning. This work started using costs, burden averted and efficiency of current and optimal treatments to demonstrate that increasing treatment coverage would be affordable, as the increased coverage largely encompassed disorders which were less costly to treat (Andrews, 2006). The Fourth National Mental Health Plan (2009–2014) included the task of developing this service planning framework and creating targets for the mix and level of mental health services to reach agreed populations.

To determine the need for interventions by groups of individuals, epidemiological data on the age-adjusted prevalence and severity of mental disorders were derived from population surveys. Population treatment targets were set depending on the average level of need within each group, determined by diagnosis, symptom duration and functional impairment. Pharmacological and psychosocial interventions and, where necessary, community support and where these will be delivered (e.g. inpatient or community settings) required for each age grouping and level of need were assembled. The interventions are aggregated into a treatment or care profile for a time period, for example, 12 months, and the resources required to deliver the interventions for each group are estimated. The National Mental Health Service Planning Framework has 155 care profiles covering the mild, moderate and severe need continua and all age groups. The interventions in each profile are for the average person in each group. All service planning, including those in this Framework, will need constant revision to incorporate new research about risk factors, incidence and remission as well as advances in prevention and treatment.