Better Access – Necessary but not sufficient

The Better Access scheme was introduced in Australia in 2006, enabling a range of mental health services provided by general practitioners, psychologists and certain allied health practitioners to be funded through Medicare. The scheme was designed to improve access to affordable mental healthcare and thus to reduce the burden of disease from common mental disorders. The use of psychological services increased greatly following introduction of the scheme. This was regarded by some as an indicator of success, while others highlighted that increased service use per se does not demonstrate whether the scheme has produced better mental health outcomes. Unfortunately, the ‘gold standard’ method of evaluation, a randomised controlled trial was not possible, given the rollout of the scheme on a nationwide basis.

Publication of a study by Pirkis et al. (2011), which concluded that Better Access was playing an important part in meeting the community’s previously unmet need for mental health care, was accompanied by several criticisms. The study demonstrated that the majority of patients using Better Access services had diagnoses of anxiety and/or depression, four-fifths of those treated had high or very high levels of psychological distress, and only two-fifths of those seen by psychologists had previously received mental healthcare. Importantly, patients experienced statistically significant improvements in symptoms from pre- to post-treatment. Methodological weaknesses of the evaluation were identified, and so many agreed that the study could not conclude that the treatment provided through the Better Access initiative was effective.

The question of whether the programme has improved population mental health has continued to be raised. This is an interesting issue, which requires a consideration of what is meant by mental health as opposed to mental disorder. The World Health Organisation (Herrman et al., 2005) defines mental health as ‘ a state of well-being in which the individual realises his or her own abilities, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to his or her community’. There are recognised risk and protective factors for mental health, which operate throughout the lifespan, with the presence of multiple risk factors and insufficient protective factors predisposing an individual to develop a mental disorder.

In a study reported in this journal, Jorm (2018) has investigated the wider population-health impacts of the introduction of the Better Access scheme. Notably, the number of Medicare-funded services rose steeply after the introduction of Better Access, but the prevalence of high and very high psychological distress (measured by scores on K-10 questionnaire) did not change, nor was the suicide rate affected by the introduction of the scheme. Jorm offers several possible explanations for this apparent lack of impact on the prevalence of psychological distress in adults or on the suicide rate of the whole population, including that increasing the provision of treatment does not address the major determinants of mental health problems in the community.

Epidemiologist Geoffrey Rose (1992) proposed that individuals with disorder reflect the characteristics of the general population in which they live, and so, there is a relationship between the average number of symptoms in the population and the number of diagnosable cases. Building on this work, Huppert (2009) notes that improving mental health of the population will require treatment of disorder when present as well as preventing disorder from occurring and enhancing well-being.

Prevalence of mental disorder is determined both by the rate of recovery from illness and the rate of occurrence of new disorders. Focusing exclusively on strategies that target treatment of mental disorders is unlikely to reduce the overall number with disorders, as they will continue to be renewed. Efforts to reduce prevalence should logically target risk factors as well as provide treatment for existing disorder. As risk factors operate at both an individual level (e.g. genotype, mother–infant attachment and adverse childhood experiences) and at the social level (e.g. poverty, unemployment, discrimination and loneliness), measures to address these need a whole of government approach, rather than being the responsibility of mental health services alone. This is a critical issue for those developing policy and funding initiatives designed to improve mental health in Australia.

Jorm concludes that there is no detectable benefit to the mental health of Australians from the introduction of the Better Access scheme, and notes that these findings are consistent with previous reports showing that large increases in treatment do not appear to reduce the prevalence of mental illness. It should be evident from the above that in the absence of other initiatives, this was not a realistic expectation. Importantly, while population mental health has not changed, the data presented do not enable any comment on how an individual who received treatment through the Better Access scheme did or did not benefit.