Is Australia resolved to deliver effective mental healthcare across the lifespan?

And thus the native hue of resolution

Is sicklied o’er with the pale cast of thought;

And enterprises of great pitch and moment,

With this regard, their currents turn awry,

And lose the name of action.

William Shakespeare – Hamlet

Allison et al. (2019) and Chanen et al. (2020) provide contrasting perspectives on the complex problems surrounding early intervention for youth, including schizophrenia. Currently, the Productivity Commission Review into Mental Health draft report affords a broader view of this debate, which has arguably been framed in overly narrow terms (Productivity Commission, 2019). This draft recommends changes to medical care systems, such as better prevention and early intervention for mental illness and suicide attempts, closing critical gaps in healthcare services, as well as systemic recommendations for better community support and housing for people with a mental illness. Allison et al. (2019) highlight the imbalance in the relative resourcing of youth mental health services compared to adult mental health services in Victoria, as well as raising concerns about the effectiveness of early intervention programmes for psychosis. Chanen et al. (2020) counter that they have evidence of the effectiveness of early intervention programmes and argue that all aspects of mental health services are likely under-resourced. Despite differences, the papers may both point towards the need for improved governance, policy and implementation of mental health services in Victoria, which is an impetus for the Royal Commission in that state and is also needed across the Commonwealth as shown in the Productivity Commission draft report.

Why we are still yet to effectively address systemic issues in mental health services in Australia is both puzzling and chastening. A plethora of reviews, commissions and inquiries have abounded over the last 35 years since the 1983 Inquiry into Health Services for the Psychiatrically Ill and Developmentally Disabled (Richmond Report). However, the results to date appear to comprise ineffective actions and much re-disorganisation of mental health services in the semblance of action (Looi and Kisely, 2019). There are problems at each level of the Commonwealth: corporate governance of mental health services must be coordinated, with a whole-of-government approach across federal, state and local levels; policy arising from a whole-of-government approach must be promulgated; planning and implementation must be predicated on coordinated policy; and most importantly, there must be evaluation of outcomes (Productivity Commission, 2019).

In the context of such systemic issues, arguments from both the Debate papers have merits. Early intervention has some evidence of efficacy, as Chanen et al. (2020) note. However, the broader question of early intervention as a paradigm shaping mental health service programmes for schizophrenia remains to be fully answered, and this is a concern expressed by Allison et al. (2019) when they question the mix of services provided currently in Victoria and argue for evaluations of effectiveness of interventions for evidence-based planning. Chanen et al. (2020) assert that all areas of mental health are relatively underfunded and argue for better overall funding, but emphasise their view that early intervention in psychosis must phase into appropriate long-term care. Chanen et al.’s (2020) criticism of care in the adult system underlines the dilemma faced by clinicians in underfunded mental health services, frustrated that they cannot provide the standard of care needed (Looi and Maguire, 2019). The funding of specialised intervention for psychosis across the life course might also result in siloing of care, if it is not integrated with general adult mental health services, in contrast to Chanen et al.’s (2020) view that funding is not a zero sum game.

The missing element in these Debate papers is priority three for Productivity Commission reform (Productivity Commission, 2019): investment in services beyond health, which traverses community supports and provision for social determinants of mental health. Thus, a broader view encompassing a whole-of-government approach to mental health services is necessary in order to address the early intervention and closing critical gaps in services as well as investment in community services beyond health.

Reflection on questions raised in the Debate papers is necessary but not sufficient; as the Productivity Commission has highlighted, a whole-of-government approach to mental healthcare is needed if we are to develop effective intervention for mental illness across the lifespan that sufficiently encompasses the many reforms needed, including, but not limited to: early intervention, closing critical gaps in services and investment in services beyond health. However, these prevailing concerns have been raised before in multiple inquiries and governance has proved difficult to date (Looi and Kisely, 2019). This is the great challenge for our resolution to improve mental healthcare, how and when will effective action be forthcoming? More than ever, we must not lose the name of action.