Abstract
In this month's issue of the Australian and New Zealand Journal of Psychiatry (ANZJP) Allen and Jackson [1] together with Jorm [2] question the evaluation by Pirkis and colleagues [3] of the Better Access initiative. The latter refers to the government-funded program that allows better access to Psychologists through the Medicare Benefits Schedule.
On the face of it everyone agrees that this is a worthy cause and that accurate evaluation of the program is essential. But the devil, literally, is in the detail. The first problem is that the initiative has gained popularity, way beyond expectations, and as such has become a victim of its own success. Presently it is costly, and costs into the future are likely to continue to increase. Sustainability of the initiative and its growth are therefore going to be an ongoing challenge. The second problem is that it may not be doing what it was designed to achieve. The authors of the editorials highlight some of the seeming inequities in the initiative such as the disproportionately poorer uptake by those that are underprivileged. If it fails to hit the mark in this regard then it is unlikely to have meaningful clinical benefit in the long term and again its sustainability will be threatened. The third problem is the extent and nature of the evaluation of the initiative, with one view suggesting that the horse has already bolted. This is possibly the most important aspect of the process and perhaps the most contentious. Evaluation is the only mechanism by which the success of the initiative specifically, its benefits can be gauged. It is also the means by which the initiative can be fine tuned and tailored. Put simply, we want to know what the initiative actually does, for whom and to what extent. On top of this we want to know how to modify the program so as to achieve the best possible outcomes. Sadly there does not seem to be a straightforward answer and though the gauntlet has been thrown it's not clear who, if anyone, will pick it up. Hence, at the very least, I urge everyone to read the evaluation by Pirkis and colleagues and the two accompanying editorials and make up your own mind. If this leaves with you with a sense of unease or heightened anxiety – rest assured you are not alone and your concern is justified.
Not wishing to conclude with a disagreement of views I would also like to highlight the article by Dodd et al. [4] that offers a consensus view. This important review provides detailed safety-monitoring guidelines for the treatment of major depression and, as such, is essential reading for all practicing clinicians.