Mental health and its disconnects

LIKE so many of us affected by mental ill health, the state of mental health care in Australia is plagued by disconnection. Here are some of those disconnects.

Disconnect #1: Awareness vs action for better care

Why are we so aware of mental ill health yet access to and quality of care remains so poor?

Awareness and open discussion of mental illness have improved exponentially in Australia through some internationally unique developments.

In beyondblue we are fortunate to have had a national marketing phenomenon generously funded by governments, which has helped to transform attitudes to depression. The ABC has added momentum to this seachange through its annual “Mental As” programming week. 

While the less attractive forms of mental illness have not yet been embraced, knowledge and understanding have improved. But there is a stark disconnect with the coast-to-coast bottlenecks in access, and the scarcity of dependable evidence-based care.  

Why have we newly aware Australians tolerated falling levels (in real terms) of investment and shrinking services? Depression and anxiety are top of the pops in public conversation yet only 16% of Australians with these conditions access even minimally adequate evidence-based care.  

It is simply unacceptable. Imagine how the public would react if people with cancer were exposed to this level of neglect. 

• Related: MJA -- Using accountability for mental health to drive reform
• Related: MJA -- Time to implement national mental health reform
• Related: MJA -- The services provided to young people through the headspace centres across Australia

And for reasons unknown, since 2013, Australians and the mental health sector have tolerated a national efficiency drive in mental health care which has heavily constrained the essential changes that the National Mental Health Commission so accurately pinpointed. 

But doesn't greater awareness lead to more investment, and better access and quality in health care? Not so far. 

In her critique of “Mental As”, Helen Razer challenged this assumption, suggesting that awareness might paradoxically be counter-productive in reducing momentum for action. For many, having the conversation seems to be enough to salve consciences and create the impression that progress is being made.

So the alchemy of translating public momentum into serious reform and investment has eluded us so far. 

There are some hard lessons to be learned from other neglected causes which have leapfrogged mental health in the political pecking order. Ironically these are close cousins of mental health, namely disability and domestic violence.

Mental illness dwarfs physical illness in the disability stakes, yet the former has so far been the afterthought and now the anomaly within the National Disability Insurance Scheme. 

Family violence, all too often a result and a cause of mental illness, kills one person a week. Mental illness kills 50. Every year it also shortens the lives of hundreds of thousands by more than decade. 

So while nobody would want the momentum behind the overdue and welcome reforms in disability and family violence to slacken one iota, mental health should not have been so easily cast aside from its pole position of some years ago.

Disconnect #2: Cost-effectiveness, mental wealth and perverse investment

Twenty-five years ago mental health care was deinstitutionalised, downsized and embedded in mainstream health care. This is a reform that has never been honestly or formally reviewed. It is becoming a field of broken dreams with increasingly perverse effects. 

Mental health is yoked to the juggernaut of acute hospital care where costs are ballooning, and the health system is said to be unsustainable. The so-called “fiscal cliff” of reduced federal funding to states beckons and there is a realistic fear that mental health care, already seriously underfunded and overwhelmed, will shrink further.  

Yet unlike the major physical illnesses such as cancer and cardiovascular disease, mental illness, because it emerges in young people and so often persists through the prime productive years of life, provides the opportunity for a major return on investment, and so is a key solution to rather than a contributor to the health funding crisis. 

The disconnect here is that mental health is the routine victim of cuts while spending on non cost-effective but emotionally salient illnesses balloons. 

Treating mental illness promptly and properly will also greatly reduce the impact of the physical non-communicable diseases since it is a major risk factor for these.

While health care should be holistic, we need to accept the disconnect in the health economics of mental and physical health and invest much more strongly in the former. Mental health means mental wealth.

Disconnect #3: Rhetoric, evidence and reality

Another enormous disconnect is between what is actually done and what would work. In other words, the gap between efficacy and effectiveness. 

Unlike other areas of health care, in mental health, the rhetoric is disconnected from reality, and these days governments are much more likely to fund programs that keep stakeholders placated and political correctness superficially intact. Real outcomes are subordinated and the avertable burden of disease remains high. 

If we simply did what is standard practice in cancer, then we would transform outcomes. Namely, prevention where possible, early diagnosis as the next best option, and guaranteed and sustained access to evidence-based care as long as it is needed. This would be cost-effective and dramatic. It is already government policy; however, implementation failure is the problem. The youth mental health reforms of recent years represent genuine progress, but are now at a crossroads.

Tackling these disconnects will require a mix of more unified, radical and purposeful leadership within the mental health sector, but most importantly it needs large scale grassroots mobilisation of the Australian public whose self-interest and common interest have not been awakened or channelled into effective action. 

One attempt to catalyse this process is reflected in the establishment of a new organisation, Australians for Mental Health, which seeks to put mental health on the political agenda for the coming federal election and beyond.  

Professor Patrick McGorry, AO, is the Executive Director of Orygen, Professor of Youth Mental Health at the University of Melbourne, and a Director of the Board of the National Youth Mental Health Foundation (headspace). He is a former Australian of the Year.