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Despite increased expenditure on mental health care in Australia, the prevalence of mental health has remained stable, and the severity is increasing. Dynamic modelling provides insight into the complex factors at play, write Sebastian Rosenberg, Jo-An Occhipinti, Adam Skinner, Ian B Hickie …
ONE of the most puzzling features of recent Australian mental health investments and reform has been the apparent stability of the prevalence of mental illness. Total expenditure on mental health services in Australia (public and private) more than doubled from $5.8 billion in 2008–09 to $11 billion in 2019–20. Over the same period, the Australian Government expenditure on mental health-related services rose from $120.38 per capita to $149.63. Most of this increase was due to the inclusion of psychology services under Medicare, as part of the Council of Australian Governments National Action Plan on Mental Health, established in 2006. The impact of this increase in spending has been to lift the rate of public access to mental health care from 35% in 2007 to 47% in 2020–21. Eleven per cent of Australians (2.9 million people) accessed 14 million Medicare-subsidised mental health-specific services in 2020–21, an increase from 7% in 2010–11.
Although substantial increases in the provision of care and public access have occurred, they have not necessarily been equitable, with access to mental health care varying depending on where people live and many Australians facing considerable out-of-pocket costs.
The prevalence of mental illness also appears to have changed very little. The Australian Bureau of Statistics (ABS) found that one in five Australians had a 12-month mental disorder in 2007 and again in 2020. Evidence from Australia and overseas suggests this is unsurprising, with little observable relationship between increased provision of care and reduced prevalence.
This has led some to question the effectiveness of increasing access to current treatments as a means of improving population mental health, instead calling for greater emphasis on primary prevention of common mental disorders. Mental health receives just over 7% of the total health budget in Australia but accounts for around 12% of the burden of disease. Arguments to close this gap are hard to sustain when evidence for the impact of spending is wanting.
So how to reconcile this puzzle, where more mental health treatment does not seem to result in lower prevalence?
We developed a system dynamics model of mental disorder incidence and treatment-dependent recovery to assess two potential explanations. The first was that there has been an increase in the individual-level risk of disorder onset – in other words, that while overall prevalence may be unchanged, this stability masks an increased level of high to very high psychological distress. The second explanation was to consider declining effectiveness of care resulting from insufficient services capacity growth.
Bayesian statistical methods were used to fit the system dynamics model to key Australian datasets (ABS; Australian Institute of Health and Welfare; the Household, Income and Labour Dynamics in Australia [HILDA] Survey) for the period 2008–2019. Estimates of yearly rates of increase in the per capita incidence of high to very high psychological distress and the proportion of patients recovering when treated indicate that the individual-level risk of developing high to very high levels of distress increased between 2008 and 2019.
However, we found no evidence for declining treatment effectiveness. Simulation analyses suggest that the prevalence of high to very high psychological distress would have decreased from 14.4% in 2008 to 13.6% in 2019 if per capita incidence had not increased over this period, which equates to a 5.47% reduction in the number of people with high to very high psychological distress in 2019.
The conclusion arising from this dynamic modelling analysis is therefore that an increase in the prevalence of high to very high psychological distress in Australia from 2008 to 2019 is attributable to an increase in the per capita incidence of higher levels of distress, rather than declining treatment effectiveness.
So, although the overall prevalence of mental illness may be stable in the community, our modelling suggests problems may be becoming more severe. Even though the causes of this are unclear, there are several relatively recent economic and social phenomena that could plausibly contribute, including increasing underemployment, declining employment security, increasing household debt, a decline in the frequency of social interaction, and increasing loneliness.
What these results show, contrary to previous contributions to the treatment-prevalence puzzle, is that if the per capita incidence of high to very high psychological distress had remained stable over the study period, increasing treatment-dependent recovery associated with a substantial increase in access to mental health care would have in fact produced a modest but significant decrease in the proportion of people with high to very high K10 (Kessler Psychological Distress Scale) scores.
System dynamics modelling offers an opportunity to better grasp and respond to the complex, fluid nature of mental health, and to advance the contentious debate (prevention versus treatment) by providing a platform for exploring the robustness of our hypotheses. The implications arising from this work are significant.
The work suggests that while there has clearly been increased mental health treatment provision in Australia from 2008 to 2019, the scale of the investment was insufficient to offset a concurrent increase in the incidence of high to very high psychological distress. New funding has failed to deliver the desired, palpable impact on community mental health but for reasons of scale, not target. Although attention to mental health has grown, commitments to reform and funding have been sporadic, with significant national investments made roughly every five years since 2006. Mental health remains characterised by underinvestment.
In fact, an earlier study provides evidence that the current pattern of severe underinvestment in public mental health services in Australia, and particularly in more effective early intervention services, perpetuates a grossly inefficient and more costly mental health care system. It concluded that “if we persist with ‘business as usual,’ nearly three times the number of mental health services currently provided per year will be required to ensure that all Australians seeking mental health care receive timely and effective treatment”. The modelling demonstrated that actual expenditure on mental health services in 2018−19 was $14.4 billion less than the $22.7 billion needed.
The modelling justifies addressing this underinvestment, suggesting there is merit not only in continued spending on mental health services but in expanding it as a legitimate and effective contribution to population mental health strategies. Addressing the substantial and persistent ‘treatment gap’ for mental disorders should remain a global and Australian public health priority, particularly for young people.
This renewed investment should be part of a broader strategy here in Australia, aimed at delivering equitable and affordable mental health care, boosting targeted prevention and earlier intervention activities, dealing with the psychosocial aspects of good mental health, and delivering genuine accountability to drive systemic quality improvement.
Dr Sebastian Rosenberg is Senior Lecturer at the Brain and Mind Centre, University of Sydney
Associate Professor Jo-An Occhipinti is the Head of Systems Modelling, Simulation and Data Science; and Co-Director of the Mental Wealth Initiative at the Brain and Mind Centre, The University of Sydney. She is also the Managing Director of Computer Simulation and Advanced Research Technologies (CSART) Ltd.
Dr Adam Skinner is a mathematical modeller and statistician at the University of Sydney’s Brain and Mind Centre. His research focuses on the development of computer simulation models designed for use as decision support tools by health policy makers.
Professor Hickie is a Professor of Psychiatry and the Co-Director of Health and Policy, Brain and Mind Centre, University of Sydney. He has led major public health and health services developments in Australia, particularly focusing on early intervention for young people with depression, suicidal thoughts and behaviours and complex mood disorders.
The statements or opinions expressed in this article reflect the views of the authors and do not necessarily represent the official policy of the AMA, the MJA or InSight+ unless so stated.
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My goodness sounds like a script out of “Monty pythons flying circus”. This is so utopian and delusional, whoever invented this needs to really get to grips with reality.
The fact Is have they thought about locations, have they consulted the community, have they considered transport to the locations, have they consulted the users of the current services, has it been costed, have the staff been consulted. These are all questions that need answering.
This plan in draft form seems to be one that will take years to implement. Has there been forward estimates of beds needed, outpatient clinics numbers, staff numbers, funding and other details been established for example 20 yrs down the track?
I am a concerned that this will be another moving the deckchairs rather than changing the attitudes of people, buildings and moving locations do not change attitudes in people. People need to be valued for who they are both consumers and staff and be kind to each other.
Or maybe the marketing efforts of the major institutes to increase awareness are working? And maybe, just maybe, the enormous investments into a privatised sector relying on Government grants isn’t?
In my reading of the systems dynamics model there are an awful lot of guesstimates of the impact of various interventions based on research generalised from privileged populations and applied to everyone else. Which might explain why the predictions of a huge increase of psychological distress on the basis of this model by the same team(.https://www.sydney.edu.au/content/dam/corporate/documents/brain-and-mind-centre/youthe/road-to-recovery-v2.pdf ) were waaay out. (. https://www.aihw.gov.au/mental-health/monitoring/mental-health-impact-of-covid). Given this predictive modelling was not really predictive, how can we trust similar models?
They may look good and produce lots of graphs but I’m not convinced they reflect community experience. And if they don’t reflect community experience why should we trust them?
Western Australia needs billions spent on new mental health infrastructure yet the state also needs immediate mental health response services and urgent care centres.
A government which truly wanted to transform the WA Mental Health system would:
Decommission & Clear the Graylands hospital site and seek to sell the site for absolute maximum profit , those profits would then be matched by new money in the budget to fund Mental Health Infrastructure across the metropolitan area.
When it comes to transforming the WA Mental Health system there is so much to do,
The WA Mental Health Commission should be completely reformed into a major service delivery agency known as Mind Health WA , and a lead reform group should be created in a Mental Health System Transformation Office as part of the Department of Premiere & Cabinet portfolio agencies .
The government should commit to at least 3 Mental Health Urgent Care Centres at Midland, Bunbury , & Perth City . These centres provide emergency department alternatives for people in acute psychological distress or experiencing acute mental health instability.
The Government should commit to a Community Mental Health Locum Nurse Response & a Youth Mental Health locum nurse program , which would initially be trialled where at least 2-3 nurses work together between 4pm to 1am on Friday & Saturday evenings in a finite metropolitan area , and Bunbury . This would be a first trial of after hours home visit nursing for very at risk populations, including young people who are expressing thoughts of suicide.
The government should establish a Mental Health Careers & Talent Attraction Initiative, MindWork , Leading Minds , this initiative would provide a relocation allowance to any suitably qualified hospital/outpatient experienced psychologist or psychiatrist who is willing to move to WA from another Australian/NZ jurisdiction. The Initiative would also create a occupational experience ambassador campaign to be implemented via major advertising & media presence in universities , TAFE & community to promote mental Health work careers . The Initiative would fund a new ‘Skills Uplift Scholarship’ providing at least 3-5 thousand dollars over the life of a masters course to individuals who are seeking to become psychologists in WA with the only proviso being that they would need to complete at least one work placement in a WA public health setting . The Scholarship would also assist & allow existing nurses within public health to study mental health nursing , psychology , or psychiatry with an initial upfront bursary of 3-5k , the ‘Skills Uplift Launch grant’ .
My initial Vision for some replaced Mental Health infrastructure in the metropolitan area consists of the following options : Closure , and demolition of every built structure at Graylands is preferred !
A new two site Mental Health Campus at Shenton Park , this would see the current Lemnos Older Adults Mental Health demolished and a new multi-storey (2-3 levels) building designed to overlook the Shenton bushland , this building would become 3-4 Ward adult mental health service , potentially Shenton Park Minds Health Campus , the second site would see the current Child & Adolescent Mental Health clinic site fully cleared which is located within strolling distance from the Lemnos site . Once the clinic and site is cleared this site would become home to a new Adult Outpatient clinic ( Minds Centre) , major occupational therapy & arts centre aswell as possible Women & infant / Young Children’s Mental Health Recovery Rehabilitation suites ( 12-20 bed) this would also be designed to overlook bushland and other parts of the built form would have panoramic views of lower Shenton park and the city beyond .
Next is the Demolition of enough space & site preparation for WA’s most state of the art & therapeutic Prevention & Recovery Centre to be located on a portion of the former City Beach High School Site , this ‘community rehabilitation & residential relapse prevention service ‘ would consist of up to 40 suites , it would be created as a co-living recovery village much like current step-up step down facilities although this particular centre would seek to improve community inclusion & have the strongest approach to enduring connection to community-based wellbeing supports, the built form would need to provide large spaces for activity . This service would be the first Prevention & Recovery Centre which accepts people from across the metropolitan or regions rather than having a geographic target area . The City Beach Prevention & Recovery Centre would be an outstanding investment & amazing location to reimagine & transform how we support people experiencing mental health decline .
Next is the possibility of providing older adult mental health wards at Osborne park hospital through expansion at that site with the possibility of repurposing current wards and building 2 new wards .
Two new Child & Young Person Mind Health & Wellbeing Centres should be built in possibly West Leederville & Cottesloe ( locations not exact ) this would replace the demolished clinic at Shenton Park .
WA’s First Youth only Step-up Step Down residential recovery centres – these would be similar in nature to the adult prevention & recovery centres but only for young people aged 14-18 and could be located ideally at Murdoch & Possibly on a site which would need to be bought from UWA which is their current podiatry school in Crawley Ave and Park ave ( Amazing location ) so close to children’s hospital and next to kings Park .
Forensic Mental Health Services would require purpose built & designed facility which could potentially be built in the suburb of Casuarina , if this is not possible then other sites in Orange Grove , Martin , Furnissdale , and Cardup could be considered .
The State Government should secure the next generation health club site at Kings Park for the centrepiece future mental health infrastructure project , ideally the current building would be demolished and a new building or set of two buildings would be created as the ‘State Centre for Minds , Creative Therapy, Research & Recovery’ , Meld Centre , this centre would be our centre for mental health service collaborative practice , research & community inclusion that acts as the lead/catalyst for culture change . The centre would act as both an outpatient clinic , recovery therapeutics & activity studios , research offices and new home for the WA Mental Health Commission offices.
Further Mental Health infrastructure would be required beyond this such as expanding capacity at existing hospitals, creating step-up-step down prevention & recovery centres in Peel Region , in Forrestfield/Kalamunda, & Forrestdale south , although this is somewhat beyond scope .
A staged approach:
• Initially at least two new adult mental healthcare wards need to be constructed at Osborne park , and a forensic mental health facility at the location that meets government and public expectation
• This initial investment will help to de-constrain the Graylands site to prepare it for clearing
• Stage two would need to be the demolition and then new builds at the Lemnos Site , ideally in tandem with the sale of Graylands and the construction of the Comprehensive Minds research and practice excellence centre at kings park , the Prevention and Recovery centre at City Beach and Youth Prevention and Recovery Centre at Murdoch
• Further projects and capacity are able to be staged beyond this as funds , sites , and planning are able to be facilitated
Modelling is a useful tool, but good old fashioned outcome data is the best measure of effectiveness. The use of standardised instruments (Post traumatic checklist, K10 , Montgomery Asberg Depression Rating scale [MADRS]) that measure longitudinal health states should be mandatory in order to claim Medicare Benefits. There is considerable evidence in the published literature that links inflammation to a range of mental health conditions especially Depression and PTSD. Neuroinflammation will not respond to psychotherapy and the use of standardised outcome measures would demonstrate that. The psychedelic drugs which are showing considerable promise in a range of mental health conditions are powerful anti-inflammatory drugs
( https://pubmed.ncbi.nlm.nih.gov/30102081/ ). This paper’s argument is similar to that of the Education Unions. Despite spending vast sums, education outcomes are falling. In both cases, the paradigm may be (or more likely is) wrong and the definition of insanity is doing the same thing over and over again while expecting a different result. We need to aggressively explore novel therapies in large scale studies. It is time to stop doing things that provide no clinical improvement and fund those that do.