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With the spotlight on mental health in the wake of the COVID-19 pandemic, now is the time to rebuild our crumbling mental health system in a way that works for the people who use it, writes Dr Jason Lee …
One of the unexpected upsides to emerge from the tumult of the past few years has been the way we view mental health challenges.
Stigma was smashed when the COVID-19 pandemic hit and it quickly became apparent that, given the right circumstances, anyone can struggle and that there is no shame in seeking support.
But it is a sad irony that the community has been encouraged to reach out for help at a time when that help often simply is not there; like throwing a life raft to someone who is drowning, only to snatch it back the moment they try to grab it.
Against this backdrop, it is not surprising we have seen passionate discussion about the Australian Government’s decision not to extend the COVID-19-related increase to Medicare-subsidised psychology sessions, following an independent review of the Better Access initiative.
This universal scheme is key pillar of our nation’s mental health system and shapes the lives of millions of people. We must ensure it is well designed, accessible, affordable, fair and connected to the rest of the system.
But focusing the debate on whether ten or 20 sessions is the appropriate number overlooks some of the evaluation’s critical findings. It also misses an opportunity to rebuild our crumbling mental health system in a way that works for the people who use it.
The conversation must be much broader than one about subsidised sessions with psychologists.
We need to radically redefine our understanding of how mental health support is delivered in this country.
The Better Access review highlighted what we already know – that people on relatively high incomes in major cities are disproportionately accessing care, while the disadvantaged and geographically disconnected can’t find or afford support.
These gaps are widening as the system buckles under increasing demand, and the residual impacts of the pandemic exacerbate chronic mental health workforce shortages.
It is clear that we cannot keep doing what we have always done.
As a start, Better Access must be redesigned to be more equitable, targeting people who need it most, as recommended by the review.
But we must also pay heed to another of the evaluation’s key findings – that this scheme, although valuable to many, is not the right fit for everyone.
They may be either too unwell for psychological support alone and need to be stepped up the ladder of care, or well enough that they can step down to less intensive options.
We need a wholesale rethink of how Better Access connects with other elements of the mental health system, with a focus on broadening both the mental health workforce and the types of support that are available to people.
Alternative supports include low intensity options, such as self-referred online treatments that integrate with face-to-face support, acute care, community-based services, school counsellors, and digital and phone options.
A key finding of the Better Access review was that the scheme is providing services to some people with relatively low levels of need who could potentially be supported through other means.
Building a system that provides more low intensity services for people experiencing mild to moderate depression or anxiety means we can free up resources to better support the “missing middle” – the gap that many people fall through when they are not sick enough for intensive, specialised hospital or community-based treatment but need more support than traditional primary care can offer.
Supervised mental health coaching is one option with a solid and expanding evidence base that can help bridge that gap. Coaches complete a 12-month training course in low intensity cognitive behavioural therapy at institutions such as Flinders University. Many have lived experience with mental health or life experience relevant to the cohort they are working with, which can foster rapport and trust.
Even though some coaches already have a background in mental health, many are part of an emerging mental health workforce that has the potential to support the nation’s buckling mental health system.
Beyond Blue’s NewAccess service is just one example of this model, with peer-reviewed research showing that seven out of ten people recover according to clinically validated measures.
NewAccess uses a new workforce of coaches who currently support people either by phone, video chat, or face-to-face in some areas, making it highly convenient, suitable for people in rural and remote communities.
Modelled on the UK’s highly successful Improving Access to Psychological Therapies (IAPT), the Australian program includes weekly supervision to ensure coaching is safe and effective and aligns with a stepped care approach.
This means people are referred to more intensive support, typically via their GP, as needed.
The service is free of charge and requires no doctor’s referral which means people can simply pick up the phone or walk in. Given many GPs are stretched, this could help improve access to care. With the person’s consent, their GP is kept in the loop.
Coaches deliver a course of low intensity cognitive behavioural therapy, typically helping people manage everyday life problems such as work stress, financial worries, or relationship issues before they become more complex problems. Importantly, outcomes and recovery are measured in real time through clinically validated measurement tools including the Patient Health Questionnaire-9 (PHQ-9), the Generalized Anxiety Disorder 7-item (GAD-7) scale, the IAPT Phobia Scale and the Work and Social Adjustment Scale.
As a psychiatrist, I see firsthand a number of people who would be well supported through such an approach. I see rural and remote Australians who have travelled hundreds of kilometres to access specialist mental health care, away from the support of their family and friends, and wonder whether this could have been prevented for some if they’d had access to the right help earlier.
This is the type of “low cost, low risk, easy to access” service that the Productivity Commission’s inquiry into mental health care recommended, finding that the lack of low intensity services was one of the key gaps in the system.
The Commission estimated half a million Australians who are not accessing any care and up to two million being treated with medication and/or individual therapy could benefit from low intensity options.
More diverse options would free up psychologists to see patients with higher levels of need, reducing waitlists.
To achieve real and lasting reform, we must think more innovatively. If nothing changes, nothing changes.
We know the need is great, but so is the opportunity.
This is the time for courage and creativity as we invest in solutions that can make a tangible difference in the lives of many Australians.
Dr Jason Lee is a psychiatrist and Beyond Blue board director
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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Credentialed Mental Health Nurses have the training and experience to deliver low, moderate through to the more intensive Mental Health treatment and support.
Better Access will not get better nor very accessible without having our Credentialed Mental Health Nurses, University trained Counselors and Provisional Psychologists included in being able to offer their services properly backed up by Medicare. Please lets not waste more money on committees and research that will point out what everyone, working in Mental Health Care already knows.
Well said Dr Lee. Another option to add into the mix would be expanding Medicare item numbers to provisional psychologists, who are currently ineligible for rebates under Medicare (but have far more training and supervision than this doing a 1 year CBT coaching course). Thought could be given to rebateable items that require less experience, like lower level anxiety and depression management. This would have a huge impact to expand the mental health workforce.