Mental health care in Australia: can we do better?

Recent tragic events, such as the Bondi Junction attack, have invoked anger, helplessness and sadness among those impacted directly and indirectly by the event, but have also raised questions about whether the event could have been prevented.

Despite close to half (43%) of the Australian population experiencing mental health problems sometime in their life, current mental health services are significantly underfunded. This is further compounded by the fragmentation of services between private and public, government and non-government agencies, federal primary care and state specialist services, and between physical health, mental health, disability and social care services and so on. This is also causing significant demoralisation and burnout among mental health professionals.

There is emerging evidence on the positive impact of investing in and integrating social care with mental health services. Specifically, interventions that build community trust and safety have been shown to mitigate crime and violence and lessen adverse mental health outcomes. For example, when those with severe mental illness are provided health care with wraparound social care, they are less likely to experience disconnection from families and communities, which might otherwise lead to loneliness/isolation, homelessness, and substance abuse; factors that are likely to result in adverse outcomes. Further, interventions and supports that improve social inclusion and connectedness have been demonstrated to result in positive outcomes.

However, mental health and disability services have an undue focus on individuals without fully integrating the critical wider context such as social determinants. This is particularly important for youth where interventions that are primarily focused on individuals inadvertently widen inequalities. In Australia, the services and funding for interventions are primarily aimed at the individual with limited or no support offered to the families and their support networks, although programs that facilitate family engagement and community belonging have been demonstrated to show better health and behavioural outcomes.

One example of such an evidence-based preventive program is Communities That Care, which, through a community building initiative for young people, has been found to be effective in reducing substance use initiation, violence, delinquency, and behavioural issues yielding a benefit to cost ratio of US$8.22 for every dollar invested. This is likely due to addressing the direct and indirect impact of stress pathways whereby adverse childhood experiences have a lasting impact on brain development and consequent life trajectory and outcomes. For example, among children with intellectual disabilities, it has been shown that there is a socio-economic gradient in relation to child and parent psychopathology with those from poorer families exhibiting more mental health and behavioural challenges. It is possible that social determinants cluster together and children living in poverty are also exposed to neighbourhood disadvantage including neglect or abuse, substance use and gang life. Such exposure to trauma, violence and crime coupled with the lack of opportunities for positive connections and social exclusion could compound the prevalence, severity and outcomes of mental illness. Thus, socio-economic adversity and social exclusion could be key modifiable determinants and families could be supported in this regard. When those with mental health issues disengage from families and services, there must be social support and government agencies that get involved to keep them safe and to keep the community safe but currently clinical psychiatric care is siloed.

A recent review has identified key targets for intervention from the perspective of social determinants to improve mental health outcomes. As the benefits of such investment would cover several government portfolios, including but not limited to health, education, employment, housing, social services, criminal justice system etc, the funding could be shared, thereby also providing unique opportunities for integration of supports between the individual, the family and their support systems as well as government agencies so that the most disadvantaged and vulnerable in our community do not fall through the cracks.

As the Australian community navigates the impact of recent events, is there an opportunity to create a national road map integrating federal, state and disability care for a more responsive, integrated, sustainable and equitable mental health service system instead of further alienating and stigmatising those with severe mental health issues? As there is significant evidence that social determinants form the most modifiable intervention targets to mitigate the onset, course and outcomes of mental health disorders, could we seize this opportunity to invest in an integrated and inclusive mental health and social care service system to address the current service gaps?

Valsamma Eapen is a Professor and Chair of Child Psychiatry, UNSW Sydney and Clinical Academic at South-Western Sydney Health District. She is a National Health and Medical Research Council (NHMRC) Senior Leadership Fellow focusing on research into neurodevelopmental disorders and leads the NHMRC Centre of Research Excellence in child and family health. Valsa is also Chair, Faculty of Child and Adolescent Psychiatry, Royal Australian and New Zealand College of Psychiatry; Co-Chair, Section on Developing countries and Oceania Zonal representative, World Psychiatric Association; and Treasurer and President Elect, International Neuropsychiatric Association.