70% of people with depression not receiving minimally adequate treatment

A recent study has found that 70% of Australians diagnosed with major depressive disorder are not receiving minimally adequate treatment.

The research, published in The Lancet Psychiatry, analysed data from 204 countries and territories to assess global access to mental health care.

Co-author Dr Damian Santomauro from the University of Queensland’s School of Public Health and the Queensland Centre for Mental Health Research said the goal was to understand whether people with depressive disorders were receiving adequate care.

“In 2021, 30% of Australians with a major depressive disorder received minimally adequate treatment. High-income regions showed the highest rates of adequate mental health treatment, but still quite low at 27% and only 7 countries had rates that exceeded 30%,” Dr Santomauro said.

What is minimally adequate treatment?

The study defined minimally adequate treatment for major depressive disorders as pharmacotherapy (one month of medication, plus four visits to a medical doctor) or psychotherapy (eight visits with any professional). 

According to Dr Santomauro, the study was subject to what data was available, which meant the definition of minimally adequate treatment was quite liberal.

“Even looking at this very liberal definition, the rates are still very, very low,” he said.

However, Professor Philip Morris, President of the National Association of Practising Psychiatrists (NAPP), questioned the parameters used.

“Some people might say that one month on an antidepressant is nowhere near an adequate treatment. You often tell the patients you may not start to feel any improvement for six to eight weeks… The idea that it’s one month of therapy is a very minimal standard.

“On the other hand, four sessions of follow up by a doctor is perhaps a bit high,” he continued.

President of the Australian Association of Psychologists Inc (AAPi), Sahra O’Doherty agreed that while four sessions would be great, it’s not practical for many people.

“From a perspective of financial accessibility and also location accessibility for patients in Australia, we know that in rural and regional areas, there just aren’t enough GPs or doctors, and the wait lists can be incredibly long. For somebody to see a doctor four times in a month, the cost of that can be really prohibitive,” she told InSight+.

Regarding eight sessions with a professional, Ms O’Doherty said it needed to be with the right person.

“Someone who is an expert in mental health. Typically, this is going to be a psychologist or someone who is skilled and trained in areas of mental health, so a mental health registered or accredited social worker, or somebody similar,” she said.

Accessibility is also a concern when finding a mental health provider, with long wait lists and price concerns.

Ms O’Doherty highlighted that eight sessions are just shy of the ten rebated sessions provided each year on a mental health care plan. However, she even questioned whether that number was adequate.

“That number of ten sessions doesn’t actually come from any research. When we’re looking at older research on cognitive behaviour therapy, that has previously recommended 12 to 18 visits,” Ms O’Doherty said.

How Australia sits globally

Australia was one of seven countries (Australia, Belgium, Canada, Germany, the Netherlands, South Korea and Sweden) that had the highest minimally adequate treatment (MAT), exceeding 30%.

“The proportion of people with major depressive disorder receiving MAT globally in 2021 was 9.1%, with 10.2% females and 7.2% males with major depressive disorder receiving MAT,” the authors wrote.

At 2%, MAT coverage was lowest in sub-Saharan Africa and 90 countries were estimated to have coverage lower than 5%.

“So, [there are] really large gaps in many places around the world,” Dr Santomauro highlighted.

However, Professor Morris argued that it’s a very western view of depression.

“The diagnosis may be identified by the DSM-4 criteria, but the country where the person is diagnosed may have extremely different views about what’s appropriate treatment for these conditions, and they’re just basically assuming that every country needs to go down the western mode,” he said.

“We have to be careful not to over interpret this, because it’s possible that some countries are doing a very good job, but they’re using treatments that are different to the Western treatments that these authors are saying is the only appropriate treatment,” Professor Morris continued. 

How to improve treatment of depression in Australia

Dr Santomauro said the results highlighted that Australia has a long way to go with treating depression.

One issue is that there aren’t enough people working in mental health.

“The feedback we keep seeing is that they’re seeing a larger demand, but that the workforce itself hasn’t increased to keep to the same rate,” he told InSight+.

Ms O’Doherty said part of the reason there are mental health workforce issues is that they’re not being adequately compensated by Medicare rebates.

“Currently, the Medicare rebates have been basically stagnant since the Better Access Scheme’s inception in 2010. The rate has increased less than $10 in that time.

“We know that it’s incredibly difficult to service all of these patients with the current workforce, because the current workforce is so overworked and isn’t being adequately compensated with these really low rebates. So we’re wanting that rebate to be raised to $150 per session for every client of every psychologist in Australia,” she said.

Dr Santomauro also highlighted that there are different treatment types for depression and the GP needs to work with the patient to make sure they find the right type.

“Don’t just try one thing and then stop, because I think that’s what a lot of people tend to do. They might try a mental health service and say, ‘Oh, this was rubbish, I’m not going to try anymore.’ They might do one or two sessions and then stop, and then they’ve gotten zero benefit from that treatment.

“It would have been a lot better if they either persisted or, if they really didn’t like it, to find an alternative,” he said.

It’s important for GPs to check in with their patients and see how that treatment is going and have other alternatives if needed.

“They (the patient) might not want to tell you that that psychologist [recommendation] you gave them was not very good for them. So if the GP is willing to follow up with that and be open to hearing that their patient didn’t benefit from their first suggestion, then to have something else up their sleeve,” Dr Santomauro concluded.

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