Telling the story of mental health

It is unusual for Foreign Affairs, a magazine published by the United States Council on Foreign Relations in New York, to contain articles on health, but the first issue of 2015 carries an essay (Darkness invisible: the hidden global costs of mental illness) by three distinguished scientists from the National Institute of Mental Health about the hidden costs of mental health.1 Based on evidence from a 2010 Harvard University study on the current and future burden of disease,2 they state that “the direct economic effects of mental illness (such as spending on care) and the indirect effects (such as lost productivity) already cost the global economy around $2.5 trillion a year”, an amount projected to rise by 2030 “to around $6 trillion, in constant dollars — more than heart disease and more than cancer, diabetes, and respiratory diseases combined”.1

The World Health Organization estimated in 2012 that about a quarter of all time lost to disability is due to mental illness, putting it at the top of the league chart.3 Unlike many other chronic illnesses, mental illness frequently strikes the young. Further, of the 800 000 people who commit suicide each year, 75% are in low-income and middle-income countries.4

Extraordinary failure

Yet, the authors of “Darkness invisible” say, the 2010 Harvard report had no impact. In wealthy countries, mental illness is still perceived as an individual or family problem rather than “as a policy challenge with significant economic and political implications”. In many low-income and middle-income countries mental care for the mentally ill is seen as an unaffordable luxury.1 The authors also point to breakthroughs in therapy, especially new medications and the capacity to communicate using mobile phones, that are now more affordable, yet are frequently overlooked.1

So what are we doing? Globally we are spending around $2 a year per individual on mental health, averaging about 25 cents per person in low-income countries. In Australia in 2004–2005 the average national per capita expenditure on mental health services was $117.5 As we have seen in Australia, the advantages of dismantling mental hospitals that “once oversaw care for the mentally ill”,1 especially those with long-standing severe illness, are accompanied by failures to provide community care for these people. The criminal justice system comes into play by default, in both the acute and long-term management of people with mental illness. In the United States, “30 percent of the country’s chronically homeless and more than 20 percent of the people incarcerated … suffer from a mental disorder”.1 The scene is dismal in Australia as well.

Darkness invisible explores new technologies including using the Internet and mobile devices to provide psychotherapeutic interventions supported by inexpensive generic medications that could be administered by health workers in the vast tracts of the earth where there are very few medical practitioners and no psychiatrists. The authors may well have wondered about the lethargy among the medical profession worldwide in creating opportunities for the training and deployment of more psychiatrists. We don’t look good as we pass this mirror. There is no substance to our defence when wealthy communities are well supplied with psychiatrists and psychologists.

A call for better advocacy

Darkness invisible concludes with a call for mental health advocates to multiply their efforts and “do a better job of explaining to officials and the public the true costs of mental illness”, and “win more allies within the medical profession by drawing attention to the fact that improved mental health leads to better overall health”.1

This call will resonate with those who perceive the lamentable consequences of unexplained political propositions and proposals: bankrupt policy replaced by sound bites and slogans. There’s a powerful story to be told about mental health, with chapters on the consequences of inadequate care on individual wellbeing and the national economy.

As a senior business executive put it to me recently, “To succeed, first you must have a convincing story, then good leadership, then the metrics”. More light, more storytelling please.

Australian Early Psychosis Research Network: national collaboration, international competitive advantage

An expansion of clinical infrastructure for early psychosis intervention offers new possibilities for research, treatment and service development

Over the past three decades, Australian researchers have pioneered a conceptual model of the clinical stages underpinning progression of potentially serious mental disorders, including psychosis. This approach, supported by growing evidence, has informed the development of new service models focusing on the mental health needs of young people.

By shifting the focus of the health sector to intervention during the early and less specific stages of mental disorders, substantial conceptual and practical progress has been made.1 This progress has generated optimism, buttressed by growing evidence of the effectiveness and cost-effectiveness of early intervention in psychosis from clinical trials and health services research conducted in Australia and around the world.2–4

Early intervention has demonstrated potential to reduce the effects of illness on age-specific developmental and occupational goals. It can also improve social and economic participation and productivity. Programs such as headspace have been scaled up across Australia, and have already improved access and engagement in stigma-free, youth-friendly settings.5 The federal government’s planned expansion of comprehensive early psychosis programs in every state and territory6 offers an unprecedented opportunity to promote innovative large-scale, multicentre research into the early stages of psychotic illness.

Against the backdrop of this expansion of innovative service delivery models, we face ongoing challenges. We have an incomplete understanding of what causes psychosis. Even when the best available treatments are delivered early and with precision, longer-term clinical and functional outcomes remain suboptimal. People with long-term psychotic illness die up to 20 years earlier than others.7 Our patients and their families expect better results.

However, the situation we face is not too different from that seen in oncology in previous years, when many standard treatments were associated with substantial toxicity, delivery systems were variable and most patients presented in the later stages of illness. Yet, breakthroughs aside, strategies such as early detection, timely intervention and sustained delivery of high-quality care throughout “critical” illness periods can substantially improve outcomes.

Stimulated by the federal government’s investment in comprehensive clinical infrastructure for early psychosis intervention, a large group of Australian psychosis researchers formed the Australian Early Psychosis Research Network (Appendix). At a recent meeting of this group, research priorities were discussed.

The group agreed that there is an urgent need for novel treatment strategies that are safer, more effective and more acceptable to patients and their families. Current candidates include omega-3 fatty acids, aspirin, N-acetylcysteine, sodium benzoate, cannabidiol and oestrogen. In the early stages of illness, there is a greater degree of clinical equipoise: the risk–benefit ratio can be unclear, with more evidence required on the effectiveness and safety of treatments. This situation creates momentum for a sequence of stepwise clinical trials, as follows:

The study of biomarkers to guide the use of such therapies using a strategy in which “target engagement” is assessed as a predictor of treatment response. This means demonstrating not only whether novel therapies work, but also how they work. This approach directly tackles the problem of heterogeneity within clinical samples assembled using current syndromal diagnostic criteria. Personalised medicine is the ultimate goal.
The further development of novel psychosocial interventions, including online platforms, which focus predominantly on functional recovery. These are particularly promising in terms of consumer engagement, clinical effectiveness and cost-effectiveness. Their integration with biological therapies and linkage with stages of illness require exploration.
The examination of how to reduce the elevated risks of premature mortality (from both cardiovascular disease and suicide) from the time of onset of psychotic illness.

There is also a need for health services research to determine not only which interventions are effective and cost-effective, but in what context. Treatment fidelity in the real world has not been studied well, and the range and quality of clinical interventions vary between and within services. Studying the effect of culture of care and model fidelity is also critical.

The ultimate goal of the Australian Early Psychosis Research Network is substantial improvement in health and social outcomes for people living with psychosis. We have an opportunity to develop a new culture in mental health that has the capacity for large-scale clinical trials with embedded biomarker research, on a par with what exists elsewhere in medicine. Federal government reform and investment gives Australia a unique competitive advantage in this. We do not intend to let this opportunity pass.

Whereto mental health reform in Australia: is anyone listening to our independent auditors?

Independent audits find consistent evidence of failure across Australia’s mental health system

There is widespread agreement that Australia’s mental health system is in critical need of reform. In a move that has left many in the mental health sector wondering if they were trapped in a rerun of Groundhog day, the Australian Government recently charged the National Mental Health Commission with undertaking a mental health review to investigate the gaps and duplications in, and effectiveness of, Australia’s mental health system.

This review followed in the wake of a long series of national and state inquiries and reviews of the mental health sector in Australia dating back to the Burdekin Report in 1993, which provided the impetus for a national mental health reform agenda.1 The findings of these reviews point to the continuing failure of successive governments to build the community-based model of care promised after the closure of stand-alone psychiatric institutions.

An additional important source of information about the mental health sector is available in the many independent audits undertaken by statutory and similar authorities. In 2013, as part of the Obsessive hope disorder report, we conducted a systematic qualitative review of all such audits undertaken in Australia between 2006 and 2013.2 Several themes emerged across the health care spectrum (Appendix). These included inadequate access to services, inadequate interagency cooperation and continuity of care, human rights concerns, gaps in training, and absence of monitoring and surveillance. The same issues were identified by Burdekin.1

Gaps in service access

We noted gaps in community mental health awareness and primary prevention programs, and inadequate access to community-based mental health care. There were also inadequate community and hospital services in justice settings, rural and remote regions; a paucity of specialised community, crisis and hospital treatment for young people; inadequate specialised community and hospital treatment for older people; and a lack of supported accommodation for people with a mental illness.

One driver of insufficient access was the inequitable distribution of the workforce across hospital and community sectors. A second was the exclusion of people from care unless they were in crisis. As noted by one young person: “Telling someone who has an eating disorder [ED] that they have not yet lost enough weight to be seen by an ED clinic is BAAAAAAAAD” (p. 50).3

Another driver of inadequate access to care was a reliance on diagnosis rather than need in allocating services. Further, uneven access to care resulted from managing demand by using strategies that were not based on need. One such strategy was to cap the number of referrals to the Access to Allied Psychological Services program that individual practitioners were permitted to provide.4

Inadequate interagency cooperation and continuity of care

Mental health care was also compromised by poor cooperation between agencies and inadequate continuity of care. This was evident across the care spectrum from prevention to accommodation, with agencies failing to follow up, share information, integrate services, agree on the division of responsibilities and develop consistency in entry criteria. For example, community mental health teams in Western Australia had shared only 19% of care plans with other professionals, such as general practitioners.5 More than one audit implicated poor interagency communication in the subsequent deaths of young people.

Human rights concerns

The audits reported human rights concerns among some crisis and inpatient services and denial of equitable access to supported accommodation. Examples included:

Consumers who were not a threat to others being transferred to hospital in police vans instead of ambulances — contrary to service protocol;
Crisis assessment and treatment team (CATT) members requesting detention of intoxicated consumers in police cells — in contravention of the relevant charter of human rights;
Consumers not being informed of their rights in hospital;
Wrongful shackling of prisoners with a mental illness in hospital;
Perceived organisational bias directed towards forensic inpatients;
Denial of privacy during inpatient consultations — in violation of the national standards for mental health privacy legislation; and
Voluntarily admitted consumers being placed in locked wards.

Further, there are reports that people with a mental illness have been systematically denied their rights to supported accommodation. In particular, in New South Wales, supported accommodation in the disability sector was not available to people with a primary diagnosis of a mental illness. The NSW Ombudsman described this situation as a denial of “fundamental rights under mental health and disability legislation” (Foreword).6 He reported estimates that suggest that between 30% and 60% of current psychiatric inpatients could be discharged if suitable supported accommodation and community supports were available (p. 47).6 The responsible government department responded that if psychiatric patients were allocated the places within current resources, other people with disability would be denied places. The Ombudsman concluded that “it is unacceptable to trade-off the rights of people with psychiatric disability against those of others” (p. 67).6

Groups who were disadvantaged

Some groups were particularly disadvantaged. Groups with particular unmet need included those in the forensic system, people from rural areas, youth and older people, Aboriginal and Torres Strait Islander Australians, those from a culturally and linguistically diverse background, veterans, and children at risk.

Disadvantage was particularly evident in forensic contexts. One auditor reported the case of a woman with schizophrenia whose medication was discontinued on her arrival in prison.7 The treatment could not be resumed until she was assessed by a prison psychiatrist 12 days later.7 Another auditor reported an initial refusal by juvenile justice staff to allow a resident to receive urgent, prescribed psychiatric medication from a CATT member.8

Gaps in training

Action was consistently recommended across services and sectors to rectify gaps in training. Examples of the training required included de-escalation training for CATT members and police including those operating tasers, specialist training in the mental health of older people, mental health literacy training for social security and immigration staff, practical training for housing sector staff in strategies for supporting people with a mental illness, training for health staff in negotiating the housing system, and exposure of police to consumer perspectives.

Inadequate monitoring and surveillance

Many audits criticised the lack of appropriate data collection and monitoring by services and programs. For example, the NSW Audit Office found that it was not possible to determine accurately the size of the NSW mental health workforce due to inadequate data.9

Limitations, accountability and the way forward

A limitation of our review is that its conclusions were derived largely from individual audits and reviews of services in particular jurisdictions. Audits can lack the rigour of health services research, a field that itself is neglected.

However, auditors can obtain information and data that researchers cannot. Moreover, the consistency in the gaps that emerged together with the findings from previous enquiries and contemporary feedback from consumers10 suggest that the areas identified require action at a systemic level. The need to improve access to services and accommodation, continuity of care, training, and cooperation across agencies and services, and to engage with human rights, is clear, as is the need to increase service access for specific groups, particularly those in forensic environments.

Why do problems with the mental health system persist? There are several reasons. Despite the wealth of data in these audit reports and their potential role in mental health reform, there are typically no accountability mechanisms to ensure that the responsible lead authorities change their practices to deal with the recommendations in these audits. Moreover, there are no formal mechanisms by which the findings and recommendations can be incorporated into national and state mental health plans or the processes of the National Mental Health Commission.

Independent evaluations of the National Mental Health Plans have repeatedly pointed to the need to strengthen accountability,11 and others have argued that the failure to develop robust monitoring and reporting contributes to the failure to deliver mental health reform in Australia.12 Governments need to consider how agencies can be held accountable if they fail to implement changes recommended by auditors. Further, we need to develop formal processes by which the findings of independent audits are reviewed systematically and the outcomes made available in an accessible form to the Australian Health Ministers’ Advisory Council, the Council of Australian Governments, and to consumers and carers.

It is vital that new investment is directed to reorganising and reforming, rather than perpetuating a dysfunctional system. Innovative approaches are required — for example, information technology has the potential to deliver critical preventive interventions that cost-effectively reduce the prevalence of mental illness, to increase access to evidence-based treatments, and to facilitate service integration and seamless data collection. Structural stigma underpins discriminatory policies and funding allocations that adversely affect those with a mental illness. Multilevel stigma reduction initiatives and awareness raising are needed to reduce stigma at all levels in our society including among policymakers and decisionmakers.

If Australia is ever to escape from Groundhog day, it is imperative that we move from audits and government reviews to the coordinated implementation of solutions.

Management of the acutely agitated patient in a remote location

A consensus statement from Australian aeromedical retrieval services

In this article, we summarise a new consensus statement from Australian aeromedical retrieval services that provides an expert opinion on the assessment and management of acutely agitated patients in remote locations. It also outlines recommendations for patients who require aeromedical evacuation to allow for inpatient medical care, high-level psychiatric care and admission, which are usually only available in regional centres and major cities. The full consensus statement is available on the Royal Flying Doctor Service website.*

Why this consensus statement is needed

Assessing and managing an acutely agitated patient in a remote location with limited resources requires adaptation of usual hospital-based procedures. There are no existing standard or evidence-based guidelines for this situation. Where remote locations have a health service at all, it is generally a small community health centre with limited facilities, staffed by nurses with telehealth support and a regular visiting medical practitioner. These clinics are not staffed after hours, except for emergencies. Thus, even a single presentation of a psychotic or suicidal patient places great strain on the local resources, especially if the patient requires supervision and restraint after hours. Legislative requirements of the relevant mental health act for voluntary versus involuntary treatment strategies must be honoured at all times, applying the principle of least restrictive care appropriate for the circumstances.

Thorough medical and mental health assessments, as well as careful planning and preparation of the patient, form the foundation of safety for all involved. Behavioural techniques and judicious use of pharmacological strategies aim to reduce arousal as much as possible. If the patient is to be discharged, adequate resolution of symptoms must have occurred and a support person must be available.

Aeromedical retrieval is often required, and patient and staff safety depends on an adequate preflight assessment. When patients require evacuation because they are so acutely unwell that they are deemed a risk to themselves or others, they also present a serious aviation safety risk. Safety of patients and their health care providers, including the aeromedical retrieval team, is paramount.

Agitated patients in remote locations are ideally sedated over the 12–24-hour period before evacuation. More rapid attempts at sedation may cause oversedation, necessitating airway management and support, or undersedation, whereby the patient remains too agitated for safe air travel. Multiple factors such as claustrophobia, air turbulence and nicotine withdrawal can result in unpredictable worsening of agitation. For the evacuating aeromedical team, there is often little alternative to performing rapid sedation of the patient, which is a difficult and unpredictable task. Intubation and ventilation, used frequently in the past, carry significant physical and mental health disadvantages, such as intensive care needs and delayed transfer to definitive psychiatric care.

Main recommendations

Patient and staff safety is the primary concern. The principles of least restrictive means of restraint and reasonable care enable optimum patient safety in the management of acute agitation. Certain minimum criteria should be adopted in this situation.

Management of acute agitation

Once reversible causes of agitation have been excluded, acute arousal should be treated with pharmacological sedation to reduce the risk of injury to all involved.

Medical monitoring

Acute sedation carries significant risks, and minimum parameters for physiological monitoring and resuscitation equipment are proposed. Continuous electrocardiographic monitoring and pulse oximetry should be used, along with blood pressure recordings. Non-invasive capnography should be available. Oxygen supply, a suction device and basic airway equipment are mandatory items.

Aeromedical retrieval to higher level of care

Aeromedical retrieval of acutely agitated patients with a mental health condition can be managed by expert triage, timing and patient preparation for transport. Involuntary assessment and treatment may be required. Pharmacological sedation and mechanical restraints are recommended in the event of unpredictable agitation in such a high-risk environment.

Ketamine sedation has an important and growing role among Australian aeromedical services in the care of acutely agitated patients. It is used as a second-line drug when emergency sedation is required and oral and parenteral first-line agents have not achieved adequate reduction of arousal. Given as a sedative infusion when ongoing sedation is required, it allows for safe transport and subsequent timely handover of the patient into psychiatric care.

Rarely, tracheal intubation and mechanical ventilation under general anaesthesia may be required, when first- and second-line measures have failed to safely reduce agitation for aeromedical retrieval. However, these measures significantly delay the transition into definitive care.

We caution against the use of any sedation in the intoxicated patient. Recommendations for optimal management of such patients are provided in the full consensus statement. For example, a period of observation to allow a reduction in the level of intoxication before transfer may be prudent, rather than attempted acute sedation for immediate transfer.

Follow-up

The management of an acutely agitated patient can be a challenging experience for all involved, including the patient and his or her family. Opportunities for feedback and debrief should be provided.

What the consensus statement introduces

The consensus statement provides detailed guidance for clinical practice, including:

Consensus advice on best practice in formal medical and mental health assessments, management of acute agitation before aeromedical evacuation and appropriate care during the retrieval process.
Minimum recommendations to ensure safety of staff and patients, including arousal management, monitoring and resuscitation requirements, as well as follow-up.
Sedation guidelines that include ketamine. Ketamine sedation has been used in Australian aeromedical retrieval of acutely agitated patients for the past 7 years and has been found to be effective and safe. For selected patients, it provides a safe and useful alternative to general anaesthesia, tracheal intubation and mechanical ventilation. Guidelines for its use in sedating acutely agitated patients are provided.

* The full consensus statement, The acutely agitated patient in a remote location: assessment and management guidelines — a consensus statement by Australian aeromedical retrieval services, is available at http://healthprofessionals.flyingdoctor.org.au/IgnitionSuite/uploads/docs/140911%20-%20Consensus%20Statement%20-%20The%20Acutely%20Agitated%20Patient%20in%20a%20remote%20locaiton.pdf

Frequency and quality of mental health treatment for affective and anxiety disorders among Australian adults

Each year, 6% of Australian adults meet criteria for an affective disorder and 14% for an anxiety disorder.1 These disorders accounted for 52% of the burden of mental and substance misuse disorders and 7% of the overall burden of disease in Australia in 2010.2 Despite efficacious pharmacological and psychological interventions, this burden persists, partly because treatment coverage and quality are suboptimal.3 Monitoring treatment quality for these disorders may identify opportunities to improve health system performance and highlight populations at risk of inadequate care.

Reports from Australia’s first National Survey of Mental Health and Wellbeing (NSMHWB) showed that, in 1997, 60% of adults with affective disorders and 35% with anxiety disorders had consulted a health professional for mental health in the previous year. Just over half of consultees reported receiving medicine or tablets (not further defined) or cognitive behaviour therapy (CBT).3 One-third of consultees saw a general practitioner only.4 Sociodemographic factors including male sex, socioeconomic disadvantage and rurality were shown to influence the likelihood and type of mental health care received, independent of diagnosis.4–8

In the decade following 1997, two major mental health reforms designed to improve treatment access and quality were introduced: in 2001, the Access to Allied Psychological Services (ATAPS) program; and, in 2006, the Better Access to Psychiatrists, Psychologists and General Practitioners through the Medicare Benefits Schedule (Better Access) initiative. These programs provide government subsidies for evidence-based psychological services delivered mainly by psychologists and other allied health providers. Information-based initiatives such as beyondblue were introduced to improve mental health literacy and demand for necessary mental health services.9 Reports from the second NSMHWB in 2007 documented a shift in provider mix since 1997, notably a doubling of psychologist care,10 and increased levels of met and perceived need, suggesting improvements in treatment access or effectiveness and willingness to seek treatment.11 However, population mental health did not improve, possibly due to inadequate treatment.9

Population levels of minimally adequate treatment (a “dose” of an evidence-based intervention above a minimum threshold consistent with treatment guidelines) for affective and anxiety disorders have been measured elsewhere,12–14 but Australian estimates are lacking. Using 2007 NSMHWB data, we examined the frequency, type and adequacy of mental health treatment among Australian adults with affective and anxiety disorders; how these estimates differ across the health sectors consulted; and the factors associated with treatment.

Methods

We analysed data from the 2007 NSMHWB,1,15 a nationally representative household survey of 8841 Australians aged 16–85 years conducted in late 2007. Respondents were selected from a stratified, multistage area sample of private dwellings. Face-to-face interviews of 90 minutes average duration were conducted by trained lay interviewers. The response rate was 60%.

The University of Queensland Behavioural and Social Sciences Ethical Review Committee approved this study.

Clinical measures

As defined by the International Classification of Diseases, 10th revision (ICD-10), affective disorders (depression, dysthymia and bipolar affective disorder) and anxiety (panic disorder, agoraphobia without panic, social phobia, generalised anxiety disorder, obsessive–compulsive disorder and post-traumatic stress disorder) experienced in the past year were assessed using a modified World Mental Health Survey Initiative Composite International Diagnostic Interview 3.0. Severity of disorder (mild, moderate or severe) was determined via an algorithm that incorporated disorder-specific role impairment and other clinical information. Past-year substance misuse disorder(s) and chronic physical conditions were also assessed.

Health care sectors consulted

Respondents were asked whether they had consulted a health professional for mental health in the past year. Those who had were interviewed further about the types of professionals consulted, and the frequency, average duration and means of payment for these consultations. Using this information, past-year consultations for mental health were grouped into sectors relevant to Australia’s mental health care system:

GP only (seeing a GP but no other health professional);
primary care allied health (seeing a psychologist or a professional such as a social worker, occupational therapist or counsellor providing specialist mental health services, except those whose services were provided within public sector mental health services — with or without a GP or other providers);
specialised mental health (seeing either: a psychiatrist or mental health nurse, or a psychologist or other professional providing specialist mental health services, whose services were provided within public sector mental health services — with or without a GP or other providers); or
other health (seeing: a professional such as a social worker, occupational therapist, counsellor providing general services; a specialist doctor or surgeon other than a psychiatrist; or a complementary or alternative medicine provider — but not seeing a GP only, a primary care allied health provider or a specialised mental health provider).

Sectors were largely mutually exclusive, other than 55 respondents who consulted both of the second two sectors.

Interventions received

Respondents who reported past-year consultations for mental health were asked to identify interventions received in those consultations from a list including: information; medicine or tablets (not further specified); talking therapies including CBT, psychotherapy and counselling; social intervention; and skills training. Respondents were also asked to name up to five medications they had taken in the previous 2 weeks for mental health and how long they had been taking each; interviewers checked available medication packaging.

Levels of treatment

We defined three levels of treatment received in the past year:

any consultation — one or more consultations with any health professional for mental health, regardless of the interventions provided;
an evidence-based intervention — either pharmacotherapy, specifically an antidepressant or mood stabiliser, or psychological therapy, namely CBT or psychotherapy;
minimally adequate treatment12 — either: taking an antidepressant or mood stabiliser for 1 month or longer, plus four or more consultations with any medical practitioner for mental health; or receiving CBT or psychotherapy, plus six or more consultations of 30 minutes or longer average duration with any health professional (except a complementary or alternative medicine therapist) for mental health. We adapted existing minimally adequate treatment criteria12 that were based on treatment guidelines and considered appropriate to the Australian health care system.

Sociodemographic measures

The survey elicited information about respondents’ age, sex, marital status, employment status, education, main income source, country of birth, urbanicity and relative socioeconomic disadvantage.

Statistical analysis

We analysed 2007 NSMHWB Basic Confidentialised Unit Record File (April 2009) data using Stata, version 11 (StataCorp). Replicate weights were applied to the data to account for the differential probability of survey selection and to ensure conformity to known population distributions. Standard errors and 95% confidence intervals were calculated using jackknife repeated replication to accommodate the complex survey design. In the subsample who met criteria for past-year affective and/or anxiety disorders, multivariate logistic regression analyses were used to identify clinical, sociodemographic and health sector correlates of each of the three levels of treatment. Of the 8841 respondents, 10 with missing data were excluded, leaving 8831 respondents in our analysis.

Results

Treatment of past-year affective and/or anxiety disorder

In the 2007 survey, 17% of Australian adults met criteria for a past-year affective and/or anxiety disorder. Of these, 39% had consulted a health professional for mental health in the past year (Box 1). The proportion of participants who consulted a health professional varied by disorder. For example, there was a 2.5-fold variation between those with anxiety disorder(s) only (27%) and those with comorbid affective and anxiety disorders (67%), and a threefold variation between those with mild (20%) and severe (64%) disorders.

Of those who consulted a health professional, two-thirds (67%) received an evidence-based treatment but only 41% received minimally adequate treatment. This equates to 26% and 16%, respectively, of all consultees with a past-year affective or anxiety disorder. There was a gradient in the likelihood of receiving an evidence-based treatment according to disorder type, and in the likelihood of receiving adequate treatment according to disorder type and severity.

Of the consultees who received an evidence-based treatment, about two-thirds received a psychological therapy and two-thirds received pharmacotherapy. The likelihood of receiving an evidence-based psychological therapy was lower among people with affective disorder(s) only (Appendix 1).

Of the consultees who received minimally adequate treatment, about equal proportions (two-thirds) received an adequate “dose” of psychological therapy and/or of pharmacotherapy (Appendix 1).

Health sectors consulted

Of those who consulted a health professional (620), 28% consulted only a GP, 43% consulted the primary care allied health sector, 31% consulted the specialised mental health sector, and 9% consulted the other health sector. Consultation with the specialised mental health sector was significantly more common among people with severe, relative to mild or moderate, disorders. Further details are shown in Appendix 2.

Treatment level by sector

Among people consulting the primary care allied health sector, receipt of an evidence-based intervention was more common among people with severe disorders and receipt of adequate treatment was more common among people with severe or comorbid disorders. Further details are shown in Appendix 3.

Correlates of treatment

In analyses controlling for clinical factors including type and severity of disorder, the odds of all levels of treatment were lower for younger, compared with middle aged, adults (Box 2). The odds of receiving an evidence-based treatment were lower among married compared with never married respondents. The odds of receiving an evidence-based treatment or minimally adequate treatment were two and six times greater, respectively, among those consulting the primary care allied health and/or specialised mental health sector(s) compared with those consulting only a GP.

Discussion

In the 2007 NSMHWB, of all people with past-year affective and/or anxiety disorders, 39% sought professional help for mental health, 26% received an evidence-based intervention, and 16% received minimally adequate treatment. Younger adults were less likely to receive any treatment, and people who consulted a GP only were less likely to receive evidence-based or minimally adequate treatment than those who consulted a mental health professional.

Potential sources of bias should be considered. First, treatment quality indicators are not universally agreed and vary across studies. In this study, adequate psychological therapy required six sessions of treatment to best fit the grouped consultation data in the NSMHWB. Although lower than the threshold of eight sessions commonly used,12 both a meta-regression and a patient-level analysis have shown little increase in benefit beyond seven sessions.16,17 Adequate pharmacotherapy relied on reports of medications taken in the past 2 weeks and required at least 1 month of medication use to fit the grouped duration data available, rather than the 2-month threshold commonly used.12 Medication dose was not available. We were able, to some extent, to specify types of psychological therapy, although psychotherapy is an umbrella term and may have included some therapies that are not evidence-based. Notwithstanding methodological and service system differences, studies have generally returned similar findings regarding the shortfall in treatment quality and variations between health sectors.12–14

Second, cross-sectional data have limitations for this purpose. The temporal relationship between clinical and treatment variables could not be established. As detail was gathered only about past-year consultations, adequate treatment for respondents who commenced treatment before, or late in, the past year may be underestimated. However, there is no reason to believe this would bias the patterns or correlates of treatment quality.13 It was not possible to examine the validity of the indicators of treatment quality; however, positive associations between similarly derived indicators of treatment quality and outcomes have been reported.18

Third, the criteria for minimally adequate treatment represent a minimum threshold for adequacy, but do not necessarily equate to optimal, individually tailored care. The criteria will require revision as the evidence base for interventions evolves.

There are many possible reasons why people who seek professional help might not receive an adequate dose of treatment. In this study, the attrition between the frequency of evidence-based and minimally adequate treatment suggests a need for strategies to improve treatment adherence. Options include quality improvement strategies to support systematic and proactive monitoring of patient adherence and outcomes.19 Little is known about the content of interventions in office-based practice; professional bodies could take a role in monitoring and providing education regarding effective practices. Educating consumers regarding the benefits of psychological therapies and what constitutes an adequate course may be helpful.13 Dissemination of psychological treatments via the internet may help reduce barriers to care and increase treatment fidelity. Most work in this area has occurred since 2007 so could not be included in our model. Internet therapies are efficacious and effective for mild, moderate and severe anxiety and depression, acceptable to patients and providers, and probably more cost-effective than face-to-face therapies.20,21

The frequencies of evidence-based and adequate pharmacotherapy and psychological therapy were similar across disorder and severity groups, except that fewer people with affective disorder(s) only received adequate psychological treatment. These patterns are inconsistent with treatment guidelines that, generally, recommend psychological therapy as first-line treatment for anxiety disorders and milder depression, and medications as an adjunct to psychological therapies for more severe depression. Further investigation of the patterns of treatment according to individual disorders is needed, but these initial findings are concerning given that CBT (face-to-face or internet) can achieve improvements for one in 2–3 patients (depending on disorder) within 6 weeks, and has about 80% adherence.20 In contrast, selective serotonin reuptake inhibitors (the most commonly prescribed antidepressants) take up to 6 weeks to reach potency and require continuation for 6 months to reduce relapse, and adherence is poor.22

In our study, as elsewhere,14 frequency and type of treatment received varied by health sector. People with more complex and/or severe disorders were most likely to receive all levels of treatment and to consult the specialised mental health sector. This suggests that treatment resources are being allocated according to need, although coverage and quality could be improved. The relatively lower frequency of evidence-based and adequate treatment among those who only consulted a GP, compared with those consulting a mental health professional, may reflect provider factors (competing demands, lack of specialised training or experience) and patient factors (poorer adherence and acceptability of mental health treatments among patients consulting this sector).4,12,13 In Australia, the 20-minute average duration of GP encounters for depression or anxiety,23 reflecting the Medicare Benefits Schedule item structure, limits GPs’ capacity to meet the threshold for adequate psychological treatment. Onsite psychotherapy and use of treatment algorithms in primary care settings have been associated with higher-quality care for depression14,24 but not improved outcomes.18 It has been suggested that the gap in treatment quality overall is more important than the differences between sectors,19 and that quality improvement strategies19 and improved collaborative care models4 should be prioritised. Research to identify the treatment elements (eg, number or duration of sessions) that contribute to poorer adequacy, within each sector, is indicated.

Further research is needed to investigate the reasons for the age-related differentials in treatment that occur along the pathway to adequate treatment; these likely involve patient and provider factors.7

Data for this study were collected in 2007. Direct evidence of changes in treatment quality is lacking, and there have been no major reforms since 2007 likely to have affected quality at a population level. A previous study estimated that treatment access for any mental disorder may have improved by 23% between the 2006–07 and 2009–10 financial years, primarily due to uptake of Better Access services.25 Applying our estimates of minimally adequate treatment to the estimated proportions of people consulting various health sectors in 2009–10,25 we might speculate that 19% of consultees with affective and/or anxiety disorders received adequate treatment in 2009–10, compared with 16% in 2007 (details upon request). A proposed third NSMHWB should allow an updated assessment of mental health treatment access and quality.

1 Prevalence of past-year affective and/or anxiety disorder among 8831 adult participants of the 2007 Australian National Survey of Mental Health and Wellbeing, and level of treatment received, by disorder type and severity

Percentage of [b] who received:

Distribution of past-year affective and/or anxiety disorders in the Australian population [a]*

Percentage of [a] who consulted for mental health [b]†

An evidence-based intervention [c]†

Minimally adequate treatment [d]†‡

% (95% CI)

Any affective and/or anxiety disorder

1517

17% (16%–18%)

39% (35%–42%)

67% (61%–72%)

41% (35%–47%)

Disorder type

Anxiety only

966

11% (10%–12%)

27% (23%–32%)

61% (53%–69%)

31% (21%–41%)

Affective only

226

3% (2%–3%)

46% (36%–56%)

61% (48%–74%)

30% (19%–41%)

Comorbid affective and anxiety

325

4% (3%–4%)

67% (60%–75%)

77% (69%–84%)

59% (51%–67%)

χ2 (P)§

67.7 (< 0.001)

10.0 (0.01)

25.1 (< 0.001)

Severity

Mild

570

7% (6%–8%)

20% (15%–25%)

61% (48%–75%)

25% (10%–40%)

Moderate

580

6% (6%–7%)

43% (37%–48%)

66% (58%–75%)

36% (28%–45%)

Severe

367

4% (3%–5%)

64% (56%–73%)

71% (62%–79%)

55% (47%–62%)

χ2 (P)§

73.7 (< 0.001)

1.7 (0.44)

19.3 (0.003)

All percentages are weighted. na = not applicable. * As represented by the study population (n = 8831). † Percentage of respondents within each disorder type or severity group. ‡ Because data on the frequencies of consultation with each type of professional were only available in grouped form, minimally adequate treatment status was deemed for 55 respondents with affective or anxiety disorders using available data regarding their possible range of eligible consultations. § df = 2.

2 Multivariate analysis* of predictors of consultation for mental health among adult participants with past-year affective and/or anxiety disorder, 2007 Australian National Survey of Mental Health and Wellbeing

	Consulted for mental health†		Received an evidence-based intervention if consulted for mental health‡		Received minimally adequate treatment if consulted for mental health‡§
	AOR (95% CI)	P¶	AOR (95% CI)	P¶	AOR (95% CI)	P¶

Female	1.5 (1.0–2.4)	0.08	1.3 (0.7–2.4)	0.46	1.3 (0.6–2.5)	0.52
Age group
16–29 years (reference)	1.0		1.0		1.0
30–39 years	1.6 (1.0–2.6)	0.04	2.7 (1.1–6.3)	0.03	2.8 (1.2–6.3)	0.02
40–59 years	1.5 (0.8–2.6)	0.11	2.8 (1.1–7.1)	0.03	2.7 (1.1–6.3)	0.03
60 years and over	1.0 (0.5–1.9)	0.89	2.0 (0.6–6.4)	0.23	1.8 (0.5–6.2)	0.36
Marital status
Never married (reference)	1.0		1.0		1.0
Married	0.9 (0.6–1.5)	0.78	0.5 (0.2–1.0)	0.04	0.9 (0.4–1.8)	0.70
Previously married	1.2 (0.7–2.2)	0.46	0.7 (0.3–1.5)	0.37	0.7 (0.3–1.7)	0.41
Employed	1.1 (0.7–1.7)	0.61	1.8 (0.6–5.3)	0.27	1.9 (0.7–5.0)	0.21
Post-school qualification	0.9 (0.6–1.4)	0.65	1.3 (0.7–2.5)	0.37	1.4 (0.8–2.7)	0.27
Main source of income, government benefit	1.4 (0.9–2.2)	0.10	0.8 (0.3–2.0)	0.57	0.8 (0.3–2.0)	0.64
Disorder type
Comorbid affective and anxiety (reference)	1.0		1.0		1.0
Anxiety only	0.4 (0.2–0.6)	< 0.001	0.5 (0.3–0.9)	0.03	0.4 (0.2–0.8)	0.01
Affective only	0.6 (0.3–1.0)	0.04	0.5 (0.2–1.1)	0.07	0.4 (0.2–0.8)	0.02
Comorbid substance use disorder	0.8 (0.5–1.4)	0.50	0.9 (0.4–2.1)	0.82	1.2 (0.5–2.9)	0.66
Two or more chronic physical disorders**	1.4 (1.0–2.0)	0.08	0.8 (0.4–1.4)	0.35	1.2 (0.8–2.0)	0.38
Severity of disorder
Mild (reference)	1.0		1.0		1.0
Moderate	2.2 (1.4–3.5)	0.001	1.2 (0.6–2.4)	0.64	1.6 (0.7–3.8)	0.28
Severe	3.8 (2.1–6.7)	< 0.001	0.8 (0.3–2.0)	0.63	1.8 (0.7–4.6)	0.22
Sector consulted
General practitioner only (reference)	na		1.0		1.0
Primary care allied health and/or specialised mental health sector(s)			1.9 (1.1–3.5)	0.03	6.0 (3.0–12.0)	0.001
Other health			0.4 (0.2–1.2)	0.09	1.2 (0.4–3.3)	0.79

AOR = adjusted odds ratio. na = not applicable. * Country of birth, urbanicity, and relative socioeconomic disadvantage were assessed for inclusion in the models but did not reach P = 0.05 in univariate analyses. † Denominator is 1517 respondents with past-year affective or anxiety disorders. ‡ Denominator is 620 respondents with past-year affective or anxiety disorder who consulted for mental health in the previous 12 months. § Because data on the frequencies of consultation with each type of professional were only available in grouped form, minimally adequate treatment status was deemed for 55 respondents with affective or anxiety disorders using available data regarding their possible range of eligible consultations. ¶ P for Wald χ2 test of association. ** Chronic physical disorders in past year included musculoskeletal conditions, cardiovascular conditions, respiratory disorders, diabetes, cancer, stroke, emphysema, anaemia, epilepsy, fluid problems, hernias, kidney problems, migraine, psoriasis, gastrointestinal ulcer, thyroid problems and tuberculosis.

Better access to mental health care and the failure of the Medicare principle of universality

Australia’s national health insurance scheme, Medicare (introduced in 1975 as Medibank), was envisioned to deliver the “most equitable and efficient means of providing health insurance coverage for all Australians”.1 Questions have been raised as to whether, 40 years after its introduction, Medicare is equitable, particularly in terms of access to mental health services.2,3 Investigations over more than 70 years in various parts of the world, including Australia, have consistently found greater levels of psychiatric disorder in areas with greater socioeconomic disadvantage.4–6

In November 2006, the Australian Government introduced the Better Access to Mental Health Care initiative (Better Access), consisting of new Medicare Benefits Schedule (MBS) items to improve access to psychiatrists, psychologists and general practitioners.7 Evaluation of the program, supported by Commonwealth government funding, highlighted the success of Better Access in increasing psychological service use. For example, the number of allied mental health services accessed almost doubled in the first year, and most users were new (68% in 2008 and 57% in 2009).8,9 The report by Harris and colleagues also commented: “Uptake rates for Psychological Therapy Services items … decreased as levels of socio-economic disadvantage increased”.8 Findings from Bettering the Evaluation and Care of Health data also suggested possible inequity, with less service provision going to more disadvantaged areas.3

Another concern is whether Better Access is reaching rural and remote communities as well as the metropolitan areas.3,10,11 Here, a primary driver may be provider availability, as the problem of securing specialist health care and other service delivery to non-metropolitan areas of Australia is well recognised.11

We obtained Medicare data on the Better Access program and related mental health care items, following a freedom of information request by one of the authors (R G) on behalf of Transforming Australia’s Mental Health Service Systems.

We aimed to determine whether adult use of mental health services subsidised by Medicare varies by measures of socioeconomic and geographic disadvantage. We hypothesised that services would be particularly inequitable where delivered by mental health professionals with higher gap payments. We conjectured that services provided by GPs, general psychologists and allied health practitioners would be relatively equitable, while services generally provided by psychiatrists and clinical psychologists would be less equitably delivered. We focused separately on item 291 (GP mental health care plan preparation by a psychiatrist), hypothesising that this item might differ in pattern from other psychiatry items.

Methods

We performed a secondary analysis of national Medicare data from 1 July 2007 to 30 June 2011. Data included all mental health services subsidised by Better Access and Medicare. Providers included GPs, psychiatrists, clinical psychologists and allied mental health practitioners.

Main outcome measures were service use rates and equity measures of concentration indexes and curves.

Data and linkage to area characteristics

Data included MBS items with associated postcode data but without other identifying information. The total number of services across all 4 years was 25 146 558. Unique records of data (consisting of unique sets of item number, consumer postcode and financial year) were suppressed to ensure confidentiality if the total of services in an area was less than 20. Based on the number of suppressed records, we estimated that a maximum of 3 084 023 service contacts could have been censored. However, the actual number of suppressed service contacts was likely to be about half this figure, and is unlikely to have caused any significant bias in analyses.

We grouped MBS items into the following categories (specific item numbers are available in Appendix 1 and Box 1):

GP mental health services created or significantly altered by Better Access;
consultant psychiatry items created or significantly altered by Better Access;
psychiatrist services in rooms. (CP+);
creation of a shared care plan by a psychiatrist (item 291);
psychological therapy services provided by a clinical psychologist; and
focused psychological strategies — allied mental health items:
- general psychologist services;
- occupational therapist services; and
- social worker services.

Consumer residential postcodes were linked to area characteristics available from public census information from the Australian Bureau of Statistics. These characteristics were remoteness area category12 and Socio-Economic Indexes for Areas (SEIFA).13 If a postcode had been assigned to more than one remoteness category, then it was allocated to the remoteness category having the greatest proportion of the population in that postcode. The SEIFA measures were the Index of Relative Socio-Economic Advantage and Disadvantage, Index of Relative Socio-Economic Disadvantage, Index of Education and Occupation, and the Index of Economic Resources.

Local implications

Variations within closely located yet differing socioeconomic status regions were examined by looking at four local government areas in major capital cities. We chose two regions ranked in the top decile for socioeconomic advantage (City of Bayside in Melbourne and North Sydney Council in Sydney) and two regions from disadvantaged areas (City of Greater Dandenong in Melbourne and City of Blacktown in Sydney).14 Postcode areas bounded entirely within each catchment were used in the service rate calculations.

Statistical analysis

To measure inequity, we plotted concentration curves and determined concentration indexes.15 Concentration indexes lie between − 1 and + 1. Negative indexes and curves above the 45° equity line represented greater usage in lower socioeconomic regions. Positive concentration indexes corresponded to curves below the equity line, and represented greater usage in higher socioeconomic regions.

We followed a convention of using an index threshold of 0.2 (or − 0.2) as indicating a high level of inequality;16,17 an index of 0.2 would result from the richest half of the population accessing 50% more services than the poorest half. For further details on our statistical methods, see Appendix 2.15,16,18

The equity line, derived from raw population rates, may underestimate need in deprived areas if greater needs are associated with lower socioeconomic status. However, in the absence of accurate and contemporary information on such associations, we did not adjust for this influence. Hence, where the curve was below the line and the index was positive, provision was judged inequitable. Where the curve was above the line and the index was negative, the finding was more suggestive but not conclusive of equitable delivery.

SEIFA

Of the four SEIFA variables, the Index of Relative Socio-Economic Advantage and Disadvantage was preferred for these analyses based on performance in calculating concentration indexes most consistently representative in direction and magnitude of values from the other indexes.

Ethics approval

Monash University Human Research Ethics Committee reviewed the study protocol and granted an exemption from ethics review because the non-identifiable data satisfied the requirements of the National Statement on Ethical Conduct in Human Research.

Results

Data were associated with 98.6% of Australian postcodes. Activity rates by year and postcode characteristics are shown in Box 2 (for absolute numbers, see Appendix 3). Most rates almost doubled across the 4 years, whereas consultant psychiatrist items predating Better Access (CP+) did not increase. Increasing remoteness was consistently associated with lower activity rates. Strong trends indicated higher use rates in less socioeconomically disadvantaged areas for most consultant psychiatry items and for clinical psychologist services; trends for other items were typically less marked.

Concentration curves are presented in Box 3 and Box 4; note that the scale (and hence the derived index) represents the population, not postcodes as in Box 2 and Appendix 3, so the pattern of results differs slightly. For key medical items shown in Box 3, the trend could be compatible with equity for items provided by GPs and for item 291. For item 306 (consultant psychiatry, 45–75 minutes), the poorest 20% of the population used about 10% of these services, while the richest 20% used over 30% (ie, more than three times the use rate). Concentration curves for key psychology and allied health items are presented in Box 4, which shows inequity for item 80010 (clinical psychology). The poorest 20% of the population by area characteristics used about 10% of these services, while the richest 20% used over 25% (ie, more than 2.5 times the use rate).

Concentration indexes for individual items are presented in Box 1. Significant negative index values were found for GP and allied health items. For reasons given earlier, related to population need, our findings suggested but do not confirm equity; area-based rates (Box 2) suggested some inequity for GP and allied health items, although less than for longer and widely used items from psychiatrists and clinical psychologists. Also of note, there were a number of index values for consultant psychiatry items with magnitude above 0.2, showing high inequity in favour of more advantaged areas. Negative indexes below − 0.2 were most common for focused psychological strategy items serviced by general psychologists, occupational therapists and social workers. Compared with psychiatrist and clinical psychologist services, these allied health services demonstrated better provision in disadvantaged areas.

Our examination of specific areas illustrates the differences that might be found in local planning exercises. We drew on examples from within the two largest Australian capital cities (Appendix 4). In Melbourne, the Dandenong area has high socioeconomic disadvantage, while the Bayside area is at the opposite extreme. However, it was the Bayside area that had much higher service use rates, with the exception of item 291, even though illness rates are likely to be much higher in Dandenong. In Sydney, there was a similar pattern of higher service activity in the North Sydney Council area compared with the more disadvantaged Blacktown area, although higher activity in Blacktown for GP items was an important exception.

Discussion

Our findings confirm previous findings19 of inequity in services provided by psychiatrists. Better Access activity rates are typically greater in more advantaged areas. There is variability between provider disciplines and items; within Better Access, this association is most strongly observed with high-volume clinical psychology services. Activity rates for Better Access and related mental health care MBS items decline with increasing remoteness across all types, reinforcing findings from previous work.8,9,20

Examination of the latest national survey did not suggest that areas of higher socioeconomic status were characterised by high use rates of Better Access items among people without disorders,7 but this may not be how inequity manifests. Rather, among people with comparable levels of diagnosable mental health problems, it may be easier for the socioeconomically advantaged to pass through the filters to specialist care.21 In other words, the criteria for stepping up a level of care may be different, and the disadvantaged may need higher levels of distress or disturbance to secure entry to care.

These results are consistent with a multitier system, where people living in more disadvantaged and more rural areas will typically receive a service model in response to mental health needs that is characterised by lower volumes of services, provided possibly by less highly trained providers. Item 291 is something of an exception among Better Access items but at a very low absolute rate.

Medicare provision through Better Access does not then conform to the kind of equitable delivery that would merit characterisation as universality. While we are not offering specific solutions to such a complex issue, we note that our key hypotheses were formulated with consideration of the likely influence of copayments as a disincentive and structural deterrence to accessing care. These findings would be compatible with a situation in which higher-paid professionals practise in areas closer to home, and where this spatial distribution aligns with direct considerations of affordability, it reduces access by people from more disadvantaged areas.

Our study has some limitations. The Medicare data do not take into account the Access to Allied Psychological Services initiative or the public mental health services provided by states and territories. Including these would require further data sources and analyses.22 Regarding funding models to public mental health services in Australia’s most populated states, Victorian public mental health services adopted transparent resource distribution processes in the late 1990s,23 including a correction to state funding based on level of private activity. In New South Wales, a special commission of enquiry recommended introducing a resource distribution formula to take into account socioeconomic factors and substitutable private services; however, this has not yet happened.24

Our data span financial years 2007–08 to 2010–11; changes to the scheme from late 201125 may have led to some changes in usage.

Without controlling for area-based need disparities,5,22 it seems most likely that our analyses may have underestimated rather than overestimated inequity.

Our findings, confirming previously demonstrated inequity in private psychiatric service activity, show that the Better Access initiative is not providing universality or consistent equity of delivery in mental health care. We hope that the findings may contribute to debate and discussion around policy incentives and strategies that work towards universal and equitable delivery of mental health care for all Australians.

1 Concentration index calculated using Index of Relative Socio-Economic Advantage and Disadvantage ranking for areas and national Medicare data, 1 July 2007 to 30 June 2011

Provider group	Consultation time (min)	Item no.	No. of patients	Concentration index* (95% CI)

General practitioner	Not timed	2702	317 117	− 0.05 (− 0.08, − 0.02)
	Not timed	2710	2 181 945	− 0.04 (− 0.07, − 0.01)
	Not timed	2712	930 248	− 0.03 (− 0.06, − 0.001)
	> 20	2713	3 019 386	− 0.08 (− 0.11, − 0.05)
Consultant psychiatry	> 45	291	22 258	− 0.08 (− 0.13, − 0.02)
	30–45	293	963	− 0.18 (− 0.34, − 0.02)
	> 45	296	303 240	0.03 (− 0.01, 0.06)
	> 45	297	14 499	0 (− 0.07, 0.07)
	> 45	299	285	0.34 (0.01, 0.7)
	< 15	300	126 179	− 0.13 (− 0.23, − 0.03)
	15–30	302	944 908	− 0.07 (− 0.14, − 0.002)
	30–45	304	1 871 116	0.04 (0.002, 0.08)
	45–75	306	2 572 228	0.21 (0.18, 0.25)
	> 75	308	111 875	0.05 (− 0.01, 0.10)
	< 15	310	0	na
	15–30	312	210	− 0.20 (− 0.29, − 0.12)
	30–45	314	1430	0.10† (− 0.07, 0.26)
	45–75	316	62 523	0.22 (0.15, 0.28)
	> 75	318	906	0.08 (− 0.04, 0.20)
	> 45	319	264 437	0.22 (0.15, 0.28)
Psychological therapy services
Clinical psychologist	30–50	80000	39 262	− 0.07 (− 0.15, 0.01)
	30–50	80005	1535	− 0.07† (− 0.31, 0.18)
	> 50	80010	3 754 815	0.13 (0.10, 0.17)
	> 50	80015	24 882	− 0.08 (− 0.15, 0)
	> 60	80020	14 436	− 0.07† (− 0.27, 0.13)
Focused psychological strategies
General psychologist	20–50	80100	108 723	− 0.26 (− 0.33, − 0.18)
	20–50	80105	9027	− 0.26 (− 0.42, − 0.10)
	> 50	80110	6 325 499	− 0.01 (− 0.04, 0.03)
	> 50	80115	194 844	− 0.14 (− 0.20, − 0.08)
	> 60	80120	25 819	− 0.02 (− 0.08, 0.04)
Occupational therapist	20–50	80125	4236	− 0.20 (− 0.33, − 0.08)
	20–50	80130	849	− 0.08 (− 0.22, 0.06)
	> 50	80135	72 607	− 0.05 (− 0.14, 0.05)
	> 50	80140	7326	− 0.06 (− 0.16, 0.04)
	> 60	80145	422	− 0.11 (− 0.24, 0.03)
Social worker	20–50	80150	3850	− 0.04† (− 0.19, 0.12)
	20–50	80155	2228	− 0.14 (− 0.43, 0.15)
	> 50	80160	472 353	− 0.02 (− 0.06, 0.02)
	> 50	80165	25 211	− 0.15 (− 0.23, − 0.07)
	> 60	80170	331	− 0.25 (− 0.44, − 0.07)

* A positive concentration index indicates inequality of service use in favour of advantaged regions. † Concentration curve with significant areas on either side of equity line.

2 Medicare-subsidised mental health and related services: use rates per 1000 population per year, 1 July 2007 to 30 June 2011

							FPS
Variable	Population	GP	CP	CP-291	CP+	PTS	Total	FPS-GenP	FPS-OT	FPS-SW

No. of MBS items		6 448 696	341 245	22 258	6 297 057	3 834 930	7 253 325	6 663 912	85 440	503 973
Use rate
Financial year
2007–08	21 249 199	55	4	0.1	74	30	60	56	0.5	3
2008–09	21 691 653	71	4	0.2	72	41	77	72	0.8	5
2009–10	22 031 750	79	4	0.3	71	48	92	84	1.2	7
2010–11	22 340 024	90	4	0.4	71	56	102	93	1.4	8
Region*
Major cities	15 104 517	79	5	0.3	92	52	92	85	1.2	6
Inner regional	3 991 501	76	3	0.3	37	32	81	74	0.6	6
Outer regional	1 897 121	50	1	0.2	13	14	46	42	0.7	4
Remote	267 159	25	0	0.0	4	5	11	10	0.0	1
Very remote	177 561	8	0	0.0	2	2	5	5	0.0	0
Socioeconomic disadvantage*†
Quintile 5	5 900 995	74	6	0.1	117	68	95	86	1.5	7
Quintile 4	4 480 536	74	4	0.3	74	44	88	82	0.7	5
Quintile 3	4 298 715	78	3	0.3	55	40	83	77	0.9	6
Quintile 2	3 508 187	77	3	0.4	44	29	76	70	0.9	5
Quintile 1	3 249 398	69	3	0.3	45	23	69	63	0.7	5

MBS = Medicare Benefits Schedule. GP = general practitioner mental health services created or significantly altered by Better Access to Mental Health Care services. CP = consultant psychiatry items created or significantly altered by Better Access. CP-291 = initial assessment for a GP shared care plan by a psychiatrist (MBS item no. 291). CP+ = all/most psychiatry items. PTS = psychological therapy provided by a clinical psychologist. FPS = focused psychological strategies: allied health items; GenP = general psychological services; OT = occupational therapy services; SW = social worker services. * Mean, 2007–2011. † Ranked by Index of Relative Socio-Economic Advantage and Disadvantage; quintile 1 = most disadvantaged.

3 Concentration curves for key medical items

IRSAD = Index of Relative Socio-Economic Advantage and Disadvantage. Item 2702 = general practitioner creation of a GP mental health treatment plan. Item 2710 = GP review of a GP mental health treatment plan. Item 291 = psychiatrist consultation for creation of a shared care plan, > 45 minutes. Item 306 = psychiatrist consultation in rooms, 45–75 minutes.

4 Concentration curves for key clinical psychology and allied health items

IRSAD = Index of Relative Socio-Economic Advantage and Disadvantage. Item 80010 = clinical psychologist consultation in rooms, > 50 minutes. Item 80110 = general psychologist consultation in rooms, > 50 minutes. Item 80135 = occupational therapist consultation in rooms, > 50 minutes. Item 80160 = social worker consultation in rooms, > 50 minutes.

The Sydney siege: courage, compassion and connectedness

Recognising and responding with both our strengths and vulnerabilities to help get through times of distress

The shock and threat of the Sydney siege on Monday 15 December 20141 have provoked large-scale responses — to the emergency, its aftermath and the implications it may have for the future. The strong response by police, counterterrorism agencies and other experts and the leadership shown by civic agencies through the hours of uncertainty were watched by the world. There was powerful engagement, concern for outcomes and an outpouring of grief over the tragedy of the hostage deaths that occurred.

The more recent adverse events in Paris, still evolving as we write,2 speak to the growing environment of terror that the global community is facing. Over the coming months, doctors, and in particular general practitioners, have an important role in helping those who may be vulnerable.

The siege

All that was seen in the human responses to the Sydney siege speaks of the compassion, courage, commitment, care and concern for others among the multitude who engaged with the attack and its consequences. The tributes and memorials of flowers attest to how deeply people were moved, and continue to be. People identify with suffering and loss, with threat and survival, with grief and anger — reflecting strengths as well as empathy.3 For some, the experience of the siege will continue and reverberate; their distress may fluctuate or continue unabated.

Elements of resilience are critical in surviving and getting through such threats. One of these elements is the value that comes from connectedness to others. There is social capital in the coming together of people and communities.4,5 The support of networks, including social media, is increasingly important in disasters and other emergencies. The #illridewithyou hashtag is an example of a show of support from strangers that builds strength. In their hearts, people yearn for the kindness of others and the possibility of a safe world where we all belong, and social media provides an opportunity to express and emphasise our shared values.

Such acts of kindness from strangers help create a sense of safety during uncertainty. People can support those affected by acknowledging what has happened and by offering help, shelter, safety and comfort. Figuratively, and at times literally, people put their arms around those who are distressed. These natural strengths and resilience are important resources for people during and after this emergency.

Altruism is a natural response in times of need. This has previously been exemplified by those who tried to rescue strangers after the Bali bombings and those who helped people descend the stairwells in the 9/11 terrorist attacks.

The aftermath

With the siege come many questions and uncertainties — the search to make meaning and to understand how this could happen. This phase of questioning can be very complex.

In circumstances where something has gone so wrong, there is, alongside the realities of complex human behaviour and beliefs, a strong demand to find fault. This is a time of building knowledge about threat and safety. The challenge lies in identifying what can be done to prevent and protect against further attack, yet still support the freedoms of a valued societal framework.

The backwards and forwards of regret and hope are the “normal” of who we are, and how we hold our own realities, strengths and specific fears. Not wanting to give up what might have been, we swing between the imagined hope that we could change what has happened and the reality of the need to move forward.

The challenges in the aftermath of such an event lie in recognising and responding with both our strengths and vulnerabilities. Courage, compassion and connection with others are powerful resources held by us all.6,7 The affectional bonds, the “love actually”, will help us protect and care for the young, the old, the injured, the vulnerable. As Ben Borgia, victim of the 2002 Bali bombings, put it, “The opportunity to be guided by good and giving people has me engaged in life again”.8

There is also a “dark side” that may follow such events, with the realisation that some individuals have both the capacity to hate and the desire for revenge. For some people, an overwhelming sense of threat and loss may bring feelings of helplessness. The images of people of all cultures and faiths presenting floral tributes after the siege can help to combat this by enhancing the positive emotions of connectedness and sense of safety.

GPs play an important role in helping patients throughout such incidents9 and through the reawakening of previous vulnerabilities. Individuals respond in their own ways to threatening situations, whether exposed directly to the danger or as indirect observers. Many of those overwhelmed by their feelings may benefit from education on “what reactions are normal”, as reported after the 2009 Black Saturday bushfires in Victoria (Ruth Wraith, Disaster Consultant and Child Psychotherapist, Victoria, personal communication).

It is important for GPs responding to the needs of their patients to recognise patterns of distress, which may present in many ways, from insomnia, profound fatigue, anger, anxiety or depression to exacerbations of pre-existing mental or physical health problems. Those patients who show continued fear, anxiety or other prolonged distress may need specialised assessment to regain a sense of safety.

Recent studies on the physical effects of disasters have highlighted the need to consider the emergence of new physical conditions. Diagnoses of stress-induced cardiomyopathy after the 2011 Queensland floods10 remind us that, alongside support for mental health conditions, surveillance for physical conditions is important. After the 9/11 terrorist attacks, a study of 2729 adults demonstrated that acute stress responses to the attack were associated with a 53% increased incidence of cardiovascular conditions over the following 3 years.11

All professionals involved in the management of and response to such events should be aware of the need for a health check for physical or mental health symptoms that develop. Excellent clinical resources exist to help assess any mental health needs both immediately and over time, and to provide important interventions as appropriate.12

For children, signs of distress vary with age and include behavioural change, such as withdrawal, acting out, fearfulness, clinginess or regression, and physical presentations such as abdominal pain. Specifically, children need protection from undue exposure to the media. Simple explanations, reassurance and affectionate bonds through comfort and holding all demonstrate to children that their world is still safe. Extensive resources are available from the Australian Child and Adolescent Trauma, Loss and Grief Network (http://earlytraumagrief.anu.edu.au).

The future

We acknowledge that terrorism has more threatening implications than a natural disaster because of the malevolent intent, which results in a greater effect in the aftermath and uncertainty about future attacks.13Consequently, terrorism events tend to have a greater effect on the health of individuals.14 Caring for people who have been affected by terrorism requires sensitive and skilled management. Dunsmore, a clinician with extensive experience in dealing with victims of terrorism, highlights “the shattering of people’s views of their world, the randomness, and the loss of the sense of safety and trust” (Julie Dunsmore, Senior Psychologist, Bali Trauma Recovery Program, NSW Health, personal communication). She emphasises the importance of human engagement and understanding the context of people’s lives, the impact of the many losses and the need to regain a sense of safety and trust. Survivors and the bereaved have stressed the importance of continuing support, in particular the community staying with them for the long haul and through difficult times such as anniversaries and other reminders.

What is critical is our strength as people, the strength of our nation and our commitment to others beyond our shores. The Australian Government provides resources on protecting our communities and ourselves.15

We may — as individuals, as families, as communities — face many challenges in tough times, but we do not give up. We endure, we struggle, we fail, we succeed, we go forward to the “new normal” and, as best we can, we look after one another, the stranger, in the face of threat and adversity.

As Australians we will stand up against threat, conflict and injustice and we will try to do our best. We will look to the future with strength and hope. As our Indigenous people, the oldest surviving culture, so wisely say:

… our strength is that we “have survived” … We depend on each other, we understand and support each other.16

Financial capacity in older adults: a growing concern for clinicians

Determination of whether an older person is capable of managing their own financial affairs is a vexing question for health and legal professionals, as well as government agencies such as courts and tribunals. This process is often stressful for older people, and families can find that deciding when to take over is a frustrating and divisive exercise. Having family members manage an older person’s assets may result in or exacerbate existing family conflict.

In this article, we define financial capacity and provide an overview of the assessment process, the potential impact of impaired capacity on older adults and implications for clinicians. We focus on best-practice suggestions for clinical management of questions of financial capacity.

What is financial capacity?

Financial capacity entails the ability to satisfactorily manage one’s financial affairs in a manner consistent with personal self-interest and values.1 Although the terms competency and capacity are often used interchangeably in this literature,2 we will refer to capacity throughout. The capacity to appropriately manage financial affairs has both performance and judgement aspects,3 which are distinct in that older people can have limitations in one or both. For example, an older person may be capable of carrying out financial transactions such as purchasing items, but not have the judgement required to spend within their financial means. Conversely, an older adult might have the judgement to assess the relative merits of competing demands on their financial resources, but lack the technical capacity to carry out financial transactions.

Financial capacity is just one domain of capacity. Others include the capacity to consent to medical treatment, make or revoke an enduring power of attorney, participate in research, make their own will, consent to sex, marry or divorce, vote, drive and live independently (covering a broad range of abilities). Eighteen key abilities covering nine domains of financial capacity have been identified4 and these range from simple tasks, such as being able to name coins and notes, to more complex tasks, such as making and explaining investment decisions (see Box 1).

Decision making and referral

Decision making can be conceptualised as a spectrum with complete autonomy at one end and substitute decision making at the other. A person is presumed to have capacity, and thus be able to make their own decisions, unless proven otherwise; however, this capacity is decision specific and may fluctuate. The United Nations Convention on the Rights of Persons with Disabilities (CRPD) entered into force in May 2008 and Australia ratified the CRPD in July 2008. The CRPD promotes supported, rather than substitute, decision making. Supported decision making can, however, be problematic. Examples of this include cases where those providing the support are not motivated to do what is in the best interests of the impaired person or where the person’s level of impairment is so severe that any form of decision making by the impaired person is no longer possible. Informal arrangements to cover both these situations are available and are outlined in a guide to guardianship and administration laws across Australia published by the Intellectual Disability Rights Service.6 The involvement of family and friends is important, and a referral to social work services or other allied health professionals may facilitate such informal arrangements. Formal arrangements can be made through guardianship boards or tribunals that operate in most states and territories (http://www.agac.org.au). Again, referral to such bodies can be intimidating for family (and sometimes even for institutions such as residential aged care facilities). Assistance and support with such a referral from allied health professionals, general practitioners or peak bodies such as Alzheimer’s Australia and Dementia Behaviour Management Advisory Services may be invaluable.

What are the potential impacts on older adults?

Impaired financial capacity renders an individual vulnerable to financial exploitation through actions such as undue influence and consumer fraud. Financial abuse is estimated to affect 1.1% of older Australians,7 and was found to be the most common form of elder abuse in a Western Australian study, particularly for older women and very old people.8 Undue influence describes a situation in which an individual is able to convince another to act in a way contrary to their will. Such influence might manifest in situations where an older person is financially capable but the family or other caregivers decide to manage the older person’s finances based on their own interests. Furthermore, consumer fraud is estimated to affect 5% of older Australians.9 Examples of such schemes often include taking advantage of cognitive decline in a vulnerable older person — as when a person purporting to be a tradesman comes to the door demanding payment for services supposedly carried out at an earlier time. Older adults who are more socially isolated or who are more dependent on paid external services in order to continue living in the community may be more vulnerable to such exploitation.

Given that older people’s share of total wealth has increased over the past two decades and is likely to continue to do so,10 the problem of financial capacity will become more pressing, and it is likely that more questions of capacity will present in primary and community health care settings.

Who is more at risk?

Recently there has been a focus on the clinical aspects of financial capacity, which broadly span cognitive, affective, instrumental and social capacity functioning.2 Older people with neurodegenerative disorders such as Alzheimer disease, Parkinson disease, frontotemporal dementia and mild cognitive impairment appear particularly vulnerable to diminishing financial capacity.3 How such changes manifest themselves, from a lifespan perspective, might be conceptualised11 as amounting to relatively minimal changes in financial capacity with normal ageing, particularly if older people have good social and instrumental support from family and friends. However, people with mild cognitive impairment may have increasing difficulty with more complex financial skills including bank statement management, bill payments and financial judgement,4 and it is important for families and health professionals to be mindful of reports or observations of such decline. Ideally, early intervention would allow for smoother transfer of financial responsibilities and perhaps avoidance of distress or embarrassment on the part of the person with declining financial skills.

People with mild Alzheimer disease have been reported to have impairments in both simple and complex financial skills, with rapid decline in a 1-year period.5 More global impairment of financial skills with probable financial incapacity has been reported in most people with moderate Alzheimer disease;12 and complete lack of financial capacity in severe Alzheimer disease.11 Over time and with increasing severity of dementia, older adults may show declining interest and engagement in their financial affairs, as well as reduced concerns about the consequences of their inaction. Such a situation may continue without family members being aware that anything is amiss. Sorting out financial concerns in cases of advanced dementia, particularly in the context of familial discord, can be challenging for health care professionals.

How to assess financial capacity

There is currently no universal standard for evaluating financial capacity. Overreliance on clinical judgement or non-specific assessment tools (such as the mini-mental state examination13) for determining specific aspects of capacity, such as the ability to make a will and distribute assets or to determine the presence of undue influence, is worrying. Failure to include specific objective measures of financial capacity as well as emotional and cognitive functioning may result in overreliance on clinical impressions rather than objective data, and may be less useful in a legal context.

A review of clinical assessment approaches to financial capacity in older adults found that current methods were based around a clinical interview, neuropsychological assessment and performance-based assessments.2 The authors stressed the need for a multipronged evaluation. The extant literature suggests that cognitive domains relevant to capacity assessment in Alzheimer disease include conceptualisation, expressive language, numeracy skills, semantic memory, verbal recall, executive function and receptive language.14 However, all relevant cognitive domains are often not systematically tested, or may be overassessed.15 Important contextual and social variables that inform interpretation of objective data16 and may be directly tied to the potential for financial abuse17 are often ignored. Moreover, reduced insight in patients about their own limitations and abilities, as well as the presence of psychiatric conditions such as depression and anxiety, can also lead to errors in judgement by patients with cognitive decline. Abilities such as insight are only infrequently examined by clinicians in the course of assessing financial capacity. Assessment of a person’s ability to understand the facts and choices related to their decisions, to distinguish between alternatives and weigh up consequences, and to make an informed choice and communicate their decision should also be made.

Unfortunately, the research literature related to financial capacity has been difficult to translate into sound clinical practice in health care settings. Capacity assessments at times rely almost completely on clinical judgement, which is not evidence-based and which may be vulnerable to bias.18 Comparability and consistency between approaches, even in a single case, may be lacking.19 Approaches to determining capacity have rarely been empirically validated with respect to their real-world reliability and utility.20 Part of the difficulty has been establishing a credible gold standard.15

What does this mean for clinicians working with older people?

Primary care providers such as GPs and community nurses are often the first to encounter older people with diminishing financial capacity,11 and they have an important role to play in acting on their concerns; for example, by discussing them with the family or referring the patient for more formal capacity assessment. Five different roles that clinicians may choose to adopt have been suggested:11 educating patients and families about the need for advance financial planning; recognising signs of possible impaired financial capacity; assessing financial impairment, financial abuse or both; recommending interventions to help patients maintain financial independence; and making timely and appropriate medical and legal referrals. This approach seems relevant to all clinicians working with older people. Ideally, all three of the suggested assessments — clinical interview, neuropsychiatry assessment and performance-based tests — would be conducted to assess capacity.

A comprehensive clinical interview is vital to directly assessing financial capacity with respect to a patient’s physical and emotional health. Objective assessment of cognitive function and potential psychiatric disorders, such as depression, anxiety, and psychosis and related symptoms such as delusions, are important and should use instruments that have been appropriately normed and, wherever possible, developed for geriatric populations. Performance-based assessment of financial capacity and decision making, as well as an assessment of a person’s vulnerability to undue influence and exploitation, are also important.2 A brief list of relevant instruments to consider appears in Box 2; this list is indicative rather than exhaustive.

Conclusions

Financial capacity is emerging as an important concern related to older people and those involved in their care. Assessment of financial capacity should include formal objective assessment in addition to a clinical interview and gathering of contextual data. There is no one instrument that can be used in isolation; use of multiple sources of data, objective performance-based tests, neuropsychiatric assessments and self-report clinical interview data is recommended. The decisions that result from an assessment of capacity can have far-reaching consequences. In order to better meet the needs of patients, their families and their carers, as well as clinicians involved in such assessments, standards and guidelines for the assessment of capacity are needed.

1 Financial conceptual model*

Domain and task

Task description

Difficulty

1 Basic monetary skills

a Naming coins/currency

Identify specific coins and currency

Simple

b Coin/currency relationships

Indicate relative monetary values of coins/currency

Simple

c Counting coins/currency

Accurately count groups of coins and currency

Simple

2 Financial conceptual knowledge

a Define financial concepts

Define a variety of simple financial concepts

Complex

b Apply financial concepts

Practical application/computation using concepts

Complex

3 Cash transactions

a One-item grocery purchase

Enter into simulated one-item transaction; verify change

Simple

b Three-item grocery purchase

Enter into simulated three-item transaction; verify change

Complex

c Change/vending machine

Obtain change for vending machine use; verify charge

Complex

d Tipping

Understand tipping convention; calculate/identify tips

Complex

4 Chequebook management

a Understand chequebook

Identify and explain parts of cheque and cheque register

Simple

b Use chequebook/register

Enter into simulated transaction; pay by cheque

Complex

5 Bank statement management

a Understand bank statement

Identify and explain parts of a bank statement

Complex

b Use bank statement

Identify specific transactions on bank statement

Complex

6 Financial judgement

a Detect mail fraud risk

Detect and explain risks in mail fraud solicitation

Simple

b Detect telephone fraud risk

Detect and explain risks in telephone fraud solicitation

Simple

7 Bill payment

a Understand bills

Explain meaning and purpose of bills

Simple

b Prioritise bills

Identify overdue utility bill

Simple

c Prepare bills for mailing

Prepare simulated bills, cheques, envelopes for mailing

Complex

8 Knowledge of personal assets/estate arrangements†

Indicate asset ownership, estate arrangements

Simple

9 Investment decision making

Understand options; determine returns; make decision

Complex

Overall financial capacity

Overall functioning across tasks and domains

Complex

* Reproduced from: Martin RC, Griffith HR, Belue K, et al. Declining financial capacity in patients with mild Alzheimer’s disease: a one-year longitudinal study. Am J Geriatr Psychiatry 2008; 16: 209-2195 with permission from Elsevier. † Requires corroboration by informant.

2 A brief list of instruments available for assessing financial capacity, decision making and vulnerability

Addenbrooke’s Cognitive Examination – III21

Informant Questionnaire on Cognitive Decline in the Elderly22

Semi-Structured Clinical Interview for Financial Capacity12

Financial Competence Assessment Inventory23

Geriatric Depression Scale24

Geriatric Anxiety Inventory25

Instrumental Activities of Daily Living Scale for elderly people26

Ethical challenges for doctors working in immigration detention

To the Editor: As psychiatrists and physicians working with adults and children in mandatory, often prolonged, immigration detention, we confirm Sanggaran and colleagues’ account.1

Quality evidence from diverse, independent, multinational sources, including legal and medical investigations over two decades, finds that immigration detention:

contravenes multiple international conventions that Australia has signed;2
harms mental health of detained children and adults, and detention employees, in a process likened to torture;3
incurs vastly greater financial and legal costs than alternatives, and makes profits for multinational companies from desperate, traumatised people;4
fails to deter people from seeking asylum and is unnecessary to prevent their absconding (because they rarely abscond);2
compromises ethics, through mandating secrecy, neutralising advocacy and destroying independent oversight;5 and
fosters conditions for systematic institutional child abuse and its lifelong consequences.6

Immigration detention fails every standard of medicine — science, ethics, health economics, pragmatics and human rights (including freedom from abuse and the right to highest attainable health standards). Yet despite accumulated evidence and established opposition from national professional bodies — including medicine, paediatrics, psychiatry, public health, psychology, nursing, social work and medical students — successive governments deny or rationalise inveterate harms, arguably implicate professionals in legitimating abuses the professionals cannot prevent, and deflect needed policy change.7 The case against immigration detention is irrefutable.

As immigration detention’s damages are unmitigated by any (mental) health intervention, and immigration detention renders clinicians ineffectual, a strong clinical and ethical argument exists for withdrawing services. Rather than health care for asylum seekers and detainees remaining with the Department of Immigration and Border Protection or being outsourced, federal or state health departments should provide and manage services and monitor standards independently. This will not resolve the problem of immigration detention, but it may attenuate some of its worst effects.

Let children cry

Better to be good at feelings than to feel good

Our society is intolerant and disrespectful of young people’s distress. We seem to dislike it when young people are angry, ashamed, frightened, sad or disappointed. There is strong encouragement to consider such distress as being a precursor of disease,1 so that parents, doctors and teachers are prone to label and intervene rather than sit with ordinary, healthy, but distressing feelings.

Distressed children are already inclined to numb themselves, whether with drugs, porn or screen time. Prescribing medication to lessen mental pain potentially adds to this numbing,2 creating a reduced state in which children are not fully themselves, and are less able to get on with the task of growing up.

We would do better to trust children’s capacity to survive and benefit from strong uncomfortable feelings; be more respectful of the time and space that is required to do so; and tolerate and manage the anxiety we experience through not intervening.

This less interventionist approach presents a substantial challenge because the distress that young people experience is a big deal. Adolescent suffering should not be dismissed as just adolescent turmoil; this turmoil can lead to a kind of madness. But it is most often an ordinary madness that requires support and containment, not diagnosis and treatment. (The term “madness” is used in keeping with the preference of many people with lived experience.3)

That somebody is distraught doesn’t mean that they are sick.4 Giving priority to catching psychiatric illness early risks disrespecting an adolescent’s need to go through hard times in order to emerge as a mature functioning adult, as occurs in situations such as these:

Janice’s parents underestimate the intensity of grief she experienced at her grandmother’s death and the space needed to deal with it.

Robert is quietly and bitterly preoccupied with the disappointment of always falling short of his father’s expectations, and it will be some time before he can come to terms with this.

Anh’s quiet, compliant and apparently positive adjustment to the violence of his childhood comes unstuck as he becomes more cognitively mature. Those around him misinterpret the change as a deterioration in his mental health.

All of these scenarios are consistent with developmental breakdown.5 As bad as the experience might be for adolescents and those around them, staying with and passing through significant dysfunction can be required to reach positive outcomes.

Confronted with potentially fatal behaviours (“she is cutting, will she kill herself?” or “he smokes dope every night, will he end up being a junkie?”), a parent might easily confuse the imperative to take these things seriously with a need to intervene on behalf of the child. It is desirable to understand and explain a young person’s distress,6 but this is not always possible, and even when it is, suffering often continues. Sometimes there is a need to take distress seriously without trying to take it away.

Of course, confronted with a distressed young person (our own or someone else’s), we need to make sure that they are adequately protected from those dangers that we can and should remove (such as domestic violence) and adequately informed about their choices; and we need to confront them when we think they are making bad choices. But going too far in any of these areas creates problems: if we overprotect, if we stray from informing to berating, if we confront in a way that is humiliating, then these apparently positive parental activities can do more harm than good.

So having done our best to make meaning from the child’s distress, and instituted sensible safety measures, we will still often feel powerless and frightened; the task for parents, carers and professionals is to “face off” that fear, acknowledging and trusting in those capacities that were apparent before the young person became distressed.

We also need to tolerate this fear and uncertainty for more than a couple of days, making space and time to stay with feelings and experiences through to completion, possibly over many months. While a sensitive well trained therapist can be helpful, engaging with the mental health system risks interrupting this completion; diagnoses and treatments (especially but not only medication) aim to put an end to distress, rather than see it through.

Another challenge to completing emotional experience is the high level of distraction through social media and multiple screens. Those old enough to have had a boring childhood might remember how boredom facilitates reverie, in turn generating creativity.7 That world cannot be recreated, but young people can be helped to accept that they need not fill every empty moment with relatively meaningless activities, and encouraged to make the time required for resolution of their strong feelings. Respecting and making space for them requires parents to tolerate unpleasant fears and anxiety. Parental duties include sleepless nights; not just with a restless toddler, but lying awake wondering what an adolescent is up to.

Distressed young people need empathy (“ability to understand and appreciate another person’s feelings, experience”)8 rather than sympathy (“a feeling or frame of mind evoked by and responsive to some external influence”).8 A sympathetic father experiences his own pain in response to his daughter’s predicament and desires to remove that pain; an empathic father also feels his own pain but gives higher priority to the child’s experience, and to understanding and/or containing her pain rather than removing his own.

So we must trust kids’ ability to survive strong feelings; make and protect the space for them to do that; and manage our own resultant anxiety. We need to give them the gift of being good at feelings, of being able to make sense of uncomfortable but healthy sadness, anger, fear and shame, rather than the gift of feeling good, which is shallow and evaporates in the face of adversity.