Govt investment in doctors of the future still falling short

As the new Chair of the Medical Workforce Committee (MWC), I am looking forward to harnessing the committee to drive the AMA’s response to the medical workforce crisis.

I would like to acknowledge Dr Stephen Parnis for his stewardship of the MWC as inaugural Chair. Like Stephen, I have a long-standing interest in medical workforce issues, and believe that ensuring Australia has the medical workforce to meet community needs is a critical challenge for governments and health policymakers.

Over the last 15 years the number of medical school places has increased substantially in response to past workforce shortages. But the need for more medical schools is over, as we know from successive sets of workforce data that Australia now has sufficient numbers of medical students. We must now focus on improving the distribution of the medical workforce, and providing enough postgraduate medical training places, particularly in rural and remote areas and the under-supplied specialty areas.

At the recent Federal Election, the AMA offered four important policy proposals to help achieve this outcome:

expanding the National Medical Training Advisory Network’s (NMTAN) workforce modelling program;
establishing a Community Residency Program;
increasing the GP training program intake; and
expanding the Specialist Training Program.

NMTAN is the Commonwealth’s main medical workforce training advisory body, and focuses on planning and coordination. It has representatives from the main stakeholder groups in medical education, training and employment.

NMTAN’s report on the psychiatry workforce was released in March. This is the first specialty report to be finalised by NMTAN since Health Workforce Australia was axed in 2014. It contains valuable data and analysis, including a projected undersupply of 125 practitioners by 2030 for the psychiatry workforce, despite a likely increase in the number of Australian-trained psychiatrists.

NMTAN is intending to beef up its work program. The AMA has argued consistently for complete workforce modelling and reporting across all medical specialties by the end of 2018; it is vital to have data sooner rather than later on imbalances across the specialties to enable effective workforce planning.

We will continue to engage with the Government of this issue. In the meantime, we await with interest the expected release of the reports on the anaesthesia and general practice workforces later this year.

An important piece of work undertaken by the MWC last year was developing the Community Residency Program for Junior Medical Officers (CRP). This is the AMA’s proposal to establish and fund a program for high-quality prevocational placements in general practice for junior doctors as a replacement for the valuable Prevocational General Practice Placements Program abolished by the Government in 2014.

We continue to lobby for our CRP. The Government’s announcement late last year that it will fund 240 rotations in general practice settings for rural-based interns is a partial replacement for the PGPPP, and was an admission by the Government that its decision to abolish the program was a backward step, especially for rural health.

As a practising GP, I am keenly aware that more resources are needed to build and maintain a sustainable GP workforce.

The AMA’s call to increase the GP training program intake to 1700 places a year by 2018 is worthy of the Government’s consideration. This must be backed with solid measures to support GP training, including incentives for supervisors and investment in training infrastructure. Rural general practices need grants to help them expand their facilities and provide more teaching opportunities for medicals students and GP registrars, and to enhance the range of services they provide.

The Commonwealth’s Specialist Training Program (STP) is a valuable workforce program that is giving specialist trainees the opportunity to train in settings outside traditional metropolitan teaching hospitals. Though the Government has committed to provide 1000 placements by 2018, the AMA strongly believes that the STP must be expanded to 1400 places a year, with the focus on encouraging specialist training in rural settings and specialties that are under-supplied.

Other areas of focus for the MWC will be promoting generalism in the medical workforce, encouraging greater gender diversity in medical leadership, and increasing clinical supervision capacity.

Progress, but much more to do.

“Congenital heart health”: how psychological care can make a difference

An integrated approach incorporating both physical and mental health is critical to “congenital heart health”

Congenital heart disease (CHD) affects more than 2400 Australian babies each year. It is the most common cause of admission to paediatric intensive care in the neonatal period,1 a leading cause of infant death2 and one of the leading causes of disease-related disability in children under 5 years of age.3 In Australia and around the world, the landscape of CHD care is rapidly evolving. With advances in medicine, survival has markedly improved over the past two decades4 and the best estimates suggest that the total population, from newborns through to adults living with CHD, now represents well over 65 000 Australians.5 These gains in survival are a triumph, but paradoxically, they bring new challenges. Earlier diagnosis, more complex treatment choices, longer survivorship and a need for transition from paediatric to adult cardiac services lead us into new territory. Embedded in each of these challenges are a range of psychological complexities, foremost of which is how to best support the wellbeing of people with CHD across a lifetime. “Congenital heart health” requires an integrated, life course approach — with equal emphasis on the physical and the psychological — beginning before birth, through infancy to adulthood. This article presents the evidence for such an approach, highlighting the areas where evidence is lacking and calling for national standards of mental health care in CHD.

Beginning before birth: the mental health of expectant parents

Fetal diagnosis of CHD has changed clinical care. Half of all babies who need heart surgery in the first year of life are now diagnosed while in the womb.6 A major advantage of fetal diagnosis is that potentially unstable newborns can be delivered close to specialised paediatric cardiac services, reducing morbidity and improving survival.7,8 Fetal diagnosis also facilitates early family counselling regarding the nature of the baby’s heart abnormality and expected prognosis. But when a parent hears words such as “your baby has tetralogy of Fallot” their world stops. Fetal diagnosis of any abnormality, major or minor, precipitates an emotional crisis for expectant parents. Threats to the health of the fetus have long been recognised as an important risk factor for psychological disturbance during pregnancy, which in turn indicates a high risk of ongoing psychiatric disorders postpartum. Research has shown that one in three mothers and fathers of infants with complex CHD report symptoms that meet clinical criteria for depression, and about 50% of parents report severe stress reactions consistent with a need for clinical care up to 1 year after their baby’s diagnosis.9 These rates far exceed documented rates of perinatal depression and anxiety in the general community10 and as health care providers, we often markedly underestimate the severity and potential consequences of these symptoms.

There is now overwhelming evidence that depression and anxiety in the perinatal period (from conception to the end of the first postnatal year) can have devastating consequences, not only for the person experiencing it, but also for his or her children and family. Parents with high distress report poorer physical health,11 greater parenting burden,12 higher health service use13 and more suicidal ideation14 compared with parents of sick children with lower distress. At least 14 independent prospective studies have demonstrated a link between maternal antenatal stress and child neurocognitive, behavioural and emotional outcomes.15 Acknowledging these findings is not to blame parents — not in any way, not at all. But to not talk about this, to not address the significant emotional toll of CHD, is to not provide optimal care.

Early life experiences can have profound consequences

Diagnosis of a life-threatening illness during a child’s formative years can have far-reaching effects that ripple through the family and across a lifetime. Infants with complex CHD experience a range of uncommon and painful events, such as separation from their mother at birth, urgent transfer to specialised intensive care, frequent invasive medical procedures, feeding difficulties and withdrawal from narcotic pain relief. These early life experiences can have profound consequences for the developing child, shaping brain development, the body’s immune system and responses to stress. Studies of individuals exposed to high levels of stress early in life consistently show that the experience of early adversity is associated with disrupted child–parent attachment and with alterations in the developmental trajectories of networks in the brain associated with emotion and cognition.16

From a neurodevelopmental perspective, children with CHD experience greater difficulties compared with their healthy peers. The risk and severity of neurodevelopmental impairment increases with greater CHD complexity, the presence of a genetic disorder or syndrome, and greater psychological stress. During infancy, the most pronounced difficulties occur in motor functioning. By early childhood, studies show that children with complex CHD have an increased risk of neurodevelopmental impairment, characterised by difficulties in fine and gross motor skills, speech and language, attention, executive functioning, emotion regulation and behaviour.17 Emotionally, 15–25% of parents report significant internalising (eg, anxiety, depression, somatisation) or externalising (eg, aggression) difficulties in their child.18 Few studies have used validated clinical assessments, but those studies that have included a clinical assessment report psychiatric illness in more than 20% of adolescents and young adults with CHD. There is also a diagnostic rate of attention deficit and hyperactivity disorder up to four times higher than in the general population.18

Navigating the transitions of adolescence

Young people must not only navigate the typical transitions of adolescence and early adulthood, they also face the challenges that come with developing a sense of identity and autonomy in the context of CHD while, at the same time, breaking the bonds formed with their paediatric team and transitioning to adult cardiovascular care. Clinicians lose their “clinical hold” on so many patients during this process, with an alarmingly high proportion of adults with CHD (24–61%) not receiving the recommended cardiac care.5,19,20 This can have catastrophic health consequences,5 yet our understanding of the factors that influence transition is wanting. In 2013, the Cardiac Society of Australia and New Zealand published a statement outlining best practices in managing the transition from paediatric to adult CHD care.21 This statement recognises the role that psychological factors play in shaping young people’s capacity to manage their heart health care, in addition to clinical, familial and practical factors.

Living with CHD into adulthood

Our understanding of the psychology of adult CHD lags decades behind our knowledge of children’s experiences. While neurodevelopmental clinics have been established at several paediatric cardiac centres across Australia, little attention is paid to neurocognitive health in adult CHD care. Without effective intervention, hardships encountered during infancy and childhood can persist for years after diagnosis and treatment. It is also possible for difficulties to emerge for the first time in adulthood, with heart failure, atrial fibrillation, cardiac surgery and recurrent strokes increasing vulnerability to neurocognitive impairment in adults with CHD. A meta-analysis of 22 survey-based studies of emotional functioning in adolescents and adults with CHD found no differences from the norm;22 however, studies using clinical interviews have found that one in three adults with CHD report symptoms of anxiety or depression warranting intervention.23 The vast majority of these adults go untreated.

An integrated psychology service dedicated to CHD

In 2010, we established an integrated clinical psychology service dedicated to CHD. Located across the Sydney Children’s Hospitals Network, we provide a statewide mental health service for children and young people with all forms of heart disease and their families (Box). Evidence-based, psychologically informed care and a variety of interventions can prevent or relieve psychological morbidity.24 National (beyondblue, 2011) and international (International Marcé Society, 2013) authorities now recognise and endorse psychosocial assessment for depression and anxiety in the perinatal period as part of routine clinical care. Integrating psychosocial assessment within existing health services has been shown to improve treatment uptake, as well as mental health and parenting outcomes, up to at least 18 months postpartum.24 Indeed, integrating psychosocial assessment within a clinical setting with which families are already engaged is a key factor distinguishing successful and unsuccessful early mental health interventions. Providing tailored skills-based training and support to staff also has the potential to overcome a range of patient (eg, stigma, cost), provider (eg, limited awareness, low confidence), and health system (eg, cost, under-prioritisation) factors that can prevent access to care. Moreover, there are costs to not offering mental health care. In neonatal intensive care, for example, targeted interventions significantly reduce maternal depression and anxiety, increase positive parent–infant interactions, and reduce health service costs by reducing the length of stay at the neonatal intensive care unit and total hospital admission.25

A call for national standards of mental health care in CHD

While there may be deep sadness associated with many aspects of CHD, there may also be deep hope and, for many, good health. Early intervention can make a profound difference for families and influence a lifetime of outcomes for a child. To transition CHD to “congenital heart health”, equal emphasis must be placed on both physical and mental health so that the successes in physical care are not undermined by the absence of adequate emotional care. Across the CHD continuum, there are still huge gaps in access to mental health services. To start to address these gaps, we call for the formation of a multidisciplinary working group to develop national standards of mental health care in CHD. We also advocate strongly for more Australian research across the discovery-to-translation pipeline such that, from early life in the womb through to adulthood, we can better understand — and prevent or assuage — the difficulties that our patients and their families experience.

Box –
Integrated model of psychological care dedicated to congenital heart disease and based at the Heart Centre for Children

National Institute for Health and Care Excellence. Antenatal and postnatal mental health: clinical management and service guidance. NICE clinical guidelines, no. 192 (updated edition). London: NICE, 2014.

[Comment] The wisdom of crowds

It is often assumed that the history of mental health is full of “terrible, dark places with chains and mistreatment”, says Alice White, Wikimedian in Residence at the Wellcome Library, London, UK (audio feature). White’s work is challenging that view. She hopes to “balance out some of the inaccuracies in the history of psychiatry and mental health” by promoting expert contributions to Wikimedia sites including Wikipedia, and “increasing accessibility” to the Wellcome Library’s extensive archives.

More resources, faster internet the key for rural health

Rural doctors have overwhelmingly identified the need for improved public hospital funding and better internet access as the most important solutions for rural health care.

In the first AMA survey of rural doctors since 2007, GPs, other specialists, salaried doctors and doctors in training were asked to rank in importance 20 proposed solutions to improve the health of rural Australians.

Almost 600 doctors took part in the 2016 AMA Rural Health Issues Survey in April.

And, as they did in 2007, they nominated “provide extra funding and resources to support improved staffing levels, including core visiting medical officers, to allow workable rosters” as their top priority.

In a sign of the growing use of internet-based communications and data, access to high-speed broadband was not a survey option nine years ago, but was ranked as second-most important in this year’s survey.

Ensuring that rural hospitals have modern facilities and equipment rose one space to third, and encouraging medical colleges to include rotations for trainees to rural areas rose from sixth to fourth.

Related: Rural doctors want support

AMA President Dr Michael Gannon said the survey results showed that rural Australia needs more resources to recruit and retain doctors and other health professionals.

“We have record numbers of medical school places and, with sufficient numbers of medical graduates coming through, the focus must now be in how we can get them to work in the places they are needed the most,” Dr Gannon said.

As one respondent said: “I cannot stress enough the importance of rotating specialist/vocational trainees into rural posts. The RACS and RACP have done so for years with great exposure and training of prospective doctors for a rural practice. Other colleges must follow suit, especially psychiatry, radiology, pathology, O&G, and emergency medicine, to name a few key deficiencies in rural placement or training.”

The survey found that rural doctors enjoy their careers but struggle with the workload and lack of support.

“It’s very hard to find locum support to take holidays/attend conferences, and as the only specialist in my field in all rural WA, extra support to maintain CPD and be able to go on holidays would be nice,” one respondent said.

But the response from the community makes the job rewarding, doctors said.

“Small towns often appreciate what little I could do for them,” one doctor said.

The survey results build on the AMA’s Plan for Better Health Care for Regional, Remote, and Rural Australia, released in May.

The Plan proposes a focus on four key areas – rebuilding country hospital infrastructure; supporting recruitment and retention of doctors; encouraging more young doctors to work in rural areas; and supporting rural practices.

“Addressing and investing in these measures will make a long-term difference to the health of Australians living in rural communities,” Dr Gannon said.

Maria Hawthorne

Photo credit: Nils Versemann / Shutterstock.com

Latest news:

Psychological distress in carers of Aboriginal children in urban New South Wales: findings from SEARCH (phase one)

The known Aboriginal children are at increased risk of mental health problems. The mental health of parents affects that of their children.

The new Psychological distress was common in parents and carers of Aboriginal children participating in SEARCH, and was associated with functional limitations, previous treatment for mental health problems, and low social connectedness.

The implications Carers with functional limitations or a history of treatment for mental health problems may require additional mental health support. Providing adequate mental health services and the funding and promoting of programs and activities that increase social connectedness should remain focuses for ACCHSs and policymakers.

Parents and carers play a critical role in the social and emotional wellbeing of their children. A link between parental and child mental health has been firmly established in the mainstream literature,1–3 but remains largely unstudied in Aboriginal health. Emerging evidence from phase one of the Study of Environment on Aboriginal Resilience and Child Health (SEARCH), however, indicates that children with carers who are not psychologically distressed have significantly better chances of enjoying social and emotional wellbeing than those with distressed carers (unpublished data of authors AW, CD and KC). These findings indicate that improving the mental health of the parents and carers of the next generation of Aboriginal young people must be a priority if real gains are to be made in closing the health and wellbeing gaps between Aboriginal and non-Aboriginal people. In contrast, qualitative research indicates that Aboriginal parents often feel unable to access mental health services because they fear that their children might be removed.4

Our study examined psychological distress in the primary carers of Aboriginal children living in urban communities and attending Aboriginal Community Controlled Health Services (ACCHSs) in New South Wales. ACCHSs provide comprehensive primary health care for Aboriginal people in a culturally appropriate manner.5,6 The carers participated in phase one of SEARCH, the largest cohort study of urban Aboriginal children ever conducted.7 Specifically, we aimed to:

determine the proportion of carers participating in the SEARCH program who meet Kessler Psychological Distress Scale (K10) criteria for high levels of psychological distress; and
examine the associations between demographic, health and community (neighbourhood and social) factors and psychological distress.

Methods

SEARCH

The protocol for phase one of the SEARCH study was published in 2010.7 SEARCH is a partnership between researchers, ACCHSs and the Aboriginal Health and Medical Research Council. The overall aim is to describe and investigate factors associated with health and illness in urban Aboriginal children aged 0–17 years who attend participating ACCHSs, as well as in their parents and caregivers.

Families in the target population were eligible to participate in phase one if the parent or caregiver was over 16 years of age and willing to provide contact information for follow-up interviews. SEARCH is conducted in partnership with four ACCHSs in NSW: Mount Druitt (Aboriginal Medical Service Western Sydney); Campbelltown (Tharawal Aboriginal Corporation); Wagga Wagga (Riverina Medical and Dental Aboriginal Corporation) and Newcastle (Awabakal Aboriginal Cooperative).

Families meeting inclusion criteria were invited by an Aboriginal research assistant to participate in SEARCH when they presented to a participating ACCHS. Participants in SEARCH will be followed up 5 years after recruitment; this article reports on the baseline cross-sectional data collected during phase one (November 2007 – December 2011).

Measures

As part of the SEARCH phase one survey, the parents or carers of participating children completed a comprehensive survey about their children’s health and wellbeing. Carers also completed a questionnaire about themselves that collected data on a range of demographic, social, lifestyle and health-related factors, including health service use, community and family resilience, and quality and safety of housing. The questionnaire was based on the Western Australian Aboriginal Child Health Survey8 and the New South Wales Child Health Survey.9

The K10 scale was used to measure non-specific psychological distress in carers.10 High K10 scores are strongly associated with current World Health Organization Composite International Diagnostic Interview (CIDI) diagnoses of anxiety and affective disorders, and are also associated with the presence of any mental disorder.11 A score of 22 or higher was deemed to indicate high levels of psychological distress, consistent with previous investigations.12 The K10 has been found to be a valid measure of distress in Aboriginal adults in NSW.13

Statistical methods

All parents or carers for whom a K10 score could be calculated (9 of 10 items must be completed for a valid score to be generated) were included in this study. Characteristics of the sample are presented as means and standard deviations or as frequencies and percentages. The proportion of carers with high psychological distress, and 95% confidence intervals (CIs), were calculated. Each variable of interest was initially included in a separate logistic regression model that controlled for age, sex and ACCHS. All variables for which P < 0.20 or which were considered to be clinically important (such as age and sex) were included in the multiple regression models. A separate model was performed for each of the three domains of explanatory variables: demographic, health, and community factors. A final model was then generated that included all significant variables from the three models.

Univariate analyses evaluated all available cases, and multivariable modelling used complete case analysis. We assessed the sensitivity of results to imputing missing data by applying the chained regressions method of multiple imputation to generate five imputed data sets. Missing values were predicted using an iterative series of appropriate regression models (logistic or multinomial), conditional with respect to the observed values of the outcome variable, independent variables used in regression modelling, and additional measured variables. This method is appropriate for arbitrary patterns of missing data, but assumes that the data are missing at random. Modelling was performed using the pooled multiple imputation dataset, including the independent variables selected from the complete case analysis (final model). Coefficients and standard errors for the variability between imputations were combined using the method of Rubin.14

Post hoc power calculations indicated that the overall sample size of 637 carers provided 80% power (α = 0.05, 2-tailed) to detect differences of 11% in categories of study factors predictive of a high K10 score (with an outcome prevalence of at least 70% in the reference category). All analyses were performed in SAS 9.4 (SAS Institute) and Stata 13 (StataCorp).

Ethics approval

The study was approved by the relevant ethics committees of the Aboriginal Health and Medical Research Council of New South Wales (reference 586/06) and the University of Sydney (reference, 12–2003/9429).

Results

A total of 637 parents and carers participated in phase one of SEARCH, of whom 589 provided sufficient data for a complete K10 score and were therefore included in our study. There were no significant differences between the demographic details of participants for whom a K10 score was or was not recorded (data not shown).

Most participating carers were female (93%); their mean age was 34 years (Box 1). Most (78%) identified as being Aboriginal and/or Torres Strait Islander. The majority reported home duties as their primary occupation (54%); unemployment was uncommon (12%). Employment status was significantly associated with the prevalence of high psychological distress (employed or studying, 13%; home duties, 19%; unemployed, 27%; P = 0.02). About half of all carers (49%) had a secondary or tertiary qualification. One in 20 carers had been removed from their natural family by a mission, the government, or a welfare agency, and 28% reported that their parents or other relatives had experienced such removal. The previous removal of carers’ parents or relatives was associated with high current psychological distress (parent removed, 31%; other relative removed, 22%; no family history of forced removal, 14%; P < 0.01).

Of the 589 participants with a calculated K10 score, 481 (82%) had values under 22, and 108 (18%) had high scores. The mean K10 score was 16.7 (range, 10–47; standard deviation, 7.5).

Socio-demographic variables associated with high psychological distress

In the final model, after adjusting for all important demographic, health and community factors, no socio-demographic variables retained a significant association with the level of psychological distress (Box 2).

Mental and physical health factors associated with psychological distress

In the fully adjusted model, several mental and physical health factors were significantly associated with higher odds of high psychological distress (Box 3). Forty-two per cent of those who reported experiencing a functional limitation (limited in any way in normal daily activities by a medical or health problem) were highly distressed. The odds of being psychologically distressed was more than four times higher for this group than for those without a functional limitation (adjusted odds ratio [aOR], 4.2; 95% CI, 1.3–13.5). Previous treatment (aOR, 3.3; 95% CI, 1.3–8.4) or hospitalisation for mental health problems (aOR, 5.5; 95% CI, 1.5–19.4) were also significantly associated with currently high levels of psychological distress. The prevalence of distress in those who had been hospitalised for mental health problems was particularly high (49%).

Neighbourhood and community factors associated with psychological distress

In the fully adjusted model, the odds of high psychological distress were lower for those who were more satisfied with their feeling part of their community (aOR for one unit increase in scale, 0.83; 95% CI, 0.70–0.98) (Box 4). For those who reported infrequent involvement in clubs and groups, the odds of high psychological distress were almost three times as high as for those who engaged with such groups at least once a month (aOR, 2.9; 95% CI, 1.2–7.3).

Discussion

Psychological distress in the carers of Aboriginal children and adolescents who participated in phase one of SEARCH was fairly common: a high or very high level of distress was measured in about 18% of carers. SEARCH may not provide a representative sample of all carers of Aboriginal children; the proportion in our study is substantially higher than the 2.6% of mothers and 1.3% of fathers with high K10 scores in the Longitudinal Study of Australian Children,2 but substantially lower than the 30% of Aboriginal adults participating in the 2012–2013 Aboriginal and Torres Strait Islander Health Survey.15 While demographic factors are commonly linked with psychological distress,16,17 they were not significant in our study after taking the impact of health and community factors into account. The factors significantly related to high psychological distress in SEARCH carers were functional limitations,18,19 previous hospitalisation or other treatment for social and emotional wellbeing, lower satisfaction with feeling part of the community, and lower involvement in clubs and groups.

Functional limitation was associated with psychological distress, and this is consistent with a growing body of evidence which suggests that disability, rather than having a particular illness per se, has the greatest impact on mental health.18 The effect of functional limitations may be particularly distressing for parents and carers because of the inherently physical nature of parenting. Some researchers have called for depression to be routinely assessed in those with functional limitations,20 and our findings suggest that clinicians should be mindful of the elevated risk of distress in such people.

The very high prevalence of current distress in those who had previously been hospitalised or received treatment for mental health problems underscores the importance of the continuity of mental health care. Our data are concerning, as previous research has highlighted incompatibilities between mainstream mental health services and the needs of Aboriginal people21,22 and identified ACCHSs as the only places where many Aboriginal parents feel they can safely access mental health care.4 Despite these findings, 87% of ACCHSs are not funded to provide mental health care services.23 As the mental health of children improves when their parents undergo treatment for their own mental health problems,20 it is likely that providing adequate care for the parents of Aboriginal children will have far-reaching benefits.

Lack of social connectedness was strongly associated with psychological distress in SEARCH carers. Those who reported low levels of satisfaction with their feelings of belonging to their community and those who reported infrequent participation in clubs and groups were significantly more likely to meet criteria for high psychological distress. These findings are consistent with the prominent role assigned to “connection to community” in the concept of social and emotional wellbeing from an Aboriginal and Torres Strait Islander perspective described by Gee and colleagues, in which the self is seen as being grounded in the family and community.24 It also accords with observations from the National Empowerment Project, which found that many of the strategies nominated by participating Aboriginal communities as improving social and emotional wellbeing were focused on increasing the connectedness of individuals, families and communities.25 The interplay between participation and feelings of belonging has been explored in earlier research which suggested that Aboriginal people who participate in Aboriginal organisations and clubs find this a highly effective means of fostering a sense of belonging in the community.26 One of the many roles ACCHSs play in maintaining the social and emotional wellbeing of the parents of Aboriginal children is their providing a place where Aboriginal people can come together.5

This article was designed to provide an overview of the associations between a range of demographic, physical and family factors and high levels of psychological distress in the carers of Aboriginal children in urban NSW. The following caveats should be noted. The data are cross-sectional, so that we can report associations, but are unable to infer the reasons for the relationships found. Phase two SEARCH data are currently being collected and will allow us to explore how mental health of carers changes over time, as well as predictors of improvement or worsening. The data we have presented pertain to Aboriginal families recruited through four ACCHSs in urban NSW, and may not be generalisable to parents and carers of Aboriginal children living in other parts of Australia.

Our article highlights some key areas for action in improving the social and emotional wellbeing of the parents and carers of Aboriginal children. Specifically, clinicians should note that those with functional limitations or a history of treatment for mental health problems are at higher risk for psychological distress and may require additional support. Increased funding that allows ACCHSs to provide mental health services, together with funding and promoting programs and activities that increase social connectedness, should remain focuses for ACCHSs and policy makers.

Box 1 –
Characteristics of carers of Aboriginal children participating in phase one of SEARCH

Variable	Total*	Kessler Psychological Distress Scale score		P^†
Variable	Total*	< 22 (Low to moderate distress)*	≥ 22 (High to very high distress)*	P^†

Number	589	481 (81.7%)	108 (18.3%)
Age (years), mean (standard deviation)	34.3 (9.9)	34.4 (10.3)	33.6 (8.4)	0.46
Aboriginal and/or Torres Strait Islander				0.05
Yes	457 (78%)	114 (88%)	16 (12%)
No	130 (22%)	365 (80%)	92 (20%)
Employment status				0.02
Employed/studying	200 (34%)	174 (87%)	26 (13%)
Unemployed/retired/unable to work	71 (12%)	52 (73%)	19 (27%)
Home duties	312 (54%)	252 (81%)	60 (19%)
Qualifications				0.62
None	289 (51%)	234 (81%)	55 (19%)
Trade certificate/diploma/other	236 (42%)	191 (81%)	45 (19%)
Bachelor or postgraduate degree	41 (7.2%)	36 (88%)	5 (12%)
Were you taken away from your natural family by a mission, the government or welfare?			0.15
Yes	28 (4.9%)	25 (89%)	3 (11%)
No	530 (93%)	427 (81%)	103 (19%)
Were either of your parents or other relatives taken away from their natural family by a mission, the government or welfare?				0.008
Yes, parent	70 (12%)	48 (69%)	22 (31%)
Yes, other relative	94 (16%)	73 (78%)	21 (22%)
No	332 (54%)	284 (86%)	48 (14%)

SEARCH = Study of Environment on Aboriginal Resilience and Child Health. * Numbers may not add to the respective total because of missing data. † Low/moderate distress v high/very high distress.

Box 2 –
Association of high psychological distress in carers of Aboriginal children in the SEARCH study with demographic factors

Variable	Total number	Number (%)	Adjusted odds ratio (95% CI), after adjusting for:
Variable	Total number	Number (%)	Age, sex, ACCHS	Age, sex, ACCHS, significant demographic factors*	Age, sex, ACCHS, all significant factors^†

Sex
Men	55	7 (13%)	1.0	1.0	1.0
Women	534	101 (19%)	1.5 (0.65–3.3)	1.3 (0.57–3.0)	1.0 (0.23–4.6)
Aboriginal and/or Torres Strait Islander
No	130	16 (12%)	1.0	1.0
Yes	457	92 (20%)	1.7 (0.98–3.0)	1.2 (0.68–2.2)
Employment status
Employed/studying	200	26 (13%)	1.0	1.0	1.0
Unemployed/retired/unable to work	71	19 (27%)	2.5 (1.3–4.9)	2.4 (1.2–4.8)	0.86 (0.24–3.1)
Home duties	312	60 (19%)	1.5 (0.93–2.5)	1.6 (0.98–2.7)	0.9 (0.35–2.3)
Qualifications
None	289	55 (19%)	1.0
Trade certificate/diploma	236	45 (19%)	1.0 (0.66–1.6)
Bachelor or postgraduate	41	5 (12%)	0.62 (0.24–1.6)
Housing tenure
Owned by someone in household	125	16 (13%)	1.0
Social housing	139	28 (20%)	1.7 (0.85–3.3)
Rental	304	61 (20%)	1.6 (0.90–3.0)
Number of children cared for
< 4	420	78 (19%)	1.0
≥ 4	48	12 (25%)	1.56 (0.78–3.2)
Carer removed from natural family
No, refused, or don’t know	540	105 (19%)	1.0
Yes	28	3 (11%)	0.60 (0.16–1.9)
Carer’s parents or other relatives removed from their natural family?
No, refused, or don’t know	399	64 (16%)	1.0	1.0
Yes, other relative	94	21 (22%)	1.5 (0.89–2.7)	1.5 (0.86–2.7)
Yes, parent	70	22 (31%)	2.4 (1.4–4.2)	2.3 (1.3–4.2)

ACCHS = Aboriginal Community Controlled Health Service. * Factors that were identified as significant (bold) in the previous column. † Factors that were identified as significant (bold) in the previous column in .

Box 3 –
Association of high psychological distress in carers of Aboriginal children in the SEARCH study with health factors

Variable	Total number	Number (%)	Adjusted odds ratio (95% CI), after adjusting for:
Variable	Total number	Number (%)	Age, sex, ACCHS	Age, sex, ACCHS, significant health factors*	Age, sex, ACCHS, all significant factors^†

Has a medical condition that will last at least 6 months
No	369	46 (12%)	1.0	1.0	1.0
Yes	201	59 (29%)	3.1 (2.0–4.8)	1.3 (0.70–2.3)	0.71 (0.27–1.9)
Functional limitations
No	452	62 (14%)	1.0	1.0	1.0
Yes	93	39 (42%)	5.3 (3.12–9.0)	3.2 (1.6–6.3)	4.2 (1.3–13.5)
Number of days’ exercise per week
None	112	28 (25%)	1.0	1.0	1.0
1–3 days	220	36 (16%)	0.58 (0.33–1.0)	0.82 (0.41–1.6)	1.2 (0.36-4.2)
4–7 days	236	41 (17%)	0.62 (0.36–1.01)	0.94 (0.48–1.9)	2.1 (0.65–6.8)
Number of stressful life events in past year
≤ 2	245	21 (9%)	1.0	1.0	1.0
≥ 3	344	87 (25%)	3.6 (2.2–6.0)	2.01 (1.2–3.8)	1.9 (0.73–4.8)
Previous treatment for social and emotional wellbeing
No	356	36 (10%)	1.0	1.0	1.0
Yes	200	69 (35%)	4.7 (3.0–7.4)	2.6 (1.5–4.5)	3.3 (1.3–8.4)
Previous hospitalisation for social and emotional wellbeing
No	518	84 (16%)	1.0	1.0	1.0
Yes	43	21 (49%)	4.7 (2.45–9.0)	2.2 (1.0–5.0)	5.5 (1.5–19.4)

ACCHS = Aboriginal Community Controlled Health Service. * Factors that were identified as significant (bold) in the previous column. † Factors that were identified as significant (bold) in the previous column in .

Box 4 –
Association of high psychological distress in carers of Aboriginal children in the SEARCH study with neighbourhood and community factors

Variable	Total number	Number (%)	Adjusted odds ratio (95% CI), after adjusting for:
Variable	Total number	Number (%)	Age, sex, ACCHS	Age, sex, ACCHS, significant community factors*	Age, sex, ACCHS, all significant factors^†

I feel l belong in this neighbourhood
Agree	360	50 (14%)	1.0	1.0	1.0
Disagree	92	30 (33%)	3.0 (1.8–5.1)	2.7 (0.91–8.2)	2.5 (0.59–10.3)
Neighbourhood has a strong sense of community
Agree	289	47 (16%)	1.0
Disagree	121	26 (21%)	1.4 (0.81–2.4)
People in neighbourhood very willing to help others
Agree	273	39 (14%)	1.0	1.0	1.0
Disagree	140	36 (26%)	2.0 (1.2–3.4)	0.46 (0.15–1.4)	0.40 (0.1–1.6)
Crime is a problem in neighbourhood
No	180	18 (10%)	1.0	1.0	1.0
Yes	378	83 (22%)	2.5 (1.5–4.23)	2.0 (0.85–4.5)	1.3 (0.49–3.6)
Participated in groups/clubs (past year)
Monthly or more	263	33 (13%)	1.0	1.0	1.0
Occasionally or never	301	70 (23%)	2.1 (1.3–3.2)	2.4 (1.2–5.0)	2.9 (1.2–7.3)
Participated in parents groups/groups related to child (past year)
Monthly or more	143	20 (14%)	1.0	1.0	1.0
Occasionally or never	410	83 (20%)	1.5 (0.90–2.6)	1.8 (0.8–4.4)	2.5 (0.89–7.3)
Satisfaction with feeling part of community,^‡ median (range of responses)	5 (1–10)	0.8 (0.71–0.85)	0.82 (0.71–0.93)	0.83 (0.70–0.98)

ACCHS = Aboriginal Community Controlled Health Service. * Factors that were identified as significant (bold) in the previous column. † Factors that were identified as significant (bold) in the previous column in . ‡ 10-point scale, with higher number indicating greater feeling of satisfaction.

Carers of Indigenous children: services and systems failure? Where to next?

We need solutions that adequately engage Indigenous carers in mental health care

In this issue of the MJA, Anna Williamson and colleagues report that 18% of a sample of primary carers of Indigenous children in urban New South Wales exhibit high or very high rates of psychological distress.1 This paper raises a number of questions. One in three carers reported that they or a relative had been removed from their primary carer as a child. This figure is astoundingly high, and leads us not only to wonder whether this rate of removal is similar in other populations in Australia, but also why the rate of psychological distress is not higher. Williamson and colleagues found no correlation between the carer having been removed themselves and currently high distress levels. We suggest that the small number involved (28, or 5% of the sample) affected the power of the analysis to detect a difference; the lack of association may reflect a psychological survival strategy of suppression, as has been found by research into the effects of childhood trauma.2

The reported high rates of distress in urban NSW carers of Aboriginal children prompts us to ponder the rates in other parts of Australia. Comparative data about parenting is sparse, with differing outcome measures and sample demographics used, but an Australian study found the rate of depressive symptoms in Indigenous mothers during the postnatal period was 12%.3 While acknowledging that this study employed a different measure (Edinburgh Postnatal Depression Scale) and targeted an earlier parenting stage, 12% is lower than the figure reported by Williamson and colleagues for their urban NSW sample. Very few studies have explored psychological distress in Indigenous communities; this must be rectified to ensure that appropriate services can be developed to support community needs.

The association between previous mental health treatment and high rates of psychological distress points to our need to find solutions that adequately engage Indigenous carers in mental health care, possibly over the longer term. Indigenous people make up only 3% of Australia’s population, but the number of community mental health occasions of service (2013–2014) was 3.3 times higher for Indigenous (1067 per 1000) than for non-Indigenous Australians (324 per 1000).4–6 This disproportionate use of services by Indigenous people should lead us to ask: why is our care in this area not better?

The average number of mental health visits per person per year was 5.8 in NSW, compared with almost twice this number (9.8 visits) for the rest of Australia.7 One could argue even 9.8 visits per year are unlikely to be adequate for an Indigenous client to develop the trust necessary for effective mental health support. The current approach of mental health services administering acute care, with a high turnover because of demand, does not support Indigenous clients and their families. With 40% of the population in this study affected by removal from family and carers, carers validly worry that children might be removed if they seek assistance with mental health from mainstream services.

Williamson and colleagues suggest funding Aboriginal Community Controlled Health Services (ACCHS) to improve mental health care within this culturally accepted system. There are currently over 150 ACCHS centres across the country; while they are a critical part of the solution, they will not bridge the need for care of acutely unwell patients, or for those geographically remote from such a service. We need to be more creative about how to engage Indigenous people in mainstream mental health services so that geographical shortfalls in ACCHS do not entail limitations to culturally appropriate medical care. Prioritising the mental health training of Aboriginal health workers and other clinicians in these services is an essential investment for improving Indigenous community trust in mental health services.

Mental health services need to be designed according to the specific needs of Indigenous families, including support for those who are suffering distress related to forced removal. Long term engagement with mental health support programs, both through ACCHS and mainstream services, is essential across life; Williamson and colleagues have highlighted the importance of parental mental health care for Aboriginal children. Funding mental health programs in the 87% of ACCHS centres not currently funded for this purpose is an important step for service delivery in the communities that have access to ACCHS.8

Further research should clarify the rates of psychological distress in Indigenous Australians in different contexts including during parenting and the perinatal period. In addition, research should examine the numbers of Indigenous Australians who experienced forced removal during childhood and the impact of the Stolen Generations, and investigate their psychological effects on a person’s ability to parent. Despite the good will of clinicians, current approaches to providing mental health services are not appropriately or effectively servicing the Indigenous, and major investment in training and the services of both ACCHS and mainstream services is a national priority.

Kimberley suicide rate highest in the world

There needs to be more innovative approaches to preventing suicide in Indigenous populations, experts say, with suicide rates in the Kimberley region among the highest in the world.

A report in the Medical Journal of Australia found that there were 125 suicides in the region between 2005 and 2014. 102 of those were Indigenous people.

“As the Kimberley Indigenous population was 13 918 at the 2011 census, this equates to an age adjusted suicide rate of 74 per 100 000 per year in this population,” the authors wrote.

Most of those people were male and less than 30 years old. 70% were not known by the district’s mental health service.

There were 476 Indigenous people who presented with deliberate self-harm or suicidal intention in 2014.

Related: Coping with patient suicide

The authors wrote that collective trauma and ongoing socio-economic deprivation were the drivers of high self-harm and suicide rates.

In an article in MJA InSight, Suicide prevention researcher and director of humanitarian projects at the Institute of Social Justice and Human Rights, Mr Gerry Georgatos said that a Royal Commission was needed into this “catastrophic humanitarian crisis”.

“A royal commission can shift the national consciousness, educate the nation as to the underlying issues while also smashing myths and stereotypes. [This] has the strongest prospect of galvanising the ways forward,” he said.

One of the authors of the MJA paper, Dr Murray Chapman, told MJA InSight that local communities need to be able to develop their own services based on their needs.

“It’s about empowerment and capacity building in communities – as opposed to imposing on the communities,” he said.

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[Perspectives] George Patton: global leader in adolescent health

“What’s a guy like you doing in a place like this?”, asked a criminologist to George Patton at a meeting on re-engagement for young offenders in Melbourne, Australia, 15 years ago. The colleague was referring to Patton’s background in clinical psychiatry and epidemiology, and his work at the Royal Children’s Hospital Melbourne. Today, Patton is a Professorial Fellow in Adolescent Health Research at the University of Melbourne and the nearby Murdoch Childrens Research Institute, and his eclectic professional positions have been an asset in his role as Chair of the Lancet Commission on adolescent health and wellbeing.

The Port Arthur massacre and the National Firearms Agreement: 20 years on, what are the lessons?

Twenty years after the Port Arthur massacre and the National Firearms Agreement (NFA), it is timely to examine how assertive national firearms regulation has prevented firearm mortality and injuries, and gun lobby claims that mental illness underpins much gun violence.

On 28 April 1996, Martin Bryant, a lone gunman using semi-automatic weapons killed 35 people at Port Arthur, Tasmania. In response, the Australian Prime Minister, John Howard, negotiated strict national gun control laws, banning automatic and semi-automatic rifles and shotguns, and introducing uniform stringent firearms licensing, a waiting period, security and storage requirements, sales regulation, and instituting compulsory buybacks of the banned weapons. Licensing required a proven genuine reason, with prohibition or cancellation for violence, apprehended violence or health reasons. The Commonwealth, states and territories implemented the NFA in 1996 and the National Handgun Control Agreement in 2002 with bipartisan support. In their wake, the national firearms stockpile reduced by one-third and public mass shootings have so far ceased. Although total homicides have declined since 1969, stabbings exceed shootings (more lately increasingly [http://www.aic.gov.au/statistics/homicide/weapon.html]), and hanging may later have substituted for gun suicides, rates of total gun deaths, homicides and suicides have at least doubled their rates of decline, suggesting that comprehensive gun control measures were responsible.1,2 A 2010 evaluation found that the reforms were averting at least 200 deaths per year and saving around $500 million annually.3

Community reactions to maintaining public memorial services after 20 years reveal the massacre’s long-term traumatic impacts. The anniversary highlights disparate issues: remembering forgotten (especially Indigenous) massacres; firearm availability; debatable relationships between mental illness, violence, guns and indiscriminate media reporting; and future actions to support rather than erode public health gains.

Following recent mass shootings in the United States, gun lobbyists claim that mentally ill people cause gun violence (http://www.theguardian.com/world/2012/dec/21/nra-full-statement-lapierre-newtown) whereas gun control advocates, including President Barack Obama, have invoked the Australian model.

The relationship of psychosis or serious mental illness and violence has been thoroughly reviewed elsewhere.4–6 Various methodological considerations (eg, institutional versus community samples, definitions of mental illness, temporal relationship of illness and violence) influence conclusions.5 However, from the US Epidemiologic Catchment Area (ECA) Study in 1990 onward, numerous international population studies have confirmed a modest but significant link between mental disorders and community violence (4% 1-year population-attributable risk [PAR] in the ECA study).4 Risks of violence for psychoses are 2–10% PAR compared with the general community, 20% PAR for personality disorders (including antisocial personality disorder), and 25% PAR for substance misuse.4 Odds are higher for homicide; Australian statewide data- and case-linkage studies indicate that people with schizophrenia perpetrated violence five times more often7 but homicide 13 times more often8 than the general community. Some studies show the relationship to be fully mediated by dispositional, situational and disinhibitory factors, including substance misuse;9 others find that substance misuse attenuates, not cancels, the relationship.7,8 Untreated active psychotic symptoms10 and past violence play key roles. Risk for violence in psychosis and schizophrenia may predate active symptoms or result from active illness or treatment. Developmental difficulties, impulsivity and anger, antisocial behaviours, social disadvantage or subculture, and substance use mediate these risks. High risk groups are generally identifiable and most violent acts should be preventable.6

Such studies confirm that most violent individuals do not have mental illness, and that the vast majority of individuals with mental illness are not violent. They are more likely to be victims not perpetrators of violence.11 Media portrayal of violence by people with mental illness reinforces public perception of their dangerousness, further stigmatising and endangering them.4 Almost half of those who die at the hands of US police have some kind of disability.12 Crucially, mental illness is strongly associated with suicide — with PARs ranging from 47% to 74%.4

Individuals who do not have mental illness perpetrate more than 95% of gun homicides.13 Rather than armed civilians reducing crime and homicide, extensive studies show that US gun availability, household gun ownership and diluting gun laws increase firearm homicide14 and suicide.15 In 27 developed countries, gun ownership strongly and independently predicted firearm homicide and suicide, whereas the predictive capacity of mental illness was of borderline significance.16

Although mass murderers who seize media attention often seem to suffer from psychosis, no research clearly verifies that most are psychotic or even suffering from severe mental illness.17 One recent analysis of mass shootings in the US reported that in 11% of cases, prior evidence of concerns about the shooter’s mental health had been brought to medical, legal or educational attention.18 Reports that 43%19 and 56%20 of US mass killers have serious mental illness may be confounded by primary diagnostic reliance on internet, law database and newspaper searches, an apparent dearth of reliable information about psychopathology and authorities’ knowledge of illness, and complications for retrospective analysis of murder–suicide or “suicide by cop”. Of 130 victims of mass gun killings in Australia and New Zealand from 1987 to 2015, 78% were slain by someone without a known history of mental illness, 88% by someone without a history of violent crime, and 56% by someone legally possessing firearms (http://www.gunpolicy.org/documents/5902-alpers-australia-nz-mass-shootings-1987-2015). Thus, the mass killer is frequently until that moment a law-abiding owner of a lawfully held gun.

Mass murder is an almost exclusively male phenomenon that is frequently planned in advance as retribution for perceived wrongs,17 to vindicate, and to potentially overcome hopelessness and invisibility with instant fame and omnipotent destruction. Many have maladaptive (eg, paranoid, sadistic, narcissistic, antisocial) personality configurations.17 Martin Bryant’s trial judge, relying on four forensic psychiatrists’ reports, noted Bryant was not suffering from mental illness but a personality disorder with limited intellectual and empathic capacities (http://www.geniac.net/portarthur/sentence.htm).

Also critical to vindictive or alcohol (or other drug) related gun violence are precipitating and background factors — situations such as domestic conflict and violence, school or work grudges, toxic social networks, and isolation.17 Whether media reporting of other mass murders primes potential perpetrators with instructions and the above incentives21 requires further investigation.

Firearm suicide, overshadowed in public debate but contributing 77% of total gun deaths in Australia in 2014 (http://www.gunpolicy.org/firearms/region/australia#number_of_gun_suicides), is of especial concern. In Queensland, the firearm suicide rate among people with a current licence far exceeded that of those with no licence.22 General rural suicide rates are roughly twice city rates. Farmers may need guns, but safe storage and removal of the weapons at vulnerable periods of life are vital to prevent suicide.

So 20 years later, what are the lessons?

The NFA, which reduced firearm deaths, particularly suicides but also homicides and mass shootings, mirrors similar benefits of comprehensive gun control measures elsewhere.23 However, prevention of firearm injury and mortality intersects with other pressing public and mental health challenges such as domestic violence and suicide, and therefore needs multidisciplinary coordinated efforts.

Following recent US gun massacres, there have been calls for better resourcing of mental health services to help identify and respond to those at risk and to regulate firearms access.24 Because people with mental illness are not categorically dangerous, and because sensitivity and specificity problems with screening for violence mean that psychiatrists are no better than laypeople or chance at prediction,4 using strategies such as screening mentally ill populations for violence risk is misguided (not to mention costly, burdensome and infringing rights). However, clinicians have a key role in monitoring and assisting regulation of firearm access, especially for high risk populations (eg, children, adolescents, suicidal people, domestic violence victims and perpetrators, farmers and rural residents, police, and security employees). Their work with legal authorities regarding time-sensitive and situation-specific risks needs further exploration.4 Legal measures include penalising alcohol intake around firearm usage; keeping guns from domestic violence and drink-driving offenders; requiring licensed shooters to surrender guns during periods of vulnerability due to anger, threats and suicidality; and a lower threshold for permanent removal of guns and gun licences. Implications for patient confidentiality, the therapeutic alliance and informed consent, also require examination. As with suicide, responsible media reporting should apply to mass violence.

The national weapons stockpile has now returned to pre-1996 levels (http://www.theconversation.com/if-lawful-firearm-owners-cause-most-gun-deaths-what-can-we-do-48567), highlighting the need to maintain and strengthen the national regulatory regime. Complacency has somewhat eroded the NFA. For example, in New South Wales, the pro-gun lobby succeeded in weakening the regulation of pistol clubs — arguably causing at least one homicide.25 NFA opponents hope to overturn the ban on semi-automatic long arms.

The NFA banned semi-automatic rifles and shotguns, but not semi-automatic handguns (pistols), which are permitted for pistol club members. The logic of stringent restrictions on rapid-fire weapons is equally applicable to handguns, which although currently accounting for few gun deaths, are the concealable weapon of choice for criminals. The medical community has long supported bans for semi-automatic handguns. We need a review, revision and tightening of existing laws and more effective restrictions and controls on possession, import and sales of handguns and other firearms, especially via the internet and by illicit imports.

In the US, the National Rifle Association insists it is not guns that kill but only bad and unhinged people (http://www.theguardian.com/world/2012/dec/21/nra-full-statement-lapierre-newtown). Yet evidence suggests that for some people who are indistinguishable within the general public, including some with interpersonal and personality issues, having easy, legal access to guns is lethal, resulting in avoidable excesses of both domestic and mass killings. Clinicians may offer much to firearm risk management yet must remain ambivalent about targeting those with mental illness for gun intervention if this is not complemented by wider gun control measures.4 The campaign to deflect social concern over firearms availability into a debate about whether people with mental illness histories should access such weapons should be exposed as a calculated appeal to prejudice.

Stepwise expansion of evidence-based care is needed for mental health reform

One of the greatest opportunities in Australian public health is to reduce the mortality and morbidity caused by mental illness. In contrast to cancer and cardiovascular disease, there have been no improvements in rates of death or disability from mental illness in recent decades. Indeed, rates of suicide have increased,1 and mental illness is the largest and fasting growing source of disability.2 Prevention, early diagnosis and sustained access to evidence-based treatment have underpinned health gains in other diseases, yet these are poorly provided by a mental health system that is characterised by a self-perpetuating focus on acute care and welfare payments.3

With mental illness projected to have the greatest impact on global economic output of all non-communicable diseases,4 there is an economic imperative to replicate what has been accomplished for other diseases. The mental health reforms announced by the Prime Minister and the Minister for Health on 26 November 2015 outlined new directions,5 two of which, in particular, are highly congruent to achieving this goal. However, the reform package is constrained by a focus on cost containment and will need further strengthening if it is to be successful.

The first welcome aim of reform is to shift the focus of mental health care towards early intervention. The National Mental Health Commission highlighted the enormous avertable personal, social and economic burden imposed by underprovision of prevention and early intervention in mental health.3 It is therefore welcome that the government has endorsed this aim,6 but notable that it has not committed the funding to make it happen. This crucial plank of reform may remain more rhetoric than reality. For example, acting on the advice of its Mental Health Expert Reference Group,7 the government announced a measure to develop much-needed new responses to young people with serious, non-psychotic mental illnesses. This is to be financed from funds that are already fully committed to an evidence-based, cost-effective model of early intervention for young people with a first episode of psychosis.8–12 Spreading already modest resources a mile wide and an inch deep would be an unpromising financing model for such a major reform objective. It would be safer and more logical to pilot a small number of novel approaches to young people with serious non-psychotic mental illness and to then provide new investment for those approaches that have most promise in terms of cost-effectiveness.

The second notable aim of reform is to move mental health services more towards providing stepped and person-centred care. This means supports must be targeted and weighted (right care, right intensity, right time) and more holistic. Achieving the goal of better targeting and weighting of support will depend on the government’s preparedness to also finance more intensive interventions, not just divert people with milder illnesses to lower intensity interventions. More holistic care may help overcome the excess burden of chronic physical illness that contributes to a median of 10 years of life lost for people with mental illness.13

The current funding constraints within which direct mental health care is provided mean that treatment, especially expert, specialised care, is heavily rationed and overly restricted to late presentations, with a duration frequently insufficient for remission and recovery. Of Australian adults with depression and anxiety, 16% receive only “minimally adequate treatment”,14 and the situation for those with psychotic illnesses reflects similar poor access to and variable quality of care.15 Unless something changes, the problem may get even worse, as federal support for state hospitals is set to reduce and state mental health services within these structures are already soft targets for hospital administrators.

Although largely neglecting the financing issue, the government has outlined potentially important actions at national and regional levels. National actions will include two national initiatives brought about by consolidating several school mental health programs that support promotion and prevention activity, and an array of digital mental health platforms. Flagged future national actions include Medicare reforms, the details of which are yet to be announced, and coordination of cross-departmental and intergovernmental activity. In a move away from centralised planning and contracting, primary health networks (PHNs) will now undertake local needs assessment and mapping, use pooled flexible funds to plan and commission a range of service responses for their regions, and work in partnership with local health networks to better integrate these services with state-funded mental health care.

These national and regional strategies to achieve earlier intervention and better targeted, stepped and more holistic care are consistent with the Commission’s recommendations3 and the advice of the government’s Mental Health Expert Reference Group,7 and have been cautiously welcomed by much of the mental health sector, which has been destabilised by chronic uncertainty.

In addition to more adequate funding, a key success factor for these reforms will be whether the PHN model of commissioning the mental health services needed in each local area functions well — and equally so in all regions. International experience suggests that devolving commissioning is not a magic bullet to improve health outcomes, that it creates predictable risks and that the impact of such measures depends on a range of supporting policy levers and environmental factors.16

Appropriate national structures, supports and oversight will be required to ensure PHNs can tailor programs to local circumstances, while maintaining fidelity to evidence-based practice and models of care. The virtue of regional planning flexibility cannot overshadow the need to invest in programs that work. Any new investment, and the repurposing of existing resources, must be channelled through commissioning of evidence-based interventions and proven models of care. It is at present unclear how this will be assured. It is essential that all major aspects of program innovation are appropriately trialled and evaluated before being codified in frameworks and guidelines that shape the development of services throughout all PHNs. International commissioning guidelines suggest that PHNs may be more likely to progress reform goals if they commission integrated, accessible, effective and holistic service platforms17 and appropriately engage consumers and carers in measurement and evaluation processes.18

Much of the funding allocated to the PHNs is focused on youth and early intervention. For young people, integrated, holistic, multicomponent primary care platforms achieve better results than do standard primary care platforms.19 The headspace platform3 will be central to how PHNs progress the reform aims of early intervention and stepped, holistic care, consistent with the Commission’s recommendation that this platform continue to be funded as a fundamental pillar of the youth mental health service system.3 As with other programs devolved to PHNs, there remains a need for strong national functions in areas such as data collection, evidence dissemination, model fidelity and workforce development. In the case of headspace, the Commission recommended these should be unified under a single national youth mental health umbrella.3

Other areas of national responsibility in the reform process, such as the digital mental health and Medicare reform agendas, also require an evidence-based and evidence-generating approach. Particular care is required in progressing the government’s plan to promote use of low-intensity and self-help strategies for people with milder forms of mental illness and to encourage general practitioners to be more sparing in referral of patients to face-to-face psychological services. Implicit in this plan is an assumption that many of the people currently accessing mental health care through primary care and the Better Access initiative could be more cost-effectively managed by e-health intervention strategies. This may well be true, at least in part, and the Better Access initiative represents a tempting target for funding cuts as it is seen as large, and is expanding. However, as an early step in the universal care pathway, a threshold of proof of safety and cost-effectiveness should be met before access to a GP and allied health professional is further constrained. E-health can be an excellent complement to all steps in the care pathway, not only the first, and it would be safer to offer it initially as a choice, rather than as a triage strategy or barrier.

The government has begun to acknowledge that we must do much better for the “missing middle” group of patients — those people with complex disorders who need to access the expert care that they are unlikely to ever receive from state-funded public mental health services.6 Care for this group should involve a step up in expertise from the initial GP and allied health professional, and ideally should involve a team approach, with input from a psychiatrist. In the case of non-response to this first step, more of the same may not be what is required for many people with complex and persistent disorders. This should be a federal responsibility, and a new model of care needs to be designed and tested in a defined subset of regions before any sweeping changes are made.

The other major group requiring consideration is older adults with persistent and disabling illnesses, particularly schizophrenia. Traditionally, being the target group for the asylums of old, they have been the major adult group eligible for state public mental health services. Yet, even they are underserved and have insecure access to care and sufficient duration of treatment, and outcomes — both physical and mental — remain well short of what is possible.15 This shortfall in care was the motivation behind the federal Partners in Recovery initiative (http://www.pirinitiative.com.au), which was formulated in 2011. This initiative, while popular, lacked a real evidence base or “road testing”, and the variability in the models of care that resulted conversely underlines the value of national templates that are based on best-available evidence and are properly tested before being scaled up. Federal funding to fill the service gaps for these patients would be better focused on more practical needs, such as family support, housing and specialised employment programs — all highly evidence-based but inadequately funded. Of great concern is that only a small proportion of these patients (estimated at about 10%) will be able to access the National Disability Insurance Scheme,20 yet it is feared that mental health funding may be lost in the process. The irony is that mental illness, by far the largest source of disability and for so long the poor cousin of the health system, is being forced into the same position within the new disability system. This must be dealt with as a matter of priority. The states should also be required to care much more adequately for their traditional core patient population.

Finally, there is an important role for new research funding programs that include, but are additional to, the National Health and Medical Research Council, and which are more directly tied to specific reform objectives. Potential reforms to Medicare Benefits Schedule items, such as incentives for GPs to provide longer consultations and for psychiatrists in private practice to integrate much better with primary care and other disciplines, as well as new and alternative uses of digital mental health strategies and systematic expansion of vocational recovery models, are areas that would benefit from such targeted funding schemes. The Medical Research Future Fund looms as an appropriate vehicle for funding some of this activity.

Australians now have a greatly increased awareness and understanding of the scale and impact of mental illness on their lives and society. The challenge is to transform this into targeted investment so that access, quality and outcomes in mental health care match those seen in physical health care.