As a psychiatrist working in the public sector, I was depressed to see that the Productivity Commission’s Inquiry Report into Mental Health – ceremoniously handed down by the prime minister – is a missed opportunity which will continue the long tradition of resource misallocation. Doubtless thousands of bureaucrat-hours were spent on its genesis, but I wonder how many of its authors have any direct experience in treating mental illness? Predictably, a good proportion of its content plays to its target audience. There is lots of anodyne sloganeering about stigma reduction, informed consent to treatment and the need for a predominantly subjective notion of ‘recovery’ uncoupled from actual remission of symptoms. Sadly, while many of these talking points will appeal to lawyers, academics and mental health advocates, there is much that will disappoint the families and clinicians involved in the unglamorous task of caring for patients with severe and enduring mental illness.
Apart from failing the ‘sniff test’, the report’s assertion that almost one in five Australians have experienced mental illness in a given year is dubious because it is based on non-rigorous self-reporting. Statistical manuals used to estimate illness prevalence – such as the DSM-5 – are increasingly filled with pseudo-diagnoses which equate the vicissitudes of normal life with mental illness. The Commission favours the term ‘mental-ill health’ over ‘mental illness’, presumably because the former has fuzzier boundaries and is less easily defined by objective measurement (the Commission also replaces the term ‘patient’ with ‘consumer’ to further muddy the waters). By blurring the differences between the kinds of mental distress experienced by Australians, the door is thrown open to all sorts of wild policy adventures and expensive solutions to peripheral problems, while obscuring the areas of most pressing need from public scrutiny and adequate resourcing.
The Headspace franchise, much lauded by the Commission, is an exemplar of confused priorities. These well-publicised and marketed, federally funded clinics will cost a staggering $263 million over seven years, yet they have failed to yield convincing health outcomes. ANU’s Professor Jeffrey Looi and colleagues have recently examined the cost-effectiveness of Headspace, concluding controversially that these federally funded ‘leviathans’ create service duplication, and actually place extra stress on state health budgets by funneling their clients into over-subscribed domestic psychiatric services.
The Commission places much faith in youth mental health ‘prevention’; a fashionable novelty which also lacks a robust evidentiary base. No amount of mental health checks for infants or embedded mental health teachers in schools will improve outcomes for schizophrenia. It is even conceivable that these experimental interventions might inadvertently generate pathology, particularly in the highly suggestible, social- media-savvy adolescent population, in which a mental illness diagnosis can be perversely considered a badge of honour.
The hot topic of suicide receives much prominence, but we should recall that previous grand schemes to reduce the prevalence of this tragic occurrence have made little difference. Many suicides, after all, occur in the absence of mental illness. There is only so much that counselling can offer someone who faces financial ruin or complete alienation from their family. A good first step might be for our governments to avoid the poverty caused by the unnecessary shutdowns of our economies in the face of a mostly non-fatal illness.
The report fails to stress the profound psychosocial disability associated with illnesses such as schizophrenia and bipolar disorder. Despite their relatively low prevalence, these conditions incur disproportionate costs in terms of healthcare, criminal justice and physical comorbidity. Patients with these illnesses can be difficult to engage and are often reluctant to take medications. The opportunity costs associated with the reduction in workforce participation for affected patients, families and carers deserve a greater chunk of the health budget than the Commission calculates. Untreated mental illness and substance misuse are the chief causes of rough sleeping. Homelessness is not fundamentally an issue of insufficient low-cost housing, as governments repeatedly suggest.
Almost $10 billion was spent on mental health in Australia in 2017-2018. Yet according the Australian Institute of Health and Welfare, growth in expenditure on public psychiatric hospitals has been decreasing since the early 2000s and is now going backwards. Some of this reduction has been offset by an increase in funding for outpatient services. But there cannot be a functioning mental health system without an adequate supply of acute, forensic, psychogeriatric and rehabilitation in-patient facilities, operated by a commensurately expanded psychiatric workforce. Australia ranks a desultory 26th out of the 34 countries in the OECD for psychiatric beds per 100,000 population. The report glosses over this deficit by declaring that bed numbers per capita have not reduced this century. The Commission notes elsewhere in their report that mental health presentations to emergency departments have risen by 70 per cent in the past five years, yet they seem reluctant to recommend expanding bed numbers to meet this surge in demand.
Speak to any emergency physician, paramedic or police officer and they will describe the chaos and aggression commonly associated with after-hours psychiatric presentations. They will bemoan the predictable and ubiquitous bed block that thwarts efforts to admit the person to a suitable ward. They will also complain about the devastating effects of ‘ice’ on the safety of staff and patients. Bizarrely, the Commission does not feel that the ice epidemic and its catastrophic and lasting psychiatric consequences warrant much specific discussion, but devotes pages to the evils of tobacco. We desperately need more dual diagnosis in-patient facilities to deal with this burgeoning public health crisis.
The Commission advances projects whose political capital exceeds their likely effectiveness. In their efforts to meet the needs of the ‘missing middle’, their vision for the future may actually limit therapeutic opportunities to those who really need them, while over-servicing the ‘worried-well’ at great taxpayer expense. In the words of the University of Queensland’s Professor Steve Kisely: ‘Mental Health deserves better than serving as a laboratory for the latest idée du jour.’
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Dr Carlos d’Abrera is a Sydney-based psychiatrist. These views are his own.
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