A problem worth solving #2: We too often fail to provide mental health consumers with the right services at the right time.

Inspired by Victoria's Royal Commission into Victoria’s Mental Health System, and my lived experience of mental illness and of the system, these research papers provide the short and (not so) sweet low down on the remaining problems worth solving. Often invisible, but oh so real, mental illness remains a neglected health issue. The system is overloaded and we must find alternative, workable solutions for 'consumers' as they meet one of life's greatest challenges.

Australia is a rich, prosperous country. It has a mental health services budget of at least $10 billion per year. About $400 per person, per year.?

And Australians are not ignorant; with most of us agreeing that large expenditure on mental health is justified, with 75% agreeing that mental health should be a top priority of public policy.

But what are we doing with good intentions and all that money?

This only emphasises the need for consumers to get the right services at the right time.

Unfortunately, there has never been enough political will to sit down and map out a consistent and thorough national strategy which speaks to the full spectrum and transient nature of mental illness. Rarely the political cooperation to adequately address the cracks consumers so often fall through, or the early signs left ignored.

And unfortunately, for a country with one of the most sophisticated and well funded health care systems in the world, we too often fail to deliver consumers the right services at the right time.

Let's begin by learning about where funding is coming from.

Australia has an exceedingly complex funding arrangements for the provision of mental health care. This leads to unclear roles and responsibilities, and an inefficient service; a patchwork of solutions and a duplication of efforts.?

And, as noted by the Australian Medical Association: "There is no agreed national design or structure that facilitates prevention or proper care for people with mental illness."? This is so despite there being a dedicated National Mental Health Suicide Prevention Plan which attempted to establish a national approach for collaborative government effort.?

Part of the reason for the persistent complexity is that health care is primarily an issue and function for the states, however, in practice, is largely funded by the commonwealth (whether directly or indirectly). A constant tension arises between who gets the money, how much, and which new agenda will be pursued next.?

And, even for consumers with chronic mental health problems, it is notoriously difficult for consumers to qualify for the NDIS through having a ‘psychosocial disability’ as they need to prove the disability is permanent. This is difficult, as their symptoms tend to fluctuate and are usually episodic. While some may argue a consumer's disability is only ‘part time’, and thus to not require the same level of support as other disabilities, they fail to appreciate the wholly debilitating nature of the inconsistency, and how society has not matured to accommodate for that inconsistency.

Sometimes the lift is more appropriate than using the stairs.

Government funding also tends to focus on ‘high risk’ consumers with serious psychiatric illnesses, as opposed to those presenting with emerging or moderate mental illness.

Above: The National Mental Health Plan adopts a ‘stepped approach’ to service delivery and resource allocation, and allocates the budget accordingly.

It is not challenged that intensity of treatment should be varied according to the patient need. However, this 'stepped approach' usually fails to allocate funding and referral pathways to ‘at-risk’ groups and consumers with early symptoms of complex mental health issues.?

However, under this system the initial assessment of risk (and a consumer's mental health needs) is often conducted by time poor GP's, duty managers, case managers, or inexperienced staff members with insufficient training or psychological knowledge. As the patients needs become more pronounced, or the underlying nature of the worker's condition becomes more obvious, the consumer is then referred on, typically on several occasions.

One ponders a more efficient system whereby psychiatrists, clinical psychologists, and perhaps even peer workers (those with lived experience of mental illness), are introduced to the worker at an earlier stage, and given more funding to the required analysis sooner rather than later. This may save money in not having to 'walk up the steps' (ie paying multiple practitioners for services which were ultimately not effective) and perhaps reduce the severity of the underlying mental illness by more accurately addressing it soon. (and reduce the level of treatment required later).

Unclear referral pathways and practitioner roles lead to a revolving door of crisis management.

In Victoria, mental health care services are poorly coordinated and not staffed adequately. Scattered throughout Melbourne and regional Victoria are various government-funded services operating independently. Meanwhile, non-government organisations provide support roles and attempt to stop people from falling through the gaps, but acquiring funding is a constant battle.?

Further, unclear referral pathways and inadequate coordination can result in consumers being bounced around the system or hitting dead ends as they desperately seek help.?

Above: The formal ‘structure’ of the mental health care system is outlined in the above diagram. However, access, referral pathways, and the communication between these services is poor.?

Ultimately, there are too many difficult cases and not enough accountability. As a patient gets handballed between various services, the practitioners tend to lose focus on their particular role and responsibilities. This disorganisation is not only bad for the consumer but an enormous waste of scarce resources.

The Victorian Government has acknowledged that the deficiencies in the mental health care system can create a 'revolving door effect'. It acknowledges that the system is crisis-driven, as opposed to being focused on early intervention, and that the interventions are failing to address the underlying causes of mental illness.?

Above: Key figures regarding the Victorian Mental Health System.

In order to address the crisis-driven response, we need to find more ways to empower consumers to cope and manage their mental illness, and this starts with clearly outlining the treatment and support available to them.

But what about Headspace?

You may be aware of the Commonwealth government's flagship mental health product 'Headspace', with 114 centres around Australia. It has poured an extraordinary amount of money into these centres and their programs.

Headspace helps thousands of young Australians struggling with life. While mental health services are the primary offering, clients also receive physical health, sexual health, addiction rehabilitation, vocational services, dietary counselling and other general assistance.

However, Headspace recently told the Commission that young people wait on average 10.5 days for their intake session, 27.8 days for their first therapy session and 11.8 days for subsequent therapy sessions.?

If you wanted to visit your GP with an alarming issue, how would you feel having to wait at least 10 days? You would probably go to the emergency department.

What about if you were a young person experiencing psychological distress, how does waiting 27.8 days for your first personalised interaction with a clinician sound? Pretty bad, right? And even worse, you might think that it is not as serious after all, or that your struggles cannot be helped anyway?

But what about Headspace's actual services? Are they effective?

Strangely, there is scarce data on this issue, especially since the 2015 review. It found only 23% of Headspace’s clients experienced an improvement in their psychological distress levels after contacting their services. That is a pretty average outcome for the Australian Government's single biggest investment in mental health. Furthermore, a significant proportion of headspace clients receive only one or two occasions of service.

So does more funding equal better outcomes??

Not necessarily. Some studies have suggested that neither Australia, nor any other comparable country, has managed to improve the mental health of its population by simply increasing the provision of mental health services.

However, that does not mean that treatments do not work; for example antidepressants for depression usually do work for people with more severe depression and anxiety. We also know a psychological therapy programme is only really effective over 6 or more sessions.

This only emphasises the need for consumers to get the right services at the right time. For example, a consumer presenting with dynamic and inconsistent symptomology should be assessed and monitored by a psychiatrist for complex illnesses such as Bi Polar disorder, and not a GP. Or, where past trauma is detected, trauma-informed practitioners must be relied on.?

We need to increase the availability of self-help options for people with milder problems, yet provide them with a clear blueprint for where to go should their symptoms get worse, along the full suite of their treatment options. Consumers should be informed and empowered with even the mildest of symptoms.?

To address the efficiencies of our current mental health care system, the government has set up a national database on service delivery, performance and outcomes. The aim is to use this database to critically evaluate whether the services provided are making a difference to national mental health. We eagerly await this data.

About the Author: Heath works as a personal injury lawyer (including psychiatric injury) and as a volunteer peer worker in the mental health industry. With lived experienced of mental illness, he is devoted to progressing mental health care and advocating for consumers.

?'I once lived in a dark house with Bi-Polar disorder. I have since fixed the lights, and they have moved out. I now carry a torch at all times. If we cohabitate again, I will not be alone, and they will know the house rules. I am in control.'

Are you experiencing psychological distress?

?Support is available!?I am not a doctor or clinician. I write from my own experiences and research only. If you are experiencing psychological distress please reach out to your treating practitioner or one of the resources below. You have more options than you think.

Lifeline Australia —?Call 13 11 14 — Lifeline is staffed by volunteer telephone crisis supporters who are ready to take calls 24/7.

Carers Australia —?Call 1800 242 63 — Counselling, emotional and psychological support services for carers and their families.

Relationships Australia —?Call 1300 364 277 — Relationship support services for individuals, families and communities.

NACCHO —?Call 02 6246 9300 — National Aboriginal Community Controlled Health Organisation.

Suicide Callback Service —?Call 1300 659 467 — Free, professional 24/7 telephone and online counselling to people who are affected by suicide.

Mensline Australia —?Call 1300 789 978 — Supports Australian men and boys dealing with family and relationship difficulties. 24/7 telephone and online support.

Beyond Blue —Call 1300 22 4636 — Telephone and online support for those experiencing depression or anxiety.

Butterfly Foundation —?Call 1800 33 4673 — Information, counselling and treatment referral for people with eating disorders.

Kids Helpline —?Call 1800 551 800 — Free, private and confidential 24/7 phone and online counselling service for young people aged 5 to 25.

1800 RESPECT —?Call 1800 737 732 — Counselling and support service for people impacted by sexual assault, domestic or family violence and abuse.

Open Arms —?Call 1800 011 046 — Veterans & Families 24/7 Counselling and support services.

QLife —?Call 1800 184 527 — Australia-wide anonymous, LGBTI peer support and referral services.