Comment

Still hoping for a change

Australia's mental health system is not improving quickly enough.

Illustration: Pat Campbell
Illustration: Pat Campbell 

Obsessive Hope Disorder is a newly discovered malady afflicting those with undeserved optimism in relation to mental health reform in Australia. It is also the playful title of a new report, released today, to commemorate the 30th anniversary of David Richmond's inquiry into Health Services for the Psychiatrically Ill and Developmentally Disabled, which provided a blueprint for mental health reform in 1983. The report also marks 20 years since Brian Burdekin's Human Rights and Equal Opportunity inquiry into the Human Rights of People with a Mental Illness.

Despite the impact mental illness has on everyday life for so many Australian families, there is a real paucity of systemic analyses and research. This makes OHD one of the few independent reports on mental services in Australia. OHD brings together multiple researchers, methods and dozens of contributors to evaluate Australia's intergenerational progress in meeting the needs of people with a mental illness. How different really are things?

What we have found is really the answer to why there are still almost-daily reports on the deficiencies of the mental health system - on why we continue to hear about ''people falling through cracks''.

We don't have cracks, because we do not have a system of care. We have not built the foundations for a system of care. Getting mental health care is a last-chance lottery. Your chances are dependent on where you live, your income and your determination. Despite 20 years of national reform efforts we do not have a national service framework, a national model of care or a workforce strategy. After deinstitutionalisation, Australia still spends more than half a billion dollars a year supporting more than 2000 beds across 16 public psychiatric institutions.

Most significantly, since Richmond's report 30 years ago, the life expectancy of people with severe mental illness has not improved. People with schizophrenia have the same life expectancy as remote indigenous Australians. This is the starkest measure of public policy failure in mental health care. Some of the most revealing research included in OHD was carried out by the Centre for Mental Health Research at the ANU, which carried out a systemic review of 32 independent, statutory authority reports on mental health carried out across Australia just between July 2006 and December 2012.

This review, perhaps unsurprisingly, revealed common themes. Consumers currently have inadequate access to mental health services right across the spectrum, from prevention to rehabilitation and recovery. Their care is frequently compromised by inadequate inter-agency co-operation. Consumers are not always treated with dignity and respect and in some instances subject to discrimination. Quality supported accommodation is very difficult to find.

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There are gaps in the training of mental health, health and non-health staff providing services to people with a mental illness, which compromises quality of care. All these problems are magnified for particular groups, particularly those in the forensic/justice system, those in rural areas, young people, people of indigenous heritage or from culturally and linguistically diverse backgrounds and children at risk.

The news is not all grim, of course. OHD also presents the findings of more than 1000 responses to community surveys on experiences with mental health services. These surveys reveal that more Australians felt able to access services than when the same survey was conducted in 2004, more people felt they were given the right amount of information about their condition or treatment and more people said they felt engaged in decision-making about their own care.

But perhaps most revealing in the OHD report are the 80 perspective pieces submitted by people working in or using Australia's mental health system. While many contributors acknowledge important progress, the vast majority agree that in terms of mental health reform, Australia has a long way to go. There are still far too many stories that document service failure at a systemic level, with people either being unable to access the right care at the right time or finding poor quality of care.

The overall health budget continues to increase at a faster rate than the mental health budget, meaning mental health's share of funding is in decline, exacerbating the disparity between the resources available and the burden of disease. There has been a chronic lack of support for, indeed neglect of, our workforce. Contributors also point to the need for better accountability at all levels, permitting quality improvement feedback for service providers and reassurance to the community at large that it has a mental health system on which it can rely.

There is a cure for Obsessive Hope Disorder, which the report reveals. Successful treatment relies on four factors. People with a mental illness need the same parity of access to and quality of care available to Australians with other major health conditions regardless of origins, income or postcode. Mental health services must be evidence-based, focused on the earliest intervention, continuity of care and linkage to social supports to enable recovery with dignity.

Australians need to be aware of the actions they can take to sustain and improve their mental health and the resilience of their communities. Finally, mental health needs to be seen and understood in relation to a bigger picture; its contribution to successful parenting, schooling, urban planning, workplace relations, national productivity and more - mental health is part of the nation's mental wealth.

For this treatment to be effective, Australia needs root-and-branch reform of roles (who does what), of practice (to ensure we fund evidence-based services), and of governance and accountability (to ensure we know what we are doing). We must put in place the foundations for sustainable improvement, not just announce one more piecemeal new service.

The report shows that, overall, it is unlikely that people with a mental illness are much better off than they were in 1983. In any other area of health, this would be a scandal.

Sebastian Rosenberg is a senior lecturer at the Brain and Mind Research Institute, University of Sydney.