Misleading claims in the mental health reform debate

The “other systematic review” cited in the 2007 Tracking Tragedy report is the 2006 report of the National Confidential Inquiry into Suicide and Homicide by People with Mental Illness (in England and Wales). This does not support Mendoza's claim. Only 27 per cent of suicides had followed any current or recent contact with the mental health system. Twenty per cent of suicides among these patients occurred within three months of discharge (5.4 per cent of total suicides), but only 18-22 per cent of these were judged preventable, representing only about 1 per cent of all suicides in England and Wales.

Unquestionably there is a need to improve discharge planning and follow-up - for many reasons, not just because of the risk of suicide. However, this is not relevant to the majority of suicide cases.

Mendoza has had the unwitting assistance of GetUp in misleading the Australian public. However, when one of us (JJ) explained why Mendoza's claim is incorrect, GetUp's response was “we'll adjust our future communications accordingly”, but inexplicably it “won't however be removing anything from the website or issuing any correction statements”. GetUp focuses on “giving everyday Australians opportunities to get involved and hold politicians accountable, on important issues”, yet it is unwilling to be held accountable for misleading everyday Australians about mental health, and its website carries information it knows to be incorrect.

Claim: 750,000 young Australians are denied desperately needed mental health services

McGorry has repeatedly claimed there is a hidden waiting-list of 750,000 young Australians who are denied access to much-needed mental health services. His website refers to “the waiting list of 750,000 young Australians currently locked out of the mental health care they and their families desperately need”.

In his submission to the Senate inquiry into COAG health reforms, McGorry explicitly linked the unmet need to insufficient funding for headspace and EPPIC. He made similar claims at a hearing (PDF 442KB). The Senate report (PDF 1.32MB) quoted his testimony uncritically. Others have also echoed his claim uncritically, including Lesley Russell (PDF 93KB) from the Menzies Centre for Health Policy. Furthermore, McGorry's claim has been implicitly endorsed by the Coalition's Real Action Plan for Better Mental Health.

McGorry's 750,000 claim is based on the 2007 National Survey of Mental Health and Wellbeing (NSMHW), which found that 671,000 (26 per cent) 16-24-year-olds experienced a mental disorder in the previous year, and only 23 per cent of them accessed treatment. McGorry's 750,000 figure, encompassing 12-25-year-olds, the focus of headspace, seems a reasonable estimate of people in that age range with untreated disorders.

However, diagnosis, particularly in surveys, is not the same as treatment need, contrary to the usual interpretation. According to Scott Henderson (an architect of the original NSMHW) and colleagues:

having symptoms, even at case level, is necessary but not sufficient to justify treatment … it is irrational to suggest that one in five adults need treatment for a case-level mental disorder. (p204)

Leading US psychiatric epidemiologists have similarly argued that prevalence rates in surveys do not represent treatment need. Robert Spitzer, a key player in the development of the DSM (Diagnostic and Statistical Manual of Mental Disorder), published a paper with the title: “Diagnosis and need for treatment are not the same”. The main reason is that many cases are not particularly serious. According to Darrel Regier (Vice-Chair of the DSM-V Task Force) and colleagues: “most episodes of mental illness are neither severe nor long-lasting”.

There is a strong bias towards treatment of people who most need it. In the NSMHW, only 17 per cent of young people with disorders (PDF 308KB) had severe disorders, 35 per cent moderate, and 48 per cent mild. Furthermore, 51 per cent of young people with severe disorders accessed treatment. And according to Gavin Andrews (another key player in the NSMHW), many cases of mental disorders are transient but the extent of remission is usually underestimated.

The gap between prevalence and help-seeking in young people is largely due to high rates of substance use disorders (particularly mild cases of harmful alcohol use) with low rates of help-seeking (particularly by young men). The relatively low threshold for diagnosis of harmful alcohol use - which has a high rate of spontaneous remission - inflates the prevalence of mental disorders. This was recently discussed in some detail by one of us (MR).

Undoubtedly some untreated young people would benefit from treatment. However, for many of them, GP services would be more appropriate than specialist services like headspace or EPPIC. Indeed, according to Andrews and colleagues, “in Australia as elsewhere, the GP is the key to treatment for most people with mental disorders”.