Towards a 21st century system of mental health care - an Australian approach

Our most precious natural resource, as individuals and as a nation, is our health. Sadly, in both developed and developing countries a major part of our health is sorely neglected - our mental health. Good mental health allows us to live longer, achieve more, have a better family life, more friends, and contribute to a safer and more productive society. Put simply, mental health means national wealth. We are increasingly coming to understand that mental ill-health lies behind a young woman’s concerns about her body image, behind bullying and youth violence, and behind binge drinking and drug abuse.

Mental ill-health weakens workplaces, burdens working families and drives the senseless loss of life from suicide. Our growing awareness of the widespread impact of mental ill-health on our lives has created overwhelming support for national action to break the silence around these issues, to end the neglect, and build a 21st century model of mental health care.

A 21st century approach to mental health is about solving the problems of needless disability and loss of life. Our current mental health care system, and its supports and services, are woefully inadequate. We need a new approach today, because every day here in Australia:

• Over 300 Australians with mental health issues will present in distress to emergency departments and be turned away without being referred to an appropriate service. Our current system has collapsed under the strain and keeps all but the most desperate at bay.
• Six Australians will die by suicide. Many more will attempt suicide or self-harm.
• Over 1000 years of healthy life will be lost to mental illhealth. This costs us up to $30 billion every year - three times the mineral resources rent tax.
• Australians are up to three times less likely to receive quality care for mental ill-health than for physical ill-health. This is healthcare apartheid.
• Thousands of Australians with severe mental illness are in our jails because there are no other options and they have not received the mental health care they needed, when they needed it.
• Thousands of Australians, mostly young people with mental illnesses, will sleep outside tonight because we don’t have adequate accommodation services to give them shelter.

These are not just numbers - they represent the pain and anguish of real people and real families. A 21st century approach to mental health must fix these problems and can provide real benefits to everyone.

What a 21st century approach to mental health will do

At the community level, a 21st century approach to mental health means that people understand what it means to be mentally healthy and are able to recognise, as they do with physical illnesses like heart disease and cancer, the earliest signs of mental ill-health. People need to feel comfortable about sharing their experience of mental ill-health with those close to them, and to ask for help if they need it. Currently,many people do not recognise when their mental health is failing and do not seek help. With the right information, everyone can be equipped with the knowledge and skills to respond to mental healthissues in a helpful way, just as we do now when someone sprains their ankle, has an asthma attack, faints or develops chest pain. A better understanding of mental health issues means that words like ‘nutter’, ‘schizo’ and ‘psycho’ will become as unacceptable as racist and sexist language is now. This is the antidote to the poison of stigma.

At the health care system level, a 21st century approach to mental health provides stigma-free comprehensive community-based mentalhealth care closely linked to the primary care system. This includes assertive mobile teams available 24 hours a day, just like all our other emergency services. This will stem the flow of people with mental health issues into our emergency departments and our hospitals.

Currently, Australians with serious mental illnesses have poorer access to quality physical health care and on average die 20 years earlier than expected, typically from suicide, cardiovascular disease, or cancer.

A 21st century health care system needs to deliver equity in access to mental and physical health care; these people need high quality physical health care so that their life expectancy comes to equal to that of the rest of the population.

Furthermore, this approach ensures that all people with persistent serious mental illness are able to live in a safe and secure environment, namely their own home. Stable housing is a basic human right; let’s finally correct this great failure of deinstitutionalisation.

A 21st century approach to mental health takes an active stance on preventive opportunities and tackles the key drivers of mental ill-health in childhood and youth, such as social disadvantage, child abuse, bullying, and poorly treated mental illness and addiction in the parents. Because the peak period for the onset of mental health difficulties that may well persist into adult life as serious mental illness is between 12 – 25 years193,194, a 21st century approach to mental health provides a stigma-free stream of care to young Australians that offers integrated, multidisciplinary expertise in a youth-friendly environment that creatively uses new technologies.

A 21st century approach to mental health sets targets for reducing the suicide toll and delivers a national suicide prevention strategy on the same scale as the campaign to reduce the road toll. Currently, suicide is the biggest killer of adults up to the age of 40. This is a public health scandal 40 per cent greater in magnitude than the road toll, and is hidden from public view by fear and shame. Let’s bring it out in the open.

Finally, a 21st century approach to mental health features strong investment in research, especially research into novel treatments. Only 3.5 per cent of today’s national health research budget goes to mental health research. This is another serious side effect of stigma and prejudice. Although we do have effective treatments, just like in heart disease, cancer and diabetes we always need to strive for safer and even more effective treatments, not only drug therapies, but novel psychological interventions and social care.

The 21st century approach in practice

Because I am most familiar with it personally, as one example of a 21st century approach that is already available to some people, I am going to present the youth mental health model that is slowly emerging around Australia. This model is built around two closely linked components: headspace, for young people with mild-to-moderate mental health issues; and EPPIC, for young people with emerging serious or complex mental illnesses.

The best way to grasp the 21st century nature of the approach represented by headspace and EPPIC is to think of that other 21st century advance - the iPhone. The breakthrough behind this modern icon is that it simply brings together in a single platform so many of the key tools or ‘applications’ we need to function in the modern world. It is engaging, efficient and hence popular; everyone wants one. headspace and EPPIC are based on the same simple idea - the one stop shop, where the main applications that young people need to protect or recover their mental health can be found.197 There’s a range of applications available: youth-friendly doctors; allied health professionals; drug and alcohol clinicians; educational/vocational expertise; and other back-up programs such as community awareness and outreach. headspace is an enhanced form of primary care based in the heart of the community, providing real expertise without stigma or strings attached.

Young people with more complex or severe forms of mental ill-health need access to additional applications such as hospital or residential care, 24-hour home-based interventions, access to specialist psychiatrists or specialised clinics - hence the need for an integrated back-up system for headspace. This back-up is EPPIC198, which provides more specialised care aimed at maximising recovery from serious mental illnesses, especially the psychotic disorders, during the challenging early years of illness when great therapeutic tenacity and sophisticated scaffolding is essential.

EPPIC has been so successful in promoting early detection and access, and reducing the disability, mortality and costs of potentially serious mental illnesses like schizophrenia, that it has been implemented in hundreds of  locations across the developed world.199 Of course there are other potentially serious disorders such as severe mood disorders, personality disorders, eating disorders and substance use disorders which need to be covered by a back-up system like this in support of headspace and other primary care settings.

Just as the iPhone was made possible by innovative engineering, so too the 21st century model of youth mental health represented by headspace and EPPIC is based on the latest in smart design and consumer-driven understanding of young people and their mental health. So what are these distinctive innovations? Let’s start with the youth focus. Traditionally mental health services have been divided between services for under 18s and over 18s. This makes no sense - we know that the emerging adult phase of 12–25 years is distinct from early childhood or older adulthood. headspace and EPPIC focus on this age range, with a youth-friendly culture that can engage young people, and offer flexible and agile responses.

Early intervention is a key principle, which means as soon as problems emerge they are recognised and responded to. This does not mean early use of medications or an excessively narrow clinical approach, but rather a stepwise pathway of care. Early intervention is an established principle in general medicine, but in mental health it has only recently broken into the mainstream.200 New technologies, especially internet-based information and therapies are a feature, and headspace and EPPIC seek to work in collaborative and complementary partnership with other innovative youth mental health services like ReachOut! and young beyondblue.

Families are welcomed and supported as a key resource in a young person’s recovery. Youth participation is a hallmark - headspace and EPPIC are services that innovate new ways of being accountable to young clients and incorporating their ideas in further service improvements. Finally, headspace and EPPIC are optimistic, with a recovery focus. There is real faith in the resilience of young people while ensuring they still receive the most expert help. The aim is to provide some of the extra scaffolding and specific interventions that so many young people need to lead healthy and fulfilled lives.

First steps towards creating this 21st century approach

All of us - governments, mental health workers and the wider community - have a common interest and important roles to play in creating a 21st century approach to mental health care here in Australia. The federal government’s recent allocation of 1.5 billion of much needed new investment in mental health is an important initial step towards transformational reform. Although the scale of this initial reform investment does not yet fully reflect the level of unmet need, the government’s package is nonetheless well balanced, smartly targeted and lays the groundwork for future reforms. The package contains measures to reduce the burden of mental illness on children and young Australians through prevention and early intervention and to improve the social inclusion and economic participation in the middle and later years of people with severe and enduring mental illness.

Some of these measures, such as the scaling up of headspace from the current 30 centres nationally to a total of 90 centres, and the first stage of a national rollout of the EPPIC model of care, are groundbreaking and will deliver better health, social and economic outcomes as well as radically changing the culture and design of Australia’s mental health system. Hard research evidence shows these programs will greatly reduce the numbers of young people ending up on disability support.

However, care needs to be taken to ensure that this new funding is focused where it has optimal prospects for improving lives and achieving significant changes in culture and practice. Much is riding on the successful rollout of the EPPIC model, so it is imperative that these new services have full fidelity to the EPPIC model, and that they are led by enthusiastic, capable change agents and are given mandates appropriate to the level of funding they are allocated. This will require specific governance, as was achieved with the national rollout of headspace. The result there has been rapid scaling up of a model with benefit to tens of thousands of Australians, and this long-overdue creation of a nationwide stream of mental health care specifically designed for young people will benefit many thousands more.

More broadly, to close the huge gap in access and quality compared with physical health care, the government’s investment package must be the first instalment of a 10-year program of scaling up of capacity in Australia’s system of mental health care. The ball is now in the court of the state and territory governments. The federal government’s package is targeted at strengthening primary and community-based care - action from the premiers is still required if acute and hospital-based care are also to get the urgent attention they need. A credible national reform and investment plan that adds state and territory investment to the federal mental health package is now crucial to successful reform.

Australia’s mental health professionals should embrace the opportunity to become change agents by engaging positively and creatively with these new measures. We should be ready to partner with government and the community in sharing the responsibility and accountability for achieving real outcomes. Success for this round of funding will help secure future investment, and as the fiscal climate improves, to comprehensively fix Australia’s mental health system. As a sector, we need to unite and work cohesively to achieve the changes our chosen field so desperately needs.

At the community level, we can all challenge and defeat stigma whenever we encounter it. It’s vital that every person who has been touched by mental ill-health share these experiences in an open and unashamed way - that’s the first step. We can all talk openly about both mental health and mental ill-health with family members, friends and colleagues. Consider doing a mental health first aid course to increase your skills and confidence about responding to the mental health needs of the people around you. We can also donate: philanthropists large and small can support mental health research, innovation and advocacy. And all of us who have been let down by our current system can let people know why they insist on a 21st century approach to mental health for all age groups by writing to the newspapers, ringing talkback radio, arranging to meet their local MP, or forming a local action group. We need to make our message heard - Australians deserve a better deal, and the community has a critical role to play in continuing to express strong support for mental health reform as one of our most pressing national priorities.

Finally, it is heartening to see how our community’s concerns and our increasing expectation that we should have access to the same quality of care for our minds as we do for our bodies has now been reflected by government action. Mental health reform now has champions across the Australian parliament, with politicians of all parties and, notably, all the leaders and the key independents committed to tackling this long neglected but vitally important challenge. Australians applaud this tri-partisan political leadership, which puts mental health above politics. I sense we have passed the tipping point; our calls for action have been heard, and our need for a new approach to mental health is now matched by our determination and the first steps towards a new capacity to deliver it. If all of us play our parts in this reform agenda, together we have every chance of creating the 21st century system of care that we so desperately need.