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Australia's Fifth National Mental Health Plan required governments to report, not only on the progress of changes to mental health service delivery, but to also plan for services that should be provided. Future population demand for treatment and care is challenging to predict and one solution involves modelling the uncertain demands on the system. Modelling can help decision-makers understand likely future changes in mental health service demand and more intelligently choose appropriate responses. It can also support greater scrutiny, accountability and transparency of these processes. Australia has an emerging national capacity for systems modelling in mental health which can enhance the next phase of mental health reform. This paper introduces concepts useful for understanding mental health modelling and identifies where modelling approaches can support health service planners to make evidence-informed decisions regarding planning and investment for the Australian population., Competing Interests: Declaration of Conflicting InterestsThe authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Objectives: This paper compares the evolution of the psychosocial sector in two Australian regions pre and post introduction of the National Disability Insurance Scheme - a major reform to the financing, planning and provision of disability services in Australia, intended to create greater competition and efficiency in the market, and more choice for service users., Methods: We used a standardised service classification instrument based on a health ecosystems approach to assess service availability and diversity of psychosocial services provided by non-government organisations in two Primary Health Network regions., Results: We identified very different evolutionary pathways in the two regions. Service availability increased in Western Sydney but decreased in the Australian Capital Territory. The diversity of services available did not increase in either Primary Health Network 4 years after the reform. Many services were experiencing ongoing funding uncertainty., Conclusion: Assumptions of increased efficiency through organisational scaling up, and a greater diversity in range of service availability were not borne out., Implications: This study shows the urgent need for evaluation of the effects of the NDIS on the provision of psychosocial care in Australia. Four years after the implementation of the NDIS at vast expense key objectives not been met for consumers or for the system as a whole, and an environment of uncertainty has been created for providers. It demonstrates the importance of standardised service mapping to monitor the effects of major reforms on mental health care as well as the need for a focus at the local level.

Objective: To explore the impact of proposed expansion of Australia's Better Access Program and alternatives., Method: Australia's Better Access Program, which costs taxpayers AUD28 million every week, is once again the focus of national political and professional scrutiny. The current Medicare Review calls for a massive expansion. This article reviews its history and context. It challenges the recommendations made by the Review. It also provides three scenarios which model the proposed expansion, with significant implications for consumers, the workforce and taxpayers., Results: The capacity for continued growth of the Program is demonstrated. At the same time., Conclusion: There has been recent evidence suggesting the impact of the programme on key mental health indicators in Australia has been negligible, while also perpetuating social, economic and geographic inequities. While advocacy for increased mental health expenditure is easy, active reform of existing patterns of service is hard. Nonetheless, this article suggests that it is timely to reconsider the structure and scale of this AUD1.5 billion annual investment, which has the potential to grow to up to AUD10 billion per year over the next decade. In our view, it is possible to make the programme fit for purpose in the 21st century. Specifically, the principal focus could be shifted to better support the interdisciplinary, team-based care that responds to the needs of people with more complex mental health problems. An increased role for incorporation of digital technologies alongside clinical services is part of the mix. The combination of changes suggested would suggest that the programme could be rebranded as 'Better Access and Quality'. This shift in the primary focus of the clinical programme away from brief interventions for those with lower needs to more sustained interventions with those with greater impairment requires new service models, as well as new regionally based health care systems. In addition, we propose specific outcomes that can be measured regionally, and collated nationally, to properly evaluate the impact of the programme and drive systemic quality improvement.

A doubling of Australian expenditure on mental health services over two decades, inflation-adjusted, has reduced prevalence of neither psychological distress nor mental disorders. Low rates of help-seeking, and inadequate and inequitable delivery of effective care may explain this partially, but not fully. Focusing on depressive disorders, drawing initially on ideas from the work of philosopher and socio-cultural critic Ivan Illich, we use evidence-based medicine statistics and simulation modelling approaches to develop testable hypotheses as to how iatrogenic influences on the course of depression may help explain this seeming paradox. Combined psychological treatment and antidepressant medication may be available, and beneficial, for depressed people in socioeconomically advantaged areas. But more Australians with depression live in disadvantaged areas where antidepressant medication provision without formal psychotherapy is more typical; there also are urban/non-urban disparities. Depressed people often engage in self-help strategies consistent with psychological treatments, probably often with some benefit to these people. We propose then, if people are encouraged to rely heavily on antidepressant medication only, and if they consequently reduce spontaneous self-help activity, that the benefits of the antidepressant medication may be more than offset by reductions in beneficial effects as a consequence of reduced self-help activity. While in advantaged areas, more comprehensive service delivery may result in observed prevalence lower than it would be without services, in less well-serviced areas, observed prevalence may be higher than it would otherwise be. Overall, then, we see no change. If the hypotheses receive support from the proposed research, then implications for service prioritisation and delivery could include a case for wider application of recovery-oriented practice. Critically, it would strengthen the case for action to correct inequities in the delivery of psychological treatments for depression in Australia so that combined psychological therapy and antidepressant medication, accessible and administered within an empowering framework, should be a nationally implemented standard.