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Australia was one of the first countries to develop a national mental health strategy. This article reviews the progress of reform, outlining some strengths, weaknesses and prospective challenges. [ABSTRACT FROM AUTHOR]

Objective: To describe a recent process by which mental health service sector leaders identified key elements of strategic, systemic and structural mental health reform. These elements could guide an incoming Federal government. Method: The paper describes the process undertaken by the Sydney Mental Health Policy Forum between 2019 and 2022. This work generated principles, key domains and finally a set of actions. Results: Five immediate actions were identified that are cost neutral or require minimal investment. Five further actions requiring realignment of existing funds and/or new funds were also identified. Conclusions: The task of mental health reform in Australia is both large and overdue. Continued investment in fragmented or piecemeal programmes and services will not propel desired change. Reform must facilitate new regional control of planning, funding and responding to community mental health needs. The actions identified by the Forum set out a menu of opportunities to guide reform over the life of the next Parliament, starting now. [ABSTRACT FROM AUTHOR]

Objective: This study set out to present data on out-of-pocket payments for Medicare mental health services provided by general practitioners (GP), psychiatrists, clinical psychologists and other psychologists, to explore how much is spent on out-of-pocket payments for mental health; if any trends could be seen; and what variations exist across regions. Methods: We performed secondary analysis of publicly available data on Medicare-subsidised GP, allied health and specialist health care across Australia. We merged and interrogated data covering the period 2013–19 and 2019–21 to create a data set covering eight full years of Medicare mental health services, arranged by profession and by region. Results: Out-of-pocket payments for mental health care in Australia have been rising consistently over the period 2013–21, at a considerably faster rate than overall expenditure on mental health care. There is wide variation in out-of-pocket payments depending on where you live. Conclusions: The impact of out-of-pocket payments on community access to mental health care is growing. This has implications, especially in poorer communities, for access to care. This should be an important consideration taken as the Australian Government considers next steps in national mental health reform, including the Better Access Program, currently under evaluation. What is known about the topic? A$35 m is spent on Medicare mental health services every week but there has been little research on the out-of-pocket payments charged to Australians. What does this paper add? Looking at Medicare data from 2013 to 2021, this paper answers three main questions: how much are out-of-pocket payments for mental health in Australia; what trends can be seen; and what variations exist? What are the implications for practitioners? Medicare's Better Access Program is under current review and this research can help practitioners, funders and policy-makers understand the significant investment made in mental health services. [ABSTRACT FROM AUTHOR]

Globally, tertiary education has been greatly affected by the Covid-19 crisis. In this essay we explore the impact of the pandemic on this educational sector in an Australian setting; specifically, we discuss how the Research School of Population Health at the Australian National University adjusted and adapted to the changing circumstances arising from the pandemic. In this respect, two adjustments (both described in detail in the text) in the way mental health education was delivered at the School were proposed to mitigate the impact of Covid-19 and enhance the university's capacity to provide quality public health education to students. Thus, this essay shows that it is possible to design educational interventions that surmount the challenges posed by the pandemic. In addition, educators may use the examples cited in this paper to guide them to respond appropriately to the challenges that have arisen in terms of health education due to Covid-19. [ABSTRACT FROM AUTHOR]

Background: The right to the highest attainable standard of mental health remains a distant goal worldwide. The Report of the UN Special Rapporteur on the right of all people to enjoyment of the highest attainable standard of physical and mental health pleaded the urgent need for governments to act through appropriate laws and policies. We argue that Australia is in breach of international obligations, with inadequate access to mental health services, inconsistent mental health legislation across jurisdictions and ongoing structural (systematic) and individual discrimination. Discussion: Inadequate access to mental health services is a worldwide phenomenon. Australia has committed to international law obligations under the Convention on the Rights of Persons with Disabilities (CRPD) to 'promote, protect and ensure the full and equal enjoyment of all human rights and fundamental freedoms by all persons with disability, with respect to their inherent dignity'. This includes people with mental health impairment and this convention includes the right to 'the highest attainable standard of mental health'. Under the Australian Constitution, ratification of this convention enables the national government to pass laws to implement the convention obligations, and such national laws would prevail over any inconsistent state (or territory) laws governing mental health service provision. Summary: The authors argue that enabling positive rights through legislation and legally binding mental health service standards may facilitate enhanced accountability and enforcement of such rights. These steps may support critical key stakeholders to improve the standards of mental health service provision supported by the implementation of international obligations, thereby accelerating mental health system reform. Improved legislation would encourage better governance and the evolution of better services, making mental health care more accessible, without structural or individual discrimination, enabling all people to enjoy the highest attainable standard of health. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Objective:: The objective of this study was to present an assessment of Australia's mental health system performance, within its social context, by comparison with other countries.Method:: A review of existing literature and databases from both Australia and overseas was undertaken. Systems permitting international comparison of mental health and its social context are few. The review is limited in scope.Results:: Although Australia was one of the first nations to develop and adopt a national mental health policy (in 1992), the data that are available suggest that we are not World leaders across the identified domains.Conclusions:: While international benchmarking can play an important role in fostering quality improvement, there are only limited mental health or social system performance data sources to utilise. It would be desirable for a more systematic international process to be established to review existing approaches and design a new multilateral strategy. It would be important that this new strategy reflected the full experience of mental health and its broader social context. [ABSTRACT FROM AUTHOR]

Objective: To consider the changing profile of Australia's mental health workforce and the implications, particularly for specialist psychiatry services.Method: We analyse data from a national collection that describes changes in the workforce over a decade, to 2017-2018.Results: While single practitioner-based psychological services flourish, other areas of more complex and team-based care are struggling to remain relevant. Psychiatry and mental health nursing, two areas that previously led Australia's response to complex mental illness, are under enormous pressure.Conclusion: The shifting balance of specialised mental health workforces is affecting the mental healthcare available in each region of Australia. Questions arise regarding the desired or optimal mix of professionals we wish to deploy. What roles should each professional group play and how should they work together? What does this mean for how various groups should be trained and paid? These data challenge the role specialist psychiatry wishes to play in leading reform. Current mental health reforms risk foundering should psychiatrists fail to take up the challenge of leadership. [ABSTRACT FROM AUTHOR]

The implementation of activity-based funding (ABF) in mental health from 1 July 2013 has significant risks and benefits. It is critical that the process of implementation is consistent with Australia's cherished goal of establishing a genuine and effective model of community-based mental health care. The infrastructure to support the application of ABF to mental health is currently weak and requires considerable development. States and territories are struggling to meet existing demand for largely hospital-based acute mental health care. There is a risk that valuable ABF-driven Commonwealth growth funds may be used to prop up these systems rather than drive the emergence of new models of community-based care. Some of these new models exist now and this article provides a short description. The aim is to help the Independent Hospital Pricing Authority better understand the landscape of mental health into which it now seeks to deploy ABF. [ABSTRACT FROM AUTHOR]

The article informs that Royal Commission into Aged Care Quality and Safety's interim report found significant over-prescribing of psychotropic medication and over-reliance on chemical restraint in aged care homes. It mentions that suicide was the leading cause of death among people between 15 to 49 years of age in Australia; and Budget 2020 made much of the so-called ‘doubling' of rebatable Medicare psychology sessions under the Better Access Program.

Purpose – This article aims to describe the process by which the new NSW Government executed its election promise to establish a Mental Health Commission for NSW. Design/methodology/approach – This case study draws on observations of the author who was expert facilitator to the Taskforce to establish the new NSW Commission. The paper synthesises the work of the Taskforce, the input of a consultation process that engaged more than 2,000 people, through six state-wide community fora, online survey and other means. In describing the nature of the new NSW Commission, the paper will also reflect on key learnings from the Taskforce's interactions with other mental health commissions, including in New Zealand, Western Australia and Canada. Findings – Widespread concern about the lack of access to quality mental health care was reflected in broad support for a new Mental Health Commission. Opinions varied about how such a new body could be effective. Strong bipartisan political support is key. Also critical is ensuring the new body has sufficient legislative power and reach. Research limitations/implications – This paper relies on the observations of a key participant in a reform process. This brings the limitations of potential bias as well as the strength of understanding that is difficult for outsiders to access. The actual impact of the new NSW Mental Health Commission will only become apparent following its 1 July 2012 start-up. Practical implications – Many jurisdictions are turning to specialised governance models, such as a Commission, to drive mental health reform. This paper identifies some of the key issues to consider in pursuing this strategy. Social implications – Commissions need to have strong engagement with consumers, carers, service providers and the general community. This paper highlights some key issues in building these links. Originality/value – The work of the Taskforce to Establish a NSW raised a range of issues relevant to any mental health reform process. Given the level of community concern about mental health care, these are important lessons. [ABSTRACT FROM AUTHOR]

Objective: In this second and final part of this series about mental health commissions, we consider the extent to which it is possible to find hard evidence that these new structures really can drive mental health reform. Four key domains of improvement are established for the purposes of this review: do commissions lead to better resources, better services, better accountability and better stakeholder engagement? A review of the evidence from both Australia and overseas is presented. The article also considers how the commissions, federal and state, will organise their relationships productively to avoid duplication and promote synergy. What of those jurisdictions without commissions? Is this genuine national reform or merely more piecemeal activity in mental health? The authors have been informed by the varying structures and functions of mental health commissions internationally and were part of the New South Wales taskforce to establish a mental health commission. They had the opportunity to visit the Western Australian and New Zealand Commissions as part of this process. Conclusion: Addressing mental illness requires a joined up approach to government and services. Commissions offer a new organisational structure designed to deliver this contiguity. There is also evidence that nascent and established commissions are delivering real reforms, including in terms of additional resources and influence. Without concerted efforts to coordinate activity, the intersection between federal and state commissions will be confused and duplications might arise. The paper calls for a new network of commissions to be established across Australia and New Zealand, to share resources and common tasks, clarify roles and build common approaches. [ABSTRACT FROM AUTHOR]

Objective: Partly in response to ongoing concerns about the state of mental health care, several jurisdictions across Australia, including the federal government, are hoping to drive change via the establishment of a mental health commission. This is the first of two articles in a series which aims to describe the background to this new trend. The commissions are being established with different powers and structures. This variety is explored and considered against a typology of commissions. Some consistent themes and goals emerge. The paper then provides a contemporary assessment of the ‘state of play’ of the nascent commissions and describes important emerging issues and differences between the models.Conclusion: There are significant differences not only in the construct of the respective commissions but also in the political circumstances in which each must work. At the same time, the problems facing mental health in Australia are ubiquitous and profound. For commissions to be successful they will require not only astute leadership but also durable, bipartisan political support and an enduring capacity to generate new resources for the mental health sector. [ABSTRACT FROM AUTHOR]

The article discusses Australia’s Better Access initiative in mental health. Enhancing affordable and equitable access to relevant psychological therapies has long been the main aim of reforming primary care-based mental health services in Australia. The Better Outcomes in Mental Health Care (BOiMHC) programme introduced in 2001 was a major breakthrough for mental health and direct support for skilled professionals, including psychologists to deliver evidence-based interventions.

Australia has a demonstrated commitment to the development of national plans and policies regarding mental health. Just how effective have these policies been in driving real reform and generating new models of effective, collaborative mental health care? This article examines some of the progress and gaps over a 20-year national planning process and considers contemporary developments affecting our federated health system. Some dangers to the trajectory of Australia's reform process become clear just when the public and political profile of mental health has reached new heights. A key gap is in relation to accountability and Australia's capacity to demonstrate clearly the real impact services have on the lives of people with a mental illness. This article gives an overview of the legacy of Australian mental health reform and presents examples of collaborative and innovative practice across mental health care, housing, employment, and quality improvement. From this analysis, the ongoing challenges for Australian mental health reform become clearer. [ABSTRACT FROM AUTHOR]

Objective: This paper proposes a framework for a systematic evaluation of the Better Access Program, the largest single component of mental health reform announced under the Council of Australian Governments National Action Plan on Mental Health 2006-11. Method: The article explores the genesis of the Program and considers extant data sets and information available with which to establish the impact of the Program on consumers and service providers. Results: There are useful data available in Australia from which to derive pre- and post-implementation analysis about the impact of the Better Access Program. There is doubt as to whether these data form part of the Federal Government's current approach to evaluation of the Program. Conclusions: Anything less than a genuine and comprehensive evaluation will leave Australia unable to assess the real impact of the Better Access Program. The merit of further expenditure in the vital area of primary mental health care will be in doubt as a consequence. [ABSTRACT FROM AUTHOR]

Introduction: This presentation will report on the journey taken in the Australian Capital Territory (ACT) towards development of an integrated regional plan for mental health and suicide prevention. Description of Policy Context and Objective: Despite some apparent natural advantages (limited size and population), mental health care in the ACT is more fractured than integrated. Our health system is under enormous pressure and currently subject to formal, independent inquiry. Our mental health services are fragmented, too often leaving people to fall into the gaps between services. Yet the ACT has the second highest expenditure on mental health services per capita in Australia. To address this situation, the Capital Primary Health Network and the ACT Health Department have invited the community to contribute to a process of co-designed reform. This has involved consumers and carers, as well as public and private health professionals from primary, secondary and tertiary services. It has also engaged people from outside of health in a broader conceptualisation of change in relation to the social determinants of health: housing, education, employment, community services, the police, prison services and others. Target Population: The entire Canberra community, as well as the broader region. Highlights (innovation, impact and outcomes): Our method began with identification of key archetypal case studies which account for around 80% of all mental health business in the ACT. We invited the Canberra community and experts to test these case studies. We asked people what would fundamentally shift the trajectory of these typical consumer journeys towards better outcomes? Responses came at different levels; some were immediate and practical short-term ideas for service improvement; others were longer term and more complex solutions to enhance integrated care - for example to shift from fee for service models of financing to other models. The level of public engagement in thinking about the future of mental health in the ACT is unprecedented. Working groups have been established, public consultation has occurred, and online feedback has been secured. A new plan is emerging from this work. But the future is uncertain. Federal and Territory governments seem to support separateness rather than integration. There are competing policy and funding paradigms - individual choice vs population-based rationing. Staff under pressure working in public services struggle to engage in processes of reform. Perspectives on priorities differ considerably between stakeholders. Comments on Transferability: The experiences of the ACT tell a story of universal interest about local change and reform. Conclusions (key findings, discussion and lessons learned): Even in a small place, where key stakeholders know each well, integration is by no means obvious or straightforward. Policy reforms must be supported by sustained effort to drive the culture of integration. With consumers and their families at the centre of this integration, care must be taken to nurture inter-disciplinary recognition and respect. This is the wellspring of genuine integration. Without this, a rich country like Australia risks wasting resources and leaving people vulnerable to poor care. [ABSTRACT FROM AUTHOR]

Despite increased advocacy and investments in mental health systems globally, there has been limited progress in reducing mental disorder prevalence. In this paper, we argue that meaningful advancements in population mental health necessitate addressing the fundamental sources of shared distress. Using a systems perspective, economic structures and policies are identified as the potential cause of causes of mental ill-health. Neoliberal ideologies, prioritizing economic optimization and continuous growth, contribute to the promotion of individualism, job insecurity, increasing demands on workers, parental stress, social disconnection and a broad range of manifestations well-recognized to erode mental health. We emphasize the need for mental health researchers and advocates to increasingly engage with the economic policy discourse to draw attention to mental health and well-being implications. We call for a shift towards a well-being economy to better align commercial interests with collective well-being and social prosperity. The involvement of individuals with lived mental ill-health experiences, practitioners and researchers is needed to mobilize communities for change and influence economic policies to safeguard well-being. Additionally, we call for the establishment of national mental wealth observatories to inform coordinated health, social and economic policies and realize the transition to a more sustainable well-being economy that offers promise for progress on population mental health outcomes. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

The authors' argue against views expressed by Pirkis et al. on the authors' SPHERE studies. The authors' refute Pirkis et al.'s observation that recruitment of patients was done through providers; instead patients were drafted by the administrative staff of general practitioners. They state that their method is in marked contrast to the data used in the evaluation of Better Access method and the limited scope of the evaluation of Better Access prevented a genu­ine assessment of the key issues.

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. [ABSTRACT FROM AUTHOR]

Background: A reconceptualised global strategy is key as nations begin to shift from crisis management to medium- and long-term planning to rebuild and strengthen their economic, social and public health systems. Efforts towards measuring, modelling, and forecasting Mental Wealth could serve as the catalyst for this reconceptualization. The Mental Wealth approach builds systemic resilience through investments which promote collective cognitive and emotional wellbeing. This paper presents the theoretical foundations for Mental Wealth. It presents, for the first time, literature across the disciplines of health and social sciences, economics, business, and humanities to underpin the development of an operational metric of Mental Wealth. Discussion: An approach which embeds social and psychological dimensions of prosperity, alongside the economic, is needed to inform the effective allocation of investments in the post-pandemic world. The authors advocate for a transdisciplinary framework of Mental Wealth to be applied in innovating population-level policy interventions to address the growing challenges brought on by COVID-19. Mental Wealth highlights the value generated by the deployment of collective mental assets and supporting social infrastructure. In order to inform this position, a review of the literature on the concepts underpinning Mental Wealth is presented, limitations of current measurement tools of mental and social resources are evaluated, and a framework for development of a Mental Wealth metric is proposed. Conclusion: There are challenges in developing an operational Mental Wealth metric. The breadth of conceptual foundations to be considered is extensive, and there may be a lack of agreement on the appropriate tools for its measurement. While variability across current measurement approaches in social resources, wellbeing and mental assets contributes to the difficulty creating a holistic and generic metric, these variations are now clearer. The operationalisation of the Mental Wealth metric will require comprehensive mapping of the elements to be included against the data available. [ABSTRACT FROM AUTHOR]

A letter to the editor is presented in response to the article "How to tackle a giant: creating a genuine evaluation of the Better Access Program," by S. Rosenberg and I. Hickie in the 2010 issue.

Background: While reducing the burden of mental and substance use disorders is a global challenge, it is played out locally. Mental disorders have early ages of onset, syndromal complexity and high individual variability in course and response to treatment. As most locally-delivered health systems do not account for this complexity in their design, implementation, scale or evaluation they often result in disappointing impacts.Discussion: In this viewpoint, we contend that the absence of an appropriate predictive planning framework is one critical reason that countries fail to make substantial progress in mental health outcomes. Addressing this missing infrastructure is vital to guide and coordinate national and regional (local) investments, to ensure limited mental health resources are put to best use, and to strengthen health systems to achieve the mental health targets of the 2015 Sustainable Development Goals. Most broad national policies over-emphasize provision of single elements of care (e.g. medicines, individual psychological therapies) and assess their population-level impact through static, linear and program logic-based evaluation. More sophisticated decision analytic approaches that can account for complexity have long been successfully used in non-health sectors and are now emerging in mental health research and practice. We argue that utilization of advanced decision support tools such as systems modelling and simulation, is now required to bring a necessary discipline to new national and local investments in transforming mental health systems.Conclusion: Systems modelling and simulation delivers an interactive decision analytic tool to test mental health reform and service planning scenarios in a safe environment before implementing them in the real world. The approach drives better decision-making and can inform the scale up of effective and contextually relevant strategies to reduce the burden of mental disorder and enhance the mental wealth of nations. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]