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The economics of mental health systems needs review

Ruth Williams

by Ruth Williams

05 Nov 05:40am

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Filed under: Community, Funding, Mental Health, Society, Welfare

27 comments

Andrew lived with mental illness and died in 2005.

Illustration: Jock Alexander

Andrew had schizophrenia, but he did not die from this – he was stabbed to death by his flatmate, who was subject to severe paranoid schizophrenia. The Victorian coronial report found various processes had failed Andrew, putting his life in danger.

A community worker had placed Andrew in this situation, despite the risks.

In his June 2009 report, State coroner David Drake called for “sweeping changes” in community care of the mentally ill.

It’s one thing to throw money at a problem, but wouldn’t it be better to allocate that money somewhere where it would actually be effective? If there are to be community-based services for people with severe diagnoses, then therapies have to “work” and services well-connected.

Let’s assume that investing in this sector was effective: symptoms and disabilities were being alleviated and the rising death rate from mental illness could technically reduce. In this scenario, there always will be alternative ways to spend finite resources.

Money can be put to financing diagnosis, and attracting more psychiatrists or more allied services. Therapeutic research could be funded, or there could be more economic research for effective policy.

Every million dollars has several alternative uses. About 6,375 mental health plans written by GPs equal around 12,000 hours of private psychiatry services funded by Medicare; or partial funding for the construction of a dedicated facility; or 20 mental illness support groups funded at $50,000 each; and so on.

Since funding is limited, what is the best use of every million dollars spent on this sector? 

If we’re genuine about good outcomes and value for money, then change must be focussed on the end of the system where people are most severely ill. These are the people who need the most help, but instead change is occurring at the easier end.

Australians “troubled by life” are currently streaming through the doors of GPs and psychologists.

That’s understandable. Life is troublesome, but this doesn’t equal a mental illness. The numbers in this group are not trivial, about 590,000 people or 4.4 percent of Australia’s population.

As a result of the financing of ‘the Worried Well’, the needs of severely mental ill people are heavily under-resourced. “Unmet need” is a term for those with a person suffering from mental disorder who do not access services - currently about 11 per cent of Australia’s population fall into this category.

Australians love Medicare, and we have much to be thankful for in it. But Australians tend to believe that Medicare is achieving equity, access and well–allocated health resources - and it is, to a degree.

What needs to be determined is where Medicare fails, and to form policy to address those problems. Many economic incentives are strange. People without a mental disorder who are using mental health services are not a trivial number, about 590,000 people or 4.4 percent of Australia’s population.

Apart from the “Worried Well”, there is also a very mentally-non-ill end of the market that Medicare is subsidising, with little in place to stop this. These are the people receiving services for mental non-illness, sport psychology, executive performance etc. 

This money could be used for those in much greater need, like child and adolescent service delivery, or other areas that are in “great need”.

Let us insist on policy which ensures mental health diagnosis is accurate. Let us insist on financing innovations that work and are value for money. Also, there are known therapies and systems that are evidence-based but not being implemented - let’s not subsidise what has no effect.

If “sweeping changes” are what we are calling for, we need a political agenda of change in community care that can work.

We have to finance what works, strengthen the connections between services, and resources have to align with severity of the condition.

Most commented

27 comments

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    • dead to me says:

      05:45am | 05/11/10

      don’t count on this ALP government to do much, amazing seeing as Mr Swan should have some empathy towards people with mental illnes.

      Reply

    • acotrel says:

      07:07am | 05/11/10

      Jeff Kennett grabbed onto the Richmond Report with both hands, and sold off our mental hospitals so we could have a casino.  It was done at a time when usage of drugs on the streets was dramatically increasing.  The expectation that druggies can successfully be integrated back into the community, with their problems unresolved, was unrealistic!  Also the lack of clinical psychologists to provide counselling is a disgrace.  The underlying problems are never resolved by prescription drugs!

      Reply

    • Damocles says:

      08:13am | 05/11/10

      @ dead to me…...that’s gold mate! Mental Swannie! Right on!

      Reply

    • TracyS says:

      09:05am | 05/11/10

      What a timely article. I recently went to a talk given by Patrick McGorry, and I was particularly struck by a slide showing statistics of the impact of various types of illnesses across the lifespan. Most of us are aware that with increasing age we are more subject to an increased risk of heart disease, cancer, stroke, osteoarthritis… Mental illness, on the other hand, tends to emerge in adolescence and early adult life. This means that the impact of mental illness in our community is amongst young people at a key developmental point in establishing their future level of functioning, and in a part of the population (young adults) who should be at their most productive.

      What is this costing society in lost productivity? Even aside from the social equity issues (which are important), surely adequate resourcing of mental health treatment would be a sound investment in the wellbeing of our communities? There is a need for improved funding for mental health services, not just better allocation of current funds.

      Reply

    • James Hunter says:

      11:21am | 05/11/10

      Trying to find a psychiatrist al all is very challenging, they are booked out for months in advance, The chances are that the one you eventually get into will specialise in the wrong area or immediately want to change all ones medications( as if medications are the be all and end all )  with little regard for the distress and indeed trauma this can cause. The medication selection appears too often to be a matter of try something different every few months until(IF) we find something that works.
      The counselling and background elucidation that used to be such an important part of the science seem to have been side tracked by the appeal to the lazy practitioner of miracle pills. The effacey of which is never what the drug companies suggest.
      No wonder people top themselves. The distress of seeing terminally usless psychiatrists is as bad as the stress and distress of trying to cope on ones own.
      Add to tha the fees typically $250 first visit then $150 pervisit. Medicare you get back about $75 so it is an expensive “Joy” that a lot cannot afford.
      Expecting help from a Government full of Politicians half of whoom should be on therapy is like waiting for sixpence from the tooth fairy.

      Reply

    • know your suburb says:

      09:00am | 06/11/10

      Psychiatrists are drug dealers. Psychologists are someone middle class you can discuss your problem with, like if you had a friend. GPs are both.

    • Robert Smissen, rural SA, God's own country says:

      12:34am | 07/11/10

      Better yet, try to find one who will go to a country city

    • Philip says:

      11:46am | 05/11/10

      I am just a “normal” GP.
      I look after a family whose son/brother “murdered” his best friend because the local mental health system allowed him to stop his medication.
      I also hate and refuse to do so-called “mental health care plans”. These are designed to be initiated by the GP for people they consider require them but the majority of requests come from psychologists who tell people to go to their GP and “get a referral”.
      We have a standing joke locally that if you want to access mental health you need to walk into the ED with your head under your arm!
      Psychiatrists look after the worried well because that pays their bills.
      There absolutely needs to be more funding for the management of the “true” mental illness!

      Reply

    • acotrel says:

      02:07pm | 05/11/10

      It seems that nobody tries to do any epidemiologic studies of mental illness amongst the young.  The case of Brodie Panlock’s bullying in the workplace, and subsequent suicide should ring warning bells! So should the case of the abbatoir worker in Yarrawonga who was harassed mercilessly, and picked up a knife, and killed the wrong person.  Sociopaths in our workplaces must be reined in by employers.  I wonder If Baillieu will back Brumby’s promise t o legislate jail terms where bullying occurs in workplaces?

      Reply

    • Grumpy says:

      02:56pm | 05/11/10

      As someone who has been “diagnosed” with depression, I have found it is difficult to find quality care in my city. I have suffered with this most of my life and now feel like I have run out of alternatives. I cant afford to spend $100 an hour on psychiatrists or Psychologist whom have been little to no help for me in the past. Do I try another one taking the risk that I will again waste my money and feel more upset for seeking an understanding of what is wrong with me? I feel sorry for those who have more severe cases of the same and illnesses like paranoid Schizophrenia. Im lucky i have the ability to keep seeking the help. I and work and generally function normal in society, even though unwillingly. I wonder if i will ever receive the help I really do require as the anti-depressant medication “lucky-dip” that general practitioners offer is nothing but futile.

      Reply

    • hot tub political machine says:

      04:42pm | 05/11/10

      Perhaps you could try a differen’t profession than pyschologist? Maybe a councillor or social worker? I know I would prefer anything but a psychologist, just because I see some flaws to the underpinning theories of their profession.

    • A "Worried Well" says:

      03:10pm | 05/11/10

      I guess I’m what you would call part of “the Worried Well” and access to a Mental Health Plan from my GP saved my life.

      I earn (only slightly) too much to have a Health Card, yet too little to actually be able to comfortably afford mental health care, and the saving of $70 per psychology session I was able to claim when I was at my worst (my psychologist was $140 a session) meant that I was able to attend sessions. If I didn’t have access to that, I wouldn’t have been able to see a psych- even the $70 was pushing my budget to the extremes- and if I hadn’t gone to see the psych when I did, I do believe that I would have killed myself.

      We as a country need to invest in preventative methods just as much as we need to invest in the very troubled sector, as if we don’t help “the Worried Well” (and what a condescending term that is!) we will have a much larger “troubled sector”.

      In all honesty, Ruth, I am utterly disgusted at your article. The inference that one sector of the mentally unwell are more deserving of public funds than another is unbalance and offensive.

      All Australians deserve the best in healthcare. Not just the rich. Not just the poor. Not just the middle class. Not just the very sick. Not just the ‘little bit sick’. EVERYONE.

      Reply

    • Mon says:

      03:54am | 06/11/10

      I too was in the same situation a couple of years ago with my mental health, “Worried Well”, and you can be reassured that YOU are NOT one of these worried well that Ruth refers to in her article. You were mentally ill - you wanted to die (by the sounds of your post) and that, in my opinion, makes you mentally ill, NOT a ‘worried well’.

      Having said this however, I do not agree with you opinion of Ruth’s article.  I congratulate her for writing it in fact - it’s about time someone spoke out about this issue. The problem at the moment is there are all these people, who are feeling a bit blue, so off they go to the doctor and the next thing you know they have major depression, are on medication and have full access to Medicare mental health services (and in some cases disability pensions from Centrelink) - when in reality, in my opinion, they just need to sit back, realise how lucky they probably are, and swallow a spoon of cement ( please note that I am NOT trivializing mental illness - I just think that some people think feeling down constitutes depression). These people, in my opinion, are trivializing mental illness and this is the main reason why being mentally ill still has huge stigma attached to it. On the other hand, there are people out there who have schizophrenia or bi polar disorder, and somehow they miss out on healthcare.

      Unfortunately, this is Australia, not Europe. I live in Europe at the moment, and the difference between Australia and over here is that public funds are managed properly by the government. The reality in Australia is that at the moment, most of the people who can afford health care are receiving it because they pay for it, and those who cannot go without. The health care system in Australia has been run into the ground by consecutive governments, to the point where I would now rather live overseas then try to get adequate healthcare back home. It would be nice to have ‘universal’ healthcare - but it’s just not going to happen in the near future in Australia. And at the moment, in terms of mental illness, I strongly believe that the very sick SHOULD receive healthcare, especially over those who are the worried well.

    • Glen says:

      03:51pm | 05/11/10

      People are on Mental Health Care Plans for Sport Psychology? I find that hard to beleive and a bit ridiculous if it is true - I’d like some figures on that.

      I have been on a Mental Health Care Plan before for “severe depression” and it’s also now a particular point of interest for me as I am now studying/training to become a Psychologist myself. 

      I definitely agree with a lot in this article - I have to say that, although I think I was the desired candidate for it, my Mental Health Care Plan was very easy to get. I can’t make judgement on those who are actually ill and ebenfit from these plans, but giving them out to the non-ill spectrum of visitors to Psychologists (who, by the way, should be free to treat whoever they wish, as Phillip said - thats how they pay their bills) is ridiculous!

      Reply

    • stephen says:

      06:58pm | 05/11/10

      Patrick McGorry quoted recently a very high percentage of youth suffering from a mental health problem.
      It was soon refuted in the media by another well-respected Doctor, who said in effect the figures are grossly exaggerated, and that misdiagnosis appears to be a problem here.
      At any rate, the Chief Medical Officer is yet to act on any advice.
      That the incidence of mental illness is apparently increasing( which is hardly disputed by any authority), should alarm not only Health Authorities, but every member of our community who wants a stable and prosperous society.
      There are many disagreements as to the extent of mental illness.
      (And it may well be the adjectives used to describe so-called eccentricities will have to be ‘medicalized’.)
      I think, quite apart from the pharmacological aspects of this disease, that a thorough and rigorous education a school will lessen its severity.

      Reply

    • acotrel says:

      03:36am | 06/11/10

      I’m not depressive, however when I visit Melbourne I never use the car radio.  The local stations make me feel physically ill.  I have a n MP3 player on which I play fairly harmonious music of a wide variey of genres.  It seems to me that the shock jocks, and the music programmes which are ‘free to air’, and compiled without regard for their audiences well-being?  It’s bad enough to be stuck in city traffic without listening to garbage.  At least in the country we have decent ABC programmes to soothe our brains.  I suggest we have a big problem in our cities, and depression is largely caused by the media. Some of our jerk politicians don’t help!

    • acotrel says:

      03:51am | 06/11/10

      Stephen, When I’m talking to anyone else, I always ask myself the question as to whether their ideas are delusional.  The answer is yes on a very large number of occasions.  Of course you have to question your own objectivity, but there are a lot of people around living in their own little world with communication difficulties.  Their mindset is distinctly ill.  I’d go so far as to say, many of the mentally ill may each have one particular psychological problem, which thay cannot resolve by themselves.  The psyche drugs can help with a reprieve, clearing their thoughts.  However clinical psychologists are needed more than psychiatrists. If the underlying problem is never resolved, the illness can be a life sentence. One thing I’d never do is empathise with a psyche patient, I believe every one of them is ill for a valid reason. Regardless of what the Chief Medical Officer might believe, mental illness is widespread, and commonplace usage of ‘recreational’ drugs is making the situation worse.

    • Clinical Psychologist says:

      09:22pm | 05/11/10

      Mental Health Services are FREE in Western Australia and most probably funded by State Governments across Australia (at least prior to the recent Federal takeover).
      The introduction of Medicare in Mental Health has shifted wait lists from the FREE sector to the FEE for SERVICE sector ie Private Practitioners where people queue for the privelidge (sp?) of paying a gap fee.

      GPs are not all to blame - however they do get paid for ‘referring’ to psychologists, counsellors, psychiatrists etc in the private sector - they do not get a medicare rebate for sending a referral to the FREE State Service.

      Patients have a choice so ask your GP for a referral to the local FREE State service; you will probably find you will be seen very quickly by an appropriate mental health professional after an initial phone call to you from a professional at that local service centre. You will also have access to a TEAM of professionals including psychiatrists, clinical psychologists, social workers, community mental health nurses, occupational therapists, suicide information officers, and pharmacists not just the ‘person in private practice’ whose prime focus is running their business in order to make a good income.

      Reply

    • know your suburb says:

      09:24am | 06/11/10

      That is so true. I had a psychologist who called himself a business man.

    • Anu says:

      06:53am | 06/11/10

      Patrick Mcgorry “statistics” are astonishingly unbelieveable and really largely amounts to the medicalisation of emotion. I do not disbelive that of course there are severely ill patients that require medication, but his figures are way beyond the extremities of what could be considered credible. Most psychiatrists know this, but who would object to the popularisation of their profession, except the 2 psychiatrists who have expressed their scepticism in the media, who appear to be acting the public interest rather than the interests of psychiatrists and the pharmaceuitical industry.

      Reply

    • know your suburb says:

      08:51am | 06/11/10

      The mentally ill are often serious drug users. These are criminals who get money out of charities and scared old ladies to finance their habits. The system deals with them by leaving them loose on the streets hoping a gang will kill them with a hot shot.

      Reply

    • Chris says:

      07:31pm | 06/11/10

      Thanks a lot! NOT!
      It’s ill informed comments like yours that makes it worse for an already stigmatized portion of society. The majority of sufferers of mental illness are not serious drug users who are criminals.
      Same may have records due to incidents where they have been unmediated and reacted badly to a situation but that is about it.
      Sure there will be drug users who suffer mental illness just as there are police, politicians, nurse, reporters, teachers and others of any part of society regardless of occupation or lifestyle.

    • Chris says:

      10:26am | 06/11/10

      At the end of the day politicians don’t give a rats about any of us esp those with mental illness, as long as they get their perks and travel allowance.
      You only have to look at places such as La Rundel and the surrounding area which was sold off to private developers at the cost of those who needed it most.
      Sure the system needed an overhaul but all the ill informed idea of community based care did was put most people on the streets as homeless or in jails to get worse.
      Before the area become the eyesore called Lancaster gate etc the former Plenty hospital and La Rundel grounds where an Ideal place for a non threatening, non confrontational health care environment. It was literally a parkland with hospital buildings throughout it, plus an extensive wildlife population. If the time, effort and money had been put into place we could have had the best mental healthcare facility in the world all with in a a stones throw of the city, next door to a Uni, close to the tram and train lines and a bus ride to 3 shopping centres. People who needed access to care close buy could be given the option of living there with an open door so they can still be part of the community at large, living and working if and when they can but also under the care and guidance of trained professional so if they start to go off the rails they could have got help immediately. It would be a big task to set it up and run but if it makes it possible for most of those people become a valued part of society like those who have no mental illness it is worth it.

      Right now there is a perfectly good hospital building rotting away out near the airport called Greenvale Hospital, that could be put to use. But of course the politicians and Public Sector fat cats will leave it there to rot until they decide to sell the land to their property developer mates at some stupidly low price so they can cash in at the expense of those in need. It’s such a joke that someone can smoke and develop lung cancer because of their own stupidity and know the services and facilities are not far away yet someone who is mentally ill through no fault of their own gets treated like a leper and has no real service available or has to go without to get treatment.

      Reply

    • Robert Smissen, rural SA, God's own country says:

      12:37am | 07/11/10

      Sad isn’t it Tony promised far mor for mental health yet Oakeshot & the other weasels put Gillard back in

      Reply

    • Lynne says:

      03:29pm | 07/11/10

      Mental health is in appalling state in this country. We live in rural NSW and, once again, we found last week that Labour cares only for the big cities but couldn’t give a rat’s behind about the rural areas.

      A new employee to our small business just moved here from WA after having been over a few months earlier with his wife to have a look at things. She’s a highly qualified mental health nurse and was told by two hospitals in the greater area that there would be work for here and she would be partly responsible in setting up proper mental health services. Yes, you heard right, despite having an area (allbeit wide-spread) of over 100,000 people to look after, there is no mental health care available. Not within several hours of driving anyway. At any rate, when they got here two weeks ago, she was then informed that whilst they would love her to start work and would dearly need her, the government has (yet again) withdrawn the funds that this area has been lobbying for for years and she was therefore not going to be able to work. Easy as that.

      We had the same problem with maternity services. Whilst everybody in the big cities can get free care, women here had to pay for a private obstetrician at every visit with the result that many women turned up in the labour ward without having had any ante-natal care. That has changed now but it took 10(!) years.

      Now, I wonder, how many suicides and murders and other tragedies have to happen because the government doesn’t care that people in rural areas live with just the same cases of depression, schizophrenia and other mental health problems as people in the big cities? Mental illness is not something people get by choice, but they need help all the same. Locally.

      Reply

    • Melissa Raven says:

      01:04pm | 12/11/10

      How on earth can a senior lecturer in economics make such a naïve claim that intervention with the most severely ill is the best value for money? The fact that they need the most help does not mean that providing that help is a good investment economically, regardless of whether or not it is justified on humanitarian or other grounds. Often it is much more cost-effective to treat many people with mild to moderate problems than to focus on those with the greatest needs.

      Reply

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      Reply
 
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