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The population impact of improvements in mental health services: the case of Australia

  • Anthony F. Jorm (a1)

Summary

A national survey in 1997 found that Australia had a high prevalence of mental disorders with low rates of treatment. Since then, treatment availability has increased greatly and unmet need has reduced. However, there is little evidence that the nation's mental health has improved.

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Copyright

Corresponding author

AFJ is supported by an NHMRC Australia Fellowship. Orygen Youth Health Research C is supported by a grant from the Colonial Foundation.

Footnotes

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See pp. 479–484, this issue

Declaration of interest

None.

Footnotes

References

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1 Andrews, G, Henderson, S, Hall, W. Prevalence, comorbidity, disability and service utilisation: overview of the Australian National Mental Health Survey. Br J Psychiatry 2001; 178: 145–53.
2 Andrews, G, Issakidis, C, Sanderson, K, Corry, J, Lapsley, H. Utilising survey data to inform public policy: comparison of the cost-effectiveness of treatment of ten mental disorders. Br J Psychiatry 2004; 184: 526–33.
3 Hollingworth, SA, Burgess, PM, Whiteford, HA. Affective and anxiety disorders: prevalence, treatment and antidepressant medication use. Aust N Z J Psychiatry 2010; 44: 513–9.
4 Pirkis, J, Harris, M, Hall, W, Ftanou, M. Evaluation of the Better Access to Psychiatrists, Psychologists and General Practitioners Through the Medicare Benefits Schedule Initiative: Summative Evaluation. Centre for Health Policy, Programs and Economics, University of Melbourne, 2011.
5 Meadows, G, Bobevski, I. Changes in met perceived need for mental healthcare in Australia from 1997 to 2007. Br J Psychiatry 2011; 199: 479–84.
6 Jorm, AF, Butterworth, P. Changes in psychological distress in Australia over an 8-year period: evidence for worsening in young men. Aust N Z J Psychiatry 2006; 40: 4750.
7 Goldney, RD, Eckert, KA, Hawthorne, G, Taylor, AW. Changes in the prevalence of major depression in an Australian community sample between 1998 and 2008. Aust N Z J Psychiatry 2010; 44: 901–10.
8 Reavley, NJ, Cvetkovski, S, Mackinnon, AJ, Jorm, AF. National depression and anxiety indices for Australia. Aust N Z J Psychiatry 2011; 45: 780–7.
9 Page, A, Taylor, R, Martin, G. Recent declines in Australian male suicide are real, not artefactual. Aust N Z J Psychiatry 2010; 44: 358–63.
10 Brugha, TS, Bebbington, PE, Singleton, N, Melzer, D, Jenkins, R, Lewis, G, et al. Trends in service use and treatment for mental disorders in adults throughout Great Britain. Br J Psychiatry 2004; 185: 378–84.

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The population impact of improvements in mental health services: the case of Australia

  • Anthony F. Jorm (a1)
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eLetters

Re:Re:The population impact of improvement in mental health services:the case of Australia

Robert D Goldney
17 March 2012

We appreciate the rejoinder by Jorm, but respectfully suggest there is an important issue which is being overlooked.We agree with his analogy that "it would be ridiculous to claim that better knowledge about cancer is a risk factor for cancer". However, better knowledge may result in an increase in recorded diagnosis of cancer, just as may occur with depression. This may or may not result in better health outcomes. Continuing with the cancer analogy, take publicity about prostate cancer and the dilemma associated with the degree of elevation of PSA levels, andwhat treatment and follow up may be appropriate. Returning to depression, given the challenge of diagnosis and what may be clinically significant, what does the increase in recorded symptoms, reflected in the increased diagnosis, mean?It is agreed that a series of cross sectional analyses can not establish causality, but the finding of poorer mental health literacy being protective for the registering of symptoms which lead to the diagnosis of depression is intriguing. Indeed, a corollary worth pursuing is whether enhancing mental health literacy results in an inappropriately higher level of reported symptoms due to introspection of those in the community who previously may have assumed their emotions were part of life, transient and not worth reporting.

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Conflict of interest: None declared

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Re:The population impact of improvement in mental health services:the case of Australia

Anthony F. Jorm, Professorial Fellow
16 February 2012

Goldney and colleagues have done some excellent research tracking mental health literacy and depression prevalence in South Australia.1 However, the conclusions they draw from this research in their letter are not justified.

Firstly, they conclude that better mental health literacy is a risk factor for depression. To draw such a conclusion requires either or cohortstudy or preferably an intervention trial. The data that Goldney et al cite consist of three cross-sectional studies carried out at different points in time. Showing cross-sectional correlations between mental healthliteracy and depression prevalence tells us nothing about risk factors fordepression.1 To draw an analogy, imagine we do a cross-sectional study showing that people who have cancer know more about cancer. It would be ridiculous to claim that better knowledge about cancer is a risk factor for cancer, yet this is exactly the sort of conclusion that Goldney and colleagues are making. By contrast, the evidence from randomized intervention trials of psychoeducation indicates a protective effect. A meta-analysis by Donker et al concluded that "brief passive psychoeducational interventions for depression and psychological distress can reduce symptoms".2

Secondly, given the lack of improvement in population mental health, Goldney et al question expenditure on broad community campaigns and argue that funds would be better spent on evidence-based treatment services. Theproblem with this conclusion is that over the period that Goldney et al have monitored prevalence of depression, uptake of clinical services has also increased greatly. We have recently published similar data for the whole of Australia over the period 1997 to 2011, showing that there has been no change in psychological distress despite an improvement in mental health literacy.3 However, as we have documented in this paper, the provision of pharmacological, psychological and e-health interventions hasdramatically increased over the same period. If there is a lack, it has been in population-based prevention programs, which have received only limited resourcing in Australia. It may be that the emphasis needs to be on reducing incidence of new cases through prevention, in addition to reducing duration of cases through clinical services.

References

1.Goldney RD, Eckert KA, Hawthorn G, Taylor AW. Changes in the prevalence of major depression in an Australian community sample between 1998 and 2008. Aust N Z J Psychiatry 2010; 44: 901-10.

2.Donker T, Griffiths DM, Cuijpers P, Christensen H. Psychoeducationfor depression, anxiety and psychological distress: a meta-analysis. BMC Med 2009; 7: 79.

3.Jorm AF, Reavley NJ. Changes in psychological distress in Australian adults between 1995 and 2011. Aust N Z J Psychiatry in press.

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Conflict of interest: None declared

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The population impact of improvement in mental health services:the case of Australia

Robert Goldney, Emeritus Professor of Psychiatry
08 February 2012

The recent Editorial of Jorm1 reviewing the potential population impact of improvements in mental health services in Australia concluded that there was "little evidence" that Australia's mental health had improved. This is either an illustration of the difficulty in demonstrating improvement or a sobering reminder that the much publicised changes have produced equivocal benefit at best. Indeed, there is also the uncomfortable possibility that some recent mental health initiatives could have been counter-productive.

Jorm referred to the South Australian community survey2 which demonstrated an increase in major depression between 1998 and 2008, but that study also noted a decrease in health related quality of life, as measured by the mental component summary score of the SF-36 between 1998 and 2008, whereas there had been no change in the physical component summary score. It is also of note that between 1998 and 2008 there was a significant increase in mental health literacy about depression in that community.3 However, it was unexpected that having poor or fair mental health literacy was significantly protective for major depression.

These findings are consistent with the work of Meadows and Bobevski4,also referred to by Jorm, who found that although there had been a significant reduction in unmet need for information, the perceived needs of service users had increased significantly.

An interpretation of these data is that we have been able to provide information which the community has absorbed, but that has not translated into better community mental health.

We were cautious in our interpretation of early 1998 to 2004 data5, suggesting that further time needed to elapse before concluding that broadprograms, while effective in promoting what can be considered process changes, may be ineffective in producing the more important outcome changeof better mental health at the community level. We are now less cautious since analysis of the 1998 - 2004 - 2008 data.

It is probably fair to state that if the initiatives were considered analogous to a pharmaceutical trial, they would have been terminated due to lack of efficacy. In the spirit of a critical appraisal of the effectiveness of all initiatives, it is time to question whether finite resources should continue to be allocated to broad community programmes, or rather to bolster evidence-based treatment services specifically targeted at those with clinically demonstrated mental illness.

?References:

1.Jorm AF. The population impact of improvements in mental health services: the case of Australia. Br J Psychiatry 2011; 199:443-4.

2.Goldney, RD, Eckert KA, Hawthorn G, Taylor AW. Changes in the prevalence of major depression in an Australian community sample between 1998 and 2008. Aust N Z J Psychiatry 2010; 44:901-10.

3.Goldney RD, Dunn KI, Dal Grande E, Crabb S, Taylor A. Tracking depression-related mental health literacy across South Australia: a decadeof change. Aust N Z J Psychiatry 2009; 43:476-83.

4.Meadows G, Bobevski I. Changes in met perceived need for mental healthcare in Australia from 1997 to 2007. Br J Psychiatry 2011; 199:479-84.

5.Goldney RD, Fisher LJ, Dal Grande E, Taylor AW, Hawthorne G. Haveeducation and publicity about depression made a difference? Comparison ofprevalence, service use and excess costs in South Australia: 1998 and 2004. Aust N Z J Psychiatry 2007; 41: 38-53.

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Conflict of interest: None declared

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