The great mental health experiment …
and why it went so wrong.
Half a century ago, governments around the world ditched their old psychiatric hospitals for something they said would work better. It didn’t.
But it also characterised those who treat mental illness as
the villains and the hospitals they worked in as hell-holes and torture
prisons. Some were like that. Most, including the vast majority of Australian
psychiatric hospitals, were the polar opposite.
But the damage was done.
By the time that film was released, Australian psychiatric
institutions had been undergoing fundamental reform for well over two decades.
At the vanguard of that reform was a progressive British psychiatrist, Dr Eric
Cunningham Dax, who was recruited by the Victorian government in 1952 to head
the state’s Mental Hygiene Authority.
As a young reporter in Melbourne in the late 1960s, I
interviewed Dr Dax several times. By then he had become a revered figure in
that state and gained an international reputation. He was a remarkable man.
In 1969 he moved to Tasmania and brought that state’s
services into the modern era.
In 1997 I spoke to him again. He was scathing about the
systems around Australia that had replaced those he had pioneered. There was
nowhere near enough community-based treatment. And he was profoundly critical
of the treatment being offered in general public hospitals: insufficient staff,
often with insufficient experience, in entirely inappropriate and
anti-therapeutic settings.
Eric Cunningham Dax’s vision of mental health care that is
effective, humane and adequate is now a fragmented, inefficient and
under-resourced shell.
What went wrong?
A 50-year
failed experiment
Australia has a poor record in
treating the massive mental health problems in the population. More and more
money is spent, without achieving any overall improvement in either the mental
health of the community or in the performance of services.
Growth in community treatment was far slower than the
decline in hospital-based care, which was substantially transferred to general
hospitals. Dax had pioneered community treatment, but this was the opposite of
his vision.
In a 2020 inquiry
report, the Productivity Commission revealed the extent of failure.
“Australia’s current mental health system is not
comprehensive and fails to provide the treatment and support that people who
need it legitimately expect,” it said. “The clinical care system has gaps,
including, but not limited to, the so-called ‘missing middle’ …
“The system of community supports in Australia is ad hoc,
with services starting and stopping with little regard to people’s needs.”
A key reason for this failure is the mismatch between mental
health policy and the people who need care. Many people can be treated
successfully in community settings with appropriate consultation with
therapists and other social support. But many of the most seriously ill cannot,
and are being failed by the mental health system in Australia and in other
countries where these policies have been followed. Without more structured
surroundings, these people are highly vulnerable to living on the streets or
going to prison.
A national
advocacy group has commented:
“Around 57% of Australia’s prisons have become de facto
mental-health institutions for our society’s sickest and most vulnerable. Right
across the country those who examine and report on the quality of this care are
telling a similar, alarming story.”
Data from the Australian Institute of Health and Welfare show
around 51% of prison entrants nationally have been diagnosed with a mental
illness; in Tasmania, the figure is 83%. 17% of Tasmanian entrants were
assessed as being at risk of self-harm against 7% nationally, and 20% reported
self-harming while in prison against 5% nationally.
“These
findings are astounding when compared with the general health of the
population, where less than 1% of adults are admitted to hospital with mental
health problems in any year and lifetime prevalence rates for schizophrenia are
0.3% to 1%,” the Institute found.
“A
number of contributing factors have been identified to help explain the high
numbers of people with mental illnesses in the criminal justice system,
including the deinstitutionalisation of mentally ill people, an increase in the
use of drugs and alcohol by people with mental illnesses, and the limited
capacity of community-based mental health services to address the needs of
mentally ill offenders.
A 1997
study of a community-based centre in California documented what can happen
when inadequately equipped services are forced to deal with seriously ill
patients. Staff at this centre had to deal with patients with serious and
long-term schizophrenia, schizoaffective disorder, bipolar disorder and
dementia. Almost all displayed psychosis. They were poorly compliant with
medication and almost all were involuntary admissions.
“Many patients displayed unacceptable sexual behaviour, such
as exhibiting themselves or masturbating in public; others tended to urinate or
defecate in public places. As a result of patient violence, the study facility
averages two staff injuries and more than four patient injuries a month that
require medical attention …
“The use of community alternatives to state hospitalization,
which is often driven by lower costs and an ideology that highly structured
care is seldom needed, is not suitable for all patients.”
In Australia, the capacity to provide long-term
institutional care for the minority of patients who require it has been
massively diminished as a result of de-institutionalisation.
But even for people in need of less-intensive care, and who
could benefit from treatment in the community, such support is too often
missing. The result is that, though we are spending more and more, we are
getting progressively poorer results.
The money
Over the past 30 years, expenditure
on mental health services has grown (in constant 2020-21 dollars) from $3.4
billion to $12.2 billion, an increase of 258%. The increase has been in an
almost-straight line, despite various state and federal governments being in
office, and despite varying policy initiatives, many inquiries and five
successive National Mental Health Strategies.
Some of that increase can be attributed to population
growth: with more people, we need more services. But that does not explain most
of the increase. The amount spent (again, in constant 2021-22 dollars) per head
of population has increased by 145%.
“Despite this enormous expenditure,”
said recent
report from the Australian National University, “there is evidence that a
substantial proportion of people with the most chronic severe mental health
conditions – schizophrenia, bipolar disorder and severe depressive disorders –
do not receive adequate care, if they receive care at all.
“The prevalence of mental illness in Australia is greater
than in many other high-income countries.”
The
impact of mental illness
That finding is confirmed by the World Burden of Disease Study,
run out of the University of Washington. In all five of the major disease
categories, Australians suffer at greater rates than in most rich countries.
This has major ramifications for
the overall burden of disease in the community. That’s measured by disability
adjusted life years, a unit calculated from estimates of premature death and
the impact of disease on the quality of life.
To put this into more context, the AIHW’s latest Burden
of Disease Study has found that mental and substance use disorders comprise
Australia’s fourth most serious cause of the loss of amenity.
It helps, perhaps, to put the toll of mental illness into
perspective, and nothing does that more eloquently than the statistics on
suicide. Comparing the numbers of suicide deaths in Australia with the road
toll shows that, though road deaths are a major blight on the community,
suicide – the ultimate consequence of poor mental health – is, at least
arithmetically, two-and-a-half times as bad.
For at least the past three decades, mental
health spending in Australia has followed total health expenditure fairly
closely, at around 7.5%. The recent apparent fall probably reflects the impact
of the pandemic.
To the extent that the available
data reveal the trends, the overall impact of mental illness and psychological
stress also remained relatively steady from the beginning of the present
century until around 2014, when mental
health scores fell, particularly among younger people. These averages do
not reveal the likely parallel increases in the numbers declining into
seriously poor mental health who are newly in need of treatment.
The lower the score, the worse someone’s
mental health becomes.
Mental illness is too important, and too disabling to
Australian society, for limited services to be unfairly and inefficiently
distributed; but that is what is happening. One measure, the number of people
who cannot afford to seek professional help even if it’s available, is an
indictment of the current system. Women are disproportionately affected. The
Australian Bureau of Statistics estimates
that overall, 833,500 people avoided or delayed seeing a mental health
professional in 2023-24 because of cost.
People aged between 25 and 34 are by far the most likely to
be impacted in this way.
“People with chronic severe mental health conditions need
care not only for their mental illnesses, but for co-existing physical
conditions and substance use problems,” wrote a group of psychiatric and
addiction medicine specialists in Don’t
Walk By, from the Australian National University.
“Yet treatment efforts are unlikely to be successful unless
the person receiving care has secure housing, healthy nutrition, and sufficient
social support to attend necessary appointments. We have identified a shortfall
in the dedicated mental health workforce of 8,310 full time equivalents (FTE)
across all disciplines, from psychiatrists, to social workers, and all
professional groups through to peer workers. The alcohol and addiction
workforce is short of 838 FTE staff nationally.”
Because mental illness is strongly associated with levels of
income and wealth (poverty is both a cause and an effect) publicly funded
services attain disproportionately significance. A 2018
study by researchers from Monash University found:
“Overall, more than 1-in-4 people making up the poorest
one-fifth of Australians have current psychological distress at a high/very
high level, and this compares to about 1-in-20 in the richest one-fifth of
Australians. Our findings indicate that about 1-in-10 people making up the
poorest one-fifth of Australians have very high distress, and this reduces to less than 1-in-50 people in the richest
one-fifth.”
By the early 1990s, when this series of figures began,
de-institutionalisation had already been in train for at least two decades, but
continued apace. Progressively, beds previously provided in psychiatric
hospitals were transferred into general hospitals or, more frequently, closed.
The policy of de-institutionalisation was described by all
state governments as a move from outdated psychiatric hospitals to
community-based residential care. But cost-cutting intervened. Public hospital
accommodation declined much further than the rise in residential care;
supported housing is a relatively new category but does not make up for the
shortfall. The result is that although the overall supply of places for mental
health patients has hardly moved over 30 years – going from 51 per 100,000
population in 1992-93 to 54 thirty years later – the quality and intensity of
care has fallen dramatically.
Despite this, staffing levels in all categories and in all
jurisdictions have increased over the past 30 years. This apparent dichotomy
raises two important questions: how effectively and efficiently are staff being
utilised? And is this apparent decline in efficiency a result, at least in part,
of inadequate capital investment?
Staffing levels are uneven around the country. By far the
least well-endowed is Tasmania, followed by New South Wales. South Australia
has the highest rates.
In all jurisdictions, resources for treating mental illness
are inadequate, but even that inadequacy is not evenly spread. Victoria, where
Eric Cunningham Dax made such advances over half a century ago, has the
nation’s lowest availability of public sector treatment for general patients,
by far the biggest category. Facilities have not kept up with population
growth. And the lack of population growth in Tasmania, the second-worst state,
flatters its result.
Victoria does somewhat better for young people, though this
accounts for relatively few patients anywhere. But Tasmania and the two
territories do not have specialist units even though young people are heavily
impacted by poor mental health. According
to the AIHW, “in 2017–18, an estimated 339,000 young people aged 18–24
(15%) experienced high or very high levels of psychological distress.” And in 2019,
“there were 461 deaths by suicide among young people aged 15–24.”
Nationally, there are only 62 patient days a year of
specialist care for every 1,000 older people. Tasmania’s tiny proportion does
not even register.
Despite massive rates of mental illness in prisons,
treatment for prisoners is even more inadequate, with only 5.5 patient days
nationally for each prisoner.
Just take
a pill!
In the absence of sufficient specialist care, general
practitioners are left with the impossible task of dealing with the vast
majority of mental health patients. Sometimes that can be done adequately in
the context of a consultation lasting 15 or 30 minutes; very often it cannot.
Australia’s extraordinarily high consumption of
antidepressants – the fifth-highest in the world, according to OECD data – is a
direct result of this situation. Antidepressants are very important for many
people with major depression but should be used with great caution, if at all,
on those whose depression is mild-to-moderate or transitory. These are
heavy-duty drugs with significant side-effects and can be very difficult to
discontinue.
The first of the new blockbuster antidepressants, selective serotonin uptake inhibitors, was introduced in 1987. Uptake was rapid and sustained. By 2022, the population-adjusted
consumption rate of antidepressants in Australia was 954% higher than it had been in 1990.
In all jurisdictions, with the possible exception of the
Northern Territory, consumption is high. Nowhere, though, is such a high
proportion of the population taking these drugs as in Tasmania. If that state
was a nation it would be third in the world, behind only Iceland and Portugal.
Prescriber patterns revel more about what’s happening.
Nationally, GPs account for 87% of all patients being prescribed
antidepressants. Psychiatrists, psychologists and other specialists account for
only 13%.
The way forward
De-institutionalisation of mental health is an experiment
that began half a century ago and which has consistently failed throughout that
time. It has delivered much worse care, weakened and fragmented the provision
of services, while failing to deliver anticipated cost savings. It is time to
think again.
Transferring the remaining acute services from specialist
psychiatric settings into busy and noisy general hospitals, together with a
precipitate decline in such services, has guaranteed both poor mental health
outcomes as well as economic inefficiency. Community-based consultations have
also been curtailed. The concentration on residential services has been far
from adequate and, in any case, are not an effective substitute for long-term
specialist treatment of these complex conditions. But long-term, consistent
treatment has become a illusion.
Returning to the patterns of 50 years ago is not practical
or desirable. Those old buildings had outlived their time. But we need to
return to a time in which people with mental illness could find a welcoming,
peaceful therapeutic environment with adequate and capable care.
Acute psychiatric facilities should be removed from general
hospitals and placed within newly-created mental health precincts surrounded by
gardens which, in themselves, are therapeutic. The noise and chaos of general
hospitals is a barrier to therapy.
Those new mental health precincts should include separate
facilities for children and adolescents, for older people, subacute and
community care, training and short-stay facilities. Community-based therapy and
support need urgent and substantial enlargement and enhancement. Specialised
social housing and other residential facilities are inadequate and need to be
expanded. There is an indispensable place in this for non-government
organisations.
Mental health precincts have the potential to create the
kind of coordinated, long-term approach to treatment that is currently
difficult and, usually, impossible. They will also be far less expensive to
build than general hospitals, easier and probably cheaper to run, and certainly
more effective in treating patients.
None of this represents a panacea. Many critical needs
cannot be addressed solely by establishing specialist precincts or by formal
treatment options. The need for preventive mental health care remains critical,
including (but not only) for young people. Not all these matters can be
addressed by state governments working alone with limited budgets. Improving
the mental health of the nation is a long-term, difficult and potentially
costly process.
But it can be done.