Mental health policy in Australia, 1988-2008

This thesis uses the theoretical framework developed by John Kingdon to analyse, from the perspective of the Commonwealth government, the problems, policy solutions and political context that led to the opening of three mental health policy windows in Australia: the adoption of Australia's National Mental Health Policy and first National Mental Health Plan in 1992, the adoption of the Second National Mental Health Plan in 1998 and the adoption of the Council of Australian Governments' National Mental Health Action Plan in 2006. Data was assembled from four sources: firstly political party documents, ministerial speeches, Parliamentary debates and government documents; secondly a systematic review of literature published in academic journals; thirdly interviews with key informants; and fourthly my own observations as an expert key participant in mental health reform. From a thematic analysis of data from the first three sources five themes emerged that describe the issues shaping the mental health policy debates over the twenty year period covered by the thesis. These themes are human rights and community attitudes, community need, service structures, service quality and effectiveness, and resources. For each of the periods that led up to the opening of the policy windows in 1992, 1998 and 2006, the problems confronting the Commonwealth government and the policy solutions proposed were identified in each of the five thematic areas. The political response that occurred at each time is also discussed. For each policy window a set of defined problems and policy solutions, specific to that window, were identified. While taking action suited the political agenda of the government, each occasion was also associated with a highly publicised mental health issue that had dominated the media and demanded a policy response. Over the twenty years mental health became a much more prominent issue and the policy space in mental health much more contested with multiple agendas competing for government attention. Because the Kingdon model was used to organise the information collected it could not be used to also validate the model. However it was not difficult to find, for each policy window, clear problems, policy solutions and a political context within which the opening of the window occurred. The events shaping the political stream were largely independent of those shaping the problem and policy streams, which themselves were not independent of each other. In most cases, the individuals who had identified the problems were also promoting and advocating policy solutions to those problems. While the Kingdon model establishes a preconfigured cyclical dynamic and does not predict when a policy window might open, it did provide a useful framework for identifying and explaining factors important in mental health policy development and adoption

The trend in mental health-related mortality rates in Australia 1916-2004: implications for policy

Background: This study determines the trend in mental health-related mortality (defined here as the aggregation of suicide and deaths coded as “mental/behavioural disorders”), and its relative numerical importance, and to argue that this has importance to policy-makers. Its results will have policy relevance because policy-makers have been predominantly concerned with cost-containment, but a re-appraisal of this issue is occurring, and the trade-off between health expenditures and valuable gains in longevity is being emphasised now. This study examines longevity gains from mental health-related interventions, or their absence, at the population level. The study sums mortality data for suicide and mental/behavioural disorders across the relevant ICD codes through time in Australia for the period 1916-2004. There are two measures applied to the mortality rates: the conventional age-standardised headcount; and the age-standardised Potential Years of Life Lost (PYLL), a measure of premature mortality. Mortality rates formed from these data are analysed via comparisons with mortality rates for All Causes, and with circulatory diseases, cancer and motor vehicle accidents, measured by both methods. Results: This study finds the temporal trend in mental health-related mortality rates (which reflects the longevity of people with mental illness) has worsened through time. There are no gains. This trend contrasts with the (known) gains in longevity from All Causes, and the gains from decreases achieved in previously rising mortality rates from circulatory diseases and motor vehicle accidents. Also, PYLL calculation shows mental health-related mortality is a proportionately greater cause of death compared with applying headcount metrics. Conclusions: There are several factors that could reverse this trend. First, improved access to interventions or therapies for mental disorders could decrease the mortality analysed here. Second, it is important also that new efficacious therapies for various mental disorders be developed. Furthermore, it is also important that suicide prevention strategies be implemented, particularly for at-risk groups. To bring the mental health sector into parity with many other parts of the health system will require knowledge of the causative factors that underlie mental disorders, which can, in turn, lead to efficacious therapies. As in any case of a knowledge deficit, what is needed are resources to address that knowledge gap. Conceiving the problem in this way, ie as a knowledge gap, indicates the crucial role of research and development activity. This term implies a concern, not simply with basic research, but also with applied research. It is commonplace in other sectors of the economy to emphasise the trichotomy of invention, innovation and diffusion of new products and processes. This three-fold conception is also relevant to addressing the knowledge gap in the mental health sector

The concept of research impact pervades contemporary academic discourse - but what does it actually mean?

Research impact is often talked about, but how clear is it what this term really means? Kristel Alla, Wayne Hall, Harvey Whiteford, Brian Head and Carla Meurk find that academic literature discusses research impact but often without properly defining it, with academic discourses mostly drawing on bureaucratic definitions originating from the UK. The authors highlight four core elements that comprise most research impact definitions and propose a new conceptualisation of research impact relevant to health policy

System-level intersectoral linkages between the mental health and non-clinical support sectors: a qualitative systematic review

Objectives: Concerns about fragmented mental health service delivery persist, particularly for people with severe and persistent mental illness. The objective was to review evidence regarding outcomes attributed to system-level intersectoral linkages involving mental health services and non-clinical support services, and to identify barriers and facilitators to the intersectoral linkage process

Mental and substance use disorders in sub-saharan Africa: predictions of epidemiological changes and mental health workforce requirements for the next 40 years

The world is undergoing a rapid health transition, with an ageing population and disease burden increasingly defined by disability. In Sub-Saharan Africa the next 40 years are predicted to see reduced mortality, signalling a surge in the impact of chronic diseases. We modelled these epidemiological changes and associated mental health workforce requirements. Years lived with a disability (YLD) predictions for mental and substance use disorders for each decade from 2010 to 2050 for four Sub-Saharan African regions were calculated using Global Burden of Disease 2010 study (GBD 2010) data and UN population forecasts. Predicted mental health workforce requirements for 2010 and 2050, by region and for selected countries, were modelled using GBD 2010 prevalence estimates and recommended packages of care and staffing ratios for low- and middle-income countries, and compared to current staffing from the WHO Mental Health Atlas. Significant population growth and ageing will result in an estimated 130% increase in the burden of mental and substance use disorders in Sub-Saharan Africa by 2050, to 45 million YLDs. As a result, the required mental health workforce will increase by 216,600 full time equivalent staff from 2010 to 2050, and far more compared to the existing workforce. The growth in mental and substance use disorders by 2050 is likely to significantly affect health and productivity in Sub-Saharan Africa. To reduce this burden, packages of care for key mental disorders should be provided through increasing the mental health workforce towards targets outlined in this paper. This requires a shift from current practice in most African countries, involving substantial investment in the training of primary care practitioners, supported by district based mental health specialist teams using a task sharing model that mobilises local community resources, with the expansion of inpatient psychiatric units based in district and regional general hospitals

The hidden burden of eating disorders : an extension of estimates from the Global Burden of Disease Study 2019

Background: Anorexia nervosa and bulimia nervosa are the only eating disorders included in the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2019, yet binge-eating disorder and other specified feeding or eating disorder (OSFED) are more prevalent. This study sought to estimate the prevalence and burden of binge-eating disorder and OSFED globally and present a case for their inclusion in GBD. Methods: We sourced studies from the GBD 2019 anorexia nervosa and bulimia nervosa epidemiological databases, two systematic reviews that included studies with epidemiological estimates of binge-eating disorder and OSFED, and experts in the field. Studies, published between Jan 1, 1998, and March 1, 2019, were included if they reported non-zero prevalence of two or more eating disorders (anorexia nervosa, bulimia nervosa, binge-eating disorder, or OSFED) and diagnosed cases according to DSM-IV or DSM-5. The proportions of total eating disorder cases that met diagnostic criteria for each individual eating disorder were estimated via network meta-regression and simulation using studies reporting eating disorder prevalence. The global cases unrepresented in GBD 2019 were estimated using the proportions from the simulation and the GBD 2019 eating disorder prevalence. Disability weights for binge-eating disorder and OSFED were then estimated along with disability-adjusted life-years (DALYs). Estimates are presented with 95% uncertainty intervals (UIs). Findings: 54 studies, of which 36 were from high-income countries, were included in the analysis. The number of global eating disorder cases in 2019 that were unrepresented in GBD 2019 was 41·9 million (95% UI 27·9–59·0), and consisted of 17·3 million (11·3–24·9) people with binge-eating disorder and 24·6 million (14·7–39·7) people with OSFED (vs 13·6 million [10·2–17·5] people with eating disorders in GBD 2019). Together, binge-eating disorder and OSFED caused 3·7 million (95% UI 2·0–6·5) DALYs globally, bringing the total eating disorder DALYs to 6·6 million (3·8–10·6) in 2019. Interpretation: Binge-eating disorder and OSFED accounted for the majority of eating disorder cases and DALYs globally. These findings warrant the inclusion of binge-eating disorder and OSFED in future iterations of GBD, which will bring the burden experienced by people living with these disorders to the attention of policy makers with the means to target this burden. Funding: Queensland Health, Australian National Health and Medical Research Council, and Bill & Melinda Gates Foundation

Should Burden of Disease Estimates Include Cannabis Use as a Risk Factor for Psychosis?

Louise Degenhardt and colleagues discuss the evidence and the debate about whether Global Burden of Disease estimates should include cannabis use as a risk factor for psychosis

Remunerating private psychiatrists for participating in case conferences

BACKGROUND: On 1 November 2000, a series of new item numbers was added to the Medicare Benefits Schedule, which allowed for case conferences between physicians (including psychiatrists) and other multidisciplinary providers. On 1 November 2002, an additional set of numbers was added, designed especially for use by psychiatrists. This paper reports the findings of an evaluation of these item numbers. RESULTS: The uptake of the item numbers in the three years post their introduction was low to moderate at best. Eighty nine psychiatrists rendered 479 case conferences at a cost to the Health Insurance Commission of $70,584. Psychiatrists who have used the item numbers are generally positive about them, as are consumers. Psychiatrists who have not used them have generally not done so because of a lack of knowledge, rather than direct opposition. The use of the item numbers is increasing over time, perhaps as psychiatrists become more aware of their existence and of their utility in maximising quality of care. CONCLUSION: The case conferencing item numbers have potential, but as yet this potential is not being realised. Some small changes to the conditions associated with the use of the item numbers could assist their uptake

An exploratory study of stakeholders' perceptions of how epidemiologic data can be utilized for policy in the field of mental health

The World Mental Health Survey Consortium, a World Health Organization and Harvard University collaboration, totaling 28 countries participated in a uniform randomized general population survey, making use of translated versions of the WHO Composite International Diagnostic Interview. One of the major purposes of the survey was to help inform policy decision makers regarding mental health. However many obstacles prevent the direct translation of survey data to policies. We report on an investigation of the mechanisms involved in the transformation of survey data into mental health policies. After conducting 11 interviews of individuals representing 12 countries that participated in the survey, we found that although governments did take an active role in the conduct of the survey, this did not necessarily translate into direct policy changes. A number of factors were noted to influence the adoption and implement ation of mental health policy changes from the survey data: the establishment of links between the research group and policymakers; the identification of costs of mental disorder; definition of clear solutions; and lastly the generation of political will. The range of countries included in this investigation has enabled comparisons in the use of evidence to influence policies in different contexts. Gaining an understanding of why some countries were successful and why others struggled in transforming survey results to policies may help to inform researchers of translational issues of research to mental health policies in the future.publishersversionpublishe