546387 research-article2014
ANP0010.1177/0004867414546387Australian & New Zealand Journal of PsychiatryJorm
Editorial
Why hasn’t the mental health of Australians improved? The need for a national prevention strategy
Australian & New Zealand Journal of Psychiatry 2014, Vol. 48(9) 795–801 DOI: 10.1177/0004867414546387 © The Royal Australian and New Zealand College of Psychiatrists 2014 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav anp.sagepub.com
Anthony F Jorm
Research carried out in Australia in the 1990s showed that mental disorders are common, disabling and often untreated. It has been proposed that increasing the provision of treatment could reduce the burden of disease from mental disorders in the population. However, despite two decades of increasing services, there has been no measurable improvement in the mental health of Australians. The only population improvement has been a reduction in the suicide rate from the late 1990s. A possible reason for the lack of progress in improving population mental health is that Australia has focused resources largely on reducing the duration of mental disorders through provision of more treatment and has neglected reducing the incidence of disorders through prevention. By contrast, the reduction in the suicide rate corresponded to the introduction of a national prevention strategy focused on suicide. Australia needs to redress the balance by developing a national prevention strategy for mental disorders using population health approaches, as a complement to the provision of clinical services for existing mental disorders.The detailed arguments for this conclusion are presented below.
The population impact of mental disorders During the 1990s, two important studies were carried out giving data on the impact of mental disorders on
the Australian population. The first was the 1997 National Survey of Mental Health and Wellbeing, which showed that mental disorders are common in the population, affecting around one in five adults in the previous 12 months. However, many of these people were found to be untreated. For affective disorders, 41% had no treatment in the previous 12 months, while for anxiety disorders it was 62% and for substance use disorders 76% (Henderson et al., 2000). This problem of under-treatment has been called the ‘treatment gap’ and has been found in all countries where similar national mental health surveys have been carried out. This problem is of such significance globally that the 2001 World Health Report made 10 recommendations for reducing the treatment gap. The other important study on the population impact of mental disorders was the Burden of Disease and Injury in Australia, 1996 (Mathers et al., 1999), which was an off-shoot of the influential Global Burden of Disease study. The innovation of this work was the use of disability-adjusted life years (DALYs) as a new method of looking at the impact of diseases and injuries on a population. When DALYs were used to measure the burden of disease in Australia in 1996, cardiovascular disease and cancer ranked as numbers 1 and 2, primarily because of their substantial effect on years of life lost through premature death, but mental disorders ranked as third, primarily because of their impact on years lived with disability.
Closing the treatment gap as a way to improve population mental health Given that mental disorders are under-treated, it seemed reasonable that if we could get more people into treatment and close the treatment gap, there might be a reduction in burden of disease from mental disorders. Estimates have been made for Australia of how much of the burden of mental disorders we could avert if we reduced the treatment gap (Andrews et al., 2004). Figure 1 shows the estimates of the burden that is currently averted through treatment of affective disorders, anxiety disorders, alcohol disorders and schizophrenia. It also shows the burden that could be realistically averted by extending treatment, and the burden that could be averted in a perfect health system. It can be seen that even under the realistic scenario, we might expect substantial reductions in disease burden by efforts to close the treatment gap.
Centre for Mental Health, Melbourne School of Population and Global Health, University of Melbourne, Parkville, Australia Corresponding author: Anthony F Jorm, Melbourne School of Population and Global Health, University of Melbourne, Parkville, VIC 3010, Australia. Email: [email protected]
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Figure 1. The burden of mental disorders that could be averted by reducing the treatment gap. (Data from Andrews et al., 2004.)
Percent of Burden Averted
60 50 40
Burden currently averted Burden that could be realis cally averted Burden that could be averted in perfect system
30 20 10 0
Category of Disorder
Progress made expanding mental health services There are consistent data showing that mental health services have expanded over the past two decades. This can be seen in increases in the amount of money spent, the size of the mental health workforce, use of services, use of pharmacological and psychological treatments, and reduction in unmet need in people receiving services. According to the 2013 National Mental Health Report (Department of Health and Ageing, 2013), total government expenditure on mental health increased by 178% in real terms between 1992/93 and 2010/11. The increase over this period was 245% for the Australian Government and 151% by state and territory governments. The national mental health workforce has also increased on a per capita basis from 80 FTE (full-time equivalent) per 100,000 in 1992/93 to 108 FTE per 100,000 in 2010/11, or an increase of 35% (Department of Health and Ageing, 2013). Use of pharmacological treatments has shown dramatic increases. From 1990 to 1998, antidepressant use increased from 12 to 36 DDDs (defined daily doses)/1000 population/
day, mainly because of a rapid increase in the use of selective serotonin reuptake inhibitors (McManus et al., 2000). This trend has continued into the present century, with a further increase from 45 to 89 DDDs/1000 population/day over the period 2000 to 2011 (Organisation for Economic Cooperation and Development (OECD), 2013). Australia is now the second highest OECD country with respect to antidepressant use, exceeded only by Iceland (OECD, 2013). Use of psychological treatments has increased dramatically, particularly following the introduction of the Better Access program in 2006. As well as subsidising mental health services from GPs, the Better Access program introduced Medicare benefits to cover services provided by psychologists and clinical psychologists. From 2007 to 2009, the use of services from psychologists increased from 10.2 to 16.4 per 100,000 persons, while the use of services from clinical psychologists increased from 4.7 to 8.9 per 100,000 persons (Pirkis et al., 2011). The data quoted above concern the quantity of services, but there are also data indicating that the quality has improved as well. Amongst people receiving mental health services, there
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was a reduction in perceived unmet need for counselling and information from 1997 to 2007 (Meadows and Bobevski, 2011). Taken together, the data on service provision and treatment show a consistent increase. This can be contrasted with the data on prevalence reviewed below.
Evidence on changes in prevalence The evidence on changes in prevalence comes from two national and one state series of surveys which have administered a short screening test for mental disorders on at least two occasions a decade or more apart. Table 1 shows the results of the three available sets of data spanning the period 1995 to 2011. The first study, by Jorm and Reavley (2012), looked at changes in Australian adults from 1995 to 2003 and then to 2011. No changes were found. The second study, by Reavley and colleagues (2011), looked at anxiety and depression symptoms in Australian adults in 1997 and 2007. An increase in anxiety was found, but no change in depression. The third study, by Goldney and colleagues (2010), looked at depression symptoms in South Australian adults in 1998, 2004 and 2008, and found a slight increase in depression. It is noteworthy that not only did these studies show there was no improvement, but what changes were found were in the opposite direction. The situation is similar in other countries where this issue has been examined. In the USA, there was no change in prevalence of mental disorders between 1990 and 2003 despite an increase in the percentage of the adult population receiving treatment from 12% over the 3-year period 1990–1992 to 20% over the 3-year period 2001–2003 (Kessler et al., 2005). Similarly, in Britain, there was no change in the prevalence of depression and mixed anxiety-depression in adults between 1993 and 2007 despite an increase in antidepressant treatment
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Jorm Table 1. Studies on changes in mental health in Australia: 1995 to 2011. Authors (year)
Population
Years measured
Measure
Findings
Jorm and Reavley (2012)
Australian adults
1995, 2003, 2011
4NS
No change in psychological symptoms
Reavley et al. (2011)
Australian adults
1997, 2007
K10 anxiety and depression
Increase in anxiety No change in depression
Goldney et al. (2010)
South Australian adults
1998, 2004, 2008
PHQ Depression
Increase in depression
4NS: 4 Neurotic Symptoms; K10: Kessler 10; PHQ: Patient Health Questionnaire.
from 1.1% to 4.9% of the population and of psychotherapy from 1.6% to 3.0% of the population (Mojtabai, 2011).
Improvement has occurred but is masked by the effects of other factors
Possible explanations for the lack of decline in prevalence
A second explanation is that services have had an effect, but it is counteracted by other factors. For example, there might be short-term social or environmental factors that push prevalence up at the same time that services are pushing it down. Such factors might include economic crises or natural disasters like bushfires or floods. However, looking at the years when the survey data were collected, it is difficult to see how short-term factors of this sort could produce the results. Another possibility is that the population may have become more open about mental health and more willing to report symptoms to survey interviewers. For example, if mental health problems become more accepted and less stigmatized over time, fewer people might hold back on reporting symptoms to a stranger who is interviewing them. There are no data available to test this possibility, but it is one worthy of further study.
There are two broad groups of potential explanations for why narrowing the treatment gap does not appear to have improved population mental health. The first group of explanations says that there really has been an improvement, but for various reasons it is hidden, whereas the second group says that there really has not been any improvement and gives an explanation of why not.
Surveys showing lack of improvement may lack statistical power The first of the explanations saying that there really has been an improvement involves the statistical power of the surveys examining change in population mental health. These may not have sufficient sample size to detect very small improvements. Power calculations on these surveys show that they have reasonable statistical power to detect a 2% drop in prevalence, but low power to detect a 1% drop. However, against this, we must consider that some of the surveys are not showing a lack of change, but actually a significant trend of worsening.
The number of services may have increased but the quality has not
quality of those services has not. There are some findings that could support this possibility. The data quoted above about unmet need among people receiving services show that, while overall unmet need has reduced, most of the improvement has been from unmet need to partially met need, rather than from unmet need to fully met need (Meadows and Bobevski, 2011). This indicates that the increase has been more in quantity than in quality. Another area where this explanation might apply is in the use of antidepressants. While antidepressant use has increased dramatically in Australia, much of this use is with older people, who are not the highest risk age group for affective and anxiety disorders (Hollingworth et al., 2010). There is thus a mismatch between need for treatment and use of antidepressants. Similarly, with the increase in psychological services under the Better Access scheme, it is possible that people are receiving non-specific supportive counselling or education about their illness, rather than therapies such as cognitive-behaviour therapy, which have the best evidence for their effectiveness.
Closing the treatment gap mainly involves milder The remaining explanations accept cases who have less to that the lack of improvement is real benefit and give an explanation of why we have not seen an improvement. One possibility of this sort is that while the number of services has increased, the
Another explanation is that the people with more severe problems are already likely to be getting services,
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Figure 2. The concepts of incidence, prevalence and recovery from mental disorders. Adapted from Gordis (2008).
and that closing the treatment gap involves getting more people with milder problems into services (Burgess et al., 2009). The 2011 National Survey of Mental Health and Wellbeing found that rates of community-based service use varied according to severity of disorder, with 63.5% of those with severe mental disorders having used services, compared to 40.2% of those with moderate severity and 17.7% of those with mild disorders. Thus, the treatment gap predominantly involves milder cases. Furthermore, there is evidence that milder cases are more likely to remit without treatment. For cases of depression, the untreated remission rate is 20–30% higher for mild–moderate than for severe disorders (Whiteford et al., 2013). So the marginal gains of further reducing the treatment gap may be small because it will largely involve the milder cases who have less to gain from treatment.
Australia has focused on treatment but neglected prevention The final possible explanation is that Australia has focused almost exclusively on treatment and neglected prevention. This explanation requires a consideration of some basic epidemiological concepts. The prevalence of a disorder (the number of cases at
a point in time) is a function of two things: the incidence, which is the rate of new disorders occurring, and the rate of recovery or deaths. Figure 2 illustrates these concepts, showing a tank containing balls with an inflow and an outflow. The inflow of balls is analogous to incidence, the balls currently in the tank are analogous to prevalence and the outflow is analogous to recoveries. The duration of a disorder is analogous to the time that a ball spends in the tank. Services are primarily aimed at producing recovery and reducing the duration of disorders—they try to get the balls out of the tank quicker. Prevention, on the other hand, aims to reduce the number of balls entering the tank. In Australia, we have put most of our resources into treatment, increasing the outflow, rather than prevention, reducing the inflow. This may be the principal reason for the lack of improvement in population mental health.
An exception to the lack of change: improvement in the suicide rate One national indicator that has shown some improvement is the suicide rate. Figure 3 shows rates for males and females from 1921 to 2012. A notable change in recent years has been the
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steady decline since the late 1990s in the suicide rate for males. For females, rates have been fairly steady in recent decades. It may be entirely coincidental, but this decline coincided with the introduction of a National Suicide Prevention Strategy in Australia. This strategy began in 1999 and continues to the present time. A major feature of this strategy is that it is a prevention strategy, not a treatment strategy. The funds for the strategy are used for community-based projects and it takes a population health approach. The sorts of activities covered by the strategy include reducing access to means of suicide, reducing inappropriate media coverage of suicide, fostering stronger and more supportive communities and schools, and intervening with groups and communities who are identified as being at higher risk of suicide. In other words, the one population indicator where Australia has had recent gains has been the subject of a preventive approach. It is not possible to be sure that this approach was the cause of the gains, but the coincidence is striking.
Is prevention of mental disorders possible? Clearly, we need to extend the approach that Australia has adopted for prevention of suicide to the prevention of mental disorders in general. In making this proposal, sceptical readers may question whether prevention of mental disorders is possible. However, two recent systematic reviews clearly indicate that it is. The first is a meta-analysis involving 32 randomized trials aiming to prevent the onset of major depressive disorder (Van Zoonen et al., 2014). This study found that it is possible to reduce the incidence of depressive disorder by 21%, and that prevention had to be carried out with 20 people to prevent one new case of depression. The second is a Cochrane review of psychological and educational
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Jorm
Figure 3. Suicide rate in Australia from 1921 to 2012. 40
Deaths per 100,000
35
male female
30 25 20 15 10 5
0 1921 1926 1931 1936 1941 1946 1951 1956 1961 1966 1971 1976 1981 1986 1991 1996 2001 2006 2011
Year
interventions for preventing depression in children and adolescents (Merry et al., 2011), which identified 53 studies involving over 14,000 participants.The authors concluded that ‘compared with no intervention, psychological depression prevention programmes were effective in preventing depression, with a number of studies showing a decrease in episodes of depressive illness over a year’.
What might a national prevention strategy cover? The evidence we have on preventive effects supports benefits over a year or more, but longer-term effects are unknown. Therefore, prevention should not be seen as an activity that is carried out early in life which necessarily has carry-over effects across the lifespan. Rather, preventive interventions may need to be carried out in an on-going way at different points in the lifespan and in different settings. To illustrate, three settings will be briefly considered here: families, schools, and workplaces. Examples are given to illustrate the types of preventive interventions that might be carried out in each of these settings.
Prevention in families There is good evidence that what parents do in raising their children can have an impact on the children’s risk for a whole range of mental health problems later in life (Ryan et al., 2010; Yap et al., 2014). For example, longitudinal studies show that the risk of anxiety disorders and depression is increased when parents show less warmth, and more inter-parental conflict, over-involvement and aversiveness. Similarly, earlier age of having the first alcoholic drink and low parental monitoring of children are associated with increased risk of alcohol misuse. Protective parental strategies could be the target of health promotion interventions, using both conventional media and the internet. Key messages might involve, for example, not fighting in front of the children and delaying the first alcoholic drink as long as possible.
Prevention in schools Schools are another important setting for prevention. The Cochrane review, cited earlier, showed that psychological and educational interventions can be effective in preventing depression
(Merry et al., 2011). Many of these interventions involve teaching cognitive-behaviour therapy skills. Naturally, one might ask how resources could be found to teach these skills in schools. Fortunately, Australia is the world leader in e-mental health, with several excellent websites providing free e-therapy, generally based on cognitive-behaviour therapy, which could be used for this purpose. It would be feasible for all high school students to work through an e-therapy website of this sort. Another area where schools could take action is with bullying, since being bullied is a known risk factor for mental health problems. Trials of anti-bullying interventions in schools show that whole-school approaches can be effective in reducing bullying (Vreeman and Carroll, 2007).
Prevention in workplaces There is considerable evidence that the characteristics of workplaces can affect the risk for mental health problems. There is also evidence that workplace prevention can be effective. A recent systematic review of trials showed that interventions
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800 applied across a whole workplace can reduce risk of depression (Tan et al., 2014).
The economic case for prevention of mental disorders Prevention, like everything else, costs resources and has to compete with other demands on the health system, including the demand for treatment. This leads to a consideration of the economic case for prevention. The Department of Health in the UK has published a report presenting the economic case for a number of preventive interventions (Knapp et al., 2011).The economic benefits of prevention programs were expressed in terms of pounds gained per pound expenditure. By simply calling the pounds dollars, we can look at the Australian equivalent. To give some examples, prevention of conduct disorder through social and emotional learning programs was estimated to pay off $83 for every dollar expended. School-based interventions to reduce bullying were estimated to pay off around $14 for every dollar expended. For workplace mental health promotion programs it was $9, and for debt advice services it was $3. (Debt advice is preventive because being in out-of-control debt is a risk factor for mental health problems.) Another way of looking at the economics of prevention is to estimate how much it costs to buy one additional full year of complete health in a person’s life. In technical jargon, how much does one DALY cost? A recent systematic review has examined the evidence on this (Mihalopoulos and Chatterton, 2014). To give some examples, it has been estimated that brief bibliotherapy for adults with mild depressive symptoms would cost $8600 per DALY. A parenting intervention aimed at children with mild anxiety would cost $7000 per DALY and school-based cognitive-behaviour therapy for children with mild depressive symptoms would cost $5400 per DALY. Compared to the costs of
ANZJP Perspectives treatments to get a similar gain, these are very good deals.
Prevention in the National Mental Health Service Planning Framework Developing a national strategy on prevention would require substantial planning. Fortunately, much of the groundwork has already been done. The Australian Government, working in collaboration with some of the states, has produced a National Mental Health Service Planning Framework. The Framework is essentially a decision aid to allow health planners to make evidence-informed decisions about where to allocate resources. Originally, the project was meant to be about treatments and services, but was fortunately extended to also include prevention and promotion. Teams of experts reviewed the evidence for preventive interventions and came to a consensus on which ones had sufficient evidence to include in the planning model. At the time of writing, the Framework is awaiting endorsement from the Mental Health Drug & Alcohol Principal Committee of the Australasian Health Ministers Advisory Council. Adopting the Framework would be an important first step towards developing a national strategy on prevention.
The need for more research on prevention While there is currently sufficient evidence on which to base a national prevention strategy, there is much that still needs researching. In particular, more needs to be known about whether there are longer-term effects of preventive interventions and there are promising areas, such as nutritional protection factors, which need to be tested in trials. A recent study on research priorities in mental health, commissioned
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by the Australian Government, found that stakeholders (including consumers, carers, clinicians and researchers) rate prevention of mental disorders as their top priority for research topics (Christensen et al., 2013). However, when the current distribution of funding on mental health research was examined, prevention was found to receive only a small proportion of funding, and the amount had actually declined from a decade earlier. Fortunately, one non-government funding agency, Australian Rotary Health, has recognized that prevention is an important but neglected area and has started to prioritize funding to this area. The formation of the Alliance for the Prevention of Mental Disorders in 2013 by a group of prevention researchers has also given an impetus to interest in this area.
Conclusion Despite increases in mental health services, the mental health of the Australian population has not improved. However, there is an important exception. The suicide rate has reduced since the late 1990s, which corresponded with the start of the National Suicide Prevention Strategy. There are several possible reasons for the lack of improvement in mental health, but a major one is that we have focused on reducing the duration of mental disorders through treatment, rather than on reducing the incidence of new disorders through prevention. The tools exist right now to develop a national strategy for the prevention of mental disorders using the National Mental Health Service Planning Framework as a foundation. There are no technical barriers to implementing a National Strategy for the Prevention of Mental Disorders. It is all a matter of political will. Keywords Mental health policy, mental health services, population mental health, prevention
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Jorm Acknowledgements This editorial is based on the Peter Karmel Lecture in Public Policy, delivered for the Academy of the Social Sciences in Australia, Canberra, 10 June 2014.
Funding The author is supported by an NHMRC Australia Fellowship.
Declaration of interest The author is a member of the executive of the Alliance for the Prevention of Mental Disorders.
References Andrews G, Issakidis C, Sanderson K, et al. (2004) Utilising survey data to inform public policy: comparison of the cost-effectiveness of treatment of ten mental disorders. British Journal of Psychiatry 184: 526–533. Burgess PM, Pirkis JE, Slade TN, et al. (2009) Service use for mental health problems: findings from the 2007 National Survey of Mental Health and Wellbeing. Australian and New Zealand Journal of Psychiatry 43: 615–623. Christensen H, Batterham PJ, Griffiths KM, et al. (2013) Research priorities in mental health. Australian and New Zealand Journal of Psychiatry 47: 3553–3562. Department of Health and Ageing (2013) National Mental Health Report 2013: Tracking Progress of Mental Health Reform in Australia 1993–2011. Canberra: Commonwealth of Australia. Goldney RD, Eckert KA, Hawthorne G, et al. (2010) Changes in the prevalence of major depression in an Australian community sample between 1998 and 2008. Australian and New Zealand Journal of Psychiatry 44: 901–910. Gordis L (2008) Epidemiology 4th ed. Philadelphia: Saunders.
Henderson S, Andrews G and Hall W (2000) Australia’s mental health: an overview of the general population survey. Australian and New Zealand Journal of Psychiatry 34: 197–205. Hollingworth SA, Burgess PM and Whiteford HA (2010) Affective and anxiety disorders: prevalence, treatment and antidepressant medication use. Australian and New Zealand Journal of Psychiatry 44: 513–519. Jorm AF and Reavley NJ (2012) Changes in psychological distress in Australian adults between 1995 and 2011. Australian and New Zealand Journal of Psychiatry 46: 352–356. Kessler RC, Demler O, Frank RG, et al. (2005) Prevalence and treatment of mental disorders, 1990 to 2003. New England Journal of Medicine 352: 2515–2523. Knapp M, McDaid D and Parsonage M (2011) Mental Health Promotion and Prevention: The Economic Case. London: Department of Health. McManus P, Mant A, Mitchell PB, et al. (2000) Recent trends in the use of antidepressant drugs in Australia, 1990–1998. Medical Journal of Australia 173: 458–461. Mathers C, Vos T and Stevenson C (1999) The Burden of Disease and Injury in Australia. AIHW cat. no. PHE 17. Canberra: Australian Institute of Health and Welfare. Meadows GN and Bobevski I (2011) Changes in met perceived need for mental healthcare in Australia from 1997 to 2007. British Journal of Psychiatry 199: 479–484. Merry SN, Hetrick SE, Cox GR, et al. (2011) Psychological and educational interventions for preventing depression in children and adolescents. Cochrane Database of Systematic Reviews 12: CD003380. Mihalopoulos C and Chatterton ML (2014) Economic evaluations of interventions designed to prevent mental disorders: a systematic review. Early Intervention in Psychiatry. Epub ahead of print 24 June. DOI: 10.1111/eip.12156. Mojtabai R (2011) The public health impact of antidepressants: an instrumental variable analysis. Journal of Affective Disorders 134: 188–197.
Organisation for Economic Cooperation and Development (OECD) (2013) Pharmaceutical consumption. Health at a glance 2013: OECD indicators. Available at: dx.doi.org/10.1787/ health_glance-2013-41-en (accessed 4 July 2014). Pirkis J, Harris M, Hall W, et al. (2011) Evaluation of the Better Access to Psychiatrists, Psychologists and General Practitioners Through the Medicare Benefits Schedule Initiative: Summative Evaluation. Melbourne: Centre for Health Policy, Programs and Economics. Reavley NJ, Jorm AF, Cvetkovski S, et al. (2011) National depression and anxiety indices for Australia. Australian and New Zealand Journal of Psychiatry 45: 780–787. Ryan SM, Jorm AF and Lubman DI (2010) Parenting factors associated with reduced adolescent alcohol use: a systematic review of longitudinal studies. Australian and New Zealand Journal of Psychiatry 44: 774–783. Tan L, Wang MJ, Modini M, et al. (2014) Preventing the development of depression at work: a systematic review and meta-analysis of universal interventions in the workplace. BMC Medicine 12: 74. Van Zoonen K, Buntrock C, Ebert DD, et al. (2014) Preventing the onset of major depressive disorder: a meta-analytic review of psychological interventions. International Journal of Epidemiology 43: 318–329. Vreeman RC and Carroll AE (2007) A systematic review of school-based interventions to prevent bullying. Archives of Pediatrics and Adolescent Medicine 161: 78–88. Whiteford HA, Harris MG, McKeon G, et al. (2013) Estimating remission from untreated major depression: a systematic review and meta-analysis. Psychological Medicine 43: 1569– 1585. Yap MB, Pilkington PD, Ryan SM, et al. (2014) Parental factors associated with depression and anxiety in young people: a systematic review and meta-analysis. Journal of Affective Disorders 156: 8–23.
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ANP0010.1177/0004867414546387Australian & New Zealand Journal of PsychiatryJorm
Editorial
Why hasn’t the mental health of Australians improved? The need for a national prevention strategy
Australian & New Zealand Journal of Psychiatry 2014, Vol. 48(9) 795–801 DOI: 10.1177/0004867414546387 © The Royal Australian and New Zealand College of Psychiatrists 2014 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav anp.sagepub.com
Anthony F Jorm
Research carried out in Australia in the 1990s showed that mental disorders are common, disabling and often untreated. It has been proposed that increasing the provision of treatment could reduce the burden of disease from mental disorders in the population. However, despite two decades of increasing services, there has been no measurable improvement in the mental health of Australians. The only population improvement has been a reduction in the suicide rate from the late 1990s. A possible reason for the lack of progress in improving population mental health is that Australia has focused resources largely on reducing the duration of mental disorders through provision of more treatment and has neglected reducing the incidence of disorders through prevention. By contrast, the reduction in the suicide rate corresponded to the introduction of a national prevention strategy focused on suicide. Australia needs to redress the balance by developing a national prevention strategy for mental disorders using population health approaches, as a complement to the provision of clinical services for existing mental disorders.The detailed arguments for this conclusion are presented below.
The population impact of mental disorders During the 1990s, two important studies were carried out giving data on the impact of mental disorders on
the Australian population. The first was the 1997 National Survey of Mental Health and Wellbeing, which showed that mental disorders are common in the population, affecting around one in five adults in the previous 12 months. However, many of these people were found to be untreated. For affective disorders, 41% had no treatment in the previous 12 months, while for anxiety disorders it was 62% and for substance use disorders 76% (Henderson et al., 2000). This problem of under-treatment has been called the ‘treatment gap’ and has been found in all countries where similar national mental health surveys have been carried out. This problem is of such significance globally that the 2001 World Health Report made 10 recommendations for reducing the treatment gap. The other important study on the population impact of mental disorders was the Burden of Disease and Injury in Australia, 1996 (Mathers et al., 1999), which was an off-shoot of the influential Global Burden of Disease study. The innovation of this work was the use of disability-adjusted life years (DALYs) as a new method of looking at the impact of diseases and injuries on a population. When DALYs were used to measure the burden of disease in Australia in 1996, cardiovascular disease and cancer ranked as numbers 1 and 2, primarily because of their substantial effect on years of life lost through premature death, but mental disorders ranked as third, primarily because of their impact on years lived with disability.
Closing the treatment gap as a way to improve population mental health Given that mental disorders are under-treated, it seemed reasonable that if we could get more people into treatment and close the treatment gap, there might be a reduction in burden of disease from mental disorders. Estimates have been made for Australia of how much of the burden of mental disorders we could avert if we reduced the treatment gap (Andrews et al., 2004). Figure 1 shows the estimates of the burden that is currently averted through treatment of affective disorders, anxiety disorders, alcohol disorders and schizophrenia. It also shows the burden that could be realistically averted by extending treatment, and the burden that could be averted in a perfect health system. It can be seen that even under the realistic scenario, we might expect substantial reductions in disease burden by efforts to close the treatment gap.
Centre for Mental Health, Melbourne School of Population and Global Health, University of Melbourne, Parkville, Australia Corresponding author: Anthony F Jorm, Melbourne School of Population and Global Health, University of Melbourne, Parkville, VIC 3010, Australia. Email: [email protected]
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Figure 1. The burden of mental disorders that could be averted by reducing the treatment gap. (Data from Andrews et al., 2004.)
Percent of Burden Averted
60 50 40
Burden currently averted Burden that could be realis cally averted Burden that could be averted in perfect system
30 20 10 0
Category of Disorder
Progress made expanding mental health services There are consistent data showing that mental health services have expanded over the past two decades. This can be seen in increases in the amount of money spent, the size of the mental health workforce, use of services, use of pharmacological and psychological treatments, and reduction in unmet need in people receiving services. According to the 2013 National Mental Health Report (Department of Health and Ageing, 2013), total government expenditure on mental health increased by 178% in real terms between 1992/93 and 2010/11. The increase over this period was 245% for the Australian Government and 151% by state and territory governments. The national mental health workforce has also increased on a per capita basis from 80 FTE (full-time equivalent) per 100,000 in 1992/93 to 108 FTE per 100,000 in 2010/11, or an increase of 35% (Department of Health and Ageing, 2013). Use of pharmacological treatments has shown dramatic increases. From 1990 to 1998, antidepressant use increased from 12 to 36 DDDs (defined daily doses)/1000 population/
day, mainly because of a rapid increase in the use of selective serotonin reuptake inhibitors (McManus et al., 2000). This trend has continued into the present century, with a further increase from 45 to 89 DDDs/1000 population/day over the period 2000 to 2011 (Organisation for Economic Cooperation and Development (OECD), 2013). Australia is now the second highest OECD country with respect to antidepressant use, exceeded only by Iceland (OECD, 2013). Use of psychological treatments has increased dramatically, particularly following the introduction of the Better Access program in 2006. As well as subsidising mental health services from GPs, the Better Access program introduced Medicare benefits to cover services provided by psychologists and clinical psychologists. From 2007 to 2009, the use of services from psychologists increased from 10.2 to 16.4 per 100,000 persons, while the use of services from clinical psychologists increased from 4.7 to 8.9 per 100,000 persons (Pirkis et al., 2011). The data quoted above concern the quantity of services, but there are also data indicating that the quality has improved as well. Amongst people receiving mental health services, there
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was a reduction in perceived unmet need for counselling and information from 1997 to 2007 (Meadows and Bobevski, 2011). Taken together, the data on service provision and treatment show a consistent increase. This can be contrasted with the data on prevalence reviewed below.
Evidence on changes in prevalence The evidence on changes in prevalence comes from two national and one state series of surveys which have administered a short screening test for mental disorders on at least two occasions a decade or more apart. Table 1 shows the results of the three available sets of data spanning the period 1995 to 2011. The first study, by Jorm and Reavley (2012), looked at changes in Australian adults from 1995 to 2003 and then to 2011. No changes were found. The second study, by Reavley and colleagues (2011), looked at anxiety and depression symptoms in Australian adults in 1997 and 2007. An increase in anxiety was found, but no change in depression. The third study, by Goldney and colleagues (2010), looked at depression symptoms in South Australian adults in 1998, 2004 and 2008, and found a slight increase in depression. It is noteworthy that not only did these studies show there was no improvement, but what changes were found were in the opposite direction. The situation is similar in other countries where this issue has been examined. In the USA, there was no change in prevalence of mental disorders between 1990 and 2003 despite an increase in the percentage of the adult population receiving treatment from 12% over the 3-year period 1990–1992 to 20% over the 3-year period 2001–2003 (Kessler et al., 2005). Similarly, in Britain, there was no change in the prevalence of depression and mixed anxiety-depression in adults between 1993 and 2007 despite an increase in antidepressant treatment
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Jorm Table 1. Studies on changes in mental health in Australia: 1995 to 2011. Authors (year)
Population
Years measured
Measure
Findings
Jorm and Reavley (2012)
Australian adults
1995, 2003, 2011
4NS
No change in psychological symptoms
Reavley et al. (2011)
Australian adults
1997, 2007
K10 anxiety and depression
Increase in anxiety No change in depression
Goldney et al. (2010)
South Australian adults
1998, 2004, 2008
PHQ Depression
Increase in depression
4NS: 4 Neurotic Symptoms; K10: Kessler 10; PHQ: Patient Health Questionnaire.
from 1.1% to 4.9% of the population and of psychotherapy from 1.6% to 3.0% of the population (Mojtabai, 2011).
Improvement has occurred but is masked by the effects of other factors
Possible explanations for the lack of decline in prevalence
A second explanation is that services have had an effect, but it is counteracted by other factors. For example, there might be short-term social or environmental factors that push prevalence up at the same time that services are pushing it down. Such factors might include economic crises or natural disasters like bushfires or floods. However, looking at the years when the survey data were collected, it is difficult to see how short-term factors of this sort could produce the results. Another possibility is that the population may have become more open about mental health and more willing to report symptoms to survey interviewers. For example, if mental health problems become more accepted and less stigmatized over time, fewer people might hold back on reporting symptoms to a stranger who is interviewing them. There are no data available to test this possibility, but it is one worthy of further study.
There are two broad groups of potential explanations for why narrowing the treatment gap does not appear to have improved population mental health. The first group of explanations says that there really has been an improvement, but for various reasons it is hidden, whereas the second group says that there really has not been any improvement and gives an explanation of why not.
Surveys showing lack of improvement may lack statistical power The first of the explanations saying that there really has been an improvement involves the statistical power of the surveys examining change in population mental health. These may not have sufficient sample size to detect very small improvements. Power calculations on these surveys show that they have reasonable statistical power to detect a 2% drop in prevalence, but low power to detect a 1% drop. However, against this, we must consider that some of the surveys are not showing a lack of change, but actually a significant trend of worsening.
The number of services may have increased but the quality has not
quality of those services has not. There are some findings that could support this possibility. The data quoted above about unmet need among people receiving services show that, while overall unmet need has reduced, most of the improvement has been from unmet need to partially met need, rather than from unmet need to fully met need (Meadows and Bobevski, 2011). This indicates that the increase has been more in quantity than in quality. Another area where this explanation might apply is in the use of antidepressants. While antidepressant use has increased dramatically in Australia, much of this use is with older people, who are not the highest risk age group for affective and anxiety disorders (Hollingworth et al., 2010). There is thus a mismatch between need for treatment and use of antidepressants. Similarly, with the increase in psychological services under the Better Access scheme, it is possible that people are receiving non-specific supportive counselling or education about their illness, rather than therapies such as cognitive-behaviour therapy, which have the best evidence for their effectiveness.
Closing the treatment gap mainly involves milder The remaining explanations accept cases who have less to that the lack of improvement is real benefit and give an explanation of why we have not seen an improvement. One possibility of this sort is that while the number of services has increased, the
Another explanation is that the people with more severe problems are already likely to be getting services,
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ANZJP Perspectives
Figure 2. The concepts of incidence, prevalence and recovery from mental disorders. Adapted from Gordis (2008).
and that closing the treatment gap involves getting more people with milder problems into services (Burgess et al., 2009). The 2011 National Survey of Mental Health and Wellbeing found that rates of community-based service use varied according to severity of disorder, with 63.5% of those with severe mental disorders having used services, compared to 40.2% of those with moderate severity and 17.7% of those with mild disorders. Thus, the treatment gap predominantly involves milder cases. Furthermore, there is evidence that milder cases are more likely to remit without treatment. For cases of depression, the untreated remission rate is 20–30% higher for mild–moderate than for severe disorders (Whiteford et al., 2013). So the marginal gains of further reducing the treatment gap may be small because it will largely involve the milder cases who have less to gain from treatment.
Australia has focused on treatment but neglected prevention The final possible explanation is that Australia has focused almost exclusively on treatment and neglected prevention. This explanation requires a consideration of some basic epidemiological concepts. The prevalence of a disorder (the number of cases at
a point in time) is a function of two things: the incidence, which is the rate of new disorders occurring, and the rate of recovery or deaths. Figure 2 illustrates these concepts, showing a tank containing balls with an inflow and an outflow. The inflow of balls is analogous to incidence, the balls currently in the tank are analogous to prevalence and the outflow is analogous to recoveries. The duration of a disorder is analogous to the time that a ball spends in the tank. Services are primarily aimed at producing recovery and reducing the duration of disorders—they try to get the balls out of the tank quicker. Prevention, on the other hand, aims to reduce the number of balls entering the tank. In Australia, we have put most of our resources into treatment, increasing the outflow, rather than prevention, reducing the inflow. This may be the principal reason for the lack of improvement in population mental health.
An exception to the lack of change: improvement in the suicide rate One national indicator that has shown some improvement is the suicide rate. Figure 3 shows rates for males and females from 1921 to 2012. A notable change in recent years has been the
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steady decline since the late 1990s in the suicide rate for males. For females, rates have been fairly steady in recent decades. It may be entirely coincidental, but this decline coincided with the introduction of a National Suicide Prevention Strategy in Australia. This strategy began in 1999 and continues to the present time. A major feature of this strategy is that it is a prevention strategy, not a treatment strategy. The funds for the strategy are used for community-based projects and it takes a population health approach. The sorts of activities covered by the strategy include reducing access to means of suicide, reducing inappropriate media coverage of suicide, fostering stronger and more supportive communities and schools, and intervening with groups and communities who are identified as being at higher risk of suicide. In other words, the one population indicator where Australia has had recent gains has been the subject of a preventive approach. It is not possible to be sure that this approach was the cause of the gains, but the coincidence is striking.
Is prevention of mental disorders possible? Clearly, we need to extend the approach that Australia has adopted for prevention of suicide to the prevention of mental disorders in general. In making this proposal, sceptical readers may question whether prevention of mental disorders is possible. However, two recent systematic reviews clearly indicate that it is. The first is a meta-analysis involving 32 randomized trials aiming to prevent the onset of major depressive disorder (Van Zoonen et al., 2014). This study found that it is possible to reduce the incidence of depressive disorder by 21%, and that prevention had to be carried out with 20 people to prevent one new case of depression. The second is a Cochrane review of psychological and educational
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Jorm
Figure 3. Suicide rate in Australia from 1921 to 2012. 40
Deaths per 100,000
35
male female
30 25 20 15 10 5
0 1921 1926 1931 1936 1941 1946 1951 1956 1961 1966 1971 1976 1981 1986 1991 1996 2001 2006 2011
Year
interventions for preventing depression in children and adolescents (Merry et al., 2011), which identified 53 studies involving over 14,000 participants.The authors concluded that ‘compared with no intervention, psychological depression prevention programmes were effective in preventing depression, with a number of studies showing a decrease in episodes of depressive illness over a year’.
What might a national prevention strategy cover? The evidence we have on preventive effects supports benefits over a year or more, but longer-term effects are unknown. Therefore, prevention should not be seen as an activity that is carried out early in life which necessarily has carry-over effects across the lifespan. Rather, preventive interventions may need to be carried out in an on-going way at different points in the lifespan and in different settings. To illustrate, three settings will be briefly considered here: families, schools, and workplaces. Examples are given to illustrate the types of preventive interventions that might be carried out in each of these settings.
Prevention in families There is good evidence that what parents do in raising their children can have an impact on the children’s risk for a whole range of mental health problems later in life (Ryan et al., 2010; Yap et al., 2014). For example, longitudinal studies show that the risk of anxiety disorders and depression is increased when parents show less warmth, and more inter-parental conflict, over-involvement and aversiveness. Similarly, earlier age of having the first alcoholic drink and low parental monitoring of children are associated with increased risk of alcohol misuse. Protective parental strategies could be the target of health promotion interventions, using both conventional media and the internet. Key messages might involve, for example, not fighting in front of the children and delaying the first alcoholic drink as long as possible.
Prevention in schools Schools are another important setting for prevention. The Cochrane review, cited earlier, showed that psychological and educational interventions can be effective in preventing depression
(Merry et al., 2011). Many of these interventions involve teaching cognitive-behaviour therapy skills. Naturally, one might ask how resources could be found to teach these skills in schools. Fortunately, Australia is the world leader in e-mental health, with several excellent websites providing free e-therapy, generally based on cognitive-behaviour therapy, which could be used for this purpose. It would be feasible for all high school students to work through an e-therapy website of this sort. Another area where schools could take action is with bullying, since being bullied is a known risk factor for mental health problems. Trials of anti-bullying interventions in schools show that whole-school approaches can be effective in reducing bullying (Vreeman and Carroll, 2007).
Prevention in workplaces There is considerable evidence that the characteristics of workplaces can affect the risk for mental health problems. There is also evidence that workplace prevention can be effective. A recent systematic review of trials showed that interventions
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800 applied across a whole workplace can reduce risk of depression (Tan et al., 2014).
The economic case for prevention of mental disorders Prevention, like everything else, costs resources and has to compete with other demands on the health system, including the demand for treatment. This leads to a consideration of the economic case for prevention. The Department of Health in the UK has published a report presenting the economic case for a number of preventive interventions (Knapp et al., 2011).The economic benefits of prevention programs were expressed in terms of pounds gained per pound expenditure. By simply calling the pounds dollars, we can look at the Australian equivalent. To give some examples, prevention of conduct disorder through social and emotional learning programs was estimated to pay off $83 for every dollar expended. School-based interventions to reduce bullying were estimated to pay off around $14 for every dollar expended. For workplace mental health promotion programs it was $9, and for debt advice services it was $3. (Debt advice is preventive because being in out-of-control debt is a risk factor for mental health problems.) Another way of looking at the economics of prevention is to estimate how much it costs to buy one additional full year of complete health in a person’s life. In technical jargon, how much does one DALY cost? A recent systematic review has examined the evidence on this (Mihalopoulos and Chatterton, 2014). To give some examples, it has been estimated that brief bibliotherapy for adults with mild depressive symptoms would cost $8600 per DALY. A parenting intervention aimed at children with mild anxiety would cost $7000 per DALY and school-based cognitive-behaviour therapy for children with mild depressive symptoms would cost $5400 per DALY. Compared to the costs of
ANZJP Perspectives treatments to get a similar gain, these are very good deals.
Prevention in the National Mental Health Service Planning Framework Developing a national strategy on prevention would require substantial planning. Fortunately, much of the groundwork has already been done. The Australian Government, working in collaboration with some of the states, has produced a National Mental Health Service Planning Framework. The Framework is essentially a decision aid to allow health planners to make evidence-informed decisions about where to allocate resources. Originally, the project was meant to be about treatments and services, but was fortunately extended to also include prevention and promotion. Teams of experts reviewed the evidence for preventive interventions and came to a consensus on which ones had sufficient evidence to include in the planning model. At the time of writing, the Framework is awaiting endorsement from the Mental Health Drug & Alcohol Principal Committee of the Australasian Health Ministers Advisory Council. Adopting the Framework would be an important first step towards developing a national strategy on prevention.
The need for more research on prevention While there is currently sufficient evidence on which to base a national prevention strategy, there is much that still needs researching. In particular, more needs to be known about whether there are longer-term effects of preventive interventions and there are promising areas, such as nutritional protection factors, which need to be tested in trials. A recent study on research priorities in mental health, commissioned
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by the Australian Government, found that stakeholders (including consumers, carers, clinicians and researchers) rate prevention of mental disorders as their top priority for research topics (Christensen et al., 2013). However, when the current distribution of funding on mental health research was examined, prevention was found to receive only a small proportion of funding, and the amount had actually declined from a decade earlier. Fortunately, one non-government funding agency, Australian Rotary Health, has recognized that prevention is an important but neglected area and has started to prioritize funding to this area. The formation of the Alliance for the Prevention of Mental Disorders in 2013 by a group of prevention researchers has also given an impetus to interest in this area.
Conclusion Despite increases in mental health services, the mental health of the Australian population has not improved. However, there is an important exception. The suicide rate has reduced since the late 1990s, which corresponded with the start of the National Suicide Prevention Strategy. There are several possible reasons for the lack of improvement in mental health, but a major one is that we have focused on reducing the duration of mental disorders through treatment, rather than on reducing the incidence of new disorders through prevention. The tools exist right now to develop a national strategy for the prevention of mental disorders using the National Mental Health Service Planning Framework as a foundation. There are no technical barriers to implementing a National Strategy for the Prevention of Mental Disorders. It is all a matter of political will. Keywords Mental health policy, mental health services, population mental health, prevention
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Jorm Acknowledgements This editorial is based on the Peter Karmel Lecture in Public Policy, delivered for the Academy of the Social Sciences in Australia, Canberra, 10 June 2014.
Funding The author is supported by an NHMRC Australia Fellowship.
Declaration of interest The author is a member of the executive of the Alliance for the Prevention of Mental Disorders.
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