Graham Meadows

Service use for mental health problems: findings from the 2007 National Survey of Mental Health and Wellbeing

Objectives: To provide an overview of 12 month rates of service use for mental health problems and mental disorders by the general Australian adult population. Method: Data came from the 2007 National Survey of Mental Health and Wellbeing (2007 NSMHWB), a nationally representative household survey of 8841 individuals aged between 16 and 85 years. Results: Overall, 11.9% of the general Australian adult population made use of any services for mental health problems in a 12 month period. Approximately one-third of people (34.9%) meeting criteria for a mental disorder did so. Female subjects with mental disorders were more likely to use services than male subjects (40.7% vs 27.5%). People in the youngest age group made relatively less use of services than older adults. Those with affective disorders were most likely to make use of services (58.6%), followed by those with anxiety (37.8%) and substance use disorders (24.0%), respectively. Mental health hospitalizations were less common than consultations with community-based providers (2.6%), whereas 34.6% consulted a community-based provider – particularly general practitioners (24.7%) and psychologists (13.2%). There was a clear dose-response effect between severity of disorders and rates of community-based service use: 63.5% of those with severe mental disorders used community-based services, compared with 40.2% and 17.7% of those with moderate and mild mental disorders, respectively. There was also a relationship between comorbidity of mental disorders and service use. Conclusions: Rates of service use for mental health problems among those with mental disorders in Australia are less than optimal. Little international guidance is available regarding appropriate levels of treatment coverage and other comparable countries face similar difficulties. Further work is required to determine what an appropriate rate of service use is, and to set targets to reach that rate. Australia has demonstrated that concerted policy efforts can improve rates of service use. These efforts should be expanded.

Perceived need for mental health care, findings from the Australian National Survey of Mental Health and Well-being

BACKGROUND The Australian National Survey of Mental Health and Well-being was designed to detect and describe psychiatric morbidity, associated disability, service use and perceived need for care. The survey employed a single-phase interview methodology, delivering a field questionnaire to a clustered probability sample of 10,641 Australians. Perceived need was sampled with an instrument designed for this survey, the Perceived Need for Care Questionnaire (PNCQ). This questionnaire gathers information about five categories of perceived need, assigning each to one of four levels of perceived need. Reliability and validity studies showed satisfactory performance of the instrument. METHODS Perceived need for mental health care in the Australian population has been analysed using PNCQ data, relating this to diagnostic and service utilization data from the above survey. RESULTS The survey findings indicate that an estimated 13.8% of the Australian population have perceived need for mental health care. Those who met interview criteria for a psychiatric diagnosis and also expressed perceived need make up 9.9% of the population. An estimated 11.0% of the population are cases of untreated prevalence, a minority (3.6% of the population) of whom expressed perceived need for mental health care. Among persons using services, those without a psychiatric diagnosis based on interview criteria (4.4% of the population), showed high levels of perceived met need. CONCLUSIONS The overall rate of perceived need found by this methodology lies between those found in the USA and Canada. The findings suggest that service use in the absence of diagnosis elicited by survey questionnaires may often represent successful intervention. In the survey, untreated prevalence was commonly not accompanied by perceived need for mental health care.

Perceived need for mental health care: influences of diagnosis, demography and disability.

BACKGROUND Recent major epidemiological studies have adopted increasingly multidimensional approaches to assessment. Several of these have included some assessment of perceived need for mental health care. The Australian National Survey of Mental Health and Wellbeing, conducted in 1997, included a particularly detailed examination of this construct, with an instrument with demonstrated reliability and validity. METHODS A clustered probability sample of 10641 Australians responded to the field questionnaire for this survey, including questions on perceived need either where there had been service utilization, or where a disorder was detected by administration of sections of the Composite International Diagnostic Interview. The confidentialized unit record file generated from the survey was analysed for determinants of perceived need. RESULTS Perceived need is increased in females, in people in the middle years of adulthood, and in those who have affective disorders or co-morbidity. Effects of diagnosis and disability can account for most of the differences in gender specific rates. With correction for these effects through regression, there is less perceived need for social interventions and possibly more for counselling in females; disability is confirmed as strongly positively associated with perceived need, as are the presence of affective disorders or co-morbidity. CONCLUSIONS The findings of this study underscore the imperative for mental health services to be attentive and responsive to consumer perceived need. The substantial majority of people who are significantly disabled by mental health problems are among those who see themselves as having such needs.

Perceived Need for Mental Health Care: Findings from the 2007 Australian Survey of Mental Health and Wellbeing

Objectives: To provide an overview of perceived need for mental health care and response of services to those needs as assessed by the general Australian adult population. Method: The Perceived Need for Care Questionnaire was administered to respondents of the Australian 2007 National Survey of Mental Health and Wellbeing. This instrument allows for self assessment of needs for five kinds of intervention from mental health services as needed in the last year. Specific needs assessed included: medication, information, counselling including psychotherapy, social interventions and skills training: Needs for care may be rated as unmet, partially met and met. Results: Approximately 14% of the population perceived a need for mental health care and between 7% and 8% perceived a met need for either counselling or medication. Need for care was less likely to be perceived by people with substance use disorders than among those with anxiety or affective disorders. For just under half of the population with perceived need (45%), all perceived needs were rated as met, and for around one in five of those with perceived needs, none of their perceived needs were met. Proportionally, needs for medication are most likely to be rated as met at 84%, needs for counselling and information are met at a rate of between 50% and 60%, skills training approximately 40%, and social interventions needs are those least likely to be rated as fully met, at 25%. Conclusions: Mental health care is delivered in large volume and often with high levels of acceptability to the Australian community, although major gaps still remain. It appears that the disparity between need and care may be proportionally larger in the areas described as skills training and social interventions than areas outside of conventional mental health service domains of provision and medication and psychotherapy or counselling.

Mindfulness-based cognitive therapy for recurrent depression: A translational research study with 2-year follow-up

Objective: While mindfulness-based cognitive therapy (MBCT) has demonstrated efficacy in reducing depressive relapse/recurrence over 12–18 months, questions remain around effectiveness, longer-term outcomes, and suitability in combination with medication. The aim of this study was to investigate within a pragmatic study design the effectiveness of MBCT on depressive relapse/recurrence over 2 years of follow-up. Method: This was a prospective, multi-site, single-blind trial based in Melbourne and the regional city of Geelong, Australia. Non-depressed adults with a history of three or more episodes of depression were randomised to MBCT + depression relapse active monitoring (DRAM) (n=101) or control (DRAM alone) (n=102). Randomisation was stratified by medication (prescribed antidepressants and/or mood stabilisers: yes/no), site of usual care (primary or specialist), diagnosis (bipolar disorder: yes/no) and sex. Relapse/recurrence of major depression was assessed over 2 years using the Composite International Diagnostic Interview 2.1. Results: The average number of days with major depression was 65 for MBCT participants and 112 for controls, significant with repeated-measures ANOVA (F(1, 164)=4.56, p=0.03). Proportionally fewer MBCT participants relapsed in both year 1 and year 2 compared to controls (odds ratio 0.45, p<0.05). Kaplan-Meier survival analysis for time to first depressive episode was non-significant, although trends favouring the MBCT group were suggested. Subgroup analyses supported the effectiveness of MBCT for people receiving usual care in a specialist setting and for people taking antidepressant/mood stabiliser medication. Conclusions: This work in a pragmatic design with an active control condition supports the effectiveness of MBCT in something closer to implementation in routine practice than has been studied hitherto. As expected in this translational research design, observed effects were less strong than in some previous efficacy studies but appreciable and significant differences in outcome were detected. MBCT is most clearly demonstrated as effective for people receiving specialist care and seems to work well combined with antidepressants.

Mental disorders and mental health care in Canada and Australia: comparative epidemiological findings

BackgroundCanada and Australia although geographically distant have similarities in human geography and history. Each has had a national mental health policy for some years, but Australia has driven policy implementation in this area harder than has Canada. Comparable epidemiological surveys from Australia in 1997 and Canada in 2002 allow us to explore relative rates of mental disorders and compare estimates of access to care from mental health services.MethodsWe compare findings from the Australian National Survey of Mental Health and Wellbeing (1997) with those from the Canadian Community Health Survey on Mental Health and Well Being, cycle 1.2 (2002).ResultsDifferences in prevalence rates and in service utilisation emerge between the two countries: Anxiety Disorders are estimated as almost 2% higher in Canada than in Australia while there is suggestion that Major Depressive Disorder, Alcohol Dependence and Drug Dependence may be more prevalent in Australia. More of the people with co-morbid disorders in Australia than in Canada make use of mental health services and a finding of marginal significance suggests that this may be true across all disorders.ConclusionsCausation cannot be determined from this study but possible explanations for differences in prevalence include changes in global economic, political and security contexts and concerns between 1997 and 2002 and the possible role of greater availability of alcohol in Australia. The findings also provide encouragement that strenuously implementing a national mental health policy may have been of benefit to people with mental health problems in Australia.

The positive effect of integrated care on depressive symptoms in stroke survivors

Background: Depressive symptoms occur in approximately one-third of stroke patients. We sought to evaluate whether an integrated model of stroke care and secondary prevention reduced depressive symptomatology in stroke survivors. Methods: The integrated care (IC) model is a multifaceted program that provides ongoing collaboration between a specialist stroke service and primary care physicians, using telephone tracking, a bi-directional information feedback loop, management of vascular risk factors, and regular screening for depressive symptoms. Results: Patients exposed to the IC model exhibited significantly fewer depressive symptoms than controls at 12 months post stroke (as measured by the PHQ-9 screening tool; p = 0.006). At 12 months, 30/91 (33%) of the treatment group had depressive symptoms, compared to 52/95 (55%) of the control group (p = 0.003). With other variables adjusted for, the major associates of being depressed at 12 months were group allocation and physical disability. Conclusion: The integrated care approach provides a framework for detecting and monitoring depressive symptoms, and appears to be protective against post-stroke depression.

Is mental health in the Canadian population changing over time

Objective: Mental health in populations may be deteriorating, or it may be improving, but there is little direct evidence to support either possibility. Our objective was to examine secular trends in mental health indicators from national data sources. Methods: We used data (1994–2008) from the National Population Health Survey and from a series of cross-sectional studies (Canadian Community Health Survey) conducted in 2001, 2003, 2005, and 2007. We calculated population-weighted proportions and also generated sex-specifc, age-standardized estimates of major depressive episode prevalence, distress, professionally diagnosed mood disorders, antidepressant use, self-rated perceived mental health, and self-rated stress. Results: Major depression prevalence did not change over time. No changes in the frequency of severe distress were seen. However, there were increases in reported diagnoses of mood disorders and an increasing proportion of the population reported that they were taking antidepressants. The proportion of the population reporting that their life was extremely stressful decreased, but the proportion reporting poor mental health did not change. Conclusions: Measures based on assessment of symptoms showed no evidence of change over time. However, the frequency of diagnosis and treatment appears to be increasing and perceptions of extreme stress are decreasing. These changes probably reflect changes in diagnostic practice, mental health literacy, or willingness to report mental health concerns. However, no direct evidence of changing mental health status was found.

Psychiatry and the need for mental health care in Australia: findings from the National Survey of Mental Health and Wellbeing

Objective: This paper describes the pattern of consultations reported with psychiatrists and primary mental health care providers in the Australian adult population. It explores whether inequalities found in utilization of psychiatric services according to area are different in degree from inequalities in utilization of medical and surgical specialists, and describes the meeting of perceived needs for mental health care within those seen by psychiatrists. Method: The National Survey of Mental Health and Wellbeing (NSMHW) was a community survey employing clustered probability sampling, with a computerized field questionnaire which included sections of the composite international diagnostic interview (CIDI), as well as self-reported service utilization and perceived needs for care. Results: By survey estimates, 1.8% of the Australian population consulted a psychiatrist in the last year. Among people with an ICD 10-diagnosed mental disorder, 7.3% consulted a psychiatrist. Only about one in five people seen by a psychiatrist report the psychiatrist as the only mental health care provider. Disadvantaged areas of the cities and remote areas, when compared with the least deprived areas of the cities, showed lower rates of utilization. This effect is stronger in psychiatry than in other specialities. Patients seeing psychiatrists seem to be a more satisfied group than those seeing only other providers; nonetheless, some needs are not well met, and the role of the psychiatrist cannot be isolated as the cause of this satisfaction. Conclusions: Most care delivered by psychiatrists is de facto shared care. Psychiatrists as clinical professionals need to be continually mindful of the need to communicate with others providing care. Psychiatric services in Australia are not delivered in an equitable manner, and the inequalities are greater for psychiatric services than for other medical specialities.

Better access to mental health care and the failure of the Medicare principle of universality.

OBJECTIVES To examine whether adult use of mental health services subsidised by Medicare varies by measures of socioeconomic and geographic disadvantage in Australia. DESIGN, SETTING AND PARTICIPANTS A secondary analysis of national Medicare data from 1 July 2007 to 30 June 2011 for all mental health services subsidised by Better Access to Mental Health Care (Better Access) and Medicare - providers included general practitioners, psychiatrists, clinical psychologists and mental health allied health practitioners. MAIN OUTCOME MEASURES Service use rates followed by measurement of inequity using the concentration curve and concentration index. RESULTS Increasing remoteness was consistently associated with lower service activity; eg, per 1000 population, the annual rate of use of GP items was 79 in major cities and 25 and 8 in remote and very remote areas, respectively. Apart from GP usage, higher socioeconomic disadvantage in areas was typically associated with lower usage; eg, per 1000 population per year, clinical psychologist consultations were 68, 40 and 23 in the highest, middle and lowest advantaged quintiles, respectively; and non-Better Access psychiatry items were 117, 55 and 45 in the highest, middle and lowest advantaged quintiles, respectively. CONCLUSIONS Our results highlight important socioeconomic and geographical disparities associated with the use of Better Access and related Medicare services. This can inform Australias policymakers about these priority gaps and help to stimulate targeted strategies both nationally and regionally that work towards the universal and equitable delivery of mental health care for all Australians.