People who haven’t heard about the mental health reforms that were introduced in Australia after last year’s budget might ask ‘What’s wrong with these changes?’ There are just so many ways to answer that question, that it is difficult to know where exactly to start. On this website, we have tried to divide this task into smaller manageable chunks that people can digest, but recently I was asked if I could bring everything together. If you haven’t been following things closely, or if you are unfamiliar with the sensitive area of mental health care, here’s a short summary of why people are upset about the changes.

The need for evidence-based mental health policy reform

Controlled research in the field of psychology has consistently led to the recommendation that at least 15 to 20 sessions of psychological treatment should be offered to people with common mental health disorders, like depression, anxiety and post-traumatic stress disorder. The initial structure of the Better Access initiative was based on some of these early findings, allowing up to 18 appointments (i.e., approaching 20). Primarily, this was based on the findings of a US study conducted by the National Institute of Mental Health called the Treatment of Depression Collaborative Research Program – the largest study of treatments for depression worldwide. The study showed initial improvement from 16 weeks of treatment, but follow up studies showed that this did not last. The chief researcher found that 33% of the sample had relapsed within 18 months, concluding that “The major finding of this study is that 16 weeks of these specific forms of treatment is insufficient for most patients to achieve full recovery and lasting remission” (Shea et al., 1992). These results are confirmed in a ‘survival analysis’ published here in Australia by Harnett et al. (2010) demonstrating that for reliable improvement to be shown in 85% of cases, at least 20 appointments are required. These results are also consistent with recent reviews in the US and the UK, including a 707 page review of treatments for depression carried out by the National Institute of Clinical Excellence (NICE) which states that for all people receiving psychological treatment of depression “the duration of treatment should typically be in the range of 16 to 20 sessions over 3 to 4 months”. Another major review for the treatment of depression conducted by the US Department of Veteran’s Affairs recommends continuation of therapy 9 to 12 months after the initial acute symptoms resolve, in order to maintain the gains of treatment and prevent relapse. This matches the clinical experience of psychologists in Australia who provide services in the Better Access initiative, which is why they are protesting the cuts. Likewise, it matches the experience of vast numbers of mental health consumers, who have in many cases needed far more than ten appointments.

Distorted statistics about the number of appointments used

The current Government is relying on figures from the recent evaluation of the Better Access initiative to justify the cuts, however, they are taking the statistics on face value without considering broader evidence. For instance, the most frequent claim we have heard is that MBS data shows that most patients use less than 10 sessions, and hence, all patients should not be able to access psychological treatment beyond that mark. That is a flawed conclusion to draw, arising from a misinterpretation of the statistics. First, many patients begin treatment, but are not able to sustain therapy for long enough. Psychotherapy can be confronting for some, but for others, pulling out of therapy comes down to the fact that a mental health condition can create such instability that regular appointments are difficult to sustain. Taking the data on MBS items used per year as a set figure for how long treatment should last gives a distorted impression of how many services are actually needed, particularly when psychological treatment spans two different calendar years. That is, if a person starts treatment in November they may only use a few appointments in that year, continuing their treatment into the next year. The MBS statistics however, will show these people as only having used a few appointments in that year. The implication is that when treatment spans several calendar years, the MBS data will only reflect a portion of their treatment split across each year, giving a significantly reduced figure for the amount of treatment that is actually required over a full episode of care. There are also positive ways to interpret these figures. For some patients, getting psychological treatment improves their condition to the point where they can earn a living, and as a result, they are then able to fund their own treatment (without using Medicare). Patients in this situation still require far more treatment than the MBS items (or survey data) reflects, however, they pay for it on their own, which is one important reason why the Better Access initiative adds value to our society. The problem is that when the Government cuts Medicare support off at ten appointments, they end up hurting the people who are most in need of psychological treatment and are least able to afford it.

Government spin about the severity of mental health conditions

Spokespeople for the Government, including the Federal Minister for Mental Health, Mark Butler, have claimed on a number of occasions that patients who need more than ten appointments can receive better treatment in other programs. Both the initial budget statement and letters that Mark Butler has written to the public about the cuts to Better Access, state that the ATAPS program is better suited for the treatment of patients with complex or severe mental health disorders. However, by contrast, the 2010-2011 Operational Guidelines for the ATAPS program directly contradict his claims, instead stating that the ATAPS program “is particularly suitable for providing short term psychological services to individuals with mild to moderate common mental illness” (page 4). Strangely, the recently appointed Minister for Health seemed to add to these contradictions in her replies to concerned members of the public who were asking for the cuts to be reversed, when she stated that, “Schemes like the Better Access initiative are in place to help people who find themselves in some really difficult circumstances”. She is correct, however, this is not consistent with the narrative coming from Mark Butler that the Better Access initiative is unsuitable for patients with complex and severe mental health disorders. Butler’s response is also inconsistent with the advice coming from other Government spokespeople who recently advised Senator Penny Wright that “both Better Access and ATAPS have the same client group”. Part of the reason for this mismatch is that Mark Butler is getting much of his policy advice from Professor Ian Hickie who has gone as far as to claim to the media (and the senate inquiry last year) that the Better Access program was never even intended to provide services to people with severe mental health issues. The COAG statement for the Better Access initiative makes it clear that the program was actually always intended to serve the needs of people with complex and severe mental health disorders, making no reference at all to mild disorders. The evaluation of the Better Access initiative also confirms this point by showing that over 80% of patients who accessed the program had serious levels of symptom severity, often with co-morbid depression and anxiety. This is a very different picture to what our current Government is now claiming, to the effect that the Better Access initiative is meant to be for mild to moderate problems!

False claims about uptake of treatment by disadvantaged groups

The Government has also repeated the false assertion that the Better Access initiative was failing hard-to-reach groups. Evidence from the Better Access evaluation shows that the program has expanded access to mental health care considerably across ALL groups, with the highest growth in uptake being in traditionally under-served populations. Even Mark Butler himself conceded this point in March last year, at a meeting for the ‘Mental Health Expert Working Group’ where he stated that the Better Access initiative had led to “an increase in treatment rates from 35% in 2007 to around 46% in 2010” – a substantial improvement. At these meetings, leading up to the cuts to psychological services, there was nothing but praise for the Better Access initiative and calls for the program to be better promoted and expanded. The figures from the evaluation of Better Access showed that the highest growth in uptake of treatment was amongst the most disadvantaged groups and that half of those who received psychological treatment had never done so in the past. What these figures show is that the Better Access initiative was increasingly reaching the most disadvantaged populations in Australian society and that it was working well in conjunction with complementary systems, such as ATAPS.

Siphoning public funds away from psychological care

Although the Government has said that all of the funding cut from the Better Access program will be reinvested into mental health, what they have not made clear to the public is that overall our access to psychological treatment services is being cut, particularly when we look at this from the perspective of an individual patient. At the senate hearing, Professor Ian Hickie made the point that “With a reduction in number of sessions, more people will get into Better Access,” stressing that “In total numbers more people will be receiving psychological services.” If this is any indication of where the policy emphasis now lies, then the Government appears to be trying to get more numbers through the door rather than delivering adequate levels of care to those who are reaching out for psychological treatment. A more significant problem however is that most of the programs where funding is being redirected do not provide any psychological treatment services, but rather, they offer mentors, personal helpers, care facilitators, and activity programs. Such programs are obviously very useful for some cases where an individual has become severely disabled, but this is obviously no substitute for psychological treatment. It seems self-defeating to let a person struggle without treatment until their condition deteriorates to the point that they require such additional support services. Further, the alternative programs, such as ATAPS, Headspace, and EPPIC, cannot be accessed by most people, regardless of their mental health status.  There are a host of barriers that prevent mental health consumers from accessing treatment via ATAPS, but the biggest barrier to treatment of all is that the ATAPS program uses a capped funding model. Despite the new investment of funding, we have evidence from several Medicare Locals regions that psychologists are being told that eligible ATAPS patients must not be provided any more than 6 appointments, except in the most extreme cases. With EPPIC and Headspace only servicing people up to 25 years of age, adults with mental health disorders are left with few alternatives besides seeing a psychiatrist, often with a long waiting list and a significant gap cost. This is quite concerning when you consider the prevalence of conditions like depression across the lifespan and the fact that the highest suicide rate in Australia is actually for middle aged men (26 deaths per 100,000 males aged 40-44).

Final thoughts

Maybe I haven’t covered everything, but I hope that this gives you an overall picture of why people are so worked up about the decision to cut Better Access. If you feel the same way as we do about this, then please, express your opposition to the cuts to psychological services by signing our petition at Change.org. You can also join us on our Facebook Group or write/email your preferred senator (here is a contact list for all of them). If you feel like telling the Federal Minister for Mental Health what you think of these changes, you can email him right here, and explain to him that cutting off treatment options for people who have mental health disorders is not acceptable to Australians. And please, share your thoughts and reflections below. Every voice makes a difference!