How many visits of psychological care? (The NMHC Report: Part 1)

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A few weeks ago the long-awaited report from the National Mental Health Commission was released. This expansive report reviewed all mental health care programs across Australia in four volumes and over 700 pages. It is clear from the report that the Commission received hundreds of letters from the public about the Better Access to Mental Health Care scheme, a program which provides access to Medicare support for psychological care. There are repeated references across the entire review pointing out the problem of limiting psychological care to just ten visits.

The following article provides a summary of what the report recommends about the number of visits of psychological care which should be available under Medicare. In the following weeks I will add further detail about the recommendations relating to other aspects of the Better Access scheme, including who the Commission suggests should provide psychological care, how the Commission thinks people should access the program, and what suggestions the Commission has about helping people access the program in rural, regional, and remote Australia. My own reflections and recommendations for change will be provided at the end of each summary.

How many appointments of psychological care?

The big question has always been how many visits should Medicare support? We know from hundreds, if not thousands of people, that the Commission received a lot of feedback from the public calling for the Better Access program to be expanded to make more appointments accessible. The document is filled with critical points about the current poor standard of care which sees Medicare support abruptly ending after just ten visits. The report makes a single recommendation on this question (Volume 1, Recommendation 13, page 95):

For severe or complex disorders, enable an extra six Better Access sessions of psychological treatment as clinically determined (a total of 16 in any one year).

In other words, the Commission has recommended that the standard course of psychological care should be ten visits, with an additional six being offered to those who have severe of complex mental health disorders. After having read the rest of that report, it remains unclear where the suggestion of offering 16 visits came from. From what I could see, there did not appear to be any public feedback asking for 16 appointments, nor evidence from research, or even a single suggestion from mental health care professionals working in the system that 16 visits would be enough.

According to the Volume 3 “by far the biggest complaint” from mental health care professionals working in the scheme was connected to Medicare’s limit of 10 visits of psychological care (page 14). Therapists suggested two possible resolutions to the problem: (1) reinstating the original 18 session limit which was available prior to 2011, or (2) providing a fairer balance between the number of psychiatry visits accessible in Medicare (50 visits) by comparison to psychological care (just 10 visits). This simple comparison of the level of support given to medical versus psychological approaches should illuminate why questions are being asked about the dominance of medical model in our system.

The Commission also heard from people living with a mental health condition, their families, and their carers. One of the top suggestions given by members of the public was that they would like to see the number of appointments available in the Better Access program increased (Volume 3, page 11). One person who offered their quotation as a case study  in the report made the following suggestion (Volume 2, page 119):

“Surely it would be better for the government if I could access around 20 visits under “Better Access” per year which would likely help me to recover to the extent that I could work full time.”

In short, there didn’t seem to be any rationale for why psychological treatment should be limited to 10 visits as a standard period of care. Likewise, there also didn’t appear to be any good reason for suggesting that 16 visits would be much better for those with complex or severe disorders. The whole notion of there being a magic number of visits which can cure mental health disorders is in itself an absurd suggestion. Indeed, the Commission itself made a point of highlighting this very issue (Volume 2, page 118):

Access to adequate services, ensuring that the number of subsidised therapeutic interventions is able to be tailored to the complexity and severity of individual need. This is much cheaper than artificially curtailing the number of sessions and leaving a person ‘lost’ to the system and without professional support.

Not just once but twice in fact (Volume 2, page 153):

“The Commission also considers that the number of sessions offered under Better Access should be based on clinical need and outcomes, rather than a pre designated number of sessions.” 

So for a moment, let’s now return to that initial recommendation: a standard 10 visits of psychological care, with an additional 6 available, but only for those who are diagnosed as having a complex or severe disorder. It is unclear how to interpret these additional criteria given that a large-scale evaluation of the Better Access program in 2011 showed that over 80% of people accessing psychological care in the program presented with severe to extremely severe symptoms of distress. The only clue that I could find in the NMHC Report was their own definition of complex and severe disorders. According to the report, complex and severe disorders include “severe depression, schizophrenia, bipolar disorder and eating disorders” (Volume 1, page 20).

More to the point however, there is a plain contradiction going on here. On the one hand the Commission recommends a fixed number of appointments, either 10 or 16 visits. On the other hand the Commission argues that the system should not rely on a pre-designated number of sessions which will artificially curtail a person’s access to treatment. I would encourage members of the National Mental Health Commission to ask around and clarify whether people who access therapy really do want the system to offer just 16 appointments of psychological care. From what I understand nobody really wants this, not even the Australian Psychological Society who has previously attempted to compromise with Government at the 16 session mark. A fortnight ago I received a response to my queries about this issue on behalf of APS Executive Director Lyn Littlefield stating the following:

“In relation to the number of sessions of Better Access, the APS has long advocated for the reinstatement of sessions that were lost under previous funding cuts.  We agree that not even under the first iteration of Better Access was the number of allowable sessions based on the evidence. The figure for the number of sessions was an arbitrary one decided on by the Government at the time.  However, it is very pleasing that, in this time of cost cutting, there is a recommendation to reinstate the lost sessions at the very least.”

It looks to me like there is practically no support backing the recommendation that 10 visits are enough, and very little evidence that 16 appointments is really that much better, particularly for those who present with more complex or severe mental health conditions.

My Recommendation

People seeking psychological care should have access to Medicare support for at least 20 standard visits of psychological care – consistent with best practice. Those who are assessed as needing more than 20 appointments should have some way to receive ongoing treatment for their condition, just as they do with medical care. It is false economy to restrict access to psychological treatment. Those who can no longer access the help they need deteriorate which reduces their capacity to work and care for both themselves and others. Restricting access to psychological care increases public health costs and compounds disadvantage.

Do you agree? What ideas do you have about how we can improve the system? Please share your thoughts below.