In collaboration with conference organisers, the Croakey Conference Reporting Service will provide an overview of key sessions and discussions.

In the article below, Suzanne Gleeson, the AHPA’s National President, identifies some of the major challenges facing the field and previews some of the conference keynotes.

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It’s time to move our focus beyond “lifestyle change” – but how?

Suzanne Gleeson writes:

The experts who will be presenting at the conference are singing from the same song sheet.

The evidence is clear – we need to move beyond “lifestyle change” to building supportive environments if we are to achieve environments that are supportive of health and wellbeing – not just for some but for all.

But while we agree on what needs to happen, the how is not so clear – and this is the challenge to those of us working in health promotion.

The conference theme  - Changing Settings: liveable vibrant healthy places – has been planned to take this agenda forward.

While the conference focuses on workplaces, children’s environments and communities, these are not isolated silos. Children matter. People matter. Places matter. The Planet matters. These are not separate from each other – they are complex, interrelated and interdependent.

Beyond health promotion “messaging”

On Monday we will hear from Professor Mark Dooris, who is Reader in Health and Sustainable Development and Director of the Healthy Settings Unit at the University of Central Lancashire, and also Visiting Professor in Wellbeing at London South Bank University.

He will actually be presenting in Norway on the same topic on the same day so cannot be with us in person; but we will hear from him on video, and he will also be beamed live into the conference for a Q and A.

His presentation draws on the successes and lessons from the past quarter century to inform future practice, highlighting the implications, challenges and principles for practice involved in adopting an holistic and integrated approach to creating healthy sustainable and connected settings.

Amongst other things, he will argue that current health promoting practice that focuses on lifestyle change – the giving of messages to captive audiences in schools, workplaces and communities – doesn’t cut the mustard.

“Like teaching children to swim in a pool of alligators”

Professor Helen Roberts from University College London, says when it comes to creating and maintaining child health, we need to separate the ‘spin from the reality’.

She argues for the need to focus on settings and interventions that influence the determinants of health including transport, housing and education.

Professor Roberts says trying to change children’s health behaviours without trying to change the food and transport environment is like trying to teach them to swim in a pool of alligators!

Her presentation will address ‘what counts’ and ‘what matters’ and will question as well ‘what works’.

The economic argument for investing in early childhood

Associate Professor Lisa Gold, a health economist from Deakin University, is an expert in the economic evaluation of health and social interventions that aim to improve population health and reduce inequalities.

She puts the economic argument for investment in early childhood. The way forward for health promotion, she says, lies in combining the international economic advocacy argument with local evidence on the cost effectiveness of promising interventions across a broad range of children’s environments.

Concerns about lack of evaluation of common programs

Ross Homel, Foundation Professor of Criminology and Criminal Justice at Griffith University in Brisbane, says ‘early developmental prevention works’.

However, he says ‘the science to service’ model has not proven to be a great success.

He warns that ‘the most common types of programs used in disadvantaged communities in Australia that revolve around ‘family support and children’s services’ are almost entirely unevaluated … an enormous investment with no evidence for their success. This, he says, is immoral.

Professor Homel will present research results from an Australian study that is amongst the first to put community-based family support services onto a scientific foundation – these are among the first in Australia and internationally.

Mental health at work

Associate Professor Tony LaMontagne, of the Melbourne School of Population and Global Health, says that mental health problems are common in working populations and many are attributable to working conditions.

If workplace mental health interventions are to realise the greatest population health benefits, they need to reduce work-related risk factors for mental health problems. They also need to promote the positive aspects of work as well as worker strengths and positive capacities.

Associate Professor LaMontagne will present his research aimed at developing an integrated approach to mental health in the workplace.

Focus on the individual in workplaces misplaced

Professor John Buchanan, Director of the Workplace Research Centre at the University of Sydney Business School, will argue that health promotion initiatives that focus on the individual in isolation and the ‘best practices’ in workplaces have only limited prospects for success.

Workplaces can only become enduring, effective sites for health promotion if structures of support are built to help people through key transitions in their working life, he says.

Examples of these structures include:

• quality group apprenticeship arrangements in the employment based training system
• transferability in entitlements such as portable long service leave arrangements to help workers gain time to recuperate and flourish beyond work
• programs that build capacity in middle management
• commitment at executive level management to make sustainable work arrangements central (and not incidental) to mainstream business practice.

• For conference tweets, check @AHPA_AU @georgecanderson  #ahpa2013

• And thanks to George Anderson (Communication Officer for the South Western Sydney and Sydney Local Health District Health Promotion Service) who has volunteered to provide some reports for Croakey on top of what is surely already a rather busy conference schedule.

If any other conference participants/tweeters are interested in contributing to Croakey’s coverage, please get in touch…

• For declarations and details on the Croakey Conference Reporting Service, please see here.

It will link you into some of the interesting and important health news from the previous fortnight, including items covered at Croakey and elsewhere.

Kellie Bisset, an experienced health and medical journalist/editor who is communications director at the Sax Institute (follow her at @medicalmedia), has kindly offered to provide this column as a probono service to Croakey readers.

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 By Kellie Bisset

A big fortnight in mental health

An active two weeks of discussion around mental health – both locally and internationally – was jump-started with the release of DSM 5, the fifth edition of the American Psychiatric Association’s Diagnostic and Statistical Manual, which has, among other things, included a new diagnosis for prolonged grief.

Has labelling of mental illness got out of hand? Writing for The Conversation, Professor Emeritus of Psychiatry at Duke University Allen Frances strongly believes the new manual will lead to “diagnostic inflation”, but others, such as Professor Nick Glozier say its influence is overstated.

This middle-of-the-road Conversation piece by psychiatry lecturer Darryl P. Watson is a good overview of the debate. Meanwhile, health news watchdog Gary Schwitzer highlights a PLOS Medicine editorial on the paradox of over-treatment it says is fuelled by pharma marketing and “profound under-recognition” of mental health issues affecting millions across the globe.

Meanwhile, the Mental Health Council of Australia and National Mental Health Commission hosted a meeting to outline the NGO sector’s long-term blueprint for improving the lives of those with mental illness and their carers. And a National Summit jointly hosted in Sydney by NSW and Federal Ministers for Mental Health explored the issue of premature death among people with mental illness. At Croakey, Mark Ragg pre-empted the summit with a piece arguing that without dollars, all the talk would be for naught.

A funding announcement was made the day before the summit; the Federal Government said headspace would be given $247 million to deliver nine early psychosis youth services under the EPPIC program. This prompted a Croakey post from Sebastian Rosenberg arguing that current state/federal governance of mental health in Australia is unworkable and cannot deliver a “new deal” for mental health. Associate Professor Jane Burns, CEO of the Young and Well Cooperative Research Centre, also blogged about the importance of allowing young people to shape research, practice and policy in youth mental health.

Also in the news was the launch of a new National Aboriginal and Torres Strait Islander suicide prevention strategy, promising a holistic, early intervention approach focused on working with Aboriginal and Torres Strait Islander peoples to build strong communities. The aims are to reduce the causes, prevalence, and impacts of suicide on individuals, families, and communities.

As the American Psychiatric Association and the Royal Australian and New Zealand College of Psychiatrists both held their annual meetings (check #APAAM13 and #ranzcp for tweetstreems), the Hunter Institute of Mental Health launched two reports on the needs and experiences of those caring for someone with a mental illness. Institute Associate Director Jaelea Skehan outlines them both in this Croakey post, and along with the SMH’s Amy Corderoy, reminds us of the daily difficulties faced by carers, who often face their own mental health issues.

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Pointed views on display in vaccination debate

Moves to amend the NSW Public Health Act to make childcare entry conditional on parents vaccinating their children or registering for an exemption have been widely praised. But some, including Julie Leask and Hal Willaby who wrote this piece on Croakey and The Conversation, argue the move is flawed and could have unintended negative consequences for children and marginalise some parents even further. The Queensland Opposition has proposed similar legislation.

Meanwhile, the RACGP has been forced to defend its continuing education program after an SMH report revealed it had accredited a training course that perpetuated vaccination myths. The broader issue of vaccination was also brought to light in a new SBS documentary – Jabbed – and The Conversation’s Sunanda Creagh reported on a new Australian Prescriber paper showing pneumococcal disease has plunged by 97% since vaccination.

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Over-diagnosis, misdiagnosis and unnecessary tests

The ABC’s Sophie Scott raised concerns over pop-up clinics that screen for heart attacks and strokes in a story that highlights once again the ethics of preventive screening for asymptomatic people. And Amy Corderoy at the SMH took aim at the millions of potentially unnecessary Vitamin D tests being ordered for healthy people.

The Hospital Alliance for Research Collaboration also heard from international expert Dr Mark Graber on how to address the untapped problem of diagnostic medical error. Dr Graber says patients play an important role in highlighting errors, but Reuters points out that research from JAMA Internal Medicine shows patients are still struggling with basic patient information materials, many of which are full of jargon and difficult to navigate.

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Perspectives on risk

It’s been more than two weeks since Angelina Jolie chose to reveal the dramatic news of her preventive double mastectomy in the New York Times and in the wake of this there has been much written and said about her decision and the broader issue of breast cancer risk. Hilda Bastian has explored the concepts of risk and overdiagnosis in this Croakey piece, which also links to other useful articles on the topic.

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Food glorious food – or not

The ongoing dialogue about the role of Big Food in the obesity epidemic took a new turn with Cancer Council Victoria research showing children are more likely to choose unhealthy foods over healthier products if they carry nutritional claims or endorsements from sporting stars.

An interesting piece from Healio.com highlights a recent discussion led by Yale researcher Dr Kelly Brownell about how the growing literature around how food affects the brain could be a “game-changing concept”. He says this potentially opens the doors to tobacco-style litigation exploring whether food manufacturers knowingly modified products.

In Australia, the Federal Government announced a further $800,000 in funding for the Food and Health Dialogue, a coalition of public health and industry groups that is working to reduce salt, sugar and saturated fat in processed foods.

Addressing obesity by designing healthier environments remains a hot topic internationally. Californian public health officials are using their latest research to influence planned cuts to transit services. And Newsday’s great story on a New Jersey real estate agent who agitates for walkable neighbourhoods shows public health advocates can be found anywhere. In the same vein, US public television station KCET has produced a series on walking, travelling to cities across the US that are transforming themselves into more walkable communities.

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Politics and Policy

Croakey offered a perspective from Stephen Duckett on Opposition health spokesman Peter Dutton’s address to last week’s Australian Institute of Company Directors meeting. His comments on Medicare Locals indicate at the very least they would be renamed under a Coalition Government.

Federal Health Minister Tanya Plibersek took on the pharmaceutical industry with a pointed media release highlighting its inconsistent position on the main drivers of increased PBS spending. And the Government released the Mason review of health workforce programs and indicated changes to the way towns are geographically classified for Government funding.

In her Lowitja O’Donoghue Oration at the University of Adelaide, CEO of Danila Dilba Health Service Olga Havnen called on the “fault lines” between politicians, bureaucrats, NGOs and the Aboriginal Community Controlled Health sector to unite to make a real difference. She said a “doctrine of risk intolerance” had taken hold and caused government funds to be moved away from community-led organisations.

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The gaps are getting bigger

Widening health gaps across Australia make it imperative to consider the social determinants of health across all policy areas, argue the Social Determinants of Health Alliance (SDOHA) and the Consumers Health Forum. Responding on Croakey to last week’s release of two reports from the COAG Reform Council, SDOHA renewed its call for Parliament to adopt the World Health Organisation’s Closing the Gap in a Generation report.

In Geneva, Medicus Mundi International and the People’s Health Movement made a very clear statement to the 66th session of the World Health Assembly calling on the WHO to “undertake more robust research and initiate actions” on social determinants of health. This, and a wrap of the assembly, can be found in this Croakey post.

In Canada, doctors are talking about the medicinal effect of increasing people’s incomes. The Canadian Medical Association is conducting a national dialogue tour to ask people how poverty affects their health. And in Britain, The Independent reports that just under a third of people are excluded from mainstream society because they cannot afford to join in cultural activities.

Iceland though, may have some answers. This BBC News Magazine article explores the lack of violent crime in the country and makes some associations with the lack of a class system and views about equality. Denmark is also looking at a systematic approach to health and wealth through technical innovation, as this Croakey piece from Dr Johnny Marshall explains.

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The smoke wars

Plain cigarette packaging is in the news again, with reports that Ireland will follow Australia’s public health lead. But as Croakey highlighted last week, there are still those determined to bend the rules; NACCHO has had to call out a company designing ‘skins for smokes’ that has appropriated the Aboriginal flag. Meanwhile, WHO Director General Dr Margaret Chan took the opportunity at the 66th World Health Assembly to make it absolutely clear that the WHO will never be on speaking terms with the tobacco industry.

Perhaps sound advice for the US Food and Drug Administration? This paper in PLOS Medicine analyses documents released through litigation to explore the industry’s attempts to influence the FDA.

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Other Croakey reading you may have missed this fortnight:

• Social media for conference reporting, evidence-based practice, self-care (and more…)
  
• Community-based journalism meets community health: Meet some of the mojos from Cherbourg
• A surprising lack of clarity around the definition of core primary health care services
  
• $100,000 is on the table for digital innovators with a #publichealth bent
  
• Concerns raised about the ethics of anti-wind farm research
  
• We should help, rather than stigmatise, vulnerable parents

And some shout outs to @sophiescott2, @reemarattan, @ivanoransky, @LRussellWolpe, @preventioninst, @healthageingAU, @EvidenceNetwork, @SimonChapman6, @AmyCorderoy for being valuable sources of news on Twitter this week.

• Kellie Bisset is The Sax Institute’s Communications Director. She has worked in mainstream and medical journalism and communications for more than 20 years. During that time she edited both of Australia’s weekly medical publications for doctors, Australian Doctor and Medical Observer and developed a strong interest in health policy and evidence. The Sax Institute is a not-for-profit organisation that drives the use of research evidence in health policy and planning.

 Mention the phrase ‘carer’ and you get an instant warm, fuzzy feeling along with a picture of someone strong and healthy, helping someone frail.  But these images can be very misleading.

It is estimated that 2.6 million Australians are carers, many of whom are providing practical day-to-day and emotional support for people experiencing mental illness.  A picture that represents this type of caring role is harder to imagine for most.  It is a situation where the illness is not visible and recognising the ‘carer’ is not always immediately obvious.

People who love, live with or support someone experiencing depression do not traditionally identify themselves as ‘carers’. This means that the significant role they play in the lives of one million Australians who experience depression every year, can go unnoticed.

The practical, physical, economic and emotional demands of supporting a loved one with a mental illness can be enormous. But to date, most of our national discussions about mental health carers have focussed on their right to be involved in service delivery only.

This is indeed an important step in the right direction and was highlighted by the Australian Government’s announcement yesterday about the national Care Aware campaign. It reinforced the need to recognise carers as partners in patient care more broadly. This announcement however, and many similar in health and mental health, just don’t go far enough.

What about a national agenda that also recognises the rights of those that care for someone with a mental illness not to have their own mental health and wellbeing compromised because of the vital caring role they play?

A case for prevention approaches

We know from research that investing in the promotion of mental health and wellbeing, and the prevention of mental ill-health, leads not only to a more efficient use of mental health resources but it has a flow-on effect to a range of other health and community outcomes.

A recent report estimated the direct health expenditure on mental illness to be $13.8 billion. A logical argument would attest that without investment in evidence-based prevention programs, that number will continue to grow.

So why is meaningful investment in prevention approaches often so hard to achieve?

The problem is that promotion of mental health and wellbeing and the prevention of mental ill-health are often seen as separate tasks to the delivery of mental health services, and have been seen as competing with service delivery for scarce resources.  Many would argue that the results are often not seen for years and so estimating the return on investment can be difficult.

But I would argue that programs addressing an immediate risk, such as those that target the information and support needs of carers, can show immediate as well as long-term benefits.

Snapshot: Supporting those who care

The Hunter Institute of Mental Health has today launched Supporting Those Who Care: Partners in Depression National Program Outcomes, showing the potentially severe mental health, family and social consequences of the caring experience.

Also released today was a summary of a six-paper research series, How Can We Best Support Those Who Care?, co-funded by beyondblue: the national depression initiative. The research series builds on what we know about the specific needs of those who care for someone with depression and the skills and capacity of the mental health workforce to address these needs.

At the very least, the National Evaluation of Partners in Depression shows that the need for the program is great. Upon entering the program, carers reported poor physical and mental health, challenges with their relationships and reduced participation in social activities.

Even more worrying, people entered the program with significant levels of psychological distress.  Levels that were much higher than the Australian population and that suggested an immediate risk of mental ill-health.

In evaluating the effectiveness of the program we were able to show significant reductions in these levels of psychological distress by the time the program ended and six months following the program.

Participants also reported improvements in relationships, a better understanding of depression and 93% had already implemented what they learnt from the program at six-month follow-up.

Video and written testimonials from those who care are available.

Snapshot: The Partners in Depression program

The Hunter Institute of Mental Health developed the Partners in Depression program to fill a national service gap.  It is six week education, support and skill building program that has been designed to address the specific needs of those who care for someone with depression, regardless of whether they see their role as a traditional caring one.

The program was first piloted in 2007–2008 with matched funding support from beyondblue, and then a three-year investment from the nib foundation meant that the program could be disseminated nationally from 2009.

The program is rolled out in partnership with locally based family and mental health workers.  At the time of the evaluation there were over 160 accredited trainers in every state and territory delivering Partners in Depression and over 1,600 people have been through the program to date. Many more have been through the program now.

Partners in Depression provides a practical solution to national policies and reports which highlight the needs of carers and also the need for prevention approaches.  By using existing mental health professionals, located within communities across Australia, we are able to develop this workforce to deliver our program at a minimal cost.

Partners in Depression is costs effective and could be rolled out in every community across Australia. The ongoing costs to deliver this program stand at just $24 per person per session.

A call to action

In releasing the evaluation and research associated with Partners in Depression, the Hunter Institute of Mental Health now calls on a national agenda that also includes prevention.  Recognising the rights of those in caring roles to be involved in service delivery is only part of the solution. We also need to recognise their right to have their own mental health and wellbeing supported.

People who love, live with and care for someone with a mental illness, including those with depression, need timely and equitable access to interventions enhance their wellbeing and prevent the onset of mental ill-health.

For full access to reports released today are available online.

Jaelea Skehan is the A/Director of the Hunter Institute of Mental Health.

Many thanks to Associate Professor Jane Burns, CEO, Young and Well Cooperative Research Centre for the following reminder as to why it is essential to engage young people in planning services for youth mental health.

Associate Professor Burns writes:

I am one of those people from a generation to know a world without computers, to make a distinction between the ‘offline’ versus ‘online’ world, real friends versus digital friends.

The world of technology – and especially the world of technology that a young person engages with – moves very quickly. Parents, teachers and other professionals who work with young people can barely keep pace with its uptake. Research relating to young people and their technology use is invariably out of date before it is published. If researchers and service providers are failing to keep pace, what hope do policy makers have?

To dismiss the role of technology use in youth mental health policy is at best ignorant and at worst dangerous. When a Minister, bureaucrat, educator, health professional or service provider dismisses the role of technology and the potential it can play in delivering services to those who are most vulnerable, those who live in remote, regional or rural communities or those families who care for children or young people who are too unwell to leave their homes because of illness or disability, I find it mind boggling.

When the opportunity came up to speak about young people and new and emerging issues for them at the GenerationNext conference, attended by over 10,000 professionals and parents, I agreed on one proviso: that I could co-present with a young person. I truly believe the only way to understand how young people use technologies and the impact it has on their day-to-day lives is through young people themselves.

Emily Mignacca is one of our Youth Brains Trust members who presented with me in Perth. Her story is highly relevant and has immediate policy implications.

She says: “The only time I truly began to realise the incredible power of the online world, was when I hit a bumpy road in my last couple of years of high school. Only 5 years ago, I vividly remember sitting on my laptop at 2am and almost ironically typing “self-harm” into that familiar Google search bar, only to be led to the worlds of ReachOut, beyondblue, Headspace and Lifeline. This one seemingly insignificant Google search became my entry point into the world of mental health. At that time, what I wanted was information, and a sense of normality that while this wasn’t okay, other people were going through the same thing – and the internet provided me with that. In the 3am darkness of my sleepless room, I was able to get a sense of support from not only the information available, but from the knowledge that it wasn’t just me against this “thing”, that I wasn’t the only one awake all night. The sense of control that I gained from the mountains of information at my fingertips gave me the courage to then seek help and essentially, join the fight.”

“Years later, thanks to smartphones, this information is now accessible literally every second of a young person’s day. Not only do we have constant access to all the information in the world, now apps have made it possible to directly interact with this information, and apply it straight to our own lives. Mood Trackers, role-play wellness games and personal mindfulness guides are all apps that I use today, and that I really believe would’ve really helped 15-year-old Emily”.

“A crucial factor is that the technologies we use need to be created, developed and utilised with young people on board every step of the way. As a young person, it can be quite clear whether a resource has been created FOR US, or WITH US. Young people are the experts of their own world and this must continue to be recognised and can be harnessed. How young people best communicate, even if this IS through technology is not necessarily WORSE than how our parents grew up, it’s just DIFFERENT”.

“What we need to work towards is building a bridge between young people, technology and the world of parents, teachers and health professionals. The reality is that for us, there is no longer a clear distinction between the online/virtual world and real life. With technology almost constantly at my fingertips, these worlds are in a permanent state of overlap. However, despite prominent media attention, this is not a bad thing”.

“Within reason, instead of endless attempts to reduce the use of technology, engage with young people, show interest in the latest app or phone or game or podcast. It’s important to remember that young people often post things online that we are too afraid to say out loud  – I certainly have done this, countless times. Engaging in this side of our lives could very possibly give you, as a parent, teacher or clinician, the first indication that something is not quite right. It should never be discounted as a possibility that we want you to see what we’re doing online; it’s often our way of crying out for help. From there, as occurred with me, a whole new world of mental health, wellness and technology is only a step away. By engaging with young people to identify the problems in their lives, we can then utilise the world of technology to provide support and build life resilience in a way that is accessible, non-threatening and incredibly familiar to us.”

Many thanks to Sebastian Rosenberg, Senior Lecturer, Brain and Mind Research Unit, University of Sydney. Sebastian writes:

The recent decision by the Federal Minister for Mental Health and Ageing Mark Butler to redirect $247m in funding for new early psychosis treatment centres from the States and Territories to headspace further highlights the moribund nature of our federalism in relation to reform of mental health.

Professor Patrick McGorry’s tenure as Australian of the Year in 2010 brought our national mental health crisis into sharp relief.  Perhaps his lasting legacy however was to persuade the Federal Government to invest in a new nationwide roll out of the Early Psychosis Prevention and Intervention Centres (EPPIC).  EPPIC is a service model McGorry has been running successfully in Melbourne since 1992.  He and his team have worked to develop an innovative and holistic approach to care for young people facing the onset of psychosis.  They have then rigorously evaluated the outcomes of their care which have been remarkable and positive; giving new hope to young people being able to avoid lifelong disadvantage, complete their education and training and instead pursue trajectories towards living what the National Mental Health Commission term ‘a contributing life’.

McGorry’s results attracted first the Federal Opposition’s, and later the Federal Government’s attention.  Prime Minister Gillard had already stated that mental health would be central to her Government’s second term agenda.  An initial allocation of $24.5m was made in the 2010 Budget and a further $222.4m was made in the 2011 Federal Budget – this was the budget of which Wayne Swan was so proud to declare had mental health as its centrepiece.

Together these announcements, would fund a network of 16 new centres like EPPIC to be rolled out and fully complete by 2016. The May 2011 press release issued by Butler announced the EPPICs would be “delivered in partnership with the states and territories”.

Three years on (or two if you ignore the 2010 announcement) and how have we gone?  Not a sod turned.  Not a brick laid.  Not a client seen.  What has happened?

The Federal government entered into negotiations with the jurisdictions about how the EPPICs would be built and how they would knit into the fabric of mental health services run by the states and territories. Inadequate as they may be, the states and territories all currently run specialist mental health services for young people. A National Partnership Agreement was announced as part of the 2011-12 Federal Budget, allocating each jurisdiction a notional amount of the total new funds, pending finalisation of negotiations.

In January 2012, the Victorian Minister for Mental Health, Mary Wooldridge, issued her own press release calling on co-investment by the Federal government to match that state’s commitment so that the new EPPIC services would be “delivered in a partnership of metropolitan public mental health services and specialist mental health services from rural regions in Victoria”.  McGorry’s existing EPPIC in Melbourne operates likes this now, as part of the suites of services run by the Melbourne Health Metropolitan Health Service.

In other words, Minister Butler and the Department of Health and Ageing needed to work consultatively with the states and territories to design mutually suitable arrangements so as to make the new EPPICs fit local circumstances.  Our patchwork national mental health ‘system’ in fact varies considerably depending on where you live in Australia.

Each state does things differently.  This made Butler’s job a little more demanding, but no more so than dozens of his predecessors. And while health generally is a responsibility shared by the Federal and state governments, in mental health and community mental health in particular this split in responsibility is now a ravine.

The jurisdictions have traditionally funded some clinical community mental health teams though these are much reduced nowadays or have been withdrawn from the high street to the hospital campus.  They also run Child and Adolescent Mental Health Services (CAMHS).  These services are stretched and struggling. Nationally and on average, the jurisdictions also direct around 10% of their mental health spending to a range of community-based non-government organisations, typically providing psycho-social support services but increasingly also providing aspects of clinical care.

McGorry’s EPPIC model is a little different again, funded by the Victorian government but not operating from a hospital campus and working hard to link up with a range of psycho-social, employment, housing and other support organisations to deliver holistic care. In any new arrangements aimed at young people, surely good links between CAMHS, EPPICs and headspace would seem most sensible.

The Federal government funds primary mental health care provided by doctors and psychologists under Medicare and very recently, has started funding their own set of psycho-social support services such as Personal Helpers and Mentors, the Day to Day Living in the Community Program and (someday) the $550m Partners in Recovery program.  These Federal community mental health programs provide funds to some of the same non-government organisations funded by the states but this seems very much by coincidence rather than design.

In a nutshell, it is precisely in the area of most concern to mental health reformers; that part of the service system which aims to avoid hospitalisation and provide as many services as possible designed to keep people living well in the community, where responsibility between the Feds and the states is most unclear.

One can never be sure what transpires in these negotiations though it is understood that some states now feel quite aggrieved, that agreements had been close to conclusion and that Butler’s unilateral decision amounted to the Federal government reneging on the initiative as it had originally been announced in Budget 2011-12.

Regardless, the Federal government’s announcement that headspace will now take carriage of the roll out of the EPPICs is the latest signal that the current governance of mental health in Australia is unworkable and cannot deliver a new deal for mental health.  Even when new funds are made available, as they have been in this case, it still seems impossible for us to surmount the federal/state divide to create a more seamless system of mental health care.

The community has been left with a fractured, piecemeal set of services rather than any genuine sense of a system. People with mental illness and their families simply do not care who funds a service.  They just want help.

Minister Butler’s press release commits the Federal government under the revised roll out arrangements to have four new centres up and running initially and two by 1 July 2013.  No apparent action for three years then two new centres in just five weeks!  The four sites chosen are western Sydney, south-east Melbourne, western Adelaide and north-east Perth.  No rationale has been made public in relation to why these sites were selected.  More significantly, the new proposal suggests the eventual national network of EPPICs will comprise only nine sites, not the sixteen originally proposed.

Headspace itself struggles to fulfil its mandate. Funding pressures combine with acute problems finding staff to compromise its capacity to deliver holistic primary mental health care in all its sites (including western Sydney).  Evaluations of headspace have highlighted this along with issues of performance, accountability and clinical governance that this new service model needs to deal with. Moving EPPIC to headspace before these matters are sorted seems risky for both parties.

But headspace is clearly funded by the Federal government this decision means Butler can stop wrangling with the jurisdictions and get on with ribbon-cutting without needing to share the stage with any state counterpart.

The EPPIC model is a world leader.  Butler’s decision represents a significant change to the model. Under the new arrangements, can the now modified national roll out of nine new EPPICS occur with proper fidelity to the original, evidence-based service model?  At what point does the model become compromised?

New investments in mental health are rare and precious, particularly when directed towards evidence-based programs such as EPPIC.  Let’s make the most of this chance.

The fifth edition of the Diagnostic and Statistical Manual for Mental Disorders (DSM-5) has copped the predicted criticisms since its release on the weekend. Most centre on the idea thatmore of us will be diagnosed with mental disorders, as the diagnostic thresholds are lowered.

Critics have also argued these thresholds will lead to an increase in claims for work-related disability or compensation, allowing more people to take extended sick leave. These claims could range from short periods of psychological distress or “not coping”, to serious and impairing illnesses such as recurrent depression or psychosis. Many systems provide income during this time off work, through tax payer-funded or organisational or personal insurance compensation.

However the DSM-5 is unlikely to increase such claims. Diagnostic thresholds for some mental disorders may be marginally lower in the new manual, but clinicians rarely rigorously apply the diagnostic criteria.

What’s changing under the DSM-5?

The DSM-5 includes small changes to the diagnosis of schizophrenia and bipolar disorder. These will have no significant effect on the workforce, as these conditions are rarely claimed to be caused by work in any compensation system.

The changes that may have significant effects on the working population are in depression and anxiety disorders, including post-traumatic stress disorder (PTSD). Contrary to popular belief, the majority of people with these disorders are employed.

The new manual includes a diagnosis for prolonged grief(depressive symptoms related to bereavement) and has a lowered threshold for PTSD. To be diagnosed with PTSD one no longer has to have experienced “fear, helplessness or horror… right after the traumatic event”. There are also some minor changes around symptom profiles – reckless or self-destructive behaviour, for instance, is now a symptom of PTSD.

How are work-related illnesses diagnosed?

The vast majority of diagnoses and treatment plans for depression, anxiety and PTSD are made by general practitioners who don’t use the DSM-5 criteria.

If anything, GPs use the World Health Organisation’s International Classification of Diseases criteria for primary care, or more commonly, rely on individuals scoring highly on theK10, which measures depressive and anxious symptoms. This measure is mandated as part of accessing a range of treatments, most notably Medicare-funded psychotherapy under the Better Access Scheme.

The psychologists they are referred to most often use another measure, the Depression Anxiety Stress Scales (DASS), to determine symptom severity.

Perhaps the most common diagnosis given to people seeking worker’s compensation for mental illness is an “adjustment disorder.” This diagnosis is incredibly easy to make, requiring an unspecified number of symptoms “such as anxiety, depression, worry, tensions and anger” which must merely be “more severe than expected” – although who decides this is moot. The DSM-5 equivalent is “mixed anxiety-depressive disorder” and is just as easy to diagnose.

More importantly, a review of WorkCover certificates shows doctors are most likely to use labels such as “stress”, “anxiety”, “burnout”, “bullying and harassment”, none of which are diagnoses. The DSM-5 will do nothing to change these labels or whether a doctor thinks a condition is or isn’t work related.

Rise in disability

For an increasing number of people, the end point of sick leave is a move onto longer-term government disability pensions. Access to these systems is generally the purview of doctors who have to determine whether the person meets a number of eligibility criteria: severity of illness, likelihood of returning to work, and so on.

Every country in the OECD has seen a gradual rise in the proportion of disability support payments attributable to mental illness, not because of any diagnostic changes but through changing patterns of work and who is working (fewer physical jobs, more women and older workers), lower levels of back pain claims (which many suggested were really “stress”), and greater recognition of depression by clinicians compared to a few decades ago.

The greatest determinants of the total numbers of disability claims are likely to be social and financial, which “push” people out of the workforce and “pull” them into benefits.

In the mid-1980s when then-UK prime minister Maggie Thatcher noted that disabled people received lower benefits than the unemployed, her right-wing government engineered a reversal of this. At the time, the UK had just over one million citizens on disability benefits and just over three million unemployed.

Following the payment changes there was a rapid rise to a peak of 2.8 million people claiming disability benefits in 2003-4 and 1.4 million unemployed; the same number of people were out of work but they were called something different and paid more. Australia had a similar change a few years later: people were “pulled” into benefits.

The likelihood that a disabled person would be unemployed compared to a healthy person has also been increasing, “pushing” disabled people out of the workforce. This “disability penalty” is highest for those with mental disorders and the trend towards short-term contracting and precarious employment has worsened this.

Last year, eligibility for disability support pensions for mental illness, which costs the Australian government some A$3.8 billion a year was changed to a new threshold. This is based on the presence of both a diagnosis, but more importantly, upon a certain percentage of whole body impairment through the use of the Psychiatric Impairment Rating Scale.

The only publicly available testing of these new scales, which impact hundreds of thousands of people, suggest that “41% of formerly eligible applicants became ineligible”. For people with psychiatric impairment there was “a comparatively high rate of downward movements” – in other words, even fewer people were eligible.

In terms of how we should weight our concerns about changes to workplace disability eligibility and claims, the actions of lawmakers and policy administrators in Australia have a far greater influence than a small group of psychiatrists across the Pacific who produced the DSM-5.

** Nick Glozier is Professor of Psychological Medicine, BMRI & Discipline of Psychiatry at the University of Sydney. Nick has received funding from the NHMRC and ARC and is on the appeal panel of the NSW Worker’s Compensation Commission. 

This article was originally published on The Conversation. A reminder to Croakey readers that TC articles are freely available for republishing under a Creative Commons licence.

A National Summit on Mental Health and Physical Health will be held in Sydney tomorrow with the aim of identifying actions that could be taken in the “immediate, short and long term” to address these longstanding health concerns.

In the article below, public health writer and publisher Dr Mark Ragg urges summit participants to come up with a ‘Closing the Gap’ style campaign to reduce the 20-25 year difference in life expectancy suffered by people with serious mental illness.

***

Will there be money on the table to address this critical issue?

Mark Ragg writes:

Tomorrow in Sydney a whole bunch of people in important positions get together with the opportunity to make a real difference for one of the most disadvantaged groups of people in this flat brown land.

They’re gathering at Parliament House for the national summit of health and mental health ministers who will discuss the physical health of people with mental illness, and expectations are high.

For it won’t just be the ministers present, who have to reconcile stakeholders’ wishes, ideology and budgetary reality. They’ll be surrounded by consumers, mental health commissioners, advocates and others who all want to see something solid happen. Spectacular isn’t necessary. Real is enough.

And this is why.

People with a serious mental illness die young, probably 25 years earlier on average than they should. And they don’t die necessarily of suicide, as significant a problem as that is. They die of all those run-of-the-mill conditions that get everybody else – heart attacks, diabetes, kidney failure, lung cancer. All things that are preventable to some extent, but not yet in that group of marginalised people.

The lifespan of people with serious mental illness is similar to that of an average person in the times of Parkes and Barton. On any given day, a person with serious mental illness is roughly twice as likely to die as a person without serious mental illness, even after adjusting for socioeconomic status.

Why?

At one level it’s complex – people with serious mental illness may find it hard to get help, to follow advice, to eat well, to keep appointments, to navigate a complex system. And some of the drugs used to treat psychotic illnesses pack the kilos on very quickly.

But at another level, it’s straightforward. Those who look after people with mental illness have not bothered to take good care of their physical health. Partly that’s a systemic and structural issue – mental health care and physical health care and divided at many levels.

But it’s also a matter of personal responsibility – many health professionals stigmatise people with mental illness, feeling their lives aren’t as important, that they don’t need all the investigations offered other people for their illnesses, and sometimes even that their cancers don’t need treating.

There’s been a real shift in thinking in the past five years or so. Nurses, psychiatrists and policy-makers have begun recognised that if everybody else is encouraged to eat well, get some exercise and quit smoking, then, well, people with mental illness should be offered the same advice.

That shift is stronger in the mental health sector than the rest of the health system, and it still has a way to go before it is the norm. And there is still a long way to go before people with mental illness are routinely offered the same investigations and treatments of their symptoms of heart disease, cancer and other physical illnesses as others.

Money has started to flow as well. On the issue of smoking, South Australia led the way, with smokers demanding help and getting it. The Cancer Council NSW saw the importance of the smoking. Health departments in South Australia and New South Wales got active and put significant funding into the issue.

But the funding has not grown in the past year or two, and may well have shrunk as state health budgets come under as much pressure as that of the Commonwealth.

South Australia has disbanded a centralised service, largely due to disputes over whether it should be funded by mental health services or drug and alcohol services, and New South Wales is yet to deliver on promises made a year or more back about further work. Queensland is a basket case, and others find themselves too stretched to deal comprehensively with the issue. The spirit is willing, but the flesh is beholden to GST distributions.

What is needed now, tomorrow, is solid action. This summit is sure to come up with a ‘Closing the Gap’ type of approach to reduce the 20-25 year difference in life expectancy suffered by people with serious mental illness. It will make efforts to give people with mental illness a better chance to reach their allotted years through prevention and by improving services. Reducing the stigma faced by people with mental illness, even among health professionals, is going to be important.

But all eyes will be on the final session, when the money is doled out. Changing people’s minds takes time and effort, as does improving services. Time and effort costs money.

Tomorrow’s summit is the first national meeting on the issue, and has importance in its own right. It is a beacon that things are changing. It is likely to signal a nationally consistent approach and a commitment to collecting data and measuring change.

But without funding to keep them going, beacons fade.

• Mark Ragg is director of RaggAhmed (www.raggahmed.com) and adjunct senior lecturer in the school of public health, University of Sydney. He has worked in this area with the NSW Government, the Cancer Council NSW and the Cancer Institute NSW.

***

PS from Croakey: Meanwhile, in other mental health news:

• A draft Global Mental Health Action Plan 2013-2020 is up for discussion at the Sixty-sixth session of the World Health Assembly now underway in Geneva.

• Earlier this week in Canberra, the Council of Non-Government Organisations on Mental Health met to progress work on developing national mental health indicators and targets. In a related interview with ABC Radio, psychiatrist and National Mental Health Commissioner Professor Ian Hickie noted that cardiovascular disease and smoking are major contributors to the life expectancy gap for people with mental illness.

Women admitted to psychiatry wards experience high levels of violence and sexual assaults, according to a report released this week by the Victorian Mental Illness Alliance Council.

Across the nine different psychiatry hospital wards surveyed in Victoria, 85% of female inpatients felt unsafe during hospitalisation, 67% reported experiencing sexual or other forms of harassment and 45% of respondents had experienced sexual assault during an in-patient admission.

The report further described that when the women patients reported the incidents, 82% found the nurses to be “not at all helpful”.

The report reveals two major areas of concern – first, that violence against women patients occurs commonly and second, that the incidents are not appropriately dealt with.

Mixed-gender wards

Prior to the 1960s, it was customary for men and women patients to be managed in separate psychiatry wards. Inpatient admissions were often for several months to years.

Since the 1960s, psychiatric inpatient units in many parts of the western world housed male and female patients together. The rationale for mixed gender wards was to mimic “normal” society as much as possible, since the psychiatry institutions became the patients’ world for many years.

Deinstitutionalisation occurred in the 1990s in Victoria, with the mainstreaming of psychiatry wards into general hospitals and closure of the institutions. Psychiatric patients were managed in the community, with short stay admissions to psychiatry wards if required. On average, patients had two to three weeks of hospitalisation in mixed-gender wards.

This rapid turnover of patients and preference for community treatment has meant that hospital wards now treat acutely and severely unwell people, who cannot be treated in the community.

And the level of illicit drug and alcohol use in the inpatient population, both prior to and during hospitalisation, heightens the level of behavioural disinhibiton in this population.

These combined factors lead to a greater risk of aggression and assault, predominantly against women inpatients, who often already have a history of sexual abuse and other traumas.

UK reforms

In response to escalating assaults in inpatient units, the United Kingdom government adopted a strict policy of gender segregation on psychiatric wards in 2006.

This followed a national audit of violence in inpatient settings, which found one-third (36%) of psychiatric inpatients had experienced, and almost half (46%) had witnessed, violence on their current ward/unit.

Patients and staff had similar perceptions of the most common factors triggering violent behaviour: illicit drug and alcohol issues, staff behaviour, space and overcrowding, medication and treatment, and frustration and boredom.

The UK National Patient Safety Agency, in its audit of violence in the acute psychiatry ward between 2003-2005, specifically examined sexual safety, with 122 incidents relating to sexual safety reported. These included allegations of rape, with the alleged perpetrator (another patient) in 40% of cases and a staff member in 60%; consensual sex; exposure; sexual advances; and touching.

The report does not detail how many incidents involved women, but comment is made that both men and women are vulnerable.

Australia lags behind

Australian governments over the past decade have provided funding to reduce domestic violence and sexual assault in the general community and subsequently developed the Women’s Safety Agenda in 2003.

The latest plan to combat violence against women sets out important programs in primary prevention, white ribbon campaigns, work with Indigenous communities and employment-related policies. But has no mention of action to be taken to prevent violence against women in psychiatric wards.

So why has violence against women in psychiatry wards been ignored?

For many decades, women with severe mental disorders were thought to be “too unreliable” to believe when they told their stories of harassment, assault and rape. Disempowered women patients, often with personal backgrounds of domestic violence, have been subjected to violence within a mental health system that is meant to care for them.

For a long time there was denial of this major issue by overstretched, under-resourced mental health systems, with an endemic culture of passivity about violence against women in psychiatric wards.

Over the past years, we have seen improvement in the reporting systems implemented in mental health services and better management of violence against patients, with some shift in the culture of inpatient units; but it is still not good enough.

Steps to reform

We need to take definitive actions to prevent violence occurring in our psychiatric inpatient units, not just implement mechanisms to report and manage the aftermath of assaults.

Investment in improved building designs of psychiatric wards is urgently needed, with special areas designated for women. Wards should be designed to be safe places of healing, with sensitivity for the traumatic backgrounds of many female patients. Privacy and safety measures can be designed into the structure of existing wards, and new units should be provide an individualised, safe space for each patient.

Importantly, the culture of psychiatry wards needs to change through staff gender-sensitivity training to ensure that the safety and privacy is provided and actively maintained for all patients.

Close monitoring of the situation by the general community and governments will ensure violence in psychiatry units is not tolerated.

The history of psychiatric institutions abounds with shameful stories of abuse and maltreatment of women. It’s time to end violence against women in our present day psychiatry wards and provide the therapeutic environment these women need.

** Jayashri Kulkarni is Professor of Psychiatry at Monash University. 

This article was originally published on The Conversation. A reminder to Croakey readers that TC articles are freely available for republishing under a Creative Commons licence.

Just when we thought we were heading for a more tolerant and accepting attitude toward people afflicted by mental illness, a feature and a news article in Saturday’s The Australian quoting leaders in the area of forensic psychiatry have revived the old mental-illness-equals-axe-murderer stigma.

One of the articles was based on a recent paper published in the journal Acta Psychiatrica Scandinavica showing a higher rate of conviction for all violent offences by people with psychiatric disorders in Victoria.

The second article examined the random attack of a stranger by a person with mental illness, which research has shown to be a rare event; most violence by mentally ill people is directed toward family and acquaintances.

Both of The Australian’s articles quoted Professor Paul Mullen and Professor James Ogloff of Monash University, who are co-authors of the Acta Psychiatrica Scandinavica study.

In 1984, Mullen wrote a paper that reported no increased risk of violence from people with a mental illness. And his 1997 review reported an increased risk of violent behaviour in a small proportion of patients. He is quoted as saying that new data has changed his views.

The newspaper articles include errors that are very damaging to the mentally ill. First, by using the umbrella term “mental illness”, they suggest that everyone with mental illness is more likely to be violent.

However, there is no increased risk of violence in most of the more common types of mental illness; the risk is almost entirely confined to a small proportion of those patients diagnosed with schizophrenia-related psychosis.

By suggesting that everyone who has a mental illness could possibly be violent (just as you and I), the articles isolate, highlight and stigmatise everyone with a mental illness, from depression and anxiety to most people with psychosis.

Most cases of more serious violence by these patients have occurred because of frightening persecutory beliefs arising from active symptoms of the illness.

The increased risk of violence in people with conditions such asbipolar disorder, on the other hand, is almost entirely due to the effects of substance abuse. And it goes without saying that violence is one of the many things people with anxiety and depression fear.

Rather than being perpetrators of violence, the mentally ill are far more likely to be its victim. This is mainly because of the disability and social disadvantage associated with being mentally ill, but also because these people are forced to associate with a small number of violent patients while in hospital.

Mental health laws in Australia detain patients in hospital after they have been deemed at risk of harm to others, rather than because they need treatment. Indeed, they do not even recognise the need for treatment.

This exposes patients who will never commit an act of violence to assault by the minority of patients who are, in fact, violent. For example, three patients have been killed in the Thomas Embling Hospital in Melbourne in as many years.

But the main omission in the two Australian articles was their failure to point out that most of the psychotic patients who committed acts of violence were not receiving treatment.

Indeed, the more serious the violence, the more likely the patient has never had the experience of remission from symptoms such as hallucinations of voices or false beliefs, or a medical explanation for their symptoms.

People with schizophrenia who are receiving treatment are rarely violent, a fact that is evident from the very low rate of violent offending by conditionally and unconditionally released forensic patients in New South Wales.

Only 12% of non-lethal serious violence by people diagnosed with psychotic illness that were dealt with in the NSW District Court, for instance, were committed by people receiving treatment at the time of their offences.

Rather than the blanket statement that the mentally ill are more violent than other members of the community, the correct conclusion is that while most people with mental illness will never commit an act of violence, people with untreated psychotic illness (and those involved in substance abuse) are more likely than the average person on the street to be seriously violent.

** Olav Nielssen is Senior Lecturer in Psychiatry at the University of New South Wales. He has received speaker’s fees from Astra Zeneca. 

This article was originally published on The Conversation. A reminder to Croakey readers that TC articles are freely available for republishing under a Creative Commons licence.

The decision to now support a Medicare-style levy to pay for the new National Disability Insurance Scheme is partly fired by the difficult budget situation.

However it is also inspired because of the Australian community’s proven support for Medicare. Few policies or programs have the universal support Medicare enjoys, with Australians fully realising that if we all chip in, according to our earning capacity, we can all share access to one of the world’s best health systems. Australians treat access to quality health care as a shared public good and have placed real value on the role of Medicare since its inception in 1984.

The Government is pretty sure we will feel the same about DisabilityCare. A new shared public insurance scheme, based on a hypothecated tax or levy, designed to provide long overdue access to quality disability services to the whole Australian community. Australians seem to prefer a situation in which they can clearly identify how their taxes will be spent and the vehicle of a levy permits this. Together with the community’s response to the undoubted moral imperative, the Government thinks the community will back this proposal wholeheartedly and, even judging by the talkback radio vox pops, they are probably right.

One of the key issues raised about the current proposal is that a half a percent rise in the Medicare levy will only generate $3.2bn, less than half the $8bn it is estimated the NDIS will cost annually to run. The balance it is said will be found from general revenue and the states. We do need to be clear that the Medicare Levy only raises a small proportion of the total Commonwealth expenditure on health, about $10bn out of total of around $60bn.

Even so, I believe that this theme of public insurance, such as Medicare and now the NDIS warrants further investigation. The NDIS is being established to address the disconnected, underfunded lottery that has been disability services in Australia over many decades. It is acknowledged that the focus of the NDIS will be on helping people with permanent disabilities. Many of these people have no prospect of functional independence and will require lifelong support. This will necessarily exclude the vast majority of people with a mental illness whose conditions are episodic rather than permanent. Of the 410,000 people estimated to be covered by the NDIS, only a tiny fraction is likely to be people with psychiatric illnesses. As has been demonstrated by our former Australian of the Year, Professor Pat McGorry, with proper mental health care, particularly based on early intervention, even people with low prevalence disorders such as schizophrenia and bipolar disorder can be treated and are able to recover to live fulfilling lives.

I therefore propose a new public insurance scheme, to be funded by a further half a percent levy on Medicare, to be known as MindCare. It will generate $3.2bn per year dedicated to growing the existing expenditure on mental health care in Australia, to finally address one of the most unfair and glaring gaps in what is otherwise a world class health system. The large deficit in mental health spending in proportion to the burden of disease is widely understood. New investments in mental health have been sporadic at best and not particularly generous, leaving our service system woefully underpowered.

It would be interesting to gauge public sentiment in relation to MindCare. While community surveys have repeatedly made it clear that Australians value mental health and are aware the system remains in crisis, would they be as willing to hypothecate away their hard earned cash as they seem to be in relation to DisabilityCare?

Can I also propose a way to pay for all this? The health budget is under greater scrutiny than ever before, as witnessed by the recent report of the Grattan Institute. Prime Minister Gillard says all options are on the table.

There have been recent efforts to curb public health spending by implementing a means test on the private health insurance rebate. Why don’t we go further and finally address what Jenny Macklin called one of the worst pieces of public policy ever implemented. Let’s abandon taxpayer subsidies for private health insurance altogether. In their January 2012 piece published by the Centre for Policy Development, John Menadue and Ian McAuley systematically debunked all the key points raised by proponents of the rebate, demonstrating that the policy is a huge budget burden, has massive administrative costs, has not eased the pressure on public hospitals, has not improved choice and does not reward self-reliance.

Australians have shown their clear preference for public insurance arrangements. Despite the rhetoric of choice and self-determination, both Labor and Liberal governments have forced the community to take up private insurance or be faced with considerable financial penalties (ironically payable via an additional surcharge on the Medicare levy). This is un-Australian. The subsidy paid by the Government to the private health insurance industry is around $5.5bn each year and growing. If people want to pay for their own private insurance well and good but let’s not use taxpayer funds, better directed to the public health system, to prop up private insurers.

Medicare, DisabilityCare and shortly no doubt DentiCare. I know it’s not a competition but people with a mental illness and their families are sick of waiting while every other body part and malady is considered more worthy.

Good health care is expensive. Mental health care is significantly underfunded. A national scheme of public insurance is the most efficient and publicly popular method to generate new funds and new services. Isolation is the enemy of good mental health. This kind of scheme is part of what holds a society together, making it more than just an assembly of individuals.

It is time for MindCare.

Sebastian Rosenberg is a Senior Lecturer at the Brain and Mind Research Unit, University of Sydney