The federal Department of Health and Ageing has recently released the draft Ten Year Roadmap for National Mental Health Reform for public consultation. For the most part, by its own admission, it continues current reform directions in mental health policy: a shift away from acute care, hospital-based services towards community-based services and supports; better co-ordination between mental health, primary health and other social services; and prompt referral for those displaying early signs of illness.
For “consumer” advocates there is probably a lot to like about the roadmap. It forecasts more accessible, co-ordinated, and personalised services for the people with protracted and/or severe conditions — those who (naturally enough) “consume” mental health services most intensively — and a new national consumers’ organisation.
Those who bemoan a lack of mental health services in disadvantaged areas, or outside the major cities, may also find reasons for hope.
As with current policy, the roadmap also acknowledges some of the wealth of evidence on social determinants of mental health; at least insofar as recognising that some groups in society tend to display higher rates of illness than others, including, inter alia: indigenous Australians, children of parents with a mental illness, people living in rural and remote regions, people in jail, adolescents, and “socio-economically disadvantaged people” (e.g. p.41).
I’ve argued previously that current policy evades some of the difficult issues on this front. The cumulative evidence on mental illness in populations, along with research on stress arousal, tells us that some aspects of life in modern environments causally contribute to illness by acting as chronic stressors.
This pathway is thought to lie behind associations found between exposure to conditions such as insecure employment, unaffordable housing, low income, social isolation, and abuse or violence, and common forms of mental illness. The uneven distribution of these factors across the population thus contributes — in no small way — to social inequalities in health outcomes.
The lesson for health promotion is that there are tremendous opportunities available for primary prevention of mental illness, by reducing population exposures to these factors. Necessarily, this requires prudent use of complementary policy measures across a range of portfolios, including measures to reduce overall socioeconomic inequality.
Current mental health policy does not venture to pursue this wider challenge. Measures to address social factors such as secure housing and employment are predominantly focused on meeting the needs of the 2% or so of people with more severe conditions. Does the roadmap do any better?
Of five key directions policy identified by the roadmap only Direction 1, on “promoting good mental health and well-being and preventing mental illness and suicide”, alludes to the possibility of primary prevention by addressing risk factors in the social environment.
And some of the longer-term actions indicated under that direction do forecast broader social programs in important areas such as early child development, education, employment opportunities and social capital building. Sustained action in these areas to “decrease exposure to known risk factors across the lifespan” (p. 17), would indeed be a welcome advance on current policy.
However, in many other ways, and in the other four key directions, the roadmap reverts to the more familiar policy ground of an individualised, biomedical approach to mental illness, focused on access to treatment, therapies and co-ordinated care for “consumers” already ill (and especially those with more severe conditions) and early referral into treatment for those with early symptoms — especially in relation to psychotic conditions.
Here, at times, we seem to encounter an implied “social selection” view; that associations between mental illness and forms of social disadvantage come about because illness “just happens” to individuals, and only then undermines their employment, education, income or housing situation (e.g. see p. 25).
While things can happen that way round, of course, social selection does not adequately explaining overall social inequalities and social gradients in mental health.
Despite some promising signs in the roadmap, policy progress in Australia on recognising and responding to social determinants of health in general, and mental health in particular, remains partial and uncertain. It is to be expected that mental health professionals and consumer advocates will argue the policy case from a client-centred perspective — a perspective also embraced in the roadmap.
However, as compelling as that case might be, we need health policy makers and political leaders to look beyond individuals’ needs, to engage with Australian and international research on social determinants of health and confront questions about socioeconomic inequalities, population health effects and policy options across areas of government activity.
It is this view that reveals the main drivers of the $5.9 billion annual productivity costs of mental illness in Australia (p. 25). And we need greater priority placed on effective, long-term, localised strategies to create health promoting environments and communities.
These are the issues I would hope would feature more prominently in an aspirational document such as the roadmap.
*Matt Fisher is research officer at the Southgate Institute for Health, Society & Equity at Flinders University