A Contributing Life – The 2013 National Report Card on Mental Health and Suicide Prevention

IINTRODUCTION

This ‘Report Card’, published at the end of 2013, is in fact a book of some 200 pages. It is the second in what will become a series of annual reports. The first in the series was reviewed in the April 2013 edition of Actuaries magazine.

The National Mental Health Commission is a high powered body chaired by Professor Allan Fels AO. The job of the government appointed Commission includes “reporting each year on how Australians are faring in their mental health and on the things that aid recovery and help make people’s lives better”. The Commission accents the positive, setting itself the task of helping “people living with mental health difficulties and their support people to live a contributing life”.

This year they have refined the wording of what that means:

The Abbott government has expanded the Commission’s brief during 2013 giving it “the task of undertaking a review of the mental health system, to identify where gaps and barriers are, and to see if money is spent effectively, efficiently and for the best outcome”. The work of the Commission may therefore be expected to continue for a number of years.

There are several aspects of this reporting which will be of direct interest to actuaries. It was noted that the 2012 Report Card quoted a number of statistics that would be useful to life and general insurance companies and their actuaries who may be involved in underwriting of people who have a history of mental health concerns.

Parts of the 2013 report show the attention that is beginning to be paid to the integration of mental health support with the Disability Care Australia program (formerly known as the National Disability Insurance Scheme, or NDIS) which is a field of interest to the actuarial profession.

To this reviewer’s mind, the 2013 report may have less immediate relevance to the work of actuaries than 2012, but the series of annual reports will continue to be worth watching closely.

THE 2013 REPORT CARD

In the wider, social, sense, the 2013 Report Card explores several fields in more detail than was possible in 2012. In particular, it provides sobering statistics considering the frequencies with which people with a mental health difficulty:

• first experience problems with mental health at young ages;
• also have issues with alcohol and substance abuse;
• are caught up with the criminal justice and prison systems;
• experience discrimination, either overtly or covertly; and
• are over represented among Aboriginal and Torres Strait Islander communities and in the LGBTI (Lesbian, Gay, Bisexual, Transgender and Intersex) sectors of society.

The Report Card builds on the 2012 work in reviewing suicide statistics and thinking how Australia may reduce suicide deaths in future.

Based on their activities in 2013, the Commission has added another eight recommendations to the 10 in their 2012 Report card (included at the end of the article). While the recommendations themselves may look like motherhood statements at first glance, the reasoning behind them is anything but bland.

The discussion backing up the new recommendations adds weight to the need for action.

For interested readers, the following bullet points are all direct quotations from the 2013 Report Card:

• A staggering 14% of Australia’s children and young people have a mental health problem. About 50% of mental health problems emerge by the mid-teens, and around 75% by age 25.
• Only 25% of young people with mental health problems receive treatment of any kind.
• Suicide is the leading cause of death among our young people.
• Getting help early when things are going wrong is vital.
• Only 7% of people with co-existing mental illness and substance misuse have received support for both problems, yet studies have shown that up to 70% of people presenting to mental health or substance use services can experience both issues.
• We know that in a year, almost 340,000 Australians will have both mental illness and a substance use disorder.
• People who have mental health issues and a substance use disorder are twice as likely to be homeless as those who had one of these problems, and twice as likely to have been in prison or a correction facility.
• Micro inequities, where minor instances of discrimination or inequality are experienced repeatedly, build up to compound a person’s experience of discrimination.
• This surely contributes to the fact that 65% of the estimated 3.2 million Australians who have experienced a mental health problem in the past 12 months have not sought help.
• Australia ranks amongst the worst OECD countries for the rate of employment of people with a disability, including mental health difficulties.
• 87% of young people in the juvenile justice system were found to have at least one psychological disorder.
• 38% of all people entering our prison system reported having been told they have a mental illness. This would equate to about 11,000 people each year. This is shocking. It is almost double the 12-month prevalence of mental illness in the general population.
• Aboriginal and Torres Strait Islander peoples are over-represented in Australian prisons. While they comprise only 3% of Australia’s population at 30 June 2012, they made up 27% of the adult prison population.
• Incarceration has serious mental health impacts for Aboriginal people, and in turn, mental health conditions are associated with high incarceration rates.
• Suicide takes one and a half times as many Australian lives each year as road accidents. Road accident deaths have substantially reduced in recent decades, but over the same period there has not been the same level of reduction in suicide rates.
• If suicide were a disease, funds would be scrambled and urgent searches started to find vaccines, causes and cures.
• Aboriginal and Torres Strait Islander people who die by suicide are half as likely as other Australians to have ever received help for a mental health problem. But they are twice as likely as non-Indigenous people to take their own lives.
• Suicidal thinking, plans and attempts among the LGBTI community are shockingly high. People who identified as lesbian, gay or bisexual reported suicidal thoughts during their lifetime at almost three times the rate of those identifying as straight, and suicidal plans or attempts during their lifetime at four times the rate.
• Each year in Australia, more than 2,200 people die by suicide, and an overwhelming three quarters of these are men.

FINDINGS FROM THE LAST TWO YEARS

The Commission’s work in 2013 continued to address the four priority areas for action identified in 2012. These are:

The Report Card for 2012 made 10 recommendations to achieve the Commission’s vision for a contributing life for people with mental health difficulties, their families and supporters.

The 2013 Report Card follows up on the response seen since then on the action steps proposed to help put each of those recommendations into place. On the whole, while there continues to be much interest in each of these areas, the response has been patchy.

In some areas the Commission has been able to report that promising initiatives are under way. In others, they express some disappointment at the lack of action to date. For example, the Commission has not yet received a formal response to their 2012 Report Card from COAG, the Council of Australian Governments.

This reviewer’s opinion was that the Commission may have been too didactic in the way it expressed its 2012 recommendations. These read more like orders to the federal and state governments than as words of advice. As the Commission is not itself a decision-making body, it may have been more productive to concentrate on ‘selling’ rather than on ‘telling’ their proposals to the governments.

To give one example, implementing all of the action steps proposed would certainly increase immediate expenditures, which would require diversion of funds from other programs.

The Commission seems to believe a general thesis, that such expenditure would be revenue positive. Enabling more people to live a contributing life will increase taxation revenue in future, as people with mental health difficulties who have been helped join the workforce, and will also reduce expenditures in other areas as the people concerned will need fewer support services.

However, money is always tight. It is more likely governments would commit to immediate extra expenditures in the mental health field if they were convinced by solid research evidence proving the financial benefits that would flow to them in the longer term.

The Commission’s first two Report Cards are surprisingly thin on data that would help with a treasury evaluation of costs and benefits. Perhaps this is an area where actuaries could make a meaningful difference.

THE COMMISSION’S RECOMMENDATIONS

(Numbers 1 to 10 are from 2012, numbers 11 to 18 were added in 2013)

1. Nothing about us, without us – there must be a regular independent survey of people’s experiences of and access to all mental health services to drive real improvement
2. Increase access to timely and appropriate mental health services and support from 6-8% to 12% of the Australian population.
3. Reduce the use of involuntary practices and work to eliminate seclusion and restraint.¹
4. All governments must set targets and work together to reduce early death and improve the physical health of people with mental illness.
5. Include the mental health of Aboriginal and Torres Strait Islander peoples in ’Closing the Gap’ targets to reduce early deaths and improve wellbeing.
6. There must be the same national commitment to safety and quality of care for mental health services as there is for general health services.
7. Invest in healthy families and communities to increase resilience and reduce the longer term need for crisis services.
8. Increase the levels of participation of people with mental health difficulties in employment in Australia to match best international levels.
9. No one should be discharged from hospitals, custodial care, mental health or drug and alcohol related treatment services into homelessness. Access to stable and safe places to live must increase.
10. Prevent and reduce suicides and support those who attempt suicide through timely local responses and reporting.
11. Co-existing mental illness and substance misuse: People with co- existing mental health difficulties and substance use problems must be offered appropriate and closely coordinated assessment, response and follow-up for their problems.
12. Early intervention: National, systematic and adequately funded early intervention approaches must remain. This must be accompanied by robust evaluation to support investment decisions, with a focus on implementation, outcomes and accountability.
13. Peer Workforce: A National Mental Health Peer Workforce Development Framework must be created and implemented in all treatment and support settings. Progress must be measured against a national target for the employment and development of the peer workforce.
14. Including families and support people: A practical guide for the inclusion of families and support people in services must be developed and implemented, and this must include consideration of the services and supports that they need to be sustained in their role.
15. Community understanding: The Commission calls for the implementation and ongoing evaluation of a sustained, multi-faceted national strategy for reducing discrimination.
16. Transitions through education: All Australians need access to alternative (and innovative) pathways through school, tertiary and vocational education and training.
17. The justice system and mental health: Where people with mental health difficulties, their families and supporters come into contact with the criminal justice system and forensic services, practices which promote a rights and recovery focus and which will reduce recidivism must be supported and expanded.
18. Suicide prevention: Governments must sign up to national targets to reduce suicide and suicide attempts and make a plan to reach them. These targets must be based on detailed modelling.

¹ Recommendation 3 refers to a person being treated for a medical illness without their consent, seclusion of patients to a single room within their home or in a treating facility and the use of straps, belts or sedation to restrain the patient’s movements.

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