Resolving the paradox of increased mental health expenditure and stable prevalence

Cost-effectiveness of system-level mental health strategies for young people in the Australian Capital Territory: a dynamic simulation modelling study

BACKGROUND

Regional mental health planning is a key challenge for decision makers because mental health care is a complex, dynamic system. Economic evaluation using a system dynamics modelling approach presents an opportunity for more sophisticated planning and important evidence on the value of alternative investments. We aimed to investigate the cost-effectiveness of eight systems-based interventions targeted at improving the mental health and wellbeing of children, adolescents, and young adults in the Australian Capital Territory (ACT).

METHODS

We assessed eight interventions for children and young people (aged ≤25 years) with low, moderate, and high-to-very-high psychological distress: technology-enabled integrated care, emergency department-based suicide prevention, crisis response service, family education programme, online parenting programme, school-based suicide prevention programme, trauma service for youths, and multicultural-informed care. We developed a system dynamics model for the ACT through a participatory process and calibrated the model with historical data, including population demographics, the prevalence of psychological distress, and mental health services provision. We calculated incremental cost-effectiveness ratios compared with business as usual for cost (AU$) per: quality-adjusted life-year (QALY), suicide death avoided, self-harm related hospital admissions avoided, and mental health-related emergency department presentation, using a 10-year time horizon for health-care and societal perspectives. We investigated uncertainty through probabilistic sensitivity analysis and deterministic sensitivity analysis, including using a 30-year timeframe.

FINDINGS

From a societal perspective, increased investment in technology-enabled integrated care, family education, an online parenting programme, and multicultural-informed care were expected to improve health outcomes (incremental QALYs 4517 [95% UI -3135 to 14 507] for technology-enabled integrated care; 339 [91 to 661] for family education; 724 [114 to 1149] for the online parenting programme; and 137 [88 to 194] for multicultural-informed care) and reduce costs ($-91·4 million [-382·7 to 100·7]; $-12·8 million [-21·0 to -6·6]; $-3·6 million  [-6·3 to 0·2]; and $-3·1 million [-4·5 to -1·8], respectively) compared with business as usual using a 10-year time horizon. The incremental net monetary benefit for the societal perspective for these four interventions was $452 million (-351 to 1555), $40 million (14 to 74), $61 million (9 to 98), and $14 million (9 to 20), respectively, compared with business as usual, when QALYs were monetised using a willingness to pay of $79 930 per QALY. Synergistic effects are anticipated if these interventions were to be implemented concurrently. The univariate and probabilistic sensitivity analyses indicated a high level of certainty in the results. Although emergency department-based suicide prevention and school-based suicide prevention were not cost effective in the base case (41 QALYs [0 to 48], incremental cost $4·1 million [1·2 to 8·2] for emergency department-based suicide prevention; -234 QALYs [-764 to 12], incremental cost $90·3 million [72·2 to 111·0] for school-based suicide prevention) compared with business as usual, there were scenarios for which these interventions could be considered cost effective. A dedicated trauma service for young people (9 QALYs gained [4 to 16], incremental cost $8·3 million [6·8 to 10·0]) and a crisis response service (-11 QALYs gained [-12 to -10], incremental cost $7·8 million [5·1 to 11·0]) were unlikely to be cost effective in terms of QALYs.

INTERPRETATION

Synergistic effects were identified, supporting the combined implementation of technology-enabled integrated care, family education, an online parenting programme, and multicultural-informed care. Synergistic effects, emergent outcomes in the form of unintended consequences, the capability to account for service capacity constraints, and ease of use by stakeholders are unique attributes of a system dynamics modelling approach to economic evaluation.

FUNDING

BHP Foundation.

Deterioration of mild anxiety and depression with Better Access treatment: implications for scaling up psychotherapy worldwide

The Australian Medicare Better Access initiative in mental health reached one in every 10 Australians in 2021 (more than 2.6 million people) with interventions targeted at mild-to-moderate anxiety and depression, provided by general practitioners, allied health professionals, and/or psychiatrists, at a cost of AUD1.2 billion. However, the overall mental health of the Australian population has not improved since the introduction of Better Access. The benefits of population-scale mental health interventions (medications and psychotherapies) might have been overestimated for milder conditions, and the iatrogenic potential underestimated. A recent evaluation of Better Access found that mild anxiety and depressive symptoms were threefold more likely to worsen (32%) rather than improve (10%). Better Access might be targeted more cost-effectively towards severe and complex conditions, for which treatment appears to have superior risk-benefit ratios. These findings have implications for similar initiatives worldwide, such as those proposed by the World Health Organization.

Antidepressant mechanisms of ketamine: a review of actions with relevance to treatment-resistance and neuroprogression

Concurrent with recent insights into the neuroprogressive nature of depression, ketamine shows promise in interfering with several neuroprogressive factors, and has been suggested to reverse neuropathological patterns seen in depression. These insights come at a time of great need for novel approaches, as prevalence is rising and current treatment options remain inadequate for a large number of people. The rapidly growing literature on ketamine's antidepressant potential has yielded multiple proposed mechanisms of action, many of which have implications for recently elucidated aspects of depressive pathology. This review aims to provide the reader with an understanding of neuroprogressive aspects of depressive pathology and how ketamine is suggested to act on it. Literature was identified through PubMed and Google Scholar, and the reference lists of retrieved articles. When reviewing the evidence of depressive pathology, a picture emerges of four elements interacting with each other to facilitate progressive worsening, namely stress, inflammation, neurotoxicity and neurodegeneration. Ketamine acts on all of these levels of pathology, with rapid and potent reductions of depressive symptoms. Converging evidence suggests that ketamine works to increase stress resilience and reverse stress-induced dysfunction, modulate systemic inflammation and neuroinflammation, attenuate neurotoxic processes and glial dysfunction, and facilitate synaptogenesis rather than neurodegeneration. Still, much remains to be revealed about ketamine's antidepressant mechanisms of action, and research is lacking on the durability of effect. The findings discussed herein calls for more longitudinal approaches when determining efficacy and its relation to neuroprogressive factors, and could provide relevant considerations for clinical implementation.

Could negative outcomes of psychotherapies be contributing to the lack of an overall population effect from the Australian Better Access initiative?

OBJECTIVE

We examine deterioration in psychotherapies, as reported in the recent evaluation of the Australian Medicare Better Access initiative.

CONCLUSION

A focus on patients who experience poor clinical outcomes helps programs minimise harm and improve quality of care. The Better Access evaluation found the mental health of 20-40% of patients deteriorated. This may partly explain why population distress and suicide rates were not reduced by the introduction of the Better Access initiative. Deterioration was more likely for milder conditions, and less likely for severe conditions, which also improved the most. Using severity as a criterion for priority setting and resource allocation may minimise patient risk and maximise benefits. Patients with severe conditions may require considerably more sessions than the current average for Better Access psychotherapies.

Equitable psychiatry, telehealth, and the COVID-19 pandemic: Analysis of national data

Background

At the beginning of the COVID-19 pandemic, it was foreseen that the number of face-to-face psychiatry consultations would suffer a reduction. In order to compensate, the Australian Government introduced new Medicare-subsidized telephone and video-linked consultations. This study investigates how these developments affected the pre-existing inequity of psychiatry service delivery in Australia.

Methods

The study analyses five and a half years of national Medicare data listing all subsidized psychiatry consultation consumption aggregated to areas defined as Statistical Area level 3 (SA3s; which have population sizes of 30 k-300 k). Face-to-face, video-linked and telephone consultations are considered separately. The analysis consists of presenting rates of consumption, concentration graphs, and concentration indices to quantify inequity, using Socio Economic Indexes for Areas (SEIFA) scores to rank the SA3 areas according to socio-economic disadvantage.

Results

There is a 22% drop in the rate of face-to-face psychiatry consultation consumption across Australia in the final study period compared with the last study period predating the COVID-19 pandemic. However, the loss is made up by the introduction of the new subsidized telephone and video-linked consultations. Referring to the same time periods, there is a reduction in the inequity of the distribution of face-to-face consultations, where the concentration index reduces from 0.166 to 0.129. The new subsidized video-linked consultations are distributed with severe inequity in the great majority of subpopulations studied. Australia-wide, video-linked consultations are also distributed with gross inequity, with a concentration index of 0.356 in the final study period. The effect of this upon overall inequity was to cancel out the reduction of inequity resulting from the reduction of face-to face appointments.

Conclusion

Australian subsidized video-linked psychiatry consultations have been distributed with gross inequity and have been a significant exacerbator of the overall inequity of psychiatric service provision. Future policy decisions wishing to reduce this inequity should take care to reduce the risk posed by expanding telepsychiatry.

Paying the price – out-of-pocket payments for mental health care in Australia

Objective This study set out to present data on out-of-pocket payments for Medicare mental health services provided by general practitioners (GP), psychiatrists, clinical psychologists and other psychologists, to explore how much is spent on out-of-pocket payments for mental health; if any trends could be seen; and what variations exist across regions. Methods We performed secondary analysis of publicly available data on Medicare-subsidised GP, allied health and specialist health care across Australia. We merged and interrogated data covering the period 2013-19 and 2019-21 to create a data set covering eight full years of Medicare mental health services, arranged by profession and by region. Results Out-of-pocket payments for mental health care in Australia have been rising consistently over the period 2013-21, at a considerably faster rate than overall expenditure on mental health care. There is wide variation in out-of-pocket payments depending on where you live. Conclusions The impact of out-of-pocket payments on community access to mental health care is growing. This has implications, especially in poorer communities, for access to care. This should be an important consideration taken as the Australian Government considers next steps in national mental health reform, including the Better Access Program, currently under evaluation.

Major Depression and Its Recurrences: Life Course Matters

Major depression is one of the most prevalent and debilitating personal and public health conditions worldwide. Less appreciated is that depression's tremendous burdens are not shared equally among all who become depressed. Some will suffer recurrences over the rest of their lives, whereas half or more will never have a recurrence. Based on these two distinctive life course prototypes, we propose a subtype distinction for research on the origins and lifetime course of major depression. A pressing goal is to determine at the time of depression's first onset who will follow which clinical trajectory. The lack of recognition of this distinction has resulted in many obstacles, including conceptual biases, methodological oversights, and definitional dead ends. Current theories are reviewed and compared. The implications for contemporary diagnostic controversies, reevaluating research on treatment and prevention, and enhancing the predictive strength of traditionally weak indicators of recurrences and recurrent depression are discussed. Expected final online publication date for the Annual Review of Clinical Psychology, Volume 18 is May 2022. Please see http://www.annualreviews.org/page/journal/pubdates for revised estimates.

Analysis of global prevalence of mental and substance use disorders within countries: focus on sociodemographic characteristics and income levels

This report presents the prevalence of mental and substance use disorders around the world discussing the impact of geographical, sociodemographic, and income characteristics on national epidemiological differences. We analysed data from the Institute of Health Metrics and Evaluation database published in 2019. The global prevalence of mental disorders was 13.0%, with higher prevalence of anxiety disorders rate (4.1%), followed by depressive disorders (3.8%, including major depressive disorder 2.49% and dysthymia 1.35%), intellectual disability (1.5%), ADHD (1.1%), conduct disorders (0.5%), bipolar disorders (0.5%), autism spectrum disorder s (0.4%), schizophrenia (0.3%), and eating disorders (0.2%, including bulimia nervosa 0.13% and anorexia nervosa 0.05%). The worldwide prevalence of substance-use disorders was 2.2%, not surprisingly, with higher prevalence of alcohol-use disorders (1.5%) than other drug-use disorders (0.8% total including: cannabis 0.32%; opioid 0.29%, amphetamine 0.10%; cocaine 0.06%). In general, high-income countries reported higher levels of mental and substance use disorders, with the exceptions of conduct and depressive disorders (no significant differences were found among low- and high-income countries), and intellectual disability (with higher prevalence in low-income countries). In regions of the America's prevalence rates of mental and substance use disorders were higher than in Europe. Western Pacific countries reported high levels of schizophrenia, and depressive disorders were highly prevalent in Africa as well as in the Americas. Intellectual disability reported higher rates in Eastern Mediterranean and South-East Asia. We discuss the cross-cultural variations in mental health expenditure and literacy as well as stigma-related factors and some of the environmental risk factors possibly related to these prevalence differences.

Mental Health in Australia: Psychological Distress Reported in Six Consecutive Cross-Sectional National Surveys From 2001 to 2018

PURPOSE

To examine Australian psychological distress trends from 2001 to 2017/18, including analysis by age, sex, location, and household income.

METHODS

Secondary analysis of the working age population (18-64 years) in six successive representative national health surveys. Measures were prevalence of psychological distress at very-high symptom level (defined by a Kessler Psychological Distress Scale (K10) score of 30 or more) and combined high/very-high level (K10 score of 22 or more). Very-high K10 scores are associated with mental health problems meeting diagnostic thresholds in past year.

RESULTS

From 2001 to 2017/18 Australian rates of K10 very-high distress rose significantly from 3.8 to 5.1% and combined high/very-high from 13.2 to 14.8%. In women aged 55-64, very-high distress rose significantly and substantially from 3.5 to 7.2% and high/very-high distress from 12.4 to 18.7%. In men aged 25-34, very-high distress increased from 2.1 to 4.0% and high/very-high from 10.6 to 11.5%. Income was strongly and inversely associated with distress (lowest vs. highest quintile adjusted OR 11.4). An apparent association of increased distress with regional location disappeared with adjustment for income.

CONCLUSION

Australia's population level of psychological distress increased significantly from 2001-2017/18, with levels highest in women and with rates inversely associated with income. This is likely to be indicative of increased community rates of mental disorders. Given that this has occurred whilst mental healthcare expenditure has increased, there is an urgent need to reconsider how best to respond to mental illness, including targeting the most vulnerable based on social determinants such as age, gender, and lower incomes.

A multilevel scenario based predictive analytics framework to model the community mental health and built environment nexus

The built environment affects mental health outcomes, but this relationship is less studied and understood. This article proposes a novel multi-level scenario-based predictive analytics framework (MSPAF) to explore the complex relationships between community mental health outcomes and the built environment conditions. The MSPAF combines rigorously validated interpretable machine learning algorithms and scenario-based sensitivity analysis to test various hypotheses on how the built environment impacts community mental health outcomes across the largest metropolitan areas in the US. Among other findings, our results suggest that declining socio-economic conditions of the built environment (e.g., poverty, low income, unemployment, decreased access to public health insurance) are significantly associated with increased reported mental health disorders. Similarly, physical conditions of the built environment (e.g., increased housing vacancies and increased travel costs) are significantly associated with increased reported mental health disorders. However, this positive relationship between the physical conditions of the built environment and mental health outcomes does not hold across all the metropolitan areas, suggesting a mixed effect of the built environment's physical conditions on community mental health. We conclude by highlighting future opportunities of incorporating other variables and datasets into the MSPAF framework to test additional hypotheses on how the built environment impacts community mental health.

Socio-economic disadvantage and resource distribution for mental health care: a model proposal and example application for Victoria, Australia

OBJECTIVE

A spreadsheet-based model for supporting equitable mental health resource distribution in Australia was developed, based on the Australian Health Survey (AHS) psychological distress findings associated with area socio-economic disadvantage (SED). An illustrative application is presented.

METHOD

Stratum-specific psychological-distress rates for area SED quintiles are applied to local government areas, catchment areas and local health networks (LHNs). A case study applies the model to Victoria, including examining recommendations in the Royal Commission into Victoria's Mental Health Services (RCVMHS) 2019 interim report for increases to bed stock in two LHNs.

RESULTS

Need-adjusted demand estimates considered as a ratio of raw population proportions for catchments range between 0.6 to 1.4 in Victoria. Applying the formula to the Royal Commission recommendations suggests the proposed distribution of beds is a reasonable correction for these two LHNs and indicates next expansion priorities for more equitable distribution to other LHNs.

CONCLUSIONS

The spreadsheet, adaptable for other states and territories, could complement National Mental Health Services Planning Framework outputs and assist in evaluation, for instance, determining potential supply shortages in the tele-mental-health response to COVID-19. We outline research directions including consideration of the moral bases of value judgements and identification of other variables including their use in parameterisation and calibration.

Prospective Associations between Sport Participation and Indices of Mental Health across Adolescence

Youth sport offers physical and psychosocial components that may be beneficial for adolescents' mental health, but the prospective directionality between sport participation and mental health has not been clearly established. The current study examined longitudinal associations between sport participation (individual and team sport) and mental health indices (depressive symptoms, anxiety symptoms, emotional symptoms, hyperactivity symptoms, conduct problems, peer problems, and prosocial behavior) across adolescence (ages 12-17) in a nationally representative Australian sample of 3956 participants at T1 (M_age = 12.41 years, SD = 0.49; 49% female), 3537 at T2 (M_age = 14.41 years, SD = 0.49; 49% female), and 3089 at T3 (M_age = 16.46 years, SD = 0.51; 49% female). Using random intercept cross-lagged panel modeling, several significant within-person effects were found. Notably, greater participation in team sport prospectively predicted fewer symptoms of depression and anxiety at subsequent timepoints. This study increases the understanding of how sport participation may relate to mental health among adolescents and provides critical evidence to inform policy.

REFOCUS-PULSAR Recovery-Oriented Practice Training in Adult Primary Mental Health Care: Exploratory Findings Including From a Pretest-Posttest Evaluation

Objectives: Australian general practitioners (GPs) are pivotal in mental health care. The REFOCUS-PULSAR (Principles Unite Local Services Assisting Recovery) primary care study aimed to improve personal recovery outcomes in adults with mental health problems consulting GPs. Design: Modified from an intended stepped-wedge cluster study, an exploratory (pre- and post-intervention) design employed cross-sectional surveys of patients consulting GPs. Setting: Eighteen primary care sites (clusters) in Victoria, Australia in 2013-2017. Participants: From 30 GPs recruited, 23 participated (76%), with 235 patient surveys returned from adults aged <75 years receiving mental health care. Intervention: A co-delivered face-to-face training intervention for GPs in recovery-oriented practice (ROP), with personal recovery a key focus, used multimedia, mnemonics, and targeted interview schedules to encourage ROP-with availability of support sessions for 1 year. Outcome Measures: Primary: the Questionnaire about the Process of Recovery full-scale score (outcome). Secondary: INSPIRE (experience), Warwick-Edinburgh Mental Well-being Scale (WEMWBS) and Kessler Psychological Distress Scale (K10) (outcomes). Other: General-practice-Users Perceived-need Inventory (experience). Results: Small positive significant effects indicated primary-outcome post-intervention improvements [t-test (233) = -2.23, p = 0.01], also improvement in two secondary outcomes (WEMWBS t(233) = -2.12, p = 0.02 and K10 t(233) = 2.44, p = 0.01). More patients post-intervention reported "no need" for further help from their GP; but in those reporting needs, there was greater unmet need for counseling. Conclusions: ROP implementation, internationally influential in specialist mental health care, here is explored in primary care where it has had less attention. These exploratory findings suggest better patient outcomes followed introducing GPs to ROP in routine practice conditions. Higher unmet need for counseling post-intervention reported by patients might be a sign of limited supply despite ROP facilitating better identification of needs. Challenges in project implementation means that these findings carry risks of bias and flag the importance establishing research infrastructure in primary care. Clinical Trial Registration: www.clinicaltrials.gov/, The Australian and New Zealand Clinical Trial Registry Identifier: ACTRN12614001312639.

Can loss of agency and oppositional perturbation associated with antidepressant monotherapy and low-fidelity psychological treatment dilute the benefits of guideline-consistent depression treatment at the population level?

Despite major expansions of evidence-based treatments of common mental disorders in recent decades, especially antidepressant medication, the point prevalence of depression has not decreased; instead it probably increased in young adults. We question whether antidepressants (AD)-monotherapy and low-fidelity-to-guideline psychological treatment (PT) might have no effect or even adverse effects in some patients and contexts that dilute the benefits of treatment at the population level, making it harder for population-based studies to detect treatment-driven prevalence reductions. Randomized Clinical Trial (RCT)s have not identified these effects because AD-monotherapy and low-fidelity PT are uncommon in RCTs where treatment protocols are specified and carefully monitored, unlike treatment in real-world settings. Second, RCTs may have missed the bigger picture of ultimate outcomes due to too short follow-ups. We elaborate two mechanisms through which AD-monotherapy and low-fidelity PT could produce adverse effects on long-term illness course. Both mechanisms are speculative and we outline how to test.

Trends in prevalence of depression in Germany between 2009 and 2017 based on nationwide ambulatory claims data

BACKGROUND

Studies based on health insurance funds unanimously indicate a rise in administrative prevalence of depression, while population surveys with standardized diagnostic procedures do not. We describe recent trends in the prevalence of depressive disorders as diagnosed in routine care from 2009-2017 in Germany.

METHODS

We used nationwide ambulatory claims data from all residents with statutory health insurance, covering 87% of the total population. Cases were defined as persons with at least one documented diagnosis of depression (ICD-10-GM codes: F32, F33 or F34.1). The administrative prevalence was computed for each year according to age, sex, degree of urbanization and severity of depression diagnosis.

RESULTS

The prevalence increased from 12.5% in 2009 to 15.7% in 2017 (+26%). Overall, women were twice as likely as men to receive a diagnosis, although the prevalence increased more strongly in men compared to women (+40% vs. +20%). Age- and sex-stratified analyses revealed the highest prevalence increase in adolescents and young men at the ages of 15-19 years (+95%) and 20-25 years (+72%). Rural areas with a low population density showed the highest rise in administrative prevalence (+34%), while big urban municipalities showed the lowest (+25%).

LIMITATIONS

Administrative claims data rely on diagnoses coded for billing purposes and thus depend on coding practice as well as patients' help seeking behavior.

CONCLUSIONS

Depressive disorders are of increasing importance in ambulatory health care in Germany. Parts of the increase may be attributed to changing cultural constructions of mental health along with the expansion of mental health care supply.

Healthcare utilization among patients with psychiatric hospitalization admitted through the emergency department (ED): A claims-based study

OBJECTIVE

To characterize the US national level healthcare utilization patterns of patients with commercial insurance plans before and after a psychiatric hospitalization admitted through the emergency department (ED) using insurance claims data.

METHOD

We identified 34,250 patients from multiple commercial health insurance providers across the US who meet our eligibility criteria. We summarized their healthcare encounters and used logistic regression models to study the patterns of healthcare utilization including prior visits, outpatient follow-ups, and hospital- or ED-readmissions.

RESULTS

Suicidal ideation was highly prevalent at the time of the index event (29.88%). Almost half of the patients (48.28%) had healthcare encounters with the same primary diagnosis one year before admission, about 5% had outpatient follow-ups or were readmitted to the hospital or ED 7 days post discharge. The post 30-day follow-ups and readmission rates were slightly higher. In general, older patients were less likely to have prior visits, follow-ups, or readmissions, and patients with SUDs, specifically alcohol dependence, opioid dependence/abuse, and stimulant dependence, were more likely to have outpatient follow-ups.

CONCLUSION

Patterns of patients' prior visits, follow-ups, and readmissions varied by demographics and psychiatric comorbidity. Additional studies are needed to further explain the spatial variations of utilization patterns.