Commissioner viewpoint: Making prevention a priority
There is some irony in the expression attributed to Albert Einstein, “absurdity is doing the same thing over and over again and expecting different results”.
Yet, arguably, this is where we find ourselves with contemporary mental health reform.
In recent decades, we have seen much needed investments in new mental health services—in acute services, community beds, primary mental health care, and youth mental health services.
These investments have been badly needed. Historically, the mental health system has been under-serviced, underfunded, and under pressure.
But extra investment in treatment services is simply not enough. Despite many millions of dollars in extra treatment services, there doesn’t appear to be much improvement in the overall mental health of our population.
Demand still grows voraciously, requiring more and more investment in treatment and long-term support services. Something needs to change.
We need to do things differently to get different results.
What we can learn from the flu
There is much to be learned from other areas of public health.
For example, the influenza pandemic of 1918–19 is estimated to have claimed 50–100 million lives[1] worldwide, more than the Great War. It strained already stretched medical systems, having huge social and economic impact. Its effect reached right across society to touch individuals and households, communities, workforces and governments of all levels.
The influenza pandemic brought with it great medical, scientific and policy drive to create a vaccine, to find a better way than filling hospitals with endless streams of sick people. Its legacy is an enduring focus on prevention, because the costs and impacts of not doing so are far more serious.
So when we look at our mental health system today, what do we see? A system heavily geared toward treatment, while investing far less than it should on prevention.
An ounce of prevention
High quality treatment and support is absolutely essential, but in our efforts to improve the service system, we have forgotten the fundamental principle, and value of, prevention.
The case for a significant change in approach is clear.
Despite our best efforts to continually buttress the service system, the prevalence of mental illness remains effectively unchanged. This is hardly surprising given it is estimated that even if we could provide the best available treatment to everyone who needs it, less than 30 per cent of the burden of mental illness could be averted[2].
It is important we don’t lose sight of the fact that much of the mental illness in our community can actually be prevented. Indeed, prevention is by far our best investment over the long term.
The cost of doing the same thing over and over again
The costs of our failure to prevent the onset and relapse of mental illness is staggering.
Each year, we spend up to $28.6 billion in direct and indirect costs[3] to treat mental illness. This figure doesn’t account for lost productivity, or the socio-emotional costs to people with lived experience and their families and carers.
The total annual bill, taking into account intangible costs such as reduced wellbeing, emotional distress, pain and suffering, is estimated to be $70 billion (or 4 per cent of GDP)[4].
Then there’s the $13 billion worth of informal care provided by carers of people living with mental illness—a figure considerably higher than the direct cost of providing mental health services (approximately $9 billion each year).
These costs are only likely to grow as governments attempt to meet ever-growing demand.
Dollars and sense
Mental health promotion, prevention and early intervention is an invest-to-save proposition.
The May 2018 analysis by Mental Health Australia and KPMG[5] clearly articulates the economic case supporting the mental health prevention, promotion and early intervention agenda.
The report outlined “quantifiable economic returns to taxpayers and the community” that just make economic sense[6], particularly for governments facing ever growing demands for more frontline services within and beyond the health sector, increasing (and often) competing public priorities, and pressures to moderate and contain expenditure[7].
A serious investment in prevention and early intervention would not only put downward pressure on demand for health services, but also free up resources to improve quality of care for those who need it and reduce the indirect costs of mental illness on the community.
Breaking the cycle
Good mental health is as vital as good physical health, and the benefits of promoting good mental health and preventing mental illness are not just economic. They are potentially life changing for individuals and families, and transformational for communities.
Good mental health allows people to participate in and enjoy life and all the opportunities it has to offer. It also allows people to experience life as meaningful, and to be creative and active citizens. Reducing the onset, duration and relapse of mental illness spares individuals and families substantial distress. It can also save lives.
Many of the actions that promote good mental health and prevent ill-health, like universal parenting programs, have much wider benefits than just reducing mental illness.
They contribute to better educational outcomes, improved workplace productivity, better physical health and reduced crime[8].
Pushing the boundaries
Prevention is more than one clear-cut strategy, it requires a set of well-coordinated strategies and activities aimed at:
- promoting good mental health and wellbeing for everyone
- reducing risks among known vulnerable groups
- intervening as early as possible at the first signs of illness and relapse, and
- supporting lasting recovery for people who have experienced significant illness [9].
It’s the daily circumstances in which we live that often have the biggest impact on our mental health.
Our early childhood experiences, the quality of our education, social inclusion and exclusion, experience of racism and discrimination, and access to housing, employment and income all have a big impact.
Few if any of these factors are directly in the control of the health system. If we are to make a major improvement in mental health through prevention, we need to look far broader than the confines of the health system to broader social and economic supports.
Improving mental health and wellbeing requires the contribution of all areas of public policy, from education, housing, employment, finance, local government, social services, welfare and the environment.
Best buys
We know that the earlier in life preventive measures are implemented, the better[10]. There is compelling evidence that shows challenges experienced later in life actually have their foundations early in life.
About 75 per cent of mental illness is apparent by the age of 25, and between one-quarter and one-half of adult mental illness is potentially preventable through appropriate interventions in childhood and adolescence[11].
The evidence tells us that experiencing four adverse events as children increases risk of adult mental health problems at least five-fold. This risk can be cut in half by having a relationship with one consistent, trusted adult during childhood[12].
It not surprising then that one of our ‘best buys’ in the prevention of mental illness is programs that support good perinatal, infant and childhood development—physically, psychologically, socially and educationally.
Like most preventive measures, the benefits of early childhood programs go well beyond mental health benefits, resulting in better physical health, better education and employment outcomes, and better family functioning.
James Heckman’s pivotal work tells us there is a 13 per cent return on investment for every dollar invested in early childhood health and learning programs[13].
The prescription
We have a great opportunity to cement mental health promotion, prevention and early intervention as the foundation of our mental health system.
There is nothing new in the prevention principle. It’s not even new thinking, it just needs to be applied with renewed vigour, focus and drive. Our challenge is not only about convincing governments about the need for investment in this critical area, but making sure we have effective ways forward.
While there is much we can and need to do in the preventative space, there are arguably few better places to start than to give Queensland children and families a great start in life.
[1] Bulletin of the History of Medicine, Volume 76, Number 1, Spring 2002, pp 105-115, https://muse.jhu.edu/article/4826/summary
[2] Jacka, F & Reavley, N 2014, ‘Prevention of mental disorders: evidence, challenges and opportunities’, BMC Medicine, vol. 12, no.75, pp.1-3
[3] National Mental Health Commission, 2014, The National Review of Mental Health Programmes and Services, Sydney
[4] National Mental Health Commission, 2014, The National Review of Mental Health Programmes and Services, Sydney (p.6)
[5] Mental Health Australia and KPMG 2018, Investing to Save: The Economic Benefits for Australia of Investment in Mental Health Reform, Final Report
[6] Mental Health Australia and KPMG 2018, Investing to Save: The Economic Benefits for Australia of Investment in Mental Health Reform, Final Report
[7] Urbis 2015, Invest now, save later: The economics of promotion, prevention and early intervention in mental health, Australia
[8] Knapp, M, McDaid, D & Parsonage, M (Eds) Mental health promotion, and mental illness prevention: the economic case Department of health London, 2011.
[9] World Health Organization Mental Health Action Plan for Europe: Facing the Challenges, Building Solutions, Geneva: WHO 2005
[10] Kessler, RC, Amminger, GP, Aguilar-Gaxiola, S, Alonso, J, Lee, S & Ustün, TB 2007, ‘Age of onset of mental disorders: a review of recent literature’, Current Opinion in Psychiatry, vol.20, no.4, pp. 359–64
[11] Kim-Cohen, J, Caspi, A, Moffitt, TE, Harrington, H, Milne, BJ, Poulton, R 2003, ‘Prior juvenile diagnoses in adults with mental disorder: developmental follow back of a prospective longitudinal cohort’ Arch Gen Psychiatry vol.60, no.7 pp.709–17.
[12] Bellis M, Hardcastle, K, For,d K, Hughes, K, Ashton, K, Quigg, Z, Butler, N. 2017 Does continuous trusted adult support in childhood impart life-course resilience against adverse childhood experiences - a retrospective study on adult health-harming behaviours and mental well-being. BMC Psychiatry.17(1)
[13] Carcia, J., Heckman, J., Leaf, D., and Prados, M. 2017. Quantifying the life-cycle benefits of a protypical early childhood program. IZA 0 Institute of Labor Economics, Bonn, Germany.
