Australia’s Billion-Dollar Question: Why Is Mental Health Not Improving With Better Access?

Amid growing mental health crisis, research raises questions about the mass rollout of brief psychotherapies in Australia.

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The prevalence of mental health issues continues to rise in Australia despite the government’s federal initiative to increase psychotherapy access to citizens. In their recent publication in Australian Psychiatry, researchers led by Stephen Allison suggest that psychotherapy may be ineffective or even cause deterioration in individuals with less severe mental health issues,

A comprehensive evaluation of the Australian Medicare Better Access initiative has revealed that a significant proportion of patients have experienced a deterioration in their mental health, leading researchers to question the program’s overall effectiveness at the population level.

The Better Access initiative, introduced in 2006, aimed to reduce the burden of mental health conditions in Australia. By 2021, one in every ten Australians had received at least one service through the program, with one in 20 having one or more psychotherapy sessions, costing the Australian government AUD 1.2 billion. Despite this significant investment, the evaluation found that rates of psychological distress and suicide have not decreased since the program’s inception.

The evaluation discovered that 20–40% of patients’ mental health worsened during treatment. This was particularly the case for those with milder mental health conditions, while those with severe conditions were more likely to improve.

“About a half of psychotherapy patients fail to improve, or their mental health deteriorates in real-world studies. Deterioration rates would be even higher in untreated populations, especially for severe conditions. Generally, deterioration is related to the underlying mental health condition or factors external to psychotherapy but is sometimes a side effect of psychotherapy,” the researchers write.
“If about 5–10% of patients deteriorate in psychotherapy, this could reduce the overall effectiveness of the Better Access initiatives at the population level.”

Psychotherapies, such as Cognitive Behavioural Therapy (CBT), are only modestly effective for common mental health conditions. This, combined with a real-world failure rate of around 50% for psychotherapy patients, may contribute to the lack of significant population-wide improvement.

The evaluation also raised concerns about the potential for adverse side effects associated with psychotherapy, including the resurfacing of unpleasant memories, the emergence of new symptoms, occupational problems, stigmatization, and self-blame, among others.

Five studies were included in the evaluation, using various methods such as clinical practice data, cross-sectional patient surveys, prospective observational studies, population-level longitudinal studies, and patient interviews.

Three of the five studies showed alarming rates of significant deterioration amongst individuals who received psychotherapy through Better Access. Study 1 observed 86,121 care episodes, indicating 10-20% of deterioration and 20-30% no change after the care. Study 3, an observational prospective study, used data from 2,199 patients who used services from primary mental health care facilities. Of the patients, 20-30% showed deterioration of mental health. Lastly, study 4 incorporated data from a large-scale Australian longitudinal study that showed of the 30,906 patients observed who used psychotherapy through Better Access, 20-40% had worse mental health outcomes.

Notably, the five studies showed  50%-100% improvement in patients after receiving psychotherapy with Better Access throughout the evaluation. Especially study 5, a qualitative interview (n=37), and Study 2, a cross-sectional patient survey (n=2013), each had an improvement rate of 100% and 91% among patients. Nevertheless, given the deterioration rates, Allison argues that Better Access needs further improvement and a better method of evaluation:

“Given that 1.3 million patients received Better Access psychological treatment in 2021, many patients may have experienced deterioration in their mental health […]. This may have offset some of the potentially positive effects of the initiative. The survey and interview studies (2 and 5 in Table 1) found far lower deterioration rates than the quantitative studies, raising concerns about the representativeness of these study populations.”

Interestingly, the studies reported varying deterioration rates depending on the chosen evaluation method. This discrepancy led to concerns about the representativeness of the study populations, particularly as the survey and interview studies found much lower rates of deterioration than the quantitative studies.

Further, across studies, patients who had less severity of mental health episodes showed the most deterioration, while those with higher severity showed the least. Based on such findings, Allison and peers argue that brief access to psychotherapy may not be fit for all individuals, especially those with less severe mental health issues. Therefore, a new policy that identifies individuals with high severity of mental health issues and concentrates resources on such a population may be more beneficial than the current status quo of a Better Access system that provides the same treatment regardless of severity.

Allison explains:

“The mass rollout of brief psychotherapies for milder conditions does not appear to reduce population distress or suicide rates, and a considerable proportion of these patients experience deterioration. […] Instead of the mass rollout of brief psychotherapies for milder conditions, prioritizing longer courses of psychotherapy for more severe conditions may minimize risk and maximize the potential benefits of the Better Access initiative.”

The evaluation concluded that, while the Better Access initiative has achieved positive outcomes for many consumers, particularly those with severe depression, anxiety, or psychological distress, there is significant room for improvement.

Future evaluations could investigate the causes of deterioration in psychotherapy, focusing on whether it is a side effect of the therapies or factors external to the treatment. Such studies could inform policymakers about the risks of Better Access psychotherapies to minimize harm and improve the program’s effectiveness.

The current evaluation and assessment of Better Access does not explain why brief psychotherapy may cause deterioration and should be a subject for future research. Nevertheless, it highlights why psychological distress and suicide rates persist at the population level despite the Better Access initiative and provides directions for improved policy.

 

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Allison S., Looi J., Kisely S., Bastiampillai T. (2023). Could negative outcomes of psychotherapies be contributing to the lack of an overall population effect from the Australian Better Access initiative? Australasian Psychiatry. doi:10.1177/10398562231172417 (Link)

9 COMMENTS

  1. Well, the first thing you can do is assay patients’ perceptual status, as psychotherapy isn’t likely to be effective with patients/clients who are troubled by perceptual distortions, particularly those that can shape patients’ attitudes (e.g. feelings of being watched or talked about).
    Next would come using the proper treatments, which present day psychiatry doesn’t have, unfortunately.

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  2. Sad to hear. The approach of the therapist is everything. If cognitive-level (top-down) techniques such as CBT/DBT are being used, it’s not surprising at all that the effects are marginal. In my view, true healing requires bottom-up modalities such as Internal Family Systems which work with the unconscious.

    “Until you make the unconscious conscious, it will direct your life.” – Carl Jung

    -Terry
    healingtheself.net

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  3. William M Epstein over several books including The Illusion of Psychotherapy, Psychotherapy as Religion and Psychotherapy and the Social Clinic, Soothing fictions has taken the best of the psychotherapy research apart and analysed it on methodological grounds. What he demonstrates is there is no evidence for any psychotherapy being effective and it can be harmful.

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  4. Why don’t the researchers find out which psychotherapists are effective? I worked a clinic in which there was a tenfold difference between the most and least effective therapist. These measures are extremely hard to get hold of, as the ineffective therapists, who often have seniority and more pay, fight tooth and nail for their ineffectiveness finding the light of day. One of the top therapists in that clinic was the lowest paid, had the least university qualifications – but had been through the system from the time she was a young child (when her parents had been killed).

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