Why Katie and two million others living with mental illnesses are the missing middle

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Two million people with mental illnesses are languishing in a no-man’s land, where state and federal governments offer few options for people who need more than 10 psychologist sessions until they reach the point of emergency care or hospital admission.

Government funding for people with mental health issues is also asymmetrical, with Australians signed up to the National Disability Insurance Scheme for psychosocial disabilities caused by mental illness receiving almost 20 times more money per person than those who can’t access the scheme.

The mental health sector says governments must urgently plug the system’s “missing middle” in the May budget and reinvest in community care such as social, employment and housing support as well as teams of health professionals.

Katie Barton, 20, has been part of the “missing middle” in Australia’s mental health system. She went to the hospital emergency department after waiting 12 months to see a specialist psychologist.Credit: Nick Moir

Twenty-year-old Katie Barton ended up in the emergency department two years ago, overwhelmed with intrusive thoughts and fearing for her safety. “It was incredibly scary and isolating time for me,” she said.

Barton’s appointments with Headspace youth services and GP sessions were never regular or specialised enough to deal with her major depressive disorder. As a student, she faced hundreds of dollars in fees and year-long waitlists to see a professional who could help treat her more complex illness.

“There’s this whole secondary space that isn’t being filled. I had to wait until I was at a crisis point and access care through the emergency department,” she said.

Once she was admitted, Barton said hospital care made her feel safe and supported. “But I don’t think it needed to get to that point. A lot of the experiences and trauma that I had to endure could have been avoided if the system was designed to support you at every stage of mental ill health, not just at both ends of the spectrum.”

Mental health experts describe the system as follows: On one side, there is hospital care for people having an acute episode or with very severe and disabling illness, which is funded by state governments.

On the other is federal government support, which for most people would be their GP or 10 Medicare-funded sessions with a psychologist each year. In 2022, these also required a $90 gap fee for 70 per cent of services.

Professor Sebastian Rosenberg, from the University of Sydney’s Brain and Mind Centre, said there is nothing in the middle. “That is the gap. Where is secondary care? It has never been properly funded. I think there was some expectation the NDIS would see that blossom in Australia, but it hasn’t occurred.”

The NDIS currently offers social support, including recovery coaches, for about 60,000 people with a psychosocial disability.

About $4 billion is allocated to that group of people each year – compared with $11 billion spent on the mental health system by state and federal governments combined to treat everyone else.

The Productivity Commission estimates one in five Australians experience mental illness each year: about 2.3 million are mild cases, 1.2 million are moderate and 800,000 are severe. About 3.3 million receive treatment through Medicare.

Rosenberg said this amounted to almost $67,000 per person spent through the NDIS, compared with $3333 per person for those not on the scheme – 20 times more money.

He said it had created a “cliff” in treatment between the last person accepted by the NDIS and the first person to miss out.

NDIS Minister Bill Shorten agrees that mental health services are not what they should be – and that is a key reason the disability scheme has become “the only lifeboat in the ocean”.

”What happened is a lot of community mental health programs were rolled into the NDIS … but they weren’t replaced,” he said in a press club speech last week.

“There is a bit of a desert … There’s people who need more than a couple of sessions of therapy but are not sufficiently impaired that they require the NDIS.”

The sector is now looking towards the May 9 budget for evidence of how the government intends to support the missing middle, after Health Minister Mark Butler cut the number of Medicare-funded psychology sessions people could access from 20 to 10 in a controversial decision late last year.

While a review showed the scheme was not distributing resources evenly, it also recommended the extra 10 sessions be retained and targeted towards those with complex mental health needs – which didn’t happen.

Youth mental health expert Patrick McGorry said people who needed the extra sessions also typically required more help than a psychologist on their own. “More salaried and team-based care is what we really need,” he said.

He wants funding for teams of psychiatrists, case managers and social therapists who could help with jobs or education.

The Australian Psychological Society says early intervention treatments are far more cost-effective than waiting for people to be admitted to hospital.

“When budgets are tight, governments must maximise patient care by focussing on what they know works best for less,” said chief executive Zena Burgess.

“Millions of Australians suffer mental illness or disorders each year under-treated, or without treatment. Well managed and led multidisciplinary teams are excellent for patients, if [they] have a choice of provider and the treating team are clear about their responsibilities and accountabilities.”

Assistant Minister for Mental Health, Emma McBride, said the government had funded primary health networks to commission local mental health services for people with ongoing and complex needs.

“The National Mental Health and Suicide Prevention Agreement recognises addressing gaps in the system of care – such as those impacting the ‘missing middle’ – is critical to improving the experiences of Australians accessing mental health services,” she said.

But chief executive of SANE, Rachel Green, said while there were some good investments, the system was largely built around exclusion and eligibility requirements.

“The kind of support and care that might help you live well and build relationships, delivered early, can change the course of life. But most of the health system [doesn’t offer that] unless you make it to the pointy end,” she said.

Green said redesigning and investing in community care would avoid both hospital costs down the line and lifelong disabilities for people with severe needs. “We need a smarter system that is not just clinical – [there needs to be] psychosocial, housing, social and family support.”

If you or anyone you know needs support call Lifeline 131 114, or Beyond Blue 1300 224 636.

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