Chapter 1: Improving wellbeing
The single most effective means of reducing the burden and impact of psychological distress, mental illness and suicide is to avoid people becoming mentally unwell in the first place.
This means that an effective system should address the full spectrum of wellbeing by building good mental health, while also responding to distress, mental health issues and severe mental illness. A strong mental health system does this by recognising the complexities of mental health, including the social and economic drivers of wellbeing.
The principles of working together, harnessing information, facilitating access, building community-based care, and delivering quality, personalised care will help to improve wellbeing for people who interact with the mental health system. However, improving wellbeing is also about promoting mental health, building protective factors and mitigating risk factors. This means taking a systems approach to building good mental health, with a focus on the broader context, including prevention and early intervention, addressing social and economic disadvantage, addressing increasing levels of loneliness, and addressing comorbidities such as substance use.
Early intervention and prevention
The National Mental Health Commission (the Commission) has always taken a strong stance on the importance of prevention and early intervention approaches. The National Children's Mental Health and Wellbeing Strategy (see Box 13) highlights opportunities for preventive actions in early childhood; however, a preventive approach should span across the life course. Supporting population mental health and wellbeing, and intervening early when individuals are at risk reduces distress, disadvantage and disability over the lifetime.
Evidence shows that policies that focus on early intervention and prevention have positive flow-on effects, particularly for the most disadvantaged in our society. Such policies also reduce the likelihood of contact with more costly supports and services, including the child protection and justice systems, acute hospital-based care, and social support payments.
According to the Productivity Commission, early intervention and prevention can help to maintain and expand the proportion of the population (an estimated 60%—5.2 million people) who are not at risk of, or do not have, a mental disorder. Early intervention and prevention are at the core of a person-led mental health system that aims to help people maintain and improve their mental health. To achieve this, the Productivity Commission recommends taking action to improve social and emotional wellbeing of children and their families, increase youth economic participation, and increase social inclusion. Reducing stigma and workforce training have also been identified as important actions to address the cultural and social barriers to improving mental health and wellbeing. These issues are discussed in Section 3, Chapter 3.
Box 13: National Children's Mental Health and Wellbeing Strategy
The National Children's Mental Health and Wellbeing Strategy will guide the Australian Government's investment in the health and wellbeing of children and their families. The strategy provides a framework to proactively promote child wellbeing, support families and communities, and help those who are struggling as early as possible to minimise any long-term impacts of poor mental health.
The strategy describes the importance of prevention and investment in early intervention, as the foundations for lifelong health and wellbeing commence long before school. It has four focus areas; each focus area contains objectives and actions that should be taken to achieve the required reform:
- • Family and community—highlights the importance of empowering families to promote mental health and wellbeing as part of routine parenting, and making it easier for families to connect with services when required. The importance of community-based approaches to health is also emphasised.
- • Service system—recognises that the current mental health service system is in need of major reform, and that it is crucial that we make it easier for families and service providers to navigate the system. The strategy also recommends incentivising collaborative care and having a system built to cater for complexity.
- • Education settings—emphasises the important role that educational settings play in promoting mental health and wellbeing in children, and discusses the additional supports that may be required for educators to build positive wellbeing cultures.
- • Evidence and evaluation—speaks to the importance of improving data collection and use, and embedding a culture of evaluation to enable an optimal system of programs and services that provides consistently high-quality supports for children and families. Importantly, the principles of co-design are central to ensuring that services meet the needs of all children and families.
The Commission held consultations in January and February 2020 with professional colleges and peak bodies to capture perspectives, current issues and gaps within systems supporting children's mental health and wellbeing. The Commission has also consulted with expert groups to capture input across mental health, early childhood and primary education, clinical and social services, parent and carer roles, Aboriginal and Torres Strait Islander children, families and communities.
The strategy entered a final consultation stage in December 2020. This is a public consultation that allows anyone to view and provide feedback on the strategy through the Commission's website. It is anticipated that consultation on the draft strategy will conclude in March 2021, and that the strategy will be finalised and launched in mid-2021.
Addressing increasing levels of loneliness
An emerging issue with significant potential to affect wellbeing is the increasing levels of loneliness found throughout society, both in Australia and internationally. This is considered an emerging public health issue as loneliness has been associated with poorer physical and mental health outcomes. For example, lonely Australians are 15% more likely to be depressed and 13% more likely to be anxious about social interactions than people who are not lonely. Recent evidence suggests that the impact of COVID-19 has exacerbated feelings of loneliness, as discussed in Section 2. However, increasing loneliness was evident well before the COVID-19 pandemic.
Findings from a survey conducted in 2018 by the Australian Psychological Society found one in two (51%) Australians felt lonely for at least one day in a week, and more than one in four (28%) felt lonely for three or more days. The Young Australian Loneliness Survey, conducted in Victoria in 2019, found that one in four (28%) young people reported problematic levels of loneliness.
Loneliness has been found to impact different groups of people more than others—in particular, older people, younger adults, people with disability who have mental health issues, people with poor health, people living alone, carers, and people from some culturally and linguistically diverse communities.
Addressing social and economic disadvantage
A system that improves wellbeing will help those who are most at risk of mental health issues. It is well established that some of the most powerful root causes of inequities in mental health are the social conditions in which people are born, grow, work, live and age, as well as the systems that shape the conditions of daily life. People living with mental illness are also more likely to experience a range of adverse social, economic and health outcomes, including homelessness, unemployment, incarceration and poor physical health.
This reciprocal relationship between mental illness and other social, economic and health factors means that many investments and policy reforms that have the potential to improve the mental health of Australians may come from outside the health sector. For example, various programs preventing discharge from acute mental health care into homelessness, examined by the Productivity Commission, demonstrated a return on investment ranging from $1.24 to $9 per dollar invested.
Many determinants of health and wellbeing need to be addressed at population, community, family and individual levels. Particularly relevant now is the impact of loss of income and work as a result of the COVID-19 pandemic. It is estimated that almost 2.7 million Australians lost their jobs, or were working reduced hours, during the pandemic‘s peak in March and April 2020. Economic disadvantage, including low income, high levels of debt and relative poverty, have clear associations with risk of mental disorders. There is evidence that, when income inequality increases, distress levels among groups of lower socioeconomic status tend to increase.
In particular, associations have been shown between financial hardship and depression, suicide, drug dependence and psychotic disorders. Strategies and policies that provide sufficient income for healthy living, such as social protection and minimum wage policies, therefore act as protective factors.
Integrating mental health and substance use
Section 1 outlines the case for integration of mental health services, alcohol and other drug (AOD) services, and supporting frameworks such as the National Drug Strategy 2017–2026 and the Fifth National Mental Health and Suicide Prevention Plan.
Despite a clear case for integration, there have been challenges in implementing these national strategies. Specifically, the different approaches by state and territory governments in addressing substance use comorbidity add a further layer of complexity in coordinating services, and funding structures can be a barrier to service integration.
Funding structures that implement rigid eligibility criteria mean that people with comorbid substance use issues can often be turned away from mental health or AOD services. Services have attempted to provide integration—for example, headspace for youth and the Adult Mental Health Centres that are currently under development. However, clinicians are primarily trained in mental health, so that services tend to be approached via this lens.
To address these longstanding challenges, the Productivity Commission has recommended that all governments integrate commissioning and provision of mental illness services and substance use services for people with both conditions. The Productivity Commission has also recommended that mental health and AOD services should jointly develop and implement operational guidelines covering screening, referral pathways, training guidelines, and other resources for mental health and AOD workers to improve outcomes for people with substance use comorbidities.
Innovation in prevention of mental ill-health and AOD comorbidity has also shown potential for improving wellbeing. Results from a trial of an online school-based prevention program targeting substance use, depression and anxiety in adolescence found that increased knowledge about alcohol, cannabis and mental health reduced the likelihood of drinking and reduced symptoms of anxiety over a 30-month period. An opportunity exists for the wider use of such prevention programs that have demonstrated their effectiveness to promote good health while addressing issues that contribute to mental distress. The Commission encourages strengthening of the evidence base behind prevention programs that address comorbidities and improve wellbeing to promote wider use of these kinds of innovations.