Meeting demand for psychological services for people with depression and anxiety: recent developments in primary mental health care

Disorders like depression and anxiety are prevalent and disabling,1 and many people with these disorders do not seek treatment or are not routinely offered treatment by their general practitioners, who are usually the first point of contact.2

In recognition of this, the Australian Government has recently instituted primary mental health care reforms. The Better Outcomes in Mental Health Care (BOiMHC) program was introduced in July 2001, followed by the Better Access to Psychiatrists, Psychologists and General Practitioners through the Medicare Benefits Schedule (Better Access) program in November 2006. Both programs have a number of components, and both include a mechanism by which GPs can refer patients with disorders such as depression and anxiety to allied health professionals (predominantly psychologists) for six sessions of evidence-based care, with capacity for additional sessions after review by the referring GP.

The BOiMHC program does this through a total of 111 Access to Allied Psychological Services (ATAPS) projects, run by Divisions of General Practice. The Divisions are variously using voucher, brokerage, register and direct referral systems to manage referrals.3 In contrast, the Better Access program offers a series of new Medicare Benefits Schedule (MBS) item numbers4 that make patients eligible for a rebate for services of registered allied health professionals if they are referred by their GP. The allied health professionals can directly bill Medicare Australia or can bill the patient, who can then obtain a partial rebate from Medicare Australia.4

There has been considerable debate about how the ATAPS projects might coexist with the newer Better Access arrangements. Uptake of both programs has been high,5-7 but there are questions as to whether Better Access may circumvent demand for the ATAPS projects. The Australian General Practice Network website states that:

It has been implicitly suggested that demand for ATAPS services in urban areas may be reduced, and that the Better Access program is less likely to meet demand in rural areas where there is a dearth of private providers who are eligible to deliver Medicare-funded services.9,10

To date, no empirical analysis has been done to inform these questions of relative demand. Here, we examine whether there was a reduction in demand for services provided through the ATAPS projects after the introduction of the Better Access program and, if so, whether this reduction was greater in urban than remote areas.

The overall monthly breakdown of sessions provided under each program is shown in Box 1. Although the monthly number of sessions provided by the Better Access program increased dramatically from the time of its introduction, the monthly number of sessions provided by the ATAPS projects remained fairly constant from 1 November 2006, showing a marginal decrease at most.

A breakdown of sessions by rural and urban areas is shown in Box 2. This shows that the increase in number of sessions provided under the Better Access program was most pronounced in urban areas, where there was an early decrease in the number of sessions provided through the ATAPS projects, which then levelled out. It also shows that the increase in number of sessions provided under the Better Access program was more gradual in rural areas, where the number of sessions provided by ATAPS projects remained relatively constant.

When the relationship between the provision of ATAPS sessions and Better Access sessions was examined within Divisions for each month, there was a negative, non-significant correlation overall (r = − 0.078; P = 0.074). For rural Divisions, the correlation was positive but also non-significant (r = 0.024; P = 0.703). For urban Divisions, there was a significant negative correlation (r = − 0.142; P = 0.019).

Overall, the findings suggest that there was a strong demand for both programs during the 5-month observation period, presumably because there was pre-existing demand for psychological services that could not be met by the ATAPS projects alone. This interpretation is consistent with a high level of unmet need previously observed in the community.11 It is also consistent with the fact that ATAPS projects were implementing demand management strategies before the introduction of the Better Access program,12 and suggests a need for ongoing monitoring of such strategies as they are made operational by both programs during the current climate of mental health reform.

These preliminary findings suggest that the ATAPS projects and the Better Access program should continue to coexist in a complementary fashion. The ATAPS projects have an established history of successful service delivery,13,14 have brought many GPs and allied health professionals “on board”,13,14 and may more easily attract allied health professionals in areas where private providers are scarce, because they can offer the certainty of salaried positions or formalised contractual arrangements. In addition, their budgets are capped, rendering their overall associated expenditure predictable. On the other hand, the Better Access arrangements may be seen as providing greater ease of referral for GPs, increased flexibility for allied health professionals, and a reimbursement mechanism that is congruent with the broader private specialist service system. The two programs are thus well placed to work together to provide access to primary mental health care. Anecdotally, some Divisions are already supporting GPs wishing to refer patients through the Better Access program, and some allied health professionals are providing services through both programs.

Of course, there are questions over and above those related to the complementarity of the two programs that should inform decisions about their future directions. For example, additional evaluation will be necessary to compare the appropriateness and effectiveness of each program. Our own research suggests that the ATAPS projects are reaching the consumers for whom they were originally designed (ie, people with anxiety and depression who may previously have had difficulty accessing services),13,15 and that they are achieving improvements in patients’ mental health, as assessed by various standardised outcome measures.16 Similar evaluative efforts are required to assess the appropriateness and effectiveness of the Better Access program.

Evidence will also need to be sought regarding the optimal number of psychological services required to meet community need, and the affordability of these services. Using epidemiological data, cost-effectiveness studies and expert advice, a recent report estimated that optimal treatment with optimal coverage would require 4.9 million psychological services per year and would be affordable.17 According to aggregated data from the ATAPS minimum dataset and the MBS website, by December 2007 the ATAPS projects and the Better Access program had provided a total of 1 954 283 sessions of care (423 530 and 1 530 753, respectively) since each program’s inception. Even with discounting for publicly funded, state-based services, this suggests that the number of services being provided is neither too many nor unaffordable.

Ongoing monitoring will be required to determine whether our preliminary findings are consistent over time, and additional evaluation evidence will be required to help shape future program delivery. However, early indications are that the two programs are providing complementary services and are working together to address a previously unmet need for mental health care.

1 Overall number of sessions provided through ATAPS projects and the Better Access program, 1 November 2006 to 31 March 2007

ATAPS = Access to Allied Psychological Services.

2 Number of urban and rural sessions provided through ATAPS projects and the Better Access program, 1 November 2006 to 31 March 2007

ATAPS = Access to Allied Psychological Services.