Improving the mental health of the population: where to next?

The need for a national strategy on preventing mental disorders

During the 1990s, two national surveys were carried out in Australia that were very influential in guiding thinking about population mental health. The first was the National Survey of Mental Health and Wellbeing, which showed that mental disorders were common, disabling and undertreated.1 The second was the National Survey of Mental Health Literacy, which showed that many members of the public had negative views of the standard psychiatric treatments that were endorsed as effective by clinical practice guidelines and mental health clinicians.2,3

This “treatment gap” suggested a clear path to improving population mental health: we needed to get more people with mental disorders to seek help and receive evidence-based treatments.4 In Australia, efforts to achieve these aims were successful. There is now a greater willingness to be open about mental disorders and to seek help,5 and the Australian public's beliefs about treatment of mental disorders have become much closer to those of professionals.6 Further, we have seen considerable increases in use of pharmacological and psychological treatments.7

However, the expected gains in population mental health have not been seen. Repeat population surveys since the 1990s, using screening tests for mental disorders, show no detectable reduction in symptoms.7,8 The one population gain that has been found is a reduction in the suicide rate, which roughly coincided with the introduction of the National Suicide Prevention Strategy in 1999.9

These observations raise the question of “where to next?” One option would be to continue to expand the reach of clinical services and reduce the treatment gap further. However, it could be argued that the marginal gains of reducing the treatment gap will become progressively smaller as treatment is applied to milder cases.

An alternative strategy is to have a greater emphasis on prevention.10 The prevalence of mental disorders is a function of incidence and duration. Prevention aims to reduce incidence, whereas treatment aims to reduce duration. We need a two-pronged effort aimed at both prevention and treatment, but the prevention prong is largely missing. It is notable that the reduction in suicide corresponded to the introduction of a strategy focused on population prevention. We need to build on this approach by developing a national strategy for the prevention of mental disorders.