Pat McGorry: The rise of the ‘unmet need’ and ‘met unneed’ in our mental health system

There has been a dramatic rise in the number of people who need mental health care falling through the cracks. Meanwhile more people without a genuine need are consuming mental health resources, writes Pat McGorry.

The 21st century promised a new dawn for Australians with mental illness.

The old 19th century asylums were being dismantled and were to be replaced by a modern mental health system fully accepted within mainstream health care.

That was the achievable dream.

A new wave of awareness was launched and prejudice and stigma were in retreat.

It was assumed that greater awareness and tolerance would result in the same access and quality of care for people with mental illness that people with physical illness enjoy.

It is true that there has been real progress in the understanding and acceptance of some forms of mental illness, and we have developed solid foundations for youth mental health care to meet the youth mental health crisis, but the new dawn has proven to be yet another false one in the quest for a fair go for all mentally ill Australians.

The proportion of the health and medical research budgets to mental health remains stuck at around 7 per cent — the same as over 30 years ago.

Meanwhile we have seen a rise in the level of mental illness, alarmingly so in young people. The benefits from improved awareness have flowed exclusively to people with less severe forms of mental illness, notably anxiety and depression, and mostly to those in the inner metropolitan suburbs of capital cities with a capacity to pay the substantial co-payments which are a feature of our private practice fee for service approach.

Health inequity in mental health care has arguably become worse.

Meanwhile the plight of people with more severe forms of mental illness – conditions such as schizophrenia, bipolar disorder, anorexia nervosa or borderline personality disorder – has steadily worsened.

Professor Pat McGorry is a respected psychiatrist who has outlined how to fix the mental health system. Picture: NCA NewsWire / David Crosling

The solemn pledges made by state governments in the 1990s – that the closure of thousands of beds during deinstitutionalisation would be accompanied by supported housing and well-funded, multidisciplinary community mental health care – have all been broken.

The public mental health system offers little more than ambulances at the bottom of the cliff. Care is limited to risk management and acute care within a narrow biomedical model which has retreated to the extent that involuntary patients are the dominant focus.

Early intervention at the onset of illness or to pre-empt relapse, a cornerstone, for example, of cancer treatment, is an abandoned dream in state government health services.

It is a bleak landscape.

We have witnessed a neglected system descend into a state of near collapse.

This neglect is putting lives and communities at risk.

The national suicide rate still sits at well over 3000 deaths per annum, and it was recently revealed that the number of parents dying at the hands of their acutely ill, inadequately treated adult children had doubled in Victoria since the Royal Commission.

These preventable tragedies are merely the tip of the iceberg of neglect.

And NSW is reliving the trauma of the Bondi Junction disaster, which would never have happened if the perpetrator had remained in treatment – treatment that had been working well until it was discontinued and he fell through the yawning gaps of the “system”.

Hundreds of thousands of Australians with severe mental illness live with preventable disability, economic disadvantage, poverty and, in far too many cases, in avoidable incarceration in the criminal justice system.

People with severe mental illness die 15-20 years earlier than everyone else, a gap larger than that for Indigenous Australians.

Federal Minister Mark Butler has labelled all this “ a national shame”. The hidden burden on ageing parents is enormous.

Even though mental illness is the largest cause of disability in Australia, only 10 per cent of even the most severely mentally ill can gain access to it, and even then it fails to provide the things that they really need, especially secure housing, specialist psychiatric care and something meaningful to do.

Professor Pat McGorry has written about the ‘unmet need’ – people who need care but can’t access it – and ‘met unneed’ – the people who consume mental health resources without a genuine need. Picture: Orygen

Instead a raft of well meaning but unskilled support workers are on offer, but with little to offer.

The federal government spends $48bn per year of the NDIS and $4bn per year on mental health care.

Fortunately, the Albanese Government has begun to recognise this unsustainable asymmetry by boosting its investment in mental health by $1b over 4 years in a well targeted set of new commitments.

And placing NDIS reform with the health portfolio under Mark Butler, an experienced minister who has a genuine understanding and soundtrack record of mental health reform is grounds for renewed optimism.

Some years ago, Professor Gavin Andrews characterised the mental health landscape as being made up of unmet need, people with a genuine need for care which was not accessible, and “met unneed”, those who consumed mental health resources without a genuine need or perhaps with a lesser need for it.

By 2025 both groups have expanded dramatically.

The National Survey of Mental Health and Wellbeing in 2022 showed an alarming rise in need for care for anxiety and depression in young people.

This reflects real unmet need in spades.

On the other hand, recent data reveals that 15 per cent of six-year-old boys are now being supported by the NDIS, predominantly with a diagnosis on the autism/neurodevelopmental spectrum.

Pat McGorry praised Mark Butler as an experienced minister with a genuine understanding of mental health reform. Picture: NewsWire / Martin Ollman

The actual rate is around 6 per cent.

This is not to say that many of the rest do not have a need for some form of support.

Rates of diagnosis of ADHD are also surging, driven in part by a welcome catch up for historical under-diagnosis, but equally by a wave of misdiagnosis which includes substantial “met unneed”.

At the same time severely disabled older adults with severe mental illness are locked out of vital health and psychosocial care.

What is the solution? The first stage, as always, is truth-telling.

The severely mentally ill have been seriously and repeatedly let down in the failed reforms of the past three decades.

The profession of psychiatry has been weakened and is in danger of being completely forced out of the public sector into a siloed, poorly accessible, private-practice model which fails the equity test.

Practising psychiatry in the current public health system is becoming untenable.

Specialist doctors experience moral injury every day as they are unable to provide the care severely ill people really need.

The state and federal governments must reimagine, redesign and rebuild the system they dismantled 30 years ago and at the scale required.

If health care must become equitable so must social care aka the NDIS.

The following are ways forward.

State governments must rethink their failed mainstreamed systems and invest heavily to bring them to scale and to meet safe and therapeutic standards.

Cancer care is the role model here with scientifically informed, compassionate care.

The federal government must drive reform from the community side building new community systems of care, shifting its investments towards a salary-based multidisciplinary team model and away from fee for service.

The mental health system needs reform, Pat McGorry says.

The NDIS must be fundamentally rethought and fund the real needs of people with enduring disability caused by severe mental illness and include housing, employment and psychosocial care.

And what can the community do? The Friendship Bench is a visionary program developed in Zimbabwe by Dr Dixon Chabanda, in which 14 grandmothers with deep wisdom and long experience were trained and worked as a team to support people with common mental health conditions.

With the backup of primary and secondary clinical care this is an amazing safety net that can be created in any community and a way in which many of the missing needs for understanding, connection and recovery can be met.

It draws on the power of community, something that we need to rebuild in our alienated digital world.

And the Australian community, with virtually every family impacted in some way, must in their own self-interest, make it clear to government that they expect and demand a fair go especially for people with severe or potentially severe mental illness.

Professor Patrick McGorry AO is a psychiatrist, professor of youth mental health at the University of Melbourne and founding editor of the journal Early Intervention in Psychiatry.

He is also the Executive Director of Orygen, a not-for-profit youth mental health research institute and charity.

Originally published as Pat McGorry: The rise of the ‘unmet need’ and ‘met unneed’ in our mental health system