The National Mental Health Policy [1,2], releasedin 1992, has been something of a guiding frameworkfor mental health reform in Australia over the past8 years. Its implementation was guided, between1993 and 1998, by the (First) National Mental HealthPlan [3]. This Plan was refined and the Policy imple-mentation continues under the Second NationalMental Health Plan [4]. There was no specific indi-cation in the Policy that Australia needed, or would infact undertake, studies to generate national informa-tion on the mental health status of the population.

In 1993 I became Chair of the Australian HealthMinister’s National Mental Health Working Group(NMHWG) which was to oversee the implementa-tion of the National Mental Health Policy and Plan.In that year, I developed a template to describe theelements of the reform process (Figure 1) which hasonly been published once, in the 1995 NationalMental Health Report [5]. The focus of mental healthreform at that time was largely on structural changesin public mental health service delivery [6]. Althoughthe template recognised the importance of estimatingthe population need for services, as well as the popu-lation outcomes of any changes arising from thereforms, I considered that national-level, overseasstudies, supplemented by local studies which hadbeen carried out within Australia, would suffice inmaking these estimations

During 1994 I was persuaded by three individuals,Gavin Andrews, Scott Henderson and Wayne Hall,to reconsider this position. Data from other countries

cannot be easily extrapolated to Australia and localstudies are not able to be reliably generalised to thenational level. I also came to the view that Australiannational-level data would be more influential at apolitical level. In December 1994 a meeting ofexperts was organised by the Commonwealth MentalHealth Branch and held at the Australian NationalUniversity in Canberra to explore the feasibility ofsuch a study. This meeting agreed that three pieces ofinformation were needed: to estimate the prevalenceof mental disorders, to determine the disability asso-ciated with these disorders and to determine the ser-vice utilisation of people with mental disorders.

A three-component survey was designed by anexpert team, recommended by the NHMWG andapproved by the Commonwealth Minister for Healthand Family Services. The several million dollarsrequired to carry it out were provided from the allo-cation to the Commonwealth Mental Health Branchunder the National Mental Health Strategy. Overallmanagement was undertaken by a Survey Manage-ment Group, which I chaired and which establisheda Technical Advisory Committee, chaired by ScottHenderson. Results from each of the components arereported in this issue of the Journal.

The first component of the survey, the NationalSurvey of Mental Health and Wellbeing was carriedout by the Australian Bureau of Statistics betweenMay and August 1997 and is comprehensive by anyinternational standard. Its size, 10 600 adults sur-veyed, is greater than the National ComorbiditySurveys (NCS) [7]. The work of the WHO Trainingand Reference Centre for the Composite InternationalDiagnostic Interview (CIDI) at the University of NewSouth Wales in developing the computerised surveyinstrument was groundbreaking. For the first time,Australia has data from a nationally representative

Introduction: the Australian mentalhealth survey

Harvey Whiteford

Australian and New Zealand Journal of Psychiatry 2000; 34:193–196

Harvey Whiteford, Mental Health Specialist (Correspondence)

Health, Nutrition and Population Sector, Human Develop-ment Network, The World Bank, Washington DC, USA. Email:hwhiteford@worldbank.org

Received 8 December 1999; accepted 15 December 1999.

sample on the 1-year prevalence of mental disorders,the disability associated with these disorders and whatservices, if any, people with mental disorders use.

The high rates of comorbidity, especially withalcohol and illicit drugs, confirms clinicians’ experi-ence. In light of this, I am even more certain that theadministrative separation of mental health and sub-stance-abuse services which exists in our healthsystems makes little sense, especially to the con-sumer and their carers. Also, the role of generalpractitioners as the primary service provider has beenconfirmed. The Second National Mental Health Planhas as a priority the need to enhance the capacity ofprimary health care workers in mental health, andthis is overdue.

The second component of the survey focused onpeople with psychotic disorders. This is of particularimportance, not least because of their use of psychi-atric resources, especially hospital beds. However,because of the relatively low prevalence of thisgroup, they would not have been adequately repre-sented in the adult household survey. It was thereforedecided that a separate ‘low-prevalence survey’would be undertaken to access this population. Thereport by Jablensky et al. presents the findings of acensus of 3800 Australians aged 18–64 years withpsychotic disorders attending mental health servicesin the Australian Capital Territory, Queensland,Victoria and Western Australia [8]. Despite all theeffort that has gone into the development of compre-hensive area-based services, the report showed thatmany of these people are still marginalised and expe-riencing considerable disability. A substantialnumber do not get the care they need from a range ofhealth and social services, and my high hopes for theinter-sectoral links element of the National Strategy

[9] have not yet been realised. This area must con-tinue to be addressed in the Second Plan.

Determining the prevalence of mental disorders inchildren and adolescents requires a different method-ology and a third study was commissioned through theUniversity of Adelaide. Sawyer et al., using a house-hold sample, studied 4500 children aged 4–17 yearsand the findings presented in their report are crucialfor this relatively neglected population [10]. As theSecond National Mental Health Plan has a muchgreater focus on children and youth, and emphasisesprevention and early intervention, planning based onthis data will be essential for the Plan’s success.

Designing and carrying out all three componentshad problems. Difficulties with instrument designand use, inclusion and exclusion criteria and sam-pling frames were just a few of the challenges. Inboth the general adult and the child and adolescentsurveys, problems were encountered between thosewho designed the surveys and those who carriedthem out. Ensuring confidentiality of respondents inthe general adult component meant some cells con-taining information were collapsed with resultantloss of specific information. The members of the Technical Advisory Group deserve considerablecredit for steering a path through what, at times,seemed like an impassable minefield.

The studies are not just academic exercises.Estimating prevalence, disability and service utilisa-tion is important. Both prevalence (or incidence) anddisability are crucial for estimating disease burden.Using a common construct for burden which quan-tifies the disease and injury burden caused by bothmortality and non-fatal health outcome, such as thedisability adjusted life-year (DALY) [11], we cancompare the impact of mental disorders with those of

THE AUSTRALIAN MENTAL HEALTH SURVEYS194

Figure 1. National mentalhealth reform template.

other health conditions. This is essential in the battlefor health resource allocation. The DALY cannot becalculated without information on disease occurrenceand disability weights. Work in Australia [12] andinternationally [13] has demonstrated the con-siderable importance of mental disorders when thisapproach is taken over mortality data alone.

However, knowing that the burden is high is onlygoing half-way. We need to know the most cost-effec-tive ways to reduce this burden. There is substantialevidence that most of the commonly used mentalhealth interventions are efficacious, that is, they workbetter than placebo in randomised, controlled trials[14]. A recent review by Shah and Jenkins [15]analysed 114 cost-effectiveness studies and 14cost–benefit studies of specific mental health inter-ventions and modes of service delivery. Despite thedifficulties with design and analysis, these typeof studies have helped refine the interventions whichcan produce the best outcomes at lowest cost.However, the vast majority compared one psychiatricintervention or mode of service delivery with another,and provided limited information on the cost andhealth gain of interventions for mental disorders com-pared with other health conditions. Very little workhas been done comparing cost and outcome in a com-mon dimension, such as QALYs or DALYs, for inter-ventions with mental disorders and other commonhealth conditions. The limited work which has beendone, however, suggests that interventions for mentaldisorders, such as schizophrenia and bipolar disorder,can result in equivalent or more savings in terms ofDALYs averted than can interventions for conditionssuch as diabetes, cancer and coronary heart disease[16]. More such studies must be done.

The findings of the surveys in the area of serviceutilisation will assist the Commonwealth, state andterritory governments and the private sector in theplanning, delivery and funding of services. Knowingmore about demographic variables, comorbidity,the perception of health status and attitudes whichdetermine health-seeking behaviour will allow unmetneeds to be more clearly defined and addressed.However, the prevalence rates for disorders found inthe household surveys are so high that no governmentor health insurance fund could possibly considerallocating resources to the level necessary to treat allpeople meeting the survey criteria for a disorder. We need disaggregation and refinement of the dataand further research to know when criteria becomesdisease, when need becomes demand, who recoversspontaneously, who should be provided with services

and whether these services should be primary healthcare or specialist services.

Despite their comprehensive scope, the nationalsurveys have gaps. Indigenous people were notspecifically catered for and we still know too littleabout their mental health needs and how to addressthem. People from non-English-speaking back-grounds were not well represented in the surveys.There has also been concern also that older peoplewere under-represented in the adult survey. Waysof addressing these short-comings must be found.Nevertheless, I believe the Australian mental healthsurveys are one of the outstanding achievements ofour National Mental Health Strategy. They are acredit to those with the wisdom to see the need forthem and the perseverance to carry them out. Theyhave provided an evidence-based platform forimprovements in the mental health of the Australianpeople.

References

1. Australian Health Ministers. National Mental Health Policy.Canberra: Australian Government Publishing Service,1992.

2. Whiteford HA. Australia’s National Mental Health Policy.Hospital and Community Psychiatry 1993; 44:963–966.

3. Australian Health Ministers. National Mental Health Plan.Canberra: Department of Health and Family Services,1992.

4. Australian Health Ministers. Second National Mental HealthPlan. Canberra: Department of Health and Family Services,1998.

5. Department of Health and Family Services. National mentalhealth report 1995: third annual report, changes inAustralia’s mental health services under the NationalMental Health Strategy 1994–5. Canberra: AustralianGovernment Publishing Service, 1996.

6. Whiteford HA, Macleod BA, Leitch E. The National MentalHealth Policy: implications for public psychiatric servicesin Australia. Australian and New Zealand Journal ofPsychiatry 1993; 27:186–191.

7. Kessler RC, McGonagle KA, Zhao S et al. Lifetime and12-month prevalence of DSM-III-R psychiatric disorders inthe United States: results from the National ComorbiditySurvey. Archives of General Psychiatry 1994; 51:8–19.

8. Jablensky A, McGrath J, Herrman H et al. Psychoticdisorders in urban areas: an overview of the Study on Low Prevalence Disorders. Australian and New ZealandJournal of Psychiatry 2000; 34:221–236.

9. Whiteford HA. Intersectoral policy reform is critical to thenational mental health strategy. Australian Journal of PublicHealth 1994; 18:342–344.

10. Sawyer MG, Kosky RS, Graetz BW, Arney F, Zubrick SR,Baghurst P. The National Survey of Mental Health andWellbeing: the child and adolescent component. Australianand New Zealand Journal of Psychiatry 2000; 34:214–220.

11. Murray CJL, Lopez AD. The global burden of disease.Cambridge, MA: Harvard University Press, 1996.

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12. Mathers C, Vos T, Stepvenson C. The burden of disease andinjury in Australia. Canberra: Australian Institute of Healthand Welfare, 1999.

13. World Health Organization. The world health report.Geneva: World Health Organization, 1999.

14. Nathan PE, Gorman JM, eds. A guide to treatments thatwork. New York: Oxford University Press, 1998.

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developing countries reviewed in the context of those fromdeveloped countries. Acta Psychiatrica Scandinavica 1999;100:1–18.

16. Cowley P, Wyatt RJ. Schizophrenia and manic depressivepsychosis. In: Jamison DT, Mosley WH, Measham AR,Bobadilla JL, eds. Disease control priority in devel-oping countries. New York: Oxford University Press,1993.

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