Women’s uptake of Medicare Benefits Schedule items for psychologists and other allied mental health professionals

Depression is particularly prevalent in women around twice that of men. While therapeutic counselling can be a highly effective form of treatment, the cost of such services has traditionally been a barrier for many women.

In November 2006, the Better Access Initiative was introduced as part of the Medicare Benefits Schedule (MBS), allowing patients suffering from mental health problems to receive up to 12 mental health services a year, including consultations to psychologists, social workers, and occupational therapists. While data suggests strong uptake of MBS mental health services, little is known about the characteristics of people who use them. As such, it is unclear whether the scheme is helping to address inequities in access to mental health treatment.

The aims of this study were to assess women’s uptake of MBS mental health services (particularly those with mental health problems), to compare the characteristics of women who have and have not used the services, and to investigate the impact of the items on the costs of Medicare services.

The study involved analysis of longitudinal survey data from the Australian Longitudinal Study on Women’s Health (ALSWH), involving three cohorts of women, who were aged 28-33, 55-60, and 80-85 when the Initiative was introduced, linked with Medicare records from November 2006-December 2007.

  • A large proportion of women who reported mental health problems made no mental health claims. Among women who reported depression, anxiety or another mental health condition on the most recent survey, only 12% of those in the younger cohort, 10% of the mid-age cohort, and 1% of the older cohort had used MBS mental health services.
  • Socioeconomically disadvantaged women were less likely to use the services, despite mental health needs.
  • Among women who used the services, very few had previously reported seeing a counsellor, psychologist or social worker, suggesting that the scheme has reached women who were not previously accessing mental health care.
  • Uptake of services was associated with a steep increase in average yearly costs for women ($100-$150), and government ($600-$800).

Although there has been rapid uptake of mental health items, uptake by women with mental health needs is low and there is potential socioeconomic inequity.

Citation: Byles J, Dolja-Gore X, Loxton D, Parkinson L, Stewart-Williams J, Women’s uptake of Medicare Benefits Schedule items for psychologists and other allied mental health professionals. Medical Journal of Australia, 2011: 194: 175-179

Risky drinking patterns are being continued into pregnancy: A prospective cohort study

Risky patterns of alcohol use prior to pregnancy increase the risk of alcohol-exposed pregnancies and subsequent adverse outcomes. It is important to understand how consumption changes once women become pregnant. The aim of this study was to describe the characteristics of women that partake in risky drinking patterns before pregnancy and to examine how these patterns change once they become pregnant.

A sample of 1577 women from the 1973–78 cohort of the Australian Longitudinal Study on Women’s Health were included if they first reported being pregnant in 2000, 2003, 2006, 2009 and reported risky drinking patterns prior to that pregnancy.

  • When reporting risky drinking patterns prior to pregnancy only 6% of women reported weekly drinking only, whereas 46% reported binge drinking only and 48% reported both.
  • Women in both binge categories were more likely to have experienced financial stress, not been partnered, smoked, used drugs, been nulliparous, experienced a violent relationship, and were less educated.
  • Most women (46%) continued these risky drinking patterns into pregnancy, with 40% reducing these behaviours, and 14% completely ceasing alcohol consumption.
  • Once pregnant, women who binged only prior to pregnancy were more likely to continue (55%) rather than reduce drinking (29%).
  • Of the combined drinking group 61% continued to binge and 47% continued weekly drinking.
  • Compared with the combined drinking group, binge only drinkers prior to pregnancy were less likely to reduce rather than continue their drinking once pregnant.

Over a third of women continued risky drinking into pregnancy, especially binge drinking, suggesting a need to address alcohol consumption prior to pregnancy.

Citation: Anderson AE, Hure AJ, Forder PM, Powers J, Kay-Lambkin FJ, Loxton DJ (2014). Risky drinking patterns are being continued into pregnancy: A prospective cohort study. PLOS One, 9 e86171

Referral for management of emotional health issues during the perinatal period: Does mental health assessment make a difference?

Routine assessment of current or past mental health issues during pregnancy and the postnatal period has been endorsed in clinical practice guidelines in Australia and a number of other countries. However, there is little evidence as to whether such assessments increase rates of referral for further treatment or management.

The aim of this study was to evaluate the impact of current and past mental health on referral for additional support or treatment during pregnancy and the first postpartum year. A subsample of 1,804 women from the 1973-78 cohort of the Australian Longitudinal Study on Women’s Health (ALSWH) provided data.

  • The strongest predictor of being given a referral for additional treatment or support during pregnancy was being asked by a health professional about past mental health.
  • Women who were asked about current mental health were also more than twice as likely to receive a referral.
  • The odds of receiving a referral were around 14 times higher for women who were asked about both their current and past mental health than for women who did not receive any form of assessment.
  • Being asked about one’s past or current mental health during the postnatal period also increased the likelihood of referral during the postnatal period.
  • The odds of receiving a referral were around 16 times higher for women who were asked about both their current and past mental health compared with women who received no assessment.
  • Experiencing significant emotional distress also predicted referral during both the prenatal and postnatal periods, suggesting that assessment did not inappropriately inflate referral rates.

The findings indicate that enquiry into risk factors such as past history (in addition to current mental health) enhances initiation of referrals, and highlights the importance of a comprehensive approach to mental health assessment.

Citation: Reilly N, Harris S, Loxton D, Chojenta C, Milgrom J, Austin M-P (2013). Referral for management of emotional health issues during the perinatal period: Does mental health assessment make a difference? Birth, 40(4), 297-306.

How do previous mental health, social support, and stressful life events contribute to postnatal depression in a representative sample of Australian women?

Postnatal depression (PND) is a debilitating condition that affects between 10-20% of Australian mothers. Several factors have been found to be predictive of PND, including a higher rate of obstetric interventions, having a caesarean birth, as well as suffering from depression and anxiety during or immediately prior to pregnancy.

However, while a number of studies have examined the predictors of PND, most have focused on events immediately prior to pregnancy and birth. The aim of this study was to examine both short- and long-term risk factors for PND using data collected before, during, and after pregnancy. The study used data from women born 1973-78, who had completed the first four surveys from the Australian Longitudinal Study on Women’s Health from 1996-2006.

  • The strongest predictor of PND was a history of depression; compared with women who had not reported depression, women who reported depression 3 or 6 years prior to pregnancy were more than twice as likely to experience PND.
  • Stressful life events reported both six years prior to, and at the time of the fourth survey were related to future PND, while women who had less affectionate support/positive social interaction were also at higher risk.
  • Contrary to other studies, demographic factors, including ability to manage on income, area of residence and education level were not associated with PND.

The findings suggest that PND has both short- and long-term risk factors. It is important that healthcare providers are aware of the range of factors that may increase the risk of PND in order to allow for a more targeted detection of women who may develop the condition.

Citation: Chojenta C, Loxton D, Lucke J (2012). How do previous mental health, social support, and stressful life events contribute to postnatal depression in a representative sample of Australian women? Journal of Midwifery and Women’s Health, 57(2), 145-150.

Lack of association between drought and mental health in a cohort of 45-61 year old rural Australian women

Drought has a range of adverse physical, economic, emotional and social consequences. However, while these may be expected to result in higher rates of mental health problems, little research has explored the relationship between drought and mental health.

The aim of this study was to investigate the impact of drought on the mental health of rural Australian women. This included examining the effects on women who may be more vulnerable to adverse effects of drought, including women who are more isolated, poorer and less educated, and women with already have long-term illness or poor mental health

The study involved 6,664 women from the Australian Longitudinal Study on Women’s Health (ALSWH), born between 1946 and 1951, who lived outside of major cities. Women were sent five surveys between 1996 and 2008, which assessed mental health and a range of other health, behavioural and demographic variables. These data were linked to information about drought for their area of residence.

A third of women experienced drought in 1998 and half the women experienced drought in 2007. Drought was less common in 1996, 2001 and 2004 with less than one in ten women experiencing drought at these time points. While experience of drought varied over time, no relationship was found between drought and mental health. This was the case both for the overall findings, as well as among the groups considered to be vulnerable.

The findings suggest that drought does not lead to poorer mental health among mid-aged Australian women. Further research is needed to see if these findings apply to men, as well as to women of other ages.

Citation: Powers JR, Dobson, AJ, Berry, HL, Graves, AM, Hanigan IC, Loxton, D (2015). Lack of association between drought and mental health in a cohort of 45-61 year old rural Australian women. Australian and New Zealand Journal of Public Health. (in early view). doi:10.1111/1753-6405.12369

History of pregnancy loss increases the risk of mental health problems in subsequent pregnancies but not in the postpartum

Women who experience a pregnancy loss, including medical termination, miscarriage, ectopic pregnancy and stillbirth, commonly experience mental health problems such as depression and anxiety following the loss. However, little is known about mental health outcomes during subsequent pregnancies and following healthy births.

The aim of this study was to examine the impact of pregnancy loss on mental health in subsequent pregnancies and during the postnatal period. Data were obtained from a sub-sample of 584 women from the Australian Longitudinal Study on Women’s Health who had previously experienced a loss.

  • Nearly half of the women (45.5%) indicated that they experienced at least one emotional issue during their most recent pregnancy with anxiety being the most commonly reported issue (26.4%), followed by stress or distress (25%), and sadness or low mood (20.2%).
  • Just over half of the women (51.9%) reported at least one emotional issue during the postnatal period, with sadness and low mood being the most commonly reported issue (30.1%), followed by stress or distress (25.3%) and anxiety (22.3%).
  • Women who had a previous pregnancy loss were more than twice as likely to report excessive worry during a subsequent pregnancy, and were also more likely to report sadness or low mood.
  • However, there was no relationship between prior pregnancy loss and any emotional issue during the postnatal period.

Women who have experienced a pregnancy loss are particularly vulnerable to mental health problems during subsequent pregnancies. It is important to monitor the mental health of these women during this time, and if necessary offer anxiety or stress interventions. Such interventions will potentially benefit the woman, as well as reduce adverse outcomes for offspring.

Citation: Chojenta C, Harris S, Reilly N, Forder P, Austin M-P, Loxton D (2014). History of pregnancy loss increases the risk of mental health problems in subsequent pregnancies but not in the postpartum. PLOS One, 9(4): e95038. doi: 10.1371/journal.pone.0095038

Predictors of antenatal alcohol use among Australian women: A prospective cohort study

A large proportion of Australian women consume alcohol during pregnancy. It is important to identify predictors of such use; however no previous study has examined a comprehensive set of predictors using a population-based sample.

Data was obtained from women from the 1973-78 cohort of the Australian Longitudinal Study on Women’s Health, who indicated they were pregnant at survey two, three, four or five (from 2000-2009). Thirty-six variables were investigated as potential predictors of alcohol use during pregnancy, including sociodemographic factors, reproductive health, mental and physical health, health behaviours, alcohol guidelines and healthcare factors.

  • Most (82%) women continued to drink alcohol during pregnancy.
  • Women were more likely to drink alcohol during pregnancy if they had consumed alcohol on a weekly basis before pregnancy, binge drank before pregnancy, or if they were pregnant while alcohol guidelines recommended low alcohol versus abstinence.
  • Drinking during pregnancy was less likely if women had a Health Care Card or if they had ever had fertility problems.

Most Australian women who drank alcohol continued to do so during pregnancy. To ensure that women can make informed decisions about alcohol use during pregnancy, healthcare professionals should be providing all women with information about the potential harms of alcohol use and the reasons why abstinence is the safest option.

Citation: Anderson AE, Hure AJ, Powers JR, Kay-Lambkin FJ, Loxton DJ (2013). Predictors of antenatal alcohol use among Australian women: A prospective cohort study. BJOG, 120:1366-1374.

Mental health service use: Is there a difference between rural and non-rural women in service uptake

bottle-tree-389059_1280Findings suggest that people from rural and remote areas of Australia have less access to mental health services than those living in major cities. This may be particularly difficult for women, who are more likely to experience mental health problems than men.

The Better Access Scheme (BAS), introduced under Medicare in November 2006, allows patients suffering from mental health problems to receive up to 10 mental health services a year, including consultations to psychologists, social workers, and occupational therapists.

The aim of this study was to identify the differences in uptake in BAS services and time taken to access the services according to area of residence, relative to need.

  • 21% of women living in major cities used at least one BAS service, compared to 18% of those in inner-regional areas, 13% in outer regional and just 7% of those in remote/very remote areas.
  • Clinical psychologist services offered under the BAS were used by 6% of women in major cities compared to 3.8% in inner regional areas, 2.8% in outer regional and by no women in remote/very remote areas.
  • Of women that accessed treatment, 78% of women living in inner regional areas, 82% in major cities, 86% in outer regional areas and 90% in remote/very remote areas had received a BAS service within 50 days of the initial GP consultation.
  • Across all areas, 12% of women reported a diagnosis of depression/anxiety without being treated under the BAS, with these figures slightly higher in inner regional and outer regional areas.

The findings suggest that women in urban areas have been better able to take up BAS services compared to women in non-urban areas.

Citation: Dolja-Gore X, Loxton DJ, D’Este CA, Byles JE (2014). Mental health service use: Is there a difference between rural and non-rural women in service uptake. Australian Journal of Rural Health, 22, 92-100.

Disparities in reported psychosocial assessment across public and private maternity settings: A national survey of women in Australia

Psychosocial assessment in the perinatal period refers to the clinical evaluation of a broad number of risk factors that may contribute to the mental health outcomes of a woman and her infant. It is recommended that all women are assessed as part of routine pregnancy and postnatal care.

However, it is not clear how comprehensive such screening is, with most research focusing solely on the assessment of depression. Furthermore, most studies that have investigated screening have not been sufficiently inclusive of the 30% of women whose maternity care is provided in the private sector.

The aim of this study was to examine rates of assessment across a range of psychosocial domains, as well as the provision of mental health promotion information. A sub-study of 1,804 women from the Australian Longitudinal Study on Women’s Health (ALSWH) provided data.

  • Rates of assessment for the prenatal and postnatal periods respectively were: current mental health 66.8%, 75.6%, mental health history 52.9%, 41.2%, level of support 69.9%, 70.1%, drug and alcohol use 67.6%, 35.3%, and domestic violence or abuse 35.7%, 31.8%.
  • Mental health promotion information was received by 78.3% of women during pregnancy, and 81.6% of women during the postnatal period.
  • During pregnancy, women who gave birth in the public sector were far more likely to report being assessed across all domains of psychosocial assessment than women in the private sector.
  • The disparity between public and private settings did not extend to the postnatal period however, with similar figures observed for most measures.
  • Differences were observed between state/territory of residence for each of the measures. For example, assessment of mental health history during pregnancy ranged from 43.3% in Victoria to 63.8% in New South Wales, while domestic violence/abuse assessment ranged from 20.2% in Western Australia to 52.8% in New South Wales.
  • During the postnatal period, 89.1% of women from Western Australia had their current mental health assessed, compared to 58.7% of Queensland women.

The results indicate that there has been significant penetration in some areas of assessment, both during pregnancy and in the postnatal period. However, the low rates of screening for mental health history and domestic violence/abuse are concerning. It is important to minimise the current shortfall in assessment rates in private maternity settings, particularly during pregnancy.

Citation: Reilly N, Harris S, Loxton D, Chojenta C, Forder P, Milgrom J, Austin M-P (2013). Disparities in reported psychosocial assessment across public and private maternity settings: A national survey of women in Australia. BMC Public Health, 13:362.