Seeing a psychologist on Medicare? Soon you'll be back to 10 sessions. But we know that's not often enough
From January 1 the number of psychology sessions covered by Medicare will be reduced to ten per year, down from the 20 the government has been subsidising during the pandemic.
But we know ten is not enough sessions for many mental health issues, and is an arbitrary number that may not reduce costs in the long run.
The federal government commissioned a review into public support and outcomes of psychology services, which has just been released. Patients and providers supported the additional sessions, which had more uptake and greater benefit for those with more severe issues. It recommended the 20 sessions per year should be retained.
Where did the number 10 come from in the first place?
In 2006, the federal government introduced the Better Access initiative through Medicare. This enabled Australians with a mental health disorder to obtain a mental health care plan from their GP and receive rebates for psychological therapy.
Initially, this allowed for up to 12 sessions per calendar year, with an additional six in exceptional circumstances. The Better Access scheme was taken up enthusiastically by the public, reflecting the high rate and burden of mental illness in the Australian community. The scheme was evaluated as having positive outcomes.
By 2011, the scheme had been capped to ten sessions a year. This appeared to be an attempt to rein in spending, while diverting funds to other mental health programs. In 2020, during the COVID pandemic, an additional ten sessions were introduced, allowing consumers to access up to 20 per calendar year.
As it currently stands, this extra ten will be removed at the end of the year. In the absence of other rationales, this appears to be another attempt to constrain government spending on the scheme.
What does the evidence say about number of sessions?
As with medicines, evidence for the use of psychological treatments is based on clinical trials. The majority of evidence for the effectiveness of psychological therapy comes from trials with a treatment length of more than ten sessions.
That’s the case for conditions including depressive disorders, anxiety disorders, obsessive-compulsive disorders, post-traumatic stress disorder, personality disorders, and schizophrenia.
Research shows between 13 and 18 sessions are required for 50% of people to reliably improve in psychological therapy.
Research also shows a dose-response relationship for psychological therapy, meaning the number of people who respond to treatment will increase when higher numbers of sessions are provided.
Findings from everyday practice show optimal doses for effective treatment range from four to 26 sessions or more. Higher numbers of sessions may be needed when mental illness is more complicated. This might be because people are experiencing multiple disorders, or where there are more severe symptoms or impacts on their life at the start of treatment.
Ten sessions won’t provide adequate treatment for many suffering from mental ill-health. And waiting until the next calendar year for the next ten sessions could see symptoms spiral in the meantime. The government has recognised this issue in the context of eating disorders, for which people may currently access up to 40 sessions of psychological treatment per calendar year by meeting specific criteria.
This is to be commended, and a step in the right direction. But it’s unclear why the same isn’t available for other significant mental illnesses.
What happens if people don’t get enough treatment?
When people are under-treated, symptoms can remain and continue to adversely impact their psychological and physical health, and quality of life.
These residual symptoms are one of the strongest predictors of relapse back into full-blown illness, including for more common disorders such as major depression and anxiety disorders.
A useful, and common, analogy for this under-treatment can be made with medical treatments. Australians would not be satisfied being prescribed half-courses of medicines. Nor would they be satisfied if bandages or casts were removed before wounds or breaks were healed.
To be effective, some treatments necessitate higher doses or longer care. Some Australians have enough money to pay privately for additional sessions, but for those who rely on bulk billing, a cap of ten sessions will leave them under-treated.
This is likely to mean individual and societal costs are persistent, whereas effective treatment in the first instance may save this burden in the long term.
Some Australians can afford to pay privately for more sessions but many can’t.
lauren mancke/unsplash, CC BY
How should the system work?
A fit-for-purpose system would provide the option of longer courses of treatment for those who have more severe issues or need more treatment to recover (and to stay recovered).
The number of sessions could be based on markers of severity (impact on day-to-day life and symptoms), complexity (duration of illness, presence of several disorders) and individual circumstances.
This “stepped” or “staging” model of treatment is not new to health care in Australia.
It’s already built into the Better Access scheme, whereby an initial six sessions are signed off, and then another four can be obtained after a second review, and then a further ten after another review again.
Changes to the number of sessions for eating disorders is a step in this right direction. But the needs of Australians with other mental illness also exist on a spectrum. Future iterations of Better Access should acknowledge and respond to these needs.
The author would like to thank Professor Caroline Hunt for her input into this article.
Read more: Want to see a therapist but don't know where to start? Here's how to get a mental health plan
Authors: David John Hallford, Senior Lecturer and Clinical Psychologist, Deakin University
