Jennifer Smith-Merry

Background: Existing approaches to estimating psychosocial disability – arising from severe mental illness – rely heavily on diagnostic categories and health service utilisation. By neglecting functional-limitation and participation restriction, such approaches limit the utility of current estimates for planning disability supports. This study addresses that gap by estimating the prevalence, functional severity and projected population counts of psychosocial disability in Australia, aligned with the World Health Organization International Classification of Functioning, Disability and Health framework. Methods: Using a repeated cross-sectional design, we analysed four waves of the nationally representative Survey of Disability, Ageing and Carers (2009, 2012, 2015, 2018). Psychosocial disability was operationally defined as a long-term mental health condition combined with disability, consistent with the International Classification of Functioning, Disability and Health framework. Survey-weighted prevalence was estimated overall and by functional severity. Pooled age- and sex-specific prevalence rates were then applied to three population growth scenarios to project counts to 2060. Results: Prevalence remained stable at 1.0% across all waves, with population counts rising from ~196,600 (2009) to ~243,800 (2018), reflecting demographic growth. People with psychosocial disability were disproportionately middle-aged, Australian-born, socioeconomically disadvantaged and living outside major cities. Under the medium growth scenario, projected counts increase from ~274,000 (2025) to ~410,000 (2060; +50%), with those experiencing profound limitation projected to nearly double (+92%). Conclusion: Shifting from diagnosis- to function-based estimation, this study provides a policy-relevant basis for psychosocial disability planning. Rapid growth in the number of profound psychosocial disability underscores the need for early intervention and coordinated psychosocial supports beyond Australia’s National Disability Insurance Scheme.

Background: Suicide mortality among people living with long-term health conditions has not previously been examined at a national population level in Australia. We examined variation in suicide mortality by physical and mental health comorbidity and across sociodemographic, geographic, and socioeconomic characteristics.Methods: We linked the 2021 Census of housing and population data to the Cause of Death Unit Record File to construct a national cohort of Australians aged 11 years and over with a long-term physical or mental health condition (n=6,833,699), followed from the Census reference date (10 August 2021) until death or 31 December 2024 (maximum follow-up 3.4 years). Crude suicide mortality rates were calculated per 100,000 person-years, and adjusted IRRs and 95% CIs were estimated using Poisson regression with a log person-time offset.Findings: There were 3,996 suicide deaths during follow-up. Compared with people reporting physical conditions only, suicide mortality was 4.47 times higher (95% CI 4.12–4.85) among those with a mental health condition only and 3.51 times higher (3.24–3.80) among those with co-occurring physical and mental health conditions. Living alone (IRR 2.79, 95% CI 2.58–3.02), unemployment (1.96, 1.68–2.27), and being outside the labour force (1.86, 1.69–2.04) were the strongest social correlates of suicide mortality, followed by Aboriginal and Torres Strait Islander status (1.41, 1.22–1.63) and remoteness (1.39, 1.10–1.76)Interpretation: Suicide mortality varied substantially by comorbidity and social circumstances. Mortality was particularly high among people with a mental health condition, with or without a physical condition. Suicide mortality also varied substantially by social, cultural, and geographic circumstances. Suicide prevention for people living with long-term health conditions should therefore address mental health comorbidity alongside the social circumstances associated with vulnerability to suicide.

Objectives: We aimed to quantify inequalities in mental health service use in Australia and identify the sociodemographic, economic, and geographic factors associated with access. Methods: We conducted a secondary analysis of the National Study of Mental Health and Wellbeing (NSMHWB, 2020–2022). We evaluated 12-month mental health service use before the survey among people who reported a mental disorder. We fitted multivariable logistic regression models adjusted for sociodemographic covariates and tested the joint (intersectional) effects of remoteness and socioeconomic area disadvantage on service use. Jackknife replicate weights accounted for the complex survey design. Results: The study included 15,893 respondents (weighted population: 19,828,348). Lifetime prevalence of any mental health disorder was 42.9% (95% CI = [42.5, 43.3]), and 21.5% (95% CI = [20.7, 22.3]) reported symptoms in the past 12 months. Among those with a 12-month disorder, 45.2% (95% CI = [39.9, 50.5]) had accessed care, and 16.5% (95% CI = [15.8, 17.2]) reported using digital or telephone services. Service use was higher in university graduates and residents of advantaged areas and lower in remote/outer regional residents and the most disadvantaged quintiles. Intersectional analysis revealed compounded inequities, with the lowest service use observed among socioeconomically disadvantaged populations in remote areas and the highest among advantaged major-city residents. Conclusion: Substantial and intersecting inequalities exist in access to mental health services, with the lowest coverage among remote, socioeconomically disadvantaged, older, and male populations. Targeted, place-based strategies – including expanded outreach and tailored digital and community-based models – are needed to reduce unmet need and improve equity.

Supported employment programs are widely implemented to improve vocational outcomes for people with severe mental illness, yet evaluations of these programs employ highly heterogeneous approaches to costing and outcome measurement. This methodological review examines how costs and outcomes have been identified, measured, and reported in randomized controlled trials of supported employment interventions conducted in high-income countries. Eligible trials were drawn from a recent rapid scoping review and analysed using narrative synthesis, with data extracted on analytical perspectives, outcome domains, costing methods, and data collection approaches. Thirty-two trials were included, of which seven incorporated an economic analysis. Vocational outcomes were consistently prioritised, while clinical, functioning, recovery-oriented, service use, and implementation outcomes were variably assessed. Economic analyses differed substantially in perspective, time horizons, cost identification and valuation, and transparency, limiting comparability and transferability. While methodological diversity reflected differing research questions and policy contexts rather than inconsistent intervention effectiveness, incomplete reporting constrained interpretation and evidence use. Based on these findings, the review outlines practical guidance for evaluators, emphasising alignment of study design with decision-making needs, transparent and perspective-consistent costing, theory-informed outcome selection, and explicit documentation of contextual and methodological choices to enhance the policy relevance and interpretability of supported employment evaluations.

Objective: Partners in Recovery (PIR) was an Australian Commonwealth Government-funded program supporting 35,000 people with complex needs, who experienced severe and persistent mental illness (SPMI). The program was designed to foster integrated care to address fragmented and missing supports. Internationally it is a rare example of a national coordination program evaluated in multiple local contexts, from multiple stakeholder perspectives. This paper examines factors that contributed to the program’s strengths and weaknesses, contextualising this in relation to the limits of subsequent supports. Methods: This case study draws together 30 program evaluation papers, identified through a range of search strategies. Utilising Arksey and O’Malley’s review framework we collaboratively developed a synthesis of themes and findings. Results: The support facilitator role was essential to implementation as was organisational environment. As a cornerstone of care for people with SPMI, support coordination required effective collaboration; strong communication; individualised, flexible, and recovery-oriented support; and a well-equipped workforce. Conclusions: Data from multiple evaluations of PIR demonstrate the importance of care coordination for SPMI which is underpinned by a recovery-oriented key worker, localised approaches and flexible funding. These are key attributes of integrated support which can inform practice and policy development for this group internationally.

The payment of individual participants for participation in research has become increasingly utilised internationally as both a device for encouraging participation and for acknowledging the time, ...

While Australia's National Disability Insurance Scheme (NDIS) was founded on principles of choice and control, for people with significant mental health challenges (what the NDIS calls ‘psychosocial disability’) these ideals often remain elusive. Support systems continue to be fractured and in the context of ongoing policy reforms, it is vital to understand expectations people have of the scheme, alongside ongoing experiences. Drawing on semi‐structured interviews with NDIS participants ( n = 30) and informal/unpaid carers ( n = 18), this research explores these expectations and lived realities. Results showed that prior to engaging with the NDIS, participants had mixed expectations of the scheme, with a lack of information accessed and confusion about what the scheme could offer. For some, expectations were also formed in the context of acute mental illness. When expectations were expressed, these were often unmet, with interviewees reporting a lack of choice and control, frustrations with the system, a lack of appropriate services, and encounters with unscrupulous or underperforming providers. Findings should inform policy directions to better align Australia's mental health ecosystem with the realities faced by those it seeks to support. Strategies are required for planning and communication about what the NDIS offers participants to inform choice and control of needed supports.

Psychosocial interventions support functional recovery and social integration for people with severe mental illness (SMI); however, their implementation remains fragmented and inconsistent. This rapid scoping review maps the landscape of psychosocial interventions for adults with SMI in high-income countries, identifying their key components, implementation challenges, and strategies to optimise delivery. Following the Cochrane rapid review guidelines, we searched MEDLINE and CINAHL (January 2009 - May 2024) and conducted manual reference screening. Eligible studies focused on non-pharmacological, community-based interventions. Thematic analysis was used to identify implementation barriers and enablers. Of 8,624 screened records, 464 studies met inclusion criteria, covering 15 intervention types. Cognitive-focused interventions (n = 100) supported employment (n = 86), and behavioural therapies (n = 66) were most studied. Outcomes focused on symptom (n = 179), daily living skills (n = 160), and cognitive states (n = 157). Implementation was often constrained by systemic, organisational, and individual-level barriers. Systemic challenges included fragmented services, stigma, cultural and linguistic barriers, and economic constraints, highlighting the need for integrated care models, policy reforms, and culturally responsive approaches. Organisational challenges such as staff resistance, insufficient training, and resource limitations underscored the importance of leadership, stakeholder engagement, and investment. At the individual level, low motivation, logistical difficulties, trauma histories, and goal misalignment reduced engagement and retention, highlighting the need for flexible, person-centred, trauma-informed approaches, strong social networks, and a balance between structure and adaptability. Selecting, adapting, and funding psychosocial interventions remain complex. This review provides a foundation for future systematic reviews of homogeneous intervention subsets to better inform policy and practice.

Carers play a critical, yet under‐recognised, role in supporting people with disability arising from mental health challenges (often referred to as psychosocial disability) to navigate systems and services. In Australia, despite carers’ centrality to the functioning of the National Disability Insurance Scheme (NDIS), little research has explored their experiences. This study examines how carers experience, and make sense of, their interactions with the NDIS. Drawing on the concept of liminality, semistructured interviews were conducted with 19 family carers across Australia. Findings reveal that carers occupy a liminal space between being ‘family’ while also being responsible for coordination, advocacy and crisis management. Three interconnected themes were identified: identity strain associated with being both family and carer; advocacy undertaken from the margins of decision‐making power; and systemic ambiguity regarding whether and how carers themselves are supported. Liminality in this context was not transitional but sustained, produced through the design and operation of the NDIS rather than the act of caring alone. Findings relevant to policy and service design in international contexts highlight the need for systemic reform that recognises carers as relational partners and enables carers to step back into familial roles with adequate supports across disability and health systems.