Examining the supply of mental health professionals in Victoria, Australia: Private psychologists
Hospital emergency departments are strained
I recently witnessed a mental health patient in an emergency department assault hospital staff and it was fair to say that it was confronting to observe such a scene. Hospital staff are placed in a situation where they are also required to de-escalate a violent situation while balancing the need to respect the reason for which the patient is there to begin with. The ED is generally a primary touchpoint for those seeking mental health which puts a substantial strain on both the patient and the staff in addressing such mental health needs.
In a previous LinkedIn post, I made reference to an interactive Shiny app I developed which contained a geographic map highlighting the incidence rate for mental health ED presentations per 100,000 population in Victoria. We see that rural areas are have a noticeably higher incidence rate.
This, however, only provide only one perspective on the area of mental health consumers in Victoria, i.e. one measure of demand specifically as presentations in the ED. What about extent and nature of the supply of mental health services? What can mental health consumers use?
Psychologists, psychiatrists and psychological services
There is a good resource on a list of mental health professionals published by The Royal Australian & New Zealand College of Psychiatrists: https://www.yourhealthinmind.org/psychiatry-explained/mental-health-professionals. This provides a nice comparison of what psychiatrists and psychologists do as well as information on other mental health professionals.
When I think about mental health services, I typically think about psychologists and psychiatrists. There are definitely other healthcare professionals who are vital for supporting mental health consumers but I was interested in what the supply of psychologists and psychiatrists specifically was for Victoria. There is obviously a risk of oversimplifying supply as only the provision of employed psychologists and psychiatrists but it’s a start. Furthermore, quantity of these professionals is not adequate for positive mental health outcomes; quality of the therapeutic relationship is critical. Previous research has yielded robust evidence supporting alliance (e.g. genuine sense of working together, quality of the patient-professional relationship) as a variable associated with positive outcomes in psychotherapy (Flückiger, Del Re, Wampold, & Horvath, 2018; Malin & Pos, 2015).
I eventually found some publicly available data (Australian Institute of Health and Welfare, 2019) to examine how many psychologists and psychiatrists were employed in Victoria. The good news (below) is that we are seeing an upward trend from 2013 to 2017 for the number of employed psychologists and psychiatrists per 100,000 population in Victoria. The only thing we don’t know is where these professionals are located as the data set does not report on the location (or better yet, the statistical region) for this workforce. So, while supply appears to be increasing, we don’t necessarily know whether supply is increasing in areas which are in higher need of psychological services.
Is there any other data sets we can use to see where these professionals are? Perhaps private psychologists?
… but why private psychologists? While psychiatrist are medically trained and prescribe medications, they may not necessarily have specialist training in psychotherapy. This is where the private psychologist plays an important role in continued recovery after hospital discharge.
Mental health consumers can seek access to a private psychologist via a mental health care plan under Medicare. This covers (Healthdirect, 2019):
If you have a mental health care plan, you will be entitled to Medicare rebates for up to 10 individual and 10 group appointments with some allied mental health services in a year. That means for certain psychologists, occupational therapists and social workers, you are also entitled to Medicare rebates for 10 individual and support group sessions in a year.
Private psychologists can assist consumers who have been previously presented at an ED and require subsequent support after utiilising the public hospital system.
The spread of private psychologists across Victoria
There isn’t really any publicly available data that drills down to an area within Victoria and shows us the number of psychologists and psychiatrists. However, there is a directory developed by the Australian Psychological Society (2019) called Find a Psychologist™ that allows users to access thousands of qualified psychologists in Australia. It’s a simple search functionality for which you can find a suitable psychologist by Issue, Name or Location.
I decided to extract data from this directory to measure the number of psychologists across the statistical area level 3 (SA3 as defined by the Australian Bureau of Statistics [ABS]). There were 2,183 private psychologists that could be extracted from the search results1.
There are several limitations with this data set though:
- It appears that the directory is an opt-in service so it won’t include all registered psychologists
- The directory only includes “psychologists who are in private practice” and hence, we won’t have a full picture of both public and private employed psychologists
- One psychologist may have multiple places of practice and thus, we can’t reliably make any measurements of level of service for the regions associated with those places
- Not all psychologists have an online profile which limits the detail we can analyse
It’s clear that the number of private psychologists practice predominantly in the Melbourne metropolitan areas which may not be a surprise at all.
Private psychologists in Victorian metropolitan areas
Let’s take a look at those areas closely below.
The number of private psychologists don’t illuminate anything significant on their own except that there appears to be lower number of psychologists in private practice for:
- Macedon Ranges
However, I have calculated a crude rate for the number of private psychologists per 100,000 population2 for each SA3. This measure at least provides a proxy for the physical accessibility of private psychologists. I have not incorporated any population data from the ABS as the reporting time difference between the ABS release for 2018 and this APS data (retrieved in 2019) would not necessarily be reliable if combined.
We can see, for example, there is a 12 private psychologists per 100,000 population in Cardinia. Compare this with Melbourne City where there is 143 private psychologists per 100,000 population. This, again, may not be surprising at first given that individual preferences for private psychologists could be based on the most lucrative area for providing services. There are other factors that could explain this difference for which we do not have data for.
Private psychologists in Victorian rural areas
It appears to be a vastly different situation for rural areas. Moira, for example, has only 1 private psychologist (as listed on the search page) for the estimated 29,981 population. This picture is not complete as it’s not ascertained how many other registered psychologists are employed in this region but are not publicly advertised on APS. This doesn’t take into account those psychologists who are working only in the public sector.
Supply (in quantity) of specific mental health services will not, alone, address mental health demand in Victoria. Jorm (2018) assessed whether the Better Access scheme in Australia, introduced in 2016, had positively affected the overall mental health of the population. The results suggest that:
The large increase in the use of mental health services after the introduction of the Better Access scheme had no detectable effect on the prevalence of very high psychological distress or the suicide rate.
This might paint a dismal picture of the effectiveness of mental health services in Victoria and could be unfair given that measurement of psychological distress may not capture any longitudinal changes for persons who have received services over time. Nonetheless, a question remains: if not quantity, then what about quality of psychological services?
Flexibility in therapeutic approaches offered
I decided then to look at the therapeutic approaches used by private psychologists. Note that the data only includes information on therapeutic approaches if the profile of the psychologist describes it. Since a psychologist can list multiple approaches, I examined only pairwise combinations across the therapeutic approaches listed.
What can we see:
- Private psychologists listed Cognitve Behaviour Therapy (CBT) most frequently compared to other therapeutic approaches. CBT is a very popular treatment for a wide range of mental health conditions.
- Mindfulness-based Cognitive Therapy (MBCT) appears to be the second highest listed therapeutic approach used among the private psychologists. Interestingly, 75.1% (320 / 426) of private psychologists who listed CBT also listed MBCT.
- There is a clear representation of third-wave psychotherapies used by private psychologists particularly for Acceptance and Commitment Therapy (ACT) and MBCT. However, Dialectical Behaviour Therapy (DBT) has a lesser representation.
The fact that multiple therapeutic approaches are listed suggests that mental health consumers have flexibility in choosing an appropriate private psychologist who would be suit their needs. However, this does not allude to the quality of the treatment and the relationship with the private psychologist.
Furthermore, this only illustrates the pairwise combinations of different therapeutic approaches listed by private psychologists. Another angle of the data is to look at how many therapeutic approaches are listed by private psychologists on their profiles. Below are the results.
We can see that the median number of therapeutic approaches is 6. There is even one private psychologist who has listed fourteen therapeutic approaches on their profile. The private domain for psycological services obviously allows private psychologists ample freedom to advertise their services but one must question that level of experience and competence in each of those approaches used. Is it simply to increase the psychologists’ marketability and if so, does this actually translate to better outcomes if the mental health consumer chooses that given psychologist? I cannot answer this question solely based on the data available.
I read a recent relevant experimental study (Blease & Kelley, 2018) on the perception of laypersons towards information published about Cognitive Behaviour Therapy (CBT) and the omission of common factors (perhaps equally, if not, more important) such as therapeutic alliance, trust, empathy. The results indicated that the common factors were rated more highly than the specific techniques of CBT as more important towards treatment outcome. The interpersonal dimension of the therapeutic services provided appears to be more valuable than the treatment techniques used.
I assume that the profiles are genuine listings of the actual therapeutic approaches used by private psychologists but the number of approaches may be a lesser important factor in the selection of an appropriate private psychologist. To be fair, I did not extract the information from the individual profiles themselves as this would require additional programming. The profile spiel may provide some insight into the degree to which private psychologists communicate these “common factors” as part of their overall service offering.
While supply of private psychologists appear to vary across the regions in Victoria (at least based on the data extracted), supply is only one factor in the provision of high quality mental health services. We can see that employed psychiatrists and employed psychologists per 100,000 population appears to be increasing over time which is great news. What is not clear is whether the workforce in Victoria is being allocated to regions that urgently require these services.
Private psychologists are important as they are the support mechanisms for mental health consumers who are discharged from the public hospital system. They connect the discharge point to ongoing recovery services. The data also indicated that there is flexibility in the therapy modalities provided by private psychologists. This is beneficial for mental health consumers as it offers them informed choice about the range of treatment options available to them.
Some caution is warranted here as there are private psychologists who have listed over 10 therapeutic approaches on their profile. While it could be true that a private psychologist has incorporated over 10 approaches, as an example, in their career - it is not clear whether this translates this to a better treatment outcome for mental health consumers.
This is, however, only one aspect of the supply of mental health professionals in Victoria. If you have ideas on what other aspects could be examined - I’d love to hear your thoughts. This analysis was completed entirely in R and web scraping was a fundamental component of this.
I’d be happy to share how I completed this. Feel free to reach out to me via the Email Me link in my home page.
Australian Institute of Health and Welfare. (2019). Mental health services in australia - mental health workforce. Retrieved from https://www.aihw.gov.au/reports/mental-health-services/mental-health-services-in-australia/report-contents/mental-health-workforce
Australian Psychological Society. (2019). Find a psychologist™. Retrieved from https://www.psychology.org.au/Find-a-Psychologist
Blease, C. R., & Kelley, J. M. (2018). Does disclosure about the common factors affect laypersons’ opinions about how cognitive behavioral psychotherapy works? Frontiers in Psychology, 9, 2635.
Flückiger, C., Del Re, A., Wampold, B. E., & Horvath, A. O. (2018). The alliance in adult psychotherapy: A meta-analytic synthesis. Psychotherapy.
Healthdirect. (2019). Mental health care plan. Retrieved from https://www.healthdirect.gov.au/mental-health-care-plan
Jorm, A. F. (2018). Australia’s “better access” scheme: Has it had an impact on population mental health? Australian & New Zealand Journal of Psychiatry, 52(11), 1057–1062.
Malin, A. J., & Pos, A. E. (2015). The impact of early empathy on alliance building, emotional processing, and outcome during experiential treatment of depression. Psychotherapy Research, 25(4), 445–459.
The search used a radius of 600 kilometres from Melbourne, VIC 3000 to cover the geographical area of Victoria, Australia.↩
Note that I have personally created the forecast for the 2019 population based on the average yearly change rate from the population data published by the ABS. The forecasts are only indicative and may not be entirely accurate.↩