Objectives: To provide an overview of 12 month rates of service use for mental health problems and mental disorders by the general Australian adult population. Method: Data came from the 2007 National Survey of Mental Health and Wellbeing (2007 NSMHWB), a nationally representative household survey of 8841 individuals aged between 16 and 85 years. Results: Overall, 11.9% of the general Australian adult population made use of any services for mental health problems in a 12 month period. Approximately one-third of people (34.9%) meeting criteria for a mental disorder did so. Female subjects with mental disorders were more likely to use services than male subjects (40.7% vs 27.5%). People in the youngest age group made relatively less use of services than older adults. Those with affective disorders were most likely to make use of services (58.6%), followed by those with anxiety (37.8%) and substance use disorders (24.0%), respectively. Mental health hospitalizations were less common than consultations with community-based providers (2.6%), whereas 34.6% consulted a community-based provider – particularly general practitioners (24.7%) and psychologists (13.2%). There was a clear dose-response effect between severity of disorders and rates of community-based service use: 63.5% of those with severe mental disorders used community-based services, compared with 40.2% and 17.7% of those with moderate and mild mental disorders, respectively. There was also a relationship between comorbidity of mental disorders and service use. Conclusions: Rates of service use for mental health problems among those with mental disorders in Australia are less than optimal. Little international guidance is available regarding appropriate levels of treatment coverage and other comparable countries face similar difficulties. Further work is required to determine what an appropriate rate of service use is, and to set targets to reach that rate. Australia has demonstrated that concerted policy efforts can improve rates of service use. These efforts should be expanded.

Military personnel are exposed to high rates of traumatic events during participation in combat and peacekeeping operations.^1-11 During the past 2 decades, evidence has suggested that deployment to combat operations is associated with increased psychological distress and decreased health-related quality of life.^1,6-15 In a well-designed study, Dohrenwend et al¹² demonstrated a dose-response relationship between the amount of combat exposure and mental disorders in Vietnam veterans. Similarly, most US and UK studies^4,9,16-18 of recent combat operations in Iraq and Afghanistan have shown a relationship between deployment and mental health problems. There has also been concern about the negative psychological impact (ie, increased self-reported distress and suicidal behavior) of peacekeeping operations.^19-34 Many of these data have been gleaned from recent peacekeeping operations where there has been significant combat and ethnic cleansing (eg, Rwanda³⁵ and Somalia^6,25,36). However, several studies^31,37 have not demonstrated an association between deployment to peacekeeping operations and psychological distress. It remains unclear whether participation in peacekeeping operations has a unique impact on psychological distress above and beyond that related to exposure to combat operations.

To examine whether adult use of mental health services subsidised by Medicare varies by measures of socioeconomic and geographic disadvantage in Australia. A secondary analysis of national Medicare data from 1 July 2007 to 30 June 2011 for all mental health services subsidised by Better Access to Mental Health Care (Better Access) and Medicare - providers included general practitioners, psychiatrists, clinical psychologists and mental health allied health practitioners. Service use rates followed by measurement of inequity using the concentration curve and concentration index. Increasing remoteness was consistently associated with lower service activity; eg, per 1000 population, the annual rate of use of GP items was 79 in major cities and 25 and 8 in remote and very remote areas, respectively. Apart from GP usage, higher socioeconomic disadvantage in areas was typically associated with lower usage; eg, per 1000 population per year, clinical psychologist consultations were 68, 40 and 23 in the highest, middle and lowest advantaged quintiles, respectively; and non-Better Access psychiatry items were 117, 55 and 45 in the highest, middle and lowest advantaged quintiles, respectively. Our results highlight important socioeconomic and geographical disparities associated with the use of Better Access and related Medicare services. This can inform Australia's policymakers about these priority gaps and help to stimulate targeted strategies both nationally and regionally that work towards the universal and equitable delivery of mental health care for all Australians.

The healthcare system has proved a challenging environment for innovation, especially in the area of health services management and research. This is often attributed to the complexity of the healthcare sector, characterized by intersecting biological, social and political systems spread across geographically disparate areas. To help make sense of this complexity, researchers are turning towards new methods and frameworks, including simulation modeling and complexity theory. Herein, we describe our experiences implementing and evaluating a health services innovation in the form of simulation modeling. We explore the strengths and limitations of complexity theory in evaluating health service interventions, using our experiences as examples. We then argue for the potential of pragmatism as an epistemic foundation for the methodological pluralism currently found in complexity research. We discuss the similarities between complexity theory and pragmatism, and close by revisiting our experiences putting pragmatic complexity theory into practice. We found the commonalities between pragmatism and complexity theory to be striking. These included a sensitivity to research context, a focus on applied research, and the valuing of different forms of knowledge. We found that, in practice, a pragmatic complexity theory approach provided more flexibility to respond to the rapidly changing context of health services implementation and evaluation. However, this approach requires a redefinition of implementation success, away from pre-determined outcomes and process fidelity, to one that embraces the continual learning, evolution, and emergence that characterized our project.