Corrigendum: Mental Health in Australia: Psychological Distress Reported in Six Consecutive Cross-Sectional National Surveys From 2001 to 2018.

[This corrects the article DOI: 10.3389/fpsyt.2022.815904.].

Mental Health in Australia: Psychological Distress Reported in Six Consecutive Cross-Sectional National Surveys From 2001 to 2018.

Purpose: To examine Australian psychological distress trends from 2001 to 2017/18, including analysis by age, sex, location, and household income. Methods: Secondary analysis of the working age population (18-64 years) in six successive representative national health surveys. Measures were prevalence of psychological distress at very-high symptom level (defined by a Kessler Psychological Distress Scale (K10) score of 30 or more) and combined high/very-high level (K10 score of 22 or more). Very-high K10 scores are associated with mental health problems meeting diagnostic thresholds in past year. Results: From 2001 to 2017/18 Australian rates of K10 very-high distress rose significantly from 3.8 to 5.1% and combined high/very-high from 13.2 to 14.8%. In women aged 55-64, very-high distress rose significantly and substantially from 3.5 to 7.2% and high/very-high distress from 12.4 to 18.7%. In men aged 25-34, very-high distress increased from 2.1 to 4.0% and high/very-high from 10.6 to 11.5%. Income was strongly and inversely associated with distress (lowest vs. highest quintile adjusted OR 11.4). An apparent association of increased distress with regional location disappeared with adjustment for income. Conclusion: Australia's population level of psychological distress increased significantly from 2001-2017/18, with levels highest in women and with rates inversely associated with income. This is likely to be indicative of increased community rates of mental disorders. Given that this has occurred whilst mental healthcare expenditure has increased, there is an urgent need to reconsider how best to respond to mental illness, including targeting the most vulnerable based on social determinants such as age, gender, and lower incomes.

Midday meals as an early childhood nutrition intervention: evidence from plantation communities in Sri Lanka.

BACKGROUND: High rates of child malnutrition are a major public health concern in developing countries, particularly among vulnerable communities. Midday meals programs can be effective for combatting childhood malnutrition among older children. However, their use in early childhood is not well documented, particularly within South Asia. Anthropometric measures and other socioeconomic data were collected for children below the age of 5 years living in selected Sri Lankan tea plantations, to assess the effectiveness of midday meals as a nutrition intervention for improving growth among young children. METHODS: The study exploits a natural experiment whereby the provision of the midday meals program is exogenously determined at the plantation level, resulting in comparable treatment and control groups. Longitudinal data was collected on heights and weights of children, between 2013 and 2015. Standardized weight-for-age, height-for-age and weight-for-height, and binary variables for stunting, wasting and underweight are constructed, following WHO guidelines. All modelling uses STATA SE 15. Random-effects regression with instrumental variables is used for modelling standardized growth while random-effects logistic regression is used for the binary outcomes. Robustness analysis involves different estimation methods and subsamples. RESULTS: The dataset comprises of longitudinal data from a total of 1279 children across three tea plantations in Sri Lanka, with 799 children in the treatment group and 480 in the control group. Results show significant positive effects of access to the midday meals program, on the growth of children. A child with access to the midday meals intervention reports an average standardized weight-for-age 0.03 (±0.01) and height-for-age 0.05 (±0.01) units higher than a similar child without access to the intervention. Importantly, access to the intervention reduces the likelihood of being underweight by 0.45 and the likelihood of wasting by 0.47. The results are robust to different model specifications and across different subsamples by gender, birthweight and birth-year cohort. CONCLUSIONS: Midday meals programs targeting early childhood can be an effective intervention to address high rates of child malnutrition, particularly among vulnerable communities in developing countries like Sri Lanka.

Spousal bereavement and the cognitive health of older adults in the US: New insights on channels, single items, and subjective evidence.

This study provides novel insights into older adults' cognitive functioning before and after widowhood onset and possible effect channels. It further examines gender heterogeneity in the adaptation to (anticipated or actual) spousal bereavement, comparing objective evidence with subjective evidence of cognitive abilities. We used longitudinal data of up to 26,584 participants of the Health and Retirement Study, aged over 50 at recruitment, assessed biennially between 1998 and 2016. Two-way fixed effects with dynamic treatment effects were estimated for various cognitive measures, including six aggregated indices and six single item scales. After adjusting for effect channels including depression, social vulnerability, and stress, there remained significant widowhood effects on older adults' cognitive health. Using single item scales, we established the adverse contemporaneous and adaptation effects on bereaved older females' short-term memory, semantic memory, and numeracy. For bereaved older males, working memory and focus-of-attention deteriorated after widowhood onset. Meanwhile, subjective memory rating remained intact, contrary to objective evidence. We conclude that cognitive transitions to and from widowhood can exhibit distinctive patterns across objective and subjective cognitive domains. With the effect channels in mind, cognitive intervention for widowed older adults should be tailored to the temporal distance to spousal loss, gender, and task.

Socio-economic disadvantage and resource distribution for mental health care: a model proposal and example application for Victoria, Australia.

OBJECTIVE: A spreadsheet-based model for supporting equitable mental health resource distribution in Australia was developed, based on the Australian Health Survey (AHS) psychological distress findings associated with area socio-economic disadvantage (SED). An illustrative application is presented. METHOD: Stratum-specific psychological-distress rates for area SED quintiles are applied to local government areas, catchment areas and local health networks (LHNs). A case study applies the model to Victoria, including examining recommendations in the Royal Commission into Victoria's Mental Health Services (RCVMHS) 2019 interim report for increases to bed stock in two LHNs. RESULTS: Need-adjusted demand estimates considered as a ratio of raw population proportions for catchments range between 0.6 to 1.4 in Victoria. Applying the formula to the Royal Commission recommendations suggests the proposed distribution of beds is a reasonable correction for these two LHNs and indicates next expansion priorities for more equitable distribution to other LHNs. CONCLUSIONS: The spreadsheet, adaptable for other states and territories, could complement National Mental Health Services Planning Framework outputs and assist in evaluation, for instance, determining potential supply shortages in the tele-mental-health response to COVID-19. We outline research directions including consideration of the moral bases of value judgements and identification of other variables including their use in parameterisation and calibration.

Lower Income Levels in Australia Are Strongly Associated With Elevated Psychological Distress: Implications for Healthcare and Other Policy Areas.

Background: Australia is a high-income country with increasing income inequality. It is unclear whether Australia's well-developed mental healthcare system is making a difference to population mental health and the Federal Government has targeted outcomes accountability in service funding strategies. In high-income countries, evidence generally suggests that income inequalities increase mental disorders among the poor. This study examined psychological-distress rates-a marker of mental ill- health-as varying by income among Australians living within and outside of capital cities. Methods: Secondary data analysis was undertaken using the population-level mental health indicator of the Kessler Psychological Distress Scale (K10) as reported for 12,332 adults in the 2011/2012 National Health Survey (NHS) of Australia. K10 scores of 22 and higher indicated high/very-high distress, and 30 and higher denoted very-high distress. Very-high distress levels are strongly predictive of serious mental illness. Results: Among the poorest one-fifth of Australians, 1 in 4 people have psychological distress at a high/very-high level; this compares to about 1 in 20 people in the richest one-fifth of Australians. About 1-in-10 people making up the poorest one-fifth of Australians have current very-high distress, and this reduces to <1-in-50 people in the richest one-fifth. These disparities are consistent both within and outside of capital cities. The national prevalence of elevated distress within income quintiles varies greatly, with Poor/Rich Quintile Ratios of typically 4-5 for high/very-high levels and 7-8 for very-high levels. These effects operate more powerfully in areas marked by higher scores on the Index of Relative Socioeconomic Disadvantage. Conclusions: Altering the strong association of lower income levels in Australia with elevated psychological distress would require a multi-dimensional social policy and healthcare approach. To assess the effectiveness of adopted strategies, population level indicators need to be developed with regular data-collection. The Poor/Rich quintile ratio (P/R QR) for high/very high K10 scores is a potential candidate for a mental health inequality outcome indicator since it is easily calculated from data obtained from a regularly conducted national survey, is easily understood and resonates with a wider audience. Further research on the development of such indicators is also needed.

Prevalence of psychological distress: How do Australia and Canada compare?

OBJECTIVE: To compare equivalent population-level mental health indicators in Canada and Australia, and articulate recommendations to support equitable mental health services. These are two somewhat similar resource-rich countries characterized by extensive non-metropolitan and rural regions as well as significant areas of socioeconomic deprivation. METHODS: A cross-national epidemiology and equity study: primary outcome was Kessler Psychological Distress Scale (K10) in recent national surveys. A secondary outcome was mental disorders rate since these surveys were 5-years apart. RESULTS: Elevated distress, defined by K10 scores (0-40 range) of 12 and over, affected 11.1% Australians and 12.0% Canadians. Elevated distress in both countries affected more people in the lowest income quintile (21-27%) compared to the richest (6%). In the lowest income quintile, 1-in-4 Australians and 1-in-5 Canadians reported elevated distress - twice the national average in both countries. Australians in the lowest income quintile (over 5 million people) have a significantly higher risk by over a 5% for elevated distress compared to their low-income Canadian counterparts. After adjusting for effects of age and gender, the relative odds in the lowest quintile compared to richest was 6.4 for Australians and 3.5 for Canadians, which remained significantly different thus confirming greater inequity in Australia. Mental disorders affected approximately 1-in-10 people in both countries. CONCLUSIONS: This adds to the mental health prevalence monitoring in these two countries by supporting an overall prevalence of elevated distress in approximately 1-in-10 people. It supports large-scale public health interventions that target elevated distress in people with low incomes to order to achieve the biggest impact, and, to reduce the greater inequity in mental health indicators in Australians, policy-makers should consider eliminating gap-fees as they are illegal in Canada. As encouraged by World Health Organization, we highlight the importance of such population-level studies so that cross-national results can be reliably compared.

Invisible work: Child work in households with a person living with HIV/AIDS in Central Uganda.

BACKGROUND: HIV/AIDS has led to increased mortality and morbidity, negatively impacting adult labour especially in HIV/AIDS burdened Sub-Saharan Africa. There has been some exploration of the effects of HIV/AIDS on paid child labour, but little empirical work on children's non-paid child work. This paper provides quantitative evidence of how child and household-level factors affect children's involvement in both domestic and family farm work for households with a person living with HIV/AIDS (PLWHA) compared to non-PLWHA households using the 2010/2011 Centre for Health Economics Uganda HIV questionnaire Survey. METHOD: Descriptive analysis and multivariate logistic modelling is used to explore child and household-level factors that affect children's work participation. RESULTS: This research reveals greater demands on the labour of children in PLWHA households in terms of family farm work especially for boys. Results highlight the expected gendered social responsibilities within the household space, with girls and boys engaged more in domestic and family farm work, respectively. Girls shared a greater proportion of household financial burden by working more hours in paid work outside the household than boys. Lastly, the study revealed that a household head's occupation increases children's participation in farm work but had a partial compensatory effect on their involvement in domestic work. Wealth and socio-economic standing is no guarantee to reducing child work. CONCLUSION: Children from PLWHA households are more vulnerable to child work in family farm work especially boys; and girls are burdened beyond the household space through paid work. Differing perspectives and solutions need to consider the contextual nature of child work.

The PULSAR Specialist Care protocol: a stepped-wedge cluster randomized control trial of a training intervention for community mental health teams in recovery-oriented practice.

BACKGROUND: Recovery features strongly in Australian mental health policy; however, evidence is limited for the efficacy of recovery-oriented practice at the service level. This paper describes the Principles Unite Local Services Assisting Recovery (PULSAR) Specialist Care trial protocol for a recovery-oriented practice training intervention delivered to specialist mental health services staff. The primary aim is to evaluate whether adult consumers accessing services where staff have received the intervention report superior recovery outcomes compared to adult consumers accessing services where staff have not yet received the intervention. A qualitative sub-study aims to examine staff and consumer views on implementing recovery-oriented practice. A process evaluation sub-study aims to articulate important explanatory variables affecting the interventions rollout and outcomes. METHODS: The mixed methods design incorporates a two-step stepped-wedge cluster randomized controlled trial (cRCT) examining cross-sectional data from three phases, and nested qualitative and process evaluation sub-studies. Participating specialist mental health care services in Melbourne, Victoria are divided into 14 clusters with half randomly allocated to receive the staff training in year one and half in year two. Research participants are consumers aged 18-75 years who attended the cluster within a previous three-month period either at baseline, 12 (step 1) or 24 months (step 2). In the two nested sub-studies, participation extends to cluster staff. The primary outcome is the Questionnaire about the Process of Recovery collected from 756 consumers (252 each at baseline, step 1, step 2). Secondary and other outcomes measuring well-being, service satisfaction and health economic impact are collected from a subset of 252 consumers (63 at baseline; 126 at step 1; 63 at step 2) via interviews. Interview-based longitudinal data are also collected 12 months apart from 88 consumers with a psychotic disorder diagnosis (44 at baseline, step 1; 44 at step 1, step 2). cRCT data will be analyzed using multilevel mixed-effects modelling to account for clustering and some repeated measures, supplemented by thematic analysis of qualitative interview data. The process evaluation will draw on qualitative, quantitative and documentary data. DISCUSSION: Findings will provide an evidence-base for the continued transformation of Australian mental health service frameworks toward recovery. TRIAL REGISTRATION: Australian and New Zealand Clinical Trial Registry: ACTRN12614000957695 . Date registered: 8 September 2014.

The PULSAR primary care protocol: a stepped-wedge cluster randomized controlled trial to test a training intervention for general practitioners in recovery-oriented practice to optimize personal recovery in adult patients.

BACKGROUND: General practitioners (GPs) in Australia play a central role in the delivery of mental health care. This article describes the PULSAR (Principles Unite Local Services Assisting Recovery) Primary Care protocol, a novel mixed methods evaluation of a training intervention for GPs in recovery-oriented practice. The aim of the intervention is to optimize personal recovery in patients consulting study GPs for mental health issues. METHODS: The intervention mixed methods design involves a stepped-wedge cluster randomized controlled trial testing the outcomes of training in recovery-oriented practice, together with an embedded qualitative study to identify the contextual enablers and challenges to implementing recovery-oriented practice. The project is conducted in Victoria, Australia between 2013 and 2017. Eighteen general practices and community health centers are randomly allocated to one of two steps (nine months apart) to start an intervention comprising GP training in the delivery of recovery-oriented practice. Data collection consists of cross-sectional surveys collected from patients of participating GPs at baseline, and again at the end of Steps 1 and 2. The primary outcome is improvement in personal recovery using responses to the Questionnaire about the Process of Recovery. Secondary outcomes are improvements in patient-rated measures of personal recovery and wellbeing, and of the recovery-oriented practice they have received, using the INSPIRE questionnaire, the Warwick-Edinburgh Mental Well-being Scale, and the Kessler Psychological Distress Scale. Participant data will be analyzed in the group that the cluster was assigned to at each study time point. Another per-protocol dataset will contain all data time-stamped according to the date of intervention received at each cluster site. Qualitative interviews with GPs and patients at three and nine months post-training will investigate experiences and challenges related to implementing recovery-oriented practice in primary care. DISCUSSION: Recovery-oriented practice is gaining increasing prominence in mental health service delivery and the outcomes of such an approach within the primary care sector for the first time will be evaluated in this project. If findings are positive, the intervention has the potential to extend recovery-oriented practice to GPs throughout the community. TRIAL REGISTRATION: Australian and New Zealand Clinical Trial Registry ( ACTRN12614001312639 ). Registered: 8 August 2014.

Mindfulness-based cognitive therapy for recurrent major depression: A 'best buy' for health care?

OBJECTIVE: While mindfulness-based cognitive therapy is effective in reducing depressive relapse/recurrence, relatively little is known about its health economic properties. We describe the health economic properties of mindfulness-based cognitive therapy in relation to its impact on depressive relapse/recurrence over 2 years of follow-up. METHOD: Non-depressed adults with a history of three or more major depressive episodes were randomised to mindfulness-based cognitive therapy + depressive relapse active monitoring (n = 101) or control (depressive relapse active monitoring alone) (n = 102) and followed up for 2 years. Structured self-report instruments for service use and absenteeism provided cost data items for health economic analyses. Treatment utility, expressed as disability-adjusted life years, was calculated by adjusting the number of days an individual was depressed by the relevant International Classification of Diseases 12-month severity of depression disability weight from the Global Burden of Disease 2010. Intention-to-treat analysis assessed the incremental cost-utility ratios of the interventions across mental health care, all of health-care and whole-of-society perspectives. Per protocol and site of usual care subgroup analyses were also conducted. Probabilistic uncertainty analysis was completed using cost-utility acceptability curves. RESULTS: Mindfulness-based cognitive therapy participants had significantly less major depressive episode days compared to controls, as supported by the differential distributions of major depressive episode days (modelled as Poisson, p < 0.001). Average major depressive episode days were consistently less in the mindfulness-based cognitive therapy group compared to controls, e.g., 31 and 55 days, respectively. From a whole-of-society perspective, analyses of patients receiving usual care from all sectors of the health-care system demonstrated dominance (reduced costs, demonstrable health gains). From a mental health-care perspective, the incremental gain per disability-adjusted life year for mindfulness-based cognitive therapy was AUD83,744 net benefit, with an overall annual cost saving of AUD143,511 for people in specialist care. CONCLUSION: Mindfulness-based cognitive therapy demonstrated very good health economic properties lending weight to the consideration of mindfulness-based cognitive therapy provision as a good buy within health-care delivery.

Mental disorders and distress: Associations with demographics, remoteness and socioeconomic deprivation of area of residence across Australia.

OBJECTIVES: Australian policy-making needs better information on socio-geographical associations with needs for mental health care. We explored two national surveys for information on disparities in rates of mental disorders and psychological distress. METHODS: Secondary data analysis using the 2011/2012 National Health Survey and 2007 National Survey of Mental Health and Wellbeing. Key data were the Kessler 10 scores in adults in the National Health Survey (n = 12,332) and the National Survey of Mental Health and Wellbeing (n = 6558) and interview-assessed disorder rates in the National Survey of Mental Health and Wellbeing. Estimation of prevalence of distress and disorders for sub-populations defined by geographic and socioeconomic status of area was followed by investigation of area effects adjusting for age and gender. RESULTS: Overall, approximately one person in 10 reported recent psychological distress at high/very-high level, this finding varying more than twofold depending on socioeconomic status of area with 16.1%, 13.3%, 12.0%, 8.4% and 6.9% affected in the most to least disadvantaged quintiles, respectively, across Australia in 2011/2012. In the most disadvantaged quintile, the percentage (24.4%) with mental disorders was 50% higher than that in the least disadvantaged quintile (16.9%) in 2007, so this trend was less strong than for Kessler10 distress. CONCLUSION: These results suggest that disparities in mental health status in Australia based on socioeconomic characteristics of area are substantial and persisting. Whether considering 1-year mental disorders or 30-day psychological distress, these occur more commonly in areas with socioeconomic disadvantage. The association is stronger for Kessler10 scores suggesting that Kessler10 scores behaved more like a complex composite indicator of the presence of mental and subthreshold disorders, inadequate treatment and other responses to stressors linked to socioeconomic disadvantage. To reduce the observed disparities, what might be characterised as a 'Whole of Government' approach is needed, addressing elements of socioeconomic disadvantage and the demonstrable and significant inequities in treatment provision.

Better access to mental health care and the failure of the Medicare principle of universality.

OBJECTIVES: To examine whether adult use of mental health services subsidised by Medicare varies by measures of socioeconomic and geographic disadvantage in Australia. DESIGN, SETTING AND PARTICIPANTS: 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. MAIN OUTCOME MEASURES: Service use rates followed by measurement of inequity using the concentration curve and concentration index. RESULTS: 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. CONCLUSIONS: 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 cyclical behaviour of public and private health expenditure in China.

This paper studies short-run cyclical behaviour of public (government and social) and private health expenditure and GDP using both time series and panel data techniques. First, national time series data have been used within a multivariate Beveridge-Nelson decomposition framework to construct the permanent and cyclical components. The correlation analysis results for the cyclical components suggest that current public health expenditure is pro-cyclical while there is no clear evidence of a correlation between cycles in private health expenditure and in GDP growth. Next, using an instrumental variable method and the generalised method of moments estimator, provincial-level panel data analyses confirm pro-cyclical impacts of government spending on health. The provincial analysis also suggests that private health expenditure in urban China has a pro-cyclical association with GDP growth, but a lack of good instruments makes it difficult to identify a clear causal link between cycles in income growth and private health expenditure. The results suggest two policy recommendations relevant to public health expenditure, in line with China's current health reforms.

Does social support in addition to ART make a difference? Comparison of households with TASO and MOH PLWHA in Central Uganda.

Social support in addition to antiretroviral therapy (ART) has been indicated to be beneficial to person living with HIV/AIDS (PLWHA) and their families, but very few ART service providers go beyond ART. This study investigates whether receipt of social support in addition to ART for PLWHA makes the households that they reside in better off than households that have PLWHA but are without social support. The analysis uses data comprising of 450 households, which is a sub-sample from the 2010/2011 Centre for Health Economics Ugandan HIV Survey, a cross-sectional survey of 596 households that was undertaken in Uganda. Data were collected from households of clients that obtained ART from two major ART service providers in Central Uganda; The AIDS Support Organisation (TASO) and Ministry of Health (MOH), Uganda. Probit models and ordinary least squares regressions are employed to compare outcomes for individuals from households with a TASO or MOH client. Outcomes for individuals in households with a TASO PLWHA are hypothesised to be superior to those from households with an MOH PLWHA given that the benefits from social support accrue not only to the PLWHA but also to the household and communities they belong to. The results confirm that individuals from a household with a TASO PLWHA are better off in terms of physical health outcomes including better productivity as non-wage labour hours and having more cash in hand and having savings. The findings highlight the importance of additional support to HIV/AIDS clients and have implications for supplementation of ART service provision with other services to maximise the benefits from ART in resource constrained countries like Uganda.

Impact of co-located general practitioner (GP) clinics and patient choice on duration of wait in the emergency department.

OBJECTIVE: To empirically model the determinants of duration of wait of emergency (triage category 2) patients in an emergency department (ED) focusing on two questions: (i) What is the effect of enhancing the degree of choice for non-urgent (triage category 5) patients on duration of wait for emergency (category 2) patients in EDs; and (ii) What is the effect of co-located GP clinics on duration of wait for emergency patients in EDs? The answers to these questions will help in understanding the effectiveness of demand management strategies, which are identified as one of the solutions to ED crowding. METHODS: The duration of wait for each patient (difference between arrival time and time first seen by treating doctor) was modelled as a function of input factors (degree of choice, patient characteristics, weekend admission, metro/regional hospital, concentration of emergency (category 2) patients in hospital service area), throughput factors (availability of doctors and nurses) and output factor (hospital bed capacity). The unit of analysis was a patient episode and the model was estimated using a survival regression technique. RESULTS: The degree of choice for non-urgent (category 5) patients has a non-linear effect: more choice for non-urgent patients is associated with longer waits for emergency patients at lower values and shorter waits at higher values of degree of choice. Thus more choice of EDs for non-urgent patients is related to a longer wait for emergency (category 2) patients in EDs. The waiting time for emergency patients in hospital campuses with co-located GP clinics was 19% lower (1.5 min less) on average than for those waiting in campuses without co-located GP clinics. CONCLUSION: These findings suggest that diverting non-urgent (category 5) patients to an alternative model of care (co-located GP clinics) is a more effective demand management strategy and will reduce ED crowding.

Mental illness and its effects on labour market outcomes.

BACKGROUND: Mental illness can impact all stages of labour market engagement: lower rates of participation in the labour market, higher rates of unemployment and employment in low-skill or low-earning occupations relative to qualifications. Systematic mental health surveys provide an opportunity to examine the scale of such impacts. Though usually cross sectional in nature, such surveys commonly include historical data by self report that can be used to construct a retrospective cohort study, within which it is possible to examine temporal sequence of illness and employment experience and thereby explore issues of causality. METHODS: The 1997 National Survey of Mental Health and Wellbeing of Adults contains comprehensive questions relating to prevalence and level of disability associated with major mental disorders. Here we employ secondary analyses of the survey data to develop three models capturing workforce participation, unemployment and occupational level. Different versions of these models employ either broad diagnostic classes or numbers of disorders as indicators of mental disorder status. After reporting findings from these models we use them in combination to estimate labour market costs for Australia. RESULTS: Each disorder reduces the chance of participation in the labour market by 1.3 percentage points, an appreciable amount given that most individuals suffering from mental disorders have multiple disorders. There is a strongly significant effect of mental illness on employment and clear evidence of reduced occupational skill level. DISCUSSION: The impact of mental illness is very strong at every stage of engagement. Limitations include the self report nature of the assessments and lack of specific income data collection within the survey instrument. IMPLICATIONS FOR HEALTH CARE PROVISION AND USE: Other work based on this survey shows poor accessibility of recovery based and rehabilitation orientated services. These are the very services that have a role to play in increasing workforce participation, employment and occupational level. IMPLICATIONS FOR HEALTH POLICIES: This assessment of these labour market effects suggests that increasing mental health care funding could yield substantial benefits to the economy. IMPLICATIONS FOR FURTHER RESEARCH: In 2007 a further survey of the Australian population was carried out that will provide an updated data set against which to re-examine this issue. The issue of comparability of the instrumentation between the two surveys will be complex, but valid comparisons across the two surveys should be feasible.