This article represents the Coalition for Better Health's policy analysis and advocacy position. It does not constitute clinical advice or a substitute for professional mental health support. Readers experiencing a mental health crisis should contact Lifeline (13 11 14) or Beyond Blue (1300 22 4636).
Australia's mental health system sits at a policy inflection point. Two decades of incremental reform have improved access for many Australians, but the system remains structurally misaligned with the scale of the problem it faces. The 2023 reversal of the COVID-era extension to 20 Medicare-rebated psychological sessions — returning the Better Access limit to 10 sessions per year — crystallised a long-running tension between budget discipline and clinical need. It triggered the most significant public backlash in Australian mental health policy in years, and it exposed a system that is not, in its current configuration, fit for purpose.
This analysis examines the current architecture of mental health Medicare support in Australia, the evidence on where it is failing, and the concrete policy changes required to build a system that responds to clinical need rather than budgetary convenience. It draws on Australian Institute of Health and Welfare (AIHW) data, the Productivity Commission's 2020 Mental Health inquiry report, and international comparators — particularly the United Kingdom's Improving Access to Psychological Therapies (IAPT) program. It is intended as a non-commercial, evidence-grounded contribution to ongoing policy debate.
The Better Access Scheme: What It Is and What It Was Meant to Do
The Better Access to Psychiatrists, Psychologists and General Practitioners through the Medicare Benefits Schedule initiative was introduced in November 2006 under the Howard Government. It represented a landmark shift in Australian mental health policy: for the first time, Medicare rebates were available for psychological therapy delivered by registered psychologists, occupational therapists, and social workers, accessed via a GP Mental Health Treatment Plan.
In its original form, Better Access provided up to six individual and three group sessions per year, later revised to 10 individual sessions. This was a genuine advance. Prior to Better Access, access to psychological therapy was largely limited to those who could afford private out-of-pocket fees — typically $180 to $300 per session — or who could navigate underfunded and fragmented state mental health services. The scheme democratised access to psychological care in a meaningful way.
By 2019, more than three million Australians per year were accessing Better Access services. The AIHW's Mental Health Services in Australia data series records Better Access as the largest single source of specialised mental health service contacts in the country. The scheme has undeniably delivered real benefit at population scale.
The COVID Extension and Its Reversal
When the COVID-19 pandemic created a documented surge in mental health presentations — particularly anxiety, depression, and acute grief — the Morrison Government temporarily extended the Better Access annual session limit from 10 to 20 individual sessions, effective from 9 November 2020. The extension was explicitly framed as temporary, tied to pandemic conditions.
The Albanese Government's decision in November 2022 — implemented from 1 January 2023 — to return the limit to 10 sessions was arguably the most contested mental health policy decision in Australia in over a decade. The backlash was immediate and came from multiple directions: the Australian Psychological Society, the Royal Australian and New Zealand College of Psychiatrists (RANZCP), consumer advocacy organisations, and a significant volume of individual Australians who had been mid-treatment when the change took effect.
The clinical objection is straightforward. Ten sessions per year is below the evidence-based treatment dose for most of the conditions for which Better Access is used. National Institute for Clinical Excellence (NICE) guidelines for generalised anxiety disorder, for instance, recommend 16 to 20 sessions of Cognitive Behavioural Therapy for moderate-to-severe presentations. Evidence-based treatment protocols for post-traumatic stress disorder (PTSD) and depression commonly require 12 to 24 sessions to achieve durable outcomes. A 10-session annual cap is not a clinical determination; it is a budget constraint retrofitted with a clinical rationale it does not have.
The University of Sydney and University of Melbourne evaluation commissioned by the Department of Health — using linked administrative data — found that a measurable proportion of clients in the 11- to 20-session range showed clinically significant improvement that would not have occurred within 10 sessions. Patients mid-treatment at the point of policy change faced an abrupt discontinuation that clinicians have described as contrary to accepted practice.
The Productivity Commission's 2020 Mental Health inquiry — which pre-dates the extension decision but directly informs the debate — explicitly recommended that Medicare-rebated session limits should be calibrated against clinical need rather than arbitrary caps. The Commission's modelling found that insufficient treatment intensity was a significant contributor to poor long-term outcomes and to the costly revolving-door pattern in which undertreated patients deteriorate, present to emergency departments, and cycle through acute inpatient care. That finding is not consistent with a 10-session cap for moderate-to-severe mental illness.
The Scale of Australia's Mental Health Burden
Any policy debate about the Better Access scheme must be anchored in the scale of what it is trying to address.
The AIHW estimates that approximately one in five Australians — around 4.8 million people — experience a mental illness in any given year. Over a lifetime, approximately 45% of Australians will meet the criteria for a mental disorder at some point. The AIHW's Australian Burden of Disease Study identifies mental and substance use disorders as the second largest contributor to total burden of disease in Australia, accounting for approximately 13% of all disability-adjusted life years (DALYs) lost.
Depression and anxiety disorders are the dominant contributors within this category. The 2022-23 National Study of Mental Health and Wellbeing found that anxiety disorders affect approximately 17% of Australians, and affective disorders (including depression) affect approximately 8%, in any 12-month period.
Suicide remains an acute public health emergency. The AIHW records approximately 3,200 deaths by suicide annually in Australia — more than double the road toll. The rate is markedly higher in regional and remote areas, in Aboriginal and Torres Strait Islander communities (where it is more than double the non-Indigenous rate), and in young people aged 15 to 44. Suicide prevention cannot be disaggregated from access to timely, adequately dosed psychological care.
These figures establish the scale of the policy task. They are not abstractions; they represent millions of Australians seeking help from a system that is not adequately resourced to provide it.
Where the System Is Failing
Cost Barriers
The Better Access scheme provides a Medicare rebate for psychological therapy, but it does not provide free therapy. Clinical psychologists — who hold a higher qualification level (generally a doctorate or master's degree in clinical psychology) — attract a higher MBS rebate than registered psychologists. As of the current MBS schedule, the rebate for a clinical psychologist standard consultation (50 minutes, item 80010) is $137.05. The Australian Psychological Society's recommended fee for the same service is $311.
The result is a gap payment — borne by the patient — of $170 to $200 per session at standard private rates, and $80 to $120 per session at the lower end of clinical psychologist pricing. For a patient accessing 10 sessions per year, the annual out-of-pocket cost can reach $1,000 to $2,000 even with Medicare rebates applied. Bulk-billing rates among clinical psychologists are negligible — estimated at well below 5% nationally outside specific community mental health programs.
This cost structure is not incidental. It is the primary reason that access to psychological therapy in Australia remains substantially correlated with income. The Productivity Commission found that individuals in the lowest income quintile were approximately half as likely to access Better Access services as those in the highest quintile, despite substantially higher rates of mental illness in lower-income populations.
Wait Times and Workforce Shortages
Even for patients who can afford gap fees, access to a clinical psychologist is not immediate. AIHW data from the Mental Health Services in Australia series indicate median wait times of four to six weeks for an initial appointment with a clinical psychologist in metropolitan areas. In regional, rural, and remote areas, wait times extend significantly — in some locations, to six to twelve months or longer, with some areas effectively having no local access at all.
The workforce constraint is structural. Clinical psychology training in Australia requires completion of an accredited postgraduate program (master's or doctorate) following undergraduate study — a training pathway of seven to eleven years in total. The number of accredited clinical psychology training places has not expanded proportionally with demand. The Productivity Commission's 2020 report found that Australia would need to significantly increase its clinical psychology workforce over the following decade simply to meet existing demand, let alone the additional demand that would result from improved access.
Rural and remote areas face a compounding problem. Clinical psychologists trained in metropolitan areas face limited incentives to practise outside major cities: higher costs of living relative to income, professional isolation, limited supervision infrastructure for early-career practitioners, and partner employment constraints. The maldistribution of the psychology workforce is not a natural outcome; it reflects a training and incentive structure that consistently produces metropolitan graduates for metropolitan markets.
Youth Mental Health: A System at Its Limit
headspace — the National Youth Mental Health Foundation — has been Australia's primary response to youth mental health since 2006. headspace centres provide early intervention services for young people aged 12 to 25, including counselling, clinical mental health support, alcohol and drug counselling, and sexual health services, through a federally funded model. The evidence base for headspace as a concept is reasonable: earlier intervention at lower acuity is clinically preferable and cost-effective relative to later intervention at higher acuity.
The problem is that in metropolitan areas, headspace centres are saturated. Wait times at many metropolitan headspace centres exceed six to twelve weeks for an initial appointment — comparable to, and sometimes longer than, private clinical psychology. The model, conceived as a low-threshold access point, has become a capacity-constrained bottleneck.
The age cut-off at 25 creates an additional gap. Young people who have been receiving support through headspace face an abrupt transition at age 25 into an adult mental health system that is less accessible, more fragmented, and carries a greater cost burden. For young people in particularly vulnerable developmental phases — establishing careers, managing relationship transitions, dealing with housing insecurity — this is not a trivial disruption.
Severe Mental Illness: The NDIS Interface Gap
The Better Access scheme was designed primarily for mild to moderate mental illness. It was not designed as the primary vehicle for people with schizophrenia, bipolar disorder type I, treatment-resistant depression, borderline personality disorder (BPD), or other severe and complex presentations. For this population, the relevant services are state-funded public mental health services — community mental health teams, acute inpatient units, and extended treatment programs.
The interface between the National Disability Insurance Scheme (NDIS) and mental health services remains one of the most poorly resolved structural problems in Australian health and disability policy. A person with a severe mental illness may qualify for NDIS support — but only if their condition produces functional impairment meeting the scheme's criteria, and only for psychosocial disability supports rather than clinical treatment. Clinical treatment remains the responsibility of state health systems and Medicare.
In practice, people with severe mental illness frequently fall between these systems. State community mental health teams have limited capacity for high-frequency contact outside crisis periods. The NDIS's psychosocial disability supports often do not substitute for clinical psychological treatment. Better Access, with its 10-session cap and moderate-illness framing, is inadequate for this population. The result is a group of highly vulnerable Australians — those with the greatest need — whose care is least reliably organised.
The Gut-Brain Axis: An Emerging Policy Dimension
Mental health reform in Australia increasingly intersects with an evidence base that most current policy does not yet accommodate: nutritional and metabolic psychiatry.
A growing body of peer-reviewed research — including meta-analyses published in The Lancet Psychiatry, JAMA Psychiatry, and Nutritional Neuroscience — establishes that nutritional status, metabolic health, and gut microbiome composition exert measurable effects on depression and anxiety outcomes. Omega-3 fatty acid supplementation has demonstrated effect sizes in depression management comparable to some antidepressant adjuncts in several randomised controlled trials. Vitamin D deficiency — prevalent in Australia despite its climate, particularly in darker-skinned populations and those with limited sun exposure — is associated with elevated depression risk. The Mediterranean dietary pattern has been shown in the SMILES trial and subsequent work to reduce depressive symptoms in clinically meaningful ways. Adaptogens and nootropic botanicals are also receiving growing research attention: bacopa monnieri, for instance, has a developing evidence base for cognitive performance and anxiety modulation that sits at the intersection of nutritional and neurological psychiatry.
These findings do not suggest that diet is a substitute for psychological therapy or pharmacotherapy. They do suggest that comprehensive mental health care should include nutritional assessment — and that GP mental health care plans, which currently have no standardised nutritional component, would benefit from one.
Policy integration of nutritional psychiatry would be modest in cost and potentially significant in outcome: a simple screen for omega-3 sufficiency, vitamin D status, and dietary pattern, built into the existing GP Mental Health Treatment Plan framework, would cost little to implement and would connect a growing evidence base to front-line care.
The UK IAPT Model: What Australia Could Learn
The United Kingdom's Improving Access to Psychological Therapies (IAPT) program — now rebranded as NHS Talking Therapies — provides a useful international comparator for Australian mental health access reform.
Launched in 2008 following the Layard-Clark proposal and implemented nationally through NHS England, IAPT established a stepped-care model for psychological therapy in which patients are assessed and matched to an appropriate level of intervention. Low-intensity interventions — guided self-help, structured group programs, online cognitive behavioural therapy — are provided by psychological wellbeing practitioners (a role that does not require full clinical psychology qualification). High-intensity interventions — individual CBT, counselling for depression, EMDR for PTSD — are provided by qualified therapists. Patients are stepped up or down the model based on clinical response.
Critically, IAPT introduced universal outcome tracking. Every patient treated under IAPT completes validated symptom measures (the PHQ-9 for depression and the GAD-7 for anxiety) at each appointment. Aggregate outcome data are reported publicly at service level, creating accountability for clinical performance. As of recent NHS data, approximately 50% of patients completing IAPT treatment move to recovery — a measurable, nationally tracked outcome.
The Australian system has no equivalent. Better Access operates without standardised outcome measurement at the service level, without public reporting of clinical outcomes, and without a stepped-care model that systematically deploys lower-cost interventions before higher-cost ones. These are not trivial omissions. They represent a fundamental absence of accountability for the clinical and financial performance of the system.
The IAPT model is not without criticism — recovery definitions, workforce qualification debates, and concerns about throughput pressure on therapists have all been raised within the UK policy literature. But the core architecture — stepped care, universal outcome tracking, public accountability — is directly relevant to the Australian reform task and substantially superior to the current Better Access model in systemic design terms.
Consistent with the case made in our analysis of preventive health investment, the evidence overwhelmingly supports earlier, lower-cost interventions as the most cost-effective point of system investment — and IAPT demonstrates what this looks like in practice.
Six Policy Recommendations
1. Restore the 20-Session Cap with Evidence-Based Review Triggers
The annual cap should be restored to 20 Medicare-rebated sessions for patients with documented moderate-to-severe mental illness, with a clinical review point at session 10 requiring GP endorsement to continue. This is not an open-ended entitlement; it is a clinical allocation consistent with the evidence base for treatment of the conditions Better Access is designed to address. The review trigger addresses legitimate budget concern without creating the blunt discontinuation produced by a hard 10-session ceiling. Cost modelling should assess the full-system return, including averted emergency department presentations, reduced inpatient admissions, and productivity gains — metrics conspicuously absent from the 2022 decision-making process.
2. Bulk-Billing Incentive Reform for Underserved Areas
The Commonwealth should introduce a targeted bulk-billing incentive for clinical psychologists practising in Modified Monash Model categories 3 through 7 — the regional, rural, and remote classification tiers where access is most constrained. A meaningful incentive — structured as a per-session loading sufficient to close the gap between MBS rebate and clinical cost — would reduce the financial barrier to rural practice for clinical psychologists. This reform mirrors the GP rural incentive framework and is directly transferable to the psychology workforce. The medication access policy debate demonstrates the well-documented pattern of how geographic and financial barriers compound to deny treatment to those with greatest need; the same principle applies with equal force to psychological services.
3. Fast-Track Training Pipeline via Supervised Practice Pathways
Australia's clinical psychology training pipeline is inadequate to meet projected demand even at current access levels. The Commonwealth should work with the Australian Psychology Accreditation Council (APAC) and university training programs to expand supervised practice pathways — models in which postgraduate registrars practise under structured supervision in community settings, generating real service capacity while completing training. This model, analogous to junior medical officer hospital placements, would simultaneously expand training throughput and produce service capacity in underserved settings. Regional and remote placements should be prioritised, with HECS debt reduction incentives for graduates who commit to a minimum period of rural practice.
4. headspace Age Extension and Transitions-of-Care Pathway
headspace eligibility should be extended to age 30, or alternatively a formal transitions-of-care pathway should be established at age 25 to facilitate warm handover to adult services, including co-case management for patients in active treatment at the point of transition. The 25-year cut-off reflects the original design parameters of a service conceived in 2006; it does not reflect current evidence on developmental trajectories, age-of-onset patterns, or the service landscape young adults face. In parallel, Commonwealth capital and recurrent funding for headspace should be increased to address the documented capacity constraints producing extended metropolitan wait times — the current situation, in which a low-threshold access point has become a high-demand bottleneck, defeats the program's clinical rationale.
5. Integrate Nutritional Psychiatry Assessment in GP Mental Health Care Plans
The Department of Health should develop a standardised nutritional assessment module for inclusion in GP Mental Health Treatment Plans (item 2710 and successors). The module should include dietary pattern screening, vitamin D status, omega-3 sufficiency, and basic hormonal screening where clinically indicated — conditions such as estrogen dominance are increasingly recognised as contributors to mood dysregulation, anxiety, and depressive presentations in women, yet remain outside standard GP mental health assessment frameworks, with referral pathways to dietetics and integrative practitioners where indicated. This reform is low-cost, grounded in a growing evidence base, and represents a practical integration of metabolic and mental health care at the front line. As noted in our broader analysis of preventive health investment in Australia, the economic case for integrating preventive and clinical care at the primary care level is strong and consistently supported by return-on-investment modelling.
6. Digital Mental Health: Prescribable Apps to Extend Between-Session Access
Australia should develop a national register of clinically validated digital mental health tools — analogous to the NHS's digital health product library — from which GPs and psychologists can recommend specific tools as part of a treatment plan. Digital tools including MindSpot, Wellbeing Plus, and several internationally validated platforms have peer-reviewed evidence supporting their efficacy for anxiety and depression. Prescribable digital tools would extend therapeutic contact between sessions, reduce reliance on practitioner time for psychoeducation, and provide a scalable low-intensity pathway within a stepped-care model. The register should include explicit evidence standards, mandatory outcome reporting, and regular review — quality requirements that currently apply inconsistently to the digital mental health sector.
Frequently Asked Questions
Why did the government reverse the 20-session limit if the evidence supported it? The November 2022 decision to return to 10 sessions was driven primarily by cost considerations. The 20-session extension had increased Better Access expenditure substantially during 2021 and 2022 — partly reflecting genuine clinical need, partly a demand surge associated with pandemic conditions. The Department of Health's advice prioritised fiscal consolidation over clinical continuity, a trade-off that the Australian Psychological Society, the RANZCP, and consumer advocates argued was inconsistent with the available evidence. The evaluation commissioned by the government itself found measurable benefit in the 11- to 20-session range, which made the reversal decision difficult to reconcile with the evidence base.
Is 10 sessions per year ever sufficient? For mild presentations — adjustment disorder, situational anxiety, acute grief — 10 sessions may be clinically adequate, particularly if supplemented with digital tools, peer support, and GP review. The problem is that Better Access is increasingly used for moderate-to-severe presentations where 10 sessions is demonstrably insufficient. The solution is a tiered model — not a uniform cap — in which session allocation is matched to severity, with review points built in rather than arbitrary annual limits.
What is the NDIS-mental health interface problem? The NDIS funds supports for psychosocial disability — housing assistance, daily living supports, community participation — but not clinical treatment for mental illness, which remains the responsibility of Medicare and state health systems. For people with severe mental illness, these two systems frequently fail to coordinate, leaving patients managing referral bureaucracy at precisely the times they are least able to do so. The Productivity Commission's 2020 Mental Health inquiry called for a dedicated Primary Health Network-led coordination function at the interface; implementation has been uneven.
Why are bulk-billing rates so low for clinical psychologists? The Medicare rebate for clinical psychology services has not kept pace with the cost of delivering those services. Between the cost of maintaining a private practice — rent, insurance, supervision, CPD, administrative overhead — and the MBS rebate, bulk-billing in clinical psychology is financially unviable for most practitioners. Lifting the rebate to a level that covers the full cost of service delivery — rather than partially subsidising it — is the only sustainable solution, and the additional fiscal cost would be substantially offset by averted downstream costs.
Conclusion
Australia's mental health system is not short of reform ambition. The Productivity Commission's 2020 report runs to thousands of pages. The National Mental Health and Suicide Prevention Plan commits to investment across prevention, early intervention, and treatment. Mental health has been the subject of bipartisan political attention for more than two decades.
What the system is short of is structural follow-through. The 2023 reversal of the 20-session limit — against the weight of available evidence and in the middle of an ongoing mental health crisis — illustrated the gap between stated commitment and policy execution. A system in which access to evidence-based psychological care is determined primarily by income, postcode, and the lottery of finding a practitioner who bulk-bills is not a system that has translated reform ambition into reform outcomes.
The six recommendations outlined here are not radical. Each has precedent in Australian or international policy. Together, they represent a coherent package: restoring a clinically defensible session limit, addressing cost and workforce barriers, extending the youth mental health model to match the evidence on developmental need, integrating nutritional psychiatry at the primary care level, and deploying digital tools within a quality-assured framework. The economic case — when averted emergency presentations, reduced inpatient costs, and productivity gains are included — is consistent with the broader evidence on preventive health investment as Australia's most cost-effective health system lever.
Mental health reform in Australia has been treated too often as a communication exercise rather than a structural challenge. The evidence is not in dispute. The policy levers exist. The question, as with so much in Australian health policy, is whether the institutional will to act on them can be sustained beyond an electoral cycle.
This article is provided for informational and policy advocacy purposes only. It is not medical advice, financial advice, or a substitute for clinical consultation. Coalition for Better Health does not provide individual medical guidance. If you or someone you know is experiencing a mental health crisis, please contact Lifeline on 13 11 14, Beyond Blue on 1300 22 4636, or present to your nearest emergency department.