Band-Aids for broken bones: why people with severe mental disorders are still missing out

Laws and institutions no matter how efficient and well arranged must be reformed or abolished if they are unjust … justice denies that the loss of freedom for some is made right by a greater good shared by others. It does not allow that the sacrifices imposed on a few are outweighed by the larger sum of advantages enjoyed by many. – John Rawls, A Theory of Justice

The minister of health’s strategic approach to mental health imposes a sacrifice on those with the most severe mental disorders, so that those with mild to moderate psychological distress can be prioritised. While this strategy might appeal to politicians, who rely on votes, it is based on a flawed understanding of mental illness and is ultimately unjust.

In 2018, He Ara Oranga was commissioned by the government in response to widespread dissatisfaction with New Zealand’s mental health services. The report recognised difficulties accessing appropriate mental health care; people with mental illness “having to fight and beg for services, not meeting the threshold for treatment, and the cruelty of being encouraged to seek help from unavailable or severely rationed services.”¹ As well as public dissatisfaction with services, specialist mental health services were under immense pressure. The Auckland District Health Board reported that the number of crisis referrals received tripled from 2010 to 2015.²

Attempting to manage this problem, in 2019 the government invested NZ$455 million in an integrated primary mental health and addiction (IPMHA) service, which provides brief support and advice for those in psychological distress via primary care–based health improvement practitioners (HIP). It was hoped that providing non-specific supports in the community would reduce the demand on specialist services and hospitals and that longer-term funding for specialist services and specific psychiatric interventions could be reduced. The New Zealand Health Strategy (2023) stated “Plans for new preventive services will need to be combined with plans to disinvest in old services … to deliver more preventive care, we expect to see changes to the distribution of funding, including towards community-based services.”³

The specialist psychiatric services to be downsized were already small by international standards. In 2016, New Zealand’s 31 psychiatric beds per 100,000 population was less than half of the OECD average (69 beds per 100,000 population)⁴ and well below the minimum of 50 beds per 100,000 population recommended by the Treatment Advocacy Center.⁵ Consequences of inadequately resourced psychiatric inpatient units are: incomplete assessment, partial treatment and premature discharges.⁶ Between 2012 and 2019 the risk of imprisonment following psychiatric admission increased by 50%, particularly impacting males, Māori and those with psychotic disorders. This suggests that poorly resourced mental health services may be increasingly reliant on the criminal justice system to contain those with major mental illness.⁷

Evaluating the investment

In 2025, Te Hiringa Mahara – the New Zealand Mental Health and Wellbeing Commission evaluated the impact of the IPMHA service. The commission applauded the increased services for mild to moderate mental illness but also acknowledged persisting difficulties accessing specialist care for those with severe mental illness.^8,9 More than 200,000 people received support for mild to moderate mental illness in 2023/2024.⁹ The most common reasons for seeking support were anxiety, low mood, chronic stress and diabetes.⁹ When surveyed, 500 psychiatrists believed the system was moving in the wrong direction and that the IPMHA service had led to increased referrals to specialist services rather than the reduction anticipated by Health New Zealand – Te Whatu Ora.¹⁰ Meanwhile, 16,000 fewer people were able to access specialist mental health services in 2023/2024 compared with 2020/2021. This reduced access was reported to be due to workforce shortages.⁸ Over 200 psychiatrists have left permanent jobs in the public system over the past 5 years.¹¹ A major reason given by psychiatrists for leaving was that the system is significantly under-resourced.¹¹ Insufficient funding for specialist services, increasing waiting lists and a lack of person-centred care continued to be observed by non-medical staff as well.¹²

Is mental illness a simple lack of “mental wellbeing needs”?

Kia Manawanui Aotearoa is a document published by the Ministry of Health – Manatū Hauora, which outlines the New Zealand Government’s long-term strategic plan for New Zealand’s mental health service provision.¹³ Kia Manawanui Aotearoa discusses mental health services providing for “people’s mental wellbeing needs” rather than treating mental illness or mental disorders. In the document, mental disorders are only mentioned twice, both times in an opening section on epidemiology. Schizophrenia and bipolar disorder are not mentioned at all. By equating mental illness with a lack of mental wellbeing needs the Ministry of Health – Manatū Hauora risks pathologising human experiences of suffering. On the surface this ideological position may seem more inclusive; however, it risks overlooking people with severe mental disorders for whom treatments are typically more effective.² Kia Manawanui Aotearoa perpetuates a conceptual misunderstanding that sees all mental illness as a continuum of psychological distress from mild to severe. If this misunderstanding was correct, then providing support for mild to moderate mental illness would reduce the number of people with severe mental illness. However, people with mild to moderate mental illness are typically presenting with different conditions to those presenting with severe mental illness. It should be no surprise that providing support for anxiety, low mood, stress and diabetes has little impact on the needs of those with schizophrenia, bipolar disorder, complex post-traumatic stress disorder (PTSD) and obsessive-compulsive disorder (OCD).

The prognosis

For someone with schizophrenia, a brief period of support from an HIP is like providing a Band-Aid for someone who has broken bones. People with severe mental illness need specific evidence-based interventions. These interventions should not be exclusively medical but sit within a biopsychosocial approach. This includes culturally appropriate psychiatric assessment and treatment, access to evidence-based psychotherapies, access to mental health rehabilitation services and sufficiently funded supported accommodation for those unable to live independently.

The current approach to mental health funding is unjust. The New Zealand Government’s current strategic approach is leaving people with severe mental disorders squeezed out at the margins and, in some cases, untreated.¹⁴ While Health New Zealand – Te Whatu Ora’s intentions have been to create a more inclusive mental health service, the consequence could inadvertently be greater inequality. Furthermore, the current approach is ineffective. Since the introduction of the IPMHA service more than 200,000 people have received support and yet at a population level self-reported psychological distress has increased and self-reported mental wellbeing has reduced.⁹ There is little evidence to suggest that non-specific mental health supports alter population distress or prevent mental illness.^2,4 In New Zealand, those with the lowest economic standard of living also express the highest psychological distress; 24.3% compared to 0.8% of those with the highest economic standard of living.¹⁵ This suggests that programmes that support economic wellbeing and social cohesion might be a better focus for preventing psychological distress at a population level. A truly preventive approach would focus on modifiable social determinants that could lower rates of mental illness in New Zealand’s future generations.¹⁶

A just and effective strategic approach to mental health would focus mental health funding on evidence-based treatment for specific conditions, while also advocating for social and economic policies that reduce the risk factors for developing mental disorders.