Beth Kotze

Selecting your options: A pilot study of short interventions with patients who deliberately self harm

The National Survey of Mental Health and Wellbeing 1 reported lifetime prevalence of suicidal ideation as 14.3% and rates of suicidal attempts as 3.1%. The highest rates for ideation were 2.9% for men and 5.3% for women from 18–24 years (with rates of 0.7% for men and 1.0% for women for suicide attempts), but rates for the 25 to 44 year group were almost as high. At least 10% of attempters will eventually die by suicide and at least half of those who complete suicide have had a previous attempt.2

The Green Card Clinic: overview of a brief patient-centred intervention following deliberate self-harm

Objectives: The aim of this study was to present an overview of the Green Card Clinic, a novel brief intervention service for patients presenting to the emergency department following deliberate self-harm (DSH) or with suicidal ideation, to examine its effectiveness in terms of service utilization, and patient and clinician feedback, and to explore the correlates of repeated DSH. Method: The aims and structure of the Green Card Clinic are described. We highlight our patient-centred approach involving self-identification of difficulties from a list of problem areas, coupled with tailored intervention strategies. Relevant data are presented and characteristics of repeat DSH patients are compared to the first-episode group. Results: Between 1998 and 2005, 456 DSH patients were referred to the clinic. Of these, 75% (n = 344) attended the first session, 43% (n = 197) the second session, 26% (n = 117) the third session, and 16% (n = 73) completed a 3–15 month follow-up. Clinic attenders (mean age 31.6 years, 57% female) reported a diverse range of self-identified problems and repeat DSH patients reported worse depression, poorer health-related behaviours, and a greater number of problems than those presenting after first-episode DSH. Conclusions: The clinic achieved high rates of first session attendance. This may have been attributable to the use of a few specific strategies aimed at increasing compliance, such as the green card, next-day appointments and assertive follow-up of non-attenders. For repeat self-harmers, we advocate an approach aimed at ‘lifestyle change’ rather than based on current psychological stressors. The Green Card Clinic service, involving a range of interventions tailored to meet the multitude of presenting needs, appears to be an acceptable and flexible approach to brief intervention for DSH.

‘Learning Organizations’: a clinician's primer

Objectives: Most clinicians are poorly informed in relation to the key concepts of organizational learning. Yet the paradigm may offer clinicians a powerful method for using their knowledge and skills to respond to the demands of a changing environment through experimentation and learning. The concept is critically examined. Organizational learning principles are presented, including a conceptual framework for assessing health services as Learning Organizations. Barriers to organizational learning and strategies to overcome these are discussed. Methods: The seminal works of Argyris and Senge are reviewed and a framework for assessing organizational learning in health services is proposed. Current area health service actions are evaluated against the ‘diagnostic’ framework for a Learning Organization. Results: Although critical examination reveals a poor empirical basis for the concept, the metaphor of the Learning Organization provides a useful conceptual framework and tools for individuals and organizations to apply in developing knowledge and effecting change. The Clinical Practice Improvement and Root Cause Analysis programs being conducted across NSW area health services meet the criteria for effective organizational learning. Conclusions: Key concepts from organizational learning theory provide a diagnostic framework for evaluating area health services as Learning Organizations and support two current strategies for overcoming barriers to organizational learning.

Blame and Accountability 2: On Being Accountable

Objective: This second paper follows an exploration of the nature of blame and addresses the balance between a ‘blame-free’ health culture and appropriate accountability. This paper aims to define and describe accountability as a key component of clinical governance and a responsive, fair and transparent health culture. Methods: The literature is examined and the concept of a fair and transparent health culture is explored. The case vignette in Part 1 is used to illustrate a particular issue of accountability. Results: The place of accountability in relation to clinicians and health organisations is elucidated. Conclusions: The necessary conditions for an accountable, responsive, fair and transparent health culture are proposed.

Blame and Accountability 1: Understanding Blame and Blame Pathologies:

Objective: In this first paper the role and dynamics of blame in the context of medical critical incidents is examined. Blame pathologies are described and the complex nature of medical adverse events and the environment are explored. Methods: The literature is examined and a case scenario explored. Results: Evidence regarding effects of a ‘blame culture’ on clinicians and organizations is presented. In an accompanying second paper the place of accountability in relation to clinicians and health organizations is elucidated. Conclusions: The necessary conditions for an accountable, responsive, fair and transparent health culture are proposed.

Actions Taken to Cope with Depression in Patients Seeking Specialist Care

OBJECTIVE To assess the rates and perceived effectiveness of actions used to cope with depression and the factors influencing these in an outpatient sample seeking help for depression. METHOD One hundred and seventy-six patients (74 male, 102 female) aged 16-82 years (M = 42, SD = 14.4 years) with a major depressive episode (DSM-IV criteria) were assessed using a number of measures that covered sociodemographics, history of psychiatric illness, actions taken to alleviate depression and their perceived effectiveness. Logistic regression analyses assessed age, gender and illness characteristics associated with the use and perceived effectiveness of strategies adopted to manage depression. RESULTS Medical interventions were used and perceived to be effective in alleviating depressive symptoms by most of the sample, as were self-help and complementary therapies. Sociodemographic and illness-related characteristics had a significant influence, with younger age and having experienced an episode of anxiety disorder found to be the strongest predictors for the use of coping strategies. Being female was the strongest predictor for their effectiveness. CONCLUSION A range of actions for depression, including medical and complementary interventions, were used and found to be helpful in a sample that had sought professional help for depression. Gender, age, depression and anxiety factors were all found to predict the use and perceived effectiveness of these strategies.

Commentary: The challenge of ensuring access to mental health services for children and adolescents:

Adequate provision of mental health services to children and adolescents is vital to address the developmental origins of mental illness, particularly the relationship between childhood trauma and later mental illness (Carr et al., 2013; Sara and Lappin, 2017). In some instances, such as the behavioural disorders of childhood, the economic case for early intervention is compelling and the long-term savings accrue to health, welfare, justice and disability systems. The study reported by Segal et al. (2018) demonstrates that service access by the younger age groups, especially infants and young children, continues to be a challenge. The authors of this study report that less than 1% of 0to 4-year olds received a mental health service in any one service setting. In contrast, approximately 10% of the group aged 18–24 years received an MBS service and 3.5% accessed state or territory funded services (excluding Emergency Departments). Only 2% of MBS Better Access expenditure was on the 0to 4-year age group. This level of service and expenditure for the 0to 4-year-old group stands in stark contrast to the Australian Burden of Disease Study (Australian Institute of Health and Welfare, 2016) which estimated a prevalence of 2.2% for severe mental disorder in this age group, and 4.4% and 8.8% for moderate and mild disorders, respectively. There is a clear service gap for this vulnerable youngest age group for whom the evidence strongly supports intervention and for whom the longterm negative consequences of trauma and untreated disorder are significant for the individual, their families and society. Quantifying the level of service delivery is a first step in a planned approach to ensuring adequate mental health service response. Segal et al. used Australian government data sets to derive number of persons aged 0–24 years who received mental health services in 2014–2015, the number of services and expenditure. The study is limited to health sector data and does not capture mental health services delivered by paediatricians, community child health and non-government organisations, and other agencies such as education, child protection and juvenile justice. Importantly, though, the authors acknowledge the multiplicity of adversities faced by children and adolescents with mental health disorders and their families. They recognise the complexity of the child’s predicament and the high-level specialised workforce competencies required to work with infants and their caregivers and disturbed adolescents in chaotic systems. Multidisciplinary services capable of providing expert consultation to partners such as maternal and child health services, and general practitioners along with long-term care and specialised treatments are required. Mental health services integrated with child protection agencies, perinatal services and education have been demonstrated to be clinically cost effective (Knapp et al., 2011). Developing and evaluating specific interventions delivered in different service settings is a priority. For example, the positively evaluated Got It! programme in NSW is based on mental health clinicians delivering early intervention in the school setting in partnership with teachers to children with disruptive behaviours in the 5-8 year old age group. There are other examples of perinatal mental health clinicians working in partnership with child protection and maternity and early childhood services to deliver positively evaluated programmes. There is still much to do in workforce training to ensure an adequate supply of mental health professionals equipped to work with this younger age group and their families/carers and provide support to partner workforces in other settings. Thus, beyond assessing the current level of service against prevalence, it is essential to determine workforce demand and competency and evaluate which interventions produce cost-effective outcomes. The draft Fifth National Mental Health Plan is due for publication in late 2017. It proposes that regionally Commentaries 730417 ANP0010.1177/0004867417730417ANZJP CorrespondenceANZJP Correspondence research-article2017