Irene Bobevski

Perceived need for mental health care: influences of diagnosis, demography and disability.

BACKGROUND Recent major epidemiological studies have adopted increasingly multidimensional approaches to assessment. Several of these have included some assessment of perceived need for mental health care. The Australian National Survey of Mental Health and Wellbeing, conducted in 1997, included a particularly detailed examination of this construct, with an instrument with demonstrated reliability and validity. METHODS A clustered probability sample of 10641 Australians responded to the field questionnaire for this survey, including questions on perceived need either where there had been service utilization, or where a disorder was detected by administration of sections of the Composite International Diagnostic Interview. The confidentialized unit record file generated from the survey was analysed for determinants of perceived need. RESULTS Perceived need is increased in females, in people in the middle years of adulthood, and in those who have affective disorders or co-morbidity. Effects of diagnosis and disability can account for most of the differences in gender specific rates. With correction for these effects through regression, there is less perceived need for social interventions and possibly more for counselling in females; disability is confirmed as strongly positively associated with perceived need, as are the presence of affective disorders or co-morbidity. CONCLUSIONS The findings of this study underscore the imperative for mental health services to be attentive and responsive to consumer perceived need. The substantial majority of people who are significantly disabled by mental health problems are among those who see themselves as having such needs.

Psychiatry and the need for mental health care in Australia: findings from the National Survey of Mental Health and Wellbeing

Objective: This paper describes the pattern of consultations reported with psychiatrists and primary mental health care providers in the Australian adult population. It explores whether inequalities found in utilization of psychiatric services according to area are different in degree from inequalities in utilization of medical and surgical specialists, and describes the meeting of perceived needs for mental health care within those seen by psychiatrists. Method: The National Survey of Mental Health and Wellbeing (NSMHW) was a community survey employing clustered probability sampling, with a computerized field questionnaire which included sections of the composite international diagnostic interview (CIDI), as well as self-reported service utilization and perceived needs for care. Results: By survey estimates, 1.8% of the Australian population consulted a psychiatrist in the last year. Among people with an ICD 10-diagnosed mental disorder, 7.3% consulted a psychiatrist. Only about one in five people seen by a psychiatrist report the psychiatrist as the only mental health care provider. Disadvantaged areas of the cities and remote areas, when compared with the least deprived areas of the cities, showed lower rates of utilization. This effect is stronger in psychiatry than in other specialities. Patients seeing psychiatrists seem to be a more satisfied group than those seeing only other providers; nonetheless, some needs are not well met, and the role of the psychiatrist cannot be isolated as the cause of this satisfaction. Conclusions: Most care delivered by psychiatrists is de facto shared care. Psychiatrists as clinical professionals need to be continually mindful of the need to communicate with others providing care. Psychiatric services in Australia are not delivered in an equitable manner, and the inequalities are greater for psychiatric services than for other medical specialities.

Changes in met perceived need for mental healthcare in Australia from 1997 to 2007

BACKGROUND The Australian National Survey of Mental Health and Wellbeing conducted in 1997 and 2007 allows for exploration of changes in perceptions of mental healthcare. Major demographic, economic and health-behaviour changes have unfolded in Australia during this time. Governments also have increased spending on mental health services and been active in mental healthcare policy-making and implementation. AIMS To compare rates of meeting of perceived need for mental healthcare between these two surveys dealing with adjustable sources of error. METHOD Combined data-sets from 1997 and 2007 were analysed to provide weighted population estimates. Selection, indirect standardisation to a common reference population and multinomial logistic regression were employed, addressing bias and confounding. RESULTS Between 1997 and 2007 perceived need for information, counselling and skills training among people who consulted a general practitioner, psychiatrist, or psychologist for mental health reasons has increased. Within these service users, increases in perceived responses from services are evident among people who have perceived needs for information provision and counselling. CONCLUSIONS Policy and service changes are among possible causal explanations. Generally, trends are in the direction that policy changes were intended to achieve, giving some encouragement that these initiatives have had some effect. Reduced unmet perceived need suggests improved access to some interventions. However, the proportion of service responses to perceived need seen as sufficient is generally unchanged. This suggests the adequacy of treatments offered, as perceived by the Australian public, may not have improved and that a continued focus on quality of care is important for the future.

Distributing mental health care resources: strategic implications from the National Survey of Mental Health and Wellbeing

Objective: This paper considers mental health services resource distribution under the Australian second national mental health plan, with its direction to mental health services to be more inclusive of people with higher prevalence psychiatric disorders. We consider inequalities in mental health in Australia, and describe the performance of the composite census variable employed in the Victorian mental health funding distribution formula, the index of relative socioeconomic disadvantage (IRSED), in predicting disorder rates and perceived needs for care. Method: We review data sets generated through the National Survey of Mental Health and Wellbeing (NSMHWB) for their utility in development of resource distribution formulae. We present analyses from the 10 641 cases examined in the household survey to explore the role of the IRSED in predicting prevalence rates of anxiety, affective, substance misuse and other disorders, as well as perceived need for care. Results: Recent epidemiological studies provide some additional sources of data to guide resource distribution, although the available data sets are found not to be optimized for examination of this issue. Greater levels of socioeconomic disadvantage of areas are associated with increased rates of morbidity in metropolitan areas, with different patterns for different disorder groups. The influence of the IRSED is more complex outside the major cities. Conclusions: The descriptive epidemiological data now available, despite significant investment, are relatively crude instruments for this current purpose. The findings support the case for using the IRSED as a proxy indicator for morbidity for the high prevalence disorders, but only within metropolitan areas. This examination confirms the existence of significant inequalities in mental health between Australian urban areas with different socioeconomic characteristics.

A cluster randomised controlled trial of a brief couple-focused psychoeducational intervention to prevent common postnatal mental disorders among women: study protocol.

Introduction Postnatal common mental disorders among women are an important public health problem internationally. Interventions to prevent postnatal depression have had limited success. What Were We Thinking (WWWT) is a structured, gender-informed, psychoeducational group programme for parents and their first infant that addresses two modifiable risks to postnatal mental health. This paper describes the protocol for a cluster randomised controlled trial to test the clinical effectiveness and cost-effectiveness of WWWT when implemented in usual primary care. Methods and analysis 48 maternal and child health (MCH) centres from six diverse Local Government Areas, in Victoria, Australia are randomly allocated to the intervention group (usual care plus WWWT) or the control group (usual care). The required sample size is 184 women in each group. English-speaking primiparous women receiving postpartum healthcare in participating MCH centres complete two computer-assisted telephone interviews: baseline at 4 weeks and outcome at 6 months postpartum. Women attending intervention MCH centres are invited to attend WWWT in addition to usual care. The primary outcome is meeting Diagnostic and Statistical Manual-IV (DSM-IV) diagnostic criteria for major depressive episode; generalised anxiety disorder; panic disorder with or without agoraphobia, agoraphobia with or without panic, social phobia, adult separation anxiety or adjustment disorder with depressed mood, anxiety or mixed depressed mood and anxiety within the past 30 days at 6 months postpartum. Secondary outcomes are self-rated general and emotional health, infant sleep problems, method of infant feeding, quality of mother–infant relationship and intimate partner relationship, and healthcare costs and outcomes. Ethics and dissemination Approval to conduct the study has been granted. A comprehensive dissemination plan has been devised. Trial registration number Australian New Zealand Clinical Trials Registry ACTRN12613000506796. UTN U1111-1125-8208.

Health anxiety and its relationship to disability and service use: Findings from a large epidemiological survey

Objective To explore the contribution of health anxiety to disability and use of mental health and medical services, independently of co-occurring mental and physical conditions. Methods Data from the Australian National Survey of Mental Health and Wellbeing 2007 were analyzed (n = 8841). Participants were aged 16 to 85 years (mean [standard deviation] = 46.3 [19.0] years) and 54% were women. Results Health anxiety accounted independently for high disability and service use. People with health anxiety were more likely to use both mental health (for psychiatrists: odds ratio [OR] = 2.1, 95% confidence interval [CI] = 1.2–3.5; for psychologists: OR = 1.9, 95% CI = 1.2–3.3) and specialist medical services (OR = 1.7, 95% CI = 1.2–2.3) than people without health anxiety. However, they were not high-frequency attenders to specialist mental health services (OR = 1.6 [95% CI = 0.9–3.0] and OR = 1.3 [95% CI = 0.6–2.9]) compared with people with other mental disorders (OR = 11.7 [95% CI = 4.3–31.8] and OR = 29.5 [95% CI = 13.5–64.6] for psychiatrists and psychologists, respectively). People with health anxiety were likely to be high-frequency attenders to general practice (OR = 2.0, 95% CI = 1.4–2.8) and specialist medical services (OR = 2.4, 95% CI = 1.7–3.6). Conclusions It is important to recognize and treat health anxiety, even when coexisting with other conditions, to prevent high disability burden and excessive service use. The cross-sectional design and self-reported outcomes may have resulted in overestimation of the associations. Future work is needed on actual service use using reviews of medical records.

Measuring postnatal demoralisation: adaptation of the Demoralisation Scale-II (DS-II) for postnatal use

ABSTRACT Objective: To examine the psychometric properties of the Demoralisation Scale II (DS-II) and adapt it for use with women in the postnatal period. Background: Demoralisation is a psychological state characterised by a sense of incompetence and feelings of helplessness and hopelessness in response to a stressful situation. The postnatal period is a life stage of many disruptions. Women may lose their confidence and become demoralised if feeling unprepared for the tasks of motherhood. The DS-II is a 16-item scale developed among cancer patients, but with content that is also relevant postnatally, including items on sense of failure, helplessness, hopelessness, isolation, entrapment and loss of purpose. Methods: Rasch analysis was used to investigate the psychometric properties of the DS-II and refine the scale for postnatal use. Results: Participants were 209 women admitted with their babies to a residential early parenting programme. A 14-item revised scale was derived, the Postnatal DS-II, showing good psychometric properties, discriminant validity and sensitivity to change, and being well targeted to the sample. Conclusion: The Postnatal DS-II could have utility as an assessment tool, helping clinicians to understand better women’s postnatal experiences, assess the effectiveness of interventions and communicate with women in a meaningful and non-stigmatising way.