Lennart Reifels

Lessons learned about psychosocial responses to disaster and mass trauma: an international perspective

At the 13th meeting of the European Society for Traumatic Stress Studies in 2013, a symposium was held that brought together international researchers and clinicians who were involved in psychosocial responses to disaster. A total of six disasters that occurred in five countries were presented and discussed. Lessons learned from these disasters included the need to: (1) tailor the psychosocial response to the specific disaster, (2) provide multi-dimensional psychosocial care, (3) target at-risk population groups, (4) proactively address barriers in access to care, (5) recognise the social dimensions and sources of resilience, (6) extend the roles for mental health professionals, (7) efficiently coordinate and integrate disaster response services, and (8) integrate research and evaluation into disaster response planning.

Innovations in primary mental healthcare

OBJECTIVE We review the evidence on innovations in Tier 2 of the Access to Allied Psychological Services (ATAPS) program, which is designed to facilitate the provision of primary mental healthcare to hard-to-reach and at-risk population groups (including women with perinatal depression, people at risk of self-harm or suicide, people experiencing or at risk of homelessness, people affected by the 2009 Victorian bushfires, people in remote locations, Aboriginal and Torres Strait Islanders and children with mental disorders) and the trialling of new modalities of service delivery (e.g. telephone-based or web-based CBT). The primary focus is on the uptake, outcomes and issues associated with the provision of ATAPS Tier 2. METHODS Drawing on data from an ongoing national ATAPS evaluation, including a national minimum dataset, key informant interviews and surveys, the impact of ATAPS innovations is analysed and illustrated through program examples. RESULTS ATAPS Tier 2 facilitates access to, uptake of and positive clinical outcomes from primary mental healthcare for population groups with particular needs, although it requires periods of time to implement locally. CONCLUSIONS Relatively simple innovations in mental health program design can have important practical ramifications for service provision, extending program reach and improving mental health outcomes for target populations. What is known about the topic? It is recognised that innovative approaches are required to tailor mental health programs for hard-to-reach and at-risk population groups. Divisions of General Practice have implemented innovations in the Access to Allied Psychological Services (ATAPS) program for several years. What does this paper add? Drawing on data from an ongoing national ATAPS evaluation, this paper presents a systematic analysis of the uptake, outcomes and issues associated with provision of the innovative ATAPS program. What are the implications for practitioners? The findings highlight the benefits of introducing innovations in primary mental healthcare in terms of increased access to care and positive consumer outcomes. They also identify challenges to and facilitators of the implementation process, which can inform innovation efforts in other primary care contexts.

Enhanced Primary Mental Health Services in Response to Disaster

OBJECTIVE Although postdisaster mental health sequelae are recognized, the role of mental health services in primary care after disasters has not been investigated. This study examined the uptake of enhanced primary mental health services delivered via the Australian government mental health response to the 2009 Victorian bushfires and considered the consumer outcomes associated with them. METHODS Data from a national Web-based minimum data set enabled description of consumers, sessions, and treatment outcomes. Key informant interviews provided supplementary qualitative data. RESULTS From January 2009 to June 2011, a total of 1,535 consumers received 9,949 sessions via enhanced primary mental health services. Most had depressive disorders, anxiety disorders, or both. Clinical outcomes data from standardized mental health outcome measures demonstrated statistically significant gains indicative of clinical improvement. CONCLUSIONS Primary mental health services were well utilized and received by bushfire-affected individuals in most areas and produced positive outcomes for consumers in terms of reducing symptoms and improving psychosocial functioning. Enhancing existing primary mental health services shows promise as a means of responding to bushfires and may be applicable internationally in other disaster contexts.

Patterns and predictors of primary mental health service use following bushfire and flood disasters.

Background Mental health care services play an important role following disasters (Reifels et al., 2013). The aim of this study is to examine patterns and predictors of primary mental health care service use, following two major Australian natural disaster events. Method Utilizing referral and session data from a national minimum dataset, descriptive and regression analyses were conducted to identify levels and predictors of the use of the Access to Allied Psychological Services (ATAPS) program over a 2-year period following two major Australian bushfire and flood/cyclone disasters. Predictor variables examined in negative binomial regression analysis included consumer (age, gender, household structure, previous mental health care history, and diagnosis) and event characteristics (disaster type). Results The bushfire disaster resulted in significantly greater service volume, with more than twice the number of referrals and nearly three times the number of sessions. Service delivery for both disasters peaked in the third quarter. Consumers affected by bushfires, diagnosed with depression, anxiety, or both of these disorders utilized sessions at significantly higher rates. Conclusions The substantial demand for primary mental health services following disaster can vary with disaster type. Disaster type and need-based variables as key drivers of service use intensity indicate an equitable level of service use. Established usage patterns assist with estimating future service capacity requirements. Flexible referral pathways can enhance access to disaster mental health care. Future research should examine the impact of program- and agency-level factors on mental health service use and factors underpinning treatment non-adherence following disaster.

Suicide prevention: Evaluation of a pilot intervention in a primary care context

Background From July 2008 to June 2011, 19 Australian Divisions of General Practice piloted specialist services for consumers at risk of suicide within a broader primary mental health program. General practitioners and other mental health staff referred suicidal consumers to specially trained mental health professionals for intensive, time-limited care. Aims To report the findings from an evaluation of the pilot. Method Data sources included a purpose-designed minimum data set, which collated consumer-level and session-level data, and a series of structured telephone interviews conducted with Divisional project officers, referrers and mental health professionals. Results There were 2312 referrals to the pilot; 2070 individuals took up the service. The pilot reached people who may not otherwise have had access to psychological care; over half of those who received services were on low incomes and about one-third had not previously accessed mental health care. Project officers, referrers and mental health professionals were all positive about the pilot and commented that it was meeting a previously unmet need. Consumers appeared to benefit, showing significant improvements in outcomes. Conclusion This evaluation provides supportive evidence for the effectiveness of a suicide prevention intervention delivered by specially trained mental health professionals in a primary mental health environment.

Improving access to primary mental healthcare for Indigenous Australians

Objective: To examine the uptake, population reach and outcomes of primary mental healthcare services provided to Indigenous Australians via the Access to Allied Psychological Services (ATAPS) program between 2003 and 2013, with particular reference to enhanced Indigenous ATAPS services introduced from 2010. Method: Utilising ATAPS program data from a national minimum data set and comparative population data, we conducted descriptive analyses, regression analyses and t-tests to examine the uptake of ATAPS services, provider agency level predictors of service reach, and preliminary outcome data on consumer level outcomes. Results: Between 2003 and 2013, 15,450 Indigenous client referrals were made that resulted in 55,134 ATAPS sessions. National Indigenous service volume more than doubled between 2010 and 2012, following the introduction of enhanced Indigenous ATAPS services. Non-Indigenous ATAPS service volume of primary care agencies was uniquely predictive of Indigenous service reach. Preliminary analysis of limited consumer outcome data indicated positive treatment gains and the need to enhance future outcome data collection. Conclusions: Concerted national efforts to enhance mainstream primary mental healthcare programs can result in significant gains in access to mental healthcare for Indigenous populations.

National telemental health responses to a major bushfire disaster

In response to the Victorian bushfire disaster in 2009, various telemental health services were provided by three national agencies: Kids Helpline (BoysTown), MensLine Australia (Crisis Support Services) and Lifeline Australia. All provider agencies used their existing national service structures and staff resources, which were expanded to respond to bushfire-related service demand. We examined service provider reports and conducted key informant interviews. Despite a lack of quantitative data on consumer outcomes and perspectives, it appears that all three telemental health services experienced significant increases in overall service uptake levels in the wake of the bushfires. Uptake of specialized telephone-, web-, email- and crisis counselling services was substantial, although that of callback services was very limited. Potential clients encountered specific barriers in relation to service access and the callback model. The bushfire experience highlighted the impact of transitory living circumstances and the increased complexity of post-disaster calls on service provision. Telemental health services need to be integrated into mainstream services and disaster response structures.

Improving access to primary mental health care for Australian children

Objective: This study examines the uptake by children aged predominantly 0–11 years of an Australian primary mental health service – the Access to Allied Psychological Services programme – which began in 2001. In particular, it considers access to, and use of, the child component of Access to Allied Psychological Services, the Child Mental Health Service, introduced in 2010. Method: Using routinely collected programme data from a national minimum dataset and regional population data, we conducted descriptive and regression analysis to examine programme uptake, predictors of service reach and consumer- and treatment-based characteristics of service. Results: Between 2003 and 2013, 18,631 referrals for children were made and 75,178 sessions were scheduled via Access to Allied Psychological Services, over 50% of which were via the Child Mental Health Service in its first 3 years of operation. The rate of referrals for children to the Child Mental Health Service was associated with the rate of Access to Allied Psychological Services referrals for consumers aged 12+ years. Conclusions: The Child Mental Health Service has increased services provided within the Access to Allied Psychological Services programme for children with emotional and behavioural issues and their families, and is potentially filling a service gap in the area of prevention and early intervention for children who have significant levels of need but are unable to access other mental health services. Our findings are policy-relevant for other developed countries with a similar primary mental health care system that are considering means of improving service access by children.

Patterns and Predictors of Primary Mental Health Service Use Following Bushfire and Flood Disasters.

OBJECTIVE To examine patterns and predictors of primary mental health care service use following 2 major Australian natural disaster events. METHODS Utilizing data from a national minimum dataset, descriptive and regression analyses were conducted to identify levels and predictors of the use of the Access to Allied Psychological Services (ATAPS) program over a 2-year period following 2 major Australian bushfire and flood/cyclone disasters. RESULTS The bushfire disaster resulted in significantly greater and more enduring ATAPS service volume, while service delivery for both disasters peaked in the third quarter. Consumers affected by bushfires (IRR 1.51, 95% CI 1.20-1.89), diagnosed with depression (IRR 2.57, 95% CI 1.60-4.14), anxiety (IRR 2.06, 95% CI 1.21-3.49), or both disorders (IRR 2.15, 95% CI 1.35-3.42) utilized treatment at higher rates. CONCLUSIONS The substantial demand for primary mental health care services following major natural disasters can vary in magnitude and trajectory with disaster type. Disaster-specific ATAPS services provide a promising model to cater for this demand in primary care settings. Disaster type and need-based variables as drivers of ATAPS use intensity indicate an equitable level of service use in line with the program intention. Established service usage patterns can assist with estimating capacity requirements in similar disaster circumstances.

Examining Disaster Mental Health Workforce Capacity

Objective: We examined the capacity of the disaster mental health workforce in Victoria, Australia, to provide the three evidence-supported intervention types of psychological first aid, skills for psychological recovery, and intensive mental health treatments. Method: Utilizing data from a cross-professional, state-level disaster mental health workforce survey (n = 791), we developed composite capacity indicators (CCI) for each intervention and performed logistic regression analyses to examine key predictors of disaster mental health workforce capacity. Results: CCI profiles highlighted significant gaps in the disaster mental health capacity of Victorian providers, with only 32—42% able to deliver current best practice interventions. Key predictors of workforce capacity common and unique to interventions were highlighted. Conclusions: Key strategies to raise Victoria’s disaster mental health workforce capacity should focus on targeted multilevel training in best practice interventions, creation of practice opportunities, and structural provider support/engagement. CCIs focused on best practice interventions provide a methodology for rapid workforce capacity assessment that can facilitate disaster preparedness planning, capacity building, and delivery of quality disaster mental health services.