Sandra Diminic

Mental health service system improvement: Translating evidence into policy

Mental disorders (including alcohol and illicit drug use disorders) are prevalent and a leading cause of health-related disability. Improving access to, and the quality of, treatments for mental disorders is a global health challenge (Collins et al., 2011) with calls to use the evidence on effective interventions to scale up services to reduce the burden of mental disorders and develop more strategic and coordinated approaches to mental health planning and service delivery. In Australia nationally coordinated mental health reform commenced in 1992 and mental health was made a national health priority area in 1996. Despite over 20 years of reform, considerable public, professional and political concerns about deficiencies in mental health services remain (Senate Community Affairs Committee, 2011). Mental health reform has almost always been incremental and cyclical. Windows of opportunity open from time to time which allow change to occur (Kingdon, 1995). Often these windows open when there is a political imperative to ‘do something’, driven by a sense of crisis and an urgency to address a problem, especially when the problem and its consequences are being repeatedly highlighted in the media. A real or perceived crisis needing urgent attention has often been a driver of government decisions to undertake mental health reform in Australia. In the lead up to the 1992 launch of the National Mental Health Policy and the 1993 Commonwealth budget, the Human Rights and Equal Opportunity Commission inquiry (the Burdekin inquiry) was identifying and publicising major shortcomings in services. The 1998 Coalition reforms were preceded by the Port Arthur shootings and, although not found to be a result of a deficiency in mental health services, the tragedy focused attention on mental health issues in political circles and a need for services in the community. Prior to the Council of Australian Governments (COAG) National Action Plan on Mental Health in 2006, the findings of the Not for Service report by the Mental Health Council of Australia, Senate inquiries and the failures that occurred in the treatment of Cornelia Rau (an Australian with a severe mental illness who was unlawfully detained for 10 months as a suspected illegal immigrant) were all very prominent. There have been similar, well-publicised examples of service failure and personal tragedy, forcing a response from government at State and Territory levels. Incremental changes, adopted in response to a crisis, will lead to piecemeal, ad hoc reform. We have never used our understanding of the needs of the population in Australia to develop a comprehensive concept of what an efficient mental health service system, from prevention through to recovery, should look like. And when service models have been developed, we have never really articulated what the policy settings of governments needed to be, in order to bring that model into existence. There is a need for an approach to mental health reform in Australia that takes a long-term perspective, informed by evidence and that does not rely on ‘crisis’-driven, ad hoc changes to service delivery.

Frequency and quality of mental health treatment for affective and anxiety disorders among Australian adults.

Objectives: To describe the frequency, type and quality of mental health treatment among Australian adults with past‐year affective and/or anxiety disorders.

Mental and substance use disorders in Sub-Saharan Africa: predictions of epidemiological changes and mental health workforce requirements for the next 40 years.

The world is undergoing a rapid health transition, with an ageing population and disease burden increasingly defined by disability. In Sub-Saharan Africa the next 40 years are predicted to see reduced mortality, signalling a surge in the impact of chronic diseases. We modelled these epidemiological changes and associated mental health workforce requirements. Years lived with a disability (YLD) predictions for mental and substance use disorders for each decade from 2010 to 2050 for four Sub-Saharan African regions were calculated using Global Burden of Disease 2010 study (GBD 2010) data and UN population forecasts. Predicted mental health workforce requirements for 2010 and 2050, by region and for selected countries, were modelled using GBD 2010 prevalence estimates and recommended packages of care and staffing ratios for low- and middle-income countries, and compared to current staffing from the WHO Mental Health Atlas. Significant population growth and ageing will result in an estimated 130% increase in the burden of mental and substance use disorders in Sub-Saharan Africa by 2050, to 45 million YLDs. As a result, the required mental health workforce will increase by 216,600 full time equivalent staff from 2010 to 2050, and far more compared to the existing workforce. The growth in mental and substance use disorders by 2050 is likely to significantly affect health and productivity in Sub-Saharan Africa. To reduce this burden, packages of care for key mental disorders should be provided through increasing the mental health workforce towards targets outlined in this paper. This requires a shift from current practice in most African countries, involving substantial investment in the training of primary care practitioners, supported by district based mental health specialist teams using a task sharing model that mobilises local community resources, with the expansion of inpatient psychiatric units based in district and regional general hospitals.

Gender-related patterns and determinants of recent help-seeking for past-year affective, anxiety and substance use disorders: findings from a national epidemiological survey

AIMS To examine: (1) gender-specific determinants of help-seeking for mental health, including health professional consultation and the use of non-clinical support services and self-management strategies (SS/SM) and; (2) gender differences among individuals with unmet perceived need for care. METHOD Analyses focused on 689 males and 1075 females aged 16-85 years who met ICD-10 criteria for a past-year affective, anxiety or substance use disorder in an Australian community-representative survey. Two classifications of help-seeking for mental health in the previous year were created: (1) no health professional consultation or SS/SM, or health professional consultation, or SS/SM only, and; (2) no general practitioner (GP) or mental health professional consultation, or GP only consultation, or mental health professional consultation. Between- and within-gender help-seeking patterns were explored using multinomial logistic regression models. Characteristics of males and females with unmet perceived need for care were compared using chi-square tests. RESULTS Males with mental or substance use disorders had relatively lower odds than females of any health professional consultation (adjusted odds ratio [AOR] = 0.46), use of SS/SM only (AOR = 0.59), and GP only consultation (AOR = 0.29). Notably, males with severe disorders had substantially lower odds than females of any health professional consultation (AOR = 0.29) and GP only consultation (AOR = 0.14). Most correlates of help-seeking were need-related. Many applied to both genders (e.g., severity, disability, psychiatric comorbidity), although some were male-specific (e.g., past-year reaction to a traumatic event) or female-specific (e.g., past-year affective disorder). Certain enabling and predisposing factors increased the probability of health professional consultation for both genders (age 30+ years) or for males (unmarried, single parenthood, reliance on government pension). Males with unmet perceived need for care were more likely to have experienced a substance use disorder and to want medicine or tablets or social intervention, whereas their females peers were more likely to have experienced an anxiety disorder and to want counselling or talking therapy. For both genders, attitudinal/knowledge barriers to receiving the types of help wanted (e.g., not knowing where to get help) were more commonly reported than structural barriers (e.g., cost). CONCLUSIONS Findings suggest a need to address barriers to help-seeking in males with severe disorders, and promote GP consultation. Exploring gender-specific attitudinal/knowledge barriers to receiving help, and the types of help wanted, may assist in designing interventions to increase consultation. Mental health promotion/education efforts could incorporate information about the content and benefits of evidence-based treatments and encourage males to participate in other potentially beneficial actions (e.g., physical activity).

Males’ mental health disadvantage: An estimation of gender-specific changes in service utilisation for mental and substance use disorders in Australia

Background: Concerns about low levels of service utilisation for mental and substance use disorders in Australia – especially among males – have prompted targeted help-seeking and stigma-reduction initiatives. Resulting changes in service utilisation according to gender are unknown. We modelled the percentage of Australian males with a mental or substance use disorder who used services each year between 2006–2007 and 2011–2012, and the types of services they used, relative to females. Methods: Twelve-month prevalence of mental and substance use disorders, stratified by gender, was synthesised from existing estimates. The percentage of males and females with these disorders who used mental health services in each year from 2006–2007 to 2011–2012 was modelled from published programme activity data, supplemented by analyses of epidemiological survey data. Uncertainty analysis quantified the effects of sampling error and assumptions on the estimates. Results: Modelling showed a significant increase in the percentage of people with mental or substance use disorders who used services for their mental health – from 32.0% in 2006–2007 to 40.0% in 2011–2012 in males and from 45.1% in 2006–2007 to 54.6% in 2011–2012 in females. Growth was driven largely by uptake of private specialised services – males’ use of these services grew by 92.7% and females’ by 115.4%. There appeared to be a non-significant decrease in use of general practitioner-only mental health care for males (−17.9%), and a significant decrease in the same for females (−35.1%); however, some assumptions made in the modelling of general practitioner-only care require validation. In 2006–2007, the percentage of females treated was 40.9% higher than for males; in 2011–2012, it was 36.6% greater. Conclusions: Recently implemented initiatives have improved males’ likelihood of service utilisation, particularly their use of specialised mental health services. Although the gender gap may have narrowed, improving males’ access to services should remain a policy priority.

System-level intersectoral linkages between the mental health and non-clinical support sectors: a qualitative systematic review

Objectives: Concerns about fragmented mental health service delivery persist, particularly for people with severe and persistent mental illness. The objective was to review evidence regarding outcomes attributed to system-level intersectoral linkages involving mental health services and non-clinical support services, and to identify barriers and facilitators to the intersectoral linkage process. Methods: A systematic, qualitative review of studies describing attempts to coordinate the activities of multiple service agencies at the policy, program or organisational level was conducted. Electronic databases Medline, PsycINFO and EMBASE were searched via OVID from inception to July 2012. Results: Of 1593 studies identified, 40 were included in the review – 26 in adult and 14 in vulnerable youth populations. Identified mechanisms to promote positive system-level outcomes included: interagency coordinating committees or intersectoral/interface workers engaged in joint service planning; formalised interagency collaborative agreements; a single care plan in which the responsibilities of all agencies are described; cross-training of staff to ensure staff culture, attitudes, knowledge and skills are complementary; service co-location; and blended funding initiatives to ensure funding aligns with program integration. Identified barriers included: adequacy of funding and technology; ensuring realistic workloads; overcoming ‘turf issues’ between service providers and disagreements regarding areas of responsibility; ensuring integration strategies are implemented as planned; and maintaining stakeholder enthusiasm. Conclusions: System-level intersectoral linkages can be achieved in various ways and are associated with positive clinical and non-clinical outcomes for services and clients. Some linkage mechanisms present greater implementation challenges than others (e.g. major technology upgrades or co-location in geographically remote areas). In some instances (e.g. co-location) alternative options may achieve equivalent benefits. Publication bias could not be discounted, and studies using high-quality research designs are scarce. The limited information base applicable to system-level integration argues strongly for the evaluation of the models that evolve in the rollout of the national Partners in Recovery initiative.

Understanding service demand for mental health among Australians aged 16 to 64 years according to their possible need for treatment.

Background: To inform decisions about mental health resource allocation, planners require reliable estimates of people who report service demand (i.e. people who use or want mental health services) according to their level of possible need. Methods: Using data on 6915 adults aged 16–64 years in Australia’s 2007 National Survey of Mental Health and Wellbeing, we examined past-year service demand among respondents grouped into four levels of possible need: (a) 12-month mental disorder; (b) lifetime but no 12-month mental disorder; (c) any other indicator of possible need (12-month symptoms or reaction to stressful event, or lifetime hospitalisation); (d) no indicator of possible need. Multivariate logistic regression analyses examined correlates of service demand, separately for respondents in each of levels 1–3. Results: Sixteen per cent of Australian adults reported service demand, of whom one-third did not meet criteria for a 12-month mental disorder (equivalent to 5.7% of the adult population). Treatment patterns tended to follow a gradient defined by level of possible need. For example, service users with a 12-month disorder received, on average, 1.6–3.9 times more consultations than their counterparts in other levels of possible need, and had 1.9–2.2 times higher rates of psychologist consultation. Service users with a lifetime but not 12-month disorder or any other indicator of need consumed a similar average number of services to people with mild 12-month mental disorders, but received relatively fewer services involving the mental health sector. Service demand was associated with increased suicidality and psychological distress in all levels of possible need examined, and with poorer clinical and functional status for those with 12-month or lifetime disorders. Conclusions: Many Australians reporting service demand do not meet criteria for a current mental disorder, but may require services to maintain recovery following a past episode or because they are experiencing symptoms and significant psychological distress.

Predictors of mental health-related acute service utilisation and treatment costs in the 12 months following an acute psychiatric admission

Objective: A key step in informing mental health resource allocation is to identify the predictors of service utilisation and costs. This project aims to identify the predictors of mental health-related acute service utilisation and treatment costs in the year following an acute public psychiatric hospital admission. Method: A dataset containing administrative and routinely measured outcome data for 1 year before and after an acute psychiatric admission for 1757 public mental health patients was analysed. Multivariate regression models were developed to identify patient- and treatment-related predictors of four measures of service utilisation or cost: (a) duration of index admission; and, in the year after discharge from the index admission (b) acute psychiatric inpatient bed-days; (c) emergency department (ED) presentations; and (d) total acute mental health service costs. Split-sample cross-validation was used. Results: A diagnosis of psychosis, problems with living conditions and prior acute psychiatric inpatient bed-days predicted a longer duration of index admission, while prior ED presentations and self-harm predicted a shorter duration. A greater number of acute psychiatric inpatient bed-days in the year post-discharge were predicted by psychosis diagnosis, problems with living conditions and prior acute psychiatric inpatient admissions. The number of future ED presentations was predicted by past ED presentations. For total acute care costs, diagnosis of psychosis was the strongest predictor. Illness acuity and prior acute psychiatric inpatient admission also predicted higher costs, while self-harm predicted lower costs. Discussion: The development of effective models for predicting acute mental health treatment costs using existing administrative data is an essential step towards a workable activity-based funding model for mental health. Future studies would benefit from the inclusion of a wider range of variables, including ethnicity, clinical complexity, cognition, mental health legal status, electroconvulsive therapy, problems with activities of daily living and community contacts.

Global Epidemiology and Burden of Schizophrenia: Findings From the Global Burden of Disease Study 2016

Introduction The global burden of disease (GBD) studies have derived detailed and comparable epidemiological and burden of disease estimates for schizophrenia. We report GBD 2016 estimates of schizophrenia prevalence and burden of disease with disaggregation by age, sex, year, and for all countries. Method We conducted a systematic review to identify studies reporting the prevalence, incidence, remission, and/or excess mortality associated with schizophrenia. Reported estimates which met our inclusion criteria were entered into a Bayesian meta-regression tool used in GBD 2016 to derive prevalence for 20 age groups, 7 super-regions, 21 regions, and 195 countries and territories. Burden of disease estimates were derived for acute and residual states of schizophrenia by multiplying the age-, sex-, year-, and location-specific prevalence by 2 disability weights representative of the disability experienced during these states. Findings The systematic review found a total of 129 individual data sources. The global age-standardized point prevalence of schizophrenia in 2016 was estimated to be 0.28% (95% uncertainty interval [UI]: 0.24-0.31). No sex differences were observed in prevalence. Age-standardized point prevalence rates did not vary widely across countries or regions. Globally, prevalent cases rose from 13.1 (95% UI: 11.6-14.8) million in 1990 to 20.9 (95% UI: 18.5-23.4) million cases in 2016. Schizophrenia contributes 13.4 (95% UI: 9.9-16.7) million years of life lived with disability to burden of disease globally. Conclusion Although schizophrenia is a low prevalence disorder, the burden of disease is substantial. Our modeling suggests that significant population growth and aging has led to a large and increasing disease burden attributable to schizophrenia, particularly for middle income countries.

Estimating service demand for respite care among informal carers of people with psychological disabilities in Australia.

Objective: To estimate service demand (willingness to seek or use services) for respite care among informal, primary carers of people with a psychological disability and to describe their characteristics.