Meeting in the middle: Improving communication in primary health care consultations with people with an intellectual disability

The increased presence and participation in Australian society of people with an intellectual disability provides challenges for the provision of primary health care. General practitioners (GPs) identify themselves as ill equipped to provide for this heterogeneous population. A major obstacle to the provision of appropriate health care is seen as inadequate communication between the GP and the person with an intellectual disability, who may or may not be accompanied by a carer or advocate. This qualitative study in which five GPs, three people with intellectual disability, seven carers and two advocates (parent and friend) were interviewed was conducted in Brisbane, Australia. The aim was to better understand the factors that have an impact upon the success of communication in a medical consultation. Findings suggested that GPs were concerned with the aspects of communication difficulties which influenced their ability to adequately diagnose, manage and inform patients. Implications for practice management were also identified. People with intellectual disability reported frustration when they felt that they could not communicate adequately with the GP and annoyance when they were not included in the communication exchange. Carers were strong advocates for the person with intellectual disability, but indicated insufficient skill and knowledge to provide the level of assistance required in the consultation. The outcome was a model of cooperation that outlined the responsibilities of all players in the medical encounter, prior to, during and after the event.

A transdisciplinary approach to adolescent forensic mental health

Objective: To examine new strategies which may be implemented to address the significant mental health and substance abuse problems of young people within the juvenile justice system. Method: Wide-ranging literature review of mental health problems within the juvenile justice population is given, illustrating the high prevalence of mental health problems within this cohort of young people. Reference is made to the differing demographics and agendas of the American justice system compared to that found in Australia. Results: It is suggested that new initiatives stemming from quality Australian studies are required in order to facilitate reform within adolescent forensic mental health. Psychiatrists need to be at the forefront of innovative policy delivery within the juvenile justice system. Conclusions: A transdisciplinary approach is required to meet the changing needs of young people within the juvenile justice system. Such a system of care recognizes that these young people and their families have multiple needs that cross traditional boundaries and a collaborative approach across agencies is essential at both the policy and practical level. Psychiatrists have an important role to play in the development of these services. A systemic process to address such needs is offered.

The International Consortium on Mental Health Policy and Services: objectives, design and project implementation

The concept of the burden of disease, introduced and estimated for a broad range of diseases in the World Bank report of 1993 illustrated that mental and neurological disorders not only entail a higher burden than cancer, but are responsible, in developed and developing countries, for more than 15% of the total burden of all diseases. As a consequence, over the past decade, mental disorders have ranked increasingly highly on the international agenda for health. However, the fact that mental health and nervous system disorders are now high on the international health agenda is by no means a guarantee that the fate of patients suffering from these disorders in developing countries will improve. In most developing countries the treatment gap for mental and neurological disorders is still unacceptably high. To address this problem, an international network of collaborating institutions in low-income countries has been set up. The establishment and the achievements of this network-the International Consortium on Mental Health Policy and Services-are reported. Sixteen institutions in developing countries collaborate (supported by a small number of scientific resource centres in industrialized nations) in projects on applied mental health systems research. Over a two-year period, the network produced the key elements of a national mental health policy; provided tools and methods for assessing a country's current mental health status (context, needs and demands, programmes, services and care and outcomes); established a global network of expertise, i.e., institutions and experts, for use by countries wishing to reform their mental health policy, services and care; and generated guidelines and examples for upgrading mental health policy with due regard to the existing mental health delivery system and demographic, cultural and economic factors.

Adult mental health needs and expenditure in Australia

Background Relatively little international work has examined whether mental health resource allocation matches need. This study aimed to determine whether adult mental health resources in Australia are being distributed equitably. Method Individual measures of need were extrapolated to Australian Areas, and Area-based proxies of need were considered. Particular attention was paid to the prevalence of mental health problems, since this is arguably the most objective measure of need. The extent to which these measures predicted public sector, private sector and total adult mental health expenditure at an Area level was examined. Results In the public sector, 41.6% of expenditure variation was explained by the prevalence of affective disorders, personality disorders, cognitive impairment and psychosis, as well as the Area's level of economic resources and State/Territory effects. In the private sector, 72.4% of expenditure variation was explained by service use and State/Territory effects (with an alternative model incorporating service use and State/Territory supply of private psychiatrists explaining 69.4% of expenditure variation). A relatively high proportion (58.7%) of total expenditure variation could be explained by service utilisation and State/Territory effects. Conclusions For services to be delivered equitably, the majority of variation in expenditure would have to be accounted for by appropriate measures of need. The best model for public sector expenditure included an appropriate measure of need but had relatively poor explanatory power. The models for private sector and total expenditure had greater explanatory power, but relied on less appropriate measures of need. It is concluded that mental health services in Australia are not yet being delivered equitably.

The Mental Health Policy Template: Domains and elements for mental health policy formulation

Mental disorders are a major and rising cause of disease burden in all countries. Even when resources are available, many countries do not have the policy and planning frameworks in place to identify and deliver effective interventions. The World Health Organization (WHO) and the World Bank have emphasized the need for ready access to the basic tools for mental health policy formulation, implementation and sustained development. The Analytical Studies on Mental Health Policy and Service Project, undertaken in 1999-2001 by the International Consortium for Mental Health Services and funded by the Global Forum for Health Research aims to address this need through the development of a template for mental health policy formulation. A mental health policy template has been developed based on an inventory of the key elements of a successful mental health policy. These elements have been validated against a review of international literature, a study of existing mental health policies and the results of extensive consultations with experts in the six WHO regions of the world. The Mental Health Policy Template has been revised and its applicability will be tested in a number of developing countries during 2001-2002. The Mental Health Policy Template and the work of the Consortium for Mental Health Services will be presented and the future role of the template in mental health policy development and reform in developing countries will be discussed.

Constraints to organizational learning during major change at a mental health services facility

This paper explains what happened during a three years long qualitative study at a mental health services organization. The study focuses on differences between espoused theory and theory in use during the implementation of a new service delivery model. This major organizational change occurred in a National policy environment of major health budget cutbacks. Primarily as a result of poor resourcing provided to bring about policy change and poor implementation of a series of termination plans, a number of constraints to learning contributed to the difficulties in implementing the new service delivery model. The study explores what occurred during the change process. Rather than blame participants of change for the poor outcomes, the study is set in a broader context of a policy environment—that of major health cutbacks.

Assessing cost-effectiveness in mental health: vocational rehabilitation for schizophrenia and related conditions

Objective: Existing evidence suggests that vocational rehabilitation services, in particular individual placement and support (IPS), are effective in assisting people with schizophrenia and related conditions gain open employment. Despite this, such services are not available to all unemployed people with schizophrenia who wish to work. Existing evidence suggests that while IPS confers no clinical advantages over routine care, it does improve the proportion of people returning to employment. The objective of the current study is to investigate the net benefit of introducing IPS services into current mental health services in Australia. Method: The net benefit of IPS is assessed from a health sector perspective using cost-benefit analysis. A two-stage approach is taken to the assessment of benefit. The first stage involves a quantitative analysis of the net benefit, defined as the benefits of IPS (comprising transfer payments averted, income tax accrued and individual income earned) minus the costs. The second stage involves application of 'second-filter' criteria (including equity, strength of evidence, feasibility and acceptability to stakeholders) to results. The robustness of results is tested using the multivariate probabilistic sensitivity analysis. Results: The costs of IPS are $A10.3M (95% uncertainty interval $A7.4M-$A13.6M), the benefits are $A4.7M ($A3.1M-$A6.5M), resulting in a negative net benefit of $A5.6M ($A8.4M-$A3.4M). Conclusions: The current analysis suggests that IPS costs are greater than the monetary benefits. However, the evidence-base of the current analysis is weak. Structural conditions surrounding welfare payments in Australia create disincentives to full-time employment for people with disabilities.

Telemedicine for rural and remote child and youth mental health services

The E-Child and Youth Mental Health Service was designed to provide children and adolescents in Queensland with access to specialist mental health consultations using telemedicine. A project officer provided a single point of contact for referral management and clinic coordination, thereby reducing barriers of access to the service. Over a six-month period from November 2004, 42 point-to-point videoconferences were conducted to nine sites in Queensland. Three multipoint conferences were also conducted. Eleven videoconferences (24%) were arranged for administrative purposes, and 34 (76%) were conducted for the delivery of clinical services (30 patients). The referral and consultation activity suggests an improvement in the capacity of rural and remote mental health service providers to deliver specialist services for children and adolescents.

Lessons from the National Mental Health Integration Program

Three projects were funded under the national Mental Health Integration Program (MHIP) in 1999, each of which employed a different model aimed at improving linkages between disparate parts of the mental health system. A national evaluation framework guided local evaluations of these projects, and this paper presents a synthesis of the findings. For providers, the projects improved working relationships, created learning opportunities and increased referral and shared care opportunities. For consumers and carers, the projects resulted in a greater range of options and increased continuity of care. For the wider system, the projects achieved significant structural and cultural change. Cost-wise, there were no increases in expenditure, and even some reductions. Many of the lessons from the projects (and their evaluations) may be generalised to other mental health settings and beyond.

The use of email in a child and adolescent mental health service: are staff ready?

All staff members of a child and adolescent mental health service were invited to participate in a survey about the use of email. Sixty-two of the 105 staff members responded to the survey, a participation rate of 59%. Of the respondents, 32 were allied health staff, 10 were nurses, seven were administrative staff, six were medical staff, three were operational staff and four were acting in a combination of these roles. The respondents reported extensive work-related email usage and considered that they were confident in using email despite low levels of training. However, they did not feel that they understood the legal and ethical issues involved. Furthermore, there was limited incorporation of email into standard record keeping. The majority of respondents thought that increased use of email would lead to a greater workload, a consequence they considered would probably increase over time. Many commented on the quick and practical use of this medium, but were wary about using email with individuals outside the service organization, especially if it were to contain clinical material. There was low use of email directly with clients, and clinicians were ambivalent about incorporating email into therapy. The results suggest that it is timely to consider the utility and appropriateness of email communication with clients and external service providers, and to formulate guidelines and procedures to ensure the confidentiality of client information and the safety of clients and staff.

Mental health literacy in rural Queensland: results of a community survey

Objectives: The aim of this study was to assess the awareness of, and attitudes to, mental health issues in rural dwelling Queensland residents. A secondary objective was to provide baseline data of mental health literacy prior to the implementation of Australian Integrated Mental Health Initiative - a health promotion strategy aimed at improving the health outcomes of people with chronic or recurring mental disorders. Method: In 2004 a random sample of 2% (2132) of the estimated adult population in each of eight towns in rural Queensland was sent a postal survey and invited to participate in the project. A series of questions were asked based on a vignette describing a person suffering major depression. In addition, questions assessed respondents' awareness and perceptions of community mental health agencies. Results: Approximately one-third (36%) of those surveyed completed and returned the questionnaire. While a higher proportion of respondents (81%) correctly identified and labelled the problem in the vignette as depression than previously reported in Australian community surveys, the majority of respondents (66%) underestimated the prevalence of mental health problems in the community. Furthermore, a substantial number of respondents (37%) were unaware of agencies in their community to assist people with mental health issues while a majority of respondents (57.6%) considered that the services offered by those agencies were poor. Conclusion: While mental health literacy in rural Queensland appears to be comparable to other Australian regions, several gaps in knowledge were identified. This is in spite of recent widespread coverage of depression in the media and thus, there is a continuing need for mental health education in rural Queensland.

Do adults in contact with Australia's public sector mental health services get better

This paper describes the outcomes of episodes of care for adults in public sector mental health services across Australia, with a view to informing the debate on service quality. Health of the Nation Outcome Scales (HoNOS) change scores and effect sizes were calculated for 14,659 acute inpatient episodes and 23,692 community episodes. The results showed that people in contact with public sector mental health services generally do get better, although the magnitude of improvement depends on the setting and episode type. This confirmatory finding is particularly positive, given current community concerns about the quality and effectiveness of mental health services.

Feel it and deal with it: mental health practitioners' experiences of exposure to the trauma of survivor clients

Empathic engagement by the trauma therapist with another person's traumatic experiences is believed to create risks for the helping professional. Much attention has been focused upon the mental health professional experiencing symptoms of distress as a result of their exposure to the material of clients who survive traumatic incidents. This thesis contains the findings of a qualitative study that centres on a group of male mental health professionals and their experiences of exposure to the trauma material of survivor clients. The participants of the study practise within an internal Employee Assistance Program that provides, among other duties, a 24 hour, 7 day response to critical incidents to a heavy transport industry. Using semi-structured, in-depth interviews, the effects on the trauma therapists are explored by analysing their reactions to their survivor clients' accounts, the impact of these experiences upon their psychological schema, the organisational culture in which they practise and its influence upon their experiences and the methods participants use to cope with the psychological effects of exposure to trauma material. Participants' experiences are closely examined for critical comparisons with vicarious traumatization. Therapists' responses reveal their continued ability and motivation to empathically engage with the trauma material of survivor clients despite the potential risks.