Developing Clinical Practice Guidelines for violence risk assessment in mental health triage : a systematic review

Background : On a global level, there is a growing trend to utilise mental health triage service systems as a way of providing consumers with access to 24 hour mental health care. At present, violence risk assessment in mental health triage lacks a suitable evidence base and clear guidelines. This presentation provides an overview of a Clinical Practice Guideline for violence risk assessment at point of entry to health services.
Aims : The objective of this study was to develop Clinical Practice Guidelines for violence risk assessment in mental health triage, and to pilot test the Clinical Guidelines in two major hospitals in Melbourne.
Method : The method employed in the study was a systematic review, as per the Australian National Health and Medical Research Council’s methodology for developing Clinical Guidelines. Research was conducted at the Royal Melbourne Hospital and the Alfred Hospital to establish the utility of the Guideline in practice.
Results : The systematic review established the highest level of evidence for violence risk assessment. Clinical Practice Guidelines for mental health triage were developed from these findings.
Conclusions : Evidence based Clinical Guidelines maximise the potential for creating safer outcomes for consumers, families/carers, and health care workers.

Practice into theory : working collaboratively with clinicians to articulate mental health triage practice

Learning objectives: To contribute to mental health nurses understanding and knowledge of mental health triage practice through the presentation of current research findings on the topic. A specific focus of the paper will be an overview of how mental health triage practice differs across the lifespan.

Mental health triage is a highly specialised area of clinical practice for mental health nursing that is in its infancy in terms of articulating practice and theory. This paper addresses the conference theme of mental health nursing practice: new roles, new challenges by presenting the findings of a qualitative research project that investigated mental health triage/duty/intake practices across the five community mental health agencies of The Alfred Hospital, Melbourne. The overall aim of the project was to work collaboratively with clinicians to further develop the quality and consistency of mental health triage, duty, and intake clinical practice across all arms of Alfred Psychiatry. The project was designed to facilitate the expansion of the mental health triage knowledge base, and thus contribute to the further development of triage clinical practice. One of the unique aspects of the project was its triangulation across the adult triage service (acute), the two Continuing Care Teams, and the specialist psychiatric services such as the Child and Adolescent Mental Health Service, the Homeless and Outreach Psychiatric Service, and the Mobile Aged Psychiatric Service. The project employed focus group method to collect in-depth, qualitative data. A series of nine focus groups were conducted at each site, which concentrated on eliciting data on the core areas of mental health triage practice such as telephone consultation skills, mental status examination, risk assessment, decision-making, negotiation, crisis assessment, secondary consultation, and documentation. The investigation produced a considerable amount of high quality, in-depth data that was analysed using content analysis methods. The project produced data that will make a significant contribution to the expanding body of knowledge on mental health triage practice.

Assessing cost-effectiveness in mental health: helping policy-makers prioritize and plan health services

Objective: We assessed, from a health sector perspective, options for change that could improve the efficiency of Australia's current mental health services by directing available resources toward 'best practice' cost-effective services.

Method: We summarize cost-effectiveness results of a range of interventions for depression, schizophrenia, attention deficit hyperactivity disorder and anxiety disorders that have been presented in previous papers in this journal. Recommendations for change are formulated after taking into account 'second-filter criteria' of equity, feasibility of implementing change, acceptability to stakeholders and the strength of the evidence. In addition, we estimate the impact on total expenditure if the recommended mental health interventions for depression and schizophrenia are to be implemented in Australia.

Results: There are cost-effective treatment options for mental disorders that are currently underutilized (e.g. cognitive–behavioural therapy (CBT) for depression and anxiety, bibliotherapy for depression, family interventions for schizophrenia and clozapine for the worst course of schizophrenia). There are also less cost-effective treatments in current practice (e.g. widespread use of olanzapine and risperidone in the treatment of established schizophrenia and, within those atypicals, a preference for olanzapine over risperidone). Feasibility of funding mechanisms and training of staff are the main second-filter issues for CBT and family interventions. Acceptability to various stakeholders is the main barrier to implementation of more cost-effective drug treatment regimens. More efficient drug intervention options identified for schizophrenia would cost A$68 million less than current practice. These savings would more than cover the estimated A$36M annual cost of delivering family interventions to the 51% of people with schizophrenia whom we estimated to be eligible and this would lead to an estimated 12% improvement in their health status. Implementing recommended strategies for depression would cost A$121M annually for the 24% of people with depression who seek care currently, but do not receive an evidence-based treatment.

Conclusions: Despite considerable methodological problems, a range of cost-effective and less cost-effective interventions for major mental disorders can be discerned. The biggest hurdle to implementation of more efficient mental health services is that this change would require reallocation of funds between interventions, between disorders and between service providers with different funding mechanisms.

Subjective wellbeing in Australian families of Holocaust survivors

This thesis explored the idea that trauma experienced by Holocaust survivors has been transferred to their children and grandchildren. Findings provided evidence for an ' intergenerational transmission of trauma, revealing children of two Holocaust survivors to be particularly at risk. The transmission oftrauma was best explained through an attachment model.

Mental health, criminal justice and culture : some ways forward?

Objective: This paper aims to offer an overview of the mental health needs of Indigenous men and women in the criminal justice system and how Indigenous cultural perspectives on mental health might infl uence forensic mental health service provision.
Conclusion: There is a need for both mental health and criminal justice agencies to collaborate more closely in developing new models of service provision that incorporate Indigenous perspectives on social and emotional wellbeing, recognize culturally specifi c mental health risk and protective factors in relation to prevention, early intervention and treatment, and take advantage of the opportunities for treatment that arise in the context of criminal justice system intervention.

Providing quality mental health nursing in primary health care settings in Kenya : A discussion paper.

Kenya, a country of 38 million people in East Africa has about 75 Psychiatrists and 500 Psychiatric Nurses, the majority work in the private sector and mainly in urban areas. Mental illness is common in Kenya, however, specialist services are sparse and primary care struggles to cope, and this has been worsened by general health programs which have been slow to appreciate the significance of mental health. The World Health Organisation recommends that provision of good quality mental health care does not only involve increasing the number of health workers but changing the skill mix and developing new competencies among existing workers. Successful implementation of mental, neurological and substance abuse disorder services in Kenya will depend on nurses, who constitute majority of the workforce located in provinces, districts and community clinics.

This discussion paper will address s key workforce issues affecting the up-scaling of mental health services, and the delivery of quality mental health nursing care in primary health care settings in Kenya. Strategies to develop skills and competencies of new and existing personnel will be discussed.

Cause and effect in studies on unemployment, mental health and suicide: a meta-analytic and conceptual review

Background There are ongoing questions about whether unemployment has causal effects on suicide as this relationship may be confounded by past experiences of mental illness. The present review quantified the effects of adjustment for mental health on the relationship between unemployment and suicide. Findings were used to develop and interpret likely causal models of unemployment, mental health and suicide. Method A random-effects meta-analysis was conducted on five population-based cohort studies where temporal relationships could be clearly ascertained. Results Results of the meta-analysis showed that unemployment was associated with a significantly higher relative risk (RR) of suicide before adjustment for prior mental health [RR 1.58, 95% confidence interval (CI) 1.33–1.83]. After controlling for mental health, the RR of suicide following unemployment was reduced by approximately 37% (RR 1.15, 95% CI 1.00–1.30). Greater exposure to unemployment was associated with higher RR of suicide, and the pooled RR was higher for males than for females. Conclusions Plausible interpretations of likely pathways between unemployment and suicide are complex and difficult to validate given the poor delineation of associations over time and analytic rationale for confounder adjustment evident in the revised literature. Future research would be strengthened by explicit articulation of temporal relationships and causal assumptions. This would be complemented by longitudinal study designs suitable to assess potential confounders, mediators and effect modifiers influencing the relationship between unemployment and suicide.

Fair relationships and policies to support family day care educators’ mental health: a qualitative study

High quality child care is a population health investment that relies on the capacity of providers. The mental health and wellbeing of child care educators is fundamental to care quality and turnover, yet sector views on the relationship between working conditions and mental health and wellbeing are scarce. This paper examines child care educators' and sector key informants' perspectives on how working in family day care influences educator's mental health and wellbeing.

An integrated workplace mental health intervention in a policing context: protocol for a cluster randomised control trial

BACKGROUND: In this paper, we present the protocol for a cluster-randomised trial to evaluate the implementation and effectiveness of a workplace mental health intervention in the state-wide police department of the south-eastern Australian state of Victoria. n. The primary aims of the intervention are to improve psychosocial working conditions and mental health literacy, and secondarily to improve mental health and organisational outcomes.

METHODS/DESIGN: The intervention was designed collaboratively with Victoria Police based on a mixed methods pilot study, and combines multi-session leadership coaching for the senior officers within stations (e.g., Sergeants, Senior Sergeants) with tailored mental health literacy training for lower and upper ranks. Intervention effectiveness will be evaluated using a two-arm cluster-randomised trial design, with 12 police stations randomly assigned to the intervention and 12 to the non-intervention/usual care control condition. Data will be collected from all police members in each station (estimated at >20 per station). Psychosocial working conditions (e.g., supervisory support, job control, job demands), mental health literacy (e.g., knowledge, confidence in assisting someone who may have a mental health problem), and mental health will be assessed using validated measures. Organisational outcomes will include organisational depression disclosure norms, organisational cynicism, and station-level sickness absence rates. The trial will be conducted following CONSORT guidelines. Identifying data will not be collected in order to protect participant privacy and to optimise participation, hence changes in primary and secondary outcomes will be assessed using a two-sample t-test comparing summary measures by arm, with weighting by cluster size.

DISCUSSION: This intervention is novel in its integration of stressor-reduction and mental health literacy-enhancing strategies. Effectiveness will be rigorously evaluated, and if positive results are observed, the intervention will be adapted across Victoria Police (total employees ~16,500) as well as possibly in other policing contexts, both nationally and internationally.

Matrix Support in Mental Health: Achievements and Limits in Primary Health Care

Changes in mental health care in the city of Fortaleza (Northeastern Brazil) have a recent historical and political process. Compared to other municipalities of the State of Ceara, which in the early 1990s were already pioneers in the process, Fortaleza has not implemented the changes due to the interests of psychiatric hospitals, of psychiatric outpatient clinics of the public network, and because of the difficulty in managing the new mental health devices and equipment present in Primary Care. In the municipality, the reorganization of mental health actions and services has required that the Primary Care Network faces the challenge of assisting mental health problems with the implementation of Matrix Support. In light of this context, we aimed to evaluate Matrix Support in mental health in Primary Care Units and to identify achievements and limitations in the Primary Care Units with Matrix Support. This study used a qualitative approach and was carried out by means of a case study. We interviewed twelve professionals from the Family Health Teams of four Units with implemented Matrix Support. The analysis of the information reveals that access, decision making, participation and the challenges of implementing Matrix Support are elements that are, in a dialectic way, weak and strong in the reorganization of services and practices. The presence of Matrix Support in Primary Care highlights the proposal of dealing with mental health within the network in the municipality. The process has not ended. Mobilization, awareness-raising and qualification of Primary Care have to be enhanced constantly, but implementation has enabled, to the service and professionals, greater acceptance of mental health in Primary Care.

The association between mental health and cigarette smoking in active duty military members

Previous research has shown an association between mental health status and cigarette smoking. This study examined four specific mental health predictors and the outcome variable any smoking, defined as smoking one or more cigarettes in the past 30 days. The population included active duty military members serving in the United States Army, Air Force, Navy and Marine Corps. The data was collected during the 2005 Department of Defense Survey of Health Related Behaviors Among Active Duty Military Personnel, a component of the Defense Lifestyle Assessment Program. The sample size included 13,603 subjects. This cross sectional prevalence study consisted of descriptive statistics, univariate analysis, and multivariate logistic regression analysis of the four mental health predictors and the any smoking outcome variable. Multivariate adjustment showed an association between the four mental health predictors and any smoking. This association is consistent with previous literature and can help guide public health officials in the development of smoking prevention and cessation programs.^

Work instability versus mental health

This contribution is part of a research on guidance and employment in La Plata , province of Buenos Aires (Argentina) undertaken jointly by the Chairs of Preventive Psychology and Vocational Guidance, both pertaining to the course of studies for Psychology at the National University of La Plata. This research is based on four axes, namely, education-work-social policies-health. This paper shall focus around the health axis, which is not provided with placement and employment services. Some unsystematical guidance experiences from the services of Adolescence and Mental Health are currently under way in the area. Research points to the existence of new demands of psychological treatment from a population ("the new poor") afraid of losing their jobs -or even unemployed- who was not in the habit of going to the public hospital. In the casuistry explored here, people afraid of losing their jobs present more psychosomatic complexities. Local population is also analysed and the said analysis is linked with several national and international research projects.

Work instability versus mental health

This contribution is part of a research on guidance and employment in La Plata , province of Buenos Aires (Argentina) undertaken jointly by the Chairs of Preventive Psychology and Vocational Guidance, both pertaining to the course of studies for Psychology at the National University of La Plata. This research is based on four axes, namely, education-work-social policies-health. This paper shall focus around the health axis, which is not provided with placement and employment services. Some unsystematical guidance experiences from the services of Adolescence and Mental Health are currently under way in the area. Research points to the existence of new demands of psychological treatment from a population ("the new poor") afraid of losing their jobs -or even unemployed- who was not in the habit of going to the public hospital. In the casuistry explored here, people afraid of losing their jobs present more psychosomatic complexities. Local population is also analysed and the said analysis is linked with several national and international research projects.