Obligatory dangerousness criteria in the involuntary commitment and treatment provisions of Australian mental health legislation

Abstract Objective Involuntary commitment and treatment (IC&T) of people affected by mental illness may have reference to considerations of dangerousness and/or need for care. While attempts have been made to classify mental health legislation according to whether IC&T has obligatory dangerousness criteria, there is no standardised procedure for making classification decisions. The aim of this study was to develop and trial a classification procedure and apply it to Australia's mental health legislation. Method We developed benchmarks for ‘need for care’ and ‘dangerousness’ and applied these benchmarks to classify the mental health legislation of Australia's 8 states and territories. Our focus was on civil commitment legislation rather than criminal commitment legislation. Results One state changed its legislation during the course of the study resulting in two classificatory exercises. In our initial classification, we were able to classify IC&T provisions in legislation from 6 of the 8 jurisdictions as being based on either ‘need for care’ or ‘dangerousness’. Two jurisdictions used a terminology that was outside the established benchmarks. In our second classification, we were also able to successfully classify IC&T provisions in 6 of the 8 jurisdictions. Of the 6 Acts that could be classified, all based IC&T on ‘need for care’ and none contained mandatory ‘dangerousness’ criteria. Conclusions The classification system developed for this study provided a transparent and probably reliable means of classifying 75% of Australia's mental health legislation. The inherent ambiguity of the terminology used in two jurisdictions means that further development of classification may not be possible until the meaning of the terms used has been addressed in case law. With respect to the 6 jurisdictions for which classification was possible, the findings suggest that Australia's mental health legislation relies on ‘need for care’ and not on ‘dangerousness’ as the guiding principle for IC&T. Keywords: Involuntary commitment; Mental health legislation; Dangerousness; Australia

Improving collaboration between private psychiatrists, the public mental health sector and general practitioners : evaluation of the Partnership Project

Objectives: We describe the evaluation of the Partnership Project, which was designed to improve linkages between public and private sector mental health services. We consider the Project's key elements: a Linkage Unit, designed to improve collaborative arrangements for consumers and promote systems-level and cultural change; and the expansion of private psychiatrists' roles to include supervision and training, case conferencing and secondary consultation. The evaluation aimed to describe the impacts and outcomes of these elements.

Method: The evaluation used de-identified data from the Linkage Unit database, the Project's billing system, and the Health Insurance Commission (HIC). It drew on consultations with key stakeholders (semistructured interviews with 36 key informants, and information from a forum attended by over 40 carers and a meeting of five public sector and three private sector psychiatrists) and a series of case studies.

Results: The Linkage Unit facilitated 224 episodes of collaborative care, many of which had positive outcomes for providers, consumers and carers. It had a significant impact at a systems level, raising consciousness about collaboration and influencing procedural changes. Thirty-two private psychiatrists consented to undertaking expanded roles, and the Project was billed $78 032 accordingly. Supervision and training were most common, involving 16 psychiatrists and accounting for approximately 80% of the total hours and cost. Commonwealth expenditure on private psychiatrists' participation in the expanded roles was not associated with a reduction in benefits paid by the HIC. Key informants were generally positive about the expanded roles.

Conclusions: The Project represented a considered, innovative approach to dealing with poor collaboration between the public mental health sector, private psychiatrists and GPs. The Linkage Unit achieved significant systems-level and cultural change, which has the potential to be sustained. Expanded roles for private psychiatrists, particularly supervision and training, may improve collaboration, and warrant further exploration in terms of costs and benefits.

Improving the outcomes of the South Australian mental health court: an examination of the predictors of success

 This thesis investigated the role that mental health problem-solving courts play within the Australian criminal justice system. It demonstrated that these courts can be an effective solution in the delivery of effective justice responses to vulnerable offenders, if administered in a manner that focuses on risk rather than clinical variables.

Mental health diversion courts: a two year recidivism study of a South Australian mental health court program.

The need to develop specialized judicial processes to deal with offenders with mental illnesses is now widely recognized and has led to the introduction of mental health court diversion programs around the world. At present, however, there is only limited evidence from which to assess the impact of these initiatives. This paper describes the South Australian model of diversion, with specific reference to the relationship between identified participant characteristics, program compliance rates, and re-offending outcomes. The results of a two-year recidivism study suggest that involvement with the program has a positive impact on recidivism, but that this is independent from the individual's level of success in the program. Lower risk offenders were more likely to achieve successful outcomes than those in the higher risk categories. The implications of these results, as well the factors that might inform the ongoing development of mental health court programs, are discussed.

Work activities of occupational therapists in Australian mental health services

The aim of this study was to obtain a profile of occupational therapists’ work activities in contemporary Australian mental health services so as to better understand the specific contribution of this profession. The study also aimed to determine whether or not actual work activity was congruent with the preferred roles of occupational therapists. A cross-sectional survey of 196 occupational therapists working in mental health was conducted. For the purposes of the study, a new instrument was developed that evaluated both actual and preferred work roles in four broad categories: administrative, general clinical skills, specialist clinical skills and community development. Respondents were engaged in a greater proportion of generic than discipline-specific work activities. They reported a preference for higher levels of activity in each of the work categories. These findings suggest that, contrary to some previous reports, not only are occupational therapists in Australia engaged in a broad spectrum of non-specialist mental health work activities, but these activities are mostly congruent with their expectations and wishes.

Mental health diversion courts : a prospective study of reoffending and clinical outcomes of an Australian mental health court program

This study is concerned with understanding the mechanisms by which mental health courts successfully improve the mental health of participants and, as a consequence, reduce subsequent offending. An analysis of preprogram and postprogram data from 112 adult offenders referred to an established mental health court in Australia revealed that, although participation in the program was associated with an overall reduction in new offenses, this was more likely to be related to preprogram risk of reoffending than improvements in mental health and well-being. The implications of these findings for the further development of court diversion programs are discussed.

Assessing cost-effectiveness in mental health : family interventions for schizophrenia and related conditions

Objective: Existing evidence suggests that family interventions can be effective in reducing relapse rates in schizophrenia and related conditions. Despite this, such interventions are not routinely delivered in Australian mental health services. The objective of the current study is to investigate the incremental cost-effectiveness ratios (ICERs) of introducing three types of family interventions, namely: behavioural family management (BFM); behavioural intervention for families (BIF); and multiple family groups (MFG) into current mental health services in Australia.

Method: The ICER of each of the family interventions is assessed from a health sector perspective, including the government, persons with schizophrenia and their families/carers using a standardized methodology. A two-stage approach is taken to the assessment of benefit. The first stage involves a quantitative analysis based on disability-adjusted life years (DALYs) averted. 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 multivariate probabilistic sensitivity analysis.

Results: The most cost-effective intervention, in order of magnitude, is BIF (A$8000 per DALY averted), followed by MFG (A$21 000 per DALY averted) and lastly BFM (A$28 000 per DALY averted). The inclusion of time costs makes BFM more cost-effective than MFG. Variation of discount rate has no effect on conclusions.

Conclusions: All three interventions are considered 'value-for-money' within an Australian context. This conclusion needs to be tempered against the methodological challenge of converting clinical outcomes into a generic economic outcome measure (DALY). Issues surrounding the feasibility of routinely implementing such interventions need to be addressed.

Some economic dimensions of the mental health jigsaw in Australia

The purpose of this paper is to demonstrate that, although there are some unique features associated with mental illness, such special features do not preclude economic analysis. As a mechanism for understanding how individual economic studies fit into the mental health sector, a conceptual framework of the components of mental health service provision is outlined. Emphasis is placed on, not simply institutional and market resources, but also on the services provided by relatives, self-help groups, etc. Australian data on parts of the mental health sector are employed to illustrate that some (and different) economic analyses can be undertaken in mental health. First, time-series data on public psychiatric hospitals are employed to demonstrate trends associated with deinstitutionalisation. Other data (for Queensland alone) indicate that there are state-based differences in the provision of such services. Second, attention is then directed to the analysis of time-series data on private fee-for-service psychiatric services. Various concepts and measures from industrial economics are applied to analyse the relative size of this service industry, the pricing behaviour of the profession, the service-mix of "the psychiatry firms" operating in Australia.

Occupational Therapy and Clinical Research in Mental Health Rehabilitation

Practitioners working in Australian mental health services are faced with the challenge of providing appropriate evidence-based interventions that lead to measurable improvement and good outcomes. Current government policy is committed to the development of strategic mental health research. One focus has been on under-researched practice areas, which include the development of psychosocial rehabilitation systems and models that facilitate recovery. To meet this challenge, an Australian rehabilitation service formed a collaborative partnership with a university. The purposes of the collaboration were to implement new forms of service delivery based on consumer need and evidence and to design research projects to evaluate components of the rehabilitation programme. This article examines the process of developing the collaboration and provides examples of how research projects have been used to inform practice and improve the effectiveness of service delivery. Challenges to the sustainability of this kind of collaboration are considered.

Consensus statement on the role of Accredited Exercise Physiologists within the treatment of mental disorders: A guide for mental health professionals

- Objective The aim is to identify the role and scope of Accredited Exercise Physiologist (AEP) services in the mental health sector and to provide insight as to how AEPs can contribute to the multidisciplinary mental health team. - Methods A modified Delphi approach was utilised. Thirteen AEPs with experience in mental health contributed to the iterative development of a national consensus statement. Six mental health professionals with expertise in psychiatry, mental health nursing, general practice and mental health research participated in the review process. Reviewers were provided with a template to systematically provide feedback on the language, content, structure and relevance to their professional group. - Results This consensus statement outlines how AEPs can contribute to the multidisciplinary mental health team, the aims and scope of AEP-led interventions in mental health services and examples of such interventions, the range of physical and mental health outcomes possible through AEP-led interventions and common referral pathways to community AEP services. - Outcome AEPs can play a key role in the treatment of individuals experiencing mental illness. The diversity of AEP interventions allows for a holistic approach to care, enhancing both physical and mental health outcomes.