Policy initiative to improve access to psychological services for people with affective and anxiety disorders: population-level analysis.

BACKGROUND: In 2006, Australia introduced new publicly funded psychological services for people with affective and anxiety disorders (the Better Access programme). Despite massive uptake, it has been suggested that Better Access is selectively treating socioeconomically advantaged people, including some who do not warrant treatment, and people already receiving equivalent services. AIMS: To explore potential disparities in Better Access treatment using epidemiological data from the 2007 National Survey of Mental Health and Wellbeing. METHOD: Logistic regression analyses examined patterns and correlates of service use in two populations: people who used the new psychological services in the previous 12 months; and people with any ICD-10 12-month affective and anxiety disorder, regardless of service use. RESULTS: Most (93.2%) Better Access psychological services users had a 12-month ICD-10 mental disorder or another indicator of treatment need. Better Access users without affective or anxiety disorders were not more socioeconomically advantaged, and received less treatment than those with these disorders. Among the population with affective or anxiety disorders, non-service users were less likely to have a severe disorder and more likely to have anxiety disorder, without a comorbid affective disorder, than Better Access users. Better Access users comprised more new allied healthcare recipients than other service users. A substantial minority of non-service users (13.5%) had severe disorders, but most did not perceive a need for treatment. CONCLUSIONS: Better Access does not appear to be overservicing individuals without potential need or contributing to social inequalities in mental healthcare. It appears to be reaching people who have not previously received psychological care. Treatment rates could be improved for some people with anxiety disorders.

SmartPlug versus silicone punctal plug therapy for dry eye: a prospective randomized trial.

PURPOSE: To evaluate the clinical efficacy, retention rates, and complications of SmartPlug insertion compared with silicone punctal plugs in patients with dry eye. METHODS: Thirty-six eyes with subjective symptoms of dry eye in addition to a tear film breakup time (TBUT) <5 seconds and evidence of ocular surface damage on rose Bengal or fluorescein staining were included. Treated eyes were randomized to either a silicone plug or SmartPlug inferior punctal occlusion. Pre- and posttreatment evaluations included subjective symptom scoring, tear meniscus height, TBUT, Schirmer test, fluorescein and rose Bengal staining, and artificial tear use. RESULTS: After a mean follow-up period of 11.2 weeks, both the silicone plug- and SmartPlug-treated eyes showed significant improvement in symptom scoring (P = 0.002 and P = 0.005, respectively), TBUT (P = 0.035 and P = 0.009, respectively), and fluorescein (P = 0.024 and P = 0.016, respectively) and rose Bengal (P = 0.008 and P = 0.046, respectively) staining. There was no significant difference in these parameters between the 2 plugs. SmartPlug-, but not the silicone plug-treated eyes showed significant improvement in mean tear meniscus height (P = 0.037). The use of artificial tear supplements was reduced in 10 (55.6%) silicone- and 11 (61.1%) SmartPlug-treated eyes. Minor complications related to plug insertion were experienced in 4 (22%) silicone- and 2 (11%) SmartPlug-treated eyes. Spontaneous plug loss occurred with 6 (33%) silicone plugs. CONCLUSIONS: This prospective randomized trial shows that SmartPlug insertion has equivalent clinical efficacy to the use of conventional silicone plugs. Both SmartPlug and silicone plug use can reduce dependency on tear supplements in >55% of patients with dry eye.

Improving access to and outcomes from mental health care in rural Australia.

OBJECTIVE: Rural Australians face particular difficulties in accessing mental health care. This paper explores whether 51 rural Access to Allied Psychological Services projects, funded under the Better Outcomes in Mental Health Care program, are improving such access, and, if so, whether this is translating to positive consumer outcomes. DESIGN AND METHOD: The paper draws on three data sources (a survey of models of service delivery, a minimum dataset and three case studies) to examine the operation and achievements of these projects, and makes comparisons with their 57 urban equivalents as relevant. RESULTS: Proportionally, uptake of the projects in rural areas has been higher than in urban areas: more GPs and allied health professionals are involved, and more consumers have received care. There is also evidence that the models of service delivery used in these projects have specifically been designed to resolve issues particular to rural areas, such as difficulties recruiting and retaining providers. The projects are being delivered at no or low cost to consumers, and are achieving positive outcomes as assessed by standardised measures. CONCLUSION: The findings suggest that the rural projects have the potential to improve access to mental health care for rural residents with depression and anxiety, by enabling GPs to refer them to allied health professionals. The findings are discussed with reference to recent reforms to mental health care delivery in Australia.

Australia's National Suicide Prevention Strategy: the next chapter.

Australia's National Suicide Prevention Strategy (NSPS) is about to move into a new funding phase. In this context this paper considers the emphasis of the NSPS since its inception in 1999. Certain high-risk groups (particularly people with mental illness and people who have self-harmed) have been relatively neglected, and some promising approaches (particularly selective and indicated interventions) have been under-emphasised. This balance should be re-dressed and the opportunity should be taken to build the evidence-base regarding suicide prevention. Such steps have the potential to maximise the impact of suicide prevention activities in Australia.

Models of psychological service provision under Australia's Better Outcomes in Mental Health Care program.

The Access to Allied Psychological Services component of Australia's Better Outcomes in Mental Health Care program enables eligible general practitioners to refer consumers to allied health professionals for affordable, evidence-based mental health care, via 108 projects conducted by Divisions of General Practice. The current study profiled the models of service delivery across these projects, and examined whether particular models were associated with differential levels of access to services. We found: 76% of projects were retaining their allied health professionals under contract, 28% via direct employment, and 7% some other way; Allied health professionals were providing services from GPs' rooms in 63% of projects, from their own rooms in 63%, from a third location in 42%; and The referral mechanism of choice was direct referral in 51% of projects, a voucher system in 27%, a brokerage system in 24%, and a register system in 25%. Many of these models were being used in combination. No model was predictive of differential levels of access, suggesting that the approach of adapting models to the local context is proving successful.

Attaching unit costs to Australia's National Survey of Mental Health and Wellbeing.

BACKGROUND: In mental health, policy-makers and planners are increasingly being asked to set priorities. This means that health economists, health services researchers and clinical investigators are being called upon to work together to define and measure costs. Typically, these researchers take available service utilisation data and convert them to costs, using a range of assumptions. There are inefficiencies, as individual groups of researchers frequently repeat essentially similar exercises in achieving this end. There are clearly areas where shared or common investment in the development of statistical software syntax, analytical frameworks and other resources could maximise the use of data. AIMS OF THE STUDY: This paper reports on an Australian project in which we calculated unit costs for mental health admissions and community encounters. In reporting on these calculations, our purpose is to make the data and the resources associated with them publicly available to researchers interested in conducting economic analyses, and allow them to copy, distribute and modify them, providing that all copies and modifications are available under the same terms and conditions (i.e., in accordance with the 'Copyleft' principle). Within this context, the objectives of the paper are to: (i) introduce the 'Copyleft' principle; (ii) provide an overview of the methodology we employed to derive the unit costs; (iii) present the unit costs themselves; and (iv) examine the total and mean costs for a range of single and comorbid conditions, as an example of the kind of question that the unit cost data can be used to address. METHOD: We took relevant data from the Australian National Survey of Mental Health and Wellbeing (NSMHWB), and developed a set of unit costs for inpatient and community encounters. We then examined total and mean costs for a range of single and comorbid conditions. RESULTS: We present the unit costs for mental health admissions and mental health community contacts. Our example, which explored the association between comorbidity and total and mean costs, suggested that comorbidly occurring conditions cost more than conditions which occur on their own. DISCUSSION: Our unit costs, and the materials associated with them, have been published in a freely available form governed by a provision termed 'Copyleft'. They provide a valuable resource for researchers wanting to explore economic questions in mental health. IMPLICATIONS FOR HEALTH POLICIES: Our unit costs provide an important resource to inform economic debate in mental health in Australia, particularly in the area of priority-setting. In the past, such debate has largely been based on opinion. Our unit costs provide the underpinning to strengthen the evidence-base of this debate. IMPLICATIONS FOR FURTHER RESEARCH: We would encourage other Australian researchers to make use of our unit costs in order to foster comparability across studies. We would also encourage Australian and international researchers to adopt the 'Copyleft' principle in equivalent circumstances. Furthermore, we suggest that the provision of 'Copyleft'-contingent funding to support the development of enabling resources for researchers should be considered in the planning of future large-scale collaborative survey work, both in Australia and overseas.

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.