Patterns, predictors, and patient-reported reasons for antidepressant discontinuation in the WHO World Mental Health Surveys.

BACKGROUND: Despite their documented efficacy, substantial proportions of patients discontinue antidepressant medication (ADM) without a doctor's recommendation. The current report integrates data on patient-reported reasons into an investigation of patterns and predictors of ADM discontinuation. METHODS: Face-to-face interviews with community samples from 13 countries (n = 30 697) in the World Mental Health (WMH) Surveys included n = 1890 respondents who used ADMs within the past 12 months. RESULTS: 10.9% of 12-month ADM users reported discontinuation-based on recommendation of the prescriber while 15.7% discontinued in the absence of prescriber recommendation. The main patient-reported reason for discontinuation was feeling better (46.6%), which was reported by a higher proportion of patients who discontinued within the first 2 weeks of treatment than later. Perceived ineffectiveness (18.5%), predisposing factors (e.g. fear of dependence) (20.0%), and enabling factors (e.g. inability to afford treatment cost) (5.0%) were much less commonly reported reasons. Discontinuation in the absence of prescriber recommendation was associated with low country income level, being employed, and having above average personal income. Age, prior history of psychotropic medication use, and being prescribed treatment from a psychiatrist rather than from a general medical practitioner, in comparison, were associated with a lower probability of this type of discontinuation. However, these predictors varied substantially depending on patient-reported reasons for discontinuation. CONCLUSION: Dropping out early is not necessarily negative with almost half of individuals noting they felt better. The study underscores the diverse reasons given for dropping out and the need to evaluate how and whether dropping out influences short- or long-term functioning.

Suicidal ideation, suicide plans and suicide attempts among Australian adults: Findings from the 2020-2022 National Study of Mental Health and Wellbeing.

OBJECTIVE: This study aimed to describe the epidemiology of suicidal ideation, suicide plans and suicide attempts, examine services received for suicide attempts, and explore the relationship between suicide attempts and self-harm without suicidal intent. METHODS: We used survey data from the 2020-2022 National Study of Mental Health and Wellbeing, which involved a nationally representative sample of Australian adults aged 16-85 (n = 15,893). Comparisons were made with the 2007 National Study of Mental Health and Wellbeing (n = 8841). RESULTS: In 2020-2022, the proportions of adults who had experienced suicidal ideation, suicide plans and suicide attempts during their lifetime were 16.6%, 7.5% and 4.9%, respectively. The proportions who had experienced these in the past 12 months were 3.3%, 1.1% and 0.3%. The odds of experiencing suicidal ideation and making a suicide plan were significantly higher in 2020-2022 than in 2007. Groups at heightened risk of suicidal ideation, suicide plans and/or suicide attempts in the previous 12 months were males, young people, people who were gay, lesbian, or bisexual or used some other term to describe their sexual identity, people outside the labour force, people from disadvantaged areas and people with mental disorders. Two-fifths of those who attempted suicide during the previous 12 months did not use health services following their attempt, and two-thirds also self-harmed without suicidal intent. CONCLUSION: The implications of these findings for the forthcoming National Suicide Prevention Strategy are discussed. Suicidal thoughts and behaviours confer risk for suicide and are significant problems in their own right. Their prevention requires a strong whole-of-government response.

The epidemiology of mental and substance use disorders in Australia 2020-22: Prevalence, socio-demographic correlates, severity, impairment and changes over time.

OBJECTIVE: Mental and substance use disorders are the leading causes of disability worldwide. Contemporary estimates of prevalence, severity and impairment are essential for service planning. This study provides estimates of prevalence, severity, impairment and demographic correlates of mental and substance use disorders in 2020-22 and changes in prevalence since 2007. METHODS: Data were from the two Australian National Surveys of Mental Health and Wellbeing conducted in 2020-22 (N = 15,893) and 2007 (N = 8841). Descriptive statistics report prevalence of lifetime and 12-month mental and substance use disorder by sex and age, proportion of people with each mental disorder by levels of severity (mild, moderate and severe) and mean days out of role by mental disorder class (mood, anxiety, substance use). Logistic regression analyses examined demographic correlates of mental disorder class and assessed changes over time. RESULTS: The lifetime prevalence of any mental or substance use disorder in 2020-22 was 40.2%. The 12-month prevalence was 20.2% (mood disorder - 7.4%, anxiety disorder - 15.7% and substance use disorder - 3.1%). Mood disorders were associated with significant impairment. The prevalence of mental disorders has changed over time, with mood and anxiety disorders increasing and substance use disorders decreasing. These changes were most evident among young adults. CONCLUSION: Mental disorders are common in Australia. Impairment associated with mental disorders remains significant. Particular focus should be paid to young adults aged 16-24 years who have shown the largest increases in anxiety and mood disorder prevalence over the past 13 years.

Antidepressant use in low- middle- and high-income countries: a World Mental Health Surveys report.

BACKGROUND: The most common treatment for major depressive disorder (MDD) is antidepressant medication (ADM). Results are reported on frequency of ADM use, reasons for use, and perceived effectiveness of use in general population surveys across 20 countries. METHODS: Face-to-face interviews with community samples totaling n = 49 919 respondents in the World Health Organization (WHO) World Mental Health (WMH) Surveys asked about ADM use anytime in the prior 12 months in conjunction with validated fully structured diagnostic interviews. Treatment questions were administered independently of diagnoses and asked of all respondents. RESULTS: 3.1% of respondents reported ADM use within the past 12 months. In high-income countries (HICs), depression (49.2%) and anxiety (36.4%) were the most common reasons for use. In low- and middle-income countries (LMICs), depression (38.4%) and sleep problems (31.9%) were the most common reasons for use. Prevalence of use was 2-4 times as high in HICs as LMICs across all examined diagnoses. Newer ADMs were proportionally used more often in HICs than LMICs. Across all conditions, ADMs were reported as very effective by 58.8% of users and somewhat effective by an additional 28.3% of users, with both proportions higher in LMICs than HICs. Neither ADM class nor reason for use was a significant predictor of perceived effectiveness. CONCLUSION: ADMs are in widespread use and for a variety of conditions including but going beyond depression and anxiety. In a general population sample from multiple LMICs and HICs, ADMs were widely perceived to be either very or somewhat effective by the people who use them.

Determinants of effective treatment coverage for posttraumatic stress disorder: findings from the World Mental Health Surveys.

BACKGROUND: Posttraumatic stress disorder (PTSD) is associated with significant morbidity, but efficacious pharmacotherapy and psychotherapy are available. Data from the World Mental Health Surveys were used to investigate extent and predictors of treatment coverage for PTSD in high-income countries (HICs) as well as in low- and middle-income countries (LMICs). METHODS: Seventeen surveys were conducted across 15 countries (9 HICs, 6 LMICs) by the World Health Organization (WHO) World Mental Health Surveys. Of 35,012 respondents, 914 met DSM-IV criteria for 12-month PTSD. Components of treatment coverage analyzed were: (a) any mental health service utilization; (b) adequate pharmacotherapy; (c) adequate psychotherapy; and (d) effective treatment coverage. Regression models investigated predictors of treatment coverage. RESULTS: 12-month PTSD prevalence in trauma exposed individuals was 1.49 (S.E., 0.08). A total of 43.0% (S.E., 2.2) received any mental health services, with fewer receiving adequate pharmacotherapy (13.5%), adequate psychotherapy (17.2%), or effective treatment coverage (14.4%), and with all components of treatment coverage lower in LMICs than HICs. In a multivariable model having insurance (OR = 2.31, 95 CI 1.17, 4.57) and severity of symptoms (OR = .35, 95% CI 0.18, 0.70) were predictive of effective treatment coverage. CONCLUSION: There is a clear need to improve pharmacotherapy and psychotherapy coverage for PTSD, particularly in those with mild symptoms, and especially in LMICs. Universal health care insurance can be expected to increase effective treatment coverage and therefore improve outcomes.

Perceived helpfulness of treatment for social anxiety disorder: findings from the WHO World Mental Health Surveys.

PURPOSE: To investigate the prevalence and predictors of perceived helpfulness of treatment in persons with a history of DSM-IV social anxiety disorder (SAD), using a worldwide population-based sample. METHODS: The World Health Organization World Mental Health Surveys is a coordinated series of community epidemiological surveys of non-institutionalized adults; 27 surveys in 24 countries (16 in high-income; 11 in low/middle-income countries; N = 117,856) included people with a lifetime history of treated SAD. RESULTS: In respondents with lifetime SAD, approximately one in five ever obtained treatment. Among these (n = 1322), cumulative probability of receiving treatment they regarded as helpful after seeing up to seven professionals was 92.2%. However, only 30.2% persisted this long, resulting in 65.1% ever receiving treatment perceived as helpful. Perceiving treatment as helpful was more common in female respondents, those currently married, more highly educated, and treated in non-formal health-care settings. Persistence in seeking treatment for SAD was higher among those with shorter delays in seeking treatment, in those receiving medication from a mental health specialist, and those with more than two lifetime anxiety disorders. CONCLUSIONS: The vast majority of individuals with SAD do not receive any treatment. Among those who do, the probability that people treated for SAD obtain treatment they consider helpful increases considerably if they persisted in help-seeking after earlier unhelpful treatments.

Perceived helpfulness of bipolar disorder treatment: Findings from the World Health Organization World Mental Health Surveys.

OBJECTIVES: To examine patterns and predictors of perceived treatment helpfulness for mania/hypomania and associated depression in the WHO World Mental Health Surveys. METHODS: Face-to-face interviews with community samples across 15 countries found n = 2,178 who received lifetime mania/hypomania treatment and n = 624 with lifetime mania/hypomania who received lifetime major depression treatment. These respondents were asked whether treatment was ever helpful and, if so, the number of professionals seen before receiving helpful treatment. Patterns and predictors of treatment helpfulness were examined separately for mania/hypomania and depression. RESULTS: 63.1% (mania/hypomania) and 65.1% (depression) of patients reported ever receiving helpful treatment. However, only 24.5-22.5% were helped by the first professional seen, which means that the others needed to persist in help seeking after initial unhelpful treatments in order to find helpful treatment. Projections find only 22.9% (mania/hypomania) and 43.3% (depression) would persist through a series of unhelpful treatments but that the proportion helped would increase substantially if persistence increased. Few patient-level significant predictors of helpful treatment emerged and none consistently either across the two components (i.e., provider-level helpfulness and persistence after earlier unhelpful treatment) or for both mania/hypomania and depression. Although prevalence of treatment was higher in high-income than low/middle-income countries, proportional helpfulness among treated cases was nearly identical in the two groups of countries. CONCLUSIONS: Probability of patients with mania/hypomania and associated depression obtaining helpful treatment might increase substantially if persistence in help-seeking increased after initially unhelpful treatments, although this could require seeing numerous additional treatment providers. In addition to investigating reasons for initial treatments not being helpful, messages reinforcing the importance of persistence should be emphasized to patients.

Perceived helpfulness of treatment for generalized anxiety disorder: a World Mental Health Surveys report.

BACKGROUND: Treatment guidelines for generalized anxiety disorder (GAD) are based on a relatively small number of randomized controlled trials and do not consider patient-centered perceptions of treatment helpfulness. We investigated the prevalence and predictors of patient-reported treatment helpfulness for DSM-5 GAD and its two main treatment pathways: encounter-level treatment helpfulness and persistence in help-seeking after prior unhelpful treatment. METHODS: Data came from community epidemiologic surveys in 23 countries in the WHO World Mental Health surveys. DSM-5 GAD was assessed with the fully structured WHO Composite International Diagnostic Interview Version 3.0. Respondents with a history of GAD were asked whether they ever received treatment and, if so, whether they ever considered this treatment helpful. Number of professionals seen before obtaining helpful treatment was also assessed. Parallel survival models estimated probability and predictors of a given treatment being perceived as helpful and of persisting in help-seeking after prior unhelpful treatment. RESULTS: The overall prevalence rate of GAD was 4.5%, with lower prevalence in low/middle-income countries (2.8%) than high-income countries (5.3%); 34.6% of respondents with lifetime GAD reported ever obtaining treatment for their GAD, with lower proportions in low/middle-income countries (19.2%) than high-income countries (38.4%); 3) 70% of those who received treatment perceived the treatment to be helpful, with prevalence comparable in low/middle-income countries and high-income countries. Survival analysis suggested that virtually all patients would have obtained helpful treatment if they had persisted in help-seeking with up to 10 professionals. However, we estimated that only 29.7% of patients would have persisted that long. Obtaining helpful treatment at the person-level was associated with treatment type, comorbid panic/agoraphobia, and childhood adversities, but most of these predictors were important because they predicted persistence rather than encounter-level treatment helpfulness. CONCLUSIONS: The majority of individuals with GAD do not receive treatment. Most of those who receive treatment regard it as helpful, but receiving helpful treatment typically requires persistence in help-seeking. Future research should focus on ensuring that helpfulness is included as part of the evaluation. Clinicians need to emphasize the importance of persistence to patients beginning treatment.

Quantifying the size of the informal care sector for Australian adults with mental illness: caring hours and replacement cost.

PURPOSE: To quantify and value the total informal support provided by family and friends to Australian adults with mental illness in 2018. METHODS: The number of mental health carers was drawn from the 2015 Survey of Disability, Ageing and Carers (SDAC), adjusted to the 2018 population. Annual caring hours by type of assistance were estimated using the SDAC, 2007 National Survey of Mental Health and Wellbeing and an online carer survey. Caring hours for each task were assigned an hourly replacement cost from the National Disability Insurance Scheme. Informal caring was valued as the sum of these costs minus expenditure on carer income support payments, estimating how much it would hypothetically cost governments to replace this care with formal support services. RESULTS: An estimated 354,000 (95% uncertainty interval (UI): 327,000-383,000) Australian mental health carers provided 186 million (95% UI: 159-215) hours of support in 2018. The estimated replacement cost was AU$8.4 billion (95% UI: 7.0-10.0), excluding AU$1.3 billion in income support. Univariate sensitivity analyses demonstrated that results were robust to variation in model inputs, with total caring hours the most influential parameter. Using an alternative estimate of mean caring hours, the replacement cost could be as high as AU$13.2 billion (95% UI: 11.2-15.4). CONCLUSION: Informal carers provide substantial support to people with mental illness, highlighting their important contribution to the mental health system and reinforcing the need for carer support services. Future valuation studies would benefit from refinement of available data collections, particularly on hours and types of care provided.

Service demand for psychological interventions among Australian adults: a population perspective.

BACKGROUND: Psychological interventions (PIs) are good practice treatment for both subthreshold and diagnosed mental disorders. Australia has implemented major reforms to expand the provision of subsidised psychological services for individuals with a diagnosed mental disorder. But there are gaps in knowledge about demand for PIs (i.e., use of and perceived need for PIs) across the population. This study uses nationally representative survey data from the 2007 Australian National Survey of Mental Health and Wellbeing to analyse demand for PIs. It also provides a method for analysing survey data to estimate demand for PIs when new survey data becomes available, along with suggestions to inform future survey development. METHODS: Nationally representative community survey respondents (n = 8841, 16-85 years) indicated their perceived need for nine types of help for mental health problems in the past 12 months, including three PIs (cognitive behavioural therapy, psychotherapy, and counselling), and whether these needs were unmet, partially met, or fully met. Types of help were grouped as: PIs only; PIs plus other; and other only. Chi-square analyses were used to examine the association between type of intervention, sociodemographic and clinical factors, and type of professional consulted; multinomial logistic regression models were used to examine predictors of type of intervention(s) received. RESULTS: 7.9% (95%CI: 7.2-8.6) received PIs. Receipt of PIs was positively associated with higher education and consulting a mental health specialist. Twice as many respondents received PIs plus medication as compared to PIs only (4.2% vs. 2.0%). Almost half (45.4, 95%CI 36.5-54.6) incurred out-of-pocket costs for treatment. The most common reason for partially met need for PIs was cost (24.8, 95%CI 17.2-34.3); for unmet need, it was preference for self-management (33.9, 95%CI 21.2-49.5). Perceived unmet need for PIs only (3.1, 95%CI 2.1-4.6) or PIs plus other interventions (5.2, 95%CI 3.9-6.9%) was lower than for other interventions only (22.8, 95%CI 18.7-27.6). CONCLUSIONS: Continued reforms in Australia means that on-going monitoring of demand for PIs, using nationally representative data, is required. This study provides a baseline for comparison of the long-term effects of these reforms; this comparison may be undertaken using data from the third iteration of Australia's NSMHWB, due for completion in 2021-22.

Perceived helpfulness of treatment for posttraumatic stress disorder: Findings from the World Mental Health Surveys.

BACKGROUND: Perceived helpfulness of treatment is an important healthcare quality indicator in the era of patient-centered care. We examine probability and predictors of two key components of this indicator for posttraumatic stress disorder (PTSD). METHODS: Data come from World Mental Health surveys in 16 countries. Respondents who ever sought PTSD treatment (n = 779) were asked if treatment was ever helpful and, if so, the number of professionals they had to see to obtain helpful treatment. Patients whose treatment was never helpful were asked how many professionals they saw. Parallel survival models were estimated for obtaining helpful treatment in a specific encounter and persisting in help-seeking after earlier unhelpful encounters. RESULTS: Fifty seven percent of patients eventually received helpful treatment, but survival analysis suggests that it would have been 85.7% if all patients had persisted in help-seeking with up to six professionals after earlier unhelpful treatment. Survival analysis suggests that only 23.6% of patients would persist to that extent. Odds of ever receiving helpful treatment were positively associated with receiving treatment from a mental health professional, short delays in initiating help-seeking after onset, absence of prior comorbid anxiety disorders and childhood adversities, and initiating treatment before 2000. Some of these variables predicted helpfulness of specific treatment encounters and others predicted persistence after earlier unhelpful encounters. CONCLUSIONS: The great majority of patients with PTSD would receive treatment they considered helpful if they persisted in help-seeking after initial unhelpful encounters, but most patients whose initial treatment is unhelpful give up before receiving helpful treatment.

Barriers to mental health care for Australian children and adolescents in 1998 and 2013-2014.

OBJECTIVE: To assess changes in barriers to mental health care for children and adolescents over 16 years. METHODS: We used data from two nationally representative surveys of Australian children and adolescents (4-17 years old), conducted in 1998 (N = 4509) and 2013-2014 (N = 6310). Barriers to care were assessed among parents who had reported a perceived partially met or unmet need for their child in the past 6 months in 1998, and the past 12 months in 2013-2014; barriers were similarly assessed among adolescents in relation to themselves. We addressed measurement inconsistencies between surveys by harmonising barriers to accommodate differences in wording and performing sensitivity analyses among those with a 1-month disorder to equalise the timeframes in which barriers were assessed. To assess change, we examined whether the rank order of the three most commonly endorsed barriers changed and whether the 95% confidence intervals (CI) around their estimates overlapped. RESULTS: Similar proportions of parents reported a partially met or unmet need in 1998 (12.9%, 95% CI = [11.7, 14.0]) as in 2013-2014 (14.3%, 95% CI = [13.2, 15.3]), but the ratio of unmet to partially met need decreased from 3:1 in 1998 to 1:1 in 2013-2014. Top three parent-endorsed barriers ('self-reliance', 'unsure where to get help', and 'cost') were the same at both time points; 'self-reliance' decreased from 65.9% (95% CI = [61.1%, 70.7%]) to 34.9% (95% CI = [31.5%, 38.3%]). Top two adolescent-endorsed barriers ('self-reliance' and 'concerned what others might think') were the same at both time points, the third differed, but none of them decreased. CONCLUSION: Perceived unmet need for mental health care for children and adolescents may have decreased between 1998 and 2013-2014, but the gap in receiving sufficient care may have increased. Despite investments in community awareness and treatment during this period, key barriers seemed largely unchanged. For parents, the decrease in self-reliance may reflect a positive shift in beliefs about the potential benefits of treatment.

Employment disadvantage and associated factors for informal carers of adults with mental illness: are they like other disability carers?

BACKGROUND: Providing unpaid support to family and friends with disabling health conditions can limit a carer's capacity to participate in employment. The emotional support needs and unpredictability of caring for people with mental illness may be particularly demanding. While previous research suggests variable employment rates across carers for different conditions, there are limited data on mental health carers specifically. METHODS: This study analysed employment patterns for working-age, co-resident carers of adults with mental illness in an Australian cross-sectional household survey, the 2015 Survey of Disability, Ageing and Carers. RESULTS: Significantly more mental health carers were not employed (42.3%, 95% CI: 36.6-48.1) compared to non-carers (24.0%, 95% CI: 23.5-24.6). Employed mental health carers were more likely to work fewer than 16 h per week (carers: 17.2%, 95% CI: 12.8-22.8, vs. non-carers: 11.7%, 95% CI: 11.3-12.1) and in lower skilled occupations (carers: 22.6, 95% CI: 17.5-28.7, vs. non-carers: 15.7, 95% CI: 15.1-16.2). Among the sub-group of primary mental health carers, 25.8% (95% CI: 15.6-39.5) had reduced their working hours to care and a further 26.4% (95% CI: 17.2-38.2) stopped working altogether. In corresponding comparisons between mental health carers and carers for people with other cognitive/behavioural conditions, and physical conditions with or without secondary mental illness, there were no differences except that mental health carers were more likely to be working in a lower skilled occupation than other cognitive/behavioural condition carers (14.8% of the latter, 95% CI 10.1-21.2). Multivariate logistic regression analyses revealed that female mental health carers were less likely to be employed if they were aged 35-54, had no post-secondary education, had a disability, or cared for someone with severe activity limitations. For male mental health carers, having a disability or caring for someone with severe limitations or who did not receive paid assistance were significantly associated with not being employed. CONCLUSIONS: These results highlight the employment disadvantage experienced by mental health carers compared to non-carers, and similarities in employment patterns across carers for different conditions. Improving the availability of paid support services for people with mental illness may be an important target to assist carers to maintain their own employment.

Identifying characteristics and practices of multidisciplinary team reviews for patients with severe mental illness: a systematic review.

OBJECTIVES: Multidisciplinary teams in mental health receive limited guidance, leading to inconsistent practices. We undertook a systematic review of the characteristics and practices of multidisciplinary team reviews for patients with severe mental illness or in relevant mental health service settings. METHODS: Sources published since 2000 were located via academic database and web searches. Results were synthesised narratively. RESULTS: A total of 14 sources were analysed. Important characteristics and practices identified included routine monitoring and evaluation, good communication, equality between team members, and clear documentation practices. Success factors included defined leadership and clear team goals. Four sources described considerations for patients with complex clinical needs, including allocating sufficient time for discussion, maintaining connections with community providers, and ensuring culturally sensitive practices. CONCLUSIONS: No single best practice model was found, due to variations in team caseload, casemix, and resourcing levels. However, key ingredients for success were proposed. Sources were mostly descriptive; there remains a lack of evidence-based guidance regarding multidisciplinary team review characteristics and practices.

The cross-national epidemiology of social anxiety disorder: Data from the World Mental Health Survey Initiative.

BACKGROUND: There is evidence that social anxiety disorder (SAD) is a prevalent and disabling disorder. However, most of the available data on the epidemiology of this condition originate from high income countries in the West. The World Mental Health (WMH) Survey Initiative provides an opportunity to investigate the prevalence, course, impairment, socio-demographic correlates, comorbidity, and treatment of this condition across a range of high, middle, and low income countries in different geographic regions of the world, and to address the question of whether differences in SAD merely reflect differences in threshold for diagnosis. METHODS: Data from 28 community surveys in the WMH Survey Initiative, with 142,405 respondents, were analyzed. We assessed the 30-day, 12-month, and lifetime prevalence of SAD, age of onset, and severity of role impairment associated with SAD, across countries. In addition, we investigated socio-demographic correlates of SAD, comorbidity of SAD with other mental disorders, and treatment of SAD in the combined sample. Cross-tabulations were used to calculate prevalence, impairment, comorbidity, and treatment. Survival analysis was used to estimate age of onset, and logistic regression and survival analyses were used to examine socio-demographic correlates. RESULTS: SAD 30-day, 12-month, and lifetime prevalence estimates are 1.3, 2.4, and 4.0% across all countries. SAD prevalence rates are lowest in low/lower-middle income countries and in the African and Eastern Mediterranean regions, and highest in high income countries and in the Americas and the Western Pacific regions. Age of onset is early across the globe, and persistence is highest in upper-middle income countries, Africa, and the Eastern Mediterranean. There are some differences in domains of severe role impairment by country income level and geographic region, but there are no significant differences across different income level and geographic region in the proportion of respondents with any severe role impairment. Also, across countries SAD is associated with specific socio-demographic features (younger age, female gender, unmarried status, lower education, and lower income) and with similar patterns of comorbidity. Treatment rates for those with any impairment are lowest in low/lower-middle income countries and highest in high income countries. CONCLUSIONS: While differences in SAD prevalence across countries are apparent, we found a number of consistent patterns across the globe, including early age of onset, persistence, impairment in multiple domains, as well as characteristic socio-demographic correlates and associated psychiatric comorbidities. In addition, while there are some differences in the patterns of impairment associated with SAD across the globe, key similarities suggest that the threshold for diagnosis is similar regardless of country income levels or geographic location. Taken together, these cross-national data emphasize the international clinical and public health significance of SAD.

A systematic review of clinician-rated instruments to assess adults' levels of functioning in specialised public sector mental health services.

BACKGROUND: Functioning is one of the key domains emphasised in the routine assessment of outcomes that has been occurring in specialised public sector mental health services across Australia since 2002, via the National Outcomes and Casemix Collection. For adult consumers (aged 18-64), the 16-item Life Skills Profile (LSP-16) has been the instrument of choice to measure functioning. However, review of the National Outcomes and Casemix Collection protocol has highlighted some limitations to the current approach to measuring functioning. A systematic review was conducted to identify, against a set of pre-determined criteria, the most suitable existing clinician-rated instruments for the routine measurement of functioning for adult consumers. METHOD: We used two existing reviews of functioning measures as our starting point and conducted a search of MEDLINE and PsycINFO to identify articles relating to additional clinician-rated instruments. We evaluated identified instruments using a hierarchical, criterion-based approach. The criteria were as follows: (1) is brief (<50 items) and simple to score, (2) is not made redundant by more recent instruments, (3) relevant version has been scientifically scrutinised, (4) considers functioning in a contemporary way and (5) demonstrates sound psychometric properties. RESULTS: We identified 20 relevant instruments, 5 of which met our criteria: the LSP-16, the Health of the Nation Outcome Scales, the Illness Management and Recovery Scale-Clinician Version, the Multnomah Community Ability Scale and the Personal and Social Performance Scale. CONCLUSION: Further work is required to determine which, if any, of these instruments satisfy further criteria relating to their appropriateness for assessing functioning within relevant service contexts, acceptability to clinicians and consumers, and feasibility in routine practice. This should involve seeking stakeholders' opinions (e.g. about the specific domains of functioning covered by each instrument and the language used in individual items) and testing completion rates in busy service settings.

An analysis of policy success and failure in formal evaluations of Australia's national mental health strategy (1992-2012).

BACKGROUND: Heightened fiscal constraints, increases in the chronic disease burden and in consumer expectations are among several factors contributing to the global interest in evidence-informed health policy. The present article builds on previous work that explored how the Australian Federal Government applied five instruments of policy, or policy levers, to implement a series of reforms under the Australian National Mental Health Strategy (NMHS). The present article draws on theoretical insights from political science to analyse the relative successes and failures of these levers, as portrayed in formal government evaluations of the NMHS. METHODS: Documentary analysis of six evaluation documents corresponding to three National Mental Health Plans was undertaken. Both the content and approach of these government-funded, independently conducted evaluations were appraised. RESULTS: An overall improvement was apparent in the development and application of policy levers over time. However, this finding should be interpreted with caution due to variations in evaluation approach according to Plan and policy lever. Tabulated summaries of the success and failure of each policy initiative, ordered by lever type, are provided to establish a resource that could be consulted for future policy-making. CONCLUSIONS: This analysis highlights the complexities of health service reform and underscores the limitations of narrowly focused empirical approaches. A theoretical framework is provided that could inform the evaluation and targeted selection of appropriate policy levers in mental health.

Assessing service use for mental health by Indigenous populations in Australia, Canada, New Zealand and the United States of America: a rapid review of population surveys.

BACKGROUND: Indigenous people in Australia, Canada, New Zealand and the United States of America experience disproportionately poor mental health compared to their non-Indigenous counterparts. To optimally allocate resources, health planners require information about the services Indigenous people use for mental health, their unmet treatment needs and the barriers to care. We reviewed population surveys of Indigenous people to determine whether the information needed to guide service development is being collected. METHODS: We sought national- or state-level epidemiological surveys of Indigenous populations conducted in each of the four selected countries since 1990 that asked about service use for mental health. Surveys were identified from literature reviews and web searches. We developed a framework for categorising the content of each survey. Using this framework, we compared the service use content of the surveys of Indigenous people to each other and to general population mental health surveys. We focused on identifying gaps in information coverage and topics that may require Indigenous-specific questions or response options. RESULTS: Nine surveys met our inclusion criteria. More than half of these included questions about health professionals consulted, barriers to care, perceived need for care, medications taken, number, duration, location and payment of health professional visits or use of support services or self-management. Less than half included questions about interventions received, hospital admissions or treatment dropout. Indigenous-specific content was most common in questions regarding use of support services or self-management, types of health professionals consulted, barriers to care and interventions received. CONCLUSIONS: Epidemiological surveys measuring service use for mental health among Indigenous populations have been less comprehensive and less standardised than surveys of the general population, despite having assessed similar content. To better understand the gaps in mental health service systems for Indigenous people, systematically-collected subjective and objective indicators of the quality of care being delivered are needed.

Reducing excess mortality due to chronic disease in people with severe mental illness: meta-review of health interventions.

BACKGROUND: People with severe mental illness (SMI) have high rates of chronic disease and premature death. AIMS: To explore the strength of evidence for interventions to reduce risk of mortality in people with SMI. METHOD: In a meta-review of 16 systematic reviews of controlled studies, mortality was the primary outcome (8 reviews). Physiological health measures (body mass index, weight, glucose levels, lipid profiles and blood pressure) were secondary outcomes (14 reviews). RESULTS: Antipsychotic and antidepressant medications had some protective effect on mortality, subject to treatment adherence. Integrative community care programmes may reduce physical morbidity and excess deaths, but the effective ingredients are unknown. Interventions to improve unhealthy lifestyles and risky behaviours can improve risk factor profiles, but longer follow-up is needed. Preventive interventions and improved medical care for comorbid chronic disease may reduce excess mortality, but data are lacking. CONCLUSIONS: Improved adherence to pharmacological and physical health management guidelines is indicated.

Systematic review of interventions for Indigenous adults with mental and substance use disorders in Australia, Canada, New Zealand and the United States.

OBJECTIVE: The aim of this study was to systematically review the evidence-base for the effectiveness of culturally unadapted, culturally adapted and culture-based interventions for Indigenous adults with mental or substance use disorders. METHODS: We conducted a systematic search of scientific databases, government websites and web-based Indigenous research repositories. We sought studies using designs comparing an intervention group to a control/comparator group or pre- and post-test designs, published between 2000 and 2015 examining interventions to improve individual-level outcomes (e.g. remission, symptoms, quality of life, functioning) or service-level outcomes (e.g. number of interventions delivered) for Indigenous adults with mental or substance use disorders in Australia, Canada, New Zealand or the United States. RESULTS: A total of 16 studies met inclusion criteria. Virtually all North American studies (6 US and 1 Canadian) evaluated culturally unadapted interventions, all of which were interventions for substance use. Two-thirds of Australian and New Zealand studies evaluated culturally adapted interventions and included samples with mental disorders. Of eight culturally unadapted psychological/psychosocial, pharmacological and educational intervention studies, seven reported significant improvements on at least one measure of psychological well-being, mental health problem severity, or significantly reduced alcohol or illicit drug use. Of seven culturally adapted psychological/psychosocial intervention studies, all reported significant improvement on at least one measure of symptoms of mental illness, functioning, and alcohol use. One culture-based psychological/psychosocial intervention study significantly reduced problem severity in medical and psychiatric domains. CONCLUSION: There remains inconclusive evidence regarding interventions due to a small and methodologically weak evidence-base. The literature would be enhanced by intervention replication and outcome standardisation, validating the outcome instruments used in Indigenous populations, including sample size calculations and using stronger research designs (e.g. interrupted time-series designs). Robust implementation and outcomes research is needed to further progress evidence-based practice in Indigenous mental health.