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.

Age Matters: Exploring Correlates of Self-Rated Health Across Four Generations of Australian Males.

The importance of addressing health disparities experienced by boys and men reached tangible prominence in Australia with adoption of the 2010 National Male Health Policy and the establishment of a national longitudinal study on male health-Ten to Men. Ten to Men is based on a holistic model of health with a strong focus on social determinants and health and well-being over the life course. Given the life course focus, we set out to assess if health-related characteristics and the correlates of self-rated health differ across the life course among four sociologically defined generations of Australian males. While some differences in the correlates of good or excellent health were observed across generations, addressing obesity and depression appear to be important for improving the health of Australian males of all ages.

Frequency and quality of mental health treatment for affective and anxiety disorders among Australian adults.

OBJECTIVES: To describe the frequency, type and quality of mental health treatment among Australian adults with past-year affective and/or anxiety disorders. DESIGN, SETTING AND PARTICIPANTS: Retrospective analysis of data for 8831 adults aged 16-85 years interviewed for the 2007 National Survey of Mental Health and Wellbeing, of whom 17% (n = 1517) met International Classification of Diseases, 10th revision (ICD-10) criteria for a past-year affective and/or anxiety disorder. MAIN OUTCOME MEASURES: Three levels of mental health treatment received in the past year: (1) any consultation with a health professional for mental health; (2) any evidence-based intervention (antidepressant medication, mood stabiliser medication, cognitive behaviour therapy and/or psychotherapy); and (3) minimally adequate treatment (a "dose" of an evidence-based intervention above a minimum threshold, consistent with treatment guidelines). RESULTS: Of participants with past-year affective and/or anxiety disorders, 39% sought professional help for mental health, 26% received an evidence-based treatment, and 16% received minimally adequate treatment. After controlling for clinical factors including type and severity of disorder, the odds of all levels of treatment were lower among younger adults (16-29 years) compared with middle-aged adults, and the odds of receiving an evidence-based treatment or minimally adequate treatment were lower among people who consulted a general practitioner only compared with a mental health professional. CONCLUSIONS: Closing the gap in treatment quality requires strategies to increase the use of evidence-based interventions, and to ensure these are delivered in sufficient doses. Research to elucidate why some patients are at increased risk of inadequate treatment, and the aspects of treatment that contribute to inadequate care, is indicated.

The burden attributable to mental and substance use disorders as risk factors for suicide: findings from the Global Burden of Disease Study 2010.

BACKGROUND: The Global Burden of Disease Study 2010 (GBD 2010) identified mental and substance use disorders as the 5th leading contributor of burden in 2010, measured by disability adjusted life years (DALYs). This estimate was incomplete as it excluded burden resulting from the increased risk of suicide captured elsewhere in GBD 2010's mutually exclusive list of diseases and injuries. Here, we estimate suicide DALYs attributable to mental and substance use disorders. METHODS: Relative-risk estimates of suicide due to mental and substance use disorders and the global prevalence of each disorder were used to estimate population attributable fractions. These were adjusted for global differences in the proportion of suicide due to mental and substance use disorders compared to other causes then multiplied by suicide DALYs reported in GBD 2010 to estimate attributable DALYs (with 95% uncertainty). RESULTS: Mental and substance use disorders were responsible for 22.5 million (14.8-29.8 million) of the 36.2 million (26.5-44.3 million) DALYs allocated to suicide in 2010. Depression was responsible for the largest proportion of suicide DALYs (46.1% (28.0%-60.8%)) and anorexia nervosa the lowest (0.2% (0.02%-0.5%)). DALYs occurred throughout the lifespan, with the largest proportion found in Eastern Europe and Asia, and males aged 20-30 years. The inclusion of attributable suicide DALYs would have increased the overall burden of mental and substance use disorders (assigned to them in GBD 2010 as a direct cause) from 7.4% (6.2%-8.6%) to 8.3% (7.1%-9.6%) of global DALYs, and would have changed the global ranking from 5th to 3rd leading cause of burden. CONCLUSIONS: Capturing the suicide burden attributable to mental and substance use disorders allows for more accurate estimates of burden. More consideration needs to be given to interventions targeted to populations with, or at risk for, mental and substance use disorders as an effective strategy for suicide prevention.

Estimating treatment rates for mental disorders in Australia.

OBJECTIVE: To estimate the percentage of Australians with a mental disorder who received treatment for that disorder each year between 2006-07 and 2009-10. METHODS: We used: (1) epidemiological survey data to estimate the number of Australians with a mental disorder in any year; (2) a combination of administrative data on people receiving mental health care from the Commonwealth and State and Territories and epidemiological data to estimate the number receiving treatment; and (3) uncertainty modelling to estimate the effects of sampling error and assumptions on these estimates. RESULTS: The estimated population treatment rate for mental disorders in Australia increased from 37% in 2006-07 to 46% in 2009-10. The model estimate for 2006-07 (37%) was very similar to the estimated treatment rate in the 2007 National Survey of Mental Health and Wellbeing (35%), the only data available for external comparison. The uncertainty modelling suggested that the increased treatment rates over subsequent years could not be explained by sampling error or uncertainty in assumptions. CONCLUSIONS: The introduction of the Commonwealth's Better Access initiative in November 2006 has been the driver for the increased the proportion of Australians with mental disorders who received treatment for those disorders over the period from 2006-07 to 2009-10. WHAT IS KNOWN ABOUT THE TOPIC? Untreated mental disorders incur major economic costs and personal suffering. Governments need timely estimates of treatment rates to assess the effects of policy changes aimed at improving access to mental health services. WHAT DOES THIS PAPER ADD? Drawing upon a combination of epidemiological and administrative data sources, the present study estimated that the population treatment rate for mental disorders in Australia increased significantly from 37% in 2006-07 to 46% in 2009-10. WHAT ARE THE IMPLICATIONS FOR PRACTITIONERS? Increased access to services is not sufficient to ensure good outcomes for those with mental disorders. It is also important to ensure that evidence-based treatment is provided to those Australians accessing these services.

Innovations in primary mental healthcare.

OBJECTIVE: We review the evidence on innovations in Tier 2 of the Access to Allied Psychological Services (ATAPS) program, which is designed to facilitate the provision of primary mental healthcare to hard-to-reach and at-risk population groups (including women with perinatal depression, people at risk of self-harm or suicide, people experiencing or at risk of homelessness, people affected by the 2009 Victorian bushfires, people in remote locations, Aboriginal and Torres Strait Islanders and children with mental disorders) and the trialling of new modalities of service delivery (e.g. telephone-based or web-based CBT). The primary focus is on the uptake, outcomes and issues associated with the provision of ATAPS Tier 2. METHODS: Drawing on data from an ongoing national ATAPS evaluation, including a national minimum dataset, key informant interviews and surveys, the impact of ATAPS innovations is analysed and illustrated through program examples. RESULTS: ATAPS Tier 2 facilitates access to, uptake of and positive clinical outcomes from primary mental healthcare for population groups with particular needs, although it requires periods of time to implement locally. CONCLUSIONS: Relatively simple innovations in mental health program design can have important practical ramifications for service provision, extending program reach and improving mental health outcomes for target populations. What is known about the topic? It is recognised that innovative approaches are required to tailor mental health programs for hard-to-reach and at-risk population groups. Divisions of General Practice have implemented innovations in the Access to Allied Psychological Services (ATAPS) program for several years. What does this paper add? Drawing on data from an ongoing national ATAPS evaluation, this paper presents a systematic analysis of the uptake, outcomes and issues associated with provision of the innovative ATAPS program. What are the implications for practitioners? The findings highlight the benefits of introducing innovations in primary mental healthcare in terms of increased access to care and positive consumer outcomes. They also identify challenges to and facilitators of the implementation process, which can inform innovation efforts in other primary care contexts.

Media awards for responsible reporting of suicide: Experiences from Australia, Belgium and Denmark.

BACKGROUND: Media awards to encourage responsible reporting of suicide have been introduced in several countries, including Australia, Belgium and Denmark. AIMS: This study aimed to examine the experiences of Australian, Belgian and Danish award recipients in preparing stories on suicide, and consider the impacts of the awards for these recipients and for media professionals more broadly. METHOD: We conducted semi-structured telephone interviews with the majority (14 out of 15) of past recipients of the awards in the three countries of interest. RESULTS: Media awards appear to show promise as a method of reinforcing national and international media guidelines on reporting suicide. The recipients of awards were proud to have had their achievements recognized in this way, and had developed a heightened awareness of the issues inherent in reporting suicide. Although relatively few had prepared subsequent stories on suicide, a number had been given opportunities to provide advice to other media professionals about how best to approach this sensitive topic. Recipients viewed the awards as an important means by which good quality reporting can be rewarded, and a springboard for raising community awareness about suicide. CONCLUSION: The experience from Australia, Belgium and Denmark suggests that media awards which recognize responsible reporting of suicide are extremely worthwhile.

Were the budgetary reforms to the Better Access to Mental Health Care initiative appropriate?--yes.

Mental health researchers Jane Pirkis and Meredith Harris say the government got it right.

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.

Service use for mental health problems: findings from the 2007 National Survey of Mental Health and Wellbeing.

OBJECTIVES: To provide an overview of 12 month rates of service use for mental health problems and mental disorders by the general Australian adult population. METHOD: Data came from the 2007 National Survey of Mental Health and Wellbeing (2007 NSMHWB), a nationally representative household survey of 8841 individuals aged between 16 and 85 years. RESULTS: Overall, 11.9% of the general Australian adult population made use of any services for mental health problems in a 12 month period. Approximately one-third of people (34.9%) meeting criteria for a mental disorder did so. Female subjects with mental disorders were more likely to use services than male subjects (40.7% vs 27.5%). People in the youngest age group made relatively less use of services than older adults. Those with affective disorders were most likely to make use of services (58.6%), followed by those with anxiety (37.8%) and substance use disorders (24.0%), respectively. Mental health hospitalizations were less common than consultations with community-based providers (2.6%), whereas 34.6% consulted a community-based provider--particularly general practitioners (24.7%) and psychologists (13.2%). There was a clear dose-response effect between severity of disorders and rates of community-based service use: 63.5% of those with severe mental disorders used community-based services, compared with 40.2% and 17.7% of those with moderate and mild mental disorders, respectively. There was also a relationship between comorbidity of mental disorders and service use. CONCLUSIONS: Rates of service use for mental health problems among those with mental disorders in Australia are less than optimal. Little international guidance is available regarding appropriate levels of treatment coverage and other comparable countries face similar difficulties. Further work is required to determine what an appropriate rate of service use is, and to set targets to reach that rate. Australia has demonstrated that concerted policy efforts can improve rates of service use. These efforts should be expanded.

Suicidal thoughts and behaviours among Australian adults: findings from the 2007 National Survey of Mental Health and Wellbeing.

OBJECTIVES: To provide an overview of the lifetime and 12 month prevalence of suicidal ideation, suicide plans and suicide attempts for Australian adults as a whole and for particular sociodemographic and clinical population subgroups, and to explore the health service use of people with suicidality. METHOD: Data came from the 2007 National Survey of Mental Health and Wellbeing (2007 NSMHWB), a nationally, representative household survey of 8841 individuals aged 16-85 years. RESULTS: A total of 13.3% of respondents had suicidal ideation during their lifetime, 4.0% had made a suicide plan and 3.2% had made a suicide attempt. The equivalent 12 month prevalence rates were 2.3%, 0.6% and 0.4%, for ideation, plans and attempts, respectively. In general, suicidality in the previous 12 months tended to be relatively more common in women, younger people, those outside the labour force, and those with mental disorders; and less common in those who were married or in de facto relationships, and those with moderate levels of education. A number of the differences in prevalence rates between sociodemographic and clinical subgroups did not reach statistical significance due to data availability constraints and the conservative tests of significance that were used by necessity. These patterns warrant further exploration. Service use for mental health problems was higher among people with suicidality than it was among the general population, but significant numbers of those experiencing suicidality did not receive treatment. CONCLUSIONS: Suicidal thoughts and behaviours are not uncommon among the Australian adult population. These thoughts and behaviours are not only predictive of subsequent fatal suicidal acts, but are significant public health problems in their own right. They are associated with high levels of burden at an individual and societal level. Further analysis is required to assess the effectiveness of the national policy frameworks in reducing the spectrum of suicidal thoughts and behaviours.

Medical morbidity and severity of depression in a large primary care sample of older Australians: the DEPS-GP project.

OBJECTIVES: To estimate the prevalence of depression among older Australians with common medical morbidities, and to determine the association between poor physical health and depression in this age group. DESIGN: Cross-sectional, postal questionnaire survey. SETTING AND PARTICIPANTS: 20 183 community-dwelling adults aged 60 years and over, under the care of 383 general practitioners participating in the Depression and Early Prevention of Suicide in General Practice (DEPS-GP) project (conducted between 2005 and 2008; the data in this article were collected during the baseline phase of the study in 2005). MAIN OUTCOME MEASURES: Depressive symptoms (measured by the nine-item depression scale of the Patient Health Questionnaire), health status (measured by the 12-item Short Form Health Survey and a medical morbidity inventory), social support (measured by the subjective support subscale from the Duke Social Support Index), and demographic and lifestyle information. RESULTS: 18 190 participants (90.1%) reported having at least one chronic physical health condition, while 1493 (7.1%) experienced clinically significant depression (3.1% major depressive syndrome; 4.0% other depressive syndrome). Most chronic physical illnesses were associated with increased odds of depression, and participants with numerous medical morbidities and a high level of functional impairment were three to four times more likely to have a depressive illness. CONCLUSIONS: Depression is more the exception than the rule in later life, and among those who are medically unwell, the level of associated impairment may determine their risk of depression more than their acquired physical illness. Many of the factors associated with depression in medically ill patients are amenable to treatment, and GPs are in a unique position to address this important public health issue.

Meeting demand for psychological services for people with depression and anxiety: recent developments in primary mental health care.

OBJECTIVE: To examine whether there was a reduction in demand for psychological services provided through the Access to Allied Psychological Services (ATAPS) projects after the introduction of the Better Access to Psychiatrists, Psychologists and General Practitioners through the Medicare Benefits Schedule (Better Access) program, and whether any such reduction was greater in urban than rural areas. DESIGN AND SETTING: A Division-level correlation analysis examining the relationship between the monthly number of sessions provided by allied health professionals through the ATAPS projects run by Divisions of General Practice, and allied health professional services reimbursed by Medicare Australia under the Better Access program, between 1 November 2006 and 31 March 2007. MAIN OUTCOME MEASURES: Uptake of each program, assessed by the number of sessions provided. RESULTS: Overall, despite dramatic uptake of the Better Access program in the first 5 months after its introduction, the demand for ATAPS services was not reduced. The correlations between the numbers of sessions provided by both programs overall (r = - 0.078; P = 0.074) and in rural Divisions (r = 0.024; P = 0.703) were not significant. However, there was a significant negative correlation between the numbers of sessions provided by both programs in urban Divisions (r = - 0.142; P = 0.019). CONCLUSIONS: For the first 5 months of the Better Access program, the two programs seemed to operate relatively independently of each other in terms of service provision, but in urban Divisions there was a move towards services provided through the Better Access program. Early indications are that the two programs are providing complementary services and are working together to address a previously unmet need for mental health care.

Impact of a specialized early psychosis treatment programme on suicide. Retrospective cohort study.

BACKGROUND: Younger people, early in the course of psychotic illness, are at high risk of suicide. AIM: To investigate the impact of a specialized early psychosis (EP) treatment programme on risk of suicide up to 8.5 years following first contact with mental health services. METHODS: A population-based, retrospective cohort study of 7760 individuals with a psychotic disorder, aged 15-29 years at first contact, ascertained from a statewide psychiatric case register. Suicides were identified by linking the psychiatric register to a coronial register of unnatural deaths. Cox proportional hazards models were used to investigate potential risk factors, including specialized EP treatment, for suicide. RESULTS: Our principal hypothesis, that suicide risk over the entire follow-up period would be significantly lower for those who received specialized EP treatment compared with those who did not, was not supported. However, a secondary analysis found that, after adjusting for other socio-demographic, clinical and treatment factors, suicide risk was 50% lower in the first 3 years following first contact with mental health services among those exposed to specialized EP treatment compared with those who were not. History of inpatient treatment, more treatment days per annum, and shorter time to establish a psychotic diagnosis were associated with increased risk. Non-participation in the labour force or in study, compared with being unemployed, exerted a protective effect. CONCLUSIONS: The EP treatment model may afford protection from suicide whilst the EP intervention is delivered and for a limited period afterwards.

Stakeholder concerns about Australia's mental health care system.

There is growing community and professional concern that the Australian mental health care system requires substantial reform. In response to these concerns, a Senate Select Committee on Mental Health has been commissioned to conduct an inquiry into the provision of mental health services. The current study involved a content analysis of 725 submissions received by the Committee, and highlighted significant areas for reform. People with mental illness face difficulties in accessing mental health care, the care they do receive is of varying quality and poorly coordinated, and necessary services from other sectors, such as housing, are lacking. These problems may be exacerbated for particular groups with complex needs or heightened levels of vulnerability. The system requires reorienting towards the consumers and carers it is designed to serve, and needs stronger governance, higher levels of accountability and improved monitoring of quality. These findings are discussed in the context of the recent acknowledgement of mental health as an issue by the Council of Australian Governments (COAG), which has called for an action plan to be prepared for its consideration by June 2006.

The relationship between media reporting of suicide and actual suicide in Australia.

This study aimed to determine whether media items about suicide were associated with differential increases in actual suicides. Data were available on 4,635 suicide-related items appearing in Australian newspapers and on radio and television news and current affairs shows between March 2000 and February 2001. These data were combined with national data on completed suicides occurring during the same period, by a process that involved identifying the date and geographical reach of the media items and determining the number of suicides occurring in the same location in selected weeks pre- and post-item. Regression analyses were conducted to determine whether the likelihood of an increase in post-item suicides could be explained by particular item characteristics. We found that 39% of media items were followed by an increase in male suicides, and 31% by an increase in female suicides. Media items were more likely to be associated with increases in both male and female suicides if they occurred in the context of multiple other reports on suicide (versus occurring in isolation), if they were broadcast on television (versus other media), and if they were about completed suicide (versus attempted suicide or suicidal ideation). Different item content appeared to be influential for males and females, with an increase in male suicides being associated with items about an individual's experience of suicide and opinion pieces, and an increase in female suicides being associated with items about mass- or murder-suicide. Item prominence and quality were not differentially associated with increases in male or female suicides. Further research on this topic is required, but in the meantime there is a need to remain vigilant about how suicide news is reported. Mental health professionals and suicide experts should collaborate with media professionals to try to balance 'public interest' against the risk of harm.

Remunerating private psychiatrists for participating in case conferences.

BACKGROUND: On 1 November 2000, a series of new item numbers was added to the Medicare Benefits Schedule, which allowed for case conferences between physicians (including psychiatrists) and other multidisciplinary providers. On 1 November 2002, an additional set of numbers was added, designed especially for use by psychiatrists. This paper reports the findings of an evaluation of these item numbers. RESULTS: The uptake of the item numbers in the three years post their introduction was low to moderate at best. Eighty nine psychiatrists rendered 479 case conferences at a cost to the Health Insurance Commission of $70,584. Psychiatrists who have used the item numbers are generally positive about them, as are consumers. Psychiatrists who have not used them have generally not done so because of a lack of knowledge, rather than direct opposition. The use of the item numbers is increasing over time, perhaps as psychiatrists become more aware of their existence and of their utility in maximising quality of care. CONCLUSION: The case conferencing item numbers have potential, but as yet this potential is not being realised. Some small changes to the conditions associated with the use of the item numbers could assist their uptake.

A review of the psychometric properties of the Health of the Nation Outcome Scales (HoNOS) family of measures.

BACKGROUND: The Health of the Nation Outcome Scales was developed to routinely measure outcomes for adults with mental illness. Comparable instruments were also developed for children and adolescents (the Health of the Nation Outcome Scales for Children and Adolescents) and older people (the Health of the Nation Outcome Scales 65+). All three are being widely used as outcome measures in the United Kingdom, Australia and New Zealand. There is, however, no comprehensive review of these instruments. This paper fills this gap by reviewing the psychometric properties of each. METHOD: Articles and reports relating to the instruments were retrieved, and their findings synthesised to assess the instruments' validity (content, construct, concurrent, predictive), reliability (test-retest, inter-rater), sensitivity to change, and feasibility/utility. RESULTS: Mostly, the instruments perform adequately or better on most dimensions, although some of their psychometric properties warrant closer examination. CONCLUSION: Collectively, the Health of the Nation Outcome Scales family of measures can assess outcomes for different groups on a range of mental health-related constructs, and can be regarded as appropriate for routinely monitoring outcomes.