How can mental health practitioners collaborate with child welfare practitioners to improve mental health for young people in out of home care?

BACKGROUND: Young people who grow up in out of home care have higher risk of poor mental health outcomes than peers who grow up with their family-of-origin. Interagency collaboration is an important service-level intervention to improve access to mental healthcare. However, few descriptions of collaboration provide guidance about collaboration between individual practitioners. AIM: This substudy aimed to contribute to a larger study-the Ripple project-through exploring the experiences of practitioners working across child welfare and mental health services regarding collaboration in the care of young people; and to identify practices that might enhance collaborative work and improve mental health outcomes. METHODS: Practitioners from across child welfare and mental health services were purposively sampled and participated in focus groups. Recordings and transcriptions of focus groups were analysed to identify themes within and between groups. A cross-sector expert advisory group was involved in this work. RESULTS: Focus groups were convened with 43 practitioners. We identified four themes during analysis, these were: shared understanding of the history and context of problems; specific skills and practices; self-awareness of workers and carers; and involving and supporting carers. CONCLUSIONS: A number of practices were identified that might lead to enhanced collaboration between agencies and across interdisciplinary care teams. Supporting mental health practitioners to adopt these might assist interagency and interdisciplinary working.

Promoting mental health in out of home care in Australia.

Young people in out of home care (OoHC) typically have worse mental health outcomes than peers who grow up within a family of origin. Innovations to improve the mental health of this group have tended to focus on pathology rather than mental health promotion and prevention of mental illnesses, and are often costly and challenging to implement. This qualitative study explored perspectives from young people with experience of OoHC in Melbourne, Australia regarding the promotion of mental health in OoHC. The study informed the subsequent development of a system-level intervention to support workers and carers in OoHC and evaluation of its implementation, the Ripple study. We conducted thematic analysis of data from interviews and focus groups with 14 young people aged 18-24 years with diverse identities and experiences of foster, kinship and residential care. We identified four key themes. These were providing a home-like environment; having someone to talk to; connecting to the wider community and having opportunities to become an active citizen. There is a need for both mental health promotion and treatment approaches in interventions to support workers and carers and young people in OoHC. Mental health promotion strategies should include a focus on enhancing existing capacities of carers and workers. Mental health promotion for young people in OoHC depends on strong intersectoral collaboration and youth participation.

'Getting our voices out there': acceptability of a mental health participation programme for young people with out of home care experience in Australia.

Youth with experience of out-of-home-care (OoHC) typically have poorer mental health than their peers in the general population, and lack opportunities to contribute to service planning. Promoting mental health through leadership training may improve young people's mental health and facilitate system change. The Bounce Project is a pilot youth-leadership mental health training programme co-designed with young people who have experienced OoHC. In this study, we evaluated the Bounce Project from the young people's perspectives to explore the acceptability, successes and limitations of the training to promote the participant's mental health and their contribution to system level change. Thirteen young people aged 18-26 years old who had experienced OoHC and participated in the Bounce Project were interviewed. Semi-structured interviews were conducted and thematically analysed. Four major themes were thereby identified: making their mark; opportunities for growth; redefining roles and pitfalls of research participation. Participants valued the opportunity to have their voices heard, participate in research and learn about mental health. Perceived negative aspects included infrequent participation opportunities, interpersonal difficulties and frustration about the limitations of research including pressure to recruit and restrictive deadlines. Participating in the Bounce Project was a mostly positive experience, but young people also encountered barriers to meaningful participation. Youth with lived experience need more avenues to participate in research and leadership, but research programmes require specific designs that take into consideration the needs of participants and create opportunities for effective and meaningful participation.

Supported decision-making from the perspectives of mental health service users, family members supporting them and mental health practitioners.

BACKGROUND: Supporting the decision-making of mental health service users fulfils professional, ethical and moral obligations of mental health practitioners. It may also aid personal recovery. Previous research on the effectiveness of supported decision-making interventions is limited. AIMS: The study aims to explore from several perspectives the barriers and facilitators to supported decision-making in an Australian context. Supported decision-making was considered in terms of interpersonal experiences and legal supported decision-making mechanisms. METHODS: In all, 90 narrative interviews about experiences of supported decision-making were conducted and analysed. Participants were mental health service users who reported diagnoses of schizophrenia, psychosis, bipolar disorder and severe depression; family members supporting them and mental health practitioners, including psychiatrists. The data were analysed thematically across all participants. RESULTS: Negative interpersonal experiences in the mental health care system undermined involvement in decision-making for people with psychiatric diagnoses and family carers. Mental health practitioners noted their own disempowerment in service systems as barriers to good supported decision-making practices. All groups noted the influence of prevailing attitudes towards mental health service users and the associated stigma and discrimination that exist in services and the broader community. They believed that legal supported decision-making mechanisms facilitate the participation of mental health service user and their family supporters in supported decision-making. CONCLUSIONS: Enabling supported decision-making in clinical practice and policy can be facilitated by (1) support for good communication skills and related attitudes and practices among mental health practitioners and removing barriers to their good practice in health and social services and (2) introducing legal supported decision-making mechanisms.

Placement Instability Among Young People Removed from Their Original Family and the Likely Mental Health Implications.

BACKGROUND: Young people in out-of-home care are more likely to experience poorer mental and physical health outcomes related to their peers. Stable care environments are essential for ameliorating impacts of disruptive early childhood experiences, including exposure to psychological trauma, abuse and neglect. At present there are very few high quality data regarding the placement stability history of young people in out-of-home care in Australia or other countries. OBJECTIVES: To undertake the first systematic census of background, care type and placement stability characteristics of young people living in the out-of-home care sector in Australia. METHODS: Data was collected from four non-government child and adolescent community service organisations located across metropolitan Melbourne in 2014. The sample comprised 322 young people (females 52.8%), aged between 12 - 17 years (mean age=14.86 [SD=1.63] years). RESULTS: Most young people (64.3%) were in home-based care settings (i.e., foster care, therapeutic foster care, adolescent care program, kinship care, and lead tenant care), relative to residential care (35.7%). However, the proportion in residential care is very high in this age group when compared with all children in out-of-home care (5%). Mean age of first removal was 9 years (SD=4.54). No gender differences were observed for care type characteristics. Three quarters of the sample (76.9%) had a lifetime history of more than one placement in the out-of-home care system, with more than a third (36.5%) having experienced ≥5 lifetime placements. Relative to home-based care, young people in residential care experienced significantly greater placement instability (χ2=63.018, p<0.001). CONCLUSIONS: Placement instability is common in the out-of-home care sector. Given stable care environments are required to ameliorate psychological trauma and health impacts associated with childhood maltreatment, well-designed intervention-based research is required to enable greater placement stability, including strengthening the therapeutic capacities of out-of-home carers of young people.

A controlled trial of implementing a complex mental health intervention for carers of vulnerable young people living in out-of-home care: the ripple project.

BACKGROUND: Out-of-home care (OoHC) refers to young people removed from their families by the state because of abuse, neglect or other adversities. Many of the young people experience poor mental health and social function before, during and after leaving care. Rigorously evaluated interventions are urgently required. This publication describes the protocol for the Ripple project and notes early findings from a controlled trial demonstrating the feasibility of the work. The Ripple project is implementing and evaluating a complex mental health intervention that aims to strengthen the therapeutic capacities of carers and case managers of young people (12-17 years) in OoHC. METHODS: The study is conducted in partnership with mental health, substance abuse and social services in Melbourne, with young people as participants. It has three parts: 1. Needs assessment and implementation of a complex mental health intervention; 2. A 3-year controlled trial of the mental health, social and economic outcomes; and 3. Nested process evaluation of the intervention. RESULTS: Early findings characterising the young people, their carers and case managers and implementing the intervention are available. The trial Wave 1 includes interviews with 176 young people, 52% of those eligible in the study population, 104 carers and 79 case managers. CONCLUSIONS: Implementing and researching an affordable service system intervention appears feasible and likely to be applicable in other places and countries. Success of the intervention will potentially contribute to reducing mental ill-health among these young people, including suicide attempts, self-harm and substance abuse, as well as reducing homelessness, social isolation and contact with the criminal justice system. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry ACTRN12615000501549 . Retrospectively registered 19 May 2015.

Meeting the primary care needs of young people in residential care.

BACKGROUND: Young people in out-of-home care, especially those with a history of multiple placements, typically have numerous and complex health needs, and worse health outcomes than their peers who grow up within a family of origin. A significant proportion of this can be attributed to policy failures and poor interagency communication. OBJECTIVE: The objective of this article is to describe the factors that contribute to the health needs of young people in out-of-home care and the tools available to support general practitioners (GPs) to provide care. DISCUSSION: GPs are crucial in the early detection of health problems and intervention for this vulnerable population. Marked social and relational problems make the high-priority task of creating a safe and trusting environment a challenge. GPs must also work within the statutory requirements of each state and territory, and navigate the complex out-of-home care system. Using recommended frameworks and maintaining effective communication and support will improve outcomes for these young people, their families and the community.

People living with psychosocial disability: Rehabilitation and recovery-informed service provision within the second Australian national survey of psychosis.

OBJECTIVE: People with psychosocial disability are an important, although often neglected, subgroup of those living with severe and persistent mental illness. Rehabilitation, provided through clinical and non-government organisations in Australia, may contribute to their personal recovery goals. We hypothesised that people with psychoses with the greatest disability and complex needs would receive services from both sectors, reflecting treatment and rehabilitation needs. METHOD: Participants in the 2010 Australian national survey of psychosis (n = 1825) were interviewed to assess demographic, functional, mental and physical health characteristics and service use in the previous year. Two subgroups were created and compared: those using services from community mental health with, and without, non-governmental organisation involvement. Group membership was predicted by hierarchical logistic regression using variables selected on a priori grounds. Usefulness of the final model was examined by calculating improvement over the rate of accuracy achievable by chance alone. RESULTS: The model was statistically significant but fell just short of useful (criterion 71.6%, model achieved 70.6%). Four independent variables contributed uniquely to predicting whether participants received both services (never married, childhood trauma, group accommodation, poor global functioning) consistent with the hypothesis. However, severe dysfunction in socialising was less likely to predict membership of the combined services group when compared with no dysfunction (p = 0.001, odds ratio = 0.384, confidence interval = [0.218, 0.677]), as was current smoking compared with none (p = 0.001, odds ratio = 0.606, confidence interval = [0.445, 0.824]). CONCLUSION: Findings suggest services provided by non-governmental organisations are targeted to those with the greatest disability although targeting could be improved. A subgroup of people with psychosis and severe disability in community mental health services do not access non-governmental services. Their unmet needs for rehabilitation and recovery have important implications for future development of community mental health, including the non-governmental sector.

Promoting mental health in Asia-Pacific: Systematic review focusing on Thailand and China.

Mental health is essential for functioning, general health, and quality of life in low and middle-income countries (LAMICs), as for high-income countries. This study aimed first to search in the English language peer-reviewed literature for reviews of mental health promotion interventions in the Asia-Pacific region. A global rapid review by Barry and colleagues indicated a paucity of publications on this topic in the peer-reviewed literature. The second aim of the study followed from this observation. Two systematic reviews of English language literature were conducted as case studies in two countries with known interest in mental health promotion, Thailand and China. The reviews covered publications in peer-reviewed journals and the "grey" literature. In Thailand, the review demonstrated: strong evidence for an empowerment program for human immunodeficiency virus (HIV)-infected mothers; a reduction in HIV-related stigma in a community-based program; and a coping program for adolescents. The second review concerned suicide prevention interventions in China. It found one relevant study, a WHO multi-site study of suicide prevention. We found surprisingly little evidence in either country of interventions focused on health equity or modifying the social determinants of mental health. We agree with Barry and colleagues that there is an urgent need to invest in the policy, practice, and research capacity for mental health promotion in LAMICs so that mental health promotion can be incorporated into the wider health promotion and global health development agenda. This includes the Global Action for Health Equity Network. Evidence-based interventions in parenting, schools, workplaces, and among older people can be initiated or adapted and evaluated in LAMIC settings.

Predictors of exercise in individuals with schizophrenia: A test of the transtheoretical model of behavior change.

INTRODUCTION: Mortality in individuals with schizophrenia, including deaths not attributable to accidents and suicide, is at least twice that of the general population. While increasing physical exercise could promote positive mental and physical health outcomes in individuals with schizophrenia, only one other study of the determinants of exercise within this population has been reported. Our study attempts to resolve this void in knowledge by testing the applicability of the transtheoretical model (TTM) of behavior change to predicting exercise behavior in those with schizophrenia. METHODS: Forty-nine participants (42 with schizophrenia and 7 with schizoaffective disorder) from three community mental health centers in Melbourne, Australia, completed a series of questionnaires, an interview, physical health measures, and had their medical records examined. These measures were used: TTM exercise stage, TTM mediators of change, health status, health-risk behaviors, use of antipsychotic medications, psychopathology, psychiatric history, and demographic information. Variables found to be significantly correlated with exercise stage were then included in a series of regression analyses to determine their relative predictive power for exercise stage. RESULTS: The results demonstrated that the TTM and its associated measures may be valid for integration into interventions for promoting exercise in individuals with schizophrenia, despite high levels of psychopathology symptoms. CONCLUSIONS: Routine clinical practice should promote exercise in people with schizophrenia and the TTM may be of benefit to this end. Strategies that promote exercise when self-perceived poor health is seen as a significant barrier are particularly important, as is the reduction of caffeine consumption and other health-adverse behaviors.

Promoting resilience in adults with experience of intimate partner violence or child maltreatment: a narrative synthesis of evidence across settings.

BACKGROUND: People who have experienced intimate partner violence (IPV) or child maltreatment (CM) are at risk of having lower resilience and adverse psychological outcomes. In keeping with the social and environmental factors that support resilience, there is a need to take a public health approach to its investigation and to identify existing initiatives in particular settings and populations that can guide its deliberate promotion. METHOD: This narrative synthesis examines quantitative and qualitative studies of interventions with resilience-related outcomes in specified health and other settings. Clinical RCTs are excluded as beyond the scope of this review. RESULTS: Twenty studies were identified for review in several settings, consisting of 14 quantitative studies, 2 review studies, 2 qualitative studies and 2 mixed-methods studies. Three quantitative studies produced strong evidence to support: a home visitation program for at-risk mothers; a methadone program for women and a substance abuse program. This review reveals that few studies use specific resilience measures. CONCLUSIONS: The topic has been little studied despite high needs for public health interventions in countries of all types. Interventions and research studies that use specific resilience measures are likely to help measure and integrate what is currently a disparate area. IMPLICATIONS: The participation of people with IPV or CM history in program and research design and implementation is indicated to support advocacy, innovation and sustainable interventions. This is especially pertinent for interventions in LAMIC and indigenous settings where continuing programs are sorely needed.

Cigarette smoking and interest in quitting among consumers at a Psychiatric Disability Rehabilitation and Support Service in Victoria.

OBJECTIVE: To gather information on smoking rates and interest in smoking cessation among consumers at a Psychiatric Disability Rehabilitation and Support Service (PDRSS). METHOD: A questionnaire was offered to all consumers at Neami Victoria by support staff in March 2007. Two hundred and eighty people (81%) completed the survey. Relationships between categorical variables were analysed using Fischer's exact test (p=0.05). RESULTS: Sixty-two per cent of consumers were smokers. Twelve per cent had previously quit smoking. PDRS consumers smoked 50% more than the general population and high rates (17%) of illegal tobacco smoking were identified. Fifty-nine per cent of smokers wanted to quit while 74% wanted to reduce. CONCLUSIONS: While smoking rates were almost four times higher than the general population, interest in quitting and cutting down was also high. IMPLICATIONS: Opportunities exist for public health advocates to collaborate with PDRSSs to increase knowledge related to smoking harms, and to reduce smoking in this group.

Characteristics of smokers with a psychotic disorder and implications for smoking interventions.

Despite high rates of smoking among people with psychotic disorders, and the associated health and financial burden, few studies have investigated the characteristics of this group of smokers. This paper reports data from 298 smokers with an ICD-10 psychotic disorder residing in the community (56.7% with schizophrenia or schizoaffective disorder), including an examination of their demographic and clinical characteristics, smoking behaviours, severity of nicotine dependence, stage of change, and reasons for smoking and for quitting. Standardized self-report instruments were used, in conjunction with structured interviews, as part of the first phase of a randomized controlled trial. On average, participants smoked 30 cigarettes per day, commenced smoking daily at about 18 years of age (5 years before illness onset), and had made 2-3 quit attempts in their lifetime. Higher levels of nicotine dependence and concurrent hazardous use of alcohol or cannabis were associated with a younger age at smoking initiation. The present sample was also more likely to report stress reduction, stimulation and addiction as reasons for smoking, compared to a general sample of smokers. Males, precontemplators and participants with concurrent hazardous substance use cited fewer reasons for quitting smoking. These and other subgroup differences in smoking characteristics are used to illustrate potential implications for the nature and timing of smoking interventions among people with a psychotic disorder.

Smoking cessation in schizophrenia. General practice guidelines.

BACKGROUND: The rate of cigarette smoking in people with schizophrenia is up to three times that of the general population, and causes much ill health and high mortality rates. There are physiological and pharmacological interactions between the symptoms of schizophrenia, antipsychotic medication and smoking which contribute to this high rate and make it more difficult for those with schizophrenia to cease smoking. OBJECTIVE: This article aims to inform general practitioners of the extent and nature of the problem, and ways to assist people with schizophrenia to reduce/cease smoking. DISCUSSION: Patients with schizophrenia often experience physical, financial and social disadvantages because of their illness. Actively encouraging and assisting smoking reduction/cessation is important to improve their quality of life as well as longevity.