Can new approaches to synthesising evidence help achieve a consensus in psychotherapy research?

OBJECTIVE: The recent debate around the College's Clinical Practice Guidelines on mood disorders have highlighted differences in opinion on interpreting evidence from randomised control trials (RCTs) for psychodynamic psychotherapy. This paper discusses new techniques of synthesising research evidence (e.g., umbrella reviews) that may help minimise disagreements in the interpretation of RCTs and foster greater consensus on treatment guidelines. CONCLUSIONS: Findings from the latest umbrella review suggest that psychodynamic therapy is an evidence-based approach, among several, for common mental disorders.

Patients languishing in emergency departments: A descriptive analysis of mental health-related emergency department presentations in Australia between 2016-17 and 2020-21.

OBJECTIVE: In the context of concerns regarding hospital access block, this paper provides a descriptive longitudinal analysis of mental health-related ED episodes in Australian public hospitals between 2016-17 and 2020-21. METHOD: We descriptively analysed Australian Institute of Health and Welfare data for mental health-related ED presentations, outcomes and 5-year trends for Australian public hospitals. RESULTS: There were more than 300,000 Australian mental health-related ED presentations in 2020-21. Presentations increased by an average annual rate of 2.8% between 2016-17 and 2020-21, commonly involving first responder (police, paramedic) attendance. From 2016-17 to 2020-21, the average annual rate of mental health-related ED presentations receiving a triage category of resuscitation increased by 13.7%, emergency by 9.4% and urgent by 4.7%. 90% of MH-related ED presentations were completed within 14 h, which was longer than the 90th percentile for all ED presentations (up to 8 h). CONCLUSIONS: Current mental health policies have not stemmed the rising tide of ED presentations. Mental health-related ED presentations are increasing in number and severity, likely due to health systemic and societal factors. Psychiatry patients stay longer in EDs than other patients. Healthcare reforms should be targeted to provide the best outcome based on principles of equity of access.

Clinical update and commentary on psychiatric care for patients experiencing workplace bullying.

OBJECTIVE: To provide a brief clinical research update and commentary advice on the practical psychiatric care of patients suffering workplace bullying. CONCLUSIONS: While there is empirical research on the prevalence and impacts of workplace bullying, there is a relative dearth of clinical research into psychiatric patient care. Accordingly, we provide commentary on practical considerations that assist in psychiatric care planning and delivery.

Commentary: Is Australian headspace socioculturally westernised, educated, industrialised, rich and democratic in conceptualisation and accessibility?

OBJECTIVE: The Australian headspace model has been proposed as an internationally significant exemplar for reducing the mental health 'treatment gap' amongst young people around the world. We provide a commentary that discusses the conceptualisation and delivery of headspace services within Australia, a predominantly Westernised, Educated, Industrialised, Rich and Democratic (WEIRD) society, as well as examining accessibility and suitability for culturally and linguistically diverse (CALD) communities. CONCLUSION: headspace was conceptualised, designed, implemented and evaluated according in a WEIRD sociocultural context, and is therefore most applicable to that setting. Australia also has CALD communities, who have not seemed to access headspace in the reported patient and staff demographics. On this basis, there may be questions about the potential generalisability of headspace models outside WEIRD societies.

Psychiatrist and trainee moral injury during the organisational long COVID of Australian acute psychiatric inpatient services.

OBJECTIVE: This paper provides a commentary on the risk of moral injury amongst psychiatrists and trainees working in the acute psychiatric hospital sector, during the third winter of the COVID-19 pandemic. CONCLUSIONS: Moral injuries arise from observing, causing or failing to prevent adverse outcomes that transgress core ethical and moral values. Potentially, morally injurious events (PMIEs) are more prevalent and potent while demand on acute hospitals is heightened with the emergence of highly infectious SARS-CoV-2-Omicron subvariants (BA.4 and BA.5). Acute hospital inpatient services were already facing extraordinary stresses in the context of increasingly depleted infrastructure and staffing related to the pandemic. These stresses have a high potential to be morally injurious. It is essential to immediately fund additional staff and resources and address workplace health and safety, to seek to arrest a spiral of moral injury and burnout amongst psychiatrists and trainees. We discuss recommended support strategies.

The new World Mental Health Report: Believing impossible things.

OBJECTIVE: We examine whether the recent World Health Organization (WHO) report on global mental health uses severity of illness as a criterion in priority setting for resource allocation. CONCLUSIONS: The WHO does not prioritise severity in the recent landmark World Mental Health Report. It recommends instead the insuperable task of scaling-up interventions for broadly defined mental health conditions, including milder distress, amongst over a billion people, with the majority living in low- and middle-income countries. Schizophrenia, the most severe and disabling of all psychiatric illnesses, is relatively neglected in the WHO report, and the disability associated with bipolar disorder is underestimated. This is inconsistent with the ethical principle of vertical equity, where the most severe illnesses should receive the greatest priority. The global mental health movement must refocus on deinstitutionalisation, and ensure adequate community and general hospital treatment for severe illnesses, especially the 24 million people with schizophrenia.

Child and Adolescent Mental Health Services in Australia: A descriptive analysis between 2015-16 and 2019-20.

OBJECTIVE: To provide analysis and commentary on Australian state/territory child and adolescent mental health service (CAMHS) expenditure, inpatient and ambulatory structure and key performance indicators. METHOD: Data from the Australian Institute of Health and Welfare and the Australian Bureau of Statistics were descriptively analysed. RESULTS: Between 2015-16 and 2019-20, overall CAMHS expenditure increased by an average annual rate of 3.6%. Per capita expenditure increased at a higher rate than for other subspeciality services. CAMHS admissions had a higher cost per patient day, shorter length of stay, higher readmission rate and lower rates of significant improvement. Adolescents aged 12-17 had high community CAMHS utilisation, based on proportion of population coverage and number of service contacts. CAMHS outpatient outcomes were similar to other age-groups. There were high rates of 'Mental disorder not otherwise specified', depression and adjustment/stress-related disorders as principal diagnoses in community CAMHS episodes. CONCLUSIONS: CAMHS inpatient admissions had lower rates of significant improvement and higher 14-day readmission rates than other ages. Australia's young population had a high outpatient CAMHS contact rate. Evidence-based modelling of CAMHS providers and outcomes may inform future service improvement.

Physician leadership during the current crisis in healthcare: A perspective drawn from anthropological and clinical leadership research.

OBJECTIVES: There are ongoing challenges in workforce sustainability and service delivery due to the COVID-19 pandemic. Recruiting credible clinical leaders can enhance outcomes through mentoring, leading by example, and creating positive work environments. We investigate the anthropology of, and related research on leadership. CONCLUSIONS: Clinical and anthropological research provides strong grounds for investing in clinical leadership. The stability of 'prestige-based' leadership can be contrasted with the outcomes of 'dominance-based' leadership that relies on force, control, and threats. Dominance-based leadership increases the risks of bullying in stressed healthcare organisations. In contrast, expert clinical leaders can exert culturally mediated effects on social learning, team cooperation and morale, and patient outcomes.

More smoke and mirrors: Fifteen further reasons to doubt the effectiveness of headspace.

OBJECTIVE: Commentary on the debate concerning the effectiveness of headspace, including the most recent independent evaluation of its services. CONCLUSIONS: The available evaluations indicate that headspace does not deliver therapy of adequate duration that results in clinically significant improvement. Most evaluations have used either short-term process measures or uncontrolled satisfaction surveys, and where there have been data on outcomes using standardised instruments, findings have been disappointing. Costs are poorly quantified and probably underestimated. Even so, headspace as a primary care intervention costs twice as much as a mental health consultation by a general practitioner and, depending on the assumptions, may not be cost effective.

Commentary on the private practice implications of the Deed of Settlement in the Honeysuckle Health - NIB Australian-Competition-Tribunal-hearing.

OBJECTIVE: To provide a commentary on the implications of the Deed of Settlement in the Honeysuckle Health - nib Australian-Competition-Tribunal Hearing. This hearing has major implications in relation to the potential for a single dominant private-health-insurance buying-group to contract for medical-purchaser-provider-agreements that might limit the clinical autonomy of patients and psychiatrists. CONCLUSIONS: The Australian Competition and Consumer Commission (ACCC) authorised the formation of a joint buying-group for private-health-insurers in 2021 to provide collective contracting and related services to private-health-insurers and other healthcare-payers. A consequent legal challenge resulted in a Deed of Settlement on 18 July 2022 that for 5 years preserves doctor-patient autonomy in clinical decision-making, the medical gaps scheme, the transparency of contractual arrangements, and if clinical data of those insured are collected by HH-nib, it must be with the full informed consent of patients. However, there remain options for private-health-insurers to apply for formation of new buying-groups, as well as to collect data and profile the general public and insured patients using online programs. Vigilance on private-health-insurer buying-groups, and the potential for US-style managed-care is warranted.

The Consortium of Australian Academic Psychiatrists for Independent Policy Research and Analysis (CAPIPRA): Aims, model, outputs, and implications for clinical academic advocacy.

OBJECTIVE: We describe an independent model of clinical academic mental health services research that is able to provide synthesised views for medico-political organisations that are engaged in advocacy for national and state evidence-based policy and planning of mental healthcare. CONCLUSIONS: CAPIPRA focuses on independent research and policy analysis using publicly available datasets on population mental health at national and state/territory levels, published in international and national peer-reviewed journals (>50 papers since 2019). We partner with medico-political organisations in evidence-based advocacy across a wide range of issues.

Private psychiatric hospital care in Australia: a descriptive analysis of casemix and outcomes.

OBJECTIVE: To provide a rapid clinical update on casemix, average length of stay, and the effectiveness of Australian private psychiatric hospitals. METHODS: We conducted a descriptive analysis of the publicly available patient data from the Australian Private Hospitals Association Private Psychiatric Hospitals Data Reporting and Analysis Service website, from 2015-2016 to 2019-2020. This was compared with corresponding reporting on public and private hospitals from the Australian Institute of Health and Welfare, and Australian Mental Health Outcomes and Classification Network. RESULTS: In 2019-2020, there were 72 private psychiatric hospitals in Australia with 3582 acute beds. There were 42,942 inpatients with 1,286,470 days of care, and a mean length of stay 19.6 days (SD 13.9) for the financial year 2019-2020. The main diagnoses were major affective and other mood disorders (49%), and alcohol and other substance abuse disorders (21%). Clinician-rated outcome measures, that is, the HoNOS, showed an improvement effect size of 1.64, while the patient-rated MHQ-14 showed an improvement effect size of 1.18. Results are similar for previous years. CONCLUSIONS: Private psychiatric hospitals provide substantial, effective psychiatric care.

Is there a missing-middle in Australian mental health care?

OBJECTIVE: The term 'missing-middle' has been prominent in discourse relating to provision of mental health care in Australia, particularly by proponents of non-governmental youth mental health services such as headspace and related adult services. We investigate whether there is an empirical basis for use of the 'missing-middle' term, founded on qualitative and quantitative research. CONCLUSIONS: Despite the widespread use of the term 'missing-middle' for advocacy in Australia, there is a lack of research characterising the epidemiological characteristics of the group. The validity of advocacy predicated on the basis of the 'missing-middle' care-gap should be reconsidered. Research, such as systematic service mapping and health needs assessment, is a necessary foundation for evidence-based mental healthcare policy, planning and implementation. Without such research, vital government funds may be deployed to 'missing-middle' programmes that may not improve Australian public health outcomes.

Telepsychiatry and face-to-face psychiatric consultations during the first year of the COVID-19 pandemic in Australia: patients being heard and seen.

OBJECTIVE: The Australian federal government introduced additional Medicare Benefits Schedule (MBS) telehealth-items to facilitate care by private psychiatrists during the COVID-19 pandemic. METHOD: We analysed private psychiatrists' uptake of video and telephone-telehealth, as well as total (telehealth and face-to-face) consultations for April 2020-April 2021. We compare these to face-to-face consultations for April 2018-April 2019. MBS-Item service data were extracted for COVID-19-psychiatrist-video- and telephone-telehealth item numbers and compared with face-to-face consultations for the whole of Australia. RESULTS: Psychiatric consultation numbers (telehealth and face-to-face) were 13% higher during the first year of the pandemic compared with 2018-2019, with telehealth accounting for 40% of this total. Face-to-face consultations were 65% of the comparative number of 2018-2019 consultations. There was substantial usage of telehealth consultations during 2020-2021. The majority of telehealth involved short telephone consultations of ⩽15-30 min, while video was used more, in longer consultations. CONCLUSIONS: Private psychiatrists and patients continued using the new telehealth-items during 2020-2021. This compensated for decreases in face-to-face consultations and resulted in an overall increase in the total patient contacts compared to 2018-2019.

Mental health services need action on organisational culture and justice.

OBJECTIVE: A commentary on the usefulness of the concepts of organisational culture, organisational climate and justice on the quality and safety of mental health services and how conditions may be improved. CONCLUSIONS: Organisational culture, organisational climate and justice impact upon the quality and safety of care, as well as well-being of staff, in mental health services. Psychiatrists and trainees, should consider, act and advocate for improved organisational culture, climate and justice. Improvement in these organisational domains can be achieved, through a coordinated framework that acts across all levels of administration, mid-level management and frontline clinical staff.

National Mental Health Performance Framework: Descriptive analysis of state and national data for 2019-2020.

OBJECTIVE: To compare key performance indicators for public state and territory specialist mental health services in Australia. METHODS: A descriptive analysis of the publicly-available National Mental Health Performance Framework key performance indicators (KPI), hosted by the Australian Institute of Health and Welfare for 2019-2020, at the national level and for states and territories. RESULTS: The real-world performance of public mental health services varied across the eight states and territories of Australia. Western Australia had the longest acute hospital stays and the lowest rates of involuntary admissions. Queensland (QLD) had the shortest acute hospital stays at the lowest cost. While the Australian Capital Territory had the highest rates of community treatment at the lowest cost, the Northern Territory had highest hospital and community costs with the most involuntary admissions. Victoria (VIC) had the lowest population percentage receiving specialised mental health services, the highest readmission rates after 28 days, and highest physical and mechanical restraint rates. CONCLUSIONS: The KPIs indicate that some states and territories show deviations from national benchmarks that may be important for consumers, carers and clinicians. For further improvement in quality and efficiency, more detailed contextual information is required, including detailed mapping of services.

Report of the House of Representatives Select Committee on Mental Health and Suicide Prevention: Commentary on an expanded psychologist role and decreased GP/psychiatrist leadership in private multidisciplinary primary mental healthcare.

OBJECTIVE: This opinion paper discusses certain recommendations of the House of Representatives Select Committee on Mental Health and Suicide Prevention pertaining to psychology, GP and psychiatric professions. CONCLUSIONS: The Committee's recommendations may compromise patient care by undermining the ability of private sector medical specialists in providing direct clinical treatment and their role in the coordination of multidisciplinary teams. Expanding private psychological therapies without GP and private psychiatry support might increase the reliance on public hospital emergency departments and public sector mental health services for severe disorders and suicidal crises. Psychiatrists and GPs need to engage in more effective policy advocacy with the Australian Government, in order to maintain their roles in leading private sector collaborative multidisciplinary care.

The Emperor's New Clothes: Head-to-Health Centres expand in the absence of evaluation of efficacy.

OBJECTIVE: To discuss concerns about the Australian federal government announcement of further funding expansion of the Adult Mental Health Centres (AMHCs), now known as Head-to-Health centres. CONCLUSIONS: The expansion of AMHCs prior to evaluation recapitulates the policy predicaments and perils of the headspace federal-infrastructure allied-health private-practice model. Comprehensive evidence-based mental healthcare planning and practice is needed, rather than stand-alone services of unclear efficacy. We describe the principles of such an approach based upon an evidence-based Health Needs Assessment.

Rapid review and commentary on the clinical implications of the population mental health consequences of the COVID-19 pandemic in Australia.

OBJECTIVE: To provide a rapid clinical review and commentary for psychiatrists on the population mental health consequences of the COVID-19 pandemic in Australia, including evidence-based findings and interventions. CONCLUSIONS: Whilst there was evidence of collective psychological resilience during the first 2 years of the COVID-19 pandemic, younger women, carers for those with COVID-19, and those with more household chores, childcare needs and higher economic strain, were at more risk. Interventions should therefore target people with these socio-demographic risk factors, as well as severe COVID-19 survivors, their relatives and frontline workers. However, the rapid spread of the Omicron SARS-CoV-2 variant has the potential for greater impacts on population mental health. Innovations in telehealth and online therapy should be incorporated into standard care. Ongoing research is needed to assess who remains most vulnerable to negative mental health impacts of the current pandemic, and especially the longer term outcomes of mental ill health. Further research should also investigate evidence-based approaches to resilience and well-being. Prospective risk/benefit analyses of infection control measures, economic effects and mental health consequences are needed.

Psychiatrist and trainee burnout: Commentary and recommendations on management.

OBJECTIVE: To comment upon the evidence-base regarding psychiatrist and trainee burnout and provide recommendations on management. CONCLUSIONS: Burnout has been conceptualised as a specific stress-related response, primarily related to work. There is a high prevalence of burnout amongst both trainees and psychiatrists internationally, with substantial consequences for personal and family wellbeing, organisational efficiency and patient care. We summarise the evidence on organisational and individual approaches to addressing burnout.