Implementing mental health screening within a youth alcohol and other drugs service

Integrated care – panacea or white elephant? A review of integrated care approaches in Australia over the past two decades

Purpose

Integrated care is widely supported as a means of improving treatment outcomes for people with co-occurring mental health and substance use disorders. Over the past two decades, Australian state and federal governments have identified integrated care as a policy priority and invested in a number of research and capacity building initiatives. This study aims to examine Australian research evaluating the effectiveness of integrated treatment approaches to provide insight into implications for future research and practice in integrated treatment.

Design/methodology/approach

This narrative review examines Australian research evaluating empirical evidence of the effectiveness of integrated treatment approaches within specific populations and evidence from initiatives aimed at integrating care at the service or system level.

Findings

Research conducted within the Australian context provides considerable evidence to support the effectiveness of integrated approaches to treatment, particularly for people with high prevalence co-occurring disorders or symptoms of these (i.e. anxiety and depression). These have been delivered through various modalities (including online and telephone-based services) to improve health outcomes in a range of populations. However, there is less evidence regarding the effectiveness of specific models or systems of integrated care, including for more severe mental disorders. Despite ongoing efforts on behalf of the Australian government, attempts to sustain system-level initiatives have remained hampered by structural barriers.

Originality/value

Effective integrated interventions can be delivered by trained clinicians without requiring integration at an organisational or structural level. While there is still considerable work to be done in terms of building sustainable models at a system level, this evidence provides a potential foundation for the development of integrated care models that can be delivered as part of routine practice.

Barriers and Facilitators of Responding to Problem Gambling: Perspectives from Australian Mental Health Services

Despite high rates of comorbidity between problem gambling and mental health disorders, few studies have examined barriers or facilitators to the implementation of screening for problem gambling in mental health services. This exploratory qualitative study identified key themes associated with screening in mental health services. Semi-structured interviews were undertaken with 30 clinicians and managers from 11 mental health services in Victoria, Australia. Major themes and subthemes were identified using qualitative content analysis. Six themes emerged including competing priorities, importance of routine screening, access to appropriate screening tools, resources, patient responsiveness and workforce development. Barriers to screening included a focus on immediate risk as well as gambling being often considered as a longer-term concern. Clinicians perceived problem gambling as a relatively rare condition, but did acknowledge the need for brief screening. Facilitators to screening were changes to system processes, such as identification of an appropriate brief screening instrument, mandating its use as part of routine screening, as well as funded workforce development activities in the identification and management of problem gambling.

Clinician identification of elevated symptoms of depression among individuals seeking treatment for substance misuse

BACKGROUND

Depression is common among those experiencing alcohol and other drug (AOD) disorders. It has been suggested that identifying depressive symptoms among this group is important for case management. Despite this, there is a lack of research examining how well clinicians perform this task within this setting.

AIMS

To determine the: (i) accuracy of clinician identified elevated symptoms of depression among clients seeking treatment for AOD misuse as compared to a standardized self-report psychiatric screening tool; and (ii) clinician and client characteristics associated with accurate identification of elevated symptoms of depression.

METHODS

The study used a descriptive cohort design. Participants from two Australian AOD outpatient clinics reported demographic data and completed the Patient Health Questionnaire (PHQ-9) to identify elevated symptoms of depression. Clinicians were asked to indicate the presence or absence of depression for individual clients. Client and clinician data were compared.

RESULTS

Sensitivity of clinician identified elevated symptoms of depression, compared with the PHQ-9, was moderate at 73.0% (95% CI=63.7, 81.0) and specificity was low with 49.5% (95% CI=39.9, 61.2) accurately identified as not having elevated symptoms of depression. AOD clinicians' years' of experience, clients' main substance and length of treatment were associated with accuracy of identification.

CONCLUSION

Clinicians identify elevated symptoms of depression with moderate accuracy amongst individuals with AOD disorders. There is a tendency to over-identify which may contribute to inaccuracies. Routine screening may assist in improving identification of depressive symptoms and place greater focus on mental health comorbidities.

Strategies to facilitate integrated care for people with alcohol and other drug problems: a systematic review

Background

There is a growing body of research highlighting the potential benefits of integrated care as a way of addressing the needs of people with alcohol and other drug (AOD) problems, given the broad range of other issues clients often experience. However, there has been little academic attention on the strategies that treatment systems, agencies and clinicians could implement to facilitate integrated care.

Methods

We synthesised the existing evidence on strategies to improve integrated care in an AOD treatment context by conducting a systematic review of the literature. We searched major academic databases for peer-reviewed articles that evaluated strategies that contribute to integrated care in an AOD context between 1990 and 2014. Over 2600 articles were identified, of which 14 met the study inclusion criteria of reporting on an empirical study to evaluate the implementation of integrated care strategies. The types of strategies utilised in included articles were then synthesised.

Results

We identified a number of interconnected strategies at the funding, organisational, service delivery and clinical levels. Ensuring that integrated care is included within service specifications of commissioning bodies and is adequately funded was found to be critical in effective integration. Cultivating positive inter-agency relationships underpinned and enabled the implementation of most strategies identified. Staff training in identifying and responding to needs beyond clinicians’ primary area of expertise was considered important at a service level. However, some studies highlight the need to move beyond discrete training events and towards longer term coaching-type activities focussed on implementation and capacity building. Sharing of client information (subject to informed consent) was critical for most integrated care strategies. Case-management was found to be a particularly good approach to responding to the needs of clients with multiple and complex needs. At the clinical level, screening in areas beyond a clinician's primary area of practice was a common strategy for facilitating referral and integrated care, as was joint care planning.

Conclusion

Despite considerable limitations and gaps in the literature in terms of the evaluation of integrated care strategies, particularly between AOD services, our review highlights several strategies that could be useful at multiple levels. Given the interconnectedness of integrated care strategies identified, implementation of multi-level strategies rather than single strategies is likely to be preferable.

Electronic supplementary material

The online version of this article (doi:10.1186/s13011-017-0104-7) contains supplementary material, which is available to authorized users.

Alcohol, drug and related health and wellbeing issues among young people completing an online screen

OBJECTIVE

Despite high levels of alcohol use, drug use and risky behaviors, rates of help-seeking amongst young people are typically low. This study explored the profile of young people (under the age of 25 years) completing an online screen, assessing substance use problem severity and wellbeing in comparison with adults completing the same screen, so as to inform development of better targeted approaches for this in-need population.

METHODS

Between 2012 and 2014, an online alcohol and drug screen was promoted across Australia on a national online counseling service. The screen assessed severity of substance use, mental health and wellbeing.

RESULTS

A total of 2939 screens were completed between December 2012 and May 2014, with 18% completed by young people. Young people reported a high severity of substance use problems (44% reported likely drug dependence) and reported significantly poorer mental health and wellbeing than adults completing the screen. This suggests that there is a population of young people in need of support who could be initially engaged through online screening.

CONCLUSIONS

Online screening should be a key component of engagement strategies for adolescent and early adult help-seeking.

Introducing mental health and substance use screening into a community-based health service in Australia: usefulness and implications for service change

Mental health issues such as depression or anxiety and alcohol or other drug (AOD) problems often remain undiagnosed and untreated despite their prevalence in the community. This paper reports on the implementation and evaluation of an AOD and depression/anxiety screening programme within two Community Health Services (CHS) in Australia. Study 1 examined results from 5 weeks of screening (March-April 2008) using the Patient Health Questionnaire (two- and nine-item, Kroenke et al. 2001, 2003), the Conjoint Screen for Alcohol and other Drug Problems (Brown et al. 2001) and the Alcohol, Smoking and Substance Involvement Screening Test (Humeniuk & Ali 2006). Of the 55 clients screened, 33% were at risk of depression or anxiety, 22% reporting moderate-severe depression. Thirteen per cent were at risk of substance use disorders. A substantial proportion of at-risk clients were not currently accessing help for these issues from the CHS and therefore screening can facilitate identification and treatment referral. However, the majority of eligible clients were not screened, limiting screening reach. A second study evaluated the screening implementation from a process perspective via thematic analysis of focus group data from six managers and 14 intake/assessment workers (April 2008). This showed that when screening occurred, it facilitated opportunities for education and intervention with at-risk clients, although cultural mores, privacy concerns and shame/stigma could affect accuracy of screen scores at times. Importantly, the evaluation revealed that most decisions not to screen were made by workers, not by clients. Reasons for non-screening related to worker discomfort in asking sensitive questions and/or managing client distress, and a reluctance to spend long periods of time screening in time-pressured environments. The evaluation suggested that these problems could be resolved by splitting screening responsibilities, enhancing worker training and expanding follow-up screening. Findings will inform any community-based health system considering introducing screening.

Implementation and evaluation of brief depression and anxiety screening in clients contacting a drug and alcohol service

INTRODUCTION AND AIMS

High prevalence mental health (HPMH) comorbidity is common in clients seeking alcohol and other drug (AOD) treatment yet can remain undetected. Although research has reported on the introduction of screening into AOD services, little research has reported on the processes surrounding the introduction or evaluated its effectiveness. This study reports on the implementation and evaluation of brief anxiety and depression screening within a specialised, publicly funded AOD service in South-East Victoria.

DESIGN AND METHODS

Study one examined the implementation of standardised HPMH screening with 114 adult clients (Mean age=35.49, SD=9.53; 64% male) telephoning an AOD service over a 5week period. Measures included severity of HPMH problems, AOD use, care plans and referrals. Study two used semistructured interviews with nine staff/managers to evaluate the effectiveness of screening and its impact on service delivery.

RESULTS

Ninety-four per cent of clients were identified at risk of anxiety or depression. Most care plans incorporated counselling, and concurrent referrals commonly involved a general practitioner. Staff and management found systematic screening increased identification and understanding of comorbid issues and enhanced client interaction but impacted on resource requirements.

DISCUSSION AND CONCLUSIONS

Most AOD treatment seekers were identified HPMH comorbid and care plans generally included counselling. Adjunctive referrals were more common for severely depressed clients. Screening was effective and enhanced client rapport. Evaluations revealed low confidence in treating HPMH issues in-house. Training may increase worker confidence in managing mental health interventions with subclinical cases, enhancing services' ability to move towards dual diagnosis capability.

Validity study of Kessler's psychological distress scales conducted among patients admitted to French emergency department for alcohol consumption-related disorders

BACKGROUND

Alcohol-related disorders (ARD) encountered in emergency departments (ED) have a high prevalence and are underestimated. It is necessary to provide professionals with a tool to identify patients in whom there is a risk that alcohol-related and mental health problems may be associated. Kessler's K6/10 psychological distress scales are fast, easy-to-use, and have been shown to achieve a good performance in the identification of psychological distress associated with ARD.

AIM

The aim of this study was to evaluate the psychometric properties of the Kessler scales, version 6 and 10, with a sample of patients admitted to EDs for alcohol consumption.

METHODS

On the day after their admission, with a zero "blood" alcohol concentration, 71 patients were randomly assigned to be assessed using 6 or 10 items version. The internal consistency and factor structure of the K6/10 versions were examined. Convergent validity was measured using the Hospital Anxiety and Depression Scale (HADS) and the Hamilton Depression Rating Scale (HDRS).

RESULTS

The prevalence of psychological distress in our sample was approximately 60%. The selected threshold scores were 10 for K6 (Sensitivity: 0.92; Specificity: 0.62) and 14 for K10 (Sensitivity: 0.95; Specificity: 0.54). The Cronbach coefficients for K6 and K10 were 0.76 and 0.84, respectively. The factor analyses indicated the multidimensional nature of K6/10. The 2 versions, containing 6 and 10 items respectively, correlated better with the HADS (0.83 and 0.70, respectively) than with the HDRS (0.51 and 0.49, respectively). The areas under the ROC Curve indicated a high level of accuracy for both the K6 (0.87) and the K10 (0.77). The difference was not statistically significant.

CONCLUSIONS

This study confirms the good psychometric characteristics of Kessler's psychological distress scale. Even though similar performances were observed for K6/10, the brevity of the K6 makes it more suitable for use in EDs.