Mental health service system improvement: translating evidence into policy

Cost-utility analysis of adjunct repetitive transcranial magnetic stimulation for treatment resistant bipolar depression

OBJECTIVE

To evaluate the cost-effectiveness of repetitive transcranial magnetic stimulation (rTMS) as an adjunct to standard care from an Australian health sector perspective, compared to standard care alone for adults with treatment-resistant bipolar depression (TRBD).

METHODS

An economic model was developed to estimate the cost per disability-adjusted life-year (DALY) averted and quality-adjusted life-year (QALY) gained for rTMS added to standard care compared to standard care alone, for adults with TRBD. The model simulated the time in three health states (mania, depression, residual) over one year. Response to rTMS was sourced from a meta-analysis, converted to a relative risk and used to modify the time in the depressed state. Uncertainty and sensitivity tested the robustness of results.

RESULTS

Base-case incremental cost-effectiveness ratios (ICERs) were $72,299 per DALY averted (95 % Uncertainty Interval (UI): $60,915 to $86,668) and $46,623 per QALY gained (95 % UI: $39,676 - $55,161). At a willingness to pay (WTP) threshold of $96,000 per DALY averted, the base-case had a 100 % probability of being marginally cost-effective. At a WTP threshold of $64,000 per QALY gained, the base-case had a 100 % probability of being cost-effective. Sensitivity analyses decreasing the number of sessions provided, increasing the disability weight or the time spent in the depression state for standard care improved the ICERs for rTMS.

CONCLUSIONS

Dependent on the outcome measure utilised and assumptions, rTMS would be considered a very cost-effective or marginally cost-effective adjunct to standard care for TRBD compared to standard care alone.

Modelling mental health service needs of Aboriginal and Torres Strait Islander peoples: a review of existing evidence and expert consensus

OBJECTIVE

To identify key mental health service components required for Aboriginal and Torres Strait Islander peoples and develop proposed modelling to modify the National Mental Health Service Planning Framework to account for the unique needs of these populations.

METHODS

Service areas and corresponding modelling rules were informed by a review and analysis of literature and data (on existing service models and policy directions) and expert group discussions on the important aspects of mental health care for Aboriginal and Torres Strait Islander peoples.

RESULTS

Eight key service areas were identified and translated into proposed modelling rules for service planning: culturally appropriate assessment; increased care coordination; more family and carer involvement and support; specified workforce; holistic primary care teams; enhanced staffing for inpatient care; integrating culture; and earlier support for behavioural and psychological symptoms of dementia.

CONCLUSIONS

This study provides a consolidated framework and implementation guidance to support more effective mental health service planning for Aboriginal and Torres Strait Islander peoples.

IMPLICATIONS FOR PUBLIC HEALTH

Better supporting planners to make informed decisions regarding mental health service provision for Aboriginal and Torres Strait Islander peoples will assist in a nationally coordinated approach to closing the mental health gap between Indigenous and non-Indigenous peoples.

Cost-utility analysis of rTMS as add-on therapy to standard care for the treatment of hallucinations in schizophrenia

Background

This research evaluates the cost-effectiveness of repetitive transcranial magnetic stimulation (rTMS) as add-on therapy to standard care for adults with schizophrenia from an Australian health system perspective.

Methods

A Markov model estimated costs in 2021 Australian dollars and Disability-Adjusted Life-Years (DALYs) averted with rTMS added to standard care compared to standard care alone over 12-months for adults aged 25–65 years with hallucinations in schizophrenia refractory to other therapies. rTMS effect size was sourced from a meta-analysis and converted to a relative risk using the Cochrane conversion method. Probabilistic sensitivity analysis evaluated uncertainty in effect size and disability weights. One-way sensitivity analyses varied rTMS session cost and effectiveness, time horizon and inpatient costs.

Results

The base-case average incremental cost-effectiveness ratio (ICER) was $87,310/DALY averted (95% UI: $10,157–$97,877). Reducing rTMS session cost to $100 lowered the ICER to $9,127/DALY (95% UI: Dominant–$50,699). A 4-year time horizon resulted in rTMS being less costly and more effective (Dominant) than standard care. Decreasing the 3-month probability of relapse with rTMS to 4.6% resulted in a 71% probability of rTMS being cost-effective.

Conclusions

Using a threshold of $50,000/ DALY averted, rTMS as add-on therapy to standard care for the treatment of refractory hallucinations in schizophrenia would not be considered a cost-effective treatment option compared to standard care alone. However, given the refractory nature of this condition and the relatively small size of this population, it may be reasonable for decision-makers to adopt a higher ICER threshold.

Regional planning for meaningful person-centred care in mental health: context is the signal not the noise

Person-centred care is at the core of a value-based health system. Its transformative potential is to enable and support key policy, planning and service developments across the system even when these go against the self-interest of individual major players. It offers a potent test for decision makers at all levels. It demands responses that are multi-level, empirically grounded, expert-informed and data-driven that must converge on the singularity of individuals in the places that they live. This requires different approaches that recognise, respect and reconcile two necessary but constitutionally disparate perspectives: the bureaucratic, overtly decontextualised, top-down, policy and planning objectives of central governments and the formally complex, dynamic and contextualised experience of individuals in the system. Conflating the latter with the former can lead unwittingly to a pervasive and reductive form of quasi-Taylorism that nearly always creates waste at the expense of value. This has parallel application in the treatment domain where outcomes are non-randomly clustered and partitioned by socioeconomic status, amplifying unwarranted variation by place that is striking in its magnitude and heterogeneity. In this paper, we propose that a combination of (1) relevant, local and sophisticated data planning, collection and analysis systems, (2) more detailed person-centred service planning and delivery and (3) system accountability through co-design and transparent public reporting of health system performance in a manner that is understandable, relevant, and locally applicable are all essential in ensuring planned and provided care is most appropriate to more than merely the 'average' person for whom the current system is built. We argue that only through a greater appreciation of healthcare as a complex adaptive (eco)system, where context is everything, and then utilising planning, analysis and management methodologies that reflect this reality is the way to achieve genuine person-centred care.

Assessing quality indicators related to mental health emergency room utilization

Background

This descriptive study compared 2014–15 to 2005–06 data on the quality of mental health services (MHS) in relation to emergency room (ER) use to assess the impact of the 2005 Quebec MH reform regarding access, continuity and appropriateness of care for patients with mental illnesses (PMI).

Methods

Data emanated from the Quebec Integrated Chronic Disease Surveillance System (Quebec/Canada). Participants (865,255 for 2014–15; 817,395 for 2005–06) were age 12 or over, with at least one MI, including substance use disorders (SUD), diagnosed during an ER visit, outpatient treatment or hospitalization. Variables included: access (ER use/frequency, hospitalization rates, outpatient consultations preceding an ER visit), care continuity (outpatient consultations following an ER visit/hospitalization, consecutive returns to the ERs), and care appropriateness (high ER use, recurrence of yearly ER visits, length of hospitalization). Frequency distributions were calculated on sex, age and geographic area for ER visits/hospitalizations in 2014–15, and between 2014 and 15 and 2005–06.

Results

PMI accounted for 12 % of the Quebec population in 2014–15 (n = 865,255), of whom 39% visited an ER for any reason. Amount and frequency of ER use and number/length of hospitalizations were almost twice as high for PMI versus patients without MI; 17% of PMI were also high/very high ER users and were frequently hospitalized. Among PMI, ER users were also frequent users of outpatient services despite a lack of follow-up appointments after ER visits or hospitalizations. Findings revealed some positive changes over time, such as decreased ER and hospitalization rates; yet overall access, continuity and appropriateness of care, as measured in this study, remained low.

Conclusions

This study demonstrated that the Quebec reform did not produce a substantial impact on ER use or substantially improved care, as hypothesized. Better access and continuity of care should be promoted to reduce the high prevalence of ER use among PMI. Quality improvement in MHS may be realized if ERs are supported by substantial and well-integrated community MH networks.

Can automated content analysis be used to assess and improve the use of evidence in mental health policy? A systematic review

BACKGROUND

This review assesses the utility of applying an automated content analysis method to the field of mental health policy development. We considered the possibility of using the Wordscores algorithm to assess research and policy texts in ways that facilitate the uptake of research into mental health policy.

METHODS

The PRISMA framework and the McMaster appraisal tools were used to systematically review and report on the strengths and limitations of the Wordscores algorithm. Nine electronic databases were searched for peer-reviewed journal articles published between 2003 and 2016. Inclusion criteria were (1) articles had to be published in public health, political science, social science or health services disciplines; (2) articles had to be research articles or opinion pieces that used Wordscores; and (3) articles had to discuss both strengths and limitations of using Wordscores for content analysis.

RESULTS

The literature search returned 118 results. Twelve articles met the inclusion criteria. These articles explored a range of policy questions and appraised different aspects of the Wordscores method.

DISCUSSION

Following synthesis of the material, we identified the following as potential strengths of Wordscores: (1) the Wordscores algorithm can be used at all stages of policy development; (2) it is valid and reliable; (3) it can be used to determine the alignment of health policy drafts with research evidence; (4) it enables existing policies to be revised in the light of research; and (5) it can determine whether changes in policy over time were supported by the evidence. Potential limitations identified were (1) decreased accuracy with short documents, (2) words constitute the unit of analysis and (3) expertise is needed to choose 'reference texts'.

CONCLUSIONS

Automated content analysis may be useful in assessing and improving the use of evidence in mental health policies. Wordscores is an automated content analysis option for comparing policy and research texts that could be used by both researchers and policymakers.

The cost-effectiveness of cognitive behavioral therapy for bulimia nervosa in the Australian context

OBJECTIVE

This study was to model the cost-effectiveness of specialist-delivered cognitive behavioral therapy for bulimia nervosa (CBT-BN) compared to no intervention within the Australian context.

METHOD

An illness-death model was developed to estimate the cost per disability-adjusted life-year (DALY) averted of CBT-BN over 2 years from the healthcare perspective. Target population was adults aged 18-65 years with BN. Results are reported as incremental cost-effectiveness ratios (ICER) in 2013 Australian dollars per DALY averted. Uncertainty and sensitivity analyses were conducted to test the robustness of results.

RESULTS

Primary analysis indicated that CBT-BN was associated with greater DALY averted (0.10 DALY per person) and higher costs ($1,435 per person) than no intervention, resulting the mean ICER of $14,451 per DALY averted (95% uncertainty interval [UI]: $8,762 to $35,650). Uncertainty analysis indicated CBT-BN is 99% likely to be cost-effective at a threshold of $50,000 per DALY averted. Including the patients' time and travel costs resulted in the mean ICER of $18,858 per DALY averted (95% UI: $11,235 to $46,026). Sensitivity analysis indicated the intervention was not cost-effective if over 80% people discontinued treatment. Other analyses including a reduced time horizon, increased remission rates, and 4-month effect size of CBT-BN increases the ICERs but these ICERs remained well below under a threshold of $50,000 per DALY averted.

CONCLUSION

This study has demonstrated that CBT-BN for adults with BN is a cost-effective treatment intervention. Further research is required to investigate the practicability of CBT-ED and the cost-effectiveness of other formats of CBT-BN delivery.

The modeled cost-effectiveness of family-based and adolescent-focused treatment for anorexia nervosa

BACKGROUND

Anorexia nervosa (AN) is a prevalent, serious mental disorder. We aimed to evaluate the cost-effectiveness of family-based treatment (FBT) compared to adolescent-focused individual therapy (AFT) or no intervention within the Australian healthcare system.

METHOD

A Markov model was developed to estimate the cost and disability-adjusted life-year (DALY) averted of FBT relative to comparators over 6 years from the health system perspective. The target population was 11-18 year olds with AN of relatively short duration. Uncertainty and sensitivity analyses were conducted to test model assumptions. Results are reported as incremental cost-effectiveness ratios (ICER) in 2013 Australian dollars per DALY averted.

RESULTS

FBT was less costly than AFT. Relative to no intervention, the mean ICER of FBT and AFT was $5,089 (95% uncertainty interval (UI): dominant to $16,659) and $51,897 ($21,591 to $1,712,491) per DALY averted. FBT and AFT are 100% and 45% likely to be cost-effective, respectively, at a threshold of AUD$50,000 per DALY averted. Sensitivity analyses indicated that excluding hospital costs led to increases in the ICERs but the conclusion of the study did not change.

CONCLUSION

FBT is the most cost-effective among treatment arms, whereas AFT was not cost-effective compared to no intervention. Further research is required to verify this result.

The population cost-effectiveness of delivering universal and indicated school-based interventions to prevent the onset of major depression among youth in Australia

AIMS

School-based psychological interventions encompass: universal interventions targeting youth in the general population; and indicated interventions targeting youth with subthreshold depression. This study aimed to: (1) examine the population cost-effectiveness of delivering universal and indicated prevention interventions to youth in the population aged 11-17 years via primary and secondary schools in Australia; and (2) compare the comparative cost-effectiveness of delivering these interventions using face-to-face and internet-based delivery mechanisms.

METHODS

We reviewed literature on the prevention of depression to identify all interventions targeting youth that would be suitable for implementation in Australia and had evidence of efficacy to support analysis. From this, we found evidence of effectiveness for the following intervention types: universal prevention involving group-based psychological interventions delivered to all participating school students; and indicated prevention involving group-based psychological interventions delivered to students with subthreshold depression. We constructed a Markov model to assess the cost-effectiveness of delivering universal and indicated interventions in the population relative to a 'no intervention' comparator over a 10-year time horizon. A disease model was used to simulate epidemiological transitions between three health states (i.e., healthy, diseased and dead). Intervention effect sizes were based on meta-analyses of randomised control trial data identified in the aforementioned review; while health benefits were measured as Disability-adjusted Life Years (DALYs) averted attributable to reductions in depression incidence. Net costs of delivering interventions were calculated using relevant Australian data. Uncertainty and sensitivity analyses were conducted to test model assumptions. Incremental cost-effectiveness ratios (ICERs) were measured in 2013 Australian dollars per DALY averted; with costs and benefits discounted at 3%.

RESULTS

Universal and indicated psychological interventions delivered through face-to-face modalities had ICERs below a threshold of $50 000 per DALY averted. That is, $7350 per DALY averted (95% uncertainty interval (UI): dominates - 23 070) for universal prevention, and $19 550 per DALY averted (95% UI: 3081-56 713) for indicated prevention. Baseline ICERs were generally robust to changes in model assumptions. We conducted a sensitivity analysis which found that internet-delivered prevention interventions were highly cost-effective when assuming intervention effect sizes of 100 and 50% relative to effect sizes observed for face-to-face delivered interventions. These results should, however, be interpreted with caution due to the paucity of data.

CONCLUSIONS

School-based psychological interventions appear to be cost-effective. However, realising efficiency gains in the population is ultimately dependent on ensuring successful system-level implementation.

Target-D: a stratified individually randomized controlled trial of the diamond clinical prediction tool to triage and target treatment for depressive symptoms in general practice: study protocol for a randomized controlled trial

BACKGROUND

Depression is a highly prevalent and costly disorder. Effective treatments are available but are not always delivered to the right person at the right time, with both under- and over-treatment a problem. Up to half the patients presenting to general practice report symptoms of depression, but general practitioners have no systematic way of efficiently identifying level of need and allocating treatment accordingly. Therefore, our team developed a new clinical prediction tool (CPT) to assist with this task. The CPT predicts depressive symptom severity in three months' time and based on these scores classifies individuals into three groups (minimal/mild, moderate, severe), then provides a matched treatment recommendation. This study aims to test whether using the CPT reduces depressive symptoms at three months compared with usual care.

METHODS

The Target-D study is an individually randomized controlled trial. Participants will be 1320 general practice patients with depressive symptoms who will be approached in the practice waiting room by a research assistant and invited to complete eligibility screening on an iPad. Eligible patients will provide informed consent and complete the CPT on a purpose-built website. A computer-generated allocation sequence stratified by practice and depressive symptom severity group, will randomly assign participants to intervention (treatment recommendation matched to predicted depressive symptom severity group) or comparison (usual care plus Target-D attention control) arms. Follow-up assessments will be completed online at three and 12 months. The primary outcome is depressive symptom severity at three months. Secondary outcomes include anxiety, mental health self-efficacy, quality of life, and cost-effectiveness. Intention-to-treat analyses will test for differences in outcome means between study arms overall and by depressive symptom severity group.

DISCUSSION

To our knowledge, this is the first depressive symptom stratification tool designed for primary care which takes a prognosis-based approach to provide a tailored treatment recommendation. If shown to be effective, this tool could be used to assist general practitioners to implement stepped mental-healthcare models and contribute to a more efficient and effective mental health system.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry (ANZCTR 12616000537459 ). Retrospectively registered on 27 April 2016. See Additional file 1 for trial registration data.

The modelled cost-effectiveness of cognitive dissonance for the prevention of anorexia nervosa and bulimia nervosa in adolescent girls in Australia

BACKGROUND

Eating disorders (EDs), including anorexia nervosa (AN) and bulimia nervosa (BN), are prevalent disorders that carry substantial economic and social burden. The aim of the current study was to evaluate the modelled population cost-effectiveness of cognitive dissonance (CD), a school-based preventive intervention for EDs, in the Australian health care context.

METHOD

A population-based Markov model was developed to estimate the cost per disability adjusted life-year (DALY) averted by CD relative to no intervention. We modelled the cases of AN and BN that could be prevented over a 10-year time horizon in each study arm and the subsequent reduction in DALYs associated with this. The target population was 15-18 year old secondary school girls with high body-image concerns. This study only considered costs of the health sector providing services and not costs to individuals. Multivariate probabilistic and one-way sensitivity analyses were conducted to test model assumptions.

RESULTS

Findings showed that the mean incremental cost-effectiveness ratio at base-case for the intervention was $103,980 per DALY averted with none of the uncertainty iterations falling below the threshold of AUD$50,000 per DALY averted. The evaluation was most sensitive to estimates of participant rates with higher rates associated with more favourable results. The intervention would become cost-effective (84% chance) if the effect of the intervention lasted up to 5 years.

CONCLUSION

As modelled, school-based CD intervention is not a cost-effective preventive intervention for AN and BN. Given the burden of EDs, understanding how to improve participation rates is an important opportunity for future research.

Pediatric eMental healthcare technologies: a systematic review of implementation foci in research studies, and government and organizational documents

Background

Researchers, healthcare planners, and policymakers convey a sense of urgency in using eMental healthcare technologies to improve pediatric mental healthcare availability and access. Yet, different stakeholders may focus on different aspects of implementation. We conducted a systematic review to identify implementation foci in research studies and government/organizational documents for eMental healthcare technologies for pediatric mental healthcare.

Methods

A search of eleven electronic databases and grey literature was conducted. We included research studies and documents from organization and government websites if the focus included eMental healthcare technology for children/adolescents (0–18 years), and implementation was studied and reported (research studies) or goals/recommendations regarding implementation were made (documents). We assessed study quality using the Mixed Methods Appraisal Tool and document quality using the Appraisal of Guidelines for Research & Evaluation II. Implementation information was grouped according to Proctor and colleagues’ implementation outcomes—acceptability, adoption, appropriateness, cost, feasibility, fidelity, penetration, and sustainability—and grouped separately for studies and documents.

Results

Twenty research studies and nine government/organizational documents met eligibility criteria. These articles represented implementation of eMental healthcare technologies in the USA (14 studies), United Kingdom (2 documents, 3 studies), Canada (2 documents, 1 study), Australia (4 documents, 1 study), New Zealand (1 study), and the Netherlands (1 document). The quality of research studies was excellent (n = 11), good (n = 6), and poor (n = 1). These eMental health studies focused on the acceptability (70%, n = 14) and appropriateness (50%, n = 10) of eMental healthcare technologies to users and mental healthcare professionals. The quality of government and organizational documents was high (n = 2), medium (n = 6), and low (n = 1). These documents focused on cost (100%, n = 9), penetration (89%, n = 8), feasibility (78%, n = 7), and sustainability (67%, n = 6) of implementing eMental healthcare technology.

Conclusion

To date, research studies have largely focused on acceptability and appropriateness, while government/organizational documents state goals and recommendations regarding costs, feasibility, and sustainability of eMental healthcare technologies. These differences suggest that the research evidence available for pediatric eMental healthcare technologies does not reflect the focus of governments and organizations. Partnerships between researchers, healthcare planners, and policymakers may help to align implementation research with policy development, decision-making, and funding foci.

Electronic supplementary material

The online version of this article (doi:10.1186/s13012-017-0608-6) contains supplementary material, which is available to authorized users.

Implementation of the Quebec mental health reform (2005-2015)

Background

This study evaluates implementation of the Quebec Mental Health (MH) Reform (2005–2015) which aimed to improve accessibility, quality and continuity of care by developing primary care and optimizing integrated service networks. Implementation of MH primary care teams, clinical strategies for consolidating primary care, integration strategies to improve collaboration between primary care and specialized services, and facilitators and barriers related to these measures were examined.

Methods

Eleven Quebec MH service networks provided the study setting. Networks were identified in consultation with 20 key MH decision makers and selected based on variation in services offered, integration strategies, best practices, and geographic criteria. Data collection included: primary documents, structured questionnaires completed by 25 managers from MH primary care teams and 16 respondent-psychiatrists working in shared-care, and semi-structured interviews with 102 network stakeholders involved in the reform. The study employed a mixed method approach, triangulating the three data sources across networks.

Results

While implementation was not fully achieved in most networks, the Quebec reform succeeded in improving primary care services with the creation of adult primary care teams, and one-stop services which increased access to care, mainly for clients with common MH disorders. In terms of clinical strategies implemented, the functions provided by respondent-psychiatrists had a greater impact on the MH primary care teams than on general practitioners (GPs) in medical clinics; whereas the implementation of best practices were indirect outcomes of another reform developed simultaneously by the Quebec substance use disorders program. The main integration strategies used for increasing continuity of care and collaboration between primary care and specialized services were those involving fewer formal procedures such as referrals between teams and organizations. The lack of operational mechanisms and protocols governing new services and structures were important barriers to primary care consolidation and service integration, as was the lack of interest and involvement of most GPs in MH.

Conclusions

Successful and sustained healthcare reform requires attention to process and outcomes as well as structural change or service reorganization. Six recommendations for more successful implementation of the Quebec MH Reform are provided, with implications for healthcare reform internationally.

Electronic supplementary material

The online version of this article (doi:10.1186/s12913-016-1832-5) contains supplementary material, which is available to authorized users.

Establishing and Governing e-Mental Health Care in Australia: A Systematic Review of Challenges and A Call For Policy-Focussed Research

BACKGROUND

Growing evidence attests to the efficacy of e-mental health services. There is less evidence on how to facilitate the safe, effective, and sustainable implementation of these services.

OBJECTIVE

We conducted a systematic review on e-mental health service use for depressive and anxiety disorders to inform policy development and identify policy-relevant gaps in the evidence base.

METHODS

Following the PRISMA protocol, we identified research (1) conducted in Australia, (2) on e-mental health services, (3) for depressive or anxiety disorders, and (4) on e-mental health usage, such as barriers and facilitators to use. Databases searched included Cochrane, PubMed, PsycINFO, CINAHL, Embase, ProQuest Social Science, and Google Scholar. Sources were assessed according to area and level of policy relevance.

RESULTS

The search yielded 1081 studies; 30 studies were included for analysis. Most reported on self-selected samples and samples of online help-seekers. Studies indicate that e-mental health services are predominantly used by females, and those who are more educated and socioeconomically advantaged. Ethnicity was infrequently reported on. Studies examining consumer preferences found a preference for face-to-face therapy over e-therapies, but not an aversion to e-therapy. Content relevant to governance was predominantly related to the organizational dimensions of e-mental health services, followed by implications for community education. Financing and payment for e-services and governance of the information communication technology were least commonly discussed.

CONCLUSIONS

Little research focuses explicitly on policy development and implementation planning; most research provides an e-services perspective. Research is needed to provide community and policy-maker perspectives. General population studies of prospective treatment seekers that include ethnicity and socioeconomic status and quantify relative preferences for all treatment modalities are necessary.

Patient characteristics and predictors of completion in residential treatment for substance use disorders

Aims and method To identify the patient characteristics and rates of retention in a residential rehabilitation drug and alcohol service (Springhill) based on an eclectic model of care. Patients were assessed using the Alcohol and Drug Outcome Measure (ADOM), a brief tool designed for the New Zealand setting. We looked at correlations between demographic, social and drug use parameters. Logistic regression assessed the relative impact of each variable on completion. Results The 183 patients who completed the data collection did not differ from 47 non-completers by demographic data; 62.2% of patients completed the programme, with equal number of men and women. One in five participants was Maori, the indigenous minority. Alcohol (51.9%) was the commonest drug of misuse, with methamphetamine (16.4%) and cannabis (14.2%) also significant. Completers were more likely to be Maori, have conflict with family and housing problems, although the last became non-significant in logistic regression. Clinical implications Retention rates are higher in Springhill than in comparable programmes. Ethnicity and family conflict predict completion, although the reasons for this are unclear. ADOM is an effective tool that can be used in a clinical setting to enable analysis of service provision.

Preventing mental illness: closing the evidence-practice gap through workforce and services planning

BACKGROUND

Mental illness is prevalent across the globe and affects multiple aspects of life. Despite advances in treatment, there is little evidence that prevalence rates of mental illness are falling. While the prevention of cardiovascular disease and cancers are common in the policy dialogue and in service delivery, the prevention of mental illness remains a neglected area. There is accumulating evidence that mental illness is at least partially preventable, with increasing recognition that its antecedents are often found in infancy, childhood, adolescence and youth, creating multiple opportunities into young adulthood for prevention. Developing valid and reproducible methods for translating the evidence base in mental illness prevention into actionable policy recommendations is a crucial step in taking the prevention agenda forward.

METHOD

Building on an aetiological model of adult mental illness that emphasizes the importance of intervening during infancy, childhood, adolescence and youth, we adapted a workforce and service planning framework, originally applied to diabetes care, to the analysis of the workforce and service structures required for best-practice prevention of mental illness.

RESULTS

The resulting framework consists of 6 steps that include identifying priority risk factors, profiling the population in terms of these risk factors to identify at-risk groups, matching these at-risk groups to best-practice interventions, translation of these interventions to competencies, translation of competencies to workforce and service estimates, and finally, exploring the policy implications of these workforce and services estimates. The framework outlines the specific tasks involved in translating the evidence-base in prevention, to clearly actionable workforce, service delivery and funding recommendations.

CONCLUSIONS

The framework describes the means to deliver mental illness prevention that the literature indicates is achievable, and is the basis of an ongoing project to model the workforce and service structures required for mental illness prevention.

Estimating service demand for respite care among informal carers of people with psychological disabilities in Australia

OBJECTIVE

To estimate service demand (willingness to seek or use services) for respite care among informal, primary carers of people with a psychological disability and to describe their characteristics.

METHODS

Analysis of data from the household component of the 2009 Survey of Disability Ageing and Carers (n=64,213 persons).

RESULTS

In Australia in 2009, 1.0% of people aged 15 years or over (177,900 persons) provided informal, primary care to a co-resident with a psychological disability. One-quarter (27.2%) of these carers reported service demand for respite care, of whom one-third had used respite services in the past three months and four-fifths had an unmet need for any or more respite care. A significantly greater percentages of carers with service demand for respite care spent 40 or more hours per week on caregiving, provided care to a person with profound activity restrictions and reported unmet support needs, compared to carers without service demand. Lack of suitable, available respite care models was a barrier to utilisation.

CONCLUSIONS

Findings confirm significant service demand for, and under-utilisation of, respite care among mental health carers.

IMPLICATIONS

Increased coverage of respite services, more flexible service delivery models matched to carers' needs and better integration with other support services are indicated.

Improving access to primary mental healthcare for Indigenous Australians

OBJECTIVE

To examine the uptake, population reach and outcomes of primary mental healthcare services provided to Indigenous Australians via the Access to Allied Psychological Services (ATAPS) program between 2003 and 2013, with particular reference to enhanced Indigenous ATAPS services introduced from 2010.

METHOD

Utilising ATAPS program data from a national minimum data set and comparative population data, we conducted descriptive analyses, regression analyses and t-tests to examine the uptake of ATAPS services, provider agency level predictors of service reach, and preliminary outcome data on consumer level outcomes.

RESULTS

Between 2003 and 2013, 15,450 Indigenous client referrals were made that resulted in 55,134 ATAPS sessions. National Indigenous service volume more than doubled between 2010 and 2012, following the introduction of enhanced Indigenous ATAPS services. Non-Indigenous ATAPS service volume of primary care agencies was uniquely predictive of Indigenous service reach. Preliminary analysis of limited consumer outcome data indicated positive treatment gains and the need to enhance future outcome data collection.

CONCLUSIONS

Concerted national efforts to enhance mainstream primary mental healthcare programs can result in significant gains in access to mental healthcare for Indigenous populations.

Developing a service platform definition to promote evidence-based planning and funding of the mental health service system

Ensuring that a mental health system provides 'value for money' requires policy makers to allocate resources to the most cost-effective interventions. Organizing cost-effective interventions into a service delivery framework will require a concept that can guide the mapping of evidence regarding disorder-level interventions to aggregations of services that are meaningful for policy makers. The 'service platform' is an emerging concept that could be used to this end, however no explicit definition currently exists in the literature. The aim of this study was to develop a service platform definition that is consistent with how policy makers conceptualize the major elements of the mental health service system and to test the validity and utility of this definition through consultation with mental health policy makers. We derived a provisional definition informed by existing literature and consultation with experienced mental health researchers. Using a modified Delphi method, we obtained feedback from nine Australian policy makers. Respondents provided written answers to a questionnaire eliciting their views on the acceptability, comprehensibility and usefulness of a service platform definition which was subject to qualitative analysis. Overall, respondents understood the definition and found it both acceptable and useful, subject to certain conditions. They also provided suggestions for its improvement. Our findings suggest that the service platform concept could be a useful way of aggregating mental health services as a means for presenting priority setting evidence to policy makers in mental health. However, further development and testing of the concept is required.