Yesterday I was asked to discuss rural mental health with some other rural health colleagues in the rural and regional electoral seat of New England in Northern inland NSW on local ABC radio. With Federal Election 2016 bearing down on us (July 2, 2016) we looked at some of the pressure points for health in the electorate. Here is the audio from our discussion… hopefully this makes a useful contribution to the local debate, and advocates for fair and reasonable mental health service distribution in rural Australia – especially for our young people.
Click here to listen – happy to hear others views as well.
photo credit Above New England
In Australia, moves are afoot to review and implement changes to the mental health services and programs on offer – including those offered to young people. Change always produces some tensions, and that will be the case again in this situation… but something had to give… change was needed to see equitable improvements, and none more obvious than for rural young people with mental health problems. So here we go – join me on the slippery slope of mental health care reform roller coaster!
The media have labelled the staged funding reductions to early psychosis services as “Futures will be lost. Health fears as youth pychosis program dropped” Read about it here: http://www.smh.com.au/federal-politics/political-news/futures-will-be-lost-health-fears-as-youth-psychosis-program-dropped-20160429-goi1hu.html
This begs more questions: The future of who…? Who will be advantaged…? And, who will be disadvantaged…? How do we achieve fairer and more equitable care for all of our young people throughout Australia? There are no easy answers or solutions… to suggest there are is to reveal a flippant disregard for the complexity of meeting the mental health needs of young people today.
I’m an optimist…
I hope that the government have got this right… and that a redistribution of youth psychosis program money will benefit young rural people more equitably as a result… Of course, advocating for the equitable mental health needs of young rural people has been my long-term professional activity of mine! So, I can only hope that this new direction to send funds to the primary health networks – will in fact work for rural and regional young people where the gaps are larger! There are some risks to note. For example, how will people be mobilised from their comfort zones to take up work in new geographical regions…? Will this be supported in the recruitment of appropriate servicing of populations? Will it really be equitable? Or just equal? Will health professionals be contracted using brokerage models as they are ‘commissioned’ for services? And, if they are, how will this new model ensure that health professionals are able to be fully employed at reasonable pay rates, in keeping with their level of expertise? How will we mitigate the risk of under-employment of people in low population communities yet maintain equitable service levels? How will the ‘gaps be filled’? Has this been fully considered?
I don’t think that the new approach to funding of youth mental health care this is such a bad thing for rural and regional young people. I have been calling for a more equitable and inclusive distribution of the mental health dollar for many years now… (eg https://www.researchgate.net/publication/275340216_Rural_nurses_A_convenient_co-location_strategy_for_rural_mental_health_care_of_young_people )
… it has not always made me popular…
The harsh reality is that rural youth often have much longer durations of untreated mental illness, poorer access to mental health services and poorer prognosis as a result… And, the largely urban-centric models of specialist youth mental health care have not met the demands for rural youth with mental health care needs. Something needs to give a little… perhaps this new funding model will be it… But – it needs to explain how it will include nursing expertise to promote mental health among young people at its core… Because, nurses are already there in all communities… and they represent a present resource that can be better engaged in primary care.
How will nurses be engaged in the primary mental health care of young rural people? The role of nursing in the models of care continues to be vaguely described at best in current strategy offerings… Only using nurses for managing chronic care (ie the Mental Health Nurse Incentive Program) is a sure-fire for short-changing the mental health of young people… becasue… young people have simply not lived long enough to have ‘achieved’ chronic mental illness status… rendering them ineligible for government supported nursing care in the main! Thus, how will this new model of funding utilise the expertise of nurses to deliver primary mental health care to young people and mitigate the early identification and intervention end of the care spectrum problems? Remembering of course that nurses make up the largest proportion of health professionals representing and the largest proportion of human resource for mental health service delivery throughout the country? Nurses need to be a large chunk of the journey towards successful new models of care – yet they seem to be overlooked in the latest iteration of change. Why?
I am not yet convinced the the Primary Health Networks will be the solution… but I am prepared to be open-minded about the possibilities… I hope we are seeing the beginnings of something substantially more useful than reshuffling deck chairs. I think closer federal collaboration with state health, education, family and community services and police/ justice services will bring more profitable benefits. But, while a two tier government approach persists in mental health service delivery (Federal and State/s), problems in administering equitable services will also persist with bureaucratic double-ups inevitable, ultimately soaking up some of the direct clinical and research spend potentials.
I agree with McGorry, that many gains have been achieved through the concentrating of specialist expertise in a small number of specialist services, and that it would be a shame to lose this. But, having built this considerable national human resource – if it were mobilised and dispersed across the country (for example, the experts geographically relocated) this have a benefit of authentically redistributing the talent and in doing so benefit more people over time. Is it time to mobilise the specialist population for greater good in health service delivery? A question for health geographers and health ecologists to ponder. Will redistribution of funding trigger a wider set of conditions in communities such that mental health is more effectively promoted? I think that this is possible: https://www.researchgate.net/publication/280134451_Rural_Mental_Health_Ecology_A_Framework_for_Engaging_with_Mental_Health_Social_Capital_in_Rural_Communities
It is not all bad news, a new model could bring with it ‘catch-up’ conditions to more vulnerable and harder to reach young populations who should have convenient access to local mental health support where and when they require it. The challenge is for mental health professionals to work together using digital technologies to bring us together, it is after all what we expect of our clients these days! That is, to be satisfied with e mental health/ telehealth and digital gateway (triage) delivery….
Perhaps health professionals will also need to adapt our practices in the ways that we work and collaborate with each other – building virtual centres of excellence rather than geographical catchments of excellence. In doing so, some castles will be dismantled – and new ones will emerge… shifts in the sands of time across the landscape of mental health service and evidence development and delivery are inevitable.
It is clear that the health budget in Australia will never be able to fund sufficient levels of mental health service delivery for Australian young people – our present budgets don’t go near sufficiency. Finding ways to squeeze a few extra drops of oil out of the rag are always going to be critical… the challenge is out for mental health researchers to be prudent in devising ways in which we can continue to do more, with less, and for politicians and policy makers to take heed of evidence as it emerges… And finally, for clinicians to be ready to adapt to the changing times as they evolve. None of that is easy!
Relevant other links:
At the moment, the media is laden with calls for reform for youth mental health in Australia. My research informs the debate:
My research specifically addressed the problem of rural young people accessing mental health care. Following one Masters (Hons) and one PhD examination of the problem, I have formed some evidence-based views on ways forward: Here is an extract (Thesis Chapter 5: pages195-197) one that relates to headspace and the potential nurses have to be a more effective contributors to early mental health care if funds were redirected from headspace for a more equitable distribution to help young rural people:
Implications for policy…
- The national mental health strategy headspace, does not currently possess the capacity to be extended to every rural community in Australia. E-headspace does have some scope to contribute a useful component to a rural youth mental health strategy if rural e-mental health knowledge brokers are available in community rural nursing settings or Medicare Local centres to facilitate this strategy in the rural environment.
- The headspace initiative should be reviewed by the Department of Health and Ageing with an aim to facilitate the redistribution of federal funds to include a contribution to the operational costs of rural nurses to act as e-mental health knowledge brokers for young rural people on a per capita basis, so that at least population-based equity of distribution of youth mental health financial resources is available in all communities, rather than, as is currently the case, restricted to one service centre in one regional community in the study site region.
- Further reform of youth mental health services is required to ensure that rural young people have reasonable access to mental health services in keeping with international progress and development about youth mental health services that challenge the traditional paradigms of youth mental health service delivery (Coughlan et al., 2011, 2013). There is wide agreement in the literature that young Australian people are underserviced in early mental health care, and that for rural young people this circumstance is further amplified (Coughlan et al., 2011; Mendoza et al., 2013; Rickwood, 2012; S. P. Rosenberg & Hickie, 2013).
- Rural nurses should be adequately funded to support e-mental health kiosks in appropriate community settings such as hospitals, multi-purpose health facilities, community agencies, schools and police stations. Rural nurses are able to collaborate with professionals from all of these sectors in such a way that collaboration of mental health helping and capacity building in rural communities is achieved and coordinated. The architects of health, social and law policy will need to accommodate the inclusion of new and innovative roles in the future. In particular, the function, role description of rural nurses, and specifically the role of rural community nurses will need to be expanded so that meaningful mental health help can be provided to early mental health help-seekers.
In press now:
Wilson, R.L. & Usher, K. (2015) Rural nurses: A convenient co-location strategy for rural mental health care of young people. Journal of Clinical Nursing. (in press April 2015).
A qualitative study was conducted in rural New South Wales, Australia, to understand the barriers to help-seeking among young rural men with emergent mental health problems. Participants who had real life experiences of these problems within their families were interviewed. Themes emerged from the data which explained some barriers to early intervention. Despite these barriers, families had developed skills in helping and in providing early mental health help to their sons. The findings of this study showed that a substantial burden on the emotional and social integrity of the family, combined with diminished psychological well-being, caused some parents to question how long they could cope before they reached ‘the end of their strings’. This downward spiralling trajectory of mental health and well-being for both the young men and their families has implications for clinical practice. Current models of mental health service delivery do not adequately capture the early help-seeking dynamics of young rural men and their families. A more flexible approach is needed to identify and help the family and the young men, without the pre-requisite for a formal medical diagnosis. Future research should involve health and well-being solution focused service delivery.
Wilson, R., Cruickshank, M., & Lea, J. 2013. Contemporary nurse: a journal for the Australian nursing profession 42(2):167-77. DOI: 10.5172/conu.2012.42.2.167
Charity week at Robb College, UNE this week beginning 30 June 2014: Young people serving the community
This post is a shout out for a residential university college I am affiliated with – Robb College, University of New England, Armidale. If you are on campus at UNE or in Armidale, NSW this week and some in brown overalls asks you to donate – DO! It is for a great cause.
photo credit: http://www.buyabale.com.au/hay-distributions
Almost 200 young people live at Robb College each year while they study at UNE. I am privileged to get to know many of them – cheering them on as they work their way towards professional futures. It is a lot of fun… each year I am amazed at the caliber of the young people I meet at Robb. Sometimes older people are quick to dismiss young people, blaming them for societal ills… But, each year the young people I meet at Robb give me great hope and inspiration for the future. The young people I know are community minded and service driven, and I admire them for that. Each year at Robb there is a major fund raiser for charity and each year I am astonished at the hard work that goes into raising vital funds for many important causes. For the last few years the residents of Robb have been raising charity funds with a nude calender. This year the cause is Buy-A Bale to support farmers who have had a tough time with drought. Please consider buying a calendar to support the charity drive over the next few weeks... and add you voice of encouragement to the development of service in the lives of these young people, as well as the farmers who receive the help.
If you would like to know more about Robb College and their charity Buy-A-Bale here are the links:
- https://twitter.com/RobbCollege @RobbCollege
Received an advance copy of my new book today – smells new, looks shiny….. so pleased with the result and very chuffed to have worked with other mental health experts on this book – Nicholas Proctor, Helen Hamer, Denise McGarry, (Me), and Terry Froggatt. Available to the Public from January 2014. Link for more details direct from publishers – Cambridge University Press.
Police and mental health clinicians co-located
This is such a good idea. Following my recent research about the emergent mental health problems of young rural people, and based on my finding too – I agree that this is an important way forward for rural communities.
Mental health nurses should be co located in police stations to improve the care of young rural people with acute mental health problems, and who as a result, become involved with the police.
Nurses are great at listening, caring and finding ways forward to improve the well-being of others – co-location with police who come into contact with young people with mental health problems is a far better way forward.
Congratulations to ACT police for piloting there program. Wishing them great success for the long haul!
Sending the challenge out to rural and regional police commands in all rural and regional centres to find a way to replicate the concept in their centres and stations!
This link takes you to a brief media review of the Canberra police program – watch it for inspiration!
Here are some facts about mental health and policing/justice….. (extracted from my almost completed PhD thesis…)
- The NSW Law Reform Commission undertook a general review of criminal law and procedures that are applied to people with cognitive and mental health impairment in NSW, and they reported that in NSW of all the young people (less than 18 years of age) detained in custody in NSW, 87% have at least one mental health problem and 73% have two or more mental health diagnoses (New South Wales Law Reform Commission., 2012).
- Young people with mental illness are over-represented in the criminal justice system compared with the wider population, where 22% of the general population have a diagnosable mental health problem and with the total prisoner population in NSW experiencing mental health problems at a rate triple that of the general population (New South Wales Law Reform Commission., 2012).
….The stated goals of policing and justice are diversionary wherever it is possible, however that requires sophisticated referral mechanisms between justice, social and health services, and these services are not always available or accessible, especially in rural regions, and so young people are not always able to engage with diversion options, and therefore are detained in custody, either because no other option is available to them, or because they have a history of offending (New South Wales Law Reform Commission., 2012).
- The average age for a young person with a mental health problem to be remanded in custody for the first time is 18 years of age and on average they will have had 15 police events recorded by that time, with a first police event occurring at an age of between 12-14 years likely; coincidentally an age where onset of mental illness is also noted (Kessler, et al., 2005; New South Wales Health., 2012; New South Wales Law Reform Commission., 2012).
It is difficult for non-mental health professionals to identify emerging mental health problems, and this is especially challenging in the context of the criminal justice system, however a mental health assessment service is available to some offenders who are fortunate enough to be dealt with by Statewide Community and Court Liaison Court Locations (CCCLS), however only 20 of these locations exist in NSW, with the service not available to the remaining 128 local court locations (New South Wales Law Reform Commission., 2012). The disparity of this service provision has been recognised by the Law Reform Commission and it has recommended an expansion of this program to all 148 local court locations (New South Wales Law Reform Commission., 2012).
- Police have powers to detain a person who they believe to be mentally ill or mentally disturbed, under the Mental Health Act 2007 (NSW), and police can formally request that the person be admitted to a involuntary mental health facility. This mode of request for admission makes up 23% of all police requests for admissions to mental health facilities, however 26% of police requests do not meet medical criteria for involuntary admission to a mental health unit (New South Wales Law Reform Commission., 2012).
- This leaves a substantial number of people who may have a mental health problem, but do not meet extreme criteria for involuntary treatment in a compromised position of not being able to access mental health help when it is needed, and at risk of reoffending and further complicating their offending track record (New South Wales Law Reform Commission., 2012).
- Collaboration between State governed Police, Health & Ambulance services in regard to supporting people with a mental health problem to access appropriate care is ideal and fits neatly with the ideals of ‘no wrong door’ to seek mental health help which are aspired to by State & National Mental Health Commissions.
- There are significant limitations within clinical decision making capabilities which need to be considered. In particular, no clinical risk assessment tools exist with adequate specificity, sensitivity and accuracy to predict harm to self or others (for example violence) by people affected by mental health disorder or illness (Ryan, Nielssen, Paton, & Large, 2010). It is not possible to accurately conclude that current clinical assessment of risk investigations will be sensitive enough to predict which clients will need higher levels of resource-heavy interventions and restrictive care, which people will require fewer and less expensive clinical resources and less restrictive care to achieve safety outcomes (Ryan, et al., 2010).
- Ryan et al (2010) reviewed the efficacy of the most commonly used risk assessment instrument, that is, the Macarthur Violence Risk Assessment, which is regarded widely as a valid for use in the prediction of violence amongst people who are acutely mentally ill (Monahan, Steadman, & Robbins, 2005). Ryan et al (2010) re-examined the data in the original study and found that the level of sensitively for accurate prediction was ambiguous and that it had very poor sensitivity in regard to accurately detecting risk related to future violence. In fact, the sensitivity of the instrument produced 9% incidence of false-negative cases, where people were categorised as being low-risk and went on to commit violent acts to themselves or others in the 20 weeks immediately following the assessment (Ryan, et al., 2010). Thus, 9% mentally ill people considered to be ‘low-risk for harm to self or others and in fact ‘high-risk’, and these people will slip through gaps in service streams of all types despite having been provided with a clinical mental health risk assessment, because to current instruments available are not sufficiently accurate to detect risk, yet they are in common use despite this paradox (Ryan, et al., 2010).
- Health services are adverse to risk events and wish to be seen to be doing everything popularly possible to reduce risk of harm to people. However Ryan et al (2010) have been able to demonstrate that based on the fidelity of the most common risk assessment tool, and the incidence of annual homicide rates by people with schizophrenia of 1 in 10,000, and if the risk assessment was conducted on every person with schizophrenia that annually 4117 people would be detained for up to a year in mental health bed-based facilities because they would achieve a ‘high-risk’ category, in order to prevent one person committing a homicide (Ryan, et al., 2010).
- However, of those people assessed as low-risk, 1 in every 22,421 people would in fact go on to commit homicide (Ryan, et al., 2010). The health resources and cost absorbed by keeping false-negative cases in hospital detract from the finance and recourse available to provide care to the low-risk cases, and some of the low-risk cases require high levels of care (Ryan, et al., 2010).
- The dispersal of health resources could be better allocated across a broader mental health agenda, and support the mental health of more people if the use of clinical risk assessment was abandoned as having any role in the clinical decision making process (Ryan, et al., 2010).
Given the frequency with which young people with mental illness are involved in justice and policing matters, and with a lack of accuracy and sensitivity in detecting risk related to acute mental ill-health, it is evident that the challenges in regard to helping young people with mental health problems and who are violent, and who do not wish to participate in mental health care, have little support available to them, and this circumstance perpetuates the problem of high number of young people with mental health problems in custody in Australia.
More research is needed to better understand how young people with emerging mental health problems can be helped earlier so that fewer young people are subject to custody arrangements related to their mental health state.
Mental Health: a person-centred approach aligns leading mental health research with the human connections that can and should be made in mental health care. It seeks to deepen readers’ understanding of themselves, the work they do, and how this intersects with the lives and crises of people with mental illness.
This book adopts a storytelling approach, which encourages engagement with the lives and needs of consumers and carers in mental health. It has a nursing focus but considers the broader health context and a range of practice settings.
Each chapter features learning objectives, reflective and critical thinking questions, extension activities and further reading. Chapters also include stories of those with direct experience recovering from mental illness, using mental health services or giving mental health support.
Mental Health: a person-centred approach is a comprehensive resource which utilises fresh thinking to support the development of safe, high-quality, person-centred care in both the Australian and New Zealand context.
Table of Contents
1. Introduction to mental health and mental illness: Human connectedness and the collaborative consumer narrative
2. Learning through human connectedness on clinical placement: Translation to practice
3. The social and emotional wellbeing of Aboriginal Australians
4. Maori mental health
5. Assessment of mental health and mental illness
6. Legal and ethical aspects in mental health care
7. Mental health and substance use
8. Nutrition, physical health and behaviour change
9. Mental health of people of migrant and refugee background
10. Gender, sexuality and mental health
11. Mental health of children and young people
12. Mental health of older people
13. Rural and regional mental health
14. Mental health in the interprofessional context
15. Conclusions: Looking to practice
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Edited by: Nicholas Procter – University of South Australia, Helen Hamer – Auckland University, Denise McGarry – Charles Sturt University, Rhonda Wilson – University of New England and Terry Froggatt – University of Wollongong
Publication Date: February 2014 AUD $89.95
• In each chapter, consumers and/or carers of people with a mental illness provide narratives of firsthand experience, to ensure readers are fully engaged with the needs of consumers and carers in mental health. Written for this text, these narratives encourage deep learning to support the development of safe, high-quality person-centred care.
• Provides a consistent human inquiry approach to engagement with people with mental illness and the people who care for them.
• Provides a nursing focus, but considers the broader health context and a range of practice settings.
• Provides a positive, respectful approach to mental health (rather than an illness focus) for the next generation of the workforce.
• Includes extensive pedagogy within each chapter, including reflective questions, key terms, critical thinking questions and learning extensions.
• Includes comprehensive online support material.
Mental Health. A Person-Centred Approach