PROJECT EVIDENCE for Treatment of Mental Disorders. The project coordinator is Dr Allan Mawdsley. The version can be amended by consent. If you wish to contribute to the project, please email admin@mhyfvic.org
[5] Early Treatment
a) Universal Health, Welfare and Educational agencies in the community [Tier 1]
b) Private practitioners and Community Mental Health services [Tier 2]
c) Specialist Mental Health services [Tier 3]
Mental health disorders occur throughout the community at various levels of severity. At present, diverse private and public sector agencies respond to aspects of mental health need in an un-coordinated manner. MHYFVic proposes a coordinating framework to ensure that appropriate care is delivered. This is described in Project Evidence PE 5 a.
[5 c ] Specialist Mental Health Services
Public sector specialist mental health services have a mandate to respond to the needs of the whole community, but with finite resources must prioritise urgent cases that are not able to be treated elsewhere. In particular, they must give priority to inpatient management of seriously mentally-ill patients in designated mental health facilities. The next priority is management of those cases outside the hospital setting. Only then can some resources be allocated to less serious degrees of mental disorder.
It is appropriate to triage the referrals and have significant barriers to intake of new cases into the hospital system so as to preserve its limited capacity from being inundated with cases that could be treated in community settings. The inherent fault has been that cases refused admission were not then adequately treated. The MHYFVic proposal is for all intake triage to be undertaken at Tier Two Community Mental Health Services.
There should be no direct referral to Tier Three units. All referrals for specialist mental health services should come through the intake service at Community Health Centres (Tier Two), staffed by Outreach Workers from the Tier Three services. In this way the specialist services can maintain control of their admissions whilst simultaneously ensuring that cases not admitted to the specialist units are provided with supported programs within the Community Health Centres.
The same Tier Three services outreach staff acting as intake workers at Community Health Centres would also provide the same service at Emergency Departments at General Hospitals and by outreach Community Assessment and Treatment Teams responding to emergency calls in the community (such as Involuntary Admission recommendations from GPs).
This proposal requires a considerable sharing of staff between the Tier Three and Tier Two services. Whilst Tier Two staff would do the bulk of case management work, the Tier Three staff would contribute the specialist intake/assessment and short-term therapy expertise, plus ongoing supervision of long-term care.
Although such job-sharing poses management difficulties, it also provides considerable professional benefits. Staff would experience a wide range of mental health problems at varying levels of severity, and see a number successfully resolved, rather than being constrained to one aspect of the range. This is likely to enhance job satisfaction, work flexibility and staff retention.
Tier Three specialist mental health services should provide:
As this project is focused on child, adolescent and family clientele, it will omit discussion of geriatric and general adult mental health services.
CHILD & ADOLESCENT MENTAL HEALTH SERVICES
Traditionally, child and adolescent mental health services have been stand-alone facilities, almost unrelated to other components of the health care system. They provided both highly specialised neuropsychiatric programs as well as generic child and family therapeutic programs of a Tier Two type. As such, they experienced chronic under-resourcing for the known community caseload, but also the obstacles to utilisation caused by stigma and lack of knowledge about their roles.
Given that most adult mental health disorders begin in childhood and adolescence, and that early intervention is more effective than treating established disorders, it is cost-effective resource allocation for improved CAMHS. However, as many cases can be treated at Tier Two level, the proposed MHYFVic model of Intake/Assessment and Short-term treatment at Tier Two level is equally applicable to CAMHS as to adult services.
The specialist multidisciplinary programs (such as autism spectrum assessments, early psychosis assessments and infant assessments), could remain at the Tier Three level whilst many generic therapeutic interventions would benefit by decentralisation to local Community Health Centres.
YOUTH MENTAL HEALTH SERVICES
In earlier decades the child and adolescent mental health services catered for the 0-18 year age range and adult services catered for the 19 year upwards age range. Younger adolescents were therefore managed within a CAMHS family-centred psychosocial context whilst the older adolescents were managed within the adult individually-centred service model.
In recent decades a youth mental health stratum has developed to cater for a 16-25 year age range during which there is a transition towards self-reliance and independence depending upon the circumstances of the person, rather than an abrupt shift that often did not match the needs of the person.
The proposed MHYFVic model of Intake/Assessment and Short-term treatment at Tier Two level is equally applicable to Youth Mental Health Services as to CAMHS and adult services. The specialist multidisciplinary programs (such as substance abuse assessments, early psychosis assessments and juvenile justice assessments), could remain at the Tier Three level whilst many generic therapeutic interventions would be better undertaken at a Tier Two community level, including at age-appropriate agencies such as Headspace.
Last updated 2 April 2020
POLICIES for Treatment of Mental Disorders
[5] Early Treatment
a) Universal Health, Welfare and Education agencies in the community. [Tier 1]
b) Private practitioners and Community Mental Health services [Tier 2]
c) Specialist Mental Health Services [Tier 3]
[5 c ] Specialist Mental Health Services
MHYFVic advocates that Specialist Mental Health Services for children and youth should be staffed at 120 Effective Full Time (EFT)/ 100,000 of the population in their age stratum, matching the level provided for adult services.
MHYFVic advocates that no more than 50% of this staffing be allocated to hospital-based services.
MHYFVic advocates that at least 50% of this staffing be allocated to community-based services and that half of this be utilised in Tier Two Community Health Centres for Intake/ Short-term assessment and treatment programs.
MHYFVic advocates that the other half of this staffing allocation be utilised for outreach consultation and CATT team service.
HYFVic advocates that this community-based staff deployment and expenditure should be undertaken collaboratively with partnering service agencies (not just decided within its own silo).
Last updated 2 April 2020
BEST PRACTICE MODELS for Treatment of Mental Disorders
[5] Early Treatment
a) Universal Health, Welfare and Educational agencies in the community [Tier 1]
b) Private practitioners and Community Mental Health services [Tier 2]
c) Specialist Mental Health services [Tier 3]
Mental health disorders occur throughout the community at various levels of severity. At present, diverse private and public sector agencies respond to aspects of mental health need in an un-coordinated manner. MHYFVic proposes a coordinating framework to ensure that appropriate care is delivered. This is described in Project Evidence PE 5 a.
[5 c ] Specialist Mental Health Services
Australian Institute of Health & Welfare reports indicate that mental health service staffing levels across the States over a period of years, has averaged about 120 Effective Full Time Staff (EFT) per 100,000 of the population. Of this, about half is devoted to hospital-based units and about half to community-based services.
Given that almost three quarters of mental health disorders first become evident in childhood and adolescence, that early treatment is more effective than delayed treatment, and that prevention of adverse consequences is ultimately less costly than treatment of serious and complex cases, there is a compelling case to argue that child, adolescent and youth mental health services should be funded to at least the same extent.
For the hospital component (which is primarily the inpatient, Emergency Department and Consultation/Liaison service), the pro-rata 60 EFT/100,000 young people of this age range would have to provide 24/7 staffing. Allowance would also be required for leave and illness absences. This rostering would determine the number of beds practicable for the region, which in turn would dictate admission and community management constraints.
The majority of beds would be utilised by older adolescents, but some provision would need to be made for children, with or without their families. Some innovative programs might be required with related agencies, such as paediatric medical wards and child protection residential programs, particularly in regions of the State where the numbers of young people in the population do not justify enough EFT staff.
For the community component, MHYFVic advocates that half of the pro-rata 60 EFT/100,000 young people in this age stratum should be deployed in Tier Three specialty programs and half in Tier Two programs (which would include the Intake/ Short-term assessment and treatment tasks, plus the outreach consultancy, CATT and training tasks). Because funding of child and youth mental health services has previously been below this benchmark, raising it to benchmark levels would enable more uniform service provision across the State. Even so, some innovative programs might be required between community health centres and collaborating agencies.
The present service network includes:
Child & Adolescent MH Services.
A network of five major metropolitan and eight rural centres provide services around the State. The State Health Department website gives the following information regarding the 0-18 age range (except Barwon 0-14 and Orygen 15-24). There are also three downloadable documents from their website.
Target population
Specialist child and adolescent mental health services are provided for children and adolescents up to the age of 18 years with serious emotional disturbance. This includes young people with a diagnosable psychiatric disorder whose condition is considered seriously detrimental to their growth or development and/or where there are substantial difficulties in the person’s social or family environment. Emotional disturbance in childhood and adolescence may present in a variety of ways.
While symptoms may include impaired reality testing, hallucinations, depression and suicidal behaviour, emotional disturbance in childhood presents more often in other ways. Hyperactivity, nightmares, fearfulness, bed-wetting, language problems, refusal to attend school, and stealing are among the behaviours that may indicate distress or disturbance. Young people from 16 to 18 years of age may receive a service from either child and adolescent mental health services or adult area mental health services depending on their needs.
Service components
Crisis assessment and treatment
Intensive mobile youth outreach support services
IMYOS provide intensive outreach mental health case management and support for adolescents with major psychological disturbance. The complex needs may include challenging, at risk and suicidal behaviours. These services work with young people who have been difficult to engage using less intensive treatment approaches.
Continuing care case management services, clinical and consultancy
These teams provide assessment and treatment of children and adolescents experiencing significant psychological distress and/or mental illness and their families. Services include crisis assessment, case management, multi-modal treatments, individual, family and group therapy and parent or carer support. They also provide consultancy services to other community agencies and service providers. These include schools, general practitioners, paediatricians, youth and family services, child protection and welfare agencies.
School early intervention programs (conduct disorder program)
Conduct disorder is the most severe type of disruptive behaviour in children and young people, with such behaviours as extreme aggression, truancy, lying, stealing, lack of empathy, or running away. Programs offering multilevel early intervention and prevention designed to reduce the prevalence and impact of conduct disorder are currently being piloted in Victoria, and are not currently available in all catchment areas.
Acute inpatient services
These services provide short-term assessment and/or inpatient treatment for children and adolescents who have a severe emotional disturbance that cannot be assessed satisfactorily or treated safely and effectively within the community. They are usually located with general hospitals. Links with metropolitan inpatient services exist for the admission of consumers from rural services.
Day programs
Child and adolescent mental health services’ adolescent day programs offer an integrated therapeutic and educational program for young people with behavioural difficulties; emotional problems such as severe depression and/or anxiety; emerging personality difficulties or a severe mental illness such as early psychosis. Issues such as relationship and/or social difficulties and non-attendance of an educational or vocational setting are addressed through intensive group therapy. These programs are not currently available in all catchment areas.
Orygen Youth Mental Health Service
Orygen’s (clinical) focus is on providing early intervention to young people with severe and/or complex mental illness. We provide care to approximately 1000 new young people each year (from the more than 4,000 young people who are referred).
Multidisciplinary teams deliver individually tailored services that comprise assessment and crisis intervention, case management, medication, psychological interventions, peer support, family support, inpatient care, group work, vocational interventions, educational assistance, and intensive outreach. Orygen also operates the Forensic Youth Mental Health Service for the custodial sites at Parkville and Malmsbury and community Forensic Youth Mental Health for all of western metropolitan Melbourne and Western Victoria.
Orygen’s clinical care program is comprised of three parts:
Orygen National is responsible for developing policy, training courses, factsheets, webinars, and clinical practice points. Orygen’s Policy Think Tank presents a number of policy opportunities for improving complex and integrated care for better youth mental health outcomes. Resources developed to support those working with young people with SLCN (Speech, Language and Communication needs) at www.speechpathologyaustralia.org.au under the Mental Health tab. Under the Training tab on the Orygen website, there is an evidence finder, where one can search on particular mental health issues, stage of illness, type of intervention, systematic reviews vs. randomised control trials, year of publication etc. Further information is available from Orygen www.orygen.org.au
Headspace
headspace Centres act as a one-stop-shop for young people who need help with mental health, physical health (including sexual health), alcohol and other drugs or work and study support.
Our 100+ centres are designed collaboratively with their young clients to ensure they are relevant, accessible and highly effective. As a result, no two headspace centres are the same, with each offering unique services that reflect the needs of its local community.
In regional and rural areas, getting access to expert psychiatrists is difficult. Our National Telehealth Service addresses this, by providing 12-25 year olds in these areas, access to highly-skilled psychiatrists via video consultations. The low-cost service ensures young people get high quality mental health care, while continuing their treatment within their local community.
eheadspace is our national online and phone support service, staffed by experienced youth mental health professionals. It provides young people and carers with a safe, secure and anonymous place to talk to a professional. It was intended to reach regional and remote young people who were unable to access a headspace centre. It has since grown in popularity with all young people – many of whom simply feel more comfortable accessing our services online.
headspace recognises the importance of work and study in a young person’s life. headspace Vocational Services support young people to reach their work and study goals– all in a confidential, online and youth-friendly environment.
Our Work and Study service supports young people whose work and study activities have been impacted by mental health problems. A Vocational Specialist helps them find, maintain or re-engage in work and/or study. Our Career Mentoring service offers young people the opportunity to work with an industry mentor to support their journey into employment. Our services are young person led, strengths based and voluntary—helping young people to take control of their work and study futures.
Emerging Minds
Emerging Minds leads the National Workforce Centre for Child Mental Health established to assist professionals and organisations who work with children and/or parents/families to have the skills to identify, assess and support children at risk of mental health conditions. The Centre incorporates three key components:
It is delivered in partnership with the Australian Institute of Family Studies (AIFS), the Australian National University (ANU), the Parenting Research Centre (PRC) and the Royal Australian College of General Practitioners (RACGP). It develops mental health policy, services, interventions, training, programs and resources in response to the needs of professionals, children and their families. It partners with family members, national and international organisations to implement evidence-based practice into the Australian context. Its resources are freely available at www.emergingminds.com.au
NOTE THAT ALTHOUGH THE STATE HEALTH DEPARTMENT EXERTS SOME COORDINATING CONTROL OVER THE CAMHS NETWORK IT REMAINS A MONOLITHIC SILO WHICH DOES NOT COORDINATE WITH OTHER SECTIONS OF THE HEALTH DEPARTMENT RESPONSIBLE FOR COMMUNITY HEALTH CENTRES IN THE MANNER ADVOCATED BY MHYFVIC.
Last updated 2 April 2020
We welcome discussion about any of the topics in our Roadmap epecially any wish to develop the information or policies.
Please send your comments by email to admin@mhyfvic.org
Speak about issues that concern you such as gaps in services, things that shouldn’t have happened, or things that ought to happen but haven’t; to make a better quality of service…….
Help achieve better access to services & better co-ordination between services together we can…….
Mental Health for the Young & their Families in Victoria is a collaborative partnership between mental health & other health professionals, service users & the general public.
MHYFVic
PO Box 206,
Parkville, Vic 3052
