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The new RANZCP guidelines for the treatment of schizophrenia and related disorders highlights what we know works. In this paper, we examine why patients so often fail to benefit from this knowledge and why clinical practice falls so far short of the recommended standard. Instead of the continuous improvement that we expect of health care in general, in psychiatry we face an accelerating decline in systems of care. There has been a sustained underinvestment in public mental health care and a shared failure by State and Federal governments to construct and commit to a governance and funding model that can deliver the standard of care that is available in other major non-communicable diseases, and which we know is equally possible for severe mental illness. This paper sets out some of the reasons for the poor quality of care received by many people with schizophrenia and related disorders in Australia, and describes ways that care could be improved. In particular, we recommend an explicit statement of what constitutes an adequate standard of care, for people at all stages of these illnesses. This would help provide transparency about whether the care provided by mental health services achieves these benchmarks, and enable publication of results comparing the performance of different states and regional services. Patients and families, as well as professional, consumer and carer organizations would then be able to see clearly where the deficits are and demand resources and care that match the recommendations. [ABSTRACT FROM AUTHOR]

Objective: In New Zealand and Australia, a renewed emphasis on equity and efficiency in the provision of mental health care has seen outcomes-focused, culturally appropriate clinical practice become essential within mental health services. Ascertaining the degree to which quality improvement and monitoring systems are enhancing professional practice and patient outcomes, however, is hindered by the difficulty of measuring the process of quality care delivery. Method: This paper argues that it is the process of care delivery (i.e. what clinicians do to, and for, patients) that is critical to the effectiveness of treatment and the degree to which treatment either inhibits or promotes an improvement in mental health recovery. Identification of the underlying causes of poor achievement of process factors is likely to positively impact on things such as readmission rates, shared care initiatives, and ultimately patient recovery. Such attention could be the difference between low-quality service provision and a high-quality service provision with positive recovery outcomes for patients. Results: Ascertaining the degree to which quality improvement and monitoring systems are enhancing professional practice and patient outcomes for indigenous people, however, is hindered by the difficulty of measuring such concepts. Australia has indeed embraced 'culturally appropriate' practice in recent years, but this appears to be piecemeal when compared with New Zealand. Certainly, there are inconsistent and variable approaches to cultural practices with indigenous people when comparing the two countries. Conclusions: Using evidence from a bicultural mental health nursing study that developed and validated generic and Maori-specific (indigenous) clinical indicators for mental health nursing standards of practice in New Zealand, it is argued that the process of care delivery is equally as important as outcome measures when ascertaining the effectiveness of nursing care. Second, this paper contends that accurate process measures must be culturally responsive to indigenous and other ethnic groups. [ABSTRACT FROM AUTHOR]

Objective: In Australia, mental health services are delivered by a complex web of public- and private-sector providers. There is a growing recognition that linkages between these groups are not optimal, and a concern that this may lead to poor outcomes. This paper illustrates a conceptual framework for developing, implementing and evaluating programmes concerned with linkages. Method: Drawing on theoretical and practical literature, this paper identifies different levels of integration, issues in evaluating programmes to address poor linkages, and features of useful evaluations. Within this context, it describes the method by which the Public and Private Partnerships in Mental Health Project (Partnership Project) is being evaluated. Conducted by St Vincent’s Mental Health Service and The Melbourne Clinic, this is one of several Demonstration Projects in Integrated Mental Health Care funded under the National Mental Health Strategy. Results: Collaboration is hard to conceptualize and collaborative programmes usually have many players and components, and tend to operate within already-complex systems. This creates difficulties for evaluation, in terms of what to measure, how to measure it, and how to interpret findings. In spite of these difficulties, the illustrative example demonstrates a model for evaluating collaborative programmes that is currently working well because it is strongly conceptualized, descriptive, comparative, constructively sceptical, positioned from the bottom up, and collaborative. Conclusions: This model, or aspects of it, could be extended to the evaluation of other mental health programmes and services that have collaborative elements. [ABSTRACT FROM AUTHOR]

Background: Socioeconomic trends herald what many describe as the Asian Century, whereby Asian economic, political and cultural influence is in global ascendency. Broadening relevant ties between Australia and Asia is evident and logical and may include strengthening alliances in mental health systems. Aim: We argue the importance of strengthening Asian mental health systems and some of the roles Australian mental health workers could have in promoting strengthening the Asian mental health system. Methods: This paper is a narrative review which sources data from reputable search databases. Results: A well-articulated Australian strategy to support strengthening the mental health system in Asia is lacking. While there are active initiatives operating in this space, these remain fragmented and underdeveloped. Coordinated, collaborative and culturally respectful efforts to enhance health education, research, policy, leadership and development assistance are key opportunities. Conclusion: Psychiatrists and other mental health professionals have a unique opportunity to contribute to improved mental health outcomes in Asia. [ABSTRACT FROM AUTHOR]

Objective: Australia's Better Outcomes in Mental Health Care (BOiMHC) programme enables GPs to refer patients with common mental disorders to allied health professionals for time-limited treatment, through its Access to Allied Psychological Services (ATAPS) projects. This paper considers whether patients who receive care through the ATAPS projects make clinical gains, if so, whether particular patient-related and treatment-related variables are predictive of these outcomes. Method: Divisions of General Practice (Divisions), which run the ATAPS projects, are required to enter de-identified data into a minimum dataset, including data on patients'' socio-demographic and clinical characteristics, the sessions of care they receive, and their clinical outcomes. We extracted data from January 2006 to June 2010, and examined the difference between mean pre- and post-treatment scores on the range of outcome measures being used by Divisions. We then conducted a linear regression analysis using scores on the most commonly-used outcome measure as the outcome of interest. Results: Pre- and post-treatment outcome data were available for 16 700 patients from nine different outcome measures. Across all measures, the mean difference was statistically significant and indicative of clinical improvement. The most commonly-used measure was the Kessler-10 (K-10), and pre- and post-treatment K-10 data were available for 7747 patients. After adjusting for clustering by Division, outcome on the K-10 was associated with age, levels of income and education, previous receipt of mental health care, number of sessions, treatment received and pre-treatment K-10 score. The benchmark was sufficiently high, however, that even the groups that fared relatively less well still showed strong improvement in absolute terms. Conclusions: Patients who receive care through the ATAPS projects are making considerable clinical gains. A range of socio-demographic, clinical and treatment-based variables are associated with the levels of outcomes achieved, but improvements are still substantial even for those in the relatively disadvantaged groups. [ABSTRACT FROM AUTHOR]

Objective: Little is known about the predictors of symptom change or the methods that might increase user ‘compliance’ on websites designed to improve mental health outcomes. The present paper: (i) examines predictors of expected final depression and anxiety scores on the MoodGYM website as a function of user characteristics; and (ii) compares the compliance rates of the original site with the new public version of the site (MoodGYM Mark II). The latter site requires compulsory completion of ‘core’ online assessments and may increase completion of site questionnaires. Method: MoodGYM Mark I participants were 19 607 visitors (public registrants) between April 2001 and September 2003 plus 182 participants who had been randomly assigned to MoodGYM in an earlier trial (The BlueMood Trial). MoodGYM Mark II participants were 38 791 public registrants of the MoodGYM Mark II site collected between September 2003 and October 2004. Symptom assessments are repeated within the website intervention to allow the examination of change in symptoms. Outcome variables were gender, initial depression severity scores, number of assessments completed and final anxiety and depression scores. Results: Men are predicted to be 0.19 units (SE = 0.095) higher than women on depression, controlling for the initial depression level and number of modules completed. For initial depression scores above 2, it is predicted that the final score will indicate improvement relative to the initial score, the magnitude of the improvement increasing as a function of the number of modules attempted. For initial anxiety scores above 2, it is predicted that the final score will indicate improvement relative to the initial score, the magnitude of the improvement increasing as a function of the number of modules attempted. Mark II registrants were more likely than to Mark I registrants to complete onsite assessments. Conclusions: Visitors to the MoodGYM site are likely to have better psychological outcomes if they complete more of the site material. Compulsory completion of core sections increases assessment completion. There is a need to examine further the significance of attrition from online interventions, to develop methods of handling missing data, and to investigate strategies to improve visitor dropout. [ABSTRACT FROM AUTHOR]

Objective: The present paper applies Goldberg and Huxley's Pathways to Care (PTC) model to the Australian health-care system to ask: who is treated in each sector and what does this tell us about the performance of the health-care system? It examines the factors associated with reaching primary care, outpatient and inpatient sectors, as well as private and public mental health services. Method: Data from the Australian National Survey of Mental Health and Wellbeing were used to determine the proportion of the population treated in each sector. Sociodemographic and clinical characteristics were examined and logistic regression was used to determine which factors were associated with use of different sectors of care. Results: Of the total population, 80.5% reached primary care, 8.2% primary care for mental health problems, 6.5% outpatient care and 0.4% reached the mental health inpatient sector. Clinical severity increased across these sectors and was an important determinant of access to care. Those consulting private practitioners were clinically similar to those consulting in the public sector. Sociodemographic characteristics were important determinants of access to primary, specialist and private mental health care. Being aged over 55 years or living in a rural area was associated with lower access to several sectors. Conclusions: Although at a broad level the health-care system is performing as expected, limited access among some groups is cause for concern. Applying the PTC model to a population sample offered useful insights into the performance of the Australian health-care system. [ABSTRACT FROM AUTHOR]

Objective: We assessed, from a health sector perspective, options for change that could improve the efficiency of Australia's current mental health services by directing available resources toward ‘best practice’ cost-effective services. Method: We summarize cost-effectiveness results of a range of interventions for depression, schizophrenia, attention deficit hyperactivity disorder and anxiety disorders that have been presented in previous papers in this journal. Recommendations for change are formulated after taking into account ‘second-filter criteria’ of equity, feasibility of implementing change, acceptability to stakeholders and the strength of the evidence. In addition, we estimate the impact on total expenditure if the recommended mental health interventions for depression and schizophrenia are to be implemented in Australia. Results: There are cost-effective treatment options for mental disorders that are currently underutilized (e.g. cognitive–behavioural therapy (CBT) for depression and anxiety, bibliotherapy for depression, family interventions for schizophrenia and clozapine for the worst course of schizophrenia). There are also less cost-effective treatments in current practice (e.g. widespread use of olanzapine and risperidone in the treatment of established schizophrenia and, within those atypicals, a preference for olanzapine over risperidone). Feasibility of funding mechanisms and training of staff are the main second-filter issues for CBT and family interventions. Acceptability to various stakeholders is the main barrier to implementation of more cost-effective drug treatment regimens. More efficient drug intervention options identified for schizophrenia would cost A$68 million less than current practice. These savings would more than cover the estimated A$36M annual cost of delivering family interventions to the 51% of people with schizophrenia whom we estimated to be eligible and this would lead to an estimated 12% improvement in their health status. Implementing recommended strategies for depression would cost A$121M annually for the 24% of people with depression who seek care currently, but do not receive an evidence-based treatment. Conclusions: Despite considerable methodological problems, a range of cost-effective and less cost-effective interventions for major mental disorders can be discerned. The biggest hurdle to implementation of more efficient mental health services is that this change would require reallocation of funds between interventions, between disorders and between service providers with different funding mechanisms. Australian and New Zealand Journal of Psychiatry 2005; 39:701–712 [ABSTRACT FROM AUTHOR]

To examine the clinical profile, treatment and social functioning of a community-based sample of young people presenting with their first episode of psychosis.Over a 2-year period, young people with their first episode of psychosis referred to early intervention services in two area mental health services in western Sydney were assessed with a battery of clinical, neuropsychological, psychophysiological and neuroanatomical measures. This paper reports the clinical results of the baseline section of the study.Of the 224 referrals to the project, 94 subjects meet inclusion criteria and agreed to take part. Subjects were divided into three diagnostic groups − ‘Schizophrenia’,‘Mood Disorders’ and‘Mixed Psychosis’, the latter principally comprised of substance induced psychotic disorders. Subjects from the‘Schizophrenia’ group differed significantly from the other two groups in that they had higher levels of negative symptoms and general psychopathology, and were less likely to be employed or engaged in study. They had poorer overall social functioning. Subjects with‘Mixed Psychosis’ were similar to those from the‘Schizophrenia’ group in that they were older and male, but they did not have the same burden of negative symptoms as the‘Schizophrenia’ group. The‘Mood Disorders’ group was younger, female and had overall a higher level of psychosocial functioning than the other two groups. Subjects from the‘Mood Disorders’ group were more likely to be managed with mood stabilisers and multiple drug therapies. The use of atypical antipsychotic medication was almost universal.Even shortly after the time of presentation to mental health services young people with a schizophrenia spectrum diagnosis have a heavier burden of symptoms and are significantly more impaired by them than young people with other psychotic illnesses. This and their symptom profile differentiated them from young people with other psychotic disorders. [ABSTRACT FROM AUTHOR]

This paper aims to provide an overview of the literature on non-sexual dual relationships, and to discuss these in the context of rural mental health practice in Australia.An internet-driven literature search was undertaken using OVID databases, which include MEDLINE, PsycINFO, CINAHL, and EMBASE: Psychiatry. Ethical codes of practice for the mental health professions of psychiatry, psychology, occupational therapy, social work and nursing were referred to. Searches were not limited by year of publication. Other unpublished material or information was included where relevant.Dual relationships are common in rural mental health practice. However, research on non-sexual dual relationship boundary issues in rural mental health is limited. Ethical codes of practice of mental health professional bodies provide little guidance regarding non-sexual dual relationships. Decision-making models addressing the ethics of dual relationships are restricted to considerations of whether to enter a dual relationship rather than how to manage such a relationship.‘Everyday’ dual relationships are a predictable part of rural mental health practice. Further research is required to identify the benefits and/or problems in clinical practice resulting from non-sexual dual relationships. Responsibility for identifying and implementing ways of appropriately managing such relationships should be shared by the patient, the clinician, mental health services and professional organizations. [ABSTRACT FROM AUTHOR]

Objective: A shortened version of a presentation to the Australian Institute of Aboriginal and Torres Strait Islander Studies, this paper raises questions regarding policy and program directions in Indigenous affairs with consequences for Indigenous health. Method: The author notes the inadequate Indigenous mental health database, and describes contemporary conflicts in the arena of Indigenous mental health, drawing on personal experience in clinical service delivery, policy and programme development. Results: Medicalized responses to the Stolen Generations report and constructions of suicide that accompanied the Royal Commission into Aboriginal Deaths in Custody are presented to demonstrate unforeseen health outcomes. Examples are also given of well-intentioned social interventions that, in the context of contemporary Indigenous society appear to be contributing to, rather than alleviating, harm. Problems of setting priorities that confront mental health service planners are considered in the light of past and continuing social disadvantage that informs the burden of mental disorder in Indigenous communities. Conclusions: The importance of acknowledging untoward outcomes of initiatives, even when motivated by concerns for social justice, is emphasized. The tension within mental health services of responding to the underpinning social issues versus providing equity in access to proven mental health services for Indigenous populations is considered. [ABSTRACT FROM AUTHOR]

Objective: This paper evaluates a range of properties for a clinician-based instrument designed for routine use in a child and adolescent mental health service (CAMHS). Method: The Health of the Nation Outcome Scales for Children and Adolescents (HoNOSCA) is a new outcome measure with great promise. Case vignettes were used to examine interrater reliability. HoNOSCA was implemented for routine outpatient use by multidisciplinary staff with a return rate of 84%. The 305 ratings obtained at assessment were analysed by age, gender and diagnosis. A sample of 145 paired ratings with a 3-month interval were examined for the measurement of change over time. Results: Interrater reliability of the total score indicates moderate reliability if absolute scores are used and good reliability if the total score is used for relative comparisons. Most scales have good to very good reliability. The scales discriminated between age and gender in the expected way. HoNOSCA correlated with clinicians’ views of change and was sensitive to change over a 3-month period. The total score seemed a proxy for severity. Conclusion: Routine outcome instruments must be explored in settings where they will be used and with realistic training. HoNOSCA appears to be of value in routine outcome measurement and although questions remain about reliability and validity, the results strongly support further investigation. [ABSTRACT FROM AUTHOR]

Objective: This paper aims to assess the utility of six measures of consumer outcomes: the Behaviour and Symptom Identification Scale, the Mental Health Inventory (MHI), the Medical Outcomes Study 36-Item Short-Form Survey, the Health of the Nation Outcome Scales, the Life Skills Profile (LSP) and the Role Functioning Scale previously recommended for the routine assessment in Australian mental health services. Method: Consumers and service providers were invited through focus group discussions and surveys to describe the perceived utility of these selected measures. Results: All six measures were rated favourably. The qualitative and quantitative findings suggest that the MHI elicited the most positive results of the consumer measures. No observer-rated scale was clearly preferred. Conclusion: The qualitative feedback obtained indicated that process and context issues may be as important to the successful use of routine instruments for the measurement of consumer outcomes in clinical practice as the choice of instrument. [ABSTRACT FROM AUTHOR]

Objective: This paper outlines the methods used, and preliminary descriptive data collected, in a study on a cohort of Maori and non-Maori patients admitted to the inpatient psychiatric services in Otago between 1990 and 1992. Method: The notes of 42 Maori and 217 non-Maori first admissions to psychiatric inpatients were reviewed. Information concerning this admission was entered onto a database and analysed. Results: The Maori admission rate was 4 per 1000 compared with 1 per 1000 for non-Maori people. This was higher than expected based on Otago population figures. Rates of family psychiatric history did not differ between Maori and non-Maori. Although Maori were found to have higher rates of social welfare support and were more likely to have no academic qualifications the differences were not significant. The sources of referral for Maori admissions were more likely to be from the law, and Maori were more likely to have had prior psychiatric inpatient treatment. The most common diagnosis for Maori and non-Maori was depressive disorders, and suicidal behaviour was common. Conclusions: Maori are overrepresented among first psychiatric inpatient admissions in Otago. They appear to be a more disadvantaged group with respect to financial support, academic qualifications and other health problems. The most common diagnosis did not differ between Maori and non-Maori cohorts. [ABSTRACT FROM AUTHOR]