**9. Social Inclusion**

224 Health Management – Different Approaches and Solutions

such as psychologists for people suffering from mental illness (Mulvale et al 2007,

Given the complexities of developing sustainable funding models for mental health, one solution would be to develop policy and funding strategies around a series of "pillars or "building blocks", similar to the Canadian Aboriginal Horizontal Framework and Council of Australian Governments National Indigenous Reform Agreement. This would align government policy to internationally accepted principles of health care and may allow a broader government overview and responsibility for the various components necessary to develop mental health. Funding could be allocated to each "pillar" and benchmarks attached to each pillar to assess progress. The "pillars" suggested are: Physical Health, Social Inclusion, Education, Effective Treatments, Substance Abuse, Mental Health Response to Disaster, Housing and Governance. Each one of these will be discussed in turn with a view to relevance and with mention of previous and current programs that could provide a

**8. The physical health of people suffering from severe mental illness** 

There is a significant amount of information that people who suffer from serious mental illness also are at increased risk of increased morbidity and premature mortality from comorbid medical illness. Viron & Stern (2010) talk of patients suffering from severe mental illness losing over 25 years of potential life with 87% of years of potential life lost being attributable to medical illness. They further comment that the mortality gap, based on data from 1997 to 2000 is 10 to 15 years wider than it was in the early 1990's. Observations at the beginning of the twentieth century noted that physical morbidity and mortality were greater amongst psychiatric patients than in the general population. Other commentators have noted the lack of thorough medical evaluation and inadequate treatment of medical disorders amongst psychiatric patients (Felker B et al 1996) . The issue of co-morbid medical conditions is particularly prominent in patients suffering from schizophrenia. This is not surprising given the social isolation, problems with adequate housing and the lack of organisation of proper meals and poor diet reported for this group of patients (Jablensky et al 2006, Brown et al 1999). High rates of tobacco and other substance use in this group also

Apart from the obvious issues of significant disability related to the illness process itself, there also appear to be a number of medical and health system barriers to recognition and management of medical illness in people with schizophrenia. Such barriers include a reluctance of non-psychiatrists to treat people with serious mental illness, frequent changes of treating doctor, lack of adequate follow up due to patients' itinerancy and lack of motivation and the available time and resources for an appropriate review of medical issues of people who may be uncooperative or have trouble communicating their physical needs (Lambert et al 2003). Higher rates of poverty in those experiencing severe mental illness (d'Amore et al 2001) along with stigma related to the experience of mental illness (Barney et al 2006) may also be further barriers patients with mental illness developing an effective relationship with a General Practitioner. The atypical antipsychotic medications may also lead to an increased prevalence of endocrine disorders such as Type 2 Diabetes (Lambert &

Chapman 2004), thus necessitating increased medical vigilance in this regard.

Moulding et al 2009)

basis of funding.

**7. A new paradigm for mental health funding** 

add to the disease burden (Jeste et al 1996).

A socially inclusive society is defined as one where all people feel valued, their differences are respected, and their basic needs are met so they can live in dignity. Social exclusion is the process of being shut out from the social, economic, political and cultural systems which contribute to the integration of a person into the community (Cappo 2002). Leff & Warner (2006) have outlined factors that lead to social exclusion for people affected by severe mental illness. These include the disabilities produced by the illness itself (such as the negative features of schizophrenia which include apathy and reluctance to engage with others), disabilities produced by professional care (including institutionalization and side effects of medication), stigmatizing attitudes of the public and self stigma of individuals (which may affect recognition of illness and ability to obtain appropriate treatment), media influences, poverty and discrimination in housing and employment.

Some of these factors are going to be considered in other sections of this chapter. The key focus on this area of social inclusion in the current context is addressing stigma and the maintenance of people suffering from severe mental illness within their social group. Sartorius (2010) discusses a range of barriers to effective campaigns to reduce stigma. He notes that anti-stigma campaigns have to be longer than a year to be effective. Sartorius comments that other factors that have been proven to reduce stigma such as legislation to effect employment and housing, ongoing promotion of useful strategies (such as education of health care professionals, public education forums for members of the public by people who have suffered from mental illness and avoidance of pejorative comments in the media) and permanent networks of interested business people, professionals, patients and their families that respond to local issues within cultures and communities.

To an extent, the *headspace* Model of Care for young people suffering from severe mental illness in Australia attempts to fulfill some of the above requirements in an organizational

A New Economic and Social Paradigm for Funding Mental Health in the Twenty First Century 227

in legislation, such as recent Mental Health Acts in Victoria and the Northern Territory of

Participation in the workforce is an important factor in social inclusion. Warner (1983) comments that a key factor for any work for people affected by severe mental illness is that there should be stable expectations geared to the level of performance that the individual can actually achieve and this is more difficult to achieve in industrial society where there are high productivity requirements and competitive performance ratings. Further issues that may interfere with effective workforce participation in developed countries are co-morbid substance abuse and physical illness (Cornwell et al 2009). Employment programs for people affected with severe mental illness that are integrated into public mental health services appear to be one way to improve outcomes. One example of this is the Individual Placement and Support Approach in the United States that has been found to have almost a three fold increase in employment participation (60% versus 22%) (Waghorn et al 2007). A recent collaboration between Mental Health Services and the Vocational Education Sector in New South Wales that integrates supported education along with supported employment for mental health consumers is hoping to have similar results, maximising chances for consumer choice in employment and enhanced long term employment outcomes (VETE 2011, J McMahon pers comm). Apart from the economic benefits of the participation of people affected by severe mental illness in paid employment, there are also other personal benefits for those such engaged such as increased pride, self esteem, empowerment and

A range of issues may assist with social inclusion of individuals affected by severe mental illness in the third world. It has been noticed that cultural mechanisms may be more accepting of mental illness in these countries (Kermode et al 2009, Postert 2010). However, Rahman & Prince (2008) note that there is a significant amount of stigma experienced by families of people affected by severe mental illness in third world countries. They go on to suggest the incorporation of mental health treatment into primary care services as a way of reducing this stigma along with the training of primary care workers in the use of psychotropic medication. It has also been noted that regular use of such medication (with a subsequent reduction of difficult behaviours) may lead to greater social function and

It has been recognised for a considerable period of time now that education in itself leads to empowerment in health. The review by DeWalt et al (2004) displayed that patients with poor literacy had poorer health outcomes including knowledge, intermediate disease markers, measures of morbidity, general health status and use of health resources. Cutler and Lleras-Muney (2006) suggest a range of mechanisms for education to enable health behaviours. They note that the effect of education increases with increasing years of education. Education in relation to income and occupational choice has some relationship to health empowerment but that different thinking and decision making patterns as a result of

Henry (2007) comments on required "development platforms" which need to be in place for education to be effective. These include: security from violence, promotion of early childhood development, a home environment that is conducive to regular patterns of sleep and study, free from overcrowding and distraction and ready access to suitable primary health service

acceptance of the person within their community (de Jong & Komproe 2006).

increased education may also have significant effects on health behaviours.

Australia (Parker et al 2010)

facilitation with coping (Dunn et al 2008).

**10. Education** 

sense. A principal aim of *headspace* is "to establish a highly accessible, more specialized multidisciplinary model of care to target the core health needs of young people"(McGorry et al 2007). To enable these objectives, *headspace* has developed a number of funded centers within Australian local communities with the aim of building greater awareness of youth mental health within these communities and building capacity within these communities to ensure early detection and early intervention of emerging mental illness and substance use disorders, create a youth and family friendly environment, benefit from significant improvements in access, service integration and quality through co-location, secondment of clinical staff and outreach and access evidence-based interventions for the treatment of mental and substance use disorders (ibid).

The engagement of family members of people suffering from severe mental illness in the treatment process is crucial. This is because of the therapeutic value that family members may bring to the care of the person through their knowledge of expert and longitudinally developed information about the person which is helpful for appreciation of psychosocial deficits and current mental state in addition to their involvement in any case planning for the person's further management (Furlong & Leggatt 1996) Further evidence that therapeutic family interventions, particularly behavioural education, in reducing relapse for people suffering from schizophrenia and thus improving the cost-effectiveness of treatment (Mihalopoulos et al 2004) add emphasis to the value of family intervention in the illness.

The psychological effects of any chronic illness in relation to the family members of the person so affected are well recognised (Bloch et al 1994) Such factors include the issues surrounding the illness itself (acute onset, chronicity, acute exacerbation), the life-cycle stage of the family and the meaning of the illness to the family. Such "meaning" will be influenced by the family's previous experience of illness and belief systems about illness (ibid). Whilst these issues are relevant in the case of family members of someone suffering from schizophrenia, there is additional evidence of the devastating additional effect of the illness on family, leading to comments such as that recently made in a textbook of mental health law that "like other service providers but perhaps more than other service providers, the family and friends of the individual will have an emotional and practical interest in the fate of that individual" (Bartlett & Sandland 2003)

The family burden of living with a person suffering from a major mental illness such as schizophrenia is well described. It has been noted that stigma associated with the illness spreads to the whole family and may cause them to avoid talking about how they are feeling or deem themselves as social outcasts, leading to barriers between them and mental health professionals (Teschinsky 2000)

Recent reviews of the pressures faced by carers of people suffering from severe mental illness describe the "Objective Burden" that involves disruption to the household routines, finances and relationships and a "Subjective Burden" which involves the psychological consequences of the individual's illness for the family (Martens & Addington 2001, Wong et al 2008). The "Subjective Burden" of the illness appears to be higher for relatives of people experiencing first onset illness associated with schizophrenia (Martens & Addington 2001) and promotes the beneficial therapeutic value of psycho-education for the family in respect to information about the illness, illness management skills, communication skills and problem solving skills (Motlova 2007) therefore being an effective way of reducing this distress through empowerment of family members. Culture and differing family belief systems may be particularly important in this regard (Lesser 2004) The legal issues of confidentiality allowing such engagement with families are complex but can be negotiated in legislation, such as recent Mental Health Acts in Victoria and the Northern Territory of Australia (Parker et al 2010)

Participation in the workforce is an important factor in social inclusion. Warner (1983) comments that a key factor for any work for people affected by severe mental illness is that there should be stable expectations geared to the level of performance that the individual can actually achieve and this is more difficult to achieve in industrial society where there are high productivity requirements and competitive performance ratings. Further issues that may interfere with effective workforce participation in developed countries are co-morbid substance abuse and physical illness (Cornwell et al 2009). Employment programs for people affected with severe mental illness that are integrated into public mental health services appear to be one way to improve outcomes. One example of this is the Individual Placement and Support Approach in the United States that has been found to have almost a three fold increase in employment participation (60% versus 22%) (Waghorn et al 2007). A recent collaboration between Mental Health Services and the Vocational Education Sector in New South Wales that integrates supported education along with supported employment for mental health consumers is hoping to have similar results, maximising chances for consumer choice in employment and enhanced long term employment outcomes (VETE 2011, J McMahon pers comm). Apart from the economic benefits of the participation of people affected by severe mental illness in paid employment, there are also other personal benefits for those such engaged such as increased pride, self esteem, empowerment and facilitation with coping (Dunn et al 2008).

A range of issues may assist with social inclusion of individuals affected by severe mental illness in the third world. It has been noticed that cultural mechanisms may be more accepting of mental illness in these countries (Kermode et al 2009, Postert 2010). However, Rahman & Prince (2008) note that there is a significant amount of stigma experienced by families of people affected by severe mental illness in third world countries. They go on to suggest the incorporation of mental health treatment into primary care services as a way of reducing this stigma along with the training of primary care workers in the use of psychotropic medication. It has also been noted that regular use of such medication (with a subsequent reduction of difficult behaviours) may lead to greater social function and acceptance of the person within their community (de Jong & Komproe 2006).

#### **10. Education**

226 Health Management – Different Approaches and Solutions

sense. A principal aim of *headspace* is "to establish a highly accessible, more specialized multidisciplinary model of care to target the core health needs of young people"(McGorry et al 2007). To enable these objectives, *headspace* has developed a number of funded centers within Australian local communities with the aim of building greater awareness of youth mental health within these communities and building capacity within these communities to ensure early detection and early intervention of emerging mental illness and substance use disorders, create a youth and family friendly environment, benefit from significant improvements in access, service integration and quality through co-location, secondment of clinical staff and outreach and access evidence-based interventions for the treatment of

The engagement of family members of people suffering from severe mental illness in the treatment process is crucial. This is because of the therapeutic value that family members may bring to the care of the person through their knowledge of expert and longitudinally developed information about the person which is helpful for appreciation of psychosocial deficits and current mental state in addition to their involvement in any case planning for the person's further management (Furlong & Leggatt 1996) Further evidence that therapeutic family interventions, particularly behavioural education, in reducing relapse for people suffering from schizophrenia and thus improving the cost-effectiveness of treatment (Mihalopoulos et al 2004) add emphasis to the value of family intervention in the illness. The psychological effects of any chronic illness in relation to the family members of the person so affected are well recognised (Bloch et al 1994) Such factors include the issues surrounding the illness itself (acute onset, chronicity, acute exacerbation), the life-cycle stage of the family and the meaning of the illness to the family. Such "meaning" will be influenced by the family's previous experience of illness and belief systems about illness (ibid). Whilst these issues are relevant in the case of family members of someone suffering from schizophrenia, there is additional evidence of the devastating additional effect of the illness on family, leading to comments such as that recently made in a textbook of mental health law that "like other service providers but perhaps more than other service providers, the family and friends of the individual will have an emotional and practical interest in the fate

The family burden of living with a person suffering from a major mental illness such as schizophrenia is well described. It has been noted that stigma associated with the illness spreads to the whole family and may cause them to avoid talking about how they are feeling or deem themselves as social outcasts, leading to barriers between them and mental health

Recent reviews of the pressures faced by carers of people suffering from severe mental illness describe the "Objective Burden" that involves disruption to the household routines, finances and relationships and a "Subjective Burden" which involves the psychological consequences of the individual's illness for the family (Martens & Addington 2001, Wong et al 2008). The "Subjective Burden" of the illness appears to be higher for relatives of people experiencing first onset illness associated with schizophrenia (Martens & Addington 2001) and promotes the beneficial therapeutic value of psycho-education for the family in respect to information about the illness, illness management skills, communication skills and problem solving skills (Motlova 2007) therefore being an effective way of reducing this distress through empowerment of family members. Culture and differing family belief systems may be particularly important in this regard (Lesser 2004) The legal issues of confidentiality allowing such engagement with families are complex but can be negotiated

mental and substance use disorders (ibid).

of that individual" (Bartlett & Sandland 2003)

professionals (Teschinsky 2000)

It has been recognised for a considerable period of time now that education in itself leads to empowerment in health. The review by DeWalt et al (2004) displayed that patients with poor literacy had poorer health outcomes including knowledge, intermediate disease markers, measures of morbidity, general health status and use of health resources. Cutler and Lleras-Muney (2006) suggest a range of mechanisms for education to enable health behaviours. They note that the effect of education increases with increasing years of education. Education in relation to income and occupational choice has some relationship to health empowerment but that different thinking and decision making patterns as a result of increased education may also have significant effects on health behaviours.

Henry (2007) comments on required "development platforms" which need to be in place for education to be effective. These include: security from violence, promotion of early childhood development, a home environment that is conducive to regular patterns of sleep and study, free from overcrowding and distraction and ready access to suitable primary health service

A New Economic and Social Paradigm for Funding Mental Health in the Twenty First Century 229

Psycho-education for the family involving information about the illness, illness management skills, communication skills and problem solving skills (Motlova 2007) has been demonstrated to be an effective way of reducing this distress. It has been shown that, as a result of the training, families become empowered to better manage their relative's mental illness and their reactions to it. A recent evaluation of formal group training provided to carers of people affected by early psychosis resulted in the carers reporting less isolation, improved confidence, greater understanding of psychosis, reduction in guilt and increased

Education of other professional groups who have involvement with people affected by severe mental illness is also an important aspect to the strategy to improve knowledge and skills and effect better management of these individuals. A good example of this is the Mental Health Intervention Team Course offered by the New South Wales Police Force (Donohue D et al 2009). It is recognised that police often are at the fore front of interactions with people who are severely affected by mental illness and may significantly aroused as a result. Kesic et al (2010) in a review of fatalities as a result of interaction with police in Victoria found that 54.2% (26/48) of the victims had a history of DSM IV Axis I disorder, 39.6% of the 48 events had a history of substance abuse/dependence, 10.4% had formal diagnosis of Axis II personality disorder and that 87.5% were known in some capacity to mental health services or police. It was also estimated that in any given year, Currently New South Wales Police Officers can expect to attend approximately 22,000 mental health related incidents (about 30% of total call outs per year) with some of the incidents posing the

The New South Wales Police Mental Health Intervention Team course runs over four days and includes formal education sessions in respect to mental illness, substance abuse, legal issues and available services in addition to "real situation" education scenarios such as role plays. The formal aims of the course are: to reduce the rate of injury to police and mental health consumers on interaction, improve awareness amongst front line police of the risks involved in mental health incidents, improve collaboration with other government and non government agencies in the response to, and management of mental health crisis incidents and reducing the time taken by police in the handover of mental health consumers to the health care system. An important aspect to the education is the participation of mental health consumers and carers in educating police about the way that they are affected by symptoms and the way that they would like to be approached during acute exacerbations of their illness. The effect of severe mental illness on the carers was also well appreciated by the police participants of the course that I attended and police commented that they found the sessions with mental health consumers and carers some of the most valuable learning that they took from the course. Police (ranging from Area Commanders to constables) who attend the course are awarded a course badge as a formal "police appointment" to be worn on their uniform at the conclusion of the course. To an extent, this also allows people who are severely affected by mental illness and who are in crisis to recognise that attending

Effective treatments (underpinned by rigorous and continuing research) are an essential component of any broad strategy for quality mental health service delivery. The treatments have specific costs that obviously inform public policy in respect to what particular

confidence in their caring role (Riley et al 2011).

biggest risk to their safety (Donohue et al 2009).

police, wearing the badge, have training to assist them.

**11. Effective treatments** 

infrastructure. A good example of the essential nature of such platforms to improved educational outcomes has been the success of the Clontarf Foundation education programs with Indigenous male adolescents in Australia. The Clontarf Foundation, a not for profit, organisation, was established in Western Australia in 2000. It was established to improve the discipline, life skills and self esteem of young Aboriginal men so that they can participate meaningfully in society. The Foundation currently has contact with 2000 young Aboriginal men in Western Australia and the Northern Territory. The Foundation's programmes to young Aboriginal men are delivered through a network of 25 Academies, each of which operates in partnership with (but independently of) a school or college. Australian Rules Football (AFL) is used to attract the young men to school and then keep them there. In order to remain in the program, participants must continue to work at school and embrace the objectives of the Foundation, Each Academy has an individual staff member who, in addition to delivering the football program, acts as a mentor and trainer addressing many of the negatives impacting on the young men's lives. Many of the Academy staff are ex AFL players. Participation by young Aboriginal men in the Clontarf Foundation has resulted in significantly increased retention rates for the participants through to the completion of secondary education and then on to participation in the workforce. By the end of 2008, 41 (76%) graduates of the 2007 program were employed. In April 2009, 51 of the 76 graduates of the 2008 program were in full time employment (Clontarf Foundation 2010)

Examples of successful education programs in mental health are: initiatives to improve mental health literacy, education programs to empower carers of people affected by severe mental illness and mental health training for police.

Health literacy appears to be a key component of improved education and health outcomes. Health literacy has been defined as "the ability to gain access to, understand and use information in ways which promote and maintain good health (Jorm et al 1997) Jorm and his colleagues found that health literacy in respect to mental health was not well developed amongst a sample of the Australian population and that this lead to unwillingness to accept help from mental health professionals or to a lack of adherence to advice given (ibid).

A potential solution to poor health literacy are the "mental health first aid training programs" developed for the Aboriginal and Torres Strait Islander Population of Australia (Kanowski et al 2009) in addition to the wider Australian population (Kitchener & Jorm 2006) The programs aim to provide help to a person developing a mental health problem or in a mental health crisis (Kanowsky et al 2009) and are aimed at Instructors who develop the skills for staff working in Aboriginal and Torres Strait Islander primary health organisations. The programs are based on education about a range of symptoms of mental illness as well as a response to a range of potential mental health scenarios such as helping a suicidal person, a person experiencing a panic attack, a person who has experienced a traumatic event and a psychotic person who is perceived to be threatening (Kitchener & Jorm 2006). It was estimated that in 2005, 350 people who worked area health services, non government organisations, government departments or as private practitioners had completed the Instructor training in Australia (ibid).

A further, school based initiative in mental health literacy is the "Mind Matters" Curriculum that was developed for Australian Secondary Schools (Wyn et al 2000) The project is based on a model of school change developed by the World Health Organisation and involves curriculum materials about emotional and mental health issues in addition to creating a school environment that is safe, responsive to student needs and that assists students in their ability to cope with challenges and stress (ibid).

Psycho-education for the family involving information about the illness, illness management skills, communication skills and problem solving skills (Motlova 2007) has been demonstrated to be an effective way of reducing this distress. It has been shown that, as a result of the training, families become empowered to better manage their relative's mental illness and their reactions to it. A recent evaluation of formal group training provided to carers of people affected by early psychosis resulted in the carers reporting less isolation, improved confidence, greater understanding of psychosis, reduction in guilt and increased confidence in their caring role (Riley et al 2011).

Education of other professional groups who have involvement with people affected by severe mental illness is also an important aspect to the strategy to improve knowledge and skills and effect better management of these individuals. A good example of this is the Mental Health Intervention Team Course offered by the New South Wales Police Force (Donohue D et al 2009). It is recognised that police often are at the fore front of interactions with people who are severely affected by mental illness and may significantly aroused as a result. Kesic et al (2010) in a review of fatalities as a result of interaction with police in Victoria found that 54.2% (26/48) of the victims had a history of DSM IV Axis I disorder, 39.6% of the 48 events had a history of substance abuse/dependence, 10.4% had formal diagnosis of Axis II personality disorder and that 87.5% were known in some capacity to mental health services or police. It was also estimated that in any given year, Currently New South Wales Police Officers can expect to attend approximately 22,000 mental health related incidents (about 30% of total call outs per year) with some of the incidents posing the biggest risk to their safety (Donohue et al 2009).

The New South Wales Police Mental Health Intervention Team course runs over four days and includes formal education sessions in respect to mental illness, substance abuse, legal issues and available services in addition to "real situation" education scenarios such as role plays. The formal aims of the course are: to reduce the rate of injury to police and mental health consumers on interaction, improve awareness amongst front line police of the risks involved in mental health incidents, improve collaboration with other government and non government agencies in the response to, and management of mental health crisis incidents and reducing the time taken by police in the handover of mental health consumers to the health care system. An important aspect to the education is the participation of mental health consumers and carers in educating police about the way that they are affected by symptoms and the way that they would like to be approached during acute exacerbations of their illness. The effect of severe mental illness on the carers was also well appreciated by the police participants of the course that I attended and police commented that they found the sessions with mental health consumers and carers some of the most valuable learning that they took from the course. Police (ranging from Area Commanders to constables) who attend the course are awarded a course badge as a formal "police appointment" to be worn on their uniform at the conclusion of the course. To an extent, this also allows people who are severely affected by mental illness and who are in crisis to recognise that attending police, wearing the badge, have training to assist them.

#### **11. Effective treatments**

228 Health Management – Different Approaches and Solutions

infrastructure. A good example of the essential nature of such platforms to improved educational outcomes has been the success of the Clontarf Foundation education programs with Indigenous male adolescents in Australia. The Clontarf Foundation, a not for profit, organisation, was established in Western Australia in 2000. It was established to improve the discipline, life skills and self esteem of young Aboriginal men so that they can participate meaningfully in society. The Foundation currently has contact with 2000 young Aboriginal men in Western Australia and the Northern Territory. The Foundation's programmes to young Aboriginal men are delivered through a network of 25 Academies, each of which operates in partnership with (but independently of) a school or college. Australian Rules Football (AFL) is used to attract the young men to school and then keep them there. In order to remain in the program, participants must continue to work at school and embrace the objectives of the Foundation, Each Academy has an individual staff member who, in addition to delivering the football program, acts as a mentor and trainer addressing many of the negatives impacting on the young men's lives. Many of the Academy staff are ex AFL players. Participation by young Aboriginal men in the Clontarf Foundation has resulted in significantly increased retention rates for the participants through to the completion of secondary education and then on to participation in the workforce. By the end of 2008, 41 (76%) graduates of the 2007 program were employed. In April 2009, 51 of the 76 graduates of the 2008 program were

Examples of successful education programs in mental health are: initiatives to improve mental health literacy, education programs to empower carers of people affected by severe

Health literacy appears to be a key component of improved education and health outcomes. Health literacy has been defined as "the ability to gain access to, understand and use information in ways which promote and maintain good health (Jorm et al 1997) Jorm and his colleagues found that health literacy in respect to mental health was not well developed amongst a sample of the Australian population and that this lead to unwillingness to accept help from mental health professionals or to a lack of adherence to advice given (ibid). A potential solution to poor health literacy are the "mental health first aid training programs" developed for the Aboriginal and Torres Strait Islander Population of Australia (Kanowski et al 2009) in addition to the wider Australian population (Kitchener & Jorm 2006) The programs aim to provide help to a person developing a mental health problem or in a mental health crisis (Kanowsky et al 2009) and are aimed at Instructors who develop the skills for staff working in Aboriginal and Torres Strait Islander primary health organisations. The programs are based on education about a range of symptoms of mental illness as well as a response to a range of potential mental health scenarios such as helping a suicidal person, a person experiencing a panic attack, a person who has experienced a traumatic event and a psychotic person who is perceived to be threatening (Kitchener & Jorm 2006). It was estimated that in 2005, 350 people who worked area health services, non government organisations, government departments or as private practitioners had

A further, school based initiative in mental health literacy is the "Mind Matters" Curriculum that was developed for Australian Secondary Schools (Wyn et al 2000) The project is based on a model of school change developed by the World Health Organisation and involves curriculum materials about emotional and mental health issues in addition to creating a school environment that is safe, responsive to student needs and that assists students in

in full time employment (Clontarf Foundation 2010)

mental illness and mental health training for police.

completed the Instructor training in Australia (ibid).

their ability to cope with challenges and stress (ibid).

Effective treatments (underpinned by rigorous and continuing research) are an essential component of any broad strategy for quality mental health service delivery. The treatments have specific costs that obviously inform public policy in respect to what particular

A New Economic and Social Paradigm for Funding Mental Health in the Twenty First Century 231

Given the above difficulties, an effective best practice model will probably be optimally provided by a knowledge of basic science, best evidence via knowledge of epidemiology and randomised controlled studies along with interpretation and individualisation related to clinical experience and available resources (Belmaker R pers comm.). However, effective treatments will continue to be a constant objective of appropriate funding priority in mental health and require a governance mechanism to review their ongoing usefulness and

In the current era, no effective mental health policy can be expected to succeed without some measures to control substance abuse that precipitates and sustains mental illness. Although this area is complex and may appear somewhat overwhelming, a brief overview of a major area of practice and public health appears to show a number of factors worthy of

There is substantial evidence that children exposed to trauma in their domestic environment are at later risk of severe mental illness such as schizophrenia (Harley et al 2010) and substance abuse (ibid). There are a number of explanatory models for this with stress exacerbating genetic vulnerability to mental illness (Xie et al 2009) and people using substances to self medicate PTSD resulting from childhood trauma as well as increased substance abuse in the context of dysfunctional personalities (Jonson-Reid et al 2009))and

Alcohol abuse continues to be a major contributor to childhood trauma (Nelson et al 2010) with the children of alcoholic parents exhibiting higher rates of anxiety and depression (Eiden et al 2009). In addition, alcohol has further effects such as the higher rates of anxiety and depression in children affected by foetal alcohol syndrome (Hellemans et al 2009) There is also a growing body of evidence in respect to the close association of substance abuse and mental illness, particularly in respect to cannabis and amphetamine abuse. Paparelli et al (2011) in their review article point to emerging consistent evidence between cannabis abuse and an increased risk of psychiatric symptoms and chronic illness. The authors also discuss the increased risk of psychosis as a result of repeated amphetamine and methamphetamine abuse and point to evidence of probable neuronal damage due to repeated methamphetamine abuse. The issue of brain damage related to amphetamine use was also demonstrated in a recent pilot study that appeared to show that 1:5 of young people who presented to a hospital ED in the context of amphetamine abuse had an occult brain lesion, as a result of their amphetamine abuse, on MRI scans (Fatovich et al 2010). A range of strategies have been suggested for successful intervention with mental illness and substance abuse. Legislative measures such as increased excise on alcohol, improved policing of drink driving and reducing availability of alcohol to young people through a minimum legal purchase age have been shown to be highly effective in reducing alcohol related harm in Germany ( Walter et al 2010). Recent information from Australia indicates that improved policing in respect to amphetamine abuse may have been a factor in reducing inpatient admissions from psychosis secondary to psycho-stimulants (Sara et al 2011). Innovative primary care approaches to managing cannabis abuse (Lubman & Baker 2010) and stimulant abuse (Frei 2010) have also found to be useful. Such management approaches involve improved screening for substance abuse and mental health problems, education and self monitoring for affected individuals, developing harm reduction strategies and patient

empowerment through exploring options for change and negotiating a change plan.

economic priority.

**12. Substance abuse and mental illness** 

policy intervention in a broad sense.

aberrant emotional attachment (Rees 2005).

economies and cultures are prepared to fund. As an example, the Tolkien II team have estimated that the average cost of treating a case of depression in Australia in 2005 was \$175,566 with psychological therapies and medication. Tolkien II Team (2006). Effective therapeutic interventions are also a major area of concern for key stakeholders of mental health services with this area being considered most important in a recent European survey of Mental Health Recovery initiatives (Turton et al 2010).

A crucial issue that informs the above economic models is the use of Evidence Based Practice as a gold standard for funding decisions. There are complexities with this issue, however. Tanenbaum (2005) defines three potential controversies and a caveat in respect to evidence base practice in mental health policy. The first controversy is how restrictive should the definition of the evidence be and whether dominant definitions privilege some forms of treatment over others. The second controversy raised by Tanenbaum is that there is a significant difficulty translating research findings into clinical practice and this relates to a larger controversy in mental health about whether practice is in fact applied science. It also focuses on a significant paradox where the 'significantly filtered" study populations of pharmaceutical trials often have little in common with the complex patients treated by clinicians (Westen 2005). Tanenbaum's third controversy is "the definition of *effective* health care and who decides the benchmarks for *effectiveness"*.

Notwithstanding the above controversies, there has been increasing emphasis in recent times on evidence based guidelines for the treatment of mental illness with initiatives such as the American Psychiatric Association Practice Guidelines (APA 2011) and the Clinical Practice Guidelines introduced by the Royal Australian and New Zealand College of Psychiatrists (RANZCP 2011)

However, research has consistently shown that education efforts alone do not appear to strongly influence healthcare provider practitioner behaviours in comparison to a range of factors that have been demonstrated to influence such behaviours such as consumer demand for services, financial incentives and penalties, administrative rules and regulations and feedback on practice patterns (Mueser et al 2003). The authors go on to suggest six Evidence-Based Packages that may be useful in the management of people affected by severe mental illness. These are collaborative psychopharmacology, assertive community treatment, family psycho education, supported employment, illness management and recovery skills and integrated dual diagnosis treatment. Mueser et al also propose an implementation strategy for the packages that will enhance their success. These involve standardized complementary training and consultation packages for mental health centres in addition to discussion with health authorities in respect to financing, regulatory and contracting mechanisms to support the introduction of the Evidence-Based Packages (ibid). Specific attitudes of mental health providers that may need to be addressed in the adoption of Evidence-Based Packages are the intuitive appeal of the package, the strength of the requirement to adopt the package on the individual, the openness to new practice and the divergence of usual practice with research based/ academically developed interventions (Aarons 2004)

Further issues that considerably affect the implementation of evidence based practice are the pressure on policy makers to justify the allocation of resources and demonstrate add on value, the need for practitioners to have confidence in the likely success of implementing the interventions and that the people who are likely to benefit see that the program and it's process of implementation are participatory and relevant to their needs. A further challenge is the application of existing evidence to good practice on the ground, particularly in disadvantaged and low income countries (Barry & McQueen 2005)

Given the above difficulties, an effective best practice model will probably be optimally provided by a knowledge of basic science, best evidence via knowledge of epidemiology and randomised controlled studies along with interpretation and individualisation related to clinical experience and available resources (Belmaker R pers comm.). However, effective treatments will continue to be a constant objective of appropriate funding priority in mental health and require a governance mechanism to review their ongoing usefulness and economic priority.

#### **12. Substance abuse and mental illness**

230 Health Management – Different Approaches and Solutions

economies and cultures are prepared to fund. As an example, the Tolkien II team have estimated that the average cost of treating a case of depression in Australia in 2005 was \$175,566 with psychological therapies and medication. Tolkien II Team (2006). Effective therapeutic interventions are also a major area of concern for key stakeholders of mental health services with this area being considered most important in a recent European survey

A crucial issue that informs the above economic models is the use of Evidence Based Practice as a gold standard for funding decisions. There are complexities with this issue, however. Tanenbaum (2005) defines three potential controversies and a caveat in respect to evidence base practice in mental health policy. The first controversy is how restrictive should the definition of the evidence be and whether dominant definitions privilege some forms of treatment over others. The second controversy raised by Tanenbaum is that there is a significant difficulty translating research findings into clinical practice and this relates to a larger controversy in mental health about whether practice is in fact applied science. It also focuses on a significant paradox where the 'significantly filtered" study populations of pharmaceutical trials often have little in common with the complex patients treated by clinicians (Westen 2005). Tanenbaum's third controversy is "the definition of *effective* health

Notwithstanding the above controversies, there has been increasing emphasis in recent times on evidence based guidelines for the treatment of mental illness with initiatives such as the American Psychiatric Association Practice Guidelines (APA 2011) and the Clinical Practice Guidelines introduced by the Royal Australian and New Zealand College of

However, research has consistently shown that education efforts alone do not appear to strongly influence healthcare provider practitioner behaviours in comparison to a range of factors that have been demonstrated to influence such behaviours such as consumer demand for services, financial incentives and penalties, administrative rules and regulations and feedback on practice patterns (Mueser et al 2003). The authors go on to suggest six Evidence-Based Packages that may be useful in the management of people affected by severe mental illness. These are collaborative psychopharmacology, assertive community treatment, family psycho education, supported employment, illness management and recovery skills and integrated dual diagnosis treatment. Mueser et al also propose an implementation strategy for the packages that will enhance their success. These involve standardized complementary training and consultation packages for mental health centres in addition to discussion with health authorities in respect to financing, regulatory and contracting mechanisms to support the introduction of the Evidence-Based Packages (ibid). Specific attitudes of mental health providers that may need to be addressed in the adoption of Evidence-Based Packages are the intuitive appeal of the package, the strength of the requirement to adopt the package on the individual, the openness to new practice and the divergence of usual practice with research

Further issues that considerably affect the implementation of evidence based practice are the pressure on policy makers to justify the allocation of resources and demonstrate add on value, the need for practitioners to have confidence in the likely success of implementing the interventions and that the people who are likely to benefit see that the program and it's process of implementation are participatory and relevant to their needs. A further challenge is the application of existing evidence to good practice on the ground, particularly in

of Mental Health Recovery initiatives (Turton et al 2010).

care and who decides the benchmarks for *effectiveness"*.

based/ academically developed interventions (Aarons 2004)

disadvantaged and low income countries (Barry & McQueen 2005)

Psychiatrists (RANZCP 2011)

In the current era, no effective mental health policy can be expected to succeed without some measures to control substance abuse that precipitates and sustains mental illness. Although this area is complex and may appear somewhat overwhelming, a brief overview of a major area of practice and public health appears to show a number of factors worthy of policy intervention in a broad sense.

There is substantial evidence that children exposed to trauma in their domestic environment are at later risk of severe mental illness such as schizophrenia (Harley et al 2010) and substance abuse (ibid). There are a number of explanatory models for this with stress exacerbating genetic vulnerability to mental illness (Xie et al 2009) and people using substances to self medicate PTSD resulting from childhood trauma as well as increased substance abuse in the context of dysfunctional personalities (Jonson-Reid et al 2009))and aberrant emotional attachment (Rees 2005).

Alcohol abuse continues to be a major contributor to childhood trauma (Nelson et al 2010) with the children of alcoholic parents exhibiting higher rates of anxiety and depression (Eiden et al 2009). In addition, alcohol has further effects such as the higher rates of anxiety and depression in children affected by foetal alcohol syndrome (Hellemans et al 2009)

There is also a growing body of evidence in respect to the close association of substance abuse and mental illness, particularly in respect to cannabis and amphetamine abuse. Paparelli et al (2011) in their review article point to emerging consistent evidence between cannabis abuse and an increased risk of psychiatric symptoms and chronic illness. The authors also discuss the increased risk of psychosis as a result of repeated amphetamine and methamphetamine abuse and point to evidence of probable neuronal damage due to repeated methamphetamine abuse. The issue of brain damage related to amphetamine use was also demonstrated in a recent pilot study that appeared to show that 1:5 of young people who presented to a hospital ED in the context of amphetamine abuse had an occult brain lesion, as a result of their amphetamine abuse, on MRI scans (Fatovich et al 2010).

A range of strategies have been suggested for successful intervention with mental illness and substance abuse. Legislative measures such as increased excise on alcohol, improved policing of drink driving and reducing availability of alcohol to young people through a minimum legal purchase age have been shown to be highly effective in reducing alcohol related harm in Germany ( Walter et al 2010). Recent information from Australia indicates that improved policing in respect to amphetamine abuse may have been a factor in reducing inpatient admissions from psychosis secondary to psycho-stimulants (Sara et al 2011). Innovative primary care approaches to managing cannabis abuse (Lubman & Baker 2010) and stimulant abuse (Frei 2010) have also found to be useful. Such management approaches involve improved screening for substance abuse and mental health problems, education and self monitoring for affected individuals, developing harm reduction strategies and patient empowerment through exploring options for change and negotiating a change plan.

A New Economic and Social Paradigm for Funding Mental Health in the Twenty First Century 233

13% and a prevalence of affective disorders at around 20 to 40 % in homeless people (Schanzer et al 2007) Homelessness is also associated with higher rates of readmission to inpatient units along with longer inpatient stays (ibid). Additionally, homelessness is linked with excess mortality and particularly so with homeless people who abuse substances (Morrison 2009). Poverty, disabling health, behavioural issues co morbid substance abuse, competition for available public housing stock along with complex processes in applying for such stock all limit the opportunity for the mentally ill to access appropriate housing (O'Hara 2007). In addition, conventional categorical funding streams, bureaucratic program requirements, narrow administrative approaches to resource allocation and management and staff skills not geared to supporting the mentally ill in normal housing have been thought to have limited

It has also been noted that housing is a significant aspect of the recovery for people affected by severe mental illness with the concept of a "home" providing "roots, identity, security, belonging and a place of emotional wellbeing" (The PLoS Medicine Editors 2008). The "home" concepts that appear to be valued by the mentally ill are considered to be markers of ontological security: namely constancy, daily routines, privacy and a secure base for identity construction (Padgett 2007). It appears that different levels of housing support may be appropriate in this regard with supervised housing being more appropriate for people with severe disability from mental illness with a graduation to independent housing in the

Apart from the humanitarian aspects of the provision of a "home" to enhance recovery for people affected by severe mental illness, there also appear to be economic benefits generally with potential savings from repeated and lengthy hospital admissions that should

The development of effective governance processes to enable the mental health of a population should be the major concern of any government and health authority. Effective governance processes should have a continuing "flow on" effect over many years with demonstrated benefit for people affected by severe mental illness, their families and communities. Mulvale et al (2007) point to the way that historical factors can mitigate against good governance in developing a modern mental health system that reflects recovery principles. Alternatively, O'Connor and Paton (2008) elaborate key aspects of a modern clinical governance framework (safety of patients and staff, consumer and family focus and participation, a skilled and valued workforce, incidents as learning opportunities, continuous improvement of clinical care, structures of accountability) and the ways that such aspects can be supported at various levels of a health system in the developed world. Governance systems should also be underpinned by strong ethical principles in respect to the appropriate treatment for people affected by mental illness. A good example of such ethical principles is the Code of Ethics produced by the Royal Australian and New Zealand

In an economic sense, it appears that the key objective of any governance system for mental health would be to maximise the potential of people affected by mental illness in respect to their human value and their contribution to their community and society in general. Porter (2010a) argues that any value in an individual's health status is measured by outputs rather than inputs and depends on actual patient outcomes, not the volume of services delivered.

successful involvement by mental health services in this area (ibid).

context of recovery (Tsai et al 2010).

encourage further strategies in this area.

College of Psychiatrists (RANZCP 2010).

**15. Governance** 
