Background to ATAPS
Summary of ATAPS Suicide Prevention service initiative evaluation findings
Implications of the ATAPS Suicide Prevention service initiative evaluation findings
11.3.1 Background to ATAPSThe Access to Allied Psychological Services (ATAPS) service initiative was established in 2003 as part of the Better Outcomes in Mental Health Care Program (BOiMHC) program. The initiative provides consumers with access to evidence-based psychological services delivered by allied health professionals, and is administered through Medicare Locals. In 2006, the Australian Government introduced the Better Access initiative to psychiatrists, psychologists and GPs through the Medicare Benefits Schedule (MBS), a similar program which facilitates access to mental health care from similar providers, but which is funded through MBS item numbers. Following the introduction of the Better Access initiative, the ATAPS service initiative shifted its focus to provide services to hard-to-reach groups and at-risk populations.
Since 2008, additional funding has been provided to the ATAPS service initiative to deliver 'Tier 2' sub-programs which address the needs of at-risk groups, or use specific modes of service delivery. The Tier 2 special-purpose funding addresses the needs of the following at-risk groups: women with perinatal depression, people at risk of suicide and self-harm, people experiencing or at high risk of homelessness, people impacted by extreme climatic events (eg, bushfires, floods, cyclones), people in remote locations including Indigenous communities, and children with mental disorders. The Tier 2 Suicide Prevention service initiative is the focus of this discussion.
The ATAPS Suicide Prevention service initiative was initially delivered through pilot demonstration projects implemented by 19 Divisions of General Practice from 2008 to 2011. The pilots were delivered by trained ATAPS professionals (psychologists, appropriately trained nurses, occupational therapists, social workers and Aboriginal and Torres Strait Islander health workers), and aimed to provide an intensive, prioritised service for people at risk of suicide (eg, those who had recently made a suicide attempt, had recently self-harmed, or were having severe suicidal thoughts) who may or may not have a mental disorder.91
The services initially delivered through the pilots were expanded nationally under the TATS package and continue to be partly funded by the NSPP. The services include focused psychological services, case management, proactive follow-up, and liaison with local accident and emergency services and state mental health services. The services continue to be delivered by health professionals who have completed additional mandatory training.92 Health professionals are required to make contact with the referred consumer within 24 hours of referral and provide the first session of care within 72 hours. Therapeutic support can occur over a period of two months, with an unlimited number of sessions during that time.
As part of the roll out of the ATAPS Suicide Prevention Service initiative nationally, a telephone support service was also rolled out. This service was initially an after-hours service; however from July 2012, it was expanded to a 24 hours per day, seven days per week, ATAPS Suicide Support Line. This project is partially funded by the NSPP. Top of page
11.3.2 ATAPS evaluationsThe Centre for Health Policy, Programs and Economics (CHPPE) at the University of Melbourne has been evaluating the general ATAPS program and its sub-programs since their inception. The most recent evaluation data on the Suicide Prevention Program is contained in the Nineteenth Interim Evaluation Report of the Evaluating the Access to Allied Psychological Services (ATAPS) program.93 This report drew on data from a purpose designed Minimum Data Set (MDS) to address the following evaluation questions:
- What is the level of uptake of ATAPS by consumers?
- What is the level of participation of ATAPS by professionals?
- What are the socio-demographic and clinical profiles of consumers of ATAPS?
- What is the nature of the treatment received by ATAPS consumers?
- Is ATAPS achieving positive outcomes for consumers? Top of page
11.3.3 Summary of ATAPS Suicide Prevention service initiative evaluation findingsThe Nineteenth Interim Evaluation Report provides combined data from the pilot and the national expansion of the Suicide Prevention service initiative, to December 2011. Key findings are outlined below.
Level of uptake by consumersTo December 2011, there had been 3,877 referrals to the ATAPS Suicide Prevention service initiative. Of these, 3,443 resulted in treatment sessions and the average number of sessions per referral was 5.9. The high proportion of referrals that translated into sessions is notable, and suggests that the program is addressing consumer need. The number of referrals peaked in the first quarter of 2011 and the number of sessions peaked in the second quarter of 2011. Two possible reasons for the subsequent decline have been suggested. First, following the national expansion of the ATAPS Suicide Prevention service initiative in 2010, the initial influx may have slowed as the consumers in need were attended to. The second possible reason in that the transition of Divisions of General Practice to Medicare Locals may have temporarily affected referral numbers due to changes in data entry processes.
Level of participation by professionalsWhilst psychiatrists, community mental health workers and emergency department staff, as well as GPs, are able to make referrals to the ATAPS Suicide Prevention service initiative, GPs are the primary referral source (87.5% of all referrals). Emergency departments were the second highest source of referrals (4.9% of all referrals).
Socio-demographic and clinical profiles of consumersThe following summary describes the socio-demographic and clinical profile of consumers accessing the ATAPS Suicide Prevention service initiative. Due to missing data, this should be considered indicative only:
- The majority of consumers were female (59.8%, compared with 35.7% men).
- The mean age was 33.9 years.
- Over half (55.7%) had low incomes.
- Almost 40% (39.9%) had a history of previous psychiatric service use (compared with 29.7% who did not have a history of previous psychiatric service use).
- 2.4% identified as Aboriginal and 0.4% identified as Torres Strait Islander.
- The vast majority spoke English at home (81%).
Nature of the treatment received by consumersMost consumers taking part in the ATAPS Suicide Prevention service initiative had sessions of 46 to 60 minutes duration. The vast majority of sessions were face-to-face, however a small percentage (6.3%) were conducted by telephone. A range of interventions were used, with four elements of cognitive-behavioural therapy (namely cognitive, behavioural, relaxation and skills training components) predominating. Other reported interventions included diagnostic assessment, psycho-education and interpersonal therapy.
Outcomes for consumersPre- and post-treatment outcome data was available for 424 (12%) consumers taking part in the ATAPS Suicide Prevention service initiative (this was based on a pre-requisite that a minimum of 50 consumers were required to have pre-and post-treatment scores on a given outcome measure in order for their data to be included in the analysis). The measures used were the Depression Anxiety and Stress Scales (DASS), the Kessler 10 (K-10) and the Modified Scale for Suicidal Ideation (MSSI). Across all these measures, the mean difference between pre-treatment and post-treatment scores was statistically significant and indicative of clinical improvement. Top of page
11.3.4 Implications of the ATAPS Suicide Prevention service initiative evaluation findingsThe discussion below considers the published evaluation findings relating to the appropriateness, effectiveness and efficiency of the ATAPS Suicide Prevention service initiative and reflects the views of AHA.
AppropriatenessBased on review of the published evaluation reports, it is clear that the ATAPS Suicide Prevention service initiative is meeting a consumer need. Consumer uptake is high, and the majority of referrals to the program have translated into sessions. Importantly, the services reached people who may not otherwise have had access to psychological care, given that more than half of the consumers were on low incomes.
The program is also supported by the evidence for best practice in suicide prevention. A number of studies have shown that a significant number of people who die by suicide seek help from primary care providers – particularly GPs – in the period leading up to their death. There is evidence from systematic reviews demonstrating that equipping physicians to recognise and treat depression is an effective approach (see Section 11.4.4).94 The ATAPS approach follows this rationale, but provides treatment by allied health professionals with expertise and time rather than by GPs. It stands to reason that strong outcomes may be produced if GPs and other health professionals with specialised health care skills work together in the delivery of care.
Importantly, the ATAPS Suicide Prevention service initiative appears to be filling a gap that has been identified in our evaluation of NSPP-funded projects (2007-13) in relation to improving the capacity of GPs and other health professionals to recognise and treat depression. While the ATAPS Suicide Prevention service initiative did not provide training for GPs, it has provided an enabling structure within which people at risk of suicide may be more readily referred for treatment.
EffectivenessThe ATAPS Suicide Prevention service initiative has produced positive consumer outcomes. Across all the outcome measures for which an adequate sample was provided, the mean difference was statistically significant and indicative of clinical improvement. That said, the extent to which the improvements have been sustained following completion of the intervention is not known.
EfficiencyIt has not been possible to establish the extent to which the ATAPS Suicide Prevention service initiative represents value for money. No economic analysis has been undertaken to date because the national expansion of the program is still in its infancy and there is limited data on outcomes at this stage.95 Top of page
Key findingsThe ATAPS Suicide Prevention service initiative is an appropriate and effective suicide prevention intervention. It is not possible to establish the efficiency of the program because the national expansion of the program is still in its infancy and there is limited data on outcomes at this stage.
91 J Fletcher, K King, B Bassilios et al, Evaluating the Access to Allied Psychological Services (ATAPS) Program: Nineteenth Interim Evaluation Report, University of Melbourne Centre for Health Policy, Programs and Economics, Melbourne, 2012
92 Department of Health and Ageing, Operational Guidelines for the Access to Allied Psychological Services Initiative, DoHA, Canberra, 2012.
93 Fletcher et al, Evaluating the Access to Allied Psychological Services (ATAPS) Program.
94 Mann et al, 'Suicide Prevention Strategies'.
95 Officer from DoHA Mental Health Services Branch, personal communication, 23 April 2013.