A number of areas outside health provide services to similar populations within our community. Policy, service planning and delivery in these areas need to be mindful of developments in the mental health area and vice versa. Examples of cross portfolio committees include the state based COAG mental health committees, and inter-departmental liaison committees. A national focus on areas such as social inclusion, or implementation of the National Mental Health and Disability Employment Strategy, provides opportunity to further engage across government and community areas.
The following sections illustrate non-health portfolio areas in which a collaborative approach to policy and service development will benefit service recipients across sectors.
- Aboriginal and Torres Strait Islander partnerships
- Alcohol and other drug services
- Children in care and youth justice
- Community services
- Correctional services and justice
- Culturally and linguistically diverse groups
- Emergency services - police, ambulance and fire authorities
- Schools and education
Aboriginal and Torres Strait Islander partnerships
OverviewCultural respect and awareness of the importance of a holistic approach across the continuum of mental health and wellbeing to mental illness are critical in the delivery of services to Aboriginal and Torres Strait Islander (ATSI) people. While some services are provided through Aboriginal Community Controlled Health Services, mainstream services need to be culturally proficient so that ATSI people feel confident to seek assistance when required.
Interface and future directionsServices need to be aware of issues of cultural safety and respect in how services are provided, and the impact of life events such as incarceration. They need to be aware of the importance of family, family dynamics and how cultural beliefs may impact on the presentation and management of mental illness. The impact of trans-generational trauma needs to be taken into account when planning and delivering services. In rural and remote communities, health and community workers need to be aware of mental health issues, and of the risks that comorbid substance abuse or physical ill health brings to mental wellbeing. ATSI specific services will need to support and inform workers in mainstream services how to provide the most appropriate interventions to Indigenous people.
Particular challenges that face service improvement in ATSI health include the diverse nature of the needs of ATSI people, and the ongoing development of the ATSI health workforce. The needs of urban ATSI people may be very different from those in remote communities, but the aim of promoting mental health and wellbeing is just as relevant. The Indigenous workforce needs to have confidence that they have access to advice and backup when required.Top of page
OverviewThe proportion of older people in Australia is increasing, as is life expectancy. While many remain in their own homes, others require the additional support of hostel or nursing home placement. Older people have an increased risk of mental health problems - through pre-existing illness, the recent onset of illness such as depression, and age specific illness such as dementia. They are also more likely to experience chronic physical health problems. They may be reliant on family or friends for support and have difficulty accessing some services because of limited mobility. They access specialist psychiatric services less than younger people. The delivery of services to ageing people in the community, and in aged care facilities, is complicated by the frequent co-existence of mental health and physical problems, sometimes with associated challenging behaviours.
Interface and future directionsServices for aged people are often delivered in partnership across health and community sectors. Care coordination is particularly important in such situations where general practice, multiple support agencies and clinical specialists are involved. While it is not expected that aged care staff will have the level of clinical skill that may be required for detailed assessment and treatment, workers from aged care and community sectors need to be aware of the risk of mental health problems, and should be able to screen, and where appropriate support, referral to more specialised services for mental health treatment and care.
Likewise, specialist mental health services for older people should develop improved capacity to support generic services, provide additional training and consultation to support the person remaining at home or in a mainstream facility. This may involve 'in-reach' of clinical services to the person's home or residential facility. Where admission to an inpatient service is indicated, discharge planning needs to incorporate advice and support to those involved in ongoing care, including family members.Top of page
Alcohol and other drug services
OverviewThere is a complex and multifactorial association between mental health problems, mental illness and excessive use of alcohol and illicit substances. Use of some substances such as cannabis and psycho stimulants is causally associated with mental health problems and mental illness. Those at increased risk for developing a mental illness, such as people who have experienced major disruptions during childhood, or exposure to trauma, are also at increased risk of developing substance dependence. This is especially so for those with high prevalence problems such as depressive illness, and anxiety disorders including post traumatic stress disorder. Children of parents with a substance abuse problem have an increased risk of developing mental health problems.
Interface and future directionsUntil fairly recently, there was little engagement between mental health services and alcohol and other drug (AOD) services. There is now considerable effort in a number of jurisdictions to better coordinate service delivery and to improve mutual understanding and respect between the sectors. Screening for mental health problems and staff training in their recognition and management leads to earlier identification and support to access appropriate services. Establishing linkages with mental health services, transfer of information and the development of joint care plans for people with multiple and complex needs will lessen duplication and discontinuity of care and support early intervention and sustained recovery.
At a state/ territory and Commonwealth level there has been investment to support workforce development, but further work is required to determine best practice in delivery of services to people with comorbid mental health problems and substance abuse. The interface between mental illness and mental health problems, and presentation to AOD services, warrant an investigation of new service delivery and care models. These may involve co-location, or one arm of service taking a lead in particular areas. For example, services focusing on psychotic disorders could provide interventions for cannabis and amphetamine users, while services for AOD could have arrangements for anxiety and affective disorders available. Headspace is one example of combined service delivery to young people. Future directions should support an improved response to mental health problems and to AOD dependency through comprehensive assessment, referral and treatment models.
The courts, police and other law enforcement officials are frequently faced with decisions regarding behavioural disturbance and its attributions. It can be difficult to distinguish at times the effects of intoxication from those of acute mental illness, and therefore to determine the most appropriate intervention and treatment. Collaboration between the courts, police, mental health services, AOD services and emergency department staff can make a significant difference to the immediate and longer term outcomes for the person involved.Top of page
Children in care and youth justice
OverviewChildren and their families who have contact with child protection services may present in the context of a particular crisis or be exposed to more enduring disadvantage and distress. Young people who come to the attention of the youth justice system often have multiple problems and challenges. These include increased risk of mental health problems, often experience of abuse or trauma, and exposure to illicit substances.
Interface and future directionsContact with these services presents an opportunity for intervention. Such intervention may directly address mental health issues, or indirectly improve mental health outcomes via services such as speech therapy or assistance at school. Intervention should work in ways that increase the young person's self confidence and resilience. Providing additional clinical and non-clinical support to parent(s) (e.g. via support for AOD issues) may be the most appropriate way to support children in the family and minimise risk. It is important that the staff working in these areas are aware of areas of vulnerability, and can adequately assess and be supported to assist the young person and his or her family.
There is sometimes a tension between the aims of child protection and youth justice services in relation to safety and risk minimisation, and those of mental health services in delivering treatment and care in the least restrictive environment. Greater effort is needed to improve understanding of the roles, responsibilities and limitations of each sector, and to develop models of service collaboration which include relevant information sharing and cross sector support.Top of page
OverviewCommunity services and mental health services often provide services to shared clients. Community services cover a diverse cross section of support services, generally provided by not-for-profit organisations which operate with a combination of charitable and government funding. Services include:
- family support
- alcohol and other drug services
- aged care
- out of home care
- carer respite
- personal support
- vocational and employment services
- homelessness services
- sexual assault services
- disability services
- women's services
- recreational services
- arts based services and
- multicultural services, including assistance to victims of torture and trauma.
Interface and future directionsOften workers in these services are at the front line, and will be involved in identifying people experiencing mental health issues, providing support to them, and promoting good mental health generally. While mental health clinical services focus on assessment and treatment, specialist and generic community services offer greater focus on opportunities that build resilience, community involvement and support that helps prevent escalation and relapse of mental illness. A partnership between the community sector and specialist mental health programs is critical to improving the mental health and wellbeing of a large number of Australians across a diverse range of cultures, locations and ages. Because of this, workers in all areas of community services need to be aware of mental health problems, including early identification and mental health first aid, the concerns faced by those with mental illness, and the needs of their carers.
Community services staff need to be aware of mental health issues to respond appropriately to people with mental illness, their families and carers. They also need an extensive knowledge of other support services that complement mental health services to facilitate local referrals between services to ensure timely and equitable access to appropriate care.
People with mental health as well as other health problems need to have their mental health needs addressed as well as their other health needs. For example, people with intellectual disability are at increased risk of experiencing a mental illness, yet this is often overlooked and access to appropriate treatment for both disabilities is limited.
Carer respite services also need training to recognise mental illness and knowledge of other support services to offer support and early intervention to people with mental illness and their carers.Top of page
Correctional services and justice
OverviewPeople who come into contact with the criminal justice system - through courts, prisons and community corrections - are more likely to have mental health problems or mental illness than the general community. They are also more likely to have alcohol and/or substance use problems. Incarceration can result in loss of contact with family, loss of accommodation and employment, and exacerbation or onset of mental illness. Indigenous people can be particularly at risk of mental health problems within a custodial environment.
Interface and future directionsScreening people for mental health problems at courts, and where possible diverting them to services in the community, supports an early intervention and prevention approach. Treatment and care within the custodial environment, and support to link with community services at the point of release, will reduce the risk of relapse of illness and is also likely to reduce the risk of recidivism. A significant proportion of those found guilty of an offence will also be managed in the community at some point - under parole or on community based orders.
Improving linkages between community correctional staff and the primary and specialist mental health service sector through better information exchange and staff training will lessen the risk of people falling between services. A particular challenge for correctional case managers is working within service criteria that fail to give sufficient weight to the complex needs of offenders. While there is a shared interest in community safety objectives, particularly where that is informed by assessment of the risk to self or others, there is less alignment between other health and corrections objectives. Offenders with apparently stable or sub-acute conditions may still require mental health support. Repeated involvement with the criminal justice system can exacerbate symptoms of mental illness. These issues are also relevant to the youth justice system. Cultural awareness and respect are particularly important in supporting ATSI people in the justice system.
It is recognised that the development of a consistent approach to the management of people with mental health problems in custody is complicated by the fact that models for the delivery of assessment and treatment services vary across jurisdictions. In some states and territories, mental health service provision is the responsibility of health, while in others it is overseen by the justice portfolio, or is a hybrid of both. Different legislative frameworks also apply. While there is general clarity with regard to the most appropriate management of offenders who have a mental illness, there is sometimes a tension regarding the management of offenders with behavioural disturbance in the context of a personality disorder. The manifestations of the most severe of these disorders continue to pose a major challenge in the correctional domain with a need for the development of specialist expertise and interventions. The National Statement of Principles for Forensic Mental Health covered a number of these areas, but has not been fully embraced across the service system. Court diversion programs and the development of mental health liaison staff within prisons are examples of collaborative joined up interventions.Top of page
Culturally and linguistically diverse groups
OverviewThe Australian community includes people from many different ethnic and cultural backgrounds. A number of issues relevant to mental health confront people who have come to Australia from other countries and cultures. They may have experienced trauma or torture in their country of origin or during the journey to Australia. They may be isolated, lacking community support and facing additional barriers because of language and cultural differences.
Interface and future directionsMental health services need to make use of professional interpreting services and to be aware of particular sensitivities associated with different religions and cultures. They need to be aware of the impact of exposure to traumatic events and of loss on the presentation of mental health problems and their treatment. This includes issues related to gender sensitivity. They need to support and nurture a bilingual workforce. Likewise, agencies who come into contact with new arrivals or who provide community and support services to people from other countries need to include consideration of their mental health needs, and establish pathways for referral or advice.
Future developments could include greater access to information in other languages, and support for multicultural community groups that recognise issues of particular concern or prevalence in a given community. The amenity of bed based and community services should include consideration of the needs of different religious groups, including issues related to gender.Top of page
Emergency services - police, ambulance and fire authorities
OverviewPolice, ambulance officers and fire fighters provide front line services. They are exposed to difficult and potentially dangerous situations, which sometimes involve those experiencing mental illness. With the shift to community based care and shortened inpatient episodes of care in less restrictive settings, there has also been increased expectation on police and others in the community to respond to people who experience mental illness.
Interface and future directionsSome mental illnesses are associated with a risk of functional disability and at times difficult behaviour. Comorbidity is common in such situations, particularly intoxication with alcohol and/or illicit substances. At such times there needs to be a close working relationship between mental health services and emergency services. Emergency service personnel have reported feeling that they were the 'meat in the sandwich', and that their concerns were given insufficient attention by those in the mental health sector.
Over the past decade, emergency services have responded to give staff greater training and support and to encourage local engagement. Transport of people experiencing mental illness has been an area of particular concern. Although ambulances are the preferred means of transport of mentally ill people, police will also be involved in transport in situations where there has been alleged offending behaviour, or when the risk of harm to the person or to others is very acute.
Emergency services should ensure their staff have adequate training in the recognition and early management of people in mental health crisis, and knowledge of the service system and how to access it. Respectful communication, patience and reassurance can defuse a situation and avert a tragic outcome. But police and ambulance staff also need to be able to access specialist services rapidly, and to have sufficient information transfer to allow them to do their job.Top of page
OverviewThere has been increasing recognition of the importance of employment or occupation in supporting good mental health, and of the impact of mental illness on absenteeism and subsequent loss of productivity. Mental health problems and mental illness often become evident in the work situation, particularly more common illnesses such as depression and anxiety disorders.
Interface and future directionsWorkplace policies and practices designed to support people to remain employed or to return to employment have been implemented in some areas, but are not yet common. Likewise, support to find suitable employment and support through the early stages of vocational placement can be very effective in assisting a person who has experienced a mental illness to rejoin the workforce. The development of policies at government level to promote more inclusive practice in support to find and keep employment is an important aspect of the recovery focus included in the fourth plan. While some models are in place, they are still relatively new and untested. Some rely on partnerships between clinical service providers, community support agencies and employment support agencies. Centrelink and employment support agencies are responsible for facilitating and supporting models which improve the placement and retention of those who are at risk of mental health problems. Staff in these agencies need to have access to information about what type of employment and support needs may be required. Clinical and community mental health services should work in ways that assist people with mental illness to seek or retain employment.Top of page
OverviewSafe, secure and affordable housing is critical for all, but particularly those with mental health problems. As such, it is important that appropriate services and support is available to all people, regardless of their housing tenure. There has been considerable attention to this area in recent years. The Homelessness White Paper considers a range of areas relevant to mental health, including a statement that people should not be discharged from health services into homelessness. But this may not always be feasible. A given person may not accept the accommodation offered. There is also pressure on services to admit very unwell people, and accommodation options are sometimes limited. Recognition of the importance of stable accommodation to the recovery process has led to greater integration across services, but further improvement in the coordination and collaboration between housing services and mental health services is still needed.
Interface and future directionsHomelessness may be both a cause and an effect of mental illness and mental health problems. Engagement with services is difficult for those who are homeless, but can be improved by services being available at homeless shelters or drop in centres. This engagement can then support movement into more secure and appropriate accommodation. Admission to an inpatient unit can precipitate homelessness, and discharge planning should include consideration of accommodation and support on discharge. Some people with mental illness may need long term supported accommodation. Others may require only transitional support.
There are a number of models for the provision of housing and support. These have demonstrated better outcomes, including sustained recovery from mental illness and return to employment. Planning for social housing developments should include consideration of the needs of people with mental illness and mental health problems, such as the proximity of clinical and support services, location and size of accommodation. Allocations made by social housing providers should also consider the needs of people with mental illnesses when offering properties, based on advice provided by mental health service providers where the person is linked with mental health services. Clinical and non-clinical mental health services should work with housing agencies to ensure tenancies are sustainable through the provision of suitable models of treatment and support.Top of page
Schools and education
OverviewKindergarten, primary and secondary education are accessed by nearly all young people. They thus provide a universal platform where mental health promotion, prevention and early intervention activities should be fostered. Identification, early intervention and, where appropriate, referral to more specialised services can make a significant difference in a child's welfare and outcome. A number of mental health problems such as anxiety and mood disorders, eating disorders and challenging behaviour may first come to notice in the school environment.
Interface and future directionsPrograms which address areas such as mental health and emotional wellbeing, bullying, challenging behaviours, healthy eating, and drug and alcohol education, are in place in some areas but could be expanded. We also need greater consistency in the range of programs provided, informed by evidence of what works best. School teaching staff and counsellors should have access to relevant training, and advice and support from the mental health specialist sector in relation to individuals or school programs.
Engagement between schools, community based mental health services, and child protection services should be supported by shared service agreements developed at a local or regional level. Transition from early childhood services to school and from primary to secondary school may represent a time of increased stress. It is during these times that staff need to be most alert to those who are at risk of dropping out of school.