Improving mental health and wellbeing care

Mental health and wellbeing

Mental health is “an integral and essential component of health . . . a state of wellbeing in which an individual realises his or her own abilities, can cope with the normal stresses of life, can work productively and is able to make a contribution to his or her community”.1 The diminishment of mental health can affect people of almost any age, and mental health disorders affect hundreds of millions of people globally. In 2019, mental health disorders caused approximately 5 per cent of the global burden of disease and 16 per cent of all years lived with disability.2 In Australia, mental health and substance use disorders accounted for 13 per cent of the total disease burden in 2018, the fourth-highest cause after cancer, cardiovascular diseases and musculoskeletal conditions, and almost half of all Australians will experience a mental health disorder at some stage in their lives.3 Youth is a particularly important life stage for prevention and early intervention, since 75 per cent of global mental illness starts by age 24.4 By 2030, depression is likely to be the second-highest cause of the global disease burden (second to HIV-AIDS) and the highest single contributor in high-income countries.5 People are more likely to have depression when they have physical illnesses (for example, diabetes, cancer)6 and may be more vulnerable to depression at particular life phases. A recent review found that 21 per cent of women worldwide experienced depression during pregnancy.7 

Around the world, health systems are slow to respond effectively to the increasing burden of mental health disorders. In low- and middle-income countries, between 76 and 85 per cent of people with mental health disorders receive no treatment.8 In wealthy countries, insensitivity to client preferences, context and culture when treating mental disorders has led to waste and harm. The United States mental health system, for example, fails to reach more than half of people with the most serious mental health disorders.9

Integrating mental health services into PHC across the life course is a viable way of closing the treatment gap and increasing access to appropriate support.10 PHC has been found to deliver better care and clinical outcomes than psychiatric hospitals for common mental health disorders, such as depression, anxiety and substance disorders, and for less acute or severe mental illness.11 There are several likely reasons. For example, PHC staff with mental health training can provide a holistic and coordinated approach to care for people who experience mental illness in combination with physical health problems. Stigma for clients with mental illness may be reduced when seeking care at a PHC service (compared with using a stand-alone mental health service), making care more acceptable. Family life and employment, and client recovery, are less disrupted when treatment can occur closer to home.12 PHC also provides more scope for non-medicalised approaches, family and community involvement in mental health care, and care models that take account of social, political and cultural environments.13 

Best-practice PHC for mental health includes prevention strategies, and screening, diagnosis and treatment for people with mental health disorders and mental health issues that affect wellbeing and physical health.14 Evidence has shown that with adequate training and support, PHC workers can screen clients for mental health and wellbeing issues, recognise psychological distress and mental health disorders, treat common problems such as anxiety and depression, and provide brief interventions for the management of hazardous substance use.15 But, traditionally, attempts to integrate mental health in PHC have been fraught with systems, resource and organisational challenges.16 

The integration of mental health services into PHC requires multidisciplinary and collaborative care models supported by effective policy and systems.17 Complementary services are needed, particularly secondary care facilities and specialist mental health professionals to whom PHC practitioners can turn for referrals, support and supervision. Care tasks should be limited and doable by staff, and clients must have access to essential psychotropic medications. Good service coordination, and collaboration with non-health sectors such as education, social and spiritual welfare, justice or employment are required to support recovery and social and emotional wellbeing.18 

Mental health and social and emotional wellbeing of Aboriginal and Torres Strait Islander peoples

Social and emotional wellbeing (SEWB) is a term preferred by many First Nations people because it includes, but extends beyond, conventional understandings of mental health and mental disorder.19 For Aboriginal and Torres Strait Islander Australians, SEWB is based on a holistic concept of health and culturally informed practices, “shaped by connections to body, mind and emotions, family and kinship, community, culture, land and spirituality”20 and by a range of social, historical, political and cultural influences (see Figure 15.1). People’s understanding of social and emotional wellbeing varies between different cultural groups and individuals, and may change across the life course (for example, factors important to a child’s SEWB compared with factors important to Elders).21

The domains of SEWB, as illustrated in Figure 15.1, can be seen as protective factors for Aboriginal and Torres Strait Islander mental health across the life course. For many people, good mental health comes through a collective sense of self and belonging, strong cultural identity, positive relationships and understanding of social roles, and connection to other aspects of life that are a source of strength and resilience. Conversely, poor mental health can be influenced by stressors such as grief and trauma, forced removal from family and Country, racism and discrimination, incarceration, displacement from culture, intergenerational trauma and economic exclusion22 – ongoing legacies of colonisation. Exposure to adverse experiences or stressful life events are risk factors for mental health disorders23 and “Western” mental health approaches that do not incorporate Aboriginal and Torres Strait Islander knowledge systems have contributed to poor access and treatment outcomes for many Aboriginal and Torres Strait Islander people.24 

Figure 15.1 Social and emotional wellbeing (SEWB) from an Aboriginal and Torres Strait Islander perspective. Source: Adapted from Gee, Dudgeon et al. 2014.

Mental health and substance use disorders are a leading contributor (19 per cent) to the illness experienced by Aboriginal and Torres Strait Islander people.25 In 2018–19, an estimated 24 per cent (187,500) of those surveyed reported a mental health or behavioural condition, with a higher rate among men than women. Anxiety was most reported (17 per cent), followed by depression (13 per cent). Sixty-six per cent of adults reported “low or moderate” levels of psychological distress and 31 per cent reported “high or very high” levels.26 Lower access to primary mental health care according to need has resulted in over-representation of First Nations clients in other parts of the health and mental health system. Hospitalisation rates for mental health, behavioural disorders and alcohol-related conditions are disproportionally high and suicide rates are especially concerning.27

As discussed in Chapter 14, Aboriginal and Torres Strait Islander young people are deeply concerned about mental health. The Mission Australia 202228 youth survey found that, while 28 per cent of Aboriginal and Torres Strait Islander young people (aged 15–19) rated their mental health as excellent or very good, over one third (34 per cent) reported feeling high psychological distress. Forty per cent didn’t know where to go for help and only 62 per cent of those who sought help consulted a health professional. Accessible culturally safe treatment pathways that can cater for the complex sociocultural factors faced by Aboriginal and Torres Strait Islander children and young people are essential for healthy futures.

Improving the mental health and wellbeing of Aboriginal and Torres Strait Islander families and communities requires systemic and transformative change,29 deep respect for Indigenous perspectives on wellbeing, Indigenous-led responses and a workforce skilled in trauma-informed care. Current policies refer to the importance of strengthening the cultural – as well as social and biomedical – determinants of health through languages, relationships, customs and community networks.30 Across Australia, Aboriginal and Torres Strait Islander communities have developed programs to strengthen Indigenous identity, resilience, wellbeing and empowerment. These programs, like the Family Wellbeing Program (see Box 15.1), focus on strengths while also reducing social and emotional wellbeing stressors (risks) and improving the capacity of communities and services to cope with these.31 They are an important part of comprehensive primary health care for Aboriginal and Torres Strait Islander people.

Recommended mental health and social and emotional wellbeing care in clinical PHC

Stresses on social and emotional wellbeing exist for all populations and all age groups. Therefore, screening and care for social and emotional wellbeing is relevant across the life course and as part of the management of many health conditions. It can prevent mental health and wellbeing issues from developing into more serious disorders and supports early intervention. High-quality PHC supports children and adults living with mental illness – and those who care for and support them – with effective clinical and non-clinical services.

These are among the essential clinical services in PHC:

• mental health and social and emotional wellbeing promotion and prevention services
• screening for social and emotional wellbeing
• brief interventions or referral when people are assessed as at risk for social and emotional wellbeing challenges
• screening, brief interventions and referral for substance misuse
• early identification and treatment of mental health disorders
• management of stable psychiatric clients
• counselling for common mental health disorders
• referral to other services when required.

PHC practitioners should provide client-centred care within their expertise and capabilities, and coordinate clients’ access to other care providers (for example, psychologists, social workers, occupational therapists) and appropriate agencies. These might be government, private or community-based services, cultural healers, community Elders or religious leaders, community or family members.

Some clients experience multiple social and emotional wellbeing and mental health issues in addition to the negative effects of social determinants such as poverty, racism and housing issues. In these circumstances, it may be appropriate to begin with case management and problem-solving approaches to tackle these issues, and to support clients to establish safety, security and stability before focusing on other healing processes.34 Individualised mental health care plans can provide a framework for coordination and continuity of care. A well-designed care plan, reviewed on a regular basis, promotes communication across disciplines and client engagement.

Clinical practice guidelines are available for the prevention and management of mental health disorders. They include guidelines for managing specific conditions, such as depression, complex trauma and post-traumatic stress, and guidelines for working with specific groups, such as refugees or First Nations people. We recommend searching reliable online sources for guidelines and resources that are relevant for your PHC context and clients’ needs.

Findings: quality of mental health care

The data presented below come mainly from six research papers and a key report published by the ABCD CQI research program between 2011 and 2019. A mental health audit tool35 and the systems assessment tool36 were used to collect data about the delivery of mental health care from 21 PHC centres between 2009 and 2014. These are the most recent audit data available. Analysis was conducted on 975 records for Aboriginal and Torres Strait Islander clients with a diagnosed mental health disorder to assess how well care reflected best-practice guidelines for mental health and wellbeing care. Stakeholders participated in data interpretation to identify priority evidence–practice gaps and factors influencing improvement.

Routine items of mental health care

Risk factors and brief interventions

Analysis of 314 client records in 17 services (2012–2014) found that, in the 12 months before the audit, the recording of risk factors and brief interventions varied between PHC centres and risk factors:

• 80 per cent of mental health clients had their alcohol use recorded; 70 per cent of high-risk alcohol users received brief interventions or counselling for alcohol use
• 85 per cent had their tobacco use recorded; 55 per cent of smokers received brief interventions or counselling for smoking
• 75 per cent (range 30–100 per cent) of clients who had drug misuse noted received brief intervention or counselling for drug misuse
• 33 per cent (range 0–80 per cent) of clients with a body mass index of more than 25 had a record of brief intervention or counselling for overweight or obesity
• the recording of mental health risk factors and interventions varied widely across PHC centres.37

Follow-up if mental health deteriorated

The research also examined whether follow-up action was recorded for clients who experienced worsening or deteriorating symptoms and behaviours related to a mental health disorder. These concerns included sleep patterns and mood, hallucinations, psychotic symptoms, medication side effects, aggressive behaviour, social withdrawal or deterioration in self-care. When worsening symptoms were recorded in client records:

• an average of 70 per cent of clients (range 30–100 per cent) were referred to another health professional, and 75 per cent received psychosocial or culturally appropriate interventions
• 70 per cent of clients had their medication reviewed; 40 per cent of these clients had their medication adjusted.38

Mental health care plans and shared care arrangements

• On average, only 50 per cent of mental health clients had a mental health care plan.
• Where care plans were recorded, most included both clinical goals and self-management or recovery goals (average of 90 per cent and 83 per cent respectively). There was more variation in the recording of self-management or recovery goals than clinical goals.
• Review of goals in the three months before the audit varied widely across PHC centres (average of 65 per cent; range 0–100 per cent) (see Figure 15.2).39 
• Shared care arrangements and referrals were not well documented (median 55 per cent, range 0–100 per cent).40

Figure 15.2 Mean percentage of health centre clients with a care plan and associated goals in their medical records. Source: Matthews, J. Bailie et al. 2016.

Overall mental health care

We analysed mental health audit data from PHC centres over three years (2011–2013). While overall levels of service delivery for mental health care were steady, lower performing health centres had improved care for clients diagnosed with mental health conditions.

• There was no clear improvement in the overall service delivery of mental health and wellbeing care. The mean and median level of care delivery was about 60 per cent over the three years (see Figure 15.3).
• There was less variation in quality of care between PHC centres, mainly because lower performing PHC centres improved their delivery of mental health services.
• Based on 12 best-practice indicators for mental health care, the lower performing PHC centres improved their overall delivery of mental health care, from 30 per cent in 2011 to around 50 per cent in 2012 and 201341 (see Figure 15.3).

Figure 15.3 Trends in overall mental health care for 12 best-practice indicators. Source: Matthews, J. Bailie et al. 2016.

The 12 best-practice indicators were recording of alchohol, tobacco and drug use; brief interventions for alcohol and drug misuse; health check withing the last 12 months; blood pressure check within the last 6 months; mental health assessment, if client had attended within the last 3 months; provision of social issues and family or individual counselling, if client had attended within the last 3 months; joint discussion regarding culturally appropriate interventions, if client had attended within the last 3 months; liver function test; serum creatinine; thyroid function test; full blood count; and follow-up action, including medication review and adjustment, referral or psychosocial or culturally appropriate intervention if deterioration in symptoms.

Systems supporting mental health care

Twenty-nine assessments of the PHC systems supporting mental health care were also analysed by researchers and PHC stakeholders. Systems assessments evaluate delivery system design, information systems and decision support, client self-management support, links with community, other health services and resources, and organisational influence and system integration.42 There were two key findings for informing system improvement:

• 100 per cent of surveyed stakeholders viewed organisational commitment to structures and processes for safe, high-quality mental health care as a priority for improvement
• 90 per cent viewed community involvement in planning mental health and wellbeing services as a priority.43

Findings: quality of screening and care for social and emotional wellbeing

The findings about the quality of screening and care for social and emotional wellbeing come from the use of four ABCD audit tools: adult preventive care, type 2 diabetes care, maternal care and child health. Altogether, more than 9,400 health records were analysed. Across the audit data, patterns emerged about the quality of social and emotional wellbeing care.

Preventive care

Preventive health records for 3,407 adults in 100 PHC centres (2012–2014) were analysed. According to health records:

• social and emotional wellbeing screening was not undertaken for 73 per cent of clients
• no further action was taken for 25 per cent of screened clients for whom a concern was recorded
• when a treatment plan was documented, follow-up was poor.

As Figure 15.4 illustrates, this represents a combined management gap of 75 per cent.

The analysis also found there was more screening of younger adults (younger than 30 years) and people older than 55 years compared with other age groups. Lower rates of screening were associated with larger service populations (more than 1,000) and health service participation in fewer CQI cycles.44

It is a similar story across care for health conditions, not just for preventive care.

Figure 15.4 Social and emotional wellbeing screening and management: gaps in screening, treatment and follow-up. Source: Langham, McCalman et al. 2017.

Diabetes care

Comorbidity of mental health disorders with chronic conditions is common. Given the increased likelihood of poor levels of SEWB for those with diabetes, screening and follow-up action is an important aspect of clinical care. A study of 1,174 records of people with diabetes from 44 PHC centres (2009) also found low screening rates for social and emotional wellbeing.

• Only 5 per cent of clients with diabetes had been screened, with only four of the 44 PHC centres using a standard depression or distress screening tool in the past year.
• 37 to 67 per cent of people with diabetes were screened in those health centres where screening had been done. A record of screening was much less likely for people with severe diabetes-related disease compared to people with less severe disease.
• Documented depression ranged from 0 to 33 per cent between health centres. Regardless of whether they had been screened, 6 per cent of clients across 24 health centres had a documented diagnosis of depression, while 5 per cent had a diagnosis of another mental illness.
• 39 per cent of clients with a current prescription for antidepressant medication did not have a documented diagnosis of depression or other mental illness in their health records.45

An earlier study of 1,592 records of people with diabetes from 62 PHC settings had also found inconsistencies in the recording of diagnoses for depression and prescribed medications:

• 62 out of the 140 clients with a recorded diagnosis of depression had no record of antidepressant medication being prescribed
• 45 clients with diabetes had a prescription for selective serotonin reuptake inhibitors (SSRIs) recorded, without a recorded diagnosis of depression.46

The study raised questions about whether health professionals working in Indigenous settings chose not to use screening tools based in Western medical models (see “Improving mental health and wellbeing care in Aboriginal and Torres Strait Islander PHC” section below), whether they resisted making a diagnosis of depression, or whether other mental disorders were being treated with antidepressant medications.

Pregnancy care

Analysis of 797 maternal health records from 36 PHC settings (2010–2012) found scope for improvement, particularly for emotional wellbeing screening.

• Only 17 per cent of all women had a record of emotional wellbeing screening during pregnancy, despite 86 per cent of women having at least four antenatal visits.
• Most women had records of assessment for social (79 per cent) and medical (86 per cent) risk factors, and risk factors such as use of cigarettes (78 per cent), alcohol (57 per cent) and illicit drugs (53 per cent) in pregnancy.
• Emotional wellbeing screening was more likely when social risk factors were noted, and when health professionals noted plans for care and birthing, antenatal education and breastfeeding.47
• 16 per cent of women identified at risk of depression were prescribed antidepressant drugs during their pregnancy.48
• Non-pharmaceutical interventions for pregnant women assessed as being at risk of having their SEWB affected included brief intervention (61 per cent), counselling (57 per cent) and cognitive behaviour therapy (5 per cent).
• About 39 per cent of women at risk of having their SEWB affected were referred to external services.49

Care for families of young children

Analysis of 2,466 health records of Indigenous children from 109 PHC centres (2012–14) found scope for improvement in service provision and in follow-up or referral when concerns were noted.

• PHC centres used the national best-practice guidelines for social and emotional wellbeing care and included important services (for example, advice about child stimulation and behaviour, and parent–child interaction).
• The proportion of families receiving social and emotional wellbeing services ranged from 11 per cent (advice about nutrition and food security) to 75 per cent (assessment of parent–child interaction).
• Almost 25 per cent of families had no clinical follow-up or referral for concerns about domestic environment, family support and financial situation, housing condition and food security.
• Families of children aged 3–11 months (40 per cent) were more likely to receive social and emotional wellbeing services than families of children aged 12–59 months (30 per cent).
• Families living in remote areas received similar services to rural and urban families.50

Emerging patterns and recent developments

Our research found that some aspects of social and emotional wellbeing care were being done well (for example, assessment of risk factors for pregnant women). However, data collected using four different audit tools (adult preventive care, type 2 diabetes care, maternal care and child health) showed many opportunities for improvement. There was considerable variation in quality of care between health centres. This is not surprising. Until recently, social and emotional wellbeing care received relatively less attention than care for physical conditions in PHC. Since we analysed these CQI data, there have been important developments in mental health, social and emotional wellbeing care and in suicide prevention for Aboriginal and Torres Strait Islander communities. Culturally sensitive screening tools (for example, aPHQ-9), 51 clinical guidelines and social and emotional wellbeing services have become more widely available. We would expect these developments to be reflected in more recently collected CQI data. Services that start from a low baseline have greater potential for large and rapid improvements in care quality.

Services that start from a low baseline have greater potential for large and rapid improvements in care quality.

Australia has adopted a stepped care model of primary mental health care. Stepped care aims to deliver the most effective yet least resource-intensive treatment to clients first, only “stepping up” to intensive and specialist services as clinically required.52 CQI has an important role in advancing the system changes needed to strengthen stepped care and to implement further evidence-based developments. CQI processes can be used to improve systems at each of the five steps:

• health promotion and preventive care for well populations
• early intervention for at-risk groups
• access to low-intensity services for those with mild mental illness
• provision of services and interventions for people with moderate illness
• adequate levels of intervention to maximise recovery, prevent escalation and provide wraparound coordinated care for people with severe mental illness.

Improving mental health and wellbeing care in Aboriginal and Torres Strait Islander PHC

Our CQI research findings support calls for strategies that integrate mental health and social and emotional wellbeing care into PHC; engage communities in social and emotional wellbeing programs; and strengthen cross-sector action to address mental health risks and protect wellbeing. Community-controlled health services are well positioned to lead the way in developing such strategies, because they have developed from models of comprehensive PHC based on a holistic concept of health with the cultural, social and emotional wellbeing of families at their centre.56

Whatever governance arrangements are in place, responding to high demands for acute and chronic illness care amongst service populations can constrain the capacity of PHC services to provide social and emotional wellbeing services. In addition, practitioners working in Aboriginal and Torres Strait Islander communities are often confronted with complex client presentations for mental health care. For example, community members may be simultaneously experiencing mental health issues, loss and cultural disconnection, financial hardship and child removal.57 Aboriginal and Torres Strait Islander staff may themselves experience significant wellbeing stressors, including stressors that come from identifying with the trauma experienced by their clients. Supporting the social and emotional wellbeing of the Aboriginal and Torres Strait Islander workforce is critical.

Our CQI research identified enablers for improving mental health and wellbeing care for Aboriginal and Torres Strait Islander clients and communities, including these features:

• good systems for recruiting, supporting and retaining PHC staff, particularly Aboriginal and Torres Strait Islander staff
• strong systems for providing PHC teams with training and support from mental health professionals
• effective strategies for building and sharing staff understanding and skills in culturally appropriate mental health and wellbeing care
• strong links between health services, communities and other agencies providing mental health and SEWB care, focusing on holistic and strengths-based approaches.58

The research findings showed that, at the time of data collection, many opportunities for social and emotional wellbeing screening and care were not taken up. One suggested reason was practitioners’ concern about the cultural suitability of screening tools based on Western medical models. This concern is being tackled through the development or adaptation of assessment tools such as the Here and Now Aboriginal Assessment tool,59 the Aboriginal and Torres Strait Islander Perinatal Mental Health guide for PHC professionals60 and the adapted Patient Health Questionnaire 9, which has phrasing culturally adapted for five Australian Aboriginal language groups.61 The Centre of Best Practice in Aboriginal and Torres Strait Islander Suicide Prevention Clearing House has links to a range of validated tools and checklists. The National guide to a preventive health assessment for Aboriginal and Torres Strait Islander people includes guidance for the prevention of depression and suicide.62 The uptake of screening tools should continue to improve as more culturally based tools and guidelines are developed.

Screening alone provides minimal benefit and has the potential to cause harm.63 To be beneficial at an individual client or population level, screening needs to be part of a broader, culturally competent assessment process entailing these aspects:

• formal training in culturally appropriate assessment
• a comprehensive client interview to explain and determine the appropriate assessment processes and any required screening
• reflective documentation of the process
• interpretation and reporting of results using cultural explanations and avoidance of labelling.64

As with all clinical assessments, there must be systems in place to ensure that a diagnosis of abnormal findings is followed by guideline-based treatment and follow-up care.65

Screening tools focus on identifying deficits and risk factors. While these are useful, identifying strengths and protective factors is integral to a comprehensive assessment66 and can support a social and emotional wellbeing care plan that helps to empower the person. Such a plan builds on individual, family and community strengths (for example, education, loving family, support networks, cultural involvement). Resources for frontline health and wellbeing workers, made by and for Aboriginal and Torres Strait Islander people, are brought together on the Wellmob website.67 Other resources are available.68 

Aboriginal and Torres Strait Islander leadership and policy support for social and emotional wellbeing, mental health and suicide prevention are well established.69 In communities, culturally capable and responsive PHC services, shaped by community-led health initiatives, have a key role in protecting social and emotional wellbeing, improving mental health and wellbeing care and supporting the self-determination of individuals and communities. PHC teams need to be supported by respected community leaders and organisations, using best-practice guidelines that identify appropriate strategies for developing care plans, including protocols for treatment, referral pathways and follow-up with PHC staff.70 

The use of CQI supports PHC teams and communities to improve mental health and social and emotional wellbeing care. Coordination between health and other service providers, such as education, employment, housing and justice, will help to support a holistic approach to promoting social and emotional wellbeing (see Box 15.2).71

References