News and Events

January 2008

Preface
In 2006 the Council of Australian Governments recognized that mental health was a major problem for the Australian community. It asked for an action plan on:

• Prevention and early intervention in mental health and substance abuse
• Coordinating primary care with specialist ambulatory and hospital care
• Improving rehabilitation and community based supports
• Improving the effectiveness of the mental health workforce, especially increasing the number of psychologists

In April 2006 there was a Commonwealth announcement that $1.9 billion be made available over a five year period with States contributing additional funds. The  intentions of the commonwealth and state governments are becoming known. (See “The National Reform Framework” Chapter 1, National Mental Health Report, 2007; Canberra, Department of Health and Ageing, Commonwealth of Australia). While money is crucial, a good plan about what to buy with the money is essential. This book is an attempt to define a good plan. Most of this was available before the details of the COAG intentions were made public, some was a consequence of subsequent consultations.

The results of the 1997 National Survey of Mental Health and Well-Being and of the series of cost effectiveness studies published 2002-6 were the origin of this project. We then proceeded, disorder by disorder, asking experts (listed on page iii) and then converted their discussions into clinical pathway diagrams, and costed the elements of direct care represented in each diagram. The first chapter of the book contains the recommendations, the rationale and a précis of the findings for each disorder. It is all most people will ever read.

We began in 2003, supported by a grant from the Department of Health and Ageing, and finished the first edition in May 2006. Consultations with stakeholders continued through to November 2006. The significant changes to this edition were incorporation of the stakeholder views, the addition of a chapter on Dementia, and a revision of the accommodation sections. What had begun as an academic planning exercise had become a political reality. The staff who contributed are listed on page iii. I am grateful that so many people trusted the enterprise in its early stages and hope that people involved in the later stage will forgive the haste.

• The final version of the Tolkien II report is a needs based, costed stepped-care model for Mental Health Services in developed countries. ‘Needs based’ means a bottom up design in which the number of people with each mental disorder, the disability resulting from that, and their desires for treatment are identified. ‘Costed’ means that the direct costs to health service are identified. The indirect costs of foregone earnings, suffering, pain or burden on carers are not identified. Cost effectiveness means that the dollar costs of direct care per unit of health gain ( in this case disability adjusted life years gained) were identified. ‘Stepped care’ means the flexible matching of treatment intensity with case severity. It extends from guided self management to hospital and is the most ethical form of health care rationing.

Gavin Andrews
Sydney, April 2007

Chapter 1
Precis and Recommendations

Preamble
When health care resources are allocated we traditionally take account of the budget available, the needs and demands of the stakeholder groups, and try for the most beneficial compromise. This is a top down approach that starts with the status quo.
This report takes a radically different approach. It is able to be different because Australia has such robust mental health data that we can calculate the health benefit that would result from effective care. First we identify the number of people with each mental disorder who seek treatment, identify the evidence as to what treatments could be of benefit, and then ask experts to describe the best intervention, at each level of severity, in terms of the staff and facilities required. It is a bottom up approach – who is in need and how could we best meet that need for treatment.

We describe the nature of services to be provided by the health professionals and calculate the direct, but not indirect, costs of ideal treatment for people with mental disorders. While each person will have different needs for treatment, there is a predictable range of mental disorders that afflict them. Just as the management of breast and colon cancer is very different, the management of the individual mental disorders can be very different. For example, while the number in treatment and the total disability produced by social phobia and by schizophrenia is nearly the same, treatment of each disorder is very different. Social phobia depends on Commonwealth funded medication or cognitive behaviour therapy and costs $560 per person per year with a prospect of many cures. Treatment for schizophrenia depends on State funded services and supported accommodation for people with a brain disease and costs $22,000 per person per year with fewer cures.

We built this Tolkien II template from the 1991 Tolkien report that outlined a model mental health service, data from the 1997 Australian Bureau of Statistics’ National Surveys of Mental Health and Well-being , data from an National Health and Medical Research Council funded set of cost effectiveness studies, data from the literature, and the advice from 40 or so expert clinicians. The procedure was to prepare a research based synopsis for each disorder, calculate the number of people with that disorder seeking treatment, control for comorbidity and decide on an optimal level of coverage. We then convened an expert working group to describe the steps in ideal treatment, and converted these views to a set of clinical pathways that specified which clinician did what, at each level of severity, what resources they needed, and finally we costed the activity in those pathways. In short, we built a needs based, costed, stepped care template. We placed the core data on our website for comment and we have presented the data to providers and consumers in all States and Territories.

This précis begins by summarizing the priorities for change for the better, then reviews the results of the cost effectiveness studies based on the Survey, continues by examining a proof of concept in respect to the cost of improved coverage, and ends with the Tolkien II report. What are the cost implications, it asks, if people with mental disorders had a similar probability of being treated as people with physical disorders and received ideal stepped care predicated on their level of severity?  The subsequent sections of this chapter explore the issue of accommodation and workforce development in more detail, followed by a summary of recommendations for each of the 15 mental disorders. 

Priority Recommendations
We identify the following five recommendations as priorities for improving mental health services in Australia. 

1. Solve the present crisis in acute psychosis care
The conditions for patients and staff will remain intolerable until the crisis in psychosis is solved. Therefore, if we want to attract staff back to mental health we need to solve the psychosis problem quickly by ensuring that step down supervised accommodation becomes available. The present crisis is due to people with psychosis who do need to go to hospital being unable to be admitted for urgent treatment because the acute hospital units are full of people with more chronic conditions who cannot be discharged. Services that can’t discharge can’t admit. Notwithstanding this, the vast majority of people with a mental disorder will never need to go to hospital. We presently have sufficient acute psychiatric beds and, according to the National Mental Health Report, 2005, have some 28 State and Territory funded places per 100,000 population for people with mental disorders who need transitional care [National Mental Health report 2005, pp 125 & 131]. The estimated need is for 55 transitional places per 100,000 population backed by additional supported permanent housing. The stepped care plan for psychosis alone estimates a need for 45 such places; using fewer acute beds, more longer stay rehabilitation places, and many more transitional places in the community, some provided by the health budget and some by non government organizations but all supported by clinical care in the facility. As recovery occurs, a movement of people from transitional care to permanent accommodation will occur, funding coming from housing budgets. We will need Commonwealth/State/NGO cooperation to bring the necessary changes about. While the barriers include economic and workforce issues, the principal barrier is a lack of agreement between the States and Commonwealth on how to fund what needs to be done.

2. Increase coverage, and thereby reduce the proportion of people going untreated
In the 1997 survey only 40% of people who had a mental disorder reported that they got any treatment whereas 80% of people with comparable physical disorders got treatment. This is particularly relevant to the high prevalence disorders of anxiety, depression, and substance use where many people are living with burden that could be averted if they sought and received evidence based treatment.  The low coverage is because people are ashamed of needing help, perceive that nothing can be done, or remember that the doctor didn’t help last time. Stigma will only disappear as knowledge about good treatment grows. Progress will be limited until the public know that their local doctor, psychologist, psychiatrist or mental health service can provide effective care. The increased access to Medicare arising from the COAG initiative will double the available workforce, but we are concerned that the majority of the new practitioners have not been trained to deliver evidence based care.

We also need to invest in outcome research from evidence based treatment so that the media can publish stories on ‘innovations and breakthroughs in service delivery’. The Commonwealth used to fund quality improvement research, but at present there is nowhere to go for funds to improve service delivery. Funding for focused health services research is needed.

3. Educate the workforce to deploy evidence based treatment
The workforce circa 1997, properly deployed, was nearly adequate for the needs as outlined in this project. With the addition of the new Medicare access scheme the workforce should be adequate. In the 1997 National Survey probably less than half the patients who received treatment reported receiving what we would deem evidence based treatment. The health system is paying for treatments that are not known to work. Many in the workforce simply do not know what to do, a situation that can be remedied by education in evidence based medicine. We need to provide a structured curriculum of continuing education for primary care physicians, and continuing education, case supervision and credentialing for all mental health staff, public and private; nurse, social worker, occupational therapist, psychologist, clinical psychologist and psychiatrist. This will improve the quality of treatment nationally as well as increasing the morale of the workforce. It is recommended that appropriate web based educational resources are developed as a national curriculum and quickly brought on line. This strategy is practical and cost effective, will increase consistency across services, and can incorporate specialist input from around Australia. 

4. Educate patients, families and carers about proven self management strategies
Many mental disorders last for many years and patients and their families need to participate in recovery programs if the maximum benefit is to be achieved. Family education when a member has schizophrenia or bipolar disorder improves a patient’s well being and ability to live in the community and also improves the wellbeing of carers. Education programs exist, but clinicians do not consistently provide them.  Web based patient and family education about depression, anxiety, substance abuse, schizophrenia or dementia could quickly and cheaply be brought on line. These would enable the family to learn about the disorder and its management with clinicians acting as mentors.

5. Use school based programs to prevent the emergence of common mental disorders

Background

1.  The National Survey (1997)
The results of the Australian National Survey of Mental Health and Well-Being (1997) provided the first data about the prevalence of mental illness in the Australian community.  Data were also gathered about the numbers of people who sought treatment for a mental disorder, and the treatment they received.  The results of the Survey provide the background data for this report.

In the 1997 Australian Survey, 22% of adults met criteria for one or more mental disorders during the previous year, and 14% met criteria in the past month. Of these current cases:

• Half were moderately or severely disabled by their mental disorder,
• Only half of these disabled people had consulted about their disorder.
• Of those that did not consult, 60% said they had no need for medicines or counseling and preferred to manage themselves and 40% said they had a need, had visited the doctor, but had not gotten help for their mental disorder.

People disabled by a disorder should feel able to consult and get effective treatment. If half the people disabled by a disorder do not receive a consultation then we have a problem in educating doctors about the recognition and management of mental disorders. If half the people say they do not want treatment then we have a serious problem in mental health literacy about the probable benefits of treatment. No society can tolerate needless disability, none should tolerate unnecessary suffering (Andrews and Henderson, Unmet Need in Psychiatry, Cambridge University Press, 2001, Andrews et al., British Journal of Psychiatry, 2001).

Mental disorders are the largest single cause of disability in Australia and in all developed economies. Effective and largely cost effective treatments exist for most common disorders. In a further set of analyses Andrews et al (British Journal of Psychiatry, 2004) examined the Survey data on people meeting criteria for one of the ten major disorders during the year. They identified each person’s principal complaint, and established that:

• The coverage, the proportion of those ill who got treatment, was 40%
• The proportion of those ill who got effective treatment was 23%
• The burden of mental disorders being averted was 13%
• The average cost per case per annum in 1997 dollars was $1,920, although different mental disorders had very different cost-per-case profiles.
• The average cost effectiveness of treatment was $30,000 per Year Lived with Disability (YLD) averted [YLD averted is a unit of health gain]. One threshold for the affordability of a treatment being accepted without question is the Gross National Income/Capita, or $27,000 in 1997 dollars.
• The Survey data on prevalence, coverage, burden averted, cost per case, total cost of diagnosis and cost effectiveness or efficiency are displayed in table 1.

Note: Estimates in disorder groups (any affective, anxiety, substance use or mental disorder) may be different to summed estimates across individual disorders due to rounding up or down of numbers for presentation.

1. Calculated from the number of adults in Australia with this disorder as a principal complaint.
2. The proportion who sought  treatment or 961,045 people, the product of columns 1&2
3. Calculated in Andrews et al 2004
4. Cost per case: the total cost divided by the estimated number treated
5. Total cost: the cost of all services, drugs and accommodation days reported by survey respondents – 1997 costs and dollars
6. Efficiency or cost effectiveness in $/YLD averted. YLD is a measure of disease burden, YLD averted a measure of health gain
   
   

The results of the National Survey and the cost-effectiveness studies were then extended to consider the cost of increasing coverage with evidence based treatment.

Asthma, osteoarthritis and rheumatoid arthritis are comparable on a number of parameters to the anxiety, mood and schizophrenic disorders respectively. Yet, about 80% of people with these physical disorders got treatment whereas, in the Survey, only 40% of people with a comparable mental disorder got treatment. If coverage for mental disorders was raised to an attainable 67% and all treatment was evidence based, would this be affordable? Andrews et al (2004, 2006) calculated that:

• The averted burden of mental disorders would improve from 13% to 28%
• The average cost per case per annum would fall from $1,920 to $1,324
• The efficiency of treatment would improve, from a cost effectiveness ratio of $30,000/YLD to $16,000 per YLD averted.
• And the increase in direct mental health costs would rise by only 16%, from $1824 million to $2123 million.

Table 2. Proof of concept: Cost-effectiveness of treatment given optimal coverage and optimal treatment with evidence based medicine. (Andrews et al., 2004, Table 4).

1. Calculated from the number of adults in Australia with this disorder as a principal complaint.
2. The maximum proportion likely to seek treatment
3. Calculated in Andrews et al 2004
4. Cost per case: the total cost divided by the estimated number treated
5. Total cost: the cost of all services, drugs and accommodation days recommended by the evidence based medicine literature – 1997 costs and dollars
6. Efficiency or cost effectiveness in $/YLD averted. YLD is a measure of disease burden
   
   
   

3.  The Tolkien II Model: Could we afford ideal stepped care to met the needs of those who seek treatment?

Given (table 2) that increased coverage with treatment in accord with evidence based medicine protocols appeared to be affordable, we sought to describe the details, the clinical pathways of such treatment, the demand for professional services, the facilities required and the costs. The present project has used the data from the Survey and from the costing studies, amplified by the advice of panels of experts, to outline a template for ‘ideal stepped-care treatment’- a flexible matching of treatment intensity and condition severity across 15 adult disorders.

The method was, disorder by disorder, to prepare a research based synopsis of a disorder, calculate the number of people with that disorder, control for comorbidity and decide on an optimal level of coverage. We then convened an expert group to describe their ideal evidence based, stepped care treatment for people with that disorder, and converted their views to a set of 15 clinical pathways that specified which clinician did what, for patients at each level of severity, and finally costed the activity in those pathways. Adding all 15 disorders together we were able to cost a needs based, stepped care model for mental disorders. Note that pathways for dementia were constructed in a similar fashion but the data are presented separately.

Stepped care presumes that the least intensive and expensive treatment is initially used in place of a more expensive treatment of equal effectiveness that might become appropriate if the first treatment fails. Though widely used, there is little empirical research evidence about stepped care, hence the need to rely on the opinions of experts. The usual sequence of a care pathway runs from GP advice + patient self management (increasingly via the web), to GP treatment, to allied mental health staff (usually clinical psychologists) treatment, to psychiatrists in ambulatory care, to inpatient admissions. The care pathway was different in each of the 15 adult disorders studied. We describe, in considerable detail, the components and costs of such ‘ideal’ stepped care for each disorder, by treatment modality, staff and frequency of service, and resources required to implement ‘ideal, stepped-care treatment’.

If the coverage, [proportion of people with a disorder being treated], had been held constant at 40% then the cost of ideal stepped care treatment would have remained around the $1800 million dollar mark, the cost of direct services in 1997, i.e. ideal stepped care treatment would have been cost neutral, but would have produced greater health gain. For the purposes of the present exercise the proportion of people receiving ideal stepped care treatment is presented at what is believed to be an attainable average coverage level of 65% [25% for alcohol dependence and bulimia nervosa, 30% for borderline personality disorder, 50% for PTSD, anorexia nervosa, neurasthenia and alcohol abuse, 100% for schizophrenia and 70% for the other 7 disorders]. The cost of ideal stepped care at increased coverage is $2,617 million in 1997 dollars for the same set of ten disorders in Tables 1 & 2 and $2,810 million if five additional disorders are added. Comparing the ten disorders in Tables 1 & 3, a 30% increase in budget would treat 60% more people and produce a 90% increase in health gain.

Table 3. Cost and effectiveness of treatment given ideal coverage and ideal mix of interventions.

Note: Estimates in disorder groups (any affective, anxiety, substance use or mental disorder) may be different to summed estimates across individual disorders due to rounding up or down of numbers for presentation.

• Calculated from the number of adults in Australia with this disorder as a principal complaint adjusted for increased coverage. Number treated with current coverage can be obtained from columns 1&2 in table 1.
• The maximum proportion likely to seek treatment
• Prorated from Table 2
• Cost per case: the total cost divided by the estimated number treated
• The cost (1997$) of all services, drugs and accommodation days recommended by the expert panels.
• The additional disorders are dementia, child and adolescent psychiatry, and emergency psychiatry. They will be the subject of a separate report.

4.  Hospital Beds and Community Accommodation

This section describes issues relating to the accommodation of individuals with severe mental illness and provides estimates of need.  Without appropriate accommodation, individuals with severe mental illness cannot be expected to rehabilitate or recover.

The crisis in mental health care in Australia is often expressed as the difficulty in obtaining a bed for someone who is acutely psychotic. Acute beds are usually full because there is nowhere to transfer patients once the acuity has lessened. Services that can’t discharge can’t admit. When acute beds are full, patients who should be admitted have to be managed in the community, the workforce has to function in crisis mode, and staff burnout, absenteeism and resignation are the consequence.

Table 4: Accommodation places, existing and recommended for people with chronic mental disorders.

We presently have, according to the National Mental Health Report, 2005, some 28 State and Territory funded general adult places per 100,000 population for people with mental disorders who need transitional care [National Mental Health Report 2005, pp125 & 131] (see Table 4). The estimated need is for 55 transitional hospital and community places per 100,000 population, a shortfall of nearly 30 places. The stepped care plan for psychosis alone estimates a need for 41 places; using fewer acute beds, more longer stay rehabilitation places, and many more transitional places in the community, some provided by the health budget and some by NGOs. As recovery occurs, a movement of people from transitional care to permanent supported accommodation will occur, funding coming from housing budgets. We will need Commonwealth/State/NGO cooperation to bring the necessary changes about. While the barriers include economic and workforce issues, the principal barrier is a lack of agreement on what needs to be done.

Our analysis is as follows:

Acute in-patient beds (present n=15/100,000; recommended n=15/100,000):

Acute inpatient units with a mean length of stay of 14 days; [recommended n=15/100,000, $518/day, NMHR 2005; table A-24, no patient fee component]. Major task is to deal with people who are a danger to themselves or others. They usually have a serious mental illness. Sometimes this is a relapse of a previous illness due to failure of adherence to treatment, interaction with drugs, alcohol or other stressors, or failure of services to provide appropriate community care. Sometimes it is due to the onset of a new illness, or an old illness but the first time in this catchment area, and people are admitted for diagnosis and immediate treatment. Some States are establishing PECC units as part of their Acute Unit although they are better attached to A&E; (mean LOS 36 hours, no patient fee component). Major task is to deal with people in crisis who may or may not have a severe mental disorder but who, for the moment, are a danger to themselves or others. An increasing clientele is people with an acute drug induced psychosis, especially due to amphetamine use. Separating such patients from the main acute unit allows the main unit to develop a better therapeutic environment.

Rehabilitation hospital beds (present n=6/100,000; recommended n=10/100,000): The purpose of a hospital based rehabilitation bed is to accept people with severe and incapacitating mental disorders whose ability to survive in a community environment is severely compromised by the severity of their psychosis, their dependence on drugs, their comorbid personality disorder, or all three. Discharge into the community is calculated to provide unacceptable risks to the patient or the community.  There were 1301 rehabilitation and extended care beds for adult psychiatric patients [6.5/100,000] in Australia in 2003 [NMHR2005 Table A23], 77% in stand alone hospitals and 60% of those in NSW, but there is no information as to whether they were being used appropriately. The adjusted bed day cost was $388/day in 2003 dollars. It is usual for the hospital to retain 85% of patient pensions [$30/day] so the net cost of these beds is $358/day. The mean LOS is some 6 months (range 1.5 – 24 months), but the scarcity of rehabilitation beds means that many acute units have patients who have been resident for 12 months or longer, longer than they would have remained in a rehabilitation unit.

Rehabilitation community based beds, 24 hour clinically staffed (present n= 3.1, recommended n= 15/100,000).States vary in the number of fully staffed community residential rehabilitation services provided. Victoria, in 2003, had more than half  of these in Australia. These fully staffed services can provide an analogous service to the rehabilitation hospital bed although at less cost but with less ability to contain very disturbed people. In 2003 there were 3.1 places per 100,000 and the bed day cost was $301 or $271 when patient fees are offset (NMHR 2005, Table A-27). This is the direct cost to the health service. This type of accommodation is not envisaged as a permanent home, but lengths of stay are longer with a mean of 18 months (range 5-72 months)..

Rehabilitation community places, staffed variably, less than 12 hours per day (present n= 3.5, recommended n= 15/100,000). In 2003 there were 3.5 places per 100,000 at a cost of $89 per day (NMHR 2005, Table A-29). As 95% were provided by NGOs, no offset for patient fees is appropriate. This type of accommodation is not envisaged as a permanent home but still lengths of stay are long, with a mean of 2 years (range 6 months to 8 years). The majority of places are occupied by people with schizophrenia who remain continually psychotic. For some their stay in the community place will be interspersed with brief admissions to inpatient units. The shortfall in the available places is considerable.

Supported permanent accommodation

Supported public housing places  (present n= 13/100,000; recommended n= 20/100,000):  Under an agreement between health departments and public housing authorities, places are targeted for people with mental disorders. The accommodation is permanent and the recipient enters into a normal rental agreement and receives clinical support from Health (70 – 140 visits per year at $83 per hour) and often receives personal mentoring from NGOs. In 2003 there were 13.2 per 100,000 such places in Australia (NMHR 2005, Table A-32), outreach costs $5,000pp/pa. These costs are not identified in this model.

Supervised hostel places  (present number unknown but probably around 10/100,000, recommended n=20/100,000):
Traditionally people on a disability support pension could afford accommodation in a boarding house or equivalent congregated living arrangement whereby they paid rent to a landlord and received some simple supervision and support. The number of people currently in such lodging is not known. Where such lodgings accepted numbers of people with mental disorders Health Departments in some States have made subsidies available to the proprietor and in return had right of access to provide clinical services to the residents. The costs are similar to those above, ie, $5,000pp/pa and again these costs do not appear in this model.

Using the opinions of experts in the Tolkien process it was envisaged that in a smoothly running fully staffed mental health service, people with chronic schizophrenia would account for 41/55 hospital and community rehabilitation places The shortfall for all but the acute units is considerable. Services that can’t discharge can’t admit, but if there were appropriate step down services then the present number of acute beds would be appropriate.

Private Hospital Acute Units: mean LOS 19 days; 8/100,000. The major task is to admit people with private health insurance who are deemed to need inpatient care. They do not admit people as involuntary patients and the level of acuity is less than in the public sector. There are no data as to the offset that private beds make to dealing with the burden of mental disorders. They are therefore not included in this set of calculations.

Other Issues:  It will be remembered that 10,000 or one in four people with schizophrenia were deemed to need accommodation in non permanent accommodation and therefore account for a majority of the need for transitional beds or places. There is a seven fold increase in time to readmission to an acute unit for programs that provide proactive care that ensures adherence to medication for people with a chronic psychosis in an alcohol and drug free environment compared to services that accept substance use and non adherence. The shift in emphasis from dependence on acute units as the major resource, to rehabilitation units plus good community accommodation and exemplary community care as the major resource should produce serious cost offsets in respect to recurrent expenditure given that we already accept responsibility for all people known to have schizophrenia. The savings come from reduced reliance on expensive acute beds and less reliance on atypical antipsychotic medications. The key issue is the capital required to provide the additional rehabilitation places.

Rozanne Haggerty at Common Ground (www.commonground.org) a US organization that provides accommodation for the homeless, has a different and attractive view: instead of moving people between different locations as they recover, one should try and maintain them in a semi permanent environment and titrate the level of care according to their clinical need. Her organization argues for self contained single person accommodation and, when necessary toleration for the use of drugs and alcohol while moving people rapidly through wet, damp and dry stages in rehabilitation. A cluster of single person dwellings could therefore substitute for the fully staffed and visited community rehabilitation places and for supportive housing and lodging. All would be in the same facility, what would change is the level of care and support as people recovered.

5.  Workforce Issues

This section discusses issues around the workforce’s ability to meet the demand of the increased coverage implied by the stepped care model.

GPs: The Beech report mentioned that GPs supplied some 10 million consultations per year to people with very broadly defined ‘mental problems’. From the 1997 survey, patients who met criteria for any of the ten mental disorders reported using 3.4 million GP consultations for their disorders. The stepped care model for the 15 disorders envisaged that general practices (GP and practice nurse) would provide 13 million general practice attendances to people for their mental disorders. We have costed on the basis that all services were provided by the GP and none by their practice nurses, hence the cost will be an overestimate. The stepped care model places considerable, but not inordinate, demands on GPs, who will need training in what they should do themselves, in what they can entrust to their practice nurses or the web based services, and when they should refer. While learning some CBT skills is often viewed as a priority, learning skills that increase patient adherence to prescribed medication is probably of greater importance. The training would be best delivered as CME over the internet (cf www.climategp.tv) and linked to the Better Outcomes and Better Access in Mental Health initiatives.

Private psychiatrists bill some 2 million services/year. In the stepped care model it was difficult to separate private from public psychiatrists. Mostly we subsumed the work of public sector psychiatrists into the work of the hospitals and into the work of the community mental health teams but perhaps a fifth of the total psychiatrist services should be attributed to the public sector and four fifths to the private sector. The model requires some 2.4 million psychiatrist services per year. In terms of workforce needs, we probably have sufficient psychiatrists. In the survey, people who met criteria for one of the ten mental disorders reported that they had received only some 1.0 million services from a psychiatrist for their mental disorder, a shortfall between what is reported over what is billed.

Clinical and four year trained psychologists are currently being included in the mainstream Medicare reimbursement systems. We have little ability to estimate their potential contribution to the workforce.  Two months after the opening of Medicare to psychologists some 1,000 clinical psychologists and 6,000 registered psychologists had registered to receive payments. If they worked an average of 0.4FTE then they could provide 14 consultation hours a week for 46 weeks a year and their capacity would be 4.5 million consultations per year.  In the Survey, people who met criteria for one of the ten mental disorders reported that they had received some 0.8 million services from psychologists for their mental disorder. In the model we envisaged needing 4.5 million services from psychologists per year for the 15 disorders. The new funding arrangements have the capacity to meet the demand

The problem is the need to provide proven cost effective psychological therapy. Clinical psychologists have the theoretical capacity to do this only if they give up other spheres of work. Medicare type reimbursement will encourage many to move from counseling the unhappy who can pay, to CBT for the unwell who now will be able to pay. Four year trained psychologists have only had a rudimentary training in the recognition and treatment of people with mental disorders. They will need access to specialist training in evidence based psychological treatments and to patient education services like www.climategp.tv . We may also need to pay for an expanded role for clinical psychologists to mentor other clinical staff.

Mental health teams: The National Survey provided little information on the role of mental health teams. Currently, mental health teams report some 5 million patient contacts per year. Many of these are quite brief. The model requires some 2 million services per year but now asks that the teams do quite complex clinical tasks, principally in the management of people with schizophrenia, mood disorders, PTSD and borderline personality disorders. To provide appropriate care to these people, the workforce will need training and supervision that will require 2-3 hours per week.

Education, training and supervision have not been costed in this model, but as public sector clinical staff report that they spend only 40% of their paid time in face to face contact with patients there is already paid time that could be used for training, much of which could be provided over the Internet.

6.  Utilizing the Internet

The stepped care paradigm requires that stepped care modalities be available. The success of this is predicated on the availability of skills and resources and, as mentioned earlier, one strategy to achieve this is to utilize the Internet.  The successful ability to use the internet for prevention and for staff and patient education has already been demonstrated by our concurrent work on Climate.tv, a knowledge transfer exercise. Climate.tv (www.climate.tv) comprises three components that can help implement the recommendations in Tolkien II:

1. Climategp.tv is a set of 16 courses for patients to help them manage their disorders. They cover all the health priority areas. There are 8 courses for people with anxiety and depression, with courses for alcohol use and dementia carers to come on line during 2007. There is matching continuing professional education courses for the clinicians so that our goal of mentored self care can be realized.
2. Climateschools.tv is a set of prevention programs aimed at the year 8 high schools health and personal development curriculum. Courses: a set of 2 courses for stress and alcohol use came on line in 2006 and courses on anxiety and on depression, on cannabis use and on psychostimulant drugs for years 9 & 10 will come on line during 2007.
3. Climatemh.tv is a set of programs for the on site education of mental health staff. A basic curriculum that focuses on the management of anxiety, depressive, alcohol and schizophrenic disorders will come on line during 2007. The full curriculum of 140 lessons will be progressively available over the ensuing two years.

7.  Managing Change

The basic problem is how one manages change. In late March 2006 the Commonwealth announced an additional $1.9 billion over five years with State funds to follow. Promising money is one thing, actually being able to spend it effectively is another, especially as some States have found that additional funds for mental health could not be spent, no staff wanted the new jobs.  In short, patients and their families are demoralized and angry, mental health professionals are demoralized and angry, and general practitioners, who are being asked to do much more, are becoming overwhelmed by the tasks in hand.

Change, like research, is the art of the possible. The advent of substantial additional funds means that a number of the problems listed above could be solved, but none can be solved the day that the money becomes available. We attempted to prioritize the issues by providing five general goals on page 3, namely solving the crisis in psychosis, improving coverage, educating the workforce, educating patients and their families, and preventing the onset of mental disorders . We now develop a timeline for each of the five goals that prioritize actions in terms of the practicality of bringing them on line. In the recommendations section that follows we make recommendations specific to each of the 15 disorders listed in Table 3.

1. Solving the crisis in psychosis
Until the crisis in psychosis is solved the conditions for patients and staff will remain intolerable, therefore, if we want to attract staff back to mental health we need to solve the psychosis problem quickly by ensuring that step down accommodation becomes available. The shortfall is serious and the capital cost of providing the necessary transitional places in the community will be of the order of $500 million in 2007. The clinical services required are already in part provided by the states and there is no need for additional funding of the new places once they are established.

2. Improving coverage
Improving coverage from an average of 40% to an average of 65% is probably attainable, 80% coverage, for the reasons already stated, is not. This will be a slow process, for to do it too quickly will mean recruiting untrained staff and staff who will be difficult to train. Increasing staff by 5% per annum over the five year period is probably attainable provided that good use is made of the stepped care design and Internet based education programs such as Climatemh.tv.

3. Educating the workforce
The workforce consists of GPs and their practice nurses, community mental health staff (mainly nurses), psychologists, clinical psychologists and psychiatrists. A taskforce of all the stakeholders should meet in early 2007 to identify the content of the relevant educational programs, the level of supervision required and the criteria for skills staff should be able to carry out in order to be credentialed and consequently remunerated. There will be rural/urban differences in credentialing and in roles.

4. Educating patients and their families
Patient and carer education improves outcome, for some it is sufficient to alleviate the disorder, but for others it facilitates the treatment program prescribed by GP or mental health specialist. Numerous education programs exist, including web based information and educational programs for major depression and dysthymia, for GAD, social phobia and panic/agoraphobia and for alcohol abuse [see www.climategp.tv].

8.  Recommendations for Specific Disorders

1. Major Depressive Disorder
Major Depressive Disorder is a principal contributor to the burden of human disease [point prevalence 3.3%].  Episodes last an average of six months [ie, two weeks to many years] then, even without treatment, remit and recur. The loss of hope, interest and energy disables and reduces adherence to treatment, and threatens work and personal relationships. The damage is cumulative. The key to management is recognition and proactive treatment with quite simple and very affordable remedies.

Current treatment with 61% coverage [n=390,000] costs $484 million and averts 16% of the burden, ideal treatment at 70% coverage would cost $592 million and avert 26% of the burden.

The key issues may be

• Recognition by doctors: in the absence of a lab test, doctors could have receptionists and practice nurses routinely administer a diagnostic questionnaire like the PHQ9. The city of New York does this.
• Standard treatment protocols should be in every general practice, protocols for patients that drop out, for patients who do not respond, and for those with atypical forms of depression.
• Motivation of patients: because depression itself reduces treatment seeking and treatment adherence, clinicians and their practice nurses may have to be more proactive. Seattle does this.

The answer may lie in systematic screening of people attending their general practitioners and in the implementation of a chronic disease management model that requires informed proactive care [see Andrews 2001, British Medical Journal].

Recommendations:

1. GPs should screen patients at risk for depression using the PHQ9, exactly as they screen the blood pressure of all patients.
2. All patients should have access to internet education about the disease and its management.
3. Patients need access to medication and CBT and proactive care during the recovery period to ensure they adhere to medication and can use cognitive behavioural strategies to inhibit relapse.

2. Dysthymia
Dysthymia is milder chronic depression [point prevalence 0.4%].  Episodes last for years and the pessimism and loss of interest and energy disables and threatens work and personal relationships. The damage is cumulative. Some of the chronicity may be due to inadequate treatment. The key to management is recognition and proactive treatment with quite simple and very affordable remedies.

Current treatment with 51% coverage [n=39,000] costs $71 million and averts 13% of the burden, ideal treatment at 70% coverage would cost $54 million and avert 27% of the burden.

Recommendations:

1. GPs should be alert for dysthymia, as it is treatable with medication and CBT. Use the PHQ9.
2. Patients need proactive care during the recovery period to ensure they adhere to medication and can use cognitive behavioural strategies to inhibit relapse.

3. Bipolar Disorder
Bipolar Disorder is a severe mood disorder [point prevalence 0.2%] in which there are sustained mood swings that disable and threaten work and personal relationships. Mood stabilizers relieve the current mood swing and can prevent future mood swings. The key to management is adherence to medication when ill, and proactive prevention with mood stabilizers and CBT during the periods of remission.

Current treatment with 66% coverage [n=47,000] costs $61 million and averts 19% of the burden, ideal treatment at 70% coverage would cost considerably more; $192 million and avert 35% of the burden.

Recommendations:

1. All patients should be on mood stabilizing medications
2. All patients should have access to computer based education about the disease and its management.
3. Patients need proactive care during the well periods to ensure they adhere to medication and use cognitive behavioural strategies to inhibit relapse.

4. Panic Disorder and Agoraphobia
Panic disorder and agoraphobia are best viewed as one disorder, typified as fear and avoidance of situations for fear of an incapacitating panic attack. Agoraphobia is the key to the disability. The point prevalence is 1.5%. It is often chronic due to inadequate treatment. The key to management is recognition and treatment with CBT or antidepressants or both.

Current treatment with 39% coverage [n=67,000] costs $82 million and averts 9% of the burden, ideal treatment at 70% coverage would cost $106 million and avert 21% of the burden.

Recommendations:

1. All patients should have access to computer based education about the disorder and its management, plus limited sessions of CBT with a GP or psychologist.
2. Patients with moderate or severe disability should receive a course of CBT delivered by a clinical psychologist.  Those who still do not remit should receive an SSRI medication managed by a GP and/or psychiatrist.

5. Social Phobia
Social phobia is typified by avoidance of social situations for fear of being judged as inadequate. The point prevalence is 1.4%. It is often chronic due to inadequate treatment. The key to management is recognition and treatment with CBT or antidepressants or both.

Current treatment with 21% coverage costs $44 million and averts 8% of the burden, ideal treatment at 70% coverage would cost $81 million and avert about 34% of the burden.

Recommendations:

1. Recognition of this disorder is poor. An educational program to improve diagnosis is needed.
2. All patients should have access to computer based education about the disorder and its management, plus limited sessions of CBT with a GP.
3. Patients with moderate or severe disability should receive a course of CBT delivered by a clinical psychologist.  Those who still do not remit should receive an SSRI medication managed by a GP and/or psychiatrist.

6. Generalized Anxiety Disorder
Generalized Anxiety Disorder is typified by excessive and uncontrollable worry. The disability results from the time spent worrying and from the fatigue that results. The point prevalence is 2%. It is a chronic disorder, often made worse by inadequate treatment. The key to management is recognition, patient education and self help, and treatment with CBT or antidepressants or both.

Current treatment with 38% coverage costs $112 million and averts 17% of the burden, ideal treatment at 70% coverage would cost $286 million and avert about 48% of the burden.

Recommendations:

1. All patients should have access to books or computer based education about the disorder and its management, plus limited sessions of CBT with a GP.
2. Patients with moderate or severe disability, and those with no disability or mild disability but who do not remit with GP assistance alone, should receive a course of CBT delivered by a clinical psychologist.  Those who still do not remit should receive an SSRI medication managed by a GP and/or psychiatrist.

7. Post Traumatic Stress Disorder
Post Traumatic Stress Disorder follows a traumatic event , when memories of the event intrude and distress. The disability results from the avoidance of situations likely to trigger the memories. The point prevalence is 1.5%. It gradually remits with the passage of years but this can be hastened by appropriate treatment. The key to management is recognition, patient understanding of what will lead to recovery, and treatment with CBT or antidepressants or both.

Current treatment with 40% coverage costs $158 million and averts 11% of the burden, ideal treatment at 50% coverage would cost $225 million and avert about 17% of the burden.

Recommendations:

1. All patients who want treatment should realize that memories have to be confronted to be mastered, with the support of either CBT or medication 
2. Ongoing litigation and compensation proceedings can inhibit recovery.

8. Alcohol Harmful Use
Excessive use of alcohol is public health issue. Harmful use [point prevalence = 0.7%] means drinking at hazardous levels that will lead to physical, occupational and relationship damage. Subjects need to be alerted to the dangers. The key to management is recognition and brief advice to all who are drinking too much. Current treatment with only 8% coverage costs $9 million and averts 2% of the burden, ideal treatment at 50% coverage [any higher is impractical] would cost $60 million and avert 14% of the burden.

Recommendations:

1. GPs should screen patients at risk for alcohol abuse using the AUDIT, exactly as they screen the blood pressure of all patients.
2. All patients should have brief advice from the GP and have access to internet education about the dangers and its management and access internet treatment.
3. Taxing alcohols according to alcohol content is an effective public health measure.

9. Alcohol Dependence
Alcohol dependence means psychological and physical dependence on alcohol leading to physical and behavioural harm [point prevalence 1.4%].  Few people seek treatment and when they do, relapse is common. The advent of new medications could, if coupled with active treatment, gradually change this picture. Current treatment with 14% coverage costs $64 million and averts 2% of the burden, ideal treatment at 25% coverage [more is impractical] would cost $113 million and avert about 8% of the burden.
                                    
Recommendations:

1. Only 10% will require detoxification and then only 5-10 days in hospital
2. Management by medication and adherence monitoring and CBT from a drug and alcohol specialist is critical to reducing relapse.

10. Schizophrenia
Schizophrenia is a relatively rare [point prevalence 0.3%], but often devastating brain disease, that results in failure of consistent logical thinking. Only 1 in 6 are in the workforce. The key to management is protective care while the person is psychotic and excellent continued care during the chronic phase. Monitoring of adherence to medication is critical.

In 1997 100% of people known to services [we estimate that 85% of people with schizophrenia are known to services] were treated [n=40,000], $740 million was spent and treatment averted 13% of the burden. Ideal care at this coverage would cost $908 million and avert some 22% of the burden. Treatment is still expensive, but because of the impact on patients, their families, and to society, there is no suggestion that significantly less money be spent, only that it be spent in more advantageous ways. The less advantageous expenditure is repeated admission to acute psychiatric units, high cost atypical antipsychotic medications with low adherence, and staff time required by preventable crises.

Recommendations:

1. All first year cases should be on risperidone or equivalent medication with adherence monitoring, and receive an average of 75 hours of services - disorder education, family education, vocational and social rehabilitation - from trained community mental health staff.
2. All cases that remain chronically unwell after the first year should remain on risperidone or clozapine with adherence monitoring for at least five years.
3. Half of all chronically unwell cases should be either in rehabilitation units under the relevant Mental Health Act, or in health department supervised or visited alcohol/drug free community accommodation under continued treatment orders.
4. The aim of such community accommodation should be to rehabilitate people towards independent living and independent working within a few years.
5. All staff should spend 5% of their time in training and 5% of their time being supervised about cases they are treating.
6. All patients and their families should have access to computer based education about the disease and its management to reinforce the family education sessions.

11. Anorexia Nervosa
Anorexia Nervosa is characterized by a refusal to maintain body weight and an intense fear of gaining weight, amenorrhea, and a disturbed body image. Although the point prevalence is low (<0.1%) the disorder can be severe and life threatening. There is no proven treatment. Current treatment depends on persuasion to eat, in hospital if there is a threat to life. Coverage is unknown, probably about 10%, and patients frequently reject treatment, denying they are thin. The proposed treatment plan would cost $30 million with 50% coverage.

12. Bulimia Nervosa
Bulimia Nervosa includes recurrent episodes of binge eating, feelings of lack of control during these episodes, and exercising, purging or fasting to prevent weight gain (point prevalence < 0.5%). The treatment of Bulimia with CBT is effective yet only quarter of people report accessing treatment. A stepped care program with some dependence on the internet could cover 25% and cost $31 million.

13. Neurasthenia [Somatoform Disorder NOS]
The Somatoform Disorders/Neurasthenia are common in primary care. Patients complain of physical symptoms like chronic fatigue or pain and resist lifestyle and cognitive changes that would be of benefit. [point prevalence 1.5%]. Current treatment with 30% coverage is variable, mainly because doctors feel powerless to assist. Ideal treatment at 50% coverage [more is impractical], that ranged from stepped care from GP+internet to specialist, would cost $22 million and produce a coherent plan for the treatment of this disorder. The cost per case is the lowest of any disorder studied.

Recommendations:

1. General practitioners are ideally placed to manage most of these cases using a healthy lifestyle approach coupled with attention focusing training.
2. CME training programs are required to raise the awareness and skills of GPs

14. Obsessive Compulsive Disorder
Obsessive Compulsive Disorder is an anxiety disorder [point prevalence 0.3%] in which repugnant thoughts repeatedly intrude despite the best efforts of the sufferer. The obsessional thoughts and the resulting compulsions can disable and threaten work and personal relationships. The key to management is exposure to the feared situation until the anxiety dissipates, or medication with antidepressants, or both. Effective treatment reaches 43% of the patients, ideal treatment at 70% coverage would cost $46 million and avert a moderate part of the burden.

Recommendations:

1. Patient education is essential: there are good self help books and web
   packages.
2. Specific treatment with exposure and response prevention, the benefits of which are long lasting, is often preferred to medication, the benefits of which are dose limited.

15. Borderline Personality Disorder
Borderline Personality Disorder means a persistent and maladaptive pattern of unstable relationships, self image and mood that usually remits with time [point prevalence 0.1-0.5%].  While few people seek treatment, some are very needy and demanding and generate considerable service costs. Current treatment with 15% coverage is often chaotic. Ideal treatment at 30% coverage [more is impractical], that ranges from stepped care from GP to specialist to long term re-education programs, would cost $64 million and produce a coherent plan for the treatment of this disorder.

Recommendations:

1. Stepped care from GP through specialist to long term day programs should be established.
2. Positive planned management would eliminate the current management by crisis.
   
   
   

Comments in regard to some additional issues

Emergency Psychiatry: In the present system, crises present many times a day, every day. In busy acute units, while all admissions are crisis admissions, a third remain in hospital for less than 48 hours. A crisis is the unanticipated risk of actual or potential harm and if unresolved, will produce a serious cost to society. Their impact should be lessened appreciably in the stepped care system by the proactive management plans. Nevertheless, crises will always occur in Bipolar Disorder, Schizophrenia and Borderline Personality Disorder, and Drug Induced Psychosis. Intoxication and relationship breakdown will continue to produce crises, and disconnected people such as the homeless will still present in crisis.

In regard to Drug Induced Psychosis due to Amphetamines, while 100,000 Australians report amphetamine use at least monthly and 23,000 report one or more psychotic symptoms each year, only 2,300 attended a hospital as a consequence of those symptoms. While the resolution of the Drug Induced Psychosis is not difficult, this acute presentation is a valuable opportunity to intervene in the prevention of continuing use of the drugs. Hence, while increased coverage is not practical, assertive treatment from rehabilitation units and from community mental health teams in conjunction with drug and alcohol services in the vulnerable phase immediately following the psychotic episode is recommended.

Two to three acute beds per 100,000 population will be required for crises and, because of the need for acute medical care, they could well be functionally integrated with Accident and Emergency Units, but staffed from mental health, exactly as is occurring in a number of Australian centres who designate these beds as ‘psychiatric emergency centres’. PECC units, with a mean patient stay of less than 48 hours, materially reduce the demand on the host inpatient unit and improve the ambiance. The unit is no longer being perturbated by emergency admissions and can proceed with therapeutic tasks. Better handling of crises should lead to improved consumer, carer and media satisfaction, and improved morale and competence among the workforce.

Mental Disorders in prisoners: The prevalence of mental disorders on admission to prison was ten times higher than that observed in a matched group in the community. Psychosis was 12 times higher, substance use 11 times, and depression and anxiety disorders 5 times higher. Screening programs in the lower courts to divert people to mental health services should be expanded. But serious violence and serious crime is associated with some mental disorders and is committed by people with existing mental disorders. Those people will need good mental health care while in prison and proactive ambulatory care by specialist forensic services after release.

Child and adolescent disorders: A small expert group met to discuss the feasibility of using this method to assess the requirements in this field. Four disorders were discussed and pathways created and costed. The method is feasible and should be implemented. Goodman in the Maudsley discussion paper #4 used exactly this approach to estimate the UK services required for children and adolescents with a mental disorder. The Australian situation is not dissimilar.

Goodman R; Maudsley Discussion Paper #4, 1997: Abstract

1. The amount spent on child and adolescent mental health services, and the types of services purchased, vary dramatically from one health authority to another. This variability partly reflects the prevailing uncertainty about what sorts of services need to be delivered, for whom, and by whom.

2. Not all childhood maladjustment and distress is a mental health problem. The majority of troubled children and teenagers either require no professional help, or need help from education, social services or voluntary agencies. For the minority of troubled young people who do have mental health problems, a wide range of effective treatments exist. Despite this, many of the treatments currently delivered in everyday child and adolescent mental health settings are of dubious or minimal value. Until this is rectified, spending more money is not necessarily the solution.

3. Comprehensive and accessible evidence-based services will not necessarily cost more than current services. There is considerable scope for obtaining more effective services and better value for money by diverting available resources away from treatments of dubious value and into treatments that have been shown to work. Young people, families and referrers would all benefit if health, education and social services clarified their respective roles. Overlapping and muddled remits stand in the way of effective help.

4. Health provision should focus on young people with core mental health problems such as anorexia nervosa, schizophrenia, severe depression, obsessive-compulsive disorder and severe hyperactivity. At present, these young people often go untreated or undertreated. The “four tier” model is unhelpful, dividing services up in a way that works against good practice. A more promising blueprint for evidence-based services involves: an outpatient service, fully funded by health, for core mental health problems; a contribution to multi-agency services for disruptive behaviours; a hospital liaison service; and intensive services. In addition, integrated district services need to provide consultation and training to primary health services and other agencies, and should take an active role in facilitating self-help groups. Because 16 and 17 year olds are particularly likely to have expensive-to-treat mental health problems, the cost of child and adolescent mental health services depends critically on its upper age limit. Thus a service for 0-18 year olds may be twice as expensive as a service for 0-16 year olds.

5. Education and social services should take the lead in the assessment and management of disruptive and delinquent children and teenagers. Health involvement is only appropriate for the minority of disruptive young people whose troublesome behaviour stems from, or gives rise to, core mental health problems.

Specialist mental health services for older people:The National Survey included people to the age of 99. We have not broken down the data by age group, nor did we ask the expert committees to comment on treatment recommendations by age group, hence we make no specific recommendation for older people.

Dementia: We have followed exactly the same protocol for dementia as we did for the other disorders: how many people have dementia, how disabled are they and what services should what proportion receive. The results are not included in tables 1,2 &3 because responsibility for the assessment and treatment of people with dementia spans the mental, physical health, and social welfare sectors of the economy.  The results for dementia are in Chapter 10.

Dementia is not rare [point prevalence in the population is 1%, 5.4% among those aged 65+, and 22% in those aged 85+]. The key to management is early diagnosis, optimized physical health care, and coordinated care by GPs and other health professionals to minimize disability, all conducted in the least restrictive environment.
People with dementia often receive no special treatment. We estimate that a third of the mild cases, two thirds of moderate cases and almost all the severe cases should be the focus of specialist intervention. Ideal stepped care  is expensive ($3.7 billion in 2005 dollars or $33,000 per case per year, a quarter more than the cost per case of schizophrenia in 2005 dollars). Because of the impact on patients, their families, and society there is no suggestion that significantly less money be spent, only that it be spent advantageously.

Recommendations:

1. Diagnosis: Everyone should have a diagnostic work up involving their general practitioner supported by visits to a specialist, and then referral to community care services that include a social worker, an occupational therapist and education from Alzheimers Australia.
2. Maintenance treatment of mild cases: Care should be community based with ongoing GP support, Aged Care Assessment Team support to many, and Cholinesterase inhibitor prescription for those in whom it is indicated.
3. Maintenance treatment of moderate cases: Ongoing formal support from GP, ACAT and HACC. Additional education and behavioural interventions from allied health staff as needed. Weekly respite care. Continuing carer education and support. Brief hospital admission as required. Increased assistance for moderate cases who live alone. Some will need residential aged care. Medication: one third on cholinesterase inhibitors; one fifth will need psychotropic medication.
4. Maintenance treatment of severe cases: All will need continuous care, the majority in residential aged care facilities, with ongoing specialist input. Medication: one in four on psychotropic medication.

Chapter 2
Aim and Method

The aim of Tolkien II was to develop a model for an ideal mental health system that is affordable within the present budget, congruent with the existing workforce skill mix and availability, and that delivers optimal treatment to those currently seeking such treatment.

The project is a logical development of the ‘Best Buys’ project that identified the cost effectiveness of current and optimal treatment for 10 mental disorders, expanded to include five additional disorders and dementia. Current treatment was based on the results of the National Survey where available, and optimal treatment on an interpretation of existing guidelines, some Australian and some from elsewhere. The problem with the guidelines is that they never specify ‘who does what’ and never specify the resources required in terms of sessions with the clinician or time in hospital or in community accommodation. This project, relying as it does on the opinions of experts – usually including the people who wrote the guidelines for Australia – is able to specify these details.

The overall project can be considered similar to a jigsaw puzzle where each of the major mental disorders in adults are individually researched and treatment plans generated.  Each disorder represents a piece in the puzzle, and when the pieces are joined together an overview (or model) for mental health service in Australia can be achieved. 

Tolkien II is a large project that involves a systematic approach to treatment planning. Because the project addresses a broad spectrum of disorders, Tolkien II allows for careful assessment of how the recommendations for each disorder fit together and the sustainability of the recommendations given the current budgetary and work force constraints.  In order to achieve this, the project involves various steps that consider the feasibility of the recommendations generated and the availability of the workforce to carry out. 

Method 

The following steps were completed for the 15 mental disorders (i.e., three affective, five anxiety disorders, the two substance use disorders, and for schizophrenia, somatoform, borderline personality and two eating disorders). A separate study using a similar method was completed for dementia. Some disorders which affect adults were not included in the national survey [eating disorders] or in the best buys study [borderline personality disorder, somatoform disorders and OCD] but there were sufficient data available to allow these shortfalls to be remedied.  Nevertheless there are a number of caveats about the comprehensiveness of the method:

What follows is a review of the 7 steps used by Tolkien II to generate a model for mental health service in Australia for the 15 mental disorders and for cognitive impairment.

Steps:

1. Prepare a structured literature summary for each disorder
A structured summary of the literature for each disorder was prepared, organized around the following topics: definition of the disorder, epidemiology, natural history, disability, access to treatment, and treatments that are known to work.

Each expert in the area will have their own ideas about the disorder, based on prior experience and the milieu in which they work. This research based summary is to provide a common ground from which each expert can see the nature of the disorder on a wider scale. Experts were free to contest the research team’s ideas about the nature, frequency and indicated treatments for each disorder but had to supply convincing evidence for the summary to be changed. The summary is an important defining document as to the purpose of the clinical pathway.

2. Use background material about practice in Australia:
Background material about practice in Australia was collected. This information was considered when developing guidelines for treatment planning.   The background material and data used by the Tolkien II included:  Prevalence estimates, frequency of consultations with health professionals, level of disability associated with disorders, and optimal treatment guidelines produced by Australia. 

Population prevalence estimates of the number of people with each disorder were obtained by using the National Survey Data.  The prevalence estimates were generated from the survey data using ICD-10 diagnostic criteria, for disorders that occurred in twelve months prior to the survey.  In cases where comorbidity occurs, only the principal complaint was included to avoid double counting.    The level of disability associated with each disorder was obtained from the National Survey data, using both formal measures of disability (SF-12) as well as the number of days that the individual experienced a reduction in role or functioning due to the mental disorder. The disability level will include the effects of any comorbid condition.
In the interests of considering only cases that used health resources (because these are the cases that the health system must treat), the prevalence rates used in Tolkien II will include only those 40% of cases who, according to the National Survey, reported attending a consultation with a health professional for a mental health or substance use problem.

To determine the cost of each treatment element used with a disorder, the Best Buys studies (see Andrews et al 2004) that were based on the National Survey data and the associated cost estimates were referred to.  Because the data was collected during 1997, all costs were maintained in 1997 dollars. 

In addition to the information provided from the Survey on treatment offered and frequency of consultations, Tolkien II will used clinical practice guidelines (when available) to inform the experts of optimal treatment for each disorder, by activity and professional group involved.  This review also endorsed patient education and computer based self help as appropriate treatment options for many people.

3. Convene an expert panel/ generate clinical pathways:
Once the Tolkien II research team had generated a literature summary about each specific disorder, and calculated the relevant prevalence and health utilization data that pertains to Australia, an expert panel was convened to consider optional treatment of each disorder.

The selection for the expert panel was based on a search for GPs, psychiatrists and clinical psychologists who had demonstrated interest in the disorder under consideration, usually by publishing.  A minimum size of an expert group was set at three (one from each discipline), but for major disorders like schizophrenia two or more from each discipline was desired. Wherever possible, experts who wrote the RANZCP Clinical Practice Guidelines were included.

Expert panel task: Having read the structured summary, the experts met together to construct a clinical pathway for a person with the disorder, usually considering separate pathways for people of varying levels of disability: that is, with mild, moderate, and severe disability. The Schizophrenia and bipolar panels adopted a different approach.  The expert group was required to construct a pathway to specify for each phase of the disorder and for each level of disability:

•  the number of GP, psychiatrist, clinical psychologist, and mental health team care sessions required and the broad focus of activities in each session,
•  the number of acute inpatient days required,
•  number of rehabilitation hospital days,
•  the number of supported accommodation days required,
•  the number of days and type of medication required.

Each clinical pathway covered one year only. If appropriate [e.g. for chronic diseases], the pathway considered treatment in the first year separately from subsequent treatment. The researcher who prepared the structured summary was present as a resource person and scribe at the expert panel meeting. Professor Andrews acted as amanuensis for the meeting, sketching out the clinical pathway decided upon by the experts. The clinical pathway is a major product of the project.

4. Calculate the frequency of services recommended and costs thereof:
Once the optimal clinical pathways for each disorder was generated we then calculated, for each disorder, the number to be treated and the number and cost of the sessions required from the GP, psychiatrist, clinical psychologist, and mental health team. The number and cost of inpatient and supported accommodation days and the number and cost of medications required was also calculated at this time.  Two tables were generated from these calculations: (1) number of services required for each disorder at each level of disability and (2) the cost of services.   These frequency and costing tables are the second major product of the Tolkien II project and are allow stakeholders to explore the cost implications of differing patterns of service delivery.

5. Combining the 15 disorders:
Once steps 1-4 have been achieved for each disorder, the spreadsheets from the 15 disorders will be combined to consider the implications for the overall mental health service, in terms of desirable treatment pathways, and whether the cost of these recommendations is sustainable.   Essentially this final step asked ‘are the pathways affordable within the present budget and do we have the required trained workforce to deliver the described services?’

A response to the first question can be achieved by taking the present 2004 all sources budget and using the health care deflators to convert it to 1997 prices.  A response to the second question is more difficult to generate. The first step planned by Tolkien II was to discover how many GP, psychiatrist, clinical psychologist, and mental health team sessions are available in Australia, and how many acute inpatient days, rehabilitation hospital days and supported accommodation days are available.  The availability estimates were contrasted with the Tolkien II recommendations.

6. Determine who does what:
Once agreement had been reached about the feasibility of the recommended clinical pathways, careful definition about respective roles was generated. This role definition is contained in each of the disorder chapters. Tolkien II recognizes that to define a clinical pathway in terms of number and costs of services is a hollow exercise; therefore it defined each clinical pathway in terms of clinical activity, which is seriously useful.

These steps were firstly completed for the 15 mental disorders - depression, dysthymia, bipolar disorder, panicdisorder/agoraphobia, social phobia, GAD, PTSD, alcohol use disorders (harmful use and dependence), schizophrenia, eating disorders (anorexia and bulimia), neurasthenia, OCD, borderline personality disorder. They were then repeated for people with dementia in 2002 dollars. Note that we were unable to cost the current treatment for this disorder.

Consultation with Stakeholders:
The draft of this manuscript was circulated to professional bodies representing each section of the workforce involved, to Commonwealth, State and Territory health departments and to consumer and carer groups. Meetings were held with consumers and carers. Presentations of the draft report were given in all States and Territories. The results of these consultations are in appendix II

Assumptions and Limitations

Every model of service provision is based on assumptions and limitations, and Tolkien II is no exemption.  Tolkien II began with a narrow frame of reference, namely to provide a draft plan for clinical mental health services in Australia based on the following sources of data and principles:

• Data from the low and high prevalence surveys of mental health and wellbeing
• Data from the cost effectiveness studies
• Literature reviews of the nature and best treatment of 15 mental disorders.
• Advice from expert clinicians about best practice clinical stepped-care pathways for each disorder
• Fiscal responsibility, balancing “ideal” with what is affordable

The following assumptions and limitations include the most pressing issues identified during the consultation process. Tolkien II aimed to describe ideal medical/psychiatric and psychological treatment.  Such services and treatment processes are likely to be sufficient for the majority of individuals with mild to moderate high prevalence mental disorders.  But individuals with severe disorders often require a broader range of services and opportunities than the medical services described in Tolkien II.  There are few descriptions of rehabilitation and recovery services for people with psychotic disorders, and few comments about the role of non-governmental organizations.

Rehabilitation
Rehabilitation is concerned with the reduction of disability that is associated with mental disorder.  Rehabilitation involves services such as:

• Assistance with activities of daily living
• Support to develop and practice effective social skills
• Support to develop and practice social and recreational activities
• Support with financial skills and management
• Vocational and employment support
• Support to gain and sustain appropriate accommodation
• Education for consumer and family

Rehabilitation services are profoundly important for individuals with severe mental disorders, and Tolkien II assumes that state mental health services or NGOs can provide adequate rehabilitation. The extent of rehabilitation services provided may be limited.  Without adequate rehabilitation services, individuals with severe mental disorders are unlikely to make a sustainable recovery. People with mental disorders have reduced workforce participation rates that range from 45% for anxiety disorders to 16% for schizophrenia, against the 74% participation rate for healthy Australians.  Funding for such programs is outside the scope of this model. 

A larger role for NGOs in the provision of rehabilitation services was recommended by many whom we consulted.  NGOs can often provide services that are highly responsive to the needs of consumers, families, and the community, including extensive integration with other services available in that community.  However, they should not be seen as a cheap alternative to state-run services, but should be adequately funded, with medium term funding arrangements to allow them to attract, train, and retain skilled staff. 

Recovery
During the consultation process many consumers emphasized the importance of the recovery models, which was not explicitly described in the draft of Tolkien II.  We understand that recovery is a unique experience for each individual and has been  defined as “the development of new meaning and purpose in one’s life as one grows beyond the catastrophic effects of mental illness” (Anthony, 1993).  This model of recovery draws attention to the wider needs of an individual, beyond remission of symptoms, and towards fulfillment of personal potential and aspirations. 

Our understanding is that recovery and rehabilitation operate concurrently, but are not dependent on each other; recovery can occur in the absence of adequate rehabilitation, but recovery may not occur even with effective rehabilitation.  The individual has the pivotal role in the process of their recovery.  Recovery cannot be ‘provided’ by mental health staff or by consumer representatives.  Instead, recovery is promoted by appropriate systems and resources, which include supporting an individual to reconstruct their goals and aspirations.

While endorsing the fundamental importance of holistic recovery, the priority recommendations in Tolkien II aim to create an environment in which recovery can be sustained.  For example, Tolkien II assumes that safe and sustainable accommodation and staff who are appropriately skilled and supported are prerequisites to promoting higher order needs such as vocational or educational aspirations.

Educating Individuals, Families, and Carers
Tolkien II assumed that education of individuals, families, and carers is a necessary component of any health intervention.  Tolkien II also assumes that where clinicians are unable to provide such education that it should be provided (or supplemented) using self-help materials that include written information and web-based materials, and support and information provided by NGOs. 

The Stepped-Care Model
Tolkien II endorses a stepped care model.  Such models divide severity of symptoms into at least three categories; mild, moderate, and severe.  These divisions were created in order to describe treatment pathways.  However, some individuals will move between these pathways.  Although it is unclear how this will affect the costings, it is expected that savings accrued after individuals move from a severe to less severe category will offset costs resulting from individuals moving in the opposite direction.

Assumptions about the Process of Health Care
Tolkien II implicitly assumes that the process of health care can be relatively orderly. But many emergency presentations are chaotic and services, from time to time, are either inefficient, overwhelmed, or/and poorly co-ordinated.  Allowances will need to be made for all these factors.

General Practitioners Providing Mental Health Services
Several people who were consulted said that GPs may not want to provide mental health services.  In contrast, we understand that most GPs are already providing support and treatment to individuals with mental illness and are motivated to further develop their skills.  Limitations to GPs providing mental health services in primary practice include the limited availability of appropriate training opportunities, the limited time available in busy general practice, and the limited funding available for longer consultations, although the additional items in the Medicare Benefits Schedule have addressed this to some extent.

Workforce Issues
Many people consulted stated that members of the workforce are frustrated, demoralized, and entrenched in current practice models, and will not support the changes proposed in Tolkien II.  Tolkien II proposes that by valuing and supporting the existing workforce (mainly mental health nurses) to reskill, by supporting the development of career pathways for all mental health professionals, and by encouraging national policies on workforce development, that the motivation to improve service delivery models will also increase.  Tolkien II estimates do not include the cost of workforce development, training, supervision or credentialing. 

Co-morbidity
The epidemiological basis of Tolkien II avoids double counting individuals with co-morbidity by asking individuals who met criteria for more than one disorder to nominate which they regarded as ‘troubling them the most’. In DSM-IV terms we then regarded this as their primary mental disorder and we attached the disability and service utilization relating to the person to this disorder.  At times this may be appropriate because the co-morbid disorder may resolve with treatment of the primary condition.  When individuals have serious ongoing co-morbid physical or social disorders that render them permanently unable to work or function in society without external support, and which require greater treatment resources this impact was captured even if artificially attributed to only one diagnosis. The impact of this strategy is unknown.

Total Bed Estimates
To our knowledge, no gold standard exists for determining bed ratios.  The bed ratios defined in Tolkien II are based on several sources: Estimates of prevalence and levels of disability; the considered opinions of leading Australian clinicians and policy makers; and details from good models in Australia and in the US, UK, and Italy. 

Point Prevalence Rates
The point prevalence rates are from Andrews et al (2001) (British Journal of Psychiatry, 178: 145-153, Table 1).  

Costs and Burden Averted
Current treatment coverage, the cost and the burden averted by current treatment is from Andrews et al (2004) (British Journal of Psychiatry, 184: 526-533, Table 2).  The burden averted by ideal treatment at increased coverage is estimated from Table 4 of the same paper.

Costs Excluded
The estimates in Tolkien II do not include: Capital costs; administration, infrastructure or  non-salary running costs; additional costs of providing services in rural and remote areas.

The Costs of Increasing Coverage
Tolkien II assumes that increasing coverage for each disorder (that is, increasing the number of people with each disorder who are treated) does not result in an increase in the cost per extra person.  Some people consulted argued that the additional people to whom treatment will be extended may include more complex cases, requiring greater resources.  While this may occur at times it will be more than offset by the additional mild disorders, in addition to offsets resulting from economies of scale.

Treatment Reported
Estimates of treatment received by participants were taken from self-report measures for the previous 12 months.  This means that Tolkien II relies heavily on an individual’s ability to report what treatments they had received and from whom.

Cost of Stepped Care Treatment
The estimated cost of stepped care treatment is a product of the expert opinions.  The frequencies of a particular consultation or service are informed estimates.  The distribution of such consultations or services is skewed so, if we nominate an average of 12 services over the year, the range will be of the order of 3 to 48, that is, some people will only need and receive a service every 6 months and others will need and receive services nearly every week.  

Comparative Costs
Treatments in the stepped care model are those identified as ideal in 2004/6 but we have deflated the costs to 1997 dollars for the mental disorders to ensure comparability with the original cost estimates of current treatment. The costs for Dementia are in 2002 dollars.

Metrics Employed – Several metrics have been reported in Tolkien II including Years lived with disability or YLD.  The simplest method of calculating YLD is to multiply the number of people with a disorder by the disability measured on a 0 to 1 scale where 0 equals a state akin to perfect health and 1 equals a state akin to death. YLDs averted is thus a measure of health gain due to fewer cases or cases with less disability or both.

Coverage of Adults
The addition of the extra five disorders to the 10 from the Best Buys studies means that Tolkien II covers almost all adult cases but does not presently allow for the cost of emergency psychiatry, or drug dependence other than alcohol.  

Non Mental Disorder Emergency Admission
Crisis services for people who do not meet criteria for a mental disorder were not calculated.  Thus people who attempt suicide but who had no formal mental disorder and people using emergency services due to intoxication or substance abuse were not included in analyses.

Disorders of Childhood or Adolescence
No estimates or treatment pathways were determined for children or adolescents with mental disorder.

References

Andrews, G, Henderson, S, Hall, W.  Prevalence, comorbidity, disability and service utilisation.  British Journal of Psychiatry 2001; 178:145-153. 

Andrews, G, Issakidis, C, Sanderson, K, Corry, J, Lapsley, H.  Utilising survey data to inform public policy: comparison of the cost-effectiveness of treatment of ten mental disorders.   British Journal of Psychiatry 2004; 184: 526-533. 

Anthony, WA.  Recovery from Mental Illness: The Guiding Vision of the Mental Health Service System in the 1990s.  Psychosocial Rehabilitation Journal 1993; 16: 11–23.

September 2007

We have vacancies for a free Web Based treatment for severe shyness.
Go to www.shyness.tv to learn about the details.

Gavin Andrews, September 2007

June 2007

www.shyness.tv website was launched to faciliatate a randomized controlled trial of the social phobia program. By the end of the month 100 people with social phobia had been recruited and allocated to intervention or waitlist control groups.

The management of anxiety course for www.climateschools.tv was made available for use by year 9 clasess in high school.

Funding for the Climateschools depression course was received from the Department of Health and Ageing.