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Mental health

Information science Letters 6 June 2022 Free

Reading the fine print: Medicare telehealth changes to disadvantage rural and remote populations

To the Editor: The rapid uptake of telehealth has been a cornerstone of the response to the coronavirus disease 2019 (COVID‐19) pandemic, and has ensured the provision of essential health care despite restrictions and lockdowns. Although not new technology, telehealth has dramatically increased in prominence and received broad acceptance by doctors and patients alike. Given its success, the Australian Government has confirmed the permanent retention of multiple telehealth item numbers within the Medicare Benefits Schedule (MBS).1 However, it is concerning that this announcement also contained the fine print that the long‐standing MBS incentive for providing telepsychiatry consultations to rural and remote patients will be abolished. This is despite patients in rural and remote communities experiencing well established difficulties accessing health care and having poorer outcomes than their metropolitan counterparts.2 Telehealth consultations have occurred in psychiatry since well before the COVID‐19 pandemic, and have filled an important gap in the workforce by increasing services available in rural and remote areas.3 Video‐based consultations are particularly suited to psychiatry as the key skills of history taking, mental state examination, and psychotherapy do not require physical proximity. Delivering diagnostic assessment and psychological treatment via telehealth have long been demonstrated to be effective and tolerable.4,5 The MBS item number 288 was introduced in 2011 as an adjunct billing code that attracted a 50% loading for psychiatric consultations conducted via telehealth for patients located in a rural or remote setting, aged care facility, or Aboriginal health service. This loading incentivised bulk‐billing of these telehealth assessments. The deletion of this item number from 1 January 2022 will likely result in two adverse consequences: i) fewer telepsychiatry consultations to rural and remote locations will be bulk billed, and ii) telepsychiatry appointments that previously were only available for rural and remote patients will increasingly be offered to metropolitan patients. This will ensure fewer and less affordable options. The cessation of the rural loading for telehealth assessments is a retrograde step that is likely to further entrench long‐standing inequities in both access to care and patient outcomes for psychiatric patients who do not live in the cities. The 288 item number should be reinstated or replaced with an alternative funding mechanism to ensure bulk billed consultations continue to be available for rural and remote patients.

Michael J Weightman

Mja2 51529
Mental health Letters 21 March 2022 Free

Social and occupational outcomes for young people who attend early intervention mental health services

To the Editor: We must clarify that the findings of Iorfino and colleagues1 do not apply to headspace clients. This understandable misperception comes from the article’s title, “early intervention mental health services”, and participants coming from “clinics” that “provide both primary care services (headspace) and more specialised services”. Quotes from an InSight+ article2 and the accompanying editorial3 infer that the findings generalise to headspace, but they do not. Although some participants in the Iorfino study came from two headspace‐branded centres, they also included young people accessing specialised services. This is evident in the limitations: “our sample was restricted to young people who remained in contact with the service for at least two years … biasing our sample towards people who required ongoing care and were accordingly more likely to have poorer outcomes”. Generally, headspace does not provide care over a period of two years or more; centres typically provide brief episodes of care, befitting young people with mild to moderate presentations for common mental health problems. The average number of sessions is 4.4 (standard deviation [SD], 6.2); 98% of clients receive 20 sessions or fewer. A negligible 0.4% of clients are still receiving care at two years. Average time between the first and last session is 73.7 days (SD, 120), about 2.5 months (headspace 2015–2021, national unpublished data). Clarification that the findings are not representative of, nor generalisable to, headspace clients is essential; the headspace initiative is not targeted at young people who need more sustained mental health care. The results are inconsistent with reported outcomes for 24 034 headspace clients from 55 fully established centres.4 Significant improvement in the Social and Occupational Functioning Assessment Scale (SOFAS) scores was evident for 37.1% of headspace clients, 43.4% had no significant change, and 19.5% significantly deteriorated. Updated outcomes are forthcoming. Importantly, multiple outcomes must be considered for headspace clients; these are young people with diverse early intervention needs — the single‐item, clinician‐rated SOFAS is insufficient to ascertain meaningful outcomes. Despite the inability to generalise from Iorfino’s study to the national headspace centre network, we agree that young people with complex and persisting mental health conditions require more resource‐intensive responses than headspace primary care services were designed for.

Debra J Rickwood · Jason Trethowan · Annette Carruthers

Mja2 51426
Mental health Letters 21 March 2022 Free

Social and occupational outcomes for young people who attend early intervention mental health services

To the Editor: Iorfino and colleagues1 reported that “two in three young people with emerging mental disorders did not experience meaningful improvement in social and occupational functioning during two years of early intervention care”. Their sample was drawn from two headspace sites. This sounds alarming, especially considering that the study is exemplary in its longitudinal design, large sample size, and robust statistical analyses. Nevertheless, clinicians should be mindful of making too much of these results. The primary weakness of this study is the measure used: the Social and Occupational Functioning Assessment Scale (SOFAS). A systematic review of measures of functioning considered evaluating the SOFAS, yet excluded it based on the grounds that “the SOFAS has been superseded by the Personal and Social Performance Scale (PSP), which demonstrates stronger psychometric performance”.2 A study in 2007 stated that “the PSP scale is proposed as an improvement over the [Global Assessment of Functioning] and SOFAS because of its clear operational instructions on how to rate the severity of disability and its distinction between levels of impairment”.3 A similar issue was noted in 2000.4 Suffice to say, the SOFAS is a superseded measure of social and occupational functioning. This is apparent at the theoretical level. The SOFAS is a single item measure, rated on a scale of 0–100, for both social and occupational functioning. How is a clinician meant to score this measure when a young person presents functioning highly in their schooling, yet poorly in their social life? Or when things are going well with friends, yet poorly with their family? With this in mind, it is no surprise that three out of the four trajectories for young people’s mental health journeys identified by Iorfino and colleagues1 demonstrated no significant improvement. This is indicative of a broader issue identified in a systematic review of 189 articles, which reported that only nine mental health outcome measures in the published literature examined functional outcomes. Of these, “no measures were designed specifically for young people aged 12 to 25 years”.5 In short, the SOFAS is an out‐of‐date, adult measure with poor inter‐rater reliability. The study by Iorfino et al1 is what we need, but not what we are ready for. There is an urgent need in youth mental health services to have valid, reliable measures of social and occupational functioning that have good construct validity. There is an urgent research need for the development of such measures that have robust psychometric properties and clinical utility. Until this issue is resolved, attempting to predict pathways of care, or measure the efficacy of these services at a population level, will remain a guessing game. Future studies should focus on the development and evaluation of these measures. The collateral damage if researchers continue to use these measures will be the young people in need of early intervention.

Peter J Lenehan

Mental health Letters 17 January 2022 Free

Suicide by young Australians, 2006–2015: a cross‐sectional analysis of national coronial data

To the Editor: In their study examining the suicide deaths of 3027 young Australians during 2006–2015, Hill and colleagues1 reported that nearly 60% of cases had experienced mental health problems during their lifetime, and around 75% of deaths were of young males. We would like to draw attention to another important statistic within these data. Specifically, 4.6% of males who died by suicide in Australia had a diagnosis of autism spectrum disorder (ASD). This is alarming, considering that the prevalence of males with ASD in Australia is estimated to be only 1.3%.2 For males in the study age range (ie, 10–24 years), the prevalence ranges from 1.2% to 3.3%, with the highest prevalence in the 10–14 year bracket. Nonetheless, the apparent high incidence of suicide by males with ASD is consistent with recent research indicating a three‐ to nine‐fold increased risk of suicide among people with ASD compared with the general population.3,4 The increased suicide risk in ASD may be explained by the high incidence of comorbid psychiatric disorders among this population.5 Indeed, in one national cohort study from Denmark, over 90% of people with ASD who attempted or died by suicide had another comorbid mental health condition.3 In addition, it is important to note the low rate of suicide reported among females with ASD (0.4%). This finding is inconsistent with large international studies that report significantly increased incidence of suicide among females with ASD compared with females in the general population, with rates similar to or exceeding that of males with and without ASD.3,4,5 Females with ASD may be underrepresented in the data presented by Hill and colleagues due to lower recognition of ASD among females or to diagnostic overshadowing, whereby ASD is overlooked in favour of other more apparent psychiatric diagnoses (eg, anxiety, borderline personality disorder, depression). Finally, we highlight the fact that there is no systematic procedure or requirement in Australia for asking about or reporting ASD diagnoses within the emergency department or hospital admission systems. Plausibly, ASD is inadequately captured in data concerning health and mental health profiles, health service system access, suicide attempts and deaths in Australia.

Darren Hedley · Mark A Stokes · Julian N Trollor

Mental health Letters 17 January 2022 Free

Preventing suicide by young people requires integrative strategies

To the Editor: The incisive editorial by Dudley and Lin1 should serve as a clarion call for the development of “more robust strategies with targeted, customised approaches … evidence‐based interventions and peer‐reviewed evaluations”. Their sobering editorial highlights the immense challenges that need to be overcome to affect the growing suicide rates underscored by Hill and colleagues.2 They point out that transgenerational trauma and socio‐economic disadvantages increase suicide in Indigenous populations and call upon collaborative governmental support to address the problem. Intriguingly, although prevalence is higher in moderate to severely disadvantaged youth, the statistics among the least disadvantaged youth are not lagging far behind.2 This suggests that there are likely additional commonalities, such as mental illness, which features in at least half of all such suicide (> 55%).2 It is in light of this confronting reality that we raise the additional need for in‐depth knowledge and mechanism‐informed targeted treatment to avert suicide. It is concerning that one‐third of parents and carers are inadequately informed of mental health services available for mentally ill youth, impeding access to appropriate services,1 which clearly needs to be addressed. But simultaneously, it is important to identify more specific interventions and discern when and how to apply them effectively. This requires a reconceptualisation of suicide as a process, which involves both broad factors within the social environment and specific changes within cognitive and emotional processing networks within the brain.3 Mental illnesses, such as depression, have an impact on the latter by creating a cognitive drive that can be modelled as sequential steps that emerge from a faulty appraisal system to engender feelings of defeat and entrapment that increase hopelessness.3 It is because of these poorly understood antecedents4 and lack of rescuing factors that suicidal ideation ensues3 and is intensified to ideation or intent by additional motivational factors before being converted volitionally to planning and attempting suicide.3 The latter alters neural network connectivity, and further increases the likelihood of future suicide.5 Such deeper insights are needed to provide a framework for targeted preventive interventions. Therefore, we strongly resonate with the authors’ demand for targeted evidence‐based interventions and urge that in addition to these much‐needed initiatives, our energies should also be invested in mechanism‐based research.

Gin S Malhi · Erica Bell · Zola Mannie

Mental health Research 8 November 2021 Free

Social and occupational outcomes for young people who attend early intervention mental health services: a longitudinal study

Young people need dynamic service models that emphasise multidisciplinary interventions and measurement-based care

Frank Iorfino · Joanne S Carpenter · Shane PM Cross · Jacob Crouse · Tracey A Davenport · Daniel F Hermens · Hannah Yee · Alissa Nichles · Natalia Zmicerevska · Adam Guastella · Elizabeth M Scott · Ian B Hickie

Mja2 51308
Environmental health Perspectives 21 October 2021 Free

The 2021 report of the MJA–Lancet Countdown on health and climate change: Australia increasingly out on a limb

The fourth annual assessment of Australia’s exposure, vulnerability and response to climate change finds us continuing to lag behind the rest of the world

Paul J Beggs · Ying Zhang · Alice McGushin · Stefan Trueck · Martina K Linnenluecke · Hilary Bambrick · Helen L Berry · Ollie Jay · Lucie Rychetnik · Ivan C Hanigan · Geoffrey G Morgan · Yuming Guo · Arunima Malik · Mark Stevenson · Donna Green · Fay H Johnston · Celia McMichael · Ian Hamilton · Anthony G Capon

Climate20change202021

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