Building the Foundations for Mental Health and Wellbeing

Transcription

1 Building the Foundations for Mental Health and Wellbeing Review of Australian and International Mental Health Promotion, Prevention and Early Intervention Policy June 2009 Statewide & Mental Health Services Department of Health and Human Services

2 Prepared by Abbie Patterson, 2009 Australian Network for Promotion, Prevention and Early Intervention for Mental Health (Auseinet): NOTE: This publication is a companion document to: Building the Foundations for Mental Health and Wellbeing: A strategic framework and action plan for implementing promotion, prevention and early intervention (PPEI) approaches in Tasmania. (June 2009)

3 Table of Contents 1. INTRODUCTION AIM BACKGROUND CONCEPTUAL FRAMEWORK PROMOTION, PREVENTION AND EARLY INTERVENTION APPROACHES TO MENTAL HEALTH...2 Mental health promotion...2 Recovery...3 Prevention...4 Relapse prevention...5 Early Intervention METHODOLOGY POLICY BACKGROUND AUSTRALIAN POLICY POLICY MODELS...10 Scope...16 Leading policy driver...20 Approach...20 Priority populations INTERNATIONAL POLICY...23 England...29 Scotland...30 Wales...33 New Zealand...33 Canada...35 United States of America SUICIDE PREVENTION COMMON POLICY AGENDAS, INFLUENCES AND THEMES HOLISTIC CONCEPT OF MENTAL HEALTH EMERGING CONCEPTS AND APPROACHES...42 Wellbeing, quality of life, happiness...42 Economic arguments...43 Positive psychology CONVERGENCE OF POLICY PRIORITIES AND THEMES STATUS OF THE EVIDENCE RISK AND PROTECTIVE FACTORS SOCIAL DETERMINANTS OF MENTAL HEALTH EFFECTIVE INTERVENTIONS ISSUES TO CONSIDER FOR TASMANIA POPULATION AND GEOGRAPHIC CONTEXT POLICY ISSUES...57 Conceptual framework and language...57 Scope of the policy...57 Whole of government approach and policy linkages...59 Priority populations Mental health inequalities...59 REFERENCES APPENDIX APPENDIX APPENDIX

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5 1. Introduction 1.1 Aim This resource provides an overview of current and recent past Australian and international policy relevant to promotion, prevention and early intervention approaches to mental health. It has been compiled specifically to support the development of Tasmania s Mental Health Services promotion, mental illness prevention and early intervention strategy and, where possible, focuses on aspects of policy relevant to tertiary mental health services. It is not intended as a critique of the quality of the various policy frameworks or the outcomes of associated implementation since very few evaluations of policy are available. Rather the aim has been to reflect on various approaches and models which have been applied to the development of promotion, prevention, early intervention and related policies with a view to informing the development of similar policy in the Tasmanian context. It defines the concepts (mental health promotion, prevention of mental ill health, early intervention, recovery and relapse prevention) and describes the spectrum of interventions which articulates the unique and interrelated nature of mental health interventions for all populations. In addition the review also points to the emergence of new or revised conceptual frameworks in the field and concepts such as the social determinants of mental health, wellbeing, positive concepts of mental health, and quality of life, etc. These developments in thinking and practice in the field are emerging as important contributors to a deepening understanding of the place of promotion, prevention and early intervention approaches to mental health across a range of settings and sectors including the mental health service sector. 1.2 Background Tasmania s Mental Health Service (Tasmanian Government Department of Health and Human Services (DHHS)) recognises the growing evidence of the benefits of promotion, prevention and early intervention approaches for the mental health of populations, as well as for preventing mental illness, and reducing the impact and duration of mental illness where it occurs. DHHS has therefore commissioned the development of a comprehensive strategy on mental health promotion, prevention of mental ill health and early intervention which supports a reduction in the prevalence of mental illness in Tasmania. The strategy and its implementation will be the responsibility of the Tasmanian Mental Health Service and will assist in statewide planning and service development. A review of Australian and international promotion and prevention policy has been undertaken in order to inform the development of the strategy. Policy development in this area can be understood within the context of mental healthcare system reform which has taken place in many countries around the world over the past 40 years. The first phase of reform around the early 60s was reflected in increased support for de institutionalisation, the shift of care to general hospital and community settings and the notion that mental health should be given equitable consideration on a par with physical health. The second phase of reform was characterised by increasing community based services and concepts of medical and rehabilitative models of care. In the third phase of reform from the mid 1990s, the emphasis has been on understanding mental health and mental ill health (and the role of programs and services) across a continuum (such as the Spectrum of Interventions see 1.3 below), recognising that a significant proportion of the population are affected by mental ill health and that the concept of recovery is achievable (Compagni, Adams & Daniels, 2006). Many concepts have, and continue to influence policy development in this area. Some of these such as the social determinants of mental health, wellbeing, positive concepts of mental health, and quality of life, are discussed in the following. Review of Australian and international mental health promotion, prevention and early intervention policy 1

6 1.3 Conceptual framework promotion, prevention and early intervention approaches to mental health The Spectrum of Interventions as originally defined by Mrazek and Haggerty (1994) (and subsequently revised by others refer Appendix 1) is widely recognised and adopted as a population framework for defining the entire range of mental health interventions encompassing promotion, prevention, early intervention, treatment and recovery approaches. The Second National Mental Health Plan was the first instance of Australian national policy to adopt the framework and, with some revisions, this continued with the development of the National Action Plan for Promotion, Prevention and Early Intervention for Mental Health 2000 (Action Plan 2000) which has formed the basis of ongoing national and state and territory promotion and prevention implementation and practice. The various adaptations of the spectrum have reflected increasing understanding of the interrelationship between the components of the spectrum and to encompass the role and scope of mental health promotion and concepts such as recovery. The most recent published refinement by Barry and Jenkins (2007) reflects a strong health promotion background and further expands the mental health promotion aspect to highlight concepts of resilience and empowerment, etc. (refer Appendix 1). Irrespective of the revisions of the spectrum, there are some important general principles: 1. The spectrum reflects a population health approach which recognises the status and mental health needs of the entire population that is people who are currently well; those at risk of mental health problems on the basis of their individual, social and/or environmental circumstances; and those who are currently, or have previously, experienced mental illhealth. 2. The delineation between the various components of the spectrum have more cross over than the visual representation may imply. For example mental health promotion strategies may overlap in some instances with primary prevention. Secondary prevention has commonalities with early intervention (early identification and early treatment). Real life interventions may reflect more than one aspect of the model. 3. Despite the original Mrazek and Haggerty model having been essentially developed as a prevention framework, all revisions have sought to demonstrate that mental health promotion can be applied across the spectrum, regardless of the status of a person s mental health. The following provides an overview of the components of the model (adapted from Rickwood, 2007). Mental health promotion Mental health promotion is about improving wellbeing for all people, regardless of whether they are currently well or ill. It is about optimising people s mental health by developing environments that are good for everyone. Mental health is affected by the events that happen in our ordinary day to day lives, as well as by significant stressful events that occur such as loss and grief, physical ill health, etc. Mental health can be promoted by making sure that public policies support the social and emotional wellbeing of individuals and groups. All environments social, physical, economic, and cultural need to be supportive of mental health. Community life is important and communities need to be empowered to take the actions required to build their capacity to support their members. All people should be supported to develop skills to understand, enhance and respond to their mental health needs. Review of Australian and international mental health promotion, prevention and early intervention policy 2

7 Much of the work in mental health promotion has been conducted within the framework of the Ottawa Charter for Health Promotion (WHO, 1986) and the Jakarta Declaration (WHO, 1997). The five platforms of the Ottawa Charter include: 1. Building healthy public policy (emphasising the role of all sectors in health outcomes) for example, public housing policies to ensure that all people have access to safe, secure and affordable housing; and media stigma reduction programs. 2. Creating supportive environments in all settings for example, accessible public transport services and wheelchair accessible footpaths and shopping areas. 3. Strengthening community action for example, community action groups which determine goals for a community and influence local planning and policy. 4. Developing personal skills for example, provision of information in a range of languages which help people understand ways to look after their mental health and wellbeing. 5. Reorienting services toward promotion, prevention and early intervention for example, drug and alcohol services which support clients to address their mental health needs as well as delivering treatment. Recovery Mental health services have a responsibility for promoting the wellbeing of individuals and communities, as much as they do for treating illness. For each of the platforms of the Ottawa Charter, there are related strategies which are specifically relevant to people with existing mental illness. For example stigma reduction initiatives, an example of creating supportive environments, aim to reduce negative stereotypes resulting in better engagement by people with mental illness in all aspects of community life including work, integrated housing, social and recreation groups, etc. Strengthening community action may involve various models of consumer led initiatives such as mutual support and advocacy groups, business enterprises, etc. The concept of recovery for people with mental illness is closely aligned with mental health promotion. In essence, mental health promotion is about maximising wellbeing, quality of life, a sense of control over one s health, and the ability to bounce back (resiliency) from the challenges of life (Pape & Galipeault, 2002). These factors are as relevant for people affected by mental illness as they are for the entire population. While definitions of recovery vary to some extent, it is commonly understood to encompass a process more than an end state, and to involve gaining control over one s life and the illness (rather then the illness having control over the individual) (Pape & Galipeault, 2002, p.12). Onken, Dumont, Ridgway et al. (2002) define recovery as the product of a dynamic interaction among individual characteristics (including hope, and a sense of meaning and self), environmental factors (including opportunities for satisfying basic material needs, social relationships, meaningful activities and peer support), and features of the service delivery system (including choice and empowerment, independence and interdependence) (as cited in Compagni et al., 2006). In the National Mental Health Plan , recovery is defined as: a deeply personal, unique process of changing one s attitudes, values, feelings, goals, skills and/or roles. It is a way of living a satisfying, hopeful and contributing life. Recovery involves the development of new meaning and purpose in one s life as one grows beyond the catastrophic effects of psychiatric disability (adapted from Anthony, 2000, p.11). Mental health promotion was not included in Mrazek and Haggerty's (1994) original spectrum of interventions. However due to the growing realisation that mental health promotion can be applied across the spectrum, it can take place simultaneously with prevention, and that enhancing the strengths of individuals, families, communities, and social systems is associated with Review of Australian and international mental health promotion, prevention and early intervention policy 3

8 prevention of later problems, it has been added to subsequent revised spectrums (refer Appendix 1). An understanding of the principles of mental health promotion is essential in relation to development of recovery oriented mental health service systems. Prevention Prevention interventions work by focusing on reducing risk factors and enhancing protective factors associated with mental ill health. Risk factors are occurrences that increase the likelihood that a mental health problem or mental illness will develop (such as long term stressors), while protective factors are those that decrease the likelihood (such as good social support). There are three major types of prevention: 1. Primary prevention seeks to prevent the onset or development of a disorder or illness. Primary prevention interventions can be targeted to population groups identified according to the level of risk. There are three different levels of risk applied: i. General or universal These are interventions that are targeted at the general public or a whole population group. No specific risk factors have been identified and the intervention is aimed at preventing mental health problems for everyone. This level of intervention has many commonalities with mental health promotion the main difference being a shift of emphasis from a positive concept of mental health to prevention of mental ill health. Interventions are designed to reduce risk factors and/or increase protective factors that are likely to be relevant to the whole population: for example, parenting programs provided for all parents; pre school education provided for all pre school children; exercise programs for all age and fitness levels; anti bullying programs in schools and workplaces; and pre natal support programs. ii. At risk or selective These are interventions aimed at individuals or population groups whose risk of developing a mental health problem or mental illness is higher than for the general population. Interventions are designed to reduce risk factors and/or increase protective factors for a population group identified as being at higher risk: for example, ongoing support for children of parents with a mental illness; support groups for people who have recently been bereaved; providing mental health related information for people with physical illnesses; and post natal support programs. iii. High risk or indicated These interventions are for people who are at very high risk of developing a mental health problem or mental illness. They are designed to reduce risk factors and/or increase protective factors for people at imminent risk of mental ill health: for example, support for refugees; counselling and support for victims of violence; support programs for people recently released from prison; suicide postvention programs; support programs for people with chronic pain and chronic illness; and post natal support for mothers with birth complications. 2. Secondary prevention targets those who are showing early signs or symptoms of mental illness or disorder and seeks to lower the prevalence of illness through early detection and treatment. Secondary prevention interventions have similarities with early intervention: for example early identification and treatment of psychosis programs for young people. 3. Tertiary prevention seeks to reduce the negative impact and associated disability of existing mental illness. Tertiary prevention interventions have similarities with relapse prevention: Review of Australian and international mental health promotion, prevention and early intervention policy 4

9 for example programs which support maintenance and stability of housing and employment for people with mental illness, supporting people with mental illness to develop life skills such as budgeting, cooking etc. Relapse prevention There has been considerable debate and varying views on the meaning of relapse prevention. However there is some agreement that recovery involves a learning process and encompasses more than the medical view of relapse which has negative connotations of deterioration, lack of compliance, etc: Relapse prevention is a specific component of the recovery process. It entails maximising wellness for people with mental illness by reducing the likelihood and impact of relapse. It involves empowering people with mental illness to recognise early warning signs or relapse and develop appropriate response plans. It requires identifying risk and protective factors for mental health, and implementing interventions that enhance protective factors and eliminate or reduce the impact of risk factors...relapse prevention is an essential, but not sufficient, component of the recovery process for people with mental illness (Rickwood, 2006, p.4). Relapse prevention strategies therefore have much in common with tertiary prevention given that a major objective is to reduce the negative impact of illness. It can be considered an adjunct to standard treatment where there is a deliberate focus on ongoing illness management aimed at reducing the likelihood and impact of future episodes of the illness. The term rehabilitation, also frequently referred to in the context of recovery approaches for people with mental illness, refers to services and resources that are made available to people with mental illness to assist them to acquire and use the skills and supports necessary for successful living. The spectrum of intervention revised by Rickwood (2006), locates relapse prevention and rehabilitation under the arc of recovery which comprises treatment and continuing care (refer Appendix 1). Early Intervention Early intervention refers to two main types: 1. Prevention focused for individuals beginning to show the early signs and symptoms of a mental health problem (early recognition/identification). Interventions of this type aim to prevent progression to a diagnosable illness: for example screening for post natal depression; mental health assessments in drug and alcohol treatment and criminal justice settings; internet websites and resources to increase mental illness awareness. 2. Treatment focused for people experiencing a first episode of mental illness (early assessment and treatment). Interventions of this type aim to reduce the impact of the mental illness in terms of its duration and the damage it may cause to the person s life, and also to foster hope for future wellbeing: for example hospital at home services; assertive outreach programs; early treatment of post natal depression. Review of Australian and international mental health promotion, prevention and early intervention policy 5

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11 2. Methodology The authors have relied primarily on their comprehensive understanding of the field and associated networks to source relevant Australian and international policies and other literature for the purpose of the review. Auseinet provides a range of workforce development, consultancy, resource development, communications and clearinghouse services to its extensive Australian and international networks and is therefore consistently engaged with policy and research developments in the field. For regions of the world less familiar to Auseinet, key international contacts have provided information about contemporary research and policy where it exists and relevant to the review. Given the specialist nature of the promotion, prevention and early intervention field, and the relatively small number of policy documents both in Australia and internationally with a dedicated promotion/prevention focus, the scope of policy resources included in the review has been based on relatively broad criteria. This being said, it has also been necessary to limit the scope of the review given the potential for policies across a broad range of sectors (including education, housing, justice, child and youth heath, etc.) to have relevance for mental health outcomes. It was not intended that the policy review be exhaustive nor encompass all interconnected (established or otherwise) policies and frameworks, but rather to provide a summary of key policy directions and issues relevant to the development of the Tasmanian promotion, prevention and early intervention strategy. Priority was given to key Australian national, state and territory, and English, Scottish, Welsh, New Zealand, Canadian and United States of America policies which: Focus specifically on mental health promotion, prevention of mental ill health and/or early intervention; Target mental health service and related sectors more broadly with articulated actions relevant to promotion, prevention and/or early intervention approaches; and Are currently being implemented (or if not currently have made an enduring and significant contribution to the development of policy and implementation). Each of these documents has been reviewed on the basis of four major areas of interest. These include: i. Scope whether or not the policy provides direction across all aspects of the spectrum or primarily only one component (such as mental health promotion); ii. Policy driver the sector or portfolio area which has taken the lead on the development of the policy (such as mental health, public health); iii. Approach whether the policy is based primarily around a targeted population approach, a determinants approach (such as economic participation, etc.), or an inclusive approach in which promotion, prevention and early intervention activity is included within an overarching mental health strategy; and iv. Priority populations the specific populations identified as priorities for action. In the following report policies are discussed on the basis of these four components as well as in relation to key policy objectives and priorities. Comments are made about consistent trends and themes which can be observed in policy directions and priorities both in Australia and internationally despite the diverse contextual and policy environments in which they exist. In addition, the review is supported by a summary of research, evidence and emerging conceptual frameworks which have made a significant contribution to policy directions, thinking, research and practice in the field. Review of Australian and international mental health promotion, prevention and early intervention policy 7

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13 3. Policy Background 3.1 Australian policy The policy environment relevant to promotion, prevention and early intervention approaches to mental health is simultaneously both narrow and diverse. While at a national level, the National Action Plan for Promotion, Prevention and Early Intervention for Mental Health 2000 (Action Plan 2000) has provided a comprehensive guiding framework for action using a population approach, few policies at the jurisdictional level focus specifically on promotion, prevention and early intervention approaches and to date, no such policy exists to specifically guide the work of mental health services in this area (refer Table 1). In this respect the work being done in Tasmania around the development of a promotion, prevention and early intervention strategy targeting the mental health service sector makes a unique contribution to the field. While commonly the role of mental health services is understood to operate exclusively at the early intervention and treatment ends of the spectrum, it can be demonstrated that tertiary mental health services also have a significant role to play in promoting mental health for people with mental illness, preventing the onset and reducing the impact of mental ill health (Pape & Galipeault, 2002). On the other hand, there is considerable activity in policy development across a diversity of settings and sectors with the potential to intersect with and support positive mental health outcomes across populations. From a social health perspective, policies concerned with such issues as access to good quality housing, child protection, disaster relief, social planning, etc. provide opportunities for supporting positive mental health and preventing mental ill health. In some cases, such as the ACT Action Plan for Mental Health Promotion, Prevention and Early Intervention and the Canberra Social Plan, this link is made explicit. In many other cases, the association between various government priorities and the benefits for mental health are only implied even though the links may be clear for those who support a holistic view of health which recognises that social, economic and environmental factors have as much impact on health outcomes as do individual factors (such as genetic predisposition, insecure attachment in childhood, etc). International bodies such as the World Health Organization (WHO) and other leaders in the field have long since advocated for the need to make explicit in policy, intersectoral approaches to improving mental health outcomes as articulated in the now widely recognised message, mental health is everybody s business. More specifically, there has been increasing support and momentum around the need to define the specific objectives and interventions associated with promoting mental health, preventing mental ill health and intervening early to identify or treat mental ill health. This has been evidenced by the work undertaken in Australia and internationally towards the development of a clear conceptual framework which articulates both the unique and interrelated objectives and strategies for promotion, prevention and early intervention approaches. As shown in Appendix 1, the Spectrum of Interventions framework originally defined by Mrazek and Haggerty in 1994 has since been adapted several times to reflect a growing understanding of the interrelationships between the components of the spectrum and to incorporate new concepts such as recovery and relapse prevention, etc. This developing understanding has been mirrored in policy in Australia which, from the development of Action Plan 2000, has seen increasing definition of strategies and actions specific to promotion, prevention and early intervention across state and territory jurisdictions. Review of Australian and international mental health promotion, prevention and early intervention policy 9

14 3.2 Policy models Within the mental health promotion, prevention of mental ill health and early intervention policy environment, several models of policy development can be observed. The model adopted is influenced by a range of factors unique to the environment in which the policy is being developed and for this reason all policies are best understood within the context of their national or jurisdictional influence. This being said two main models operate within current policy development: 1. A dedicated approach which makes promotion, prevention and early intervention approaches to mental health an explicit policy directive. 2. An embedded approach in which strategies relevant to promotion, prevention and early intervention are identified as a component of an overarching strategy (usually mental health). Each of these models can be distilled further by focusing on four main (and interrelated) components. These include: i. Scope inclusive of strategies relative to the spectrum (such as mental health promotion); ii. Policy driver the sector or portfolio area which has taken the lead on the development of the policy (such as mental health, public health, etc); iii. Approach whether the policy is based primarily around the needs of: - identified populations (population approach), - the determinants of mental health (such as economic participation, etc.) (determinants approach), or - whether strategies for promotion, prevention and early intervention are incorporated within other priority areas (such as reform of mental health services) (inclusive approach); and iv. Priority populations the specific populations identified as priorities for action. Table 1 provides summary information about selected Australian and state and territory policy documents in relation to the four main components. This is discussed in more detail in the following. Review of Australian and international mental health promotion, prevention and early intervention policy 10

15 Table 1: Australian policy components Title Policy model Scope (promotion; promotion & prevention; PPEI) Lead policy driver Relevance to mental health service sector Approach (population, determinants, inclusive) Priority populations National Action Plan for Promotion, Prevention and Early Intervention for Mental Health 2000 (Australia) Dedicated PPEI Mental Health The mental health service sector is identified as a key strategic sector for actions associated with the majority of priority populations. NOTE: Appendix 2 provides a summary of key objectives and priorities identified in Australian national and state and territory policies Appendix 3 provides details of related policy documents and other resources for Australian states and territories Population Whole of community Perinatal and infants 0 2 years Toddlers and preschoolers 2 4 years Children 5 11 years Young people years Young adults years Adults Older adults Individuals, families and communities experiencing adverse life events Rural and remote communities Aboriginal peoples and Torres Strait Islanders People from diverse cultural and linguistic backgrounds Consumers and carers Media Health professionals and clinicians Review of Australian and international mental health promotion, prevention and early intervention policy 11

16 Title Policy model Scope (promotion; promotion & prevention; PPEI) Lead policy driver Relevance to mental health service sector Approach (population, determinants, inclusive) Priority populations National Action Plan on Mental Health (Council of Australian Governments (COAG)) Embedded PPEI Mental Health Identifies the mental health system as a key contributor across all areas of the Action Plan including promotion, prevention and early intervention activity. Inclusive Varies across individual national, state and territory implementation plans ACT Action Plan for Mental Health Promotion, Prevention and Early Intervention Dedicated PPEI Mental Health The MH service sector is named in areas of action across all priority groups. However there is a strong emphasis on the need to bring together all service sectors to achieve goals as set out in the Plan. Population Whole of population Children Young people Aboriginal and Torres Strait Islander people Culturally and linguistically diverse communities People who have experienced mental illness and their carers People at risk of abusing alcohol and drugs Media and public affairs Health professionals and workforce development Workplaces Review of Australian and international mental health promotion, prevention and early intervention policy 12

17 Title Policy model Scope (promotion; promotion & prevention; PPEI) Lead policy driver Relevance to mental health service sector Approach (population, determinants, inclusive) Priority populations Queensland Plan for Mental Health Embedded PPEI Mental Health Role of mental health services identified in key actions for Priority 1 promotion, prevention and early intervention. Inclusive: The Plan articulates six principles: Principle 2 Resilience and recovery Principle 5 Promotion, prevention and early intervention Includes five priority areas for reform: Priority 1 promotion, prevention and early intervention Vary according to the Priority focus. Western Australian Mental Health Promotion, Illness Prevention and Early Intervention Strategic Framework Dedicated PPEI Mental Health Mental health services sector identified as a driver for action within the Spectrum of Interventions (Barry adaptation, 2007) adopted for the strategy. Inclusive: Achievements pursued through collaboration, coordination and partnerships Not specified Review of Australian and international mental health promotion, prevention and early intervention policy 13

18 Title Policy model Scope (promotion; promotion & prevention; PPEI) Lead policy driver Relevance to mental health service sector Approach (population, determinants, inclusive) Priority populations Victorian Health Promotion Foundation: A Plan for Action : Promoting Mental Health and Wellbeing Dedicated Promotion Public Health Does not specifically target mental health services for action. Individuals affected by mental illness are not identified as a priority population Determinants: Social inclusion Freedom from discrimination and violence Access to economic resources Children Young people Women and men Older people Indigenous communities Culturally diverse communities Rural communities Because Mental Health Matters: Victoria mental health reform strategy Embedded Prevention Early interventi on Recovery Social inclusion Mental Health Strategy for reform of mental health service system Inclusive: Strategies are integrated across 8 Reform Areas: 1. Promoting mental health and wellbeing 2. Early in life 3. Pathways to care 4. Specialist care 5. Support in the community 6. Reducing inequalities 7. Workforce and innovation 8. Partnership and accountability Consumers and carers in the specialist service system Women and men Children and young people Older people Aboriginal communities CALD and refugee communities GLBTI communities People with co existing disability Offenders and victims People with multiple and complex needs Review of Australian and international mental health promotion, prevention and early intervention policy 14

19 Title Policy model Scope (promotion; promotion & prevention; PPEI) Lead policy driver Relevance to mental health service sector Approach (population, determinants, inclusive) Priority populations NSW Community Mental Health Strategy Dedicated PPEI Mental Health Targeted to community mental health programs delivered by public mental health services and specialist NGOs Inclusive: Strategies are grouped around 3 main areas: Specialist mental health services Community mental health service partnerships Quality, innovation, research and infrastructure Vary across strategy areas. Some populations which get special mention include: Aboriginal and Torres Strait Islanders Culturally and linguistically diverse Rural and remote Forensic clients Older people Young people Children People with a co morbidity of mental illness and problematic drug and alcohol use; or mental illness and intellectual disability. Stepping Up: A Social inclusion Action Plan for Mental Health Reform (SA) Embedded Prevention and early interventio n Social inclusion Recovery Social Inclusion Mental health services in all aspects of reform Inclusive: Recommendations structured around 8 main themes. Vary according to recommendations. Populations with a special focus include: Aboriginal people Country dwellers People with complex needs Review of Australian and international mental health promotion, prevention and early intervention policy 15

20 Scope The scope of a policy or framework document may be influenced by a range of factors. For example the sector or portfolio area which has led the development of the policy (such as Mental Health), and its associated target population/s will influence the emphasis of the strategy within the spectrum. A strategy which focuses on the needs of people affected by mental ill health is more likely to encompass early intervention and recovery interventions and actions than a policy which targets positive mental health for the general population. The scope may also be influenced by the existence, or otherwise, of related or complementary policies 1, and government priorities at the time of development of the policy. A complete analysis would require a comprehensive mapping process for each Australian state and territory encompassing policy within and beyond the mental health sector. The following provides a brief overview of the scope of policy within the current Australian environment. At a national level, the National Action Plan for Promotion, Prevention and Early Intervention for Mental Health 2000 led the way by addressing the complete promotion, prevention and early intervention spectrum. Taking a population approach, Action Plan 2000 has provided a framework for targeting activity to promote mental health, and prevent and reduce mental ill health for the whole community, groups across the lifespan (such as perinatal and infants, older adults, etc.), other priority populations (such as rural and remote communities, Aboriginal and Torres Strait Islanders, etc.) and strategic priority groups (such as consumers and carers, media, etc.) Despite more recent national policy developments, Action Plan 2000 continues to be recognised as a relevant and contemporary framework for guiding population based approaches. The Council of Australian Governments (COAG), National Action Plan on Mental Health outlines government investment in mental health programs and initiatives within five major areas for action comprising: 1) Promotion, prevention and early intervention; 2) Integrating and improving the care system; 3) Participation in the community and employment, including accommodation; 4) Coordinating care; and 5) Increasing workforce capacity. The major focus of the National Action Plan is to strengthen the capacity of the mental health service system, and to facilitate collaboration across the jurisdictions. It is within this context that promotion, prevention and early intervention approaches are targeted, and in this respect is weighted more heavily in the direction of prevention, early intervention and recovery oriented strategies. Examples of interventions identified in the COAG National Action Plan include: Public information and education activities that improve community awareness of risk factors for mental ill health and promote social inclusion and support; Support groups for children of parents with mental illness; Health services for young people that focus on early intervention; Specialist mental health services for older people; and Statewide 24 hour 7 days a week mental health service access by telephone. In February 2009, consultation commenced on the draft 4 th National Mental Health Plan. A summary of key areas identified for national activity in the draft 4 th National Plan relevant to promotion, prevention and early intervention for mental health includes: Greater investment in recovery oriented services including access to a variety of accommodation options and vocational programs; Improved mental illness literacy for the whole population; Stigma reduction programs for the whole population and clinical and non clinical workforces; 1 Refer to Appendix 3 for information about linked and/or related policies and documents for all policies identified in Table 1. Review of Australian and international mental health promotion, prevention and early intervention policy 16

21 Targeted early intervention programs for children and families; Further development of suicide prevention activities; Coordinated drug and alcohol and mental health services; Place based treatment and support programs for homeless and other disadvantaged groups; and Expansion of family support particularly in rural and regional areas. The 4 th National Plan emphasises the need for a whole of government approach and highlights the relevance of a range of sectors to the objectives of the Plan. These include: general practice, alcohol and other drugs services, emergency services, correctional services, housing, schools and education, community services, child protection and youth justice, Indigenous health and wellbeing, immigration, ageing and employment. The ACT Action Plan for Mental Health Promotion, Prevention and Early Intervention is currently the only example of a state/territory policy which mirrors the scope of Action Plan The ACT Action Plan provides a dedicated promotion, prevention and early intervention focus and identifies a number of populations for specific attention. These are not necessarily identified as populations across the lifespan, but more targeted to populations at potentially higher risk of mental ill health and strategic priority groups. The ACT Action Plan is currently in review and is due to be developed for a further term during This sits within the context of the development of the Mental Health Services Plan which is currently in draft form and identifies the ACT Action Plan as a complementary strategy. Western Australia also provides a dedicated Mental Health Promotion, Illness Prevention and Early Intervention Strategic Framework However this summary document is primarily directed to establish key roles and collaborative partnerships and major strategic priorities and themes. It does not identify priority populations or specific activities and programs for implementation. Of potentially more specific relevance to the mental health services sector, A Recovery Vision for Rehabilitation: Psychiatric rehabilitation policy and strategic framework, focuses on the needs of people with existing mental ill health including quality of life; optimal health and wellbeing; and action towards residential, educational, recreational and vocational goals. The framework articulates the strategies required to implement a recovery oriented rehabilitation approach which complements treatment services. These are consistent with a recovery orientation as defined previously including: Identification of the person s needs and life goals; Providing relationship and environmental supports; Assisting the development of skills effective for life management; Participation in community life without the experience of discrimination and prejudice; etc. Other state policy documents including the Queensland Plan for Mental Health ; and the NSW Community Mental Health Strategy also encompass strategies across the spectrum. However they differ from policies described previously. Rather than taking a dedicated promotion, prevention and early intervention approach, actions have been incorporated within principles or strategic action areas of an overarching mental health strategy (discussed further in Approach below). The Queensland Plan identifies five priority areas for reform of mental health care. The first of these priorities is identified as promotion, prevention and early intervention and associated actions include the establishment of the Queensland Centre for Mental Health Promotion, Prevention and Early Intervention, improving mental health literacy for non clinical workers, strengthening responses for perinatal and infant mental health, and reducing suicide risk and Review of Australian and international mental health promotion, prevention and early intervention policy 17

22 mortality among identified high risk groups. A recovery orientation is central to the intent and scope of the plan. This builds on the framework and principles outlined previously in the Queensland Health paper (2005), Sharing responsibility for recovery: Creating and sustaining recovery oriented systems of care for mental health. The NSW Community Mental Health Strategy is positioned within the context of several other NSW Government mental health planning frameworks. These include: NSW: A New Direction for Mental Health (2006) NSW: Interagency Action Plan for Better Mental Health (2005) A New Direction for NSW: State Health Plan (2007). Each of these frameworks articulates strategic directions to support promotion, prevention and early intervention approaches to mental health. In particular the NSW Interagency Action Plan focuses on the shared roles for preventing mental illness and early intervention across government and NGOs including health, education, juvenile justice, ageing and disability, police, welfare and housing. The NSW Community Mental Health Strategy extends on existing policy by focusing on the specific role of community mental health programs within the system of mental health care delivered by public mental health services and specialist non government organisations. The primary focus of the strategy is to outline actions and programs required to ensure recovery oriented community mental health services. The community mental health model identified for the strategy comprises two key components: 1) specialist community mental health services including core services and programs for people of all ages, across all service settings and specialist community services for particular age groups; and 2) community mental health partnerships across a range of health departments (housing, education and training, police and ambulance, etc.) and non government organisations. States which have taken a unique approach within the Australian policy environment are Victoria Victorian Health Promotion Foundation: A plan for action : Promoting mental health and wellbeing; and South Australia Stepping Up: A social inclusion action plan for mental health reform Victoria, well recognised for its leading contribution in Australia to a better understanding of the factors which influence mental health and wellbeing, dedicates policy (A Plan for Action) to define a framework and effective actions for mental health promotion within a health promotion framework. In this respect A Plan for Action takes a broad population approach and emphasises the role of diverse settings for action including housing, transport, community services, corporate, education, public, workplace, arts, sport and recreation, local government, health, justice and academia. Within this framework the health sector does not necessarily feature more strongly than any other sector and the emphasis is on a positive construct of health rather than the absence of health (or ill health per se). The needs of people affected by mental ill health are not identified as specific populations for attention within this framework. In March 2009, Victoria released Because Mental Health Matters: Victorian Mental Health Reform Strategy This strategy is built around the following components: Core elements prevention, early intervention (in life, illness and episode), recovery, and social inclusion. Outcomes prevalence of mental health problems; health impacts (mental and physical); and social and economic impacts. Review of Australian and international mental health promotion, prevention and early intervention policy 18

23 Guiding principles consumer centred service provision; family and carer inclusion; population based planning; social model of health; equity and responsiveness to diversity; and evidence based practice. The strategy builds on previous plans by taking a whole of community and whole of government perspective, covering programs and services that respond to people experiencing the spectrum of mental health conditions, and emphasising partnerships and shared responsibility. The strategy is structured around eight reform Areas. These are: 1. Promoting mental health and wellbeing 2. Early in life 3. Pathways to care 4. Specialist care 5. Support in the community 6. Reducing inequalities 7. Workforce and innovation 8. Partnership and accountability Unique to this strategy is the articulation of a mental health outcomes framework. This provides a shared basis for planning across the various levels of the service system, government programs, and agencies and sectors at the local level, and for monitoring improvements. It also provides a mechanism for identifying differences in access and health inequalities by specific population groups and those living in particular geographical regions. The framework is structured around three domains: Level One: Health and community outcomes Involving population surveys and other data to assess achievement over time of agreed population outcomes such as reductions in prevalence of mental health problems, level of disability associated with mental health problems and associated social and economic impacts. Level Two: Determinants of mental health Indicators will be used to assess how a range of risk and protective factors impact on mental health and wellbeing for the general population and for those with existing mental illness. This draws on an integrated biopsychosocial model of mental health and illness. Level Three: Performance of the service system This level pertains to local services and programs both individually and collectively and will include indicators on how efficiently they are delivering outcomes for consumers and carers. This will provide an overview of the effectiveness and value for money of mental health and other investments. It should reveal how service culture is changing and how the experience of clients and their families and carers is improving. Stepping Up: A social inclusion action plan for mental health reform developed by the South Australian Social Inclusion Unit for the South Australian government, takes a unique approach by using the concept of social inclusion as the guiding framework for reforming mental health services in Australia. Recommendations for action provided in the plan are centred around nine major areas. All have various degrees of relevance to principles of effective promotion, prevention and early intervention: 1) Developing a people centred system; 2) Understanding the people who use the mental health system; 3) Implementing a stepped system of care with community services at its centre; 4) Developing a workforce for the future; 5) Focusing on Review of Australian and international mental health promotion, prevention and early intervention policy 19