12. Key Initiatives and Areas of Interest to the Chief Psychiatrist

Electro-Convulsive Therapy

Electroconvulsive Therapy (ECT) is not dealt with as a special treatment under the Mental Health Act 2013. It is one mode of treatment which may be authorised by the Mental Health Tribunal for involuntary patients. It may also be administered to voluntary patients who possess decision making capacity. ECT, while accepted by mental health clinicians, the Royal Australian and New Zealand College of Psychiatrists and a topic of much research, has frequently been viewed by non-professionals as a treatment to be feared. It is reported on in these pages to provide the Minister with relevant background and factual data.

ECT is a therapeutic medical procedure for the treatment of severe psychiatric disorders. It has efficacy in treating clinical depression, mania and psychosis, and is occasionally used to treat other neuropsychiatric conditions. Its primary purpose is to quickly and significantly alleviate psychiatric symptoms. It is a treatment which may be potentially life-saving.

ECT involves the delivery of an electrical current to induce a seizure for therapeutic purposes. It is always delivered by a medical practitioner who is appropriately trained and credentialed. Prior to the treatment, another medical practitioner ensures that the patient is anaesthetized. A muscle relaxant is administered with the anaesthetic so there is minimal physical movement during the seizure.

The patient wakes several minutes after the procedure is completed. Careful evaluation of the patient takes place before, during and after the ECT. Treatments are usually given one to three times per week. The length of a course of ECT is highly variable with the average number of treatments used to treat depression ranging from eight to twelve. Some patients may require treatment with continuation or maintenance ECT because other treatments have not been effective in preventing illness relapse. Maintenance ECT typically ranges from an ECT treatment given every week to every few weeks.

There have been substantial developments which have improved the practice of ECT in recent years and there are several valid treatment approaches. There is no single protocol for administering ECT. The treatment approach needs to be individualised to the patient, the disorder and the response to ECT. The practice of ECT is supported by active research aimed at improving efficacy and minimising side effects.

The selection of patients for ECT is conducted by a specialist Psychiatrist with appropriate training and expertise in ECT. Voluntary patients must be able to give informed consent to ECT and involuntary patients will require authorisation for ECT from the Mental Health Tribunal.

Strategic Service Development

There are a number of initiatives which, while not directly related to the operation of the Act, are system level and whole of service issues, warrant the consideration of the Chief Psychiatrist as the senior mental health clinician in Tasmania.

Consumer and carer participation

Consumer and carer participation in the development of recovery-oriented services is paramount as recovery involves partnership between mental health consumers, their carers and families, and health service providers. Recovery seeks to empower consumers in taking control of their lives and therefore calls for a different relationship with the clinician or treatment provider than traditional treatment services which embrace the clinician or provider as the ‘expert’[7].

To ensure that we continue to deliver the best mental health care and to support individual journeys of recovery, we need to work directly with consumers, their carers and family, in a positive and genuine spirit of partnership, to ensure that a consumer’s individual and family needs are met. The evolution of consumer and carer participation in Tasmania continues with far greater involvement today in the evaluation and design of the mental health service system than ever before.

The Rethink Mental Health Project

A key election commitment and priority for the new government is the development of a long term plan for mental health.  The Plan will guide investment in mental health, and is a commitment to develop an integrated system that provides support in the right place, at the right time and with clear signposts about where and how to get help.

A significant component of the long term plan is the Rethink Mental Health Project. This is an important project aimed at shaping the future of mental health service delivery in Tasmania. It is aimed at achieving better outcomes for consumers, their families and carers from existing mental health expenditure and focussing resources onto frontline services and support.

Broadly, the Rethink Project will provide an independent analysis of Tasmanian public, private, federal, state and community sector delivered mental health services.  It will map existing services and identify service limitations, gaps and barriers for consumers, families and carers, analyse the full range of public, private, federal, state and community sector delivered mental health services and make recommendations for system reform and strategic investment into services, workforce and capital infrastructure.

The Rethink Mental Health Project will deliver a long-term plan for mental health in Tasmania that guides investment into the next decade, establishes priorities and identifies strategies to enable changes to be realised. The plan will be informed by feedback from many stakeholders, with a significant consultation process seeking views from consumers, their families and carers, clinicians, service providers and other key stakeholders taking place.

Consultation has involved consumers and carers and key organisation that work to ensure their voices are heard. These include Flourish – Mental Health Action in Our Hands, Mental Health Carers Tasmania, the Mental Health Council of Tasmania, clinicians of public mental health services, GP’s, primary health providers, private practitioners and community sector organisations.

The Chief Psychiatrist is a member of the Rethink Mental Health Project Steering Committee.

Suicide Prevention

A major concern is the prevalence of suicide in Tasmania, and the risk factors that may lead to suicide. Suicide rates for Tasmania are higher than the national average for both males and females and Tasmania has the second highest rate of suicide across Australia.  This is an issue for the whole of government and the community, and merits a comprehensive approach.

The Chief Psychiatrist is working with the Mental Health, Alcohol and Drug Directorate in leading state government funded suicide prevention policy, planning, purchasing and monitoring in Tasmania; and is a member of the Tasmanian Suicide Prevention Committee, which provides high level strategic advice and leadership in suicide prevention activities in Tasmania, with a particular focus on implementation of Tasmania’s Suicide Prevention Strategy. The Chief Psychiatrist is also a member of the Tasmanian Suicide Prevention Strategy Steering Committee and the Tasmanian Youth Suicide Prevention Strategy Steering Committee. During the 2014-15 year the Chief Psychiatrist has provided almost 12 hours of formal training and presentations to clinicians and other groups on suicide prevention.

The Chief Psychiatrist has an important role in providing advice to the Directorate regarding the evidence for suicide prevention strategies and in the implementation of the Government’s suicide prevention election commitments as follows:

  • Assisting communities with the implementation of Community Action Plans to prevent suicide.
  • Establishing early intervention referral pathways, especially following suicide attempt or self-harm.
  • Delivering suicide prevention awareness training to people in key occupations to recognise and respond to the signs.
  • Ensuring Tasmanian researchers can access information needed to allow in-depth analysis of Tasmanian suicides, to better target prevention strategies.
  • Developing a targeted Youth Suicide prevention Strategy (YSPS) for Tasmania in partnership with the Youth Network of Tasmania (YNOT).
  • Undertaking analysis of suicide ‘hotspots’ to mitigate risks if places are known for repeat suicides.

Physical Health of Patients with Chronic Mental Illness

Another area of concern is the physical health of patients with chronic mental illness. It is estimated that patients with chronic mental illness have a life expectancy as much as 25 years less than those in the general public[8]. Many factors contribute to this, including the side effects of medication to treat serious mental illness, the development of metabolic syndrome, cardiovascular disease, hypertension, respiratory disease and cancers. Smoking, alcohol and drug use, poor dietary habits and a sedentary lifestyle also play a major part.

The development of good physical assessment and monitoring procedures will be essential to addressing the physical health needs of patients. Additionally, we will need to ensure that mental health services are integrated in the most efficient manner possible with all relevant services, particularly other medical services such as General Practitioners and alcohol and drug services.

The Chief Psychiatrist is currently developing a Clinical Practice Guideline outlining an approach to management of the physical health of patients with mental illness to support clinical mental health services to further develop this area of practice.

Safety and Quality

Every Tasmanian with mental health needs should be able to access high quality, safe mental health services that uphold the rights and responsibilities of the consumer, their carers and their family.

The National Standards for Mental Health Services (the Standards) were first introduced in 1996 to assist in the development and implementation of appropriate practices and guide continuous quality improvement in mental health services. The Standards have been regarded as a positive in the mental health service sector and have been integral in shaping how services responded to the needs and expectations of consumers and carers.

The Standards were revised in 2010 with Standard 2: Safety, stating: The activities and environment of the MHS are safe for consumers, carers, families, visitors, staff and its community.

Quality improvement and innovation are action areas under the Fourth National Mental Health Plan 2009 – 2014. The recent National Mental Health Report 2013 outlined progress against a range of actions including the development of a national mental health research strategy to drive collaboration and inform the research agenda.

Developing and maintaining a safe and high quality mental health care system is a core function of all mental health care staff. It requires strong leadership, team work and a shared commitment to fostering a culture of service improvement to achieve the best outcomes for mental health consumers. Safeguarding this system requires a commitment to high standards of care and ongoing accountability; to new and emerging evidence and innovation in care; robust clinical governance; and the integration of the views of mental health consumers, their family and carers through strengthening consumer and carer participation. It also requires a commitment to safety and quality in non-clinical settings and within the broader community.

One area of the mental health care system that has been in focus recently is seclusion and restraint.  Australian public mental health services have been progressing initiatives to reduce the use of seclusion and restraint in acute settings in line with the National safety priorities in mental health: a national plan for reducing harm, endorsed by Australian Health Ministers in October 2005. This is an issue that is gaining collective national momentum through the National Reducing Seclusion and Restraint project underway through the National Mental Health Commission in which Tasmania is involved.

The Chief Psychiatrist represents Tasmania as a member of the Safety and Quality Partnership Standing Committee (SQPSC), a sub-group of the Mental Health Standing Committee (MHSC). The SQPSC provides expert technical advice and recommendations on the development of national policy and strategic directions for safety and quality in mental health taking into consideration the National Mental Health Strategy, the current Fourth National Mental Health Plan and mainstream health initiatives. The SQPSC may respond, through the provision of advice to the MHSC, on emerging issues of concern and related safety and quality issues. Issues of concern to the SQPSC include:

  • The implementation of National Standards
  • Suicide Prevention – here, the SQPC is focusing on improving the clinical approach through benchmarking and standards.
  • Physical Health Care – improving the outcomes for people with serious mental illness and psychological wellbeing of people with chronic illness.
  • Adverse Medication Events – examining medication safety and focusing on reducing adverse events.
  • Restrictive Practice – reducing restrictive/coercive practices and maintaining a focus on reducing seclusion and restraint in mental health facilities.
  • Trauma Informed Care – this is a strategic direction for policy and practice reform across all mental health services and aims at recognition and acknowledgement of trauma and its prevalence, alongside awareness and sensitivity to its dynamics.
  • Peer Workforce – consumer and carer peer workers are an integral part of the mental health workforce with the level of consumer and carer workers employed within mental health services being a key indicator for a recovery oriented system.
  • National Disability Insurance Scheme Quality and Safeguarding Framework – primary areas of importance to mental health involve supported decision making, National Standards and restrictive practices.

Participation in the work of the SQPSC enables the Chief Psychiatrist to report on the progress of these initiatives from the Tasmanian perspective and to ensure, through the Mental Health, Alcohol and Drug Directorate, that they become a focus of attention for the delivery of mental health services within the THOs.

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[7] 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, Department of Health and Human Services, Tasmania

[8] Improving the Physical Health of People with Severe Mental Illness, June 2012, Department of Health, Victoria