Beverley Raphael-presentation

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Beverley Raphael-presentation

  1. 1. THE CHALLENGES OF CHANGE FORMENTAL HEALTH:CULTURES, CONSENSUS, AND FUTUREDEVELOPMENTProfessor Beverley RaphaelProfessor, Population Mental Health & Disasters, UWSProfessor, Psychological Medicine, ANUMHCC Conference 2011: Trauma Informed Care and Practice:Meeting the ChallengeFour Points by Sheraton, Sydney23-24 June 2011
  2. 2. CHALLENGES FOR CHANGE
  3. 3. HOW CAN WE ACHIEVE TRAUMA INFORMEDCARE? (i) Why might we need this? How do we know? Could it “Make a Difference” ?  For whom  How  How do we know Do we “DO It” Now? Who would PAY for it?
  4. 4. HOW CAN WE ACHIEVE TRAUMA INFORMEDCARE? (ii) Why Should We “Do” it? What will it Involve? Who Wants it? Or Not? How Can it happen? How will we know if works? How can we have what we need and when? Our way!
  5. 5. WHAT CHALLENGES TO WE FACE FOR THEFUTURE? The problems & the successes Lifetime Psychiatric Disorder 2007 Current prevalence and increases Numbers More Problems A rich, happy, successful country ? ? ?
  6. 6. Slade, T., Johnston, A., OakleyBrowne, M.A., Andrews, G., Whiteford, H., 2007National Survey of Mental Health and Wellbeing:methods and key findings. Australian and New ZealandJournal of Psychiatry 2009; 43:594605
  7. 7. SPECTRUM OF CHILD ADVERSITIESMultiple Adversities and Measures (Jacobs et al)Milieu of “Family”  “Retrospective”, “Prospective”  Independent or not  “Validated” e.g. Legal, Medical Clustering of Multiple Adversities especially with severe CSA, CPA, neglect Adversities: Common part of Family Life?Milieu of “Environment”  Multiple, external/accidents  Disasters, disease: Acts of God/Man Trauma, Loss Dislocation, Disruptions etc
  8. 8. CHILD ADVERSITIES: FAMILYMultiple Studies, Consistent Findings Child Adversities associated with (Green NCS 2010) Onset of All Groups of Mental Disorders (Mood, Anxiety, Substance, Disruptive, etc)  44.6% of childhood Onset  25.9-32.0% Later, Adult OnsetSevere sex, physical abuse & neglect + maladaptive family functioning e.g. parental MI, SA criminality, family conflict, violencealso WMH Survey: Repeats findings
  9. 9. PROSPECTIVE: ISLE OF WIGHT (1964 COHORT UK) (COLLISHAW, RUTTER ET AL, 2007) OR Adolescents  Depression 15.5  Suicidal ideas 8.87  Anxiety 8.11  Conduct/Dis 4.57 with adversities  Peer Relations Mid-Life  Major depression recurrent 8.8  Suicidal behaviour 4.8 1958 UK Birth Cohort (Clark et al, 2010) Sexual abuse OR 3.4, PA OR 2.6 pathology 3 or more adversities OR 3.7Predicts Onset and Persistence
  10. 10. PROSPECTIVELY ASCERTAINED: ABUSE &MENTAL HEALTH IN YOUNG ADULTS (16-27)(SCOTT ET.AL. 2010)Child Protection Agency History 12 months & Lifetime Mental Health PTSD 5.1 Mood 1.86 OR all ANX2.41 when retrospective reports out Substance 1.71 All disorder groups and 3 or more disorders 12 months & lifetime
  11. 11. CHILD ADVERSITY: ADULT “STRESSSENSITISATION” (MCLAUGLIN ET.AL 2009) Child Adversity + past year life stresses risk MD, PTSD, ANX, perceived stress 3 or more CA’s MDD 27.3% -v- no CA’s 14.8% PTSD also Cumulative adversity (Schilling) Total CA & incremental CA – depression, drugs, anti-social but SEVERITY of CA’s not no’s poorer mental health
  12. 12. CHRONIC ADVERSITIES AND ONSET ALL LIFESTAGES (BENJET 2010)Predict psychopathlogy onset for childhood mood; anxiety adolescent substance adult life disruptive (children)Childhood family dysfunction and abuse (MFF)Strong prediction (WMH Survey)Old age e.g. CSA + mental Health (Draper et al 2008)
  13. 13. CHILDHOOD ADVERSITIES: SUICIDE RISKCSA and suicide attempts (Bebbington et al 2009) British NCS Parp 28% for women 7% men Risk for onset and persistent riskChildhood adversities World MH Survey Risk suicide attempts and ideation OR 1.2 & 5.1 with number of adversities Sexual & physical abuse est risk for adolescent Associations still, adjusting life MHCSA Data & Coronial Data Linkage (Cutajer et al 2010) Suicide RR 18.09 most in 30’s Fatal overdose RR 49.22 most mental health women higher
  14. 14. CHILDHOOD ADVERSITY: PHYSICAL HEALTHChild Sexual Abuse & Physical illness in (Psych pts)(Talbot et al 2009) Severe CSA medical health burden = 7.9 years of illness (musculo-skeletal, respiratory)Child physical abuse (longitudinal Springer 2009) smoking, bronchitis etc mental health, ulcer BMI, smoking & MH General HealthAll adversities (Dube et al 2010) (PA, SA, MFF)associated current smoking obesity poorer general health premature death
  15. 15. CHILD ABUSE & NEGLECT IN AUSTRALIA 2010Prevalence: NCPCH Price – Robinson et al (2010) (review of studies) – estimates Physical Abuse 5-10% Neglect 1.6-12.2% ?estimate Emotional Maltreatment 11% Witnessing Family Violence 12-23% Sexual Abuse Male Female Non-penetrative 12-16% 23-36% penetrative 4-8% 7-12% (issues of reporting, substantiation)Clustering with family functioning adversities
  16. 16. AUSTRALIAN STUDIES OF CHILD ADVERSITY Multiple Studies as international: retrospect; “prospective”; longitudinal (eg MUSP) Note: Roseman & Rodgers (2004) – PATH Project  59.5% some adversity, 37% > 1 multiple often domestic conflict; parental psychopathology and substance abuse  Severe adversities, physical & sexual abuse and neglect – uncommon but cluster with multiple and other severe adversities  Average 4.8 other adversities with severe sexual abuse, 5.9 with physical and 6.8 with neglect
  17. 17. INDIGENOUS CHILDREN TRAUMA, LOSS &GRIEF (WAACHS) (MEIO ET AL 2005) Child Adversities and Social & Emotional WB: parent taken away; parent mental/physical illness, single parent or other care, criminal, SA, PA, etc Maladaptive family functioning stressors Increased risk of all disorders 4-11 years >2 25% > 7 42% risk 5.5x 12-17 years 19% 34% Protective, resilient quality of parenting No illnesses, stressors, care, no violence NOTE also child sexual abuse report (Coorey 2001)
  18. 18. WHY MIGHT WE NEED THISPeople with Mental Health Problems and Mental Illnesses Have more adverse experiences  Discrimination  Marginalisation  Economic and social problems  Homelessness  Assault and other trauma  Losses – self, dignity, family Negative Treatment aspects e.g.  Seclusion, restraint, etc  Medication, legislation etc
  19. 19. DO WE KNOW WHAT COULD MAKE ADIFFERENCE What do people with illness think? Respected studies say that consumers identify stressful experiences as contributing to their illness. What do Service Providers think?  Not known systematically  Many would agree Have we Policies and Programs that address: “Trauma”/Adversity as an aspect of Health and Mental Health?
  20. 20. WHAT DO WE DO ABOUT THIS?
  21. 21. WHAT DO WE DO National Mental Health strategy 4th National Mental Health Plan Multiple Developments over time  States & Territories, collaborations, common themes, outcomes & data reporting  Australian Government Initiatives  Primary Care, Better Outcomes, ATAPS etc  Special initiatives e.g. beyondblue, depression  Private Sector – Medicare and other rebates  PBS (Pharmaceutical Benefits Scheme)
  22. 22. WHAT IS DONE TO ADDRESS THESE MENTALHEALTH VULNERABILITIES (AUSTRALIA EXAMPLE) Distance Resources  Web based programs, call centres e.g.  ACATLGN; Raising Children; COPMI;Kids Help Line; ARACY  National Networks e.g. National Association Prevention CAN  Australian Institute of Family Studies  National Child Protection Clearing House Multiple Agencies, Advocacy-services, state and territory  Care Systems  Child protection services and counselling  Child & adolescent mental health  Linked programs, late programs (older adults)
  23. 23. WHAT DO WE DO (CONTINUED) E-Health Systems  Information  Interventions Non-Government Sector  e.g. SANE, MHCA, States, General Specific  e.g. advocacy, information, support services, consumer & Carers, Housing, Employment COAG: Across sectors of government, health, family, disability, indigenous etc
  24. 24. WHAT DOES THE COMMUNITY SECTOR DONOW
  25. 25. POPULATION HEALTH STRATEGIES Positive mental health & wellbeing, mental “health”, fitness, love, work, play, relationships Building resilience – individual/societal, communities of engagement, neighbourhood, organisations (e.g. sport, work), youth, on-line etc Connectedness & care & social capital Violence: prevention, zero tolerance, public health education, integration for mental health Building Health Capital/Mental Health
  26. 26. WHAT DO WE DO ABOUT IT? Adults Treatments for PTSD Trauma Focussed CBT etc Look after other adversities and their effects on Mental Health? Cultures and trauma Complex, communal and multiple traumas
  27. 27. COULD IT MAKE A DIFFERENCE? Looking after “trauma” in Mental Health Care. In Public, important, community, NGO’s, GP, Psych, P rivate Sectors etcResearch is needed Do we assess “trauma”, what would we do? e.g. prevention, early intervention, clinical treatments, etc Would it make a difference ? ? ? ? What do we do for Those with Greatest Need?
  28. 28. AUSTRALIAN CHILDREN’S ADVERSITIES 0-14 Children’s Mental Health (4-14) SDQ  8% general and 13% Indigenous  Emotional or behavioural problems: 15%/24%  Conduct problems: 15%/24%  Hyperactivity: 10%/16% Indigenous Adults:  2 x higher psychiatric disorders  40% life stressors in previous 12 months Hospital Separations – 40% higher Indigenous Adversity: WAACHS etc Higher > 3  risk
  29. 29. WHAT DO WE NEED TO DO: DEVELOP TRAUMAIN FORMED CARE Build & Translational: Evidence base of what is needed, what would work best, and for whom Who will advocate? How can it happen? How can we all be part of such an initiative
  30. 30. SCIENCE FOR MENTAL HEALTHADDRESSING OUR NEEDS, OURSTRENGTHS, OUR WAY
  31. 31. TRANSLATIONAL RESEARCH FRAMEWORKFOR TRAUMA INFORMED CARE Phase I: basic research – efficacy, safety RCT’s and some clinical Phase II: translation to:  Real patients / real life  Guidelines, needs, acceptability  Effectiveness, cost- effective Phase III: addresses policy for clinical and public health and for sustainability “Continuous Improvement” – etc. Through R & D in Ed & T; QI
  32. 32. TRANSLATIONAL CHALLENGES (i) Engaging stakeholders, consumers, carers, service providers Complex and multifaceted:  Conditions, contexts, components, and relevance for various populations / individuals  And, who deals with CHILDREN and their NEEDS IN THESE CONTEXTS? Integrating it all to a set of cycles of RESEARCH implementation evaluation, renewal cycles
  33. 33. TRANSLATIONAL CHALLENGES (ii) Develop Systems to  Encompass research and service systems across  Primary care; community; hospital; private etc  Clinical, population levels  Indigenous, culture, rural  Cultural Diverse communities  Workforce and professional development  Education and Training Acceptability; engagement, commitment, action, progressive development
  34. 34. CHILDREN & ADVERSITIES/TRAUMA (an example) Assessing in CAMHS Services (McAndrew, 2010) Diagnosis & Treatment Evaluation Needed Research Studies What Family adversities could be addressed Can we “CLOSE THE GAP” for children with greatest need?
  35. 35. TRANSLATIONAL CHALLENGES (iii) Costs, benefits, complexity and effectiveness, governance, and outcomes over time Flexibility and capacity to be research active, research valued, research development and emerging, future need Politics, advocacy, resources for the change, the good, the critically appraised. Not ideology, but benefits, betterment for individuals, families, children, young, old, other. WE – THE PEOPLE
  36. 36. WHAT DO WE WANT? Lobbying:  Change Barriers  Services have ways of working  Cultures, beliefs Engaging providers to explore, test, own possible research outcomes  Education & training positives  Resources – cost benefits
  37. 37. WHAT CAN MAKE IT HAPPEN? Engagement of Leaders Science, need, benefits for people, systems Positives, risks, “Story” Collaborative discussion for resources, commitment Building program progressively and monitoring indicators and programs Contributions of policy & programs to better mental health outcomes and better systems of care
  38. 38. DOES IT HAPPEN Cycles of Ongoing Translational Research & Service Development Integrated to Optimise Care  Addressing adversities  Identifying strengths  Enhancing capacity for those affected, carers, families, communities or services Monitoring need, processes & celebrating achievements, hopeful & resilient trajectories
  39. 39. MENTAL HEALTH: EVERYBODY’S BUSINESS Research and Development is Everybody’s BusinessTranslating and Developing Knowledge and Skills for Better Mental Health

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