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
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?
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!
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 ? ? ?
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
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
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
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
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
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
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)
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
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
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
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
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)
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
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?
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)
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)
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
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
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
COULD IT MAKE A DIFFERENCE? Looking after “trauma” in Mental Health Care. In Public, important, community, NGO’s, GP, Psych, P rivate Sectors etcResearch 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?
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
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
SCIENCE FOR MENTAL HEALTHADDRESSING OUR NEEDS, OURSTRENGTHS, OUR WAY
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
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
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
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?
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
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
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
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
MENTAL HEALTH: EVERYBODY’S BUSINESS Research and Development is Everybody’s BusinessTranslating and Developing Knowledge and Skills for Better Mental Health