Sue leads the Zero Suicide Institute of Australasia.
It was March 1963 when volunteers at Lifeline Australia first answered calls from people experiencing crises in their lives. It was an innovation of the time. Sixty years on those phone lines still provide critical crisis support but they are increasingly being complemented by other innovations in mental health care.
Dr John Brayley, chief psychiatrist for South Australia Health, has seen many such innovations enter the field of mental health. He shares his experiences and hopes for the future of mental health services, both in Australia and globally.
When the Washington Declaration was released in 2020, it called for quality crisis care to be available for “everyone, everywhere, every time.” It is needed. Too often, people present to the emergency department for crisis care because they cannot get access to care in a timely way.
In the 2023 Commonwealth Fund survey, 17% of Australians did not access mental health care In the past 12 months due to costs. This was second only to the US at 21%. In Germany, as few as 3% did not seek care. No matter what country, lack of access leads to later crisis and emergency presentations. This is why innovation must be encouraged and supported.
South Australia has vast rural and remote areas that call for innovation to address mental ill-health and suicidal distress. Innovations like the Urgent Mental Health Care Centre in Adelaide offer a home-like environment with an equal mix of lived experience and health professional staff. Safe Haven Cafés offer peer support in a non-medical environment and mobile services, which respond within one hour by going to where the person is located. “These alternative models of care are what the community wants and needs. They are replacing the unwelcoming bright lights of noisy emergency departments”, said Dr Brayley.
Keeping pace with community need and preferences
Linkages with local emergency services and hospitals are critical to the success of new community-based services. Dr Brayley says police and ambulance officers are always on the frontline of community situations in which mental distress is involved. “In South Australia, we have been working with police, ambulance and The Royal Flying Doctor Service, which manages remote responses and air evacuation, for more than 20 years”, he said. An important part of the collaboration is local liaison groups between emergency services that can discuss support for individuals and system improvements, with all services working together to solve problems. In addition, new co-response services, pairing a paramedic with a mental health worker, have been implemented. These are positive developments that recognise the traditional hospital-based model of care could not keep pace with community needs and preferences.
A common call among mental health advocates is the need for service parity between mental health care and physical health care. Dr. Brayley agrees it is an area that requires greater focus for policy development. The Global Burden of Disease study reports that mental health impacts range from 13-15% of the total burden of disease; however, the proportion of the health budget is much lower. In Australia, it has hovered around 8%. Advocates in all countries want to bring these into closer alignment.
One avenue to achieve greater parity at a local level is the design of a clinical pathway. Hospitals have used them for years for conditions such as chest pain, stroke, renal and sepsis as a way of offering evidence-based care while taking into account consumer choice. Dr Brayley says if a hospital can establish a chest pain pathway, the same should be done for mental health. “It is a robust and well-tried approach but in mental health, the design of a Suicide Prevention Pathway has only recently had wholesale uptake as the Zero Suicide Healthcare framework is rolled out through health services”, he said.
Mental health advocates also express concerns at the perceived mismatch between quality clinical care and demands upon management to contain costs and increase throughput of patients. Dr Brayley contends that mental health is not unique. “We all want to deliver high-quality care, and respond to need.” The significant demands placed on hospitals are partly addressed through the community alternatives described above, along with appropriate follow-up and support on discharge.
Is technology detracting from human connection?
Another area of innovation gaining popularity in mental health is technology-based responses. The question many ask is whether we are placing too much effort on developing these resources.
Technology advances are progressing our knowledge, understanding and access to better healthcare. In mental health, digital technology supports storage of safety plans, access to patient-controlled records, communication with therapists and different forms of homework in therapy. All of which are useful adjuncts to face-to-face interactions for crisis care.
“In South Australia, we have a rich history of video conferencing due to our geography. For more than 30 years, we have used it for mental health assessment and follow-up. Telehealth has delivered specialist mental health care when it is otherwise not available. In 2006, staff from the Chester Pierce Division of Global Psychiatry at Massachusetts General Hospital saw our telehealth model as one that had global application. We also saw telehealth services expand significantly during the recent Covid-19 pandemic”.
One of the concerns expressed by mental healthcare professionals is that telehealth should not become the only approach offered. Face-to-face engagement builds rapport and is critical when suicidal ideation is discussed. Being in the moment with the person is important and significant and this happens best in real life. Ideally, a combination of telehealth and in-person visits should be available. “But we cannot make assumptions about preferences. Interestingly, my colleagues working with young people say face-to-face is often their preferred contact — so it is important not to make assumptions about any group and their technology preferences.”
Dr Brayley noted that telehealth is a necessary fact of life in a country like Australia. The vast distances often mean health services are not accessible at the moment they may be needed. There are emerging technologies that offer new hope for better care in remote areas, such as better video and sound, telepresence and holographic imaging, or mixed reality.
According to Arrigo Palumbo from Magna Græcia University in Italy, who published a systematic review exploring mixed reality, this innovative approach blends elements of the real and digital worlds. In mixed reality, the person can interact and move elements and environments, both physical and virtual, using both sensory and imaging technologies. It offers the possibility of having one foot in the real world and the other in an imaginary place. It is an immersive experience and allows the person and the health professional to interact with the surrounding environment using holograms whilst engaging their senses throughout. In conclusion, Dr Palumbo cautions that mixed reality is an aspect of healthcare requiring more research.
Data collection, systems and workforce need significant attention
Improvements to health services are increasingly informed by establishing personalised and measurable outcomes that relate to the person’s goals and priorities. This data is taken in combination with satisfaction of health services supports quality improvement. Suicide prevention strategies that are quality-focused have a range of other benefits that improve the recovery journey. Better engagement and follow-up and person-centred services deliver outcomes beyond the suicide prevention goal — they deliver a better quality service.
A significant outcome for all health systems is the prevention of mortality and countries that are linking suicide registers with health databases have access to more rigorous data about suicide. The standardisation of suicide rates supports health systems in making comparisons between services and across jurisdictions. Good data also enables services to measure loss of life as a result of both mental ill-health and physical health problems, which is important because people with mental health problems die prematurely from physical health conditions. “We know from evidence that any reduction in loss of life has a huge impact on people, families and the community. Better data is not just about improving mental health care but the total care for the person”, Dr Brayley said.
As new service models and technology applications continue to evolve, the question arises about the readiness of the workforce to respond to these changes. Like many other countries, Australia has a critical shortage of all disciplines and an increasing demand on services. The new National Mental Health Workforce Strategy recognises the need for additional support by way of training and supervision. It also sees the Lived Experience (Peer) workforce is an integral part of the mental health workforce. Dr Brayley is optimistic about future recruitment into mental health. “Those coming through the university system have a high interest in mental health. We need to ensure there are enough places for specialty training and supervision structures in place so people can be trained in clinical settings and maximise their work experience. Despite the publicity about the challenges of mental health services and the demands of the work, I hear reports of many staff wanting to undertake mental health nursing and, in recent years, applications for psychiatry training trending in the right direction”, he said.
Keeping pace with innovation
One question that arises in any discussion of innovation is whether health systems can keep pace with research developments. In 2018, Australia established a dedicated suicide prevention research fund, independently managed by the peak body Suicide Prevention Australia. While the impact of this fund is soon to be reported, establishing a similar fund for mental health crisis care would be advantageous.
Dr Brayley agrees that this would be a good addition. There is a lack of health services research generally and specifically mental health services research. As in most countries, funding is directed to clinical treatments and causes of illness. Creating new funds to examine the delivery of care improves the quality of care and strengthens the nexus between research, clinical care and teaching. In terms of crisis care, funding new models linked with suicide prevention needs more research.
In South Australia, Dr Brayley would like to see research done in many different places. There are health practitioners doing PhDs exploring innovative ideas but with limited, if any, funding”, he said. A specific fund directed to local services and practitioners would be beneficial and accelerate the implementation of innovative ideas. This is one of the major challenges for all healthcare, not just mental health. “Implementation does not keep pace with innovation, and more research is needed on effective implementation and sustaining change. Linking research with clinical care positively impacts our health professionals and the people we seek to help”, said Dr Brayley.
