Introducing mental health and substance use screening into a community-based health service in Australia: usefulness and implications for service change

Abstract

Mental health issues such as depression or anxiety and alcohol or other drug (AOD) problems often remain undiagnosed and untreated despite their prevalence in the community. This paper reports on the implementation and evaluation of an AOD and depression/anxiety screening programme within two Community Health Services (CHS) in Australia. Study 1 examined results from 5 weeks of screening (March-April 2008) using the Patient Health Questionnaire (two- and nine-item, Kroenke et al. 2001, 2003), the Conjoint Screen for Alcohol and other Drug Problems (Brown et al. 2001) and the Alcohol, Smoking and Substance Involvement Screening Test (Humeniuk & Ali 2006). Of the 55 clients screened, 33% were at risk of depression or anxiety, 22% reporting moderate-severe depression. Thirteen per cent were at risk of substance use disorders. A substantial proportion of at-risk clients were not currently accessing help for these issues from the CHS and therefore screening can facilitate identification and treatment referral. However, the majority of eligible clients were not screened, limiting screening reach. A second study evaluated the screening implementation from a process perspective via thematic analysis of focus group data from six managers and 14 intake/assessment workers (April 2008). This showed that when screening occurred, it facilitated opportunities for education and intervention with at-risk clients, although cultural mores, privacy concerns and shame/stigma could affect accuracy of screen scores at times. Importantly, the evaluation revealed that most decisions not to screen were made by workers, not by clients. Reasons for non-screening related to worker discomfort in asking sensitive questions and/or managing client distress, and a reluctance to spend long periods of time screening in time-pressured environments. The evaluation suggested that these problems could be resolved by splitting screening responsibilities, enhancing worker training and expanding follow-up screening. Findings will inform any community-based health system considering introducing screening.

Risk Assessment in Mental Health: Introducing a Traffic Light System in a Community Mental Health Team

“…It is likely that others internationally who are interested in implementing new arrangements for SU risk management would benefit from considering a TLS system, and in using AR to implement it. International literature indicates that risk management is a complex phenomenon in mental health [7,13, 14, 15], that risk assessment is essential [12], and that introducing a TLS which is easy to understand, broadly familiar to clinical teams, cheap to implement, and flexible and responsive to improvements and deteriorations in clients’ mental health can help [20, 22]. It has been well-received by this team and has provided a solution to this workplace problem by using the knowledge of those most intimately involved with that problem.…”

“…Recognition of risk is important in reducing its effect by identifying appropriate care pathways, particularly when risks are complicated (for example by co-existing substance misuse with a mental health issue). Thomas and Staiger [12] note that some Australian practitioners found asking personal questions difficult, resulting in risks being missed on initial assessment, and propose that a screening tool would help with questioning and build a better picture of the risks involved; and this may be useful internationally where risks include socio-economic deprivation, and poor rural access to metal health services [13], mental health and substance abuse co-morbidity [14], and unemployment causing the risk of maladaptive coping strategies such as the use of alcohol, tobacco and general self-neglect [15]. A certain degree of risk may be beneficial to SUs, who may otherwise become deskilled at managing facets of their own daily living [16, 17].…”

Risk Assessment in Mental Health: Introducing a Traffic Light System in a Community Mental Health Team

“…It is likely that others internationally who are interested in implementing new arrangements for SU risk management would benefit from considering a TLS system, and in using AR to implement it. International literature indicates that risk management is a complex phenomenon in mental health [7,13,14,15], that risk assessment is essential [12], and that introducing a TLS which is easy to understand, broadly familiar to clinical teams, cheap to implement, and flexible and responsive to improvements and deteriorations in clients' mental health can help [20,22]. It has been wellreceived by this team and has provided a solution to this workplace problem by using the knowledge of those most intimately involved with that problem.…”

“…Recognition of risk is important in reducing its effect by identifying appropriate care pathways, particularly when risks are complicated (for example by coexisting substance misuse with a mental health issue). Thomas and Staiger [12] note that some Australian practitioners found asking personal questions difficult, resulting in risks being missed on initial assessment, and propose that a screening tool would help with questioning and build a better picture of the risks involved; and this may be useful internationally where risks include socio-economic deprivation, and poor rural access to metal health services [13], mental health and substance abuse co-morbidity [14], and unemployment causing the risk of maladaptive coping strategies such as the use of alcohol, tobacco and general self-neglect [15]. A certain degree of risk may be beneficial to SUs, who may otherwise become deskilled at managing facets of their own daily living [16,17].…”

Dental Patients with Major Depressive Disorder

“…Additional modifications of the criteria for MDD reclassify dysthemia (a form of chronic mild depression) to include it as a part of chronic depression and consider bereavement in making a diagnosis of MDD [7]. Substance abuse disorders are common among those individuals with MDD [8], and the most serious outcome of depressive disorders is suicide, the psychiatric disorder most commonly linked with depression, with a 20 % greater risk of suicide in those with depression than in the general population. For example, two out of three individuals who complete suicide are depressed, whereas, approximately seven of 100 men and one of 100 women, who have been diagnosed with depression in their lifetime, will complete suicide [9].…”