2.4

3.5

5.3

Odds Ratios† Predictors Suicide AttemptsBOYS 13.5 years

† adjusted for family dysfunction, significance p<.001, except ** p<.01; * p<.05

SEXUALABUSE

ANTISOCIAL

SUICIDE RISK

DRUG ABUSE

HOPELESSNESS

DEPRESSION

20.6SUICIDE

ATTEMPT

5.4**

9.4

6.4

The changing face of mental health services

In the 80s

We dealt more withAnxiety DisordersDepressionDevelopmental problemsMinor behavioural problems

Drug induced psychosis and ADHD were rareBipolar Disorder & Asperger’s almost

unknown

In the new Millennium

Serious conduct disorder and delinquency (for which we have a limited skill set)

Self-harming behaviours (60% of our CYMHS referrals in a recent survey)

Drug induced psychosis (where we are fighting a losing battle)

A wide range of disorders which may have their origins in Poor Attachment and Social Exclusion (where social change is necessary, which may be outside our ambit)

In the new Millennium

Family Crises (more families seem unable to cope with normal developmental transitions)

Depression (which may itself have origins in Poor Attachment and Social Exclusion) seems to be at epidemic proportions, and is overwhelming our skill set, but….

Anxiety Disorders (for which we have a rich skill set) are now the hidden calamity (particularly Social Phobia)

Antidepressant Use 1995 (Number)

MALE FEMALE

0-14 15-24 0-14 15-24

Amitryptiline 1727

Dothiepin 2198 724

Doxepin 199 41 178

Fluoxetine 852 63 2134

Other 27,292 4083 4940 2845

Total 27,491 7,134 5044 7417

ABS, 1999

Medication Use (18-34 yrs)NHS Survey 2005

704,200 used psychotropics 41,548 (5.9%) Citalopram 25,351 (3.6%) Paroxetine 51,407 (7.3%) Sertraline 11,972 (1.7%) Other SSRI 20,422 (2.9%) Venlafaxine 12,676 (1.8%) Tricyclics 12,676 (1.8%) Other Antidepressant 10.1% Anxiolytics 83.5% other including 69.2% Vitamins and

MineralsTable 15, page 36 Ausstats 2005

= 18.5% Total SSRIs= 18.5% Total SSRIs

Western Australian Child Health Survey:

Children with Mental Health* Problems Number (‘000) Per

centMales 30.0 20.0Females 23.5 15.4

4 to 11 year olds 30.8 16.012 to 16 year olds 22.7 20.6

All children 53.5 17.7* as determined by caregiver and teacher using the Child Behavioural Checklist

Zubrick et al 1995

Mental & Behavioural Problems, 2005

0-14 Rate % 15-24 Rate %

Alcohol/Drug np 19,000 0.71

Mood DisordersMood Disorders 30,300 0.77 144,600 5.4

AnxietyAnxiety 89,700 2.3 123,600 4.6

Psychol Devel 100,600 2.57 60,800 2.26

Behavioural 116,300 2.97 34,700 1.29

Other 19,400 0.49 21,000 0.78

Symptoms/Signs 8,300 0.21 7,600 0.28

Total 263,000 6.71 267,800 9.94

Population Total 3,920,600 2,693,000

My own experience

A PERSONAL CONTEXTLondon 1968-9

Analytic psychotherapy (Irving Kreeger, Gordon Stuart Prince)

Hypnosis (Marcuse) Behaviour Therapy (Marks and Gelder)

Canterbury 1970-74 Child Psychotherapy (Ken Munro Fraser) Structural Family Therapy (Minuchin) 25 bed inpatient Unit

A PERSONAL CONTEXT

Adelaide 1974-82 (Children’s Hospital) Infant Observation Child and Adolescent Psychotherapy Transactional Analysis (Berne) Gestalt therapy Group therapy Strategic Family Therapy (Gerard, Epstein,

Haley) Systemic Family Therapy (Palazzoli et al) Narrative Therapy (White, Epston)

A PERSONAL CONTEXT

Private Practice 1982-86 Expert Family Therapy group 2 years

Flinders Medical Centre 1986-2001 Cognitive Behavioural Therapy Individual Therapy Family Therapy (Screens and Teams) Solution Focussed Therapy (de Shazer

and Insoo Kim Berg 1990)

A Note about Private Practice

Solid Clinical Work10-12 hours per day, on the hour every

hour600 new cases in 4 years - ie about 3

new cases per weekSome school visitsSome supervision and Teaching of

registrarsArt classes one afternoon a week to

preserve sanity

If you want effectiveness and efficiency in a service, there is no substitute for highly skilled, well supervised, experienced

clinicians.

Clinical Work

Central to what we doYet we can never be quite certain what

goes on in the consulting roomNo measures, no online reporting, no

audio can really tell you what goes onCurrent administrative attempts to find

out are self serving and overwhelm the clinical process

The best Risk Management is to have good clinicians

On Entry to Clinical Service

2 week full time Orientation Program16 week twice a week therapy training

program in houseOption for lengthy training and

supervision with expert therapists (eg Malcolm Robinson or Michael White for CAMHS in South Australia) with service sharing the cost and the time cost.

Clear Clinical Expectations

1-2 new cases a week ie 70-75 per annum on average

(range 50-100) For 30 therapists in a service you

could manage about 2200 new cases10± clinical follow-ups a week

ie about 500 follow-up per annum For 30 therapists about 15,000 slots

per annum

Therapist Burnout

Too little trainingToo little supervisionToo little varietyToo many casesToo much paperwork

Important to provide enrichment - special project development, teaching, evaluation, research, publication

Issues

You must have staff who have energy to reach out

You must avoid the ‘Exclusive Service’ mentality: “we exclude everyone who does not

meet DSM4 criteria”

Every minute you take away from a clinician doing best quality clinical work wrecks

any attempt to provide efficiency.

Sustainable Service Development South

Australia Southern CAMHS (Flinders Medical Centre - 15 years) 2 teams to 6 teams No rural service, to 3 rural teams 12 therapists to 40 therapists No teaching, to Masters level programs No research, to 22 programs including two

longitudinal programs CHASP Accreditation 1994 (the first CAMHS

ever) Gold Award THEMHS 1994

Clinical Work 1985

Systematised interviewing (Eisen & Irwin)

4 sessions of assessment with an initial interview with the family, then two interviews with the child, then a family feedback session.

The problem was that the mean number of sessions attended was only 3, with a mode of 1.

Clinical Work 1995

We reviewed 200 clients to see what had happened to them.

50% had ‘got what they wanted’20% felt the service had little to

offer their problem

Clinical Work 2008Initial Consult System

Single sessionAsked the patients what they wanted to

achieve by the end of the sessionListed their problems and ranked themDiscussed alternatives for change in the

most pressing problemsPsychoeducational approachChecked at the end of the session to

see whether they had got what they wanted

Window Shopping is OK!

Registration as a Case

Genuine issue hereDo you register at the first session

- even if they are never going to come back?

Or do you wait until they commit to some specific course of therapy

Sustainable Service Development Queensland

(2001- ) RCH & District CYMHS Since 2001, Service to BYDC CYFOS Development MHATODS Team Therapy supervision ++ Reworking of CL Team and after hours service EI Strategy - KOPING strategy Recent ACHS Accreditation, exceeding most

standards Publications (35 per annum - only 7-10 mine) Silver THEMHS award 2006

RCH & Brisbane North CYMHS

We monitor clinical and other activity, and provide feedback to staff on a regular basis through team leaders

We are meeting ALL of the criteria in the National Workforce Standards documents