Abstract
Overview:
• Clinically significant mental health problems are common in New Zealand. Many people, particularly those with mild to moderate conditions, are first seen in primary health care and general practice settings.
• The Primary Mental Health Initiatives (PMHIs) represent a significant investment in primary care service delivery and infrastructure. The initiatives were delivered within a timeframe requiring a rapid evolution of service development, and were sustained over a two-year period.
• A range of service delivery models was developed, offering choice to both service users and practitioners. All services were offered at no charge to services users. Every model contained some elements specific to local need.
• The PMHIs were perceived as being efficient and responsive to consumer need, and were judged a success by both practitioners and service users.
• It is unlikely that any single model could be universally applied as none contained all successful elements of an optimal model.
• No service delivery model offered an inherently superior value for money, or an inherently more cost-effective service compared to others.
• The PMHIs provided services to address the needs of service users with a wide range of symptoms and problems. The ability to address undifferentiated and sub-threshold symptom complexes, as well as well-defined conditions such as depression and anxiety, was welcomed by service users.
• Up to 80% of service users benefited from the variety of interventions offered.
• Although common, mental health disorders such as anxiety and depression are complex and it is not surprising that 20% of service users did not improve. Spontaneous remission (getting better without any treatment) is also relatively common. Several studies suggest that it would be reasonable to expect anywhere between 30 and 50% of patients to improve under ‘care as usual’ conditions and fewer under ‘no treatment’ conditions. The 80% improvement rate therefore represents a significant and beneficial treatment effect, which was generally sustained at six months in those for whom data were available.
• Service users expressed satisfaction with the care given by the initiatives.
• Mental health needs arising from mild to moderate common mental health conditions, including those involving social complexity, can be addressed by primary care. Did PMHIs reach different population groups?
• Targeting of services to high-needs populations was a challenge for many PMHIs. Well- defined criteria for determining clinical eligibility for care are important.
• Services for Māori included both kaupapa Māori and mainstream service options, and having both options available was perceived as optimal by Māori. Evaluation of the Primary Mental Health Initiatives: Summary Report ix
• The initiatives provided access to Māori in excess to their proportion in the enrolled population. However, given the higher prevalence of some common mental health conditions among Māori, it is likely there was still some under-utilisation of services by Māori.
• There was under-utilisation by Pacific peoples and significant under-utilisation by Asian people in the PMHIs.
• The mental health needs of children and young people overall were not sufficiently met by the PMHIs, and over half did not offer services to this group.
• Few PMHIs offered services to service users over 65 years of age. Workforce
• The success of the PMHIs was based in part on the investment made in dedicated staff positions such as mental health co-ordinators and mental health nurses. These staff require appropriate administrative support, and need a framework for professional development and supervision.
• The PMHIs are an example of effective interdisciplinary team work. In the majority of initiatives, care was provided by more than one discipline. The involvement of practice nurses was not always facilitated.
• There is currently no optimally structured training or education programme for primary mental health care that includes all disciplines.
Infrastructure and methodologies:
• The majority of initiatives made relatively little use of advanced information technology (IT) platforms for administrative and clinical management, or for structured clinical decision support.
• The use of clinical outcome measures was encouraged, both to support the evaluation and as a clinical tool. Further use of assessment and diagnostic tools would mean a significant change in primary mental health care practice.
• A wide range of psychological counselling and therapy approaches was used. There is a need to understand which elements of these interventions contribute to successful management.
Further work:
• Further work is required to define an optimal balance between psychological and pharmacological therapies within primary mental health care.
• Further work is also required to define appropriate and acceptable funding systems to resolve issues of health needs, equity and ability to pay.
• Future development in primary mental health should clarify the appropriate contribution, in terms of funding and co-ordination, from the Ministry of Health and District Health Boards, and should attempt to achieve a degree of equity and consistency in overall service provision.