A critical review of the use in New South Wales mental health services of the principles of psychiatric epidemiology to guide the setting of clinical priorities, resource allocation and outcomes evaluation

The development of mental health services in Australia and internationally is entering a new era. Due to landmark reports by the World Health Organisation (1996) and the Office of the Surgeon General of the United States, Dr David Satcher (1999) the area of mental illness has been given a much higher priority within health generally. In Australia the National Health Policy (1994) identified the area of mental illness as a national health priority but lamented the absence of epidemiological information to guide service planning and development. In New South Wales the report of the Chief Health Officer, Dr George Rubin (1996) highlighted the absence of even basic epidemiological data concerning the mental health of the community and called for a major effort to address this serious deficiency. It seemed to a large extent that mental health in sharp contrast to public health services generally had been shaped substantially by historical forces rather than scientific disciplines such as epidemiology. There had not even been a concerted effort to evaluate the rich reservoir of clinical and epidemiological information to be obtained from the hundreds of thousands of patients treated in public mental health services. While in classical epidemiological terms they may constitute the \u27tip of the iceberg\u27, they are the recipient of $400 million worth of services annually in New South Wales alone. The author is the longest serving Area Director of Mental Health Services in New South Wales and in 1996 was appointed as the New South Wales Health Department representative to the National Mental Health Information Modelling Project. This highlighted deficiencies, ambiguities and confusion in psychiatric nomenclature, taxonomies and service relationships. There were few ‘baselines\u27 to work from compared to the measurement systems in place in general health such as casemix and Diagnostic Related Groups. The author was encouraged by senior public servants to examine the reasons for this situation and to propose a model or overall framework to guide future clinical priority setting, resource allocation and outcomes evaluation in mental health services. The methodology of this thesis is based therefore on a systematic review of contemporary literature and emerging expert opinion. There has been unprecedented access to national and international authorities and documentation has been drawn from the following sources: *Commonwealth of Australia publications including planning and policy papers, independent reviews, published evaluations and critiques, Human Rights Commission reports. *New South Wales Health Department publications including policy documents, position papers, reports of expert working groups, annual reports, parliamentary reports, circulars, draft discussion papers, senior executive background and briefing papers. *a wide variety of Australian and international texts and journals on mental illness and epidemiology including the Comprehensive Textbook of Psychiatry which is generally regarded as authoritative. *university publications such as course notes for undergraduate and postgraduate epidemiology courses. *papers presented at international conferences on psychiatric epidemiology. The limitations of this research may be summarised as: *its restriction to broad planning and service development elements within the total mental health system. The aim is to postulate a credible overall framework for the future planning, development and evaluation of mental health services, guided to a large extent by Morris\u27 (1964) uses of epidemiology on an equivalent model. *elements such as mental health casemix, disability measurement and outcome evaluation are evolving and need to be incorporated into this wider model. *the argument for Morris\u27 uses of epidemiology is related in this review to treated prevalence rates as an example of how to better inform priority setting, resource allocation and outcomes evaluation at the national, state and most importantly the Area Health Service level through capturing critical epidemiological and clinical data from the large populations in treatment in public mental health service. *the area of prevention and early intervention is not addressed in detail. *the introductory chapter concerning the contributions of epidemiology to public health generally is limited due to the vast nature of this area and is simply meant to contextualise later chapters. The results of this research have significant implications for decision makers at all levels. Clearly while epidemiology is extant it has not been used to its full potential within mental health. There is an urgent requirement to draw together in a coherent fashion the full range of disparate endeavours currently being implemented within mental health services and benchmark them against Morris\u27 uses of epidemiology or an equivalent model. This will provide a framework to guide current and future action, establish priorities and facilitate evaluation. In effect such a model will fill the void that will undoubtedly be left following the passage of the transitional National Mental Health Plan, associated strategy and reforms. Planners, researchers, clinicians and administrators require a model in which they can believe and practically support and, above all, is sustainable. This critical review systematically describes the factors that have contributed to the development of mental health services, the complexities, associated reform process and most importantly a viable, credible model for future development. The recommendations at the conclusion of this thesis represent the preliminary steps required to ensure this occurs, and will be utilised by the Department of Health and hopefully Area Mental Health Services