Acquired brain injury needs to be acknowledged at the national mental health policy level

Acquired brain injury and mental illness

In this paper, we highlight the absence of acquired brain injury (ABI) in national mental health policy framework, and argue for its inclusion into policy and service provision for improved mental health outcomes. The National Policy on Services for People with ABI (Fortune and Wen, 1999) provides a broad definition of ABI, which involves injury to the brain that can occur as a result of trauma, hypoxia, infection, tumour, substance abuse, degenerative neurological disorders or stroke (Fortune and Wen, 1999). This definition, while representing a wide array of disorders, is accepted by the Victorian ABI service providers and state-wide ABI services. Having an ABI is strongly linked with dual or multiple disabilities, and mental illness is a particularly common co-morbidity (Anstey et al., 2004; Australian Institute of Health and Welfare, 2009; David et al., 2009).

The disorders under the umbrella term ABI are diverse, and differ in their underlying neuropathology, clinical manifestations and epidemiology, for instance with regard to traumatic brain injury, stroke versus neurodegenerative disorders. This diversity renders the link between ABI and mental illness complex, however, at a simplistic level, it can be stated that this link is not necessarily unidirectional. ABI can precede or exacerbate mental illness and vice versa; and the relationship between the two disorders can take various forms:

1. People with no prior psychiatric history can develop a psychiatric disorder following ABI, for instance new emerging psychosis following traumatic brain injury (David et al., 2009; Kim et al., 2007).

2. Pre-existing mental illness can become more severe, or change form following an ABI. For instance, a person with previous major depressive disorder can develop bipolar affective disorder following trauma to the brain (Kim et al., 2007).

3. Having a mental illness increases the risk of incurring ABI, such as increased traumatic brain injury risk in people with psychiatric disorders (Fann et al., 2002).

Evidence from epidemiological and clinical research certainly points towards a strong relationship between ABI/ mental illness co-morbidity and poor psychosocial outcomes (Australian Institute of Health and Welfare, 2009), and provides a basis for approaching ABI-mental illness as a core aspect of mental health service provision. For instance, traumatic brain injury (TBI) often results in long-lasting disability with cognitive, physical, behavioural and psychiatric dimensions (Ponsford et al., 1995). TBI is prevalent at population level, with Northern Finland and Christchurch New Zealand birth-cohort studies indicating 1.2% to 1.8% of annual incidence (McKinlay et al., 2008; Winqvist et al., 2007). Importantly, the risk of TBI increases markedly within certain groups, with 60.3% TBI prevalence rates noted in prisoners (Shiroma et al., 2010). Sustaining a TBI in childhood or adolescence is linked to a two-fold increased risk of developing mental disorders in adulthood (Timonen et al., 2002); at least one in five TBI patients display psychiatric symptoms even years after injury (Koponen et al., 2002). Further, mental illness is often complex, with co-morbid depression, anxiety, increased risk of suicidality and suicide attempts (Silver et al., 2001; Simpson and Tate, 2007). Thus, psychiatric and psychological input is a crucial part of both short-term and long-term care and rehabilitation.

The role of the mental health system

The complexity of dual diagnosis of ABI and mental illness necessitates policy and service provision that target and account for both disabilities. As such, mental health services have a central role in optimising care. In acute psychiatric settings, almost one in three inpatients have some form of ABI, at higher rates than observed in other illness groups (McGuire et al., 1998). The presence of ABI in patients with mental illness can create challenges for clinicians and mental health services. As highlighted in a recent summary paper (Brain Injury Australia, 2007), the presence of ABI is often poorly recognised, and ‘staff in many mental health services are unaware that a significant percentage of their clients may have an ABI; and even when ABI is detected, it may not be considered a relevant factor…’ (p. 7). Further, there are issues when ABI is identified. Anecdotally, when patients are referred to adult mental health intake, with for instance psychosis and early-onset dementia, it is not uncommon for them to be accepted very reluctantly, or sometimes to be refused on the grounds that some other kind of service would be ‘more appropriate’. On the other hand, older-age mental health services are better equipped and receptive to patients with dementia, the incidence of which increases with older age.

Despite the neurobiologically heterogeneous nature of ABI disorders, at a clinical level, there are common core skills required for clinicians to appropriately screen and manage ABI at service provision level; and coordinated services are needed that target age-, gender-, and at times, culture-specific groups for early intervention, for instance, younger adult men with TBI, who often present with aggression (Kim et al., 2007). Mental health services play a clear role for patients with ABI (Department of Human Services VIC, 2004b); this has strong implications for the skills and training of staff, for organisation of services, and for mental health service policy. Within this context, we examined key relevant documents to see to what extent and in what ways the ABI issue is addressed at national policy level.

ABI is not acknowledged by the national mental health policy documents

Australia is amongst the leading governments in the world, alongside the UK, the USA and New Zealand, in adopting a mental health policy with a shift toward community service provision (Judd, 2008). The Australian government endorsed its first mental health policy in 1992, with the most recent update being in 2008. The 2008 National Mental Health Policy (NMHP) forms an integral part of the National Mental Health Strategy (Australian Government, 2008); is endorsed by the Commonwealth, states and territories of Australia; and provides the basis for the Fourth National Mental Health Plan, for 2009–2014 (Australian Government, 2009b).

We examined the 2008 NMHP and the Fourth National Mental Health Plan, posing the question as to whether and how the ABI issue was acknowledged and incorporated. A careful reading of the policy document revealed that the NMHP did not refer to ABI or related concepts. A word search also showed the lack of any relevant terms (e.g. ABI, brain impairment, neurological, stroke), except for a possible implicit reference under other conditions: ‘…many mental illnesses are comorbid with drug and alcohol problems and other conditions’. Further, the Fourth National Mental Health Plan failed to incorporate the ABI service providers under its targeted partnerships. In contrast, the NMHP’s approach to another form of dual disability, i.e. substance abuse-mental illness, was more inclusive, with the policy acknowledging it as an important co-morbidity, targeting partnerships with alcohol and drug services, and aligning the policy with the Drug Strategy under the National Reform (Australian Government, 2008, 2009b).

Similarly, the revised 2010 National Standards for Mental Health Services (Australian Government, 2010) does not incorporate ABI, while acknowledging input from alcohol and other drug sectors. A word search indicates that dementia is acknowledged as a significant co-morbidity with mental illness, noting its prominence in aged care settings. Other ABI-relevant terms are not referred, while physical and intellectual disability is integrated. Further, the draft Ten Year Roadmap for National Mental Health Reform (Australian Government, 2012), which is a long-term national reform plan to guide action and investment over the next 10 years, again fails to incorporate ABI in its vision.

As a contrast, we examined the policy framework in Victoria via relevant 2001–10 Department of Human Services documents that historically led to development of state-wide dual-diagnosis mental health services. In 2001, the state government released its ABI Strategic Plan that led to the Multiple and Complex Needs Initiative (MACNI) in 2004 (Department of Human Services VIC, 2010), and the ABI and Mental Illness Issues Paper and Protocol (Department of Human Services VIC, 2004a, 2004b), which targeted multidisciplinary assessment and coordinated service planning for people with high-level multiple and complex needs including mental illness and ABI. The program has provided long-term services to a group of challenging and costly clients, and in 2009, it was revised under the updated Human Services (Complex Needs) Act 2009 (Department of Human Services VIC, 2009). Drawing on these activities, the Victorian government has recently integrated ABI into its 2009–2019 Victorian Mental Health Reform Strategy (Department of Human Services VIC, 2009).

In parallel, the 2004 ABI and Mental Illness Paper and Protocol reviewed the role of service providers, and in particular, outlined a clear role for mental health services in providing optimum care to this group. Under its area mental health service system, Victoria has also implemented two state-wide dual-diagnosis services for diagnostic, treatment and community rehabilitation of adults (Department of Human Services VIC, 2004b; Meadows and Singh, 2003): the Community Brain Disorders Assessment and Treatment Service and the Neuropsychiatry Unit. Further, there are a number of supporting ABI specialist services (e.g. ABI Behaviour Consultancy), programs (e.g. Slow to Recover program) and non-government organisations (e.g. Brain Injury Matters). Other organisations such as the Victorian Dual Disability Service (mental illness and intellectual disability) often manage ABI as another source of complexity.

While we have examined Victoria’s approach to ABI-mental illness, we note that other states and territories have also acknowledged the issue at varying degrees. For instance, under its 2007–2017 mental health plan (Queensland Government, 2008), the Queensland government stipulated that it would achieve strengthened local capacity to provide specialist mental health care to people with ABI by 2017. Similarly, the NSW government recently released a document on care and support pathways for people with ABI (NSW Government, 2011), and provided specific referral pathways for ABI patients with mental health issues.

Overall, while specific state and territory initiatives exist, the ABI issue is not acknowledged at the national policy and planning level, and there are no incentives for management of ABI within the mental health system, raising questions about the policy process. As a result, we argue that the approach to ABI management is fragmented at mental health service provision level, with poorly articulated assumptions about how services should operate. A number of barriers can be considered as to why the ABI issue is missing from the national mental health policy framework:

1. At the national level, ABI is not recognised as an issue in relation to mental health. The issue is simply neglected within the strong recent mental health debate, and at political, policy and service provision levels. Further, the ABI sector consists of a range of independent organisations, which focus on specific disorders (e.g. stroke, TBI, multiple sclerosis, dementia), each with its own set of disparate services, professionals and non-government organisations. However, the ABI and mental illness problem requires unified action by multiple service providers and agents.

2. While a recent AIHW disability report (Australian Institute of Health and Welfare, 2009) documents ABI and psychiatric disability co-morbidity rates, evidence is lacking on the effective service delivery means and needs (Department of Human Services VIC, 2004a). Limited evidence to inform policy and service provision hinders generation of policy solutions that are ‘publicly acceptable’ and ‘resonate with politicians’ (Buse et al., 2005).

3. Political will is another possible barrier, considering that the political context in which the 2008 NMHP was revised (Australian Government, 2009a, 2009c) left little scope for introducing ABI into the agenda. Nevertheless, points 1 and 2 above are major barriers beyond political will, as the platform for integrating ABI issue into national framework is not ripe.

Potential steps for moving ABI into the NMHP agenda

The lack of ABI within the national policy and service provision framework strongly implies that a number of targeted and converging strategies are required to incorporate the ABI issue into the national mental health agenda. Development, planning and implementation of strategies should ideally be theoretically driven (e.g. policy cycle, agenda setting), with room to identify and analyse gaps and barriers for policy development (Buse et al., 2005; Colebatch, 2009). An effective response requires national and state-wide mental health policies that acknowledge the ABI as an integral component of mental health provision; support and propose incentives to manage people with ABI and mental illness in the community; and implement internal clinical practice guidelines for detection and management of ABI in mental health services. To achieve these, upstream and downstream approaches are needed to incorporate ABI issues into (i) national mental health policy framework; (ii) state and territory mental health policies; and (iii) clinical mental health service provision (at minimum, clinical practice guidelines, and appropriate workforce training).

The first approach bears particular weight as the lack of recognition of ABI at the national level reflects on many aspects of health provision, ranging from budget to service planning and workforce training. At the upstream level, a forward-planning approach is required, and the ABI-mental illness co-morbidity issue should be recognised as a public matter. Service providers and academics should jointly implement strategies to raise the profile of ABI at state and territory levels. These strategies should utilise existing evidence on ABI and mental illness, and incorporate advocacy, non-government organisations to influence the federal government.

At service provision level, in both public and private sectors, ABI should be considered as an integral part of acute and community mental health provision. We note that, even within the successful Victorian model, the state-wide area mental health services still remain unequipped to manage psychiatric patients with ABI, in spite of the fact that they ‘are responsible for providing clear, relevant information and advice to clients, carers and/or services requesting assistance in respect of ABI and mental illness issues’ (Department of Human Services VIC, 2004b). Evidence-based clinical practice guidelines are needed to ensure appropriate screening of each ABI patient at service entry point, and to achieve successful management of ABI patients during service provision. Staff training is also crucial to optimally manage what are often complex and challenging clinical scenarios in mental health services.

Throughout these activities, a significant goal involves investment in evidence gathering (Kingdon, 1984) to bring the issue to the attention of policy-makers and politicians, to establish a basis that supports policy and systemic changes, and to demonstrate the public health importance of the problem. Such evidence gathering requires collaborative effort and a unified approach by diverse stakeholders including researchers, clinicians, service providers, ABI representatives and non-government organisations. A significant step in this respect would be a national inquiry into the place and management of ABI in mental health services across Australia. A further step would be a national web portal collating evidence that informs policy-makers on the ABI-mental illness issue. Finally, dissemination of evidence via mass media is crucial to inform the public and to generate public debate.

Conclusion

In brief, the limited profile of the ABI-mental illness issue at a national level, and its absence from the national mental health framework, contrasting with the more successful example in Victoria, indicate that strategies are needed that systematically target issues surrounding agenda setting. The absence of the ABI issue in the national policy framework hinders optimum care of this dual-diagnosis group, while downstream approaches are equally crucial, such as development of clinical practice guidelines for screening and management of ABI in mental health services. Targeting activities for elevating the ABI issue into the NMHP agenda, as discussed above, should involve a multilevel approach. The solutions to the issue should be developed by strategically addressing and targeting a balanced investment in a variety of converging strategies, including recognition of the problem at a national level via collaboration of multiple stakeholders, and development of a strong evidence base to inform policy solutions. Stakeholders with particular knowledge and interest in the issue, through a collaborated approach, can provide the leadership and visibility to generate the public interest required, and to create the essential local support and public demand. These steps are crucial to create a platform to incorporate ABI into the NMHP and relevant other policies at the national level that would provide the basis for improved service provision for this important form of co-morbidity and translate into positive public health outcomes.