Mental Health Review Paper 2018 Part A

Primary Author: Sophie Allen – Inner East Primary Care Partnership
Academic Review: Dr Melissa Petrakis - Lecturer and Coordinator Health and Mental Health Unit, Faculty of Medicine Nursing and Health Science, Monash University

Severe and persistent mental illness is a concept distinct and separate from mental wellbeing. There are similarities and boundaries between the two.

A mental illness is ‘a clinically recognisable set of symptoms or behaviours associated with distress and with interference with personal functions’. (ABS, 2009) The symptoms of mental illness differ between people but usually comprise some combination of abnormal thoughts, emotions, behaviour and relationships with others. Mental disorders are more than variations within the normal range, but are clearly abnormal or pathological. They are sustained or recurring, and result in some personal distress or impaired functioning in at least one area of life. (WHO, 2001)

The Severe and Persistent Mental Illness portal does not cover organic disorders such as dementia, Alzheimer disease, acquired brain injury, disease or dysfunction, or autism; or behavioural disorders such as anorexia nervosa. However, it is not always possible to isolate those illnesses within some the data that is available and will affect some of the statistics at times.

The following definitions of severe and persistent mental illnesses come from both the World Health Organisation’s International Statistical Classification of Diseases and Related Health Problems 10th Revision and the American Psychiatric Association’s DSM-5. (WHO, 2010) (APA, 2013)

Schizophrenia Spectrum disorders (F20-F29 DSM)

Schizophrenia typically begins in late adolescence/early adulthood (though onset tends to be later in women). Behaviour can be seriously disturbed during some phases, leading to adverse social consequences. (WHO, 2001) The most important psychopathological phenomena include thought echo; thought insertion or withdrawal; thought broadcasting; delusional perception and delusions of control; influence or passivity; hallucinatory voices commenting or discussion the patient in the third person; thought disorders and negative symptoms.

Schizophrenia spectrum disorders can be continuous, or episodic, or there can be one or more episodes with complete or incomplete remission. Complete symptomatic and social recovery occurs in about half of all cases with drug therapy and psychosocial care. (WHO, 2001)

Mood Affective Disorders (F30-F39 DSM)

Mood disorders affect 6.2% of Australians (7.1% of women and 5.3% of men). (ABS, 2009) They include: bipolar disorder and depressive disorders (major depressive disorder, persistent mood affective, or depressive, disorders).

Anxiety disorders (F40-F49, F90-98 DSM)

Anxiety disorders generally have symptoms which include pounding heart, sweating, trembling, shaking and having difficulty breathing. In Australia, anxiety disorders are the most common mental disorder, affecting 14% of all people, though not always at a severe and persistent level. (ABS, 2009) Anxiety disorders include: phobic anxiety disorder, agoraphobia, panic disorder, generalized anxiety disorder, obsessive compulsive disorder.

Trauma and stressor-related disorders (F40-F49 DSM)

Trauma and stressor-related disorders are thought to arise as a direct consequence of acute severe stress or continued trauma. They interfere with successful coping mechanisms and therefore lead to problems of social functioning, for example, post-traumatic stress disorder, and adjustment disorders.

Somatoform Disorders (F40-F49 DSM)

Presentation of physical symptoms which produce distress, discomfort and pain, despite no evidence of organic disturbance or dysfunction. The symptoms are real and not under the control of the client but are representative of unconscious conflict. The course of the disorder is chronic and fluctuating and is often associated with disruption of social, interpersonal, and family behaviour.

Conduct Disorders (F60-F69, F90-98 DSM)

Disorders characterized by a repetitive and persistent pattern of dissocial, aggressive, or defiant conduct, in which the rights of others or major age-appropriate societal norms or rules are violated. Examples include: aggression to people and animals; destruction of property; deceitfulness or theft; serious violations of rules.

Personality Disorders (F60-F69, F20-29 DSM)

A variety of conditions and behaviour patterns of clinical significance which tend to be persistent and appear to be the expression of the individual’s characteristic lifestyle. They represent extreme or significant deviations from the way in which the average individual in a given culture perceives, thinks, feels and, particularly, relates to others. Examples include; paranoid personality disorder, schizoid personality disorder and schizotypal (personality) disorder, and borderline personality disorder (the most common of personality disorders).

Definitions

Disability (mental illness), in relation to a person, means:

• total or partial loss of the person’s bodily or mental functions; or
• a disorder or malfunction that results in the person learning differently from a person without the disorder or malfunction; or
• a disorder, illness or disease that affects a person’ thought processes, perception of reality, emotions or judgment or that results in disturbed behaviour;

and includes a disability that:

• presently exists; or
• previously existed but no longer exists: or
• may exist in the future; or
• is imputed to a person.

To avoid doubt, a disability that is otherwise covered by this definition includes behaviour that is a symptom or manifestation of the disability. (CTH, 1992)

Mental Health: a state of emotional and social wellbeing. It influences how individual’s cope with normal stresses of life, and whether they can achieve their potential. (ABS, 2008)

Mental health problem: Diminished cognitive, emotional or social abilities but not to the extent that the criteria for a mental illness are met. (CTH, 2009)

Mental Illness: a clinically diagnosable disorder that significantly interferes with an individual’s cognitive, emotional or social abilities. It includes short and long term conditions. (ABS, 2008)

Mental illness: A clinically diagnosable disorder that significantly interferes with an individual’s cognitive, emotional or social abilities. The diagnosis of mental illness is generally made according to the classification systems of the Diagnostic and Statistical Manual of Mental Disorders (DSM) or the International Classification of Diseases (ICD). (CTH, 2009)

Personal Recovery: Being able to create and live a meaningful and contributing life in a community of choice with or without the presence of mental health issues. (CTH, 2013)

Psychosocial Disability: relates to the ‘social consequences of disability’ – the effects on someone’s ability to participate fully in life as a result of mental ill-health. Those affected are prevented from engaging in opportunities such as education, training, cultural activities, and achieving their goals and aspirations. Not everyone with a mental illness will have a level of impairment that will result in a psychosocial disability. (MHCA, 2014)

Psychotic disorders: (A) diverse group of illnesses that have their origins in abnormal brain function and are characterised by fundamental distortions of thinking, perception and emotional response… The two main symptoms are delusions and hallucinations. (CTH, 2011)

Recovery: A personal process of changing one’s attitudes, values, feelings, goals, skills and/or roles. It involves the development of new meaning and purpose and a satisfying, hopeful and contributing life as the person grows beyond the effects of psychiatric disability. The process of recovery must be supported by individually-identified essential services and resources. (CTH, 2009)

Recovery-oriented mental health practice: the application of sets of capabilities that support people to recognise and take responsibility for their own recovery and wellbeing and to define their goals, wishes and aspirations. (CTH, 2013)

Recovery-oriented practice encapsulates mental health care that:

• Recognises and embraces the possibilities for recovery and wellbeing created by the inherent strength and capacity of all people experiencing mental health issues;
• Maximises self-determination and self-management of mental health and wellbeing;
• Assists families to understand the challenges and opportunities arising from their family member’s experiences. (CTH, 2013)

Social and emotional well-being: an holistic Aboriginal definition of health that includes: mental health; emotional, psychological and spiritual well-being; and issues impacting specifically on well-being in Aboriginal and Torres Strait Islander communities such as grief, suicide and self-harm, loss and trauma. (CTH, 2009)

Scope for Action

There are similarities and boundaries between the concepts of mental health promotion and mental illness prevention. They are distinct, yet interrelated. (WHO, 2004) (Davis, 2014)

Mental Health Promotion

Mental health promotion usually refers to the promotion of positive mental health in people who are not at risk, people who are at an increased risk, and people who are currently experiencing mental health problems. It focuses on the individual, social and environmental conditions that enable optimal psychological performance.

Mental Illness Prevention

Mental illness prevention focuses on mental health disorders of either a temporary or a permanent nature. Interventions work to reduce risk factors and to enhance protective factors in order to reduce the incidence, prevalence, or recurrence of mental illness symptoms and to decrease the impact of that illness on the affected person, their families and their communities. (WHO, 2004)

Strategic & Legislative Context

International Policy

United Nations Convention on the Rights of Persons with Disabilities

The purpose of the UN Convention on the Rights of Persons with Disabilities is to ‘promote, protect and ensure the full and equal enjoyment of all human rights and fundamental freedoms by all persons with disabilities, and to promote respect for their inherent dignity.’

A person with a disability is defined to include people who have long-term physical, mental, intellectual or sensory impairments which in interaction with various barriers may hinder their full and effective participation in society on an equal basis with others.’ (UN, 2006)

See also World Health Organization Mental Health Action Plan 2013-2020.

National Policy

The Roadmap for National Mental Health Reform 2012-2022

The Roadmap underpins the National and State government mental health strategies, policies, plans and frameworks. It confirms a national commitment to ongoing mental health reform.

There are six priorities recognized:

• Promoting person-centred approaches
• Improving the mental health and social and emotional wellbeing of all Australians
• Preventing mental illness
• Focusing on early detection and intervention
• Improving access to high quality services and supports
• Improving the social and economic participation of people with mental illness. (COAG , 2012)

National Mental Health Strategy

The Strategy is the framework which guides mental health reform in Australia. It aims to:

• Promote the mental health of the Australian community
• Prevent the development of mental disorder where possible
• Reduce the impact of mental disorder on individuals, families and communities
• Assure the rights of people with mental illness. (DH, 2014)

Recovery-oriented Framework

The Strategy outlines the recovery-oriented framework for practice, culture and service delivery in mental health service provision. Recovery oriented approaches focus on the needs of the people who use services and challenges traditional notions of professional power and expertise. It reflects a respect for the experience, expertise and strength that all people, including service users, can contribute to the treatment of mental health issues. Central to the concept of recovery are hope, self-determination, self-management, empowerment, advocacy, inclusion and freedom from stigma and discrimination. (CTH, 2013)

Terminology

The language of recovery is essential to the National Mental Health Strategy to combat discrimination and disempowerment. The following descriptors are used throughout the Strategy:

• ‘person’, ‘people with lived experience’, ‘lived expertise’ and ‘experts by experience’ rather than ‘clients’, ‘service users’ or ‘patients’.
• ‘family and support people’ includes family members, partners, friends or anyone whose primary relationship with the person concerned is a personal, supportive and caring one.
• ‘mental health issues’, ‘challenges’ and ‘emotional distress’ are used in place of, and at times alongside, the term ‘mental illness’. (CTH, 2013)

The Strategy incorporates a National Mental Health Policy 2008, and a National Mental Health Plan (2009-2014).

National Mental Health Policy 2008

The National Mental Health Policy sets the broad agenda for efforts in mental health reform and is implemented via national plans and other developments in individual jurisdictions. (CTH, 2009)

The aims of the policy are to:

• Promote mental health and well-being and, where possible, prevent the development of mental health problems and illness
• Reduce the impact of mental health problems and illness
• Promote recovery
• Assure the rights of people with mental health problems and illness, and enable them to participate meaningfully in society. (CTH, 2009)

Fourth National Mental Health Plan (2009-2014)

The Fourth National Mental Health Plan priority areas and planned outcomes are:

• Social Inclusion and Recovery (community understanding, improved social outcomes, coordinated care)
• Prevention and Early Intervention (improved understanding and support, improved help seeking, recognition of co-morbidities)
• Service Access, Coordination and Continuity of Care (improved access to care, effective and efficient use of services)
• Quality Improvement and Innovation
• Accountability. (CTH, 2009)

E-Mental Health Strategy for Australia

Three key areas for action are:

1. Improving Access and Services (establishment of an E-mental health portal, the Virtual Clinic, and other online mental health support services)
2. E-Mental Health Support Service (an E-mental health support service for clinician support)
3. Promotion and Evaluation of the new E-Mental Health Service Environment. (DHA, 2012)

National Carer Strategy

The National Carer Strategy gives effect to the principles of the Carer Recognition Act 2010. The vision of the policy is that ‘carers in Australia are valued and respected by society. They have rights, choices, opportunities and capabilities to participate in economic, social and community life’.

A carer includes family members, friends, relatives, siblings, foster carers, grandparents or neighbours, regardless of the amount of care, support and assistance they provide. (CTH, 2011)

National Disability Strategy 2010-2020

The National Disability Strategy (NDS) adopts the principles of the rights of people with a disability set out in the UN Convention on the Rights of People with a Disability.

There are six policy areas covered by the NDS:

1. Inclusive and Accessible Communities (people with disability live in accessible and well designed communities with opportunity for full inclusion in social, economic, sporting and cultural life.)
2. Rights Protection, Justice and Legislation (people with disability have their rights promoted, upheld and protected.)
3. Economic Security (people with disability, their families and carers have economic security, enabling them to plan for the future and exercise choice and control over their lives.)
4. Personal and Community Support (people with disability, their families and carers have access to a range of supports to assist them to live independently and actively engage in their communities.)
5. Learning and Skills (people with disability achieve their full potential through their participation in an inclusive high quality education system that is responsive to their needs. People with disability have opportunities to continue learning throughout their lives.)
6. Health and Wellbeing (people with disability attain highest possible health and wellbeing outcomes throughout their lives). (CTH, 2011)

Other Policies

• National Aboriginal and Torres Strait Islander Suicide Prevention Strategy 2013
• National Standards for Mental Health Services
• Disability and carers policy and research publications from the Department of Social Services
• National Aboriginal and Torres Strait Islander Health Plan 2013-2023

National Legislation

National Disability Insurance Scheme Act 2013 (CTH, 2013)

Under the NDIS, any person under the age of 65 who acquires a permanent (or likely to be permanent) disability that substantially reduces their functional capacity, will be eligible for funding of support services based on their individual needs. People with a significant and enduring psychiatric disability are included in the NDIS. To meet the access criteria for the NDIS under the Act, the prospective participant must meet certain disability and early intervention requirements.

The NDIS is a three tiered system:

• Tier 3 provides the highest level of support for participants who are eligible under the NDIS criteria. Tier 2 support provides for Local Area Coordinators who will link people who need some support to mainstream services and community supports.
• Tier 2 is called ‘Information, Linkages and Capacity Building’. Tier 2 will be developed to build the capacity of the community, people with disability, their families and carers, and greater community inclusion in order to reduce demand for and level of support required from individually funded responses. (CTH, 2015)
• Tier 1 is to build community awareness of disability issues.

Disability Requirements for the NDIS

A person will meet the disability requirements under the Act if:

• The person has a disability that is attributable to one or more intellectual, cognitive, neurological, sensory or physical impairments or to one or more impairments attributable to a psychiatric condition; and
• The impairment or impairments are, or are likely to be, permanent; and
• The impairment or impairments result in substantially reduced functional capacity to undertake, or psychosocial functioning in undertaking, one or more of the following activities:
• Communication;
• Social interaction;
• Learning;
• Mobility;
• Self-care;
• Self-management; and
• The impairment or impairments affect the person’s capacity for social and economic participation; and
• The person is likely to require support under the National Disability Insurance Scheme for the person’s lifetime.

Early Intervention Requirements for the NDIS

A person will meet the early intervention requirements under the Act if:

The person:

• Has one or more identified intellectual, cognitive, neurological, sensory or physical impairments that are, or are likely to be, permanent: or
• Has one or more identified impairments that are attributable to a psychiatric condition and are, or are likely to be, permanent; or
• Is a child who has developmental delay; and

The CEO is satisfied that provision of early intervention supports for the person is likely to benefit the person by reducing the person’s future needs for supports in relation to disability; and

The CEO is satisfied that provision of early intervention supports for the person is likely to benefit the person by:

• Mitigating or alleviating the impact of the person’s impairment upon the functional capacity of the person to undertake communication, social interaction, learning, mobility, self-care or self-management; or
• Preventing the deterioration of such functional capacity; or
• Improving such functional capacity; or
• Strengthening the sustainability of informal supports available to the person, including through building the capacity of the person’s carer.

The NDIS and Mental Illness

Participants in the NDIS with a psychiatric condition who have significant and permanent functional impairment will have support needs from both the NDIS and the health and mental health system. The NDIS is designed to address the functional impact of the psychiatric condition, not to provide activities designed to alleviate psychiatric conditions. (CTH, 2014) A person living with mental illness may be eligible for the NDIS if that permanent impairment substantially reduces their ability to undertake one or more of the following:

• Communication
• Social interaction
• Learning
• Mobility
• Self-care
• Self-management
• Social and economic participation. (MIFV, 2011)

People who are deemed ineligible to receive Tier 3 support under the NDIS, but who are showing signs of having a psychiatric condition will be assisted under Tier 2 to be referred to mainstream health and mental health services responsible for diagnosis and treatment. The Scheme will not cover any out of pocket costs resulting from access to these services.

Tension between the NDIS and mental health services

Many concerns have been expressed regarding the tension between the NDIS and mental health service and support, including:

• The NDIS has been shaped by the specialist disability sector and does not fully serve the needs of the mental health sector. The definitions of impairment and permanence under the Act are problematic when applied to mental health and recovery.
• The requirement for ‘permanent’ impairment is juxtaposed with the recovery model proposed by Australian mental health policy and the Victorian Mental Health Act.
• Many people with persistent and severe mental health problems do not view themselves as ‘disabled’.
• The Australian Federal and State governments have agreed that funding from their existing mental health programs will be included in the NDIS funding pool.
• NDIS may not be flexible enough to respond to the fluctuating support needs of people who have a mental illness of an episodic nature. People who experience mental illness may not meet the criteria for support under the NDIS because they are not deemed to have a permanent impairment.
• There are many challenges in predicting permanent impairment for mental illness, so early intervention support may be difficult to access.
• Tier 2 supports need to be developed immediately and mapping of current programs and services for people with psychosocial disability need to be mapped in each State and Territory.
• NDIS supports are predominantly compensatory and do not involve the psychosocial rehabilitative approaches designed to remediate impairment and build capacity.
• Support for carers appears to be limited to training in parenting skills or managing behaviours of concern. Carer support programs will be limited, with only a proportion of carer support funding remaining outside of the NDIS. (Williams & G, 2014) (Meldrum, n.d.) (MHCA, 2014) (MHCA, 2014)

Key Definitions in the NDIS Act

Permanent Impairment

An impairment that varies in intensity (such as an impairment of chronic episodic nature) may be considered permanent.

An impairment is, or is likely to be, permanent only if there are no known, available and appropriate evidence-based clinical, medical or other treatments that would be likely to remedy the impairment.

An impairment may be permanent even if the severity of its impact on the functional capacity of the person may fluctuate or there are prospects that the severity of the impact of the impairment on the person’s functional capacity, including their psychosocial functioning, may improve. (CTH, 2013)

Substantially Reduced Functional Capacity

An impairment results in substantially reduced functional capacity of a person to undertake one or more of the relevant activities if its result is that:

• The person is unable to participate effectively or completely in the activity, or to perform tasks or actions required to undertake or participate effectively or completely in the activity, without assistive technology, equipment (other than commonly used items such as glasses) or home modifications; or
• The person usually requires assistance (including physical assistance, guidance, supervision or prompting) from other people to participate in the activity or to perform tasks or actions required to undertake or participate in the activity; or
• The person is unable to participate in the activity or to perform tasks or actions required to undertake or participate in the activity, even with assistive technology, equipment, home modifications or assistance from another person. (CTH, 2013)

Early Intervention Benefit to the Participant

The evidence for benefit that must be considered is:

• The likely trajectory and impact of the person’s impairment over time; and
• The potential benefits of early intervention on the impact of the impairment on the person’s functional capacity and in reducing their future needs for supports; and
• Evidence from a range of sources, such as information provided by the person with disability or their family members or carers. The CEO may also in some cases seek expert opinion. (CTH, 2013)

Reasonable and Necessary Supports

In relation to mental health, the NDIS will fund the following reasonable and necessary supports:

• Assistance to coordinate supports and assistance with daily personal activities (community reintegration and day to day living including assistance with planning, decision-making, personal hygiene, household tasks, social relationships and financial management);
• Development of daily living and life skills (to increase the participant’s ability to live as autonomously as possible including skills in daily life activities, communication and social skills, problem solving and managing funding of supports);
• Assistance with accommodation and tenancy obligations (to guide, prompt, or undertake activities to ensure the participant obtains/retains appropriate accommodation, including specialist tenancy support services where no other tenancy support option is available);
• Assistance with daily life tasks in a group or shared living arrangement (non-clinical) – where residential accommodation is provided as an integral part of non-clinical care);
• Assistance with transport (specialist transport to and from health appointments required as a result of a participant’s disability (where no other transport option is appropriate and not substituting for parental responsibility). (CTH, 2013)

The NDIS will generally not fund:

• Diagnosis of psychiatric conditions;
• Clinical treatment;
• Early interventions related to mental health;
• Residential care (clinical) where the primary purpose is for inpatient treatment or clinical rehabilitation;
• Mental health crisis services. (CTH, 2014)

Carers and the NDIS

One of the general guiding principles of the NDIS Act is that ‘the role of families, carers and other significant persons in the lives of people with disability is to be acknowledged and respected’. (CTH, 2013)

Under the guidelines to the Act, while the participant is the central focus of the plan, the consideration of ‘informal supports’ must take account the carer’s circumstances, capacity and future plans. (CTH, 2014)

The following matters will be considered in determining what it is reasonable to expect families, carers, informal networks and the community to provide:

• The extent of any risks to the wellbeing of the participant arising from the participant’s reliance on the support of family members, carers, informal networks and the community; and
• The suitability of family members, carers, informal networks and the community to provide the supports that the participant requires, including such factors as:
• The age and capacity of the participant’s family members and carers, including the extent to which family and community supports are available to sustain them in their caring role; and
• The intensity and type of support that is required and whether it is age and gender appropriate for a particular family member or carer to be providing that care; and
• The extent of any risks to the long term wellbeing of any of the family members or carers (eg a child should not be expected to provide care for their parents, siblings or other relatives or be required to limit their educational opportunities); and
• The extent to which informal supports contribute to or reduce a participant’s level of independence and other outcomes.

Other considerations come into play if the person with the disability is a child. (CTH, 2013)

Carer Recognition Act 2010 (Cth)

The object of the Carer Recognition Act is to ‘increase recognition and awareness of carers and to acknowledge the valuable contribution they make to society’. (CTH, 2010)

A carer is someone who provides ‘personal care, support and assistance to another individual who needs it because that other individual:

• Has a disability; or
• Has a medical condition (including a terminal or chronic illness); or
• Has a mental illness; or
• Is frail and aged.’

Under this Act, ‘carer’ does not mean those caring for people under a contract for services, while doing voluntary work for an organisation, or as part of a training course. Nor is an individual a ‘carer’ simply because they are a partner, parent, child, relative or guardian, or lives with an individual who requires care. (CTH, 2010)

The Act includes a Statement for Australia’s Carers.

Victorian Policy

Victorian Mental Health Reform Strategy 2009-2019 Because Health Matters

Reforms are based on the elements of prevention, early intervention, recovery and social inclusion.

There are eight reform areas:

1. Promoting mental health and wellbeing – preventing mental health problems by addressing risk and protective factors.
2. Early in life – helping children, adolescents, and young people (0-25 years) and their families
3. Pathways to care – streamlining service access and emergency responses
4. Specialist care – meeting the needs of adults and older people with moderate to severe mental illness
5. Support in the community – building the foundations for recovery and participation in community life
6. Reducing inequalities – responding better to vulnerable people
7. Workforce and innovation – improving capacity, skills, leadership and knowledge
8. Partnership and accountability – strengthening planning, governance and shared responsibility for outcomes. (DHS, 2009)

Victorian Public Health and Wellbeing Plan 2015-2019

The plan includes promoting mental health. (VIC, 2015)

Other Policies

• The Melbourne Charter for Promoting Mental Health and Preventing Mental and Behavioural Disorders
• Koolin Balit: Victorian Government strategic directions for Aboriginal health 2012-2022
• Koolin Balit State-wide Action Plan: 2013-2015
• Victoria’s Priorities for Mental Health Reform 2013-2015
• VicHealth Action Agenda for Health Promotion
• VicHealth: Improving Aboriginal health and wellbeing local government action guide no. 2
• The Victorian Refugee and Asylum Seeker Health Action Plan 2014-2018

Victorian Legislation

Mental Health Act 2014 (Vic)

Mental health legislation provides for the assessment, detention and compulsory treatment of people with severe mental illness. (DoH, 2014) In Victoria the Mental Health Act 2014 (Vic) replaced the Mental Health Act 1986 and represents a major reform of mental health legislation by putting people with a mental illness at the centre of decision-making about their treatment, care and recovery. It also recognises the family and carers of those people. (DoH, 2014)

Mental health service providers must have regard for the twelve ‘mental health principles’ included in Section 11 of the Act. (Vic, 2014) They are in resources:

Recovery-oriented Framework and Supported Decision Making

The major reforms under the legislation in this regard include:

• A presumption of capacity – all people are presumed to be able to make treatment decisions. They should be provided with information and support to make these decisions. The Act includes a capacity test and principles to assist determination of whether they can or cannot give informed consent to treatment, and where they are deemed to be unable to consent, they must be supported to be involved in the decision-making process to the greatest extent possible.
• A right for patients to seek a second psychiatric opinion at any time about their treatment and whether the treatment criteria still apply to the patient. The intention is to empower patients to make decisions or participate in decision making regarding their treatment. A patient is entitled to apply to the Chief Psychiatrist for a review of their treatment in the event that recommendations of the second psychiatrist are not adopted by the authorised psychiatrist.
• An advance statement may be made to record a person’s treatment preferences in the event that they become too unwell to communicate their treatment preferences.
• A patient can nominate a person to receive information and to support the patient during a compulsory treatment order. This person will represent the patient’s views and preferences, but cannot make treatment decisions on behalf of the patient. (Department of Health, 2014)

Compulsory Treatment Orders

The legislation promotes voluntary treatment in preference to compulsory treatment wherever possible by introducing three different types of compulsory treatment orders:

• Assessment Order (AO): a medical or mental health practitioner can make an assessment order if their patient appears to have a mental illness and needs treatment to prevent serious harm to themselves, serious deterioration in their mental or physical health, or serious harm to another person. The AO allows an authorised psychiatrist to assess the person to determine whether they have a mental illness and require compulsory treatment. The AO will last up to a maximum of 72 hours.
• Temporary Treatment Order (TTO): At the assessment the authorised psychiatrist can make a Temporary Treatment Order if the criteria for compulsory treatment applies. This order has a maximum duration of 28 days. The person’s treatment must be regularly reviewed and the TTO must be revoked immediately if the criteria no longer apply.
• Treatment Order (TO): If a patient remains under a TTO at the end of the period of the order, the Mental Health Tribunal will conduct a hearing to decide whether the criteria for a TO apply. TOs have a maximum duration of six months for an Inpatient TO or twelve months for a Community TO. For young people the maximum duration of any TO is three months. A patient can make an application to the Mental Health Tribunal to have the order revoked at any time. Any decision made by the Mental Health Tribunal can be reviewed by application to the Victorian Civil and Administrative Tribunal. (Department of Health, 2014)

Safeguards to Protect the Rights and Dignity of People with Mental Illness

Extra mechanisms which protect the rights of people with a mental illness under the legislation are:

• Mental Health Tribunal: The Tribunal is to take a holistic approach in making decisions which encompasses a patient’s recovery goals, treatment preferences and the views of the nominated person, carer, guardian or parent of a young person, and to take into account any second psychiatric report.
• Electroconvulsive Treatment (ECT): ECT may only be performed with the approval of the Mental Health Tribunal on a patient who does not have capacity to give informed consent or a person under 18 years of age. Also, ECT will not be compulsorily performed on any patient with capacity to give informed consent who has refused ECT.
• Restrictive Interventions: Restrictive interventions (bodily restraint and seclusion) now includes physical restraint as well as mechanical restraint and seclusion. They must only be used after all reasonable and less restrictive options have been tried or considered.
• A Statement of Rights is included in the legislation. Patients must be informed of their rights which includes the right to make or participate in decisions about treatment and care, even where a patient does not have the capacity to provide informed consent. (Department of Health, 2014)

Oversight and Service Improvement

The legislation establishes an independent Mental Health Complaints Commissioner (MHCC). The role of the Chief Psychiatrist has been redefined to focus on supporting mental health service providers to deliver quality mental health services. Community Visitors will continue to monitor the adequacy and appropriateness of public mental health services.

Carers Recognition Act 2012 (Vic)

Enacted to recognise, promote and value the role of people in care relationships, to recognise their different needs, to support and recognise the benefits to the community that care relationships bring, and to promote the understanding of the significance of care relationships.

Under the Act a care relationship is defined as a person providing another person, or receiving from another person, care because one of the persons in the relationship:

• Has a disability
• Is older
• Has a mental illness
• Has an ongoing medical condition.

The Act sets out three Care Relationship Principles, and the obligations of care support organisations. (Vic, 2012)

Paper continues in Part B