Pathways of recovery: preventing further episodes of mental illness (monograph)

The role of the acute and specialist mental health system

Page last updated: 2006

A fundamental reorientation of approach to treatment is required in acute clinical settings. This can be the first opportunity to commence relapse prevention, yet one that often goes unrealised. All too frequently the acute response focuses on ameliorating current symptoms and early discharge, with no follow-up into the community. It was noted during the consultations that the emphasis in acute settings was on admission, and too little time was devoted to discharge planning. When discharge plans were part of routine practice, they were often delayed by several months after the discharge.

It was noted earlier that attitudes toward the recovery of people with mental illness were especially negative in acute mental health settings. This was a strong finding of the evaluation of the Second Mental Health Plan and the Out of hospital, Out of mind report of the MHCA (Groom et al 2003). A great deal of emphasis needs to be put on changing attitudes of the workforce in acute settings, and some suggested strategies are rotating staff around acute and community settings, and ensuring the inclusion of consumer consultants in acute settings, as they provide positive role models for consumers and staff alike.

The importance of maintenance medication in preventing relapse was noted earlier, yet people in the consultations, particularly general practitioners, reported experiences of people being discharged from hospital with only three days' medication and no GP appointment. Given that it could take three or more weeks to obtain an appointment with the GP, this was a period of significant risk. It was argued that a major impact on relapse could be achieved by ensuring that an appointment was made prior to discharge to see the GP in the first few days after discharge, and that other necessary supports were put in place to ensure that the person was able to attend this appointment.

An ongoing role for the acute and specialist mental health systems in continuing care is critical for people with mental illness who require a high level of support in the community. Continuing care for many people seriously affected by mental illness is provided by general practice (Jablensky et al 2000), but GPs need to be supported by specialist mental health services in this regard.

I'm not going to agree to take on a mental health client if I know that I'm going to have to spend four hours on the phone getting a response from acute care when I need it. —GP
The CLIPP Project (Consultation Liaison in Primary Care Psychiatry) is a large GP shared mental health care initiative developed and evaluated in Victoria over the last eight years (Meadows 2003). The project involves, firstly, the development of psychiatric liaison attachments to general practices involving collaboration and consultation from sector psychiatrists. The second aspect involves the transfer of a selected group of psychiatric services clients into shared care, with GPs using the channels of communication and collaboration developed in the liaison attachments.

Importantly, the CLIPP model uses the concept of a 'relapse signature', involving recognition of early warning signs of relapse, to simplify clinical monitoring. This model of service delivery provides a supportive mechanism for mental health service clients to be reintegrated into general health care within a seamless service delivery structure. The program processes have been comprehensively reported (see CLIPP manual page on the Victorian Department of Health website (www.health.vic.gov.au)) and provide an effective model of collaboration between general practice and psychiatry to support people with a high level of need in the community and ensure that relapse prevention takes place.