Trends in Primary Mental Health Care Service Use and Subsequent Self-Harm in Western Sydney Australia: Policy and Workforce Implications

Abstract

Background: This study investigated the trends in primary mental health care (PMHC) service use and hospital-treated self-harm in Western Sydney (Australia). Methods: A data linkage study and descriptive ecological study of PMHC referrals investigated the trends in referrals, treatment attendance, hospital-treated self-harm, and health care practitioners (HCPs) for the period of 2013−2018 (n = 19,437). Results: There was a substantial increase in referrals from 2016. The majority of referrals were females (60.9%), those aged <45 years (71.3%), and those presenting with anxiety or affective disorders (78.9%). Referrals of those at risk of suicide increased from 9.7% in 2013 to 17.8% in 2018. There were 264 (2.2%) cases of subsequent hospital-treated self-harm, with higher rates among those at risk of suicide and those who attended <6 sessions. The number of HCPs per referral also increased from 2013, as did waiting times for treatment initiation. Conclusion: Individuals presenting to PMHC services at risk of suicide, and who subsequently presented to a hospital setting following self-harm, were more likely to either not attend services following a referral or to attend fewer services. This trend occurred in the context of an increase in the number of clients per HCP, suggesting workforce capacity has not kept pace with demand.

Keywords: mental health policy; primary mental health care; psychological treatments; self-injurious behavior.

Figure 1

Number of referrals to primary mental health care (PMHC) services by gender, Western Sydney Primary Health Network, 2013–2018. Referrals with a missing suicide risk flag were considered as suicide referrals for those who received suicide-prevention-specific services (there were 222 referrals with missing suicide flags, which were replaced due to being at risk of suicide).

Figure 2

Trends in hospital-treated self-harm within 12 months of last service contact by sex and age group, Western Sydney Primary Health Network, 2013–2018. Any hospital treated self-harm presentation (including cases of undetermined intent) within 12-months of the last service contact (or referral date for referrals that did not result in at least one follow-up treatment session) was presented as a proportion of primary mental health care service referrals in each year.

Figure 3

Hospital-treated self-harm within 12 months after the last service contact date by number of sessions, Western Sydney Primary Health Network, 2013–2018. Any hospital treated self-harm presentation (including cases of undetermined intent) within 12-months of the last service contact (or referral date for referrals that did not result in at least one follow-up treatment session) was presented as a proportion of primary mental health care service referrals over each session category.

Figure 4

Trends in workforce capacity and patients per health care practitioner, Western Sydney Primary Health Network, 2013–2018. We excluded 2113 referrals, received from July 2016 to 31 December 2018, for 2082 clients (explained in the Supplementary Materials) due to the unavailability of HCP-identifiable information. However, de-identified HCP identifier information is available in the PMHC MDS for these excluded referrals, but there may be multiple HCP IDs for the same HCP given by different PMHC service provider organization levels if any HCP works in multiple PMHC service provider organizations.

Figure 5

Trends in waiting time between referral and first treatment session by risk of suicide, Western Sydney Primary Health Network, 2013–2018. Waiting time was calculated based on the difference between the first session date and the referral date. Referrals of those who never attended at least one treatment session were excluded. Additionally, 1285 (8%) referrals were excluded due to the missing risk of suicide. A further 660 (4.5%) referrals, including those who were referred for low-intensity treatments, were excluded, as most of them accessed services via telephone and received services on the same day.

Figure 6

Trends in treatment non-attendance and sessions per referral by risk of suicide, Western Sydney Primary Health Network, 2013–2018. We excluded 2113 (10.9%) referrals. Of these referrals, 1784 (84%) comprised clients who were referred to low-intensity interventions, and this group was likely to have low session attendance per referral, especially those who accessed services via telephone, compared to other referrals. From the remaining 329 referrals, 70 had missing suicide flags and other data quality issues.