Relapse prevention has been a major part of the policy agenda since the advent of the National Mental Health Strategy in 1992. It was fundamental to many of the priority areas for reform and especially pertinent in the move from institutional to community-based mental health care. In the First Plan, which applied from 1992-1998, relapse prevention was evident in the prioritising of community care options following deinstitutionalisation. In the Second Plan, which covered the period from 1998-2003, relapse prevention was made more explicit with greater emphasis placed on promotion and prevention at that time.
In response to the higher priority afforded promotion and prevention in the Second Plan, a National Action Plan for Promotion, Prevention and Early Intervention for Mental Health [Action Plan 2000] was developed and published in 2000 by the National Mental Health Promotion and Prevention Working Party, which is auspiced by the Australian Health Ministers' Advisory Council National Mental Health Working Group and the National Public Health Partnership Group. This document, and its accompanying Monograph 2000, presented a rationale and framework for intervening earlier in the developmental trajectory of mental health problems and mental illnesses, based on a growing body of evidence demonstrating that more could be done to reduce the impact of mental illness by widening the spectrum of interventions beyond a treatment approach. Interventions to promote mental health for all Australians regardless of their current mental health status, to prevent the development of mental health problems and mental illnesses for those at risk, and to intervene early for those people showing signs of mental illness, were advocated in order to invest in the longer-term to improve the mental health and wellbeing of Australians.
Action Plan 2000 and Monograph 2000 describe a spectrum of interventions for mental health, arguing that a balance of interventions across the entire spectrum is required to effectively meet challenges in mental health care (see figure 2). These documents concentrated on the first half of the spectrum and did not consider issues of promotion, prevention and early intervention in terms of continuing care for people with mental illness. It was acknowledged, however, that many of the issues relevant to promotion, prevention and early intervention for mental health were also likely to be pertinent to relapse prevention, but that there were sufficient distinctions to warrant the separate consideration of relapse prevention within another document.
In Action Plan 2000, relapse prevention was included in the spectrum of interventions under the sections termed 'Continuing Care', which was defined as:
- Continuing care comprises interventions for individuals whose disorders continue or recur. The aim is to provide optimal clinical treatment and the necessary rehabilitation and support services in order to prevent relapse or the recurrence of symptoms, and to maintain optimal functioning to promote recovery. Rehabilitation may focus on vocational, educational, social, and cognitive functioning. Ongoing mental health promotion and the reduction of risk factors and enhancement of protective factors are still relevant at this end of the spectrum to facilitate and support recovery and ongoing wellbeing. (Monograph 2000 p33 )
Relapse prevention refers to interventions in response to the early signs of recurring mental disorder for people who have already experienced a mental disorder. Relapse prevention is a critical issue for this group of people, their families, mental health services and the wider community. Recognition of the early signs of recurrent disorder and the appropriate treatment responses comprise a unique area of investigation. (Monograph 2000 p33)
Since publication of Action Plan 2000 and Monograph 2000 there has been increased emphasis on continuing care pathways for people who have experience mental illness. The Evaluation of the Second National Mental Health Plan (2003) reported that continuity of care "remains an elusive goal for the complex systems that deliver mental health care. In particular, follow-up care into the community after hospitalisation for an acute episode is often lacking and puts consumers at risk." (p2). Relapse prevention and early intervention, for first and recurrent episodes of mental illness, were identified as areas where there remains considerable need for improvement in terms of Australia's mental health care system. Continuity of care, in all its forms—across the course of an episode of illness, across the lifespan, and across service sectors—urgently required action and innovation.
The importance of applying a recovery orientation within mental health services was also identified in the Evaluation of the Second National Mental Health Plan. The concept of recovery has emerged as a central issue and is strongly advocated by many people who have been affected by mental illness. As a consequence, providing services to people with mental illness within a recovery orientation is a fundamental principle of the National Mental Health Plan 2003-2008, in which recovery is defined as:
a deeply personal, unique process of changing one's attitudes, values, feelings, goals, skills and/or roles. It is a way of living a satisfying, hopeful and contributing life. Recovery involves the development of new meaning and purpose in one's life as one grows beyond the catastrophic effects of psychiatric disability. (adapted from Anthony 2000 p11)
A growing body of clinical evidence reveals that the long-term prognoses of people with mental illness are more hopeful than previously realised (Anthony 2000). Outdated beliefs of the inevitable adverse impact of mental illness should no longer be perpetuated, and instead, an atmosphere of hope and a belief in human potential must pervade mental health service delivery. Implementing a recovery orientation requires an attitude shift for many service providers in order to support consumer rights and provide the types of services that maximise wellbeing for people with mental illness. Specific approaches and plans aimed at reducing the likelihood and impact of relapse are an important component of this approach to continuing care.
Figure 2. Spectrum of interventions for mental health
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Text equivalent below for Figure 2The spectrum of interventions for mental health is presented as a semi-circle, with each segment in the semi-circle representing a particular intervention.The spectrum is underpinned by mental health promotion.
The interventions that make up prevention are:
- symptom identification
- early treatment
- standard treatment
- engagement with longer-term treatment and support (including relapse prevention)
- long term care