Royal Commission into Victoria’s Mental Health System - Final Report

The Victorian Royal Commission released its report. It is available from: https://finalreport.rcvmhs.vic.gov.au/

The report is in 5 volumes and 4 appendices. It is a big report: the volumes range from 36Mb to 54Mb.

Very little of the report relates to autistic Victorians.

The report mentions the national Burdekin Report 1993 only once; the mention is in the context of mental illness and "minor offences and infringements". The Burdekin report limited "dual diagnosis" to mean only intellectual disability and mental illness. The Victorian report defines:

Dual disability Term defined in the Commission’s interim report as people living with both mental illness and an acquired or neurodevelopmental disability (such an intellectual disability, autism spectrum disorder, attention-deficit/hyperactivity disorder or a communication disorder).

This this broader meaning for dual disability is a welcome development.

The report observes:

Box 5.1: Dual disability services
The Commission has heard that diagnostic overshadowing (attributing symptoms of mental illness to disability), and a lack of understanding of differences in the way mental illness may present in people with acquired or neurodevelopmental disabilities, are barriers to accessing care. Alfred Health, which has a specialist youth mental health and intellectual disability service, identified a range of challenges in identifying mental illness in children and young people with intellectual disabilities, including communication, behavioural and emotional challenges, that can mask or complicate presentation of mental health symptoms.

Self‑aggression, self‑injury and destruction of property may be seen as behaviours related to acquired or neurodevelopmental disability, rather than signs of mental illness or psychological distress. Given that public specialist mental health services seldom provide services for people presenting with behavioural problems in the absence of mental illness, attributing behaviour to disability, rather than mental illness, reduces the chances of a person receiving appropriate mental health services.

The Commission for Children and Young People shared the personal account of Jamie, a child living in residential care with a lengthy history of child protection involvement. It described how Jamie experienced high levels of self‑harming and suicidal behaviour, multiple hospital presentations, police attendances and admissions to secure welfare services. When Jamie sought help, ‘a lack of shared understanding by mental and non‑mental health services about the ‘cause’ of Jamie’s presenting issues resulted in a disjointed service response that failed to consistently support his safety, wellbeing and development’.

There is a mix of supports available to support people with a dual disability. The statewide Victorian Dual Disability Service, which is a consultation service, offers supports to other service providers. The Centre for Developmental Disability Health Victoria, now within Monash Health, provides assessment and limited psychiatric intervention to support GPs. Two Mental Health Intellectual Disability Initiatives—one adult initiative based in the Monash Health catchment and one youth initiative in the Alfred Health catchment—provide assessment, diagnosis and intervention within their catchment populations. The Commission has heard that these services currently only provide care for a small proportion of people living with dual disability in Victoria; for example, the adult service cannot keep up with demand.

The Victorian Government’s Intellectual Disability Mental Health 10‑year Plan Technical Paper states, ‘[t]here are limited specialist services for dual disability in Victoria and Australia and the needs of this population are not adequately acknowledged and integrated with mental health and disability service policy and strategy.’

Evidence suggests clinicians lack sufficient training in the management and care of clients with dual disabilities.274 The Victorian Dual Disability Service and the Centre for Developmental Disability Health Victoria are important sources of secondary advice for clinicians. However, these services typically lack an after‑hours crisis service, and can have restrictive acceptance criteria.

The Commission has been told there is a need for specialist dual disability training and higher qualifications in dual disability for paediatric and adult psychiatry and psychology, and across the disability sector. There is also a need to promote greater expertise and training in dual disabilities in the wider mental health workforce.

It is the Commission’s view that there is a need for greater, structured investment in statewide dual disability services to support the functions of specialist assessment, diagnosis and intervention (including after‑hours support) and in consultation and liaison, to ensure the broader workforce has sufficient dual disability training and decision support.

This report repeats Burdekin's strategy of having a specialist "dual disability service" for treating people with "dual disability". While Victoria still has such a service, the report says it is now badly under-resourced. Similar units created in other states/territories following Burdekin's recommendations are either chronically under-resourced or have disappeared completely. This strategy has not proven effective.

The whole health sector should look to the inclusion models that the education sector is developing for more effective approaches to supporting subpopulations of patients, including people with dual disability needing mental health services and supports.