Keywords

Mental disorders are the most prevalent illnesses in adolescence and have the potential to carry the greatest burden of illness (WHO, 2014) and stigma into adult life. Governments in higher income countries have responded to this challenge by allocating more resources for community-based and inpatient mental health treatment services directed to youth (Health Service Executive (Ireland), 2012; House of Commons Health Committee, 2014; National Mental Health Development Unit, 2009; NSW Health, 2011; Royal College of Psychiatrists, 2015). However, options remain limited for those young people with severe mental illness requiring secure inpatient care. Specialist child and adolescent mental health (CAMH) inpatient units are typically designed to provide short-term care when the acute phase of a mental illness poses danger to the young person or the community. The aims are to assess and to stabilize the young person then discharge them to treatment in the community. Length of stay is usually measured in weeks rather than months (Hazell et al., 2016). Unfortunately, some young people experience either repeated or unremitting episodes of mental illness requiring longer periods of inpatient treatment. Delivering such treatment in an acute mental health unit is feasible, but it requires the diversion of already limited resources to develop a customized treatment plan in an environment that is not fit for purpose (Thompson et al., 2021). In addition, repeated exposure to newly admitted, acutely unwell patients, can destabilize young people with chronic mental illness. Owing to the limited number of specialist acute CAMH beds, a proportion of young people experiencing chronic or relapsing mental disorders are redirected to adult mental health inpatient facilities (Hazell et al., 2016; Wheatley et al., 2004). In recognition of this problem the Ministry of Health for the state of New South Wales (NSW), Australia in a draft planning document stated

To improve care for young people with significant impairment who require treatment in an inpatient setting due to continuing risk, two new additional specialist non-acute inpatient units will be established with state-wide roles and appropriate design and staffing arrangements for those who are still receiving involuntary treatment. NSW does not currently have specialised units of this type for young people. Care pathways to and from these units will be carefully considered and the allocations will need to factor access to families/carers and other community supports with appropriate accommodation options for visitors. (referenced in NSW Health, 2011)

Funding for the first of these units was announced in 2007, to be situated on the campus of a newly opened psychiatric hospital, and in close proximity to other CAMH services and a general hospital. After a planning phase of approximately 18 months, the unit opened in 2009. The purpose of this book is to describe the multidisciplinary model of care delivered by the unit. We acknowledge that many jurisdictions do not have the resources to establish a unit that fulfils such a specialized role within the system of care. Nevertheless, we hope that the learnings derived from the unit may generalize to other specialist CAMH inpatient settings. We are also mindful that longer stay inpatient care runs counter to the trend towards briefer hospital admissions within the context of a continuum of care (Blanz & Schmidt, 2000). We share the view that most young people experiencing mental health problems can be managed by community resources, augmented if necessary by brief admissions for crisis resolution. We do question how helpful such crisis admissions are, since the capacity to deliver therapeutic intervention is limited. For new patients such admissions may afford the clinical team time to arrange comprehensive community support. For a patient with a chronic or relapsing psychiatric condition this is no longer relevant. There is, as argued above, a subgroup of young people with serious mental disorders for whom a longer hospitalization is the optimal care.

The Walker Unit (named for nineteenth century NSW colonial politician, merchant banker and philanthropist Thomas Walker) was thus established as a specialist longer-term adolescent inpatient unit as part of the “phase of illness model of care” at the Concord Centre for Mental Health (CCMH). The “phase of illness model” delineates patient groups in order to target phase-specific treatments to improve patient outcomes. The Walker Unit is one of seven phase-specific mental health units at CCMH. Indications for the psychiatric hospitalization of children and adolescents include the need for intensive observation or investigation to inform diagnosis, to manage significant risk associated with a psychiatric condition or its treatment, or to manage medical complications of a psychiatric condition (Perkes et al., 2019). It was anticipated the reason for admission to the Walker Unit would mostly involve the management of risk arising from one or more of the following:

  1. 1.

    severe and unremitting psychotic disorders

  2. 2.

    severe and unremitting mood disorders

  3. 3.

    unremitting suicidality and dangerous deliberate self-harm

  4. 4.

    behavioural disturbance arising from neuropsychiatric conditions such as autism

Chronic and unremitting eating disorder was also considered, but lack of sufficient medical support especially for children under the age of 16 has precluded the admission of patients who are physically compromised. In addition, treatment for severe eating disorder is available from statewide specialized inpatient units for adults and for young people operating from other hospitals in NSW. Young people with a history of criminal behaviour may be admitted to the Walker Unit, but there is a statewide juvenile forensic mental health inpatient facility operating from another location. Admission to the Walker Unit has, however, been used as a step-down from forensic hospital and to facilitate progressive re-integration to the community.

Most patients admitted to the Walker Unit have had a substantial period of treatment in an acute inpatient setting. Some patients are received through inter-hospital transfer, while others are admitted during a time when they are living in the community. Most have a high level of risk of self-harm and/or harm to others. A history of prolonged school disengagement or school dysfunction is a feature common to most young people attending the programme. Many also experience a family history of mental illness and/or chronic dysfunction and interpersonal difficulties, which have served to precipitate and/or exacerbate the severity and persistence of the mental illness and associated problems. While it was anticipated most patients would be detained under the provisions of the NSW Mental Health Act, the experience of the unit during the period 2015 to 2020 was that this was the case for only a minority (28%). The five most common primary diagnoses in the period 2015–2020 were depression (37%), schizophrenia (16%), post-traumatic stress disorder (12%), autism (7%) and obsessive-compulsive disorder (7%). We are aware that using the primary diagnosis to describe a patient population has its limitations. We examined data from structured diagnostic interviews conducted on a subgroup of patients admitted in the period 2020–2021. When all concurrent diagnoses were considered, the most common psychopathologies were anxiety (27%), depression (23%), non-schizophrenic psychosis (10%) attention-deficit/hyperactivity disorder (10%) and oppositional defiant disorder (10%). The second set of diagnoses more accurately reflects the day to day work of the Walker Unit.

Treatment at the Walker Unit includes multimodal strategies. The longer length of admission at the Walker Unit enables pharmacotherapy to be carefully reviewed and optimized. Most young people are prescribed less psychotropic medication on discharge than at admission. The psychotherapeutic treatments include evidence-based and novel interventions delivered via individualized, group-based and family-based formats to assist in the development and recovery of the young person. Weekly family therapy is designed to promote the lasting change required within the family system in order to help the young person maintain their mental health post discharge. An admission to the Walker Unit involves several phases encompassing assessment, the establishment of a therapeutic alliance, defining therapeutic goals, implementation of treatment strategies, and finally, planning transfer of care to facilitate re-integration into community-based treatment. Education programmes delivered by the Walker Unit Learning Centre provide essential components of rehabilitation and restoration of developmental tasks.

The short to medium term goal of the Walker programme is a reduction or remission in the presenting symptoms. The longer term goal is to achieve a level of independent functioning in the young person that is consistent with their mental age. Coexisting physical conditions requiring medical monitoring or support are managed through consultation with the relevant subspecialty unit of the adjacent general hospital, or in some instances with the nearest paediatric hospital. All young people are discharged to stable accommodation, but in some cases not to the care of their families. All young people have an established educational or vocational pathway on discharge, although this may not be a return to the previous school of enrolment. The experience of the unit has been that young people who have a mental illness severe enough to require intensive longer stay inpatient treatment typically need the support of a special needs school or program.

The Walker Unit endeavours to tailor its programme to meet the particular needs of the young person. In the early phases of an admission, most young people reside in the unit seven days a week. As the admission progresses, patients are granted increasing amounts of leave off the ward including overnight leave, used as part of re-integration to home and education. Although length of stay varies, in the period 2015 to 2020, goals were achieved within six months for 64% of patients. Admissions extended beyond a year for 6% of patients owing to exceptional circumstances. Long admissions were avoided where possible because of the risk of institutionalization and disengagement with resources in the community.

In the chapters that follow, we will examine the physical environment of the unit, and the adaptations that have been made to ensure its functionality. We will consider the therapeutic milieu and the role played by multidisciplinary team members individually and collectively in its maintenance. We will describe clinical processes such as admission and discharge planning, formulation and case review. We will consider the specific roles of professionals including nurses, teachers, psychotherapists, psychologists, social workers, art therapists, music therapists, speech therapists, occupational therapists, dieticians, pharmacists and medical staff. We will describe the suite of therapies offered to patients. We will describe the steps taken to maintain and enhance the physical wellbeing of patients, including the optimization of pharmacotherapy. We will describe how the unit operates within the framework of the Mental Health Act. We will consider training and education. Finally, we will describe how the unit responded to challenges caused by the COVID-19 pandemic.