Appendix - IAR DST Domains Quick reference guide - Version 1

Domain 1 - Symptom Severity and Distress

Assessment of an individual on this domain should consider:

• current symptoms and duration & level of distress
• experience of mental illness
• are symptoms improving/worsening, is distress improving/worsening, are new symptoms emerging?

Scoring

0 = No problem in this domain

No descriptors apply.

1 = Mild or sub diagnostic

• Currently experiencing some, but not all, of the symptoms associated with an anxiety disorder (e.g., symptoms like excessive worry, difficulty concentrating) or depressive disorder (e.g., symptoms like sadness, irritability, exhaustion, disrupted sleep, anger) that have typically been present for less than 6 months (but this may vary). Current symptoms at a level that would likely result in a diagnosis or associated with a mild level of distress.
• Currently experiencing mild distress.
• Currently experiencing symptoms (described above) at sub-diagnostic level but risk of escalating.

2 = Moderate

• Currently experiencing symptoms indicative of an anxiety disorder (e.g., excessive worry,panic, racing mind, difficulty concentrating) or depressive disorder (e.g., excessive sadness, irritability, exhaustion, disrupted sleep, loss of interest and pleasure) that have typically been present for more than 6 months (but this may vary) but symptoms may be of more recent origin. Symptoms are at a level that would likely meet diagnostic criteria, and/or are associated with a moderate to high levels of distress.
• Currently experiencing moderate to high levels of distress.
• History of a diagnosed mental health condition that has not responded to treatment, with continuing symptoms & moderate to high levels of distress.

3 = Severe

• A history of significant and ongoing symptoms indicative of a severe mental illness (e.g., hallucinations, paranoia, disordered thinking, extreme mood variation, delusions, extreme avoidant behaviour) but the symptoms are mostly well managed or are re-appearing and at risk of escalation without ongoing assistance.
• Other mental health condition that is associated with high to very high levels of distress.
• Recent onset of symptoms indicative of a severe mental illness and/or the person is experiencing high to very high levels of distress.
• Has been admitted to hospital for a mental health condition in previous 12 months.

4 = Very severe

• A history of significant & persistent symptoms that are indicative of a severe mental illness (e.g., hallucinations, paranoia, disordered thinking, extreme mood variation, delusions, severe avoidant behaviour) and symptoms are mostly poorly managed.
• Recent onset of symptoms that are indicative of a severe mental illness (e.g., hallucinations, paranoia, disordered thinking, extreme mood variation, delusions, severe avoidant behaviours) presenting in the context of significant complexity requiring multiple agency involvement.
• Other long-term mental health condition presenting in the context of significant complexity that requires multiple agency involvement.

Domain 2 - Risk of Harm

This domain is focussed on examining:

• suicidality – current and past suicidal ideation, attempts
• self-harm (non-suicidal self-injurious behaviour) – current and past
• deterioration of mental state that poses danger to self or others
• self-neglect that poses a risk to the person’s safety

Scoring

0 = No problem in this domain

No descriptors apply.

1 = Low risk of harm

• No current suicidal ideation but may have experienced ideation in the past (with no previous intent, plan or attempts)
• May have engaged in behaviours in the past that posed a risk to others but no current or recent instances
• Occasional non-suicidal self-injurious acts in the recent past and not requiring surgical treatment

2 = Moderate risk of harm

• Current suicidal ideation, without plan or intent. But may have had intent, plans or attempts in the past unrelated to current episode or current life stressors.
• Current or recent behaviours that pose a non-life-threatening risk to self or others
• Frequent non-suicidal self-injurious acts in the recent past and not requiring surgical treatment

3 = High risk of harm

• Current suicidal ideation with intent and history of suicidal attempts. No plan or strong reluctance to carry out plan, strong protective factors and a commitment to engage in a safety plan including involvement of family, significant others and services.
• Current or recent life-threatening self-harm or dangerous behaviours to self or others.
• Clearly compromised self-care ability to the extent that indirect or unintentional harm to self is likely. This includes indirect harm to self-associated with conditions such as anorexia nervosa.
• Frequent non-suicidal self-injurious acts in the recent past and requiring surgical treatment

4 = Very high risk of harm

• Current suicidal intention with plan and means to carry out. Few or no protective factors.
• Long term history of repeated and life-threatening self-harm or dangerous behaviour to self or others that is prominent in the person’s current presentation.
• Evidence of current severe symptoms (e.g., hallucinations, avoidant behaviour, paranoia, disordered thinking, delusions) with behaviour that poses an imminent danger to self or others.
• Extremely compromised self-care ability to the extent that the person is in real and present danger and experiencing harm related to these deficits.

Domain 3 - Functioning

Assessment of an individual on this domain should consider:

• a person’s ability to fulfil usual roles/ responsibilities
• impact on or disruption to areas of life (e.g., employment, parenting, education, or other social roles)
• impact on the person’s basic activities of daily living (e.g., self-care, mobility, toileting, feeding, and personal hygiene).

Scoring

0 = No problem in this domain

No descriptors apply.

1 = Mild impact

• Diminished ability to function in one or more of their usual roles, including work, social, parenting/care of dependents, education but without significant or adverse consequences.
• The person experiences brief and transient disruptions in functioning

2 = Moderate impact

• Functioning is impaired in more than one of their usual roles including work, social, parenting and family, education, to the extent that they are unable to meet the requirements of those roles on average 1 to 2 days per month.
• The person experiences occasional difficulties with basic activities of daily living but without threat to health.

3 = Severe impact

• Significant difficulties with functioning, resulting in disruption to many areas of the person’s life (e.g., work, education, interpersonal relationships, self-care) but the person can function independently with adequate treatment and community support.
• The person experiences difficulties with basic self-care (hygiene, eating, appearance) on a frequent, consistent basis but without threat to health.

4 = Very severe to extreme impact

• Profound difficulties with functioning, resulting in major disruption to virtually all areas of the person’s life (e.g., unable to work or participate in education, withdrawal from interpersonal relationships).
• Mental health condition contributes to severe and persistent self-neglect that poses a threat to health.

Domain 4 - Impact of Co-existing Conditions

Assessment of an individual on this domain should consider:

• substance use/misuse and the associated impact on the individual
• physical health condition and the associated impact on the individual’s concurrent mental health condition
• intellectual disability or cognitive impairment

Scoring

0 = No problem in this domain

No descriptors apply.

1 = Minor impact

• Occasional episodes of substance misuse but any recent episodes are limited, are not currently causing any concerns and do not impact on the concurrent mental health condition of the person.
• Physical health condition(s) present but are stable and do not have an impact on the concurrent mental health condition of the person.

2 = Moderate impact

• Ongoing or episodic substance abuse impacting on, or with the potential to impact on, the concurrent mental health condition of the person or ability to participate in treatment.
• Physical health condition present and impacting significantly on the mental health condition of the person or their ability to participate in treatment.

3 = Severe impact

• Substance use occurs at a level that poses a threat to health or represents a barrier to mental health related recovery.
• Physical health condition present and require intensive medical monitoring and are seriously affecting the mental health of the person (e.g., worsened symptoms, heightened distress).
• Intellectual disability or cognitive impairment that impacts significantly on the mental health condition and impedes the person’s ability to participate in treatment

4 = Very severe impact

• Severe substance use disorder with inability to limit use without specialist AOD intervention, in the context of a concurrent mental health condition.
• Significant physical health conditions exist which are poorly managed or life threatening, and in the context of a concurrent mental health condition.
• Severe intellectual disability or severe cognitive impairment that impacts significantly on the mental health condition and impedes the person’s ability to participate in treatment.

Domain 5 - Treatment and Recovery History

Assessment of an individual on this domain should consider:

• whether there has been previous treatment (including specialist or mental health inpatient treatment)
• if the person is currently engaged in treatment
• their response to past or current treatment

When considering this domain relevant treatment refers to treatment by a qualified mental health provider rather than informal care provided by friends, family or social networks.

Scoring

0 = No prior treatment history

• No history of previous treatment for a mental health condition.
• In a current treatment arrangement that is appropriate and meets person’s needs.

1 = Full recovery with previous treatment

• Previously sought help for earlier episode(s) and generally able to achieve full recovery with no need for ongoing intervention.

2 = Moderate recovery with previous treatment - Previously received treatment for earlier episode(s) and generally able to achieve and maintain partial recovery with limited support.

3 = Minor recovery with previous treatment

• Recently received treatment for an episode(s) with only minor improvement.
• Previously accessed intermittent specialist supports (e.g., psychiatry services, state and territory specialist mental health services) for current or previous episode but limited response.
• Currently receiving treatment but is not making the expected level of progress despite intensive, structured and medical supports delivered over an extended period.

4 = Negligible recovery with previous treatment

• Recently received treatment for an episode with negligible or no improvement despite intensive, structured and medical supports delivered over an extended period.
• Ongoing need for or use of specialist supports (e.g., psychiatry services, state and territory services).
• Currently receiving treatment but is deteriorating despite intensive, structured and medical supports delivered over an extended period.

Domain 6 - Social and Environmental

Assessment of an individual on this domain should consider life circumstances that may be associated with distress such as:

• significant transitions (e.g., job loss, relationship breakdown, sudden or unexpected death of loved one)
• trauma (e.g., physical, psychological or sexual abuse, witnessing or being a victim of an extremely violent incident, natural disaster)
• experiencing harm from others (including violence, vulnerability, exploitation)
• interpersonal or social difficulties (e.g., conflict with friend or colleague, loneliness, social isolation, bullying, relationship difficulties)
• performance related pressure (e.g., work, school, exam stress)
• ability to or difficulty having basic physical, emotional, environmental or material needs met (such as homelessness, unsafe living environment, poverty)
• illness
• legal issues

Scoring

0 = No problem in this domain

No descriptors apply.

1 = Mildly stressful environment

• Person experiences their environment as mildly stressful.

2 = Moderately stressful environment

• Person experiences their environment as moderately stressful.

3 = Highly stressful environment

• Person experiences their environment as highly stressful.

4 = Extremely stressful environment

• Person experiences their environment as extremely stressful.

Domain 7 - Family and Other Supports

This initial assessment domain should consider whether informal supports are present and their potential to contribute to recovery. A lack of supports might contribute to the onset or maintenance of the mental health condition and/or compromise ability to participate in the recommended treatment.

Scoring

0 = Highly supported

• Substantial and useful supports willing to and capable of providing ample emotional support.

1 = Well supported

• A few useful supports are available and willing to and capable of providing support in times of need.

2 = Limited supports

• Usual sources of useful support may be reluctant to provide support, difficult to access, or have insufficient resources to provide support whenever it is needed.

3 = Minimal supports

• Very few actual or potential useful sources of support are available.

4 = No supports

• No useful sources of support are available.

Domain 8 - Engagement and Motivation

Assessment of an individual on this domain should include:

• the individual’s understanding of the symptoms, condition, impact
• the individual’s ability and capacity to manage the condition
• the individual’s motivation to access necessary supports (particularly importance if considering self-management options)

Scoring

0 = Optimal

• Complete understanding of condition and impacts.
• Takes an active role in managing condition.
• Motivated about recovery and competently accesses support as needed.

1 = Positive

• Good understanding of condition and impacts.
• Capable of taking an active role in managing condition.
• Mostly willing to accept supports as needed.

2 = Limited

• Limited understanding or confusion about condition and impacts.
• Unlikely to access supports without prompting and encouragement.
• Limited interest in taking an active role in managing condition.

3 = Minimal

• Rarely accepts reality of condition but may acknowledge associated situational difficulties.
• No ability or interest in managing the condition.
• Some reluctance to accept supports, does not use resources available.

4 = Disengaged

• No awareness or understanding of the condition and impacts.
• Actively avoids managing the condition.
• Deliberately avoids potentially useful and available supports.