Australia has a mental health crisis. Despite a number of national mental health plans and a decade of changes to public mental health services, individuals, patients, families, carers and support groups from all around Australia are saying that the care of mentally ill individuals is a disgrace. The experience of these groups is backed up by recent reports into the state of mental health nationwide (see recent “Not for Service” report and the Senate Select Committee report on mental health). This crisis primarily affects public mental health services.
Causes of the crisis
In my opinion the problems in mental health stem from the following difficulties.
There are not enough mental health services to meet the needs of patients. This leads to rationing. In the current situation resources are so limited that rationing has to be tightened to extreme degrees and as a result only the most severely ill patients are offered treatment. Other patients who are very ill but fall under the rationing threshold may not get appropriate care. This rationing is most acutely felt when decisions are made to admit patients to psychiatric inpatient care from hospital emergency departments, when decisions are made to discharge patients from inpatient care, and when decisions are made to determine which patients are offered intensive case management by community mental health clinics. The severity of rationing nowadays means that patients who need hospital admission may not get it, that patients who need longer stays in hospital may be discharged too early, and those patients who need intensive community case management and follow-up may not get it. These flaws in the provision of treatment can have disastrous consequences; an article in The Australian newspaper (Kate Legge, July 19, 2005) drew attention to 42 suicide deaths in Victoria in young people under age 30 over a two year period where inadequate treatment was linked to the suicide. Lack of mental health beds for high-risk patients, too rapid discharge, and lack of intensive treatment were problems identified. A Queensland Health report in early 2007 highlighted the problems for patients trying to access a health system under pressure. The report identified 140 unexpected deaths of patients treated by Queensland Health in the previous year. More than half of these deaths (86) were of mentally ill patients who accessed Queensland Health. Most of the deaths were by suicide; either within a week of a patient being assessed in Queensland Health emergency departments and not being admitted, or within a week of discharge from a psychiatric admission. This disproportionate number of deaths of psychiatric patients raises the question of how well Queensland Health services are serving mentally ill individuals. One of the major problems is the lack of acute psychiatric beds (and back-up extended care beds) across Queensland, making admission of very ill individuals difficult and potentially forcing early discharge of inpatients. It is amazing that psychiatric inpatient units are continually at 100% occupancy, making them unable to meet the demands of fluctuating clinical pressures. Increasing inpatient bed numbers would allow inpatient units to operate at the more conventional 85% occupancy – allowing admission of patients when needed without rationing. Inadequate intensive community follow-up case management of these highly vulnerable individuals means that too few patients are managed closely in the community and are open to the possibility of self-harm.
New mental health acts and policies
New revisions of state mental health acts have been introduced around Australia over the past two decades. These acts are often more ‘enlightened’ than the ones they replace in that they give more weight to patient autonomy and to the least restrictive forms of treatment being used. However, these acts can be misused because of the pressures of rationing that apply at the moment and this can lead to patients being treated inappropriately. The mental health acts may be used as a ‘fig leaf’ to cover inadequate inpatient beds (“your son doesn’t meet criteria for admission”), or mental health act provisions may be invoked for patients who do not need to be involuntary just in order to access community case management. Another article in The Australian (Clara Pirani, July 4, 2005) highlighted psychiatrists needing to use these practices in order to get appropriate care for their patients. Unfortunately, across the world the introduction of new mental health policies, acts and plans are associated with increased suicide rates compared with national drug policies that are associated with lowered suicide rates. Drug policies usually reduce drug supply and provide more rehabilitation treatment whereas new mental health acts and plans tend to make treatment more difficult to access.
‘Mainstreaming’ of mental health services
Over the past 20 years there has been a push by public mental health services to ‘mainstream’ the care of individuals suffering from mental illness. This means providing services for them within the general health system rather than a separate service for psychiatric illness. While this has emphasized the role of the general practitioner in providing treatment, and had some (limited) benefit of reducing stigma and curtailing the excesses of some treatment practices in the older, or more isolated, stand alone psychiatric facilities, the policy more broadly has been a failure. The unique needs of individuals suffering mental illness have not been fully appreciated and provided for and this has led to a secondary marginalization of mentally ill patients in general health services. One needs to look no further than the way patients with mental illness and substance abuse are treated in busy public hospital emergency departments to see evidence of this marginalization. Indeed, belatedly, there is now recognition that separate psychiatric emergency departments need to operate in public hospitals. But beyond the emergency department the mentally ill need inpatient units with plenty of space, sub acute and extended care treatment facilities, and properly supervised community residential accommodation – all features that are not usually offered or supported by general health services.
Failure to publish mortality data
Mortality figures for individuals under the care of public mental health services have been kept very quiet. In NSW, for example, although figures for deaths occurring in people while theoretically under the care of the mental health services have been collected since 1992, systematic publication has always been refused. A particularly alarming development was that the only paper published on the figures by NSW Health in 1995, covering a 39-month period from 1992 to 1995, had pooled these figures, giving an average of 76 such deaths per year. The paper failed to mention that, as eventually emerged in a 200-page report released very quietly on 23rd December 2003, the figures were actually 68 in 1993, 72 in 1994, jumping to 100 in 1995, i.e. a dramatic and alarming increase of 47% in just three years, which has continued subsequently to a total increase of at least 300% since 1992. Data and trends on mortality from natural causes (including a breakdown of causes of death), suicide, homicide, police shootings, and accidents are not readily available. Nor are data on the number of deaths and severe assaults that are caused by individuals under mental health care.
Limited training opportunities
Australia faces a looming crisis in training of psychiatrists and other mental health professionals. A large number of psychiatrists and psychiatric nurses are reaching retirement age and there are too few coming through to replace them. In addition, the training opportunities for a balanced, comprehensive training experience in psychiatry are limited. Public adult mental health services have gradually but progressively narrowed their clinical focus to patients suffering from drug induced and functional psychoses, patients on forensic orders, and the more severe (often Cluster B – antisocial, borderline) personality disorders. This is an important but very limited view of psychiatry. Many of these services do not provide the breadth of clinical conditions and treatment environments and programs required to provide an attractive and comprehensive training experience for registrars and other mental health professionals. As most training positions are in the public sector (with some exceptions), this is causing serious problems for the training of the next generation of mental health professionals. A recent study from the University of NSW shows that while medical students at the start of their training are favourably disposed to psychiatry, by the end of their clinical training they have a negative view of the discipline! Either the other medical and surgical specialities are better at attracting students, or the experience of clinical psychiatry in the current teaching settings is a ‘turn off’. I suspect the latter. Students find it difficult to identify with aggressive, psychotic, heavily sedated, locked up and often forensic patients that populate public mental health units now. Lack of identification leads to lack of interest in psychiatry as a career.
Having got to a ‘mental health crisis,’ what can be done?
In my opinion the first action is to emphasize accountability at the point of the patient – clinician contact. The patient placing his or her care in the hands of a doctor, nurse or other mental health professional needs to know that that clinician has the patient’s welfare at heart and that the treatment needs of the patient will not be inappropriately influenced by the demands of rationing applied by the mental health service. This form of accountability will lead to a profound change in the way public mental health services are provided and resourced. Substantial staffing and facility enhancements and additional funding will be required to support this change. As a method of enhancing accountability, the Gold Coast Institute of Mental Health and the Gold Coast Medical Association has called for an audit or commission of inquiry into all suicides to review each pathway to death and any contact the person had with treatment services in order to monitor the quality of mental health care.
An audit or standing commission of inquiry into all suicide deaths
An audit or commission of inquiry should be established to examine the pathways to death in all cases of suicide in Australia, whether occurring in hospital or in the community. The inquiry should have the power to call witnesses. The inquiry should be required to focus on the pathway to death of the individual and the nature of contact over the preceding three months between the individual and public (and private) mental health services. The inquiry should make regular comment about the quality of services and make recommendations about improving these services. The inquiry should also examine how the regulations of state mental health acts are being applied to see if they are being used to cover inadequacies in the provision of acute inpatient care and intensive community care. The focus should be on the nature of the contacts with mental health services (and to a lesser extent with other practitioners) in the weeks and months prior to the suicide. In my role as executive director of the Gold Coast Institute of Mental Health and as a private practitioner, I get contacts from families and partners of individuals who have committed suicide, who in the days or weeks prior to the suicide were taken by these relatives/friends to mental health services where they explained to staff the gravity of the situation and the threats of harm to self or others by the individual, yet the individual was not admitted or provided with intensive case management. This is not a unique experience. The Brisbane Courier Mail reported on four suicides in far north Queensland where the adequacy of treatment by mental health services leading up to the suicide is being investigated by the Coroner. Although suicide is a multi-determined behavior, surely the quality of mental health services for those who make contact with them prior to suicide has some role to play in preventing tragic outcomes – if not, then we should not be in the business of providing care. I do not think we can just wash our hands and say that these suicides are “not preventable”. Some suicides might be preventable if we hospitalize people at lower levels of concern than we do now. This is an important point: due to limited acute, sub-acute and extended care beds, and perverse use of new (more liberal) mental health acts, access to safe supervised hospital accommodation is so severely rationed that many patients who need this type of care are not getting it. The traditional medical admonition of “when in doubt, play it safe” has been turned on its head in public psychiatry; now it is hard to get at-risk patients admitted unless it has been proved beyond doubt that they will definitely self-harm or harm others. As a result of this situation we have been calling for an audit or standing commission of inquiry into all suicide deaths. A commission of inquiry will provide the opportunity to examine all evidence and witnesses (including health providers and mental health service managers) and to make recommendations about improving services. The advantage of a judicial commission is that it will be independent of government and health services and should be able to make findings and recommendations unbiased by outside influences.
Publish mortality data and number of mentally ill in prisons and homeless
It is important to publish mortality data from natural causes (including a breakdown of causes of death), suicide, homicide, police shootings, and accidents. Mortality data and operative complication rates are now becoming required even for individual surgeons. Anaesthetists for many years have provided a model of how to use their tiny number of deaths to reduce mortality even further. If, as in all other life-threatening illnesses/procedures, we keep track of all the deaths, note whether the numbers are increasing, and look carefully at each one to see how, when and whether it could have been prevented, then that will tell us clearly how well the system is working. Data should be published on the numbers of deaths or serious assaults caused by individuals suffering from mental illness under care of public mental heath services. In mental illness we also have two other measures which, although social rather than medical, are nevertheless definite enough to be counted as clear indicators of how the system is working. These are the number of gaoled and homeless individuals with a significant mental illness.
Replace ‘mainstreaming’ with ‘parallel but integrated’ mental health services
Let us acknowledge that the ‘mainstreaming’ policy has its limitations and a move to another model is now needed. An alternate model would recognize the special needs of individuals with mental illness and build a system of care from there while utilizing the strengths and services that comes from close association with general health services. This change in direction would facilitate the development of community, emergency department, inpatient, sub acute, extended care, and residential supervised accommodation services that better meet the needs of the mentally ill. Parallel but integrated services should replace the ‘mainstream’ model. A major build of clustered 24-hour supervised accommodation around embedded rehabilitation and recovery services is urgently needed for longer stay patients.
Enhance training opportunities
A substantial increase in training opportunities beyond public mental health services is required for medical students, registrars, allied health professionals and nurses in order to provide comprehensive knowledge and skills in psychiatry. More training positions in the private sector and in other settings (such as non government organizations [NGO] services) are needed and should be affiliated with learning organizations such as universities and institutes. Methods of funding these positions will be a major challenge, but without this broadening of psychiatric training the profession will wither. With foresight and vision, regional medical communities might just provide the opportunities needed to overcome this looming crisis. The establishment of training positions for doctors, nurses and other mental health professionals in private hospitals and clinics, and NGO services, all affiliated with local medical schools and educational institutes would go a long way to place mental health training on a secure footing. Even within the public sector a change in the teaching environment would help – dedicating some inpatient and outpatient services for voluntary patients only would expand the range of conditions seen and the types of treatment interventions able to be employed, thus offering a more satisfying learning experience.
While a major investment of public resources is required to deal with the mental health crisis, the money will not be well spent unless issues of accountability, service direction and training are addressed.
Comments would be appreciated.