Abstract
DEAR SIR
We are an experienced group of public sector psychiatrists. We work in a number of integrated mental health services in New South Wales (NSW) and have attempted to provide quality mental health services in an equitable manner within the constraints of the NSW public health-care system. We are writing to raise and discuss an issue we believe is severely impeding our ability to work in public practice. We believe this issue affects all public sector psychiatrists and erodes the possibility of a meaningful, long-term career in the public sector.
We are concerned about the mismatch between public statements and policy, public expectations and perceptions and the reality of what can be achieved in public psychiatric practice. A number of factors influence this dynamic, including the following.
The symptom severity and level of behavioural disturbance of patients seen in the public sector, and in particular the increasing levels of violence to which both patients and mental health workers are exposed. This violence may be directed to others or toward the patients themselves. Due to the overall reduction in bed numbers and the push to discharge patients from hospital as rapidly as possible, the forming of meaningful therapeutic relationships is consequently discouraged and undermined. In contrast, while the evidence base for lengthy hospital stays is virtually non-existent, the system does not accept negative outcomes. In fact a culture of apportioning blame for these outcomes has served to exacerbate the process of demoralization among psychiatrists.
The public expectation that public sector psychiatrists are able to contain and prevent violence in all patients with severe personality disorders. Although we might assist in preventing violence in patients who are psychotic, there is no evidence that we can accurately predict or in any way prevent violence in personality disordered patients. In addition, there is no evidence that we alter the outcome for those suicidal patients with severe personality disorders who express suicidal ideation or repeatedly self harm. Once again, when decisions are made that result in negative outcomes, the public sector psychiatrist is held to account. In addition, it has been suggested that some hospitals’ insurers are considering not representing doctors at coronial inquiries because there is little to be gained for the hospital apart from incurring legal costs. This will no doubt add to the stress experienced by doctors as a result of these difficult processes.
The information made available to the public by various mental health authorities is often incomplete and inaccurate. Attempts to portray services in a simplistic, positive light has the effect of creating unrealistic expectations that cannot be met. Much fanfare is made of the various projects to assist in the prevention of youth suicide or the prevention of suicide in patients with a variety of mental illnesses. We feel that although it is important to provide the public with information, it is also extremely important to provide a truthful and balanced view. We have not succeeded in decreasing the suicide rates. Rates vary but approximately 10% of patients with schizophrenia and 15% of patients with affective disorders will kill themselves. Despite the best of intentions, we know that patients are at highest risk for suicide on the day and in the month they are discharged from hospital. This does not seem to be affected by the length of stay in hospital. These facts are not presented or taken into consideration when the public awareness of mental health issues is raised.
As discussed here, the vast array of evidence that we have thus far on preventive interventions serves to elucidate the problems but does not actually provide solutions. Nonetheless, psychiatrists are held to account for patient suicides and other acts of aggression. (The situation is further complicated by the unclear lines of authority and accountability in the mental health-care system. The contributions of various multidisciplinary team members are to be encouraged but largely it is the psychiatrist who is held responsible for negative outcomes, whether he/she is in control of the management protocol or not. There do not appear to be any clear guidelines on the process of decision-making in multi-disciplinary settings, nor in the lines of responsibility and accountability that are recognized and adopted across the various disciplines.)
We therefore find ourselves caught between trying to provide evidence-based quality services from a limited resource base amid unrealistic expectations from the public who are, in turn, informed by policy makers intent on promoting popular achievements (e.g. the funding of a new suicide prevention programme or the opening of a newly renovated psychiatric unit in a general hospital). The closing down of most institutional beds and the push to provide services in the community (without adequate resources) all serve to increase expectations and create intolerable pressures for those working within the public system.
What we are requesting is an environment that enables the provision of quality services within a reasonable resource base. This will encourage the formation of stronger therapeutic relationships with clients, an increase in the practice of evidence-based interventions and the continued striving for improving outcomes. Part of the solution may involve the provision of State-wide units for violent patients, which could reduce the violence and anti-therapeutic environment in which patients and clinicians find themselves in general hospitals.
Of paramount importance is a realistic and truthful public debate about what we can and cannot achieve given current resources and our current knowledge base. If the present rhetoric continues unchallenged, and the outcomes remain the same, this will serve to erode public confidence in mental health services and further demoralize committed public psychiatrists.