Abstract
DEAR SIR,
Australia has a mental health crisis. Despite two 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 the recent ‘Not for Service’ report (http://www.mhca.org.au/notforservice/report/index.html) and Senate Select Committee report on mental health (http://www.aph.gov.au/Senate/committee/mentalhealth_ctte/report/)). This primarily affects public mental health services.
CAUSES OF THE CRISIS
In my opinion, the problems in mental health stem from the following difficulties.
Rationing
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 may be 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 admitted, that patients who need longer stays in hospital to aid recovery 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 (Kate Legge, 19 July 2005) drew attention to 42 suicide deaths in Victoria among young people under the age of 30 over a 2 year period where inadequate treatment was linked to the suicide. Lack of mental health beds for highrisk patients, too rapid discharge and lack of intensive treatment were problems identified.
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 use of the least restrictive forms of treatment. 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 resources (‘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 to access community case management. Another article in The Australian (Clara Pirani, 4 July 2005) highlighted psychiatrists needing to use these latter practices in order to get appropriate care for their patients. Unfortunately, across the world, the introduction of new mental health acts, and mental health policies and plans are associated with increased suicide rates when compared with national drug policies that are associated with lowered suicide rates. 1 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. Clearly, something is seriously wrong with these new mental health initiatives.
‘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 has 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 from mental illness have not been fully appreciated and provided for under mainstreaming 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 (24 hour) community residential accommodation –all features that are not usually provided 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 difficult to access (Lennane J: personal communication). 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. Readily available data of this nature would be expected of medical and surgical health services, but are not routinely published by mental health services. As a result, we have little idea of the ongoing performance of mental health services on the most serious of outcomes –mortality.
Limited training opportunities
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) 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 programmes 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 notable exceptions), this is causing serious problems for training the next generation of mental health professionals.
HAVING GOT TO A ‘MENTAL HEALTH CRISIS’, WHAT CAN BE DONE?
Accountability
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 (http://www.gcimh.com.au) and the Gold Coast Medical Association have called for a standing commission of inquiry into all suicides in order to monitor the quality of mental health care.
A standing commission of inquiry into all suicide deaths
A standing (ongoing) 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 and examine them under oath. The inquiry should be required to focus on the pathway to death of the individual and the nature of contact over the preceding year between the individual and public (and private) mental health services. The inquiry should make regular comment on 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.
Publish data on mortality and number of mentally ill in prisons and who are homeless
All mental health departments should regularly (annually or six monthly) publish mortality data from natural causes (including a breakdown of causes of death), as well as from suicide, homicide, police shootings and accidents for all individuals under the care of public mental health services. This information will allow clinicians, patients, carers, administrators, politicians and interested members of the public to evaluate the progress of mental health services and see how well the system is working. Data on the number of deaths and severe assaults caused by individuals suffering from mental illness under care of public mental heath services should also be published. Two other measures should be counted as clear indicators of how the system is performing. These are the number of people in gaols and who are homeless who are suffering from a mental illness (Lennane J: personal communication). Publication of these data from regular surveys will give an indication of the effectiveness of broader psychosocial care provided for the mentally ill.
Replace ‘mainstreaming’ with ‘parallel but integrated’ mental health services
Let us acknowledge that the ‘mainstreaming’ policy has had its day and we need to move to another model of service provision. An alternate model would recognize the special needs of individuals with mental illness and build a system of care from that position while utilizing the advantages and medical services that comes from close association with general health services. This change in direction would facilitate the development of specialized community, emergency department, inpatient, subacute, 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 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-govern-mental organizations’ 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.
CONCLUSION
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.