Finding direction in mental health

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 recent 'Not for Service Report'). This primarily affects public mental health services.

In my opinion, the problems in mental health stem from the following difficulties. First, 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 in-patient care from hospital emergency departments, when decisions are made to discharge patients from in-patient 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 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. A recent article in The Australian newspaper (Kate Legge, 19/7/05) 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.

Second, 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 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 in order to access community case management. Another article in The Australian (Clara Pirani,4/7/05) highlighted psychiatrists needing to use these practices in order to get appropriate care for their patients.

Third, 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 emphasised 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 marginalisation 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 marginalisation. Indeed, belatedly, there is now recognition that separate psychiatric emergency departments need to operate in public hospitals. But beyond the emergency department,  mentally ill people need in-patient 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.

Having got to this "mental health crisis" what can be done?

In my opinion, the first action is to emphasise 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 has called for a standing coronial 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.

The second action is to acknowledge that the “mainstreaming” policy has its limitations and a move to another model is now needed. An alternative model would recognise the special needs of individuals with mental illness and build a system of care from there, while utilising 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, in-patient, sub-acute, extended care, and residential supervised accommodation services that better meet the needs of mentally ill people. 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 and service direction are addressed.