Australian mental health in crisis

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.

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 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 means that patients who need hospital admission may not get it, patients who need longer stays in hospital may be discharged too early, and those 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 less than 30-years-old 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 per cent 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 per cent 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 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.

“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 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 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 New South Wales, 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 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 quietly on December 23, 2003, the figures were actually 68 in 1993, 72 in 1994, jumping to 100 in 1995, i.e. a dramatic increase of 47 per cent in just three years, which has continued subsequently to a total increase of at least 300 per cent 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 the 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.

By the time they get to their clinical years medical students have a negative view of psychiatry. Either the other medical and surgical specialties 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?

Accountability

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 the 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.

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 and should focus on the pathway to death of the individual and the nature of contact over the preceding three months between the individual and 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.

The 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 hospitalise people at lower levels of concern than we do now.

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 unbiased findings and recommendations.

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 jailed 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 alternative model would recognise the special needs of individuals with mental illness and build a new system of care while utilising the strengths and services that comes from close association with general health services.

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 organisations) are needed and should be affiliated with learning organisations 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.

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.