Australian mental health in crisis

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.