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.
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.
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