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Australian mental health in crisis

By Philip Morris - posted Tuesday, 2 October 2007


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.

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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.

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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.

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About the Author

Dr Philip Morris is Executive Director of the Gold Coast Institute of Mental Health. He is Medical Director of Mirikai, a young adult drug and alcohol rehabilitation program on the Gold Coast and he has a private psychiatric practice, The Memory Clinic, on the Gold Coast and in Brisbane. Dr Morris is the President of the Gold Coast Medical Association.

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