14 October 2017
We’re coming to the end of Mental Health Awareness Week which is always held during the week of World Mental Health Day (10 October). Not a mention of mental health however from our politicians this week, who have been very busy trying to work out who should be in power. I suppose we should be grateful for all the talk about improving mental health services during the election campaign, though I would point out that action in this area would be much better than talk.
Too many kiwis are suffering with inadequate access to mental health services they desperately need. Our suicide rates lead the world statistics. Unlike other medical conditions where physical injury is obvious for all to see, mental illness is harder to understand because it is unseen. Much easier to sympathise with someone who has a broken leg and understand their immobility issues than with someone who is depressed, schizophrenic or suffers from PTSD and understand what they are going through.
We’ve made some gains in understanding, largely due to the excellent work of people like Sir John Kirwan who have made mental illness less stigmatized. But we’ve a long way to go yet, especially in providing easy access to quality treatment. I wrote an article for my weekly political publication (Heather Roy’s Diary) in 2008 about mental health. Sadly, not much has changed. Let’s hope, when a government is formed that some of that pre-election concern to improve services translates into action.
Heather Roy’s Diary article
(first published on 1 August 2008)
This week I discovered that the five-year plan for the Hutt Valley DHB’s Mental Health services proposes that the number of acute inpatient beds be reduced from 28 to just eight for a catchment of almost 140,000 people.
There are also currently 32 acute beds in Wellington Hospital’s mental health ward. This unit is constantly under pressure – frequently with many more patients than beds, and several patients committing suicide while in care in recent years. I’m sure this plan to cut bed numbers will not be confined to the Hutt.
The problems began in the 1970’s with the fashionable trend to ‘community care’, and the subsequent de-institutionalisation. The few acute beds now left nationwide are often taken by medium and long-term patients with nowhere else to go. Many of the NGOs paid to care for these patients refuse the severe or tricky patients and cherry pick. Hospital beds, occupied by these patients cannot then be used for the acute patients they are intended for.
Police cells also often house the mentally unwell while a psychiatric bed is frantically sought. Unfortunately far too many people with a psychiatric condition are in prison, having committed and been convicted of crimes when their main problem is having fallen through the cracks of a mental health system that has failed them. An estimated 15% of the prison population suffers from a mental illness that should be treated.
There is much reason to be optimistic about providing quality care to the mentally unwell. Drug therapies developed since the 1950’s have revolutionized many lives worldwide. This spurred the mass closures of the old psychiatric asylums, which were huge institutions run along authoritarian lines. At its height Porirua Hospital housed 2000 patients.
For most of these people de-institutionalization was a good thing but there was flawed thinking, based mainly on financial savings that closure of big hospitals brought. Community care was embraced with most psychiatric problems dealt with in out-patient clinics and patients using mainstream medical services for other requirements. However the pendulum swung too far, with costs of psychiatric care rising steeply and accounting for around 10 percent of total health expenditure. In theory at least this part of Vote:Health is ring-fenced funding.
In short, New Zealand’s Mental Health policy over the past 20 years has been disastrous. Policy decisions have managed to squander scientific medical advances so that the burden of long-term illness has not declined as with other areas of medicine.
Further, the skyrocketing use of ‘recreational’ drugs has added greatly to the complexity of issues experienced by with mental illness. ‘Dual diagnosis’ – those with a mental illness and a drug or alcohol addiction – is becoming increasingly common.
Mental Health Services need to be administered separately from other arms of the Health service. This is for their own protection, as their budgets are routinely looted to pay for hospital overheads – a fact that is strenuously denied, but which is an inevitable consequence of the appraisal of senior hospital executives. Surgical procedures for example are easy to count, while mental health outcomes are hard to measure, increasing the temptation to swap money between budgets.
What we need to do is get away from the false dichotomy between ‘hospital’ and ‘community’. Psychiatric conditions come in a range of severities and disability and therefore require a range of services. It should be possible for a patient to move smoothly between areas of varying clinical support, but it is not under the current system which is split between 20 DHBs and further split between hospital and trust providers.
A patient should be able to access an acute bed for a short period and move on to medium-term care with less support when their condition stabilizes. Recognition that some will require long-term support would go a long way to alleviating the situation where acute beds are clogged with these patients, or worse, where too many mentally unwell kiwis live rough on the streets or in prisons because the health system has given up on them and society has turned a blind eye to their plight.
The fact is that the closure of large psychiatric hospitals was welcome where it reflected improved treatment, but unwelcome when all long term hospital beds were closed for reasons of political correctness. While treatments improved, nothing works 100% of the time and there are many options that continue to be ignored. Sheltered villages for example, could provide the care that many people require, either in the short or long term.
Advertising campaigns to address the stigma issues attached to mental illnesses are slowly working with the general public but until policy makers take real notice of the issues of the mentally unwell – including proper housing – nothing will change and psychiatry will continue to be the ‘poor cousin’ of the heath sector.