The Ailing State of Mental Health Care and A Roadmap to Recovery: Overcoming the Mental Health Care Crisis
Prof Philip Morris AM
22 July 2024
Good morning. Kia ora.
Mental health care systems are facing a crisis, marked by systemic failures and inadequacies despite years of reforms and national initiatives. Here’s a closer look at the challenges and proposed solutions.
While this talk is focussed on Australia, I did try to find out what challenges face mental health services and systems in New Zealand.
NZ Hearld on Sunday! Police trying to distance themselves from involvement in mental health. Like Australia – Queensland police moving in the same direction – wanting to avoid mental health callouts and extended time in emergency departments. This is a problem for ‘mainstreaming’. I will discuss this later.
Both Australian and New Zealand have annual suicide tolls. 3249 in Australia in 2023, a rate of 12.3/100,000. In New Zealand 565 in 2023, a rate of 10.6/100,000. In Australian rate increases with age (especially older men), in New Zealand rate higher in younger individuals (18-35). Compare with road mortality toll in Australia 1266 in 2023, a rate of 4.8/100,000. In New Zealand 343 deaths in 2023, a rate of 7.2/100,000. The suicide deaths are three times that of the road fatalities. Yet, there is no public accounting of this information by nation, state or region! I will mention this phenomenon later.
The practice structure of psychiatry in Australia and New Zealand is very different. Mainly public service positions in New Zealand, but in Australia a mixed public and private setting of practice. About 60-70% of psychiatry in Australia is in private practice. This has major implications for the type of patients seen in the two settings and well as for providing comprehensive and diverse training and skills. This is less of a problem for New Zealand.
Finally, both countries face a severe shortage of mental health workforce – psychiatrists, nurses, clinical psychologists.
So, the following remarks apply to Australia, but some also are relevant to New Zealand.
Resource Shortage and Rationing of Services
- Severe shortage of resources leads to rationing of mental health services (especially public mental health services).
- Only the most severely ill individuals receive treatment, leaving many without care. This ignores the ‘missing middle’.
- Consequences include delayed hospital admissions, premature discharges, and insufficient follow-up care (especially for high-risk patients).
- Linked to alarming rates of suicide, especially following post-emergency department visits and premature discharges. Queensland study of 140 ‘unexpected deaths’. More that 50% mental health patients, most died by suicide either one week following an emergency department presentation or one week after discharge from a psychiatric unit.
Impact of Mental Health Acts and Policies
- New policies often exacerbate the crisis rather than alleviating it.
- Acts prioritize patient autonomy but may hinder involuntary treatment when needed.
- Some patients placed under involuntary treatment at discharge to ensure follow-up care.
- Paradoxically, correlates with increased suicide rates, reflecting barriers to access.
Mainstreaming of Mental Health Services
- Integration into general health services aims to reduce stigma and improve access. A reaction to past psychiatric hospital excesses.
- However, often marginalizes mentally ill patients within the broader health system. Unique needs of patients not met.
- Inadequate treatment for those with co-occurring substance abuse issues.
- Calls for separate psychiatric emergency departments to address specific needs. Now we have examples of police forces not wanting to participate in mental health roles.
Closure of Psychiatric Hospitals
- Closing or downsizing large psychiatric hospitals dispossessed and displaced chronically ill patients.
- Lack of appropriate clinical care and rehabilitation opportunities. Limited clinically supervised long term accommodation leads to relapse.
- Exacerbates shortage of inpatient beds for newly disturbed patients. Chronic, often psychotic, patients now fill acute beds in inpatient psychiatric units
Lack of Transparency and Accountability
- Limited publication of mortality data (suicide, natural causes, homicide, serious assaults, police shootings) for individuals under mental health care.
- Hinders understanding of the crisis and implementation of targeted interventions.
- Neglects accountability and quality improvement measures.
Workforce Challenges
- Limited attractive training opportunities for mental health professionals – now results in depleted mental health workforce.
- Shortage of psychiatrists and psychiatric nurses.
- Unattractive training environment in Australian public sector jeopardizes future care quality and availability.
A Roadmap to Recovery: Overcoming the Mental Health Care Crisis
Mental health systems must take decisive action to reform its mental health care system. Here’s a proposed roadmap:
Emphasizing Accountability
- Prioritize patient welfare in mental health services. The patient must be at the apex of mental health care systems.
- Invest in staffing, facilities, and funding to support accountability.
- Conduct audits or inquiries into suicide deaths to monitor care quality both at local and regional levels. An example of one community mental health clinic. The inquiry must examine the ‘pathway’ to suicide.
Transparency and Reporting
- Publish comprehensive mortality data and outcomes for individuals under care.
- Track mentally ill populations in prisons and homeless communities.
- Guide interventions and improvements based on data insights.
- Establish a ‘suicide toll’ by nation, state, region for public and private mental health services. Use this data to measure effectiveness of interventions. For example, since isolation is a profound risk factor for suicide, then the effect of reducing isolation in the community and providing public education and training in mental health first aid could be assessed by this form of data.
Reassessing Mental Health Policies
- Move towards a model of ‘parallel but integrated’ mental health services.
- Develop specialized care alongside general health services, in the form of appropriate architecture, and step-down and rehabilitation units.
- Build clustered residential accommodation with 24-hour support for patients with severe chronic conditions to replace closed psychiatric hospitals.
Enhancing Workforce Development
- Increase training positions in diverse settings.
- Broaden the scope of psychiatric training.
- Welcome psychiatrists and other mental health professionals with compatible mental health qualifications.
- Cultivate a skilled and compassionate mental health care workforce.
Conclusion
Addressing the mental health care crisis requires bold reforms and collective effort. By prioritizing accountability, transparency, policy reassessment, and workforce development, mental health services can build a responsive and effective mental health care system accessible to all who need it. I hope these principles can be helpful to Australia and New Zealand.
Thank you. Mihi.
Philip Morris