Don’t Condemn Patients to Park Bench or Prison

Posted to site March 19, 2010

WHO cares about acute psychiatric beds? Nobody apparently. That is, nobody does until they need one.

When relatives or friends become so severely mentally unwell that they can no longer take care of themselves and neither families nor community mental health teams can look after them, a hospital bed is an absolute necessity.

When someone is so deluded that the real world turns on them with hostility, when they are so disorganised or aggressive that they are a danger to themselves or others, and when they are at risk of taking their own lives, a hospital bed can be life-saving.

But acute psychiatric beds in Australia are in short supply and chances are that when such a bed is needed none will be available. Why is this? Why is it that across Australia acute psychiatric beds are constantly full so that many who require urgent admission are turned away or have to wait for unacceptably long periods when they are severely ill?

Psychiatric bed numbers in Australia have decreased by 80 per cent over the past 40 or so years, during which time the population of the country has doubled.

Australia now has one of the lowest numbers of psychiatric beds per capita in the developed world, at about 60 per cent of the level recommended by experts.

Bed reductions accelerated when health planners saw new developments in community mental health care as a sign that hospitals were becoming unnecessary, since people with severe mental illness could be treated in their homes instead. Money was saved by closing beds, but the savings were not redirected sufficiently towards community services and supported housing.

This policy overlooked the fact that many patients were too ill to be treated in the community, and home-based treatments did not work for everyone, especially those who didn’t have homes or whose families were unable to care for them.

The consequences of this catastrophic reduction in acute psychiatric beds have been high rates of psychiatric illness among the homeless and the prison population. Another important consequence is that the atmosphere in many of our crowded, overworked and stressed psychiatric inpatient units resembles that in badly run menageries.

High rates of aggression and loud and demanding behaviours have become commonplace.

Among such clamour there is constant pressure to discharge patients prematurely to make room for new admissions, leading to high rates of early readmission when treatment in the community inevitably collapses.

It is almost impossible to maintain a therapeutic environment under such conditions and treat the high proportion of involuntary patients, many of whom
have complex needs requiring carefully considered, expert assessment. Yet the units are understaffed and patients are under the care of the most junior
and inexperienced doctors working with insufficient supervision.

The neglect of hospital-based care has led to substandard facilities, and even new units are often poorly designed, with insufficient provision for privacy,
recreational space and therapeutic activities. This sends a message that psychiatric patients are not deserving of respect and consideration, and they
act accordingly.

On the other hand, well-designed, humane hospital environments are inherently respectful of patients, who are then more likely to behave civilly as a consequence.

It is not, however, just a question of numbers, quality or distribution of acute psychiatric beds. Many hospital admissions can be averted by comprehensive, high quality community-based care and treatment, adequate levels of supported housing, assertive community case management and soundly based rehabilitation with supported employment programs.

But Australia’s investment in these services has been inadequate.

When such services of good quality are readily available, then hospital admission becomes much less likely.

But when hospitalisation does become necessary, these community services enable early discharge and successful return to the community, thus averting the access block caused by having nowhere to discharge patients to.

Unfortunately, since these services are insufficiently developed in Australia, the pressure builds up in the hospitals and the inevitable casualties spill
into the streets and prisons.

The problem is thus twofold. There are not enough beds because we have gone too far with our bed closures. There are not enough community mental health services to help prevent admissions in the first place, or to provide ongoing community-based support, treatment and rehabilitation, without which the park bench and the prison become the alternatives to the hospital bed.

It is time for a root-and-branch reform of Australia’s mental health system. The problems with the system have been well known for far too long as dozens of reports attesting to the inadequacies of mental health care have gathered dust in government archives across the country. We are past the point where piecemeal change and unco-ordinated partial reforms can deliver the change that is needed. Australia needs a comprehensive restructure of its mental healthcare system now. This must include co-ordinated expansion of hospital-based facilities and community-based services. One without the other will fail.

Vaughan J. Carr is a professor in the school of psychiatry at the University of NSW, based at St Vincent’s Hospital, and chief executive of the Schizophrenia Research Institute.


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