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VICTORIAN findings that a growing number of children and adolescents are presenting to emergency departments (EDs) in mental health crises highlight a “national scandal”, says a leading psychiatrist.
Professor Patrick McGorry, executive director of Orygen, the National Centre of Excellence in Youth Mental Health, said that the increasing number of young Australians presenting to EDs with mental health disorders was the result of state governments’ demonstrable disinvestment in community mental health services across the lifespan.
“Australian Institute of Health and Welfare has revealed that this pattern is particularly marked in Victoria because of severe underfunding in recent years of community-based mental health services, but it’s a national trend,” said Professor McGorry, who is also professor of Youth Mental Health at the University of Melbourne.
“It’s caused by disinvestment in crisis assessment and treatment teams, and community mental health. The only way you can get mental health care is by ending up in a crisis situation in an ED, but EDs and acute inpatient units are traumatic, even toxic, for patients and these days really just contain risk. What’s happening here is the legacy of failed deinstitutionalisation and is a national scandal.”
Professor McGorry was commenting on research published in the MJA that found that from 2008 to 2015 there had been a 46% increase in mental health presentations to Victorian EDs in people aged 19 years and under. This represented an average annual increase of about 6.5% for mental health presentations, while physical health presentations increased by an average of about 2% annually.
In 2008, mental health presentations accounted for 1.7% of all presentations, but by 2015, this had increased to 2.2%.
Self-harm accounted for 22.5% (11 770) of mental health presentations, psychoactive substance abuse for 22.3% of presentations (11 694), while stress-related, mood, and behavioural and emotional disturbances accounted for 40.3% (21 127) of presentations.
Professor Ian Hickie, codirector of the University of Sydney’s Brain and Mind Centre, said that demand for mental health services was growing across all aspects of the health system.
“When that demand is not met in the primary care sector, through early intervention, or the ambulatory care sector, and it becomes more severe and out of control, the end result is presentations in the emergency setting,” said Professor Hickie, who is also a National Mental Health Commissioner. “If that is the only place to go, then that’s where families and young people will go.”
Professor Hickie said that the study highlighted the worrying trend of increasing self-harm in young adolescents, particularly in the group aged 10–14 years. Young people in the 10–14 year age group represented 14.8% of mental health presentations in 2008, increasing to 18.5% in 2015.
“The problem is slowly getting worse at younger ages and we have not developed a sophisticated service capability to respond,” he said.
Dr Paul Robertson, Chair of the Faculty of Child and Adolescent Psychiatry at the Royal Australian and New Zealand College of Psychiatrists, said that it was likely that the increasing ED presentations reflected both an increase in the number of children and adolescents with mental health difficulties, as well as an increase in help-seeking behaviour.
“There has been an increase in help-seeking behaviour around mental health problems in our population, but the difficulty is having effective and accessible services to provide that help. The service provision hasn’t kept up with that demand for treatment,” Dr Robertson said.
Dr Simon Judkins, president of the Australasian College for Emergency Medicine (ACEM), said that EDs were seeing an increasing number of patients with mental health disorders across all age groups.
“When people do come to the hospital in a crisis and need to be admitted, there just aren’t the beds for them, so patients are spending extraordinary amounts of time – often 8–12 hours – in EDs, which is obviously detrimental to their ongoing wellbeing,” Dr Judkins said, adding that the ACEM had had reports of patients spending 3–4 days in EDs waiting for inpatient beds.
In February 2018, the ACEM released the findings of its Mental Health Access Block study and called for a new approach to mental health care in EDs, including mandatory reporting of cases involving waiting times for inpatient beds of more than 12 hours.
Dr Judkins said that the MJA study clearly showed that patients and parents didn’t know where to go to get help for mental health or could not afford care.
“That’s something that should ring enormous alarm bells that people in need of care are not getting care because they don’t know where to go, can’t be seen in time or can’t afford care; I don’t think that’s something that our community would think is fair.”
In an MJA podcast, lead researcher Professor Harriet Hiscock, Director of the Royal Children’s Hospital (RCH) Health Services Research Unit, said that further research was needed but a lack of mental health literacy among parents seemed to be one factor driving the increase in ED presentations.
She said that an RCH child health poll indicated that parents of primary school-aged children in particular had difficulty in recognising mental health problems in their children.
Professor Hiscock said that parents also struggled to know where to turn for help, but there were places to go.
“In the community, it’s anything from the GP who might refer you to a psychologist or a paediatrician or a psychiatrist. Schools have counsellors and psychologists, which are obviously really involved with children’s mental health, so there are other places to go, but often the parents don’t recognise that there is a problem, or they are not sure where to go,” she said.
In the MJA study, the researchers said that potential solutions included public health campaigns to improve awareness among caregivers of mental health symptoms and where to seek help. They also said that providing GPs with skills and financial resources for managing social, emotional and behavioural problems during early childhood was important.
But both Professors Hickie and McGorry said that upskilling GPs was not the answer.
“There is no effective system sitting around late primary school/early puberty, and what we are seeing is a growth in the need for serious, coordinated multidisciplinary care,” Professor Hickie said. “The simple ‘send it back to GPs and we’ll pay GPs more to do it’ isn’t going to work.”
Professor Hickie said that the Better Access initiative had a role to play, but out-of-pocket costs rendered services out of reach for many parents.
Professor McGorry said that states and territories needed to invest in a revived assertive community mental health system, which had “fallen to ruins”, particularly in Victoria, in the past 10–15 years.
He said, for young people, the headspace model was part of the solution, but it was only resourced to address early stage and mild to moderate presentations and needed to be urgently strengthened.
“[headspace is] currently not able to deal with the more complex and life-threatening situations. That’s what the state governments are supposed to fund through public mental health care, but they do not, and the Federal Government should also contribute to this missing step in the system of care,” he said. “You could say that headspace is the ‘thin green line’ in mental health care, but it needs to be a lot thicker if you are going to turn back this tide of mental health presentations to EDs,” he said, adding that renewed investment in community-based care across the lifespan was also crucial.
“I support the AMA’s call earlier this year for this to be urgently addressed.”
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“The only way you can get mental health care is by ending up in a crisis situation in an ED, but EDs and acute inpatient units are traumatic, even toxic, for patients and these days really just contain risk. What’s happening here is the legacy of failed deinstitutionalisation and is a national scandal.” This is indeed a scandal, with EDs being seen as the fallback for shortcomings in so many other systems. In the guise of “mainstreaming”, mental health services have displaced their acute care roles to EDs, without providing the post-ED services that these acute patients need. It is not uncommon for admitted mental health patients to spend DAYS in a confined area of ED – the antithesis of the environment that is needed for their care. Competent advanced-practice nurses can provide early assessment, but may have no power in moving patients to more appropriate areas for care. There is huge disparity between public and private services, and yet socio-economic factors are particularly important in mental health recovery.
I have had to navigate the youth metal health space myself recently, with a daughter diagnosed with an eating disorder. If it is this difficult to find the right resources with a 25 plus year career in health, how does someone with no experience manage to find the right resources and assistance? Youth mental health funding is a disgrace.
From website drphilipmorris.com
Mainstreaming’ of mental health services
Over the past 20 years there has been a push by public mental health services to ‘mainstream’ the care of individuals suffering from mental illness. This means providing services for them within the general health system rather than a separate service for psychiatric illness. While this has emphasized the role of the general practitioner in providing treatment, and had some (limited) benefit of reducing stigma and curtailing the excesses of some treatment practices in the older, or more isolated, stand alone psychiatric facilities, the policy more broadly has been a failure. The unique needs of individuals suffering mental illness have not been fully appreciated and provided for and this has led to a secondary marginalization of mentally ill patients in general health services. One needs to look no further than the way patients with mental illness and substance abuse are treated in busy public hospital emergency departments to see evidence of this marginalization. Indeed, belatedly, there is now recognition that separate psychiatric emergency departments need to operate in public hospitals. But beyond the emergency department the mentally ill need inpatient units with plenty of space, sub acute and extended care treatment facilities, and properly supervised community residential accommodation – all features that are not usually offered or supported by general health services.
Replace ‘mainstreaming’ with ‘parallel but integrated’ mental health services
Let us acknowledge that the ‘mainstreaming’ policy has its limitations and a move to another model is now needed. An alternate model would recognize the special needs of individuals with mental illness and build a system of care from there while utilizing the strengths and services that comes from close association with general health services. This change in direction would facilitate the development of community, emergency department, inpatient, sub acute, extended care, and residential supervised accommodation services that better meet the needs of the mentally ill. Parallel but integrated services should replace the ‘mainstream’ model. A major build of clustered 24-hour supervised accommodation around embedded rehabilitation and recovery services is urgently needed for longer stay patients.
Conclusion
While a major investment of public resources is required to deal with the mental health crisis, the money will not be well spent unless issues of accountability, service direction and training are addressed.