Inpatient and compulsory treatment: when doctors need help

WHILE I have written elsewhere (here and here) about the experience of depression and treatment as well as the importance of seeking help, I want to address overcoming the barriers doctors may face in having an inpatient admission and the potential role of compulsory mental health treatment.

I am a psychiatry trainee nearing Fellowship and based in regional Victoria. I have worked at a few different metropolitan and regional services in different states over the years and know a lot of people in medicine and allied fields.

I also have been battling depression for the better part of the past year. I’ve engaged with a variety of psychotherapy approaches to address particular issues with mixed success. Medication options for me are limited due to tolerability, but I have a combination that works as well as it can. I have had acute and maintenance transcranial magnetic stimulation (TMS) to target residual excessive reactivity to negative events and intrusive thoughts of suicide as well as residual physical symptoms (mainly reduced appetite).

Initially, all of my treatment had been in the outpatient setting. I had chosen to do outpatient TMS to reduce the impact on my daily life. Little did I know how much TMS would affect my energy levels – I get absolutely exhausted and spend much of my free time during a course sleeping. I decided that if I needed TMS again, I would opt for an inpatient setting so that it could be over faster (and actually have less impact on my daily life).

There is also the issue of health fund coverage for outpatient TMS; I am only aware of two funds that cover it, to a very limited extent. Thus, I recently had a voluntary, private mental health admission with the main purpose being maintenance TMS. I decided to be admitted earlier than initially planned because of increasing suicidal ideation and tearfulness.

For myself, I knew it was time for hospital when I started to become angry that I had protective factors, resenting having obligations to others in my life, and wishing I could die without harming anyone else. It is a very unsettling place to be.

Most doctors have some impression of inpatient mental health wards, particularly in the public sector, that is based on personal experience as a clinician either specialising in psychiatry or as part of hospital rotations.

In the public system, we treat patients who are the most unwell and the least able to have care in any other setting. We also care for people who may have serious substance use disorders or severe personality disorders.

I would not be surprised if my colleagues reading this have images of inpatient psychiatric wards that are not so dissimilar to that of the general population as we would like to think, a view that has been influenced by often negative depictions in popular culture.

In my clinical experience, public psychiatric wards can range from chaotic and scary to pleasant and social, and I don’t intend to malign public mental health by any means. We work with what we have, and some services have done absolutely amazing things with very limited resources. Consider, though, as a doctor, would you want to be an inpatient where you have worked? If you had to choose between managing precariously at home versus sending a close relative to your ward, where would your comfort sit?

I do not have any illusions that it would be nearly as pleasant as my private admission, but sometimes it is necessary to be somewhere – anywhere – safer.

My admission has been a transformative experience. Even though it is a private facility, I still had many concerns.

Confidentiality was at the top of my list (both colleagues and co-patients included). Although I am quite open about my experiences with mental health difficulties, there are of course some things I am very private about. I was also concerned about being required to go to group sessions, the expectation to socialise on the ward, the act of relinquishing a lot of control over my daily routine and comfort, and maintaining my religious observances while in hospital.

It has taken me many months to come to the point of accepting inpatient care. I had planned a Prevention and Recovery Care (short term clinician-led residential psychiatric rehabilitation) admission during a period that was going to be particularly stressful in my life, but in the end I made alternative arrangements.

I have also considered crisis admissions when suicidal ideation was particularly severe, but I always found an excuse not to go to hospital. Often it was telling myself that my risk was not high enough for a public system admission, that I had work to do, or that I couldn’t justify paying my health fund excess.

There was always an excuse not to check myself in when I should have. While my psychotherapist pointed out the ludicrous nature of my reasoning, it was TMS that gave me what I perceived as a legitimate reason to go to hospital.

Being an inpatient has given me the confidence to be an inpatient regularly for maintenance TMS, but it has also given me reassurance to seek admission when my risk escalates or my mental health deteriorates.

I am still highly concerned about confidentiality and I avoid other patients (who may one day be my patients or at least know my patients). I do want to maintain some degree of separation in that regard. I am, however, able to take a break from my stressors and do work on myself without the distractions of work and home. I am also able to know for sure that I am safe while I recover.

I suppose I also in some way feared judgment from colleagues that kept me from seeking admission, but the reality is that I have experienced nothing but care, respect, and even admiration. One nurse said that I set a good example for other clinicians by coming into hospital. That’s what I hope to do by being open about my own experiences and writing about them to reach a wider audience.

There was a point, looking back, at which, had I been assessing myself, I would have made myself a compulsory patient. Somehow, I made it out the other end, but it was a very dark time.

I think it is important to address compulsory treatment, as this is a fear that many have, both within the profession and among lay people. Each country, state and territory has its own legislation around compulsory mental health treatment, but there is a general movement in mental health in Australia and New Zealand toward being as least restrictive as possible.

When we are affected by mood disturbance, substances or psychosis, we begin to lose our capacity to make sound assessments and decisions around our own mental health, risks and treatment, even if we retain our judgment around assessing and treating our patients. As much as we rely on them professionally, safety plans may not be followed when someone becomes very distressed.

I am firmly of the opinion that being a health professional needs to be taken as high risk on the same level as things we take very seriously, such as access to firearms. Relatively recent Australian research tells us that:

“Suicide rates for female health professionals were higher than for women in other occupations (medical practitioners: incidence rate ratio [IRR], 2.52; 95% CI, 1.55–4.09; P < 0.001; nurses and midwives: IRR, 2.65; 95% CI, 2.22–3.15; P < 0.001). Suicide rates for male medical practitioners were not significantly higher than for other occupations, but the suicide rate for male nurses and midwives was significantly higher than for men working outside the health professions (IRR, 1.50; 95% CI 1.12–2.01; P = 0.006). The suicide rate for health professionals with ready access to prescription medications was higher than for those in health professions without such access or in non-health professional occupations. The most frequent method of suicide used by health professionals was self-poisoning.”

Data from overseas tell us that health care workers, especially those working in mental health, die by suicide at rates much higher than the general population. Health care workers (especially doctors and pharmacists) also know far too much about anatomy and pharmacology, as well as what “works” and “doesn’t work” based on what we have seen clinically. First attempts can be lethal on this basis. We also know what to say to reassure people and how the system works.

Although I can’t speak for others, my experience is that doctors tend to be decisive and driven people. We carry out our decisions one way or another. When the decision is to die, this is a very dangerous situation.

There is absolutely no shame in requiring compulsory mental health treatment. Compulsory treatment is designed to override the inaccurate perceptions we have of our own risk and needs that I described above. Compulsory treatment also does not guarantee an Australian Health Practitioner Regulation Agency (AHPRA) notification, which requires that practising your profession would pose significant risk to the public.

I have stipulated in my own management plan that compulsory treatment should be considered if hospitalisation is indicated or if I am unable to engage in a very solid safety plan. I hope sharing this sets an example to others who could be concerned about seeking help or about having compulsory treatment.

My message is fundamentally: seek help, whether that is inpatient or outpatient, in-area or out-of-area, formally or informally. If you find yourself requiring compulsory care, it is not a failure or something to be embarrassed about. Recovery means being able to overcome our difficulties and be more able to reach out early in the future.

Dr Israel Berger is a Child and Adolescent Psychiatry Advanced Trainee at Goulburn Valley Health and is involved in medical and public health education at the University of Sydney and Monash University.

If this article has raised issues for you please reach out to any of the following resources:

DRS4DRS: 1300 374 377

• NSW and ACT … 02 9437 6552
•     Victoria … 03 9280 8712
•     Tasmania … 1800 991 997
•     Queensland … 07 3833 4352
•     WA … 08 9321 3098
•     SA and NT … 08 8366 0250

 Medical benevolence funds

•  NSW … https://www.mbansw.org.au/ 
• Queensland … https://mbaq.org.au/
• Victoria … https://www.vmba.org.au/
• South Australia … http://doctorshealthsa.com.au/resources/medical-benevolent-association-of-sa

AMA Peer Support Line … 1300 853 338 or 1800 991 997

Hand-n-Hand Peer Support … www.handnhand.org.au

If you or someone you know is having suicidal thoughts, there are people here to help. Please seek out help from one of the below contacts:

•      Lifeline | 13 11 14 | 24-hour Australian crisis counselling service
•     Suicide Call Back Service | 1300 659 467 | 24-hour Australian counselling service
•     beyondblue | 1300 22 4636 | 24-hour phone support and online chat service and links to resources and apps

The statements or opinions expressed in this article reflect the views of the authors and do not necessarily represent the official policy of the AMA, the MJA or InSight+ unless so stated.

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