Since the 1960s, the number of hospital beds for treating people with mental illnesses has declined dramatically in most OECD countries.
Australia has been among the most assiduous in implementing reform, reducing its public sector mental health beds by 80% during the past half century.
We now have one of the lowest number of psychiatric beds per capita in the developed world.
So what’s been happening behind hospital doors while the spotlight of attention has been on the development of community mental health services?
And what are the consequences for in-patient care of those with the most severe psychiatric disorders, such as people with schizophrenia and major mood disorders?
Research from the United Kingdom
A recent study published in the British Medical Journal reports that as the number of beds for the mentally ill has declined by more than 60% in England over 1988-2008, the rate of involuntary admissions under the Mental Health Act increased in synchrony – by more than 60% over the same period.
Involuntary admissions in the United Kingdom and Australia mostly involve acute care for the severely mentally ill in crises who cannot be managed in the community.
These admissions occur when there’s a danger of a patient harming herself or others, and usually apply to those with very severe mental illness.
Since the rates of severe mental illness haven’t increased dramatically over the past 20 years, have fewer available beds contributed to the rise in involuntary admissions?
Have delays in admission caused clinical deterioration, or have admissions that are too brief to achieve full remission of illness been responsible for early relapses?
The BMJ study doesn’t answer these questions and no study of comparable scope has been conducted in Australia. But, we do know something about what it’s like behind hospital doors in Australia when bed availability is severely constrained.
Lack of Australian data
A study conducted in New South Wales 10 years ago, when bed numbers in Australia had just about reached their nadir, found that just under half of all admissions were involuntary and 65% of beds were occupied by involuntary patients.
In that study of over 5,500 admissions in one year, around a quarter were very acute with risk assessments rated “high or extreme”; a quarter to a third involved incidents of aggression or absconding; and serious aggressive behaviour occurred in 11% of admissions against a general background of threatening behaviour and low-grade hostility.
Admissions were brief, with a median stay of 8 days. Rates of early, unplanned re-admissions were almost twice the State benchmark, and bed occupancy was high (over 88%).
Bed occupancy was in the critical range of over 90% about half the time, meaning that on these occasions there was insufficient spare capacity to manage the emergency admissions waiting at the door.
So, what’s it like to be in such an environment where, incidentally, the provision of psycho-social therapies is minimal or non-existent?
The emotional quality of the social environment, as measured by group levels of anxiety, aggression, activity and social behaviour, deteriorates as occupancy rates and proportions of involuntary patients increase.
The price paid for low numbers of hospital beds is a higher rate of involuntary admissions.
The flow-on consequences for patients entails treatment in an environment that is stressful, counter-therapeutic and sometimes unsafe.
For staff, it’s almost certainly professionally unrewarding and it’s traumatising for all involved.
Designing solutions
It’s important to consider the purpose of in-patient care for severe mental illness.
A recent The Lancet editorial emphasises “asylum”, in the sense of shelter and protection, a place of refuge and safety.
That’s true but there’s more to it than that. The default position of in-patient care in Australia is already care and protection for the severely mentally ill in crisis. These people need asylum in the most urgent sense of that term.
But they should also receive a standard of in-patient care recommended by the (UK) Royal College of Psychiatrists, including:
occupancy levels of 85% or less;
maximum ward size of 18 beds,
a purpose designed physical environment;
structured therapeutic activities;
proportionate and respectful approach to risk and safety;
information and support for patients and carers;
a recovery-based approach with effective community linkages;
psychological therapies;
personalized care with daily one-to-one staff contacts; and
socially and culturally sensitive care.
In addition to providing a safe and expert treatment environment for people prior to them being in desperate straits, in-patient mental health facilities should also provide the possibility of admission for the purpose of diagnostic evaluation and review of difficult problems – just as admissions occur for similar reasons in other medical specialties.
Similarly, mental health hospital beds should be provided for the initiation and monitoring of complex or new treatments that carry some level of risk or may be experimental in nature.
With fewer than 7,000 public hospital mental health beds for a country with a population of more than 22.5 million, Australia has been too enthusiastic in its pursuit of closing psychiatric beds.
In an era when the public debate on mental health has focused on the benefits of early intervention, it’s time to strike a balance and reflect on the dire and often forgotten needs of people with established and enduring psychiatric illnesses for whom hospital care is often essential.
Do you think the focus on community-based care for the mentally ill has shut out those with serious illness who can’t be helped within the community? Leave your comments below.