26 Jul 2019

Can New Zealand's mental health crisis be cured?

From Insight, 3:00 pm on 26 July 2019

Mental health services are in line for the biggest shake-up they've had in half a century. It's needed to arrest the country's shameful suicide rates and to deal with growing distress among up to a million New Zealanders. Health Correspondent Karen Brown explores the pressure points and whether real change will happen.

From the balcony of his flat, a few streets away Bruce can see the bleak, grey office blocks of Wellington Hospital that tower over the ward he ends up in when things get bad.

Bruce was diagnosed with psychosis in the early 1980s and has been in and out of Capital and Coast District Health Board's mental health wards since.

A former journalist and public servant, Bruce, lives in dread of the psychotic attacks that come on with little warning.

"Well it's a nightmare ... a nightmare," he says of the violent episodes. "My problem is it comes on really fast, and I have a lot of support people helping me out, but despite that I still get sick, which is a little bit disturbing."

He's on a benefit but living independently at his Newtown flat, supported by community mental health service Pathways.

His home is just shy of a 10-minute walk to the hospital. He knows he can get there easily when he needs to, whatever the hour, but it's not that simple.

"You can't just bowl along to the mental health ward and say, 'I need help'. You've got to go through the system. And that involves waiting in emergency ... for a heck of a long time." He says hospitals have teams that specialise in acute cases - known as CATT teams - which visit if called. "If I phone them up they'll come 'round and assess me, but I keep forgetting to do that".

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A long-awaited report from a Mental Health and Addiction Inquiry panel found that the mental health system is set up to respond to people with a diagnosed mental illness, but "does not respond well to other people who are seriously distressed". The quality of services is variable, there is no continuum of care, support often does not arrive early enough, and wider social needs are often not addressed. Hospital emergency departments [EDs] around the country remain the front line for people like Bruce - people who need mental health care in an emergency.

EDs have always been available and willing to treat those with mental health crises and that won't change. But they've complained that many are overwhelmed by steep rises in both overall presentations to ED, and increasingly, mental health patients.

Auckland emergency doctor Scott Orman told a conference in Wellington recently that in the past five years there's been a 60 percent increase in mental health consultations in the ED at Auckland City Hospital. Overnight consultations of this nature had doubled.

"The unfortunate paradox is that the most unwell patients from a mental health point-of-view, in order to maintain safety, end up in the most visible, brightly lit and noisy parts of the department. This is very harmful."

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 Brightly-lit, noisy hospital environments can be distressing for mental health patients. Photo: 123rf.com

Under the strip lights at Waikato hospital’s emergency department, phones ring and medical notes are fiercely tapped out on keyboards as patients and doctors glide in and out of cubicles to the sound of beeping medical equipment. For most patients and staff it’s possible to zone out and ignore the beeps and frenetic atmosphere.

President elect of the Australasian College for Emergency Medicine, John Bonning, says for those in mental distress the scene that surrounds him in the Waikato hospital ED is in many cases the opposite of what they need. "These are high-need patients. We want to look after them, but they can also have drug-induced psychoses, and we've had instances of staff being physically and verbally threatened,” he says. “These are real issues - it's not a wonderful environment for people who are actually decompensating [becoming psychotic] and not coping."

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Photo: RNZ Insight/Karen Brown

The doctors stress mental health patients should still come to ED when they need to, but the right staff, and an environment that’s suited to them, needs to be provided; particularly quiet rooms with softer lighting to calm distressed patients. At Waikato’s ED, there’s now a dedicated mental health nurse practitioner and extra staff to provide targeted services.

An extra $8 million over four years was provided in the Budget for all DHBs to improve ED services.

For Bruce, his focus is to avoid hospital and stay in the community as much as possible.

"I say every time I get out of hospital I'm never going back, just because it's such a nightmare. It's not the staff's fault or anything. It's nobody's fault. It's just that in there, everybody's out of their head."

Before the Budget in May, the government earmarked $1.9 billion over the next four years for improvements. Of that, $455m is to go towards new frontline services aimed at meeting a wider range of needs.

"Last time I was in hospital, they sent me out to respite [care] first. They've got a house up in Brooklyn, like a hotel, [where] you get all your meals cooked for you. That's really good that they've still got some of those places 'cos they've been shutting a lot of the halfway houses and stuff," says Bruce.

He has been in his own place for 19 years, and what's crucial is avoiding isolation. “I think it's probably true of everyone who has mental illness ... that the one thing you can't really do is cut yourself off."

Pathways is helping with that. Bruce says it's provided what's called a "navigator" (support worker) for him, and together they're working on things like how to use a smartphone to stay connected. He also goes to a couple of local coffee groups where "we talk about everything we want to talk about". He's also got the media, and his books and records to keep him entertained.

Bruce says he used to go to a day service where he could meet up with others. He would like to see services like these return to help him stay connected and keep on the right track.

Ashika, who lives in Wellington, has her own battle; with schizophrenia. She says more day services would help. Sometimes she likes to feel isolated and other times not; it often comes down to what "the voices" in her head are telling her.

Sometimes the voices are "good voices" and suggest something like a walk to a nearby park or shopping area. Other times, they’re not. "It just gets angry and starts telling me to … they're anti-everything and just get angry and all that."

Ashika is also living independently with Pathways support.

The smoke of musky incense hangs in the air of the flat she moved into a year ago. She feels happy and at home here, surrounded by treasured soft toys and her delicately painted elephant trinkets. She says the comfort and stability of her new home has helped keep her mental health on track.

She loves art, particularly drawing angels. There is a soft-focus, gentleness to her drawing style. If there was anything she could change about the system it would be introducing more opportunities to do activities and meet up with others in the same situation. “Just a group of people with schizophrenia, so we can talk to each other about the problems and they can relate to it.”

Health Ministry deputy director-general of mental health and addiction, Robyn Shearer, says the Budget offered "a good platform for change," and more announcements will be coming soon, with sector forums expected to begin across the country in late July.

"That's going to be our first opportunity to start talking to the sector about the type of initiatives where we need to increase volumes of services for people. So some of what's happening now, but get more people accessing them and provide an opportunity for people to give us their ideas via an expression-of-interest process for new initiatives."

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The Health ministry's Robyn Shearer. Photo: RNZ Insight/Karen Brown

Shearer says there will be new community-based services to give people more options, or, "earlier help when and where they need it".  

She acknowledges there are vacancies "across the board" for psychiatrists, nurses, allied health and psychologists, which is challenging as “we can't just find people overnight.''

She also says they'll work fast with non-governmental groups that are already working on workforce development and in mental health. "This is our largest workforce we have and our largest opportunity where we have support workers who can work with people in their homes or in community settings."

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