Emergency Care in Mental Health - Literature review Example

Running Header: Emergency Care in Mental Health: Is the use of the Ambulance Service and other emergency departments of New South Wales, Australia, in emergency care of those with mental health and substance abuse issues a misapplication of Health Resources? Student’s Name: Name of Institution: Instructor’s Name: Course Code: Date of Submission: Introduction Since 2007, the Ambulance Service of the New South Wales, Australia, as well as other emergency health departments has increased their emergency services to people with mental illnesses and substance abuse problems. Substance abuse here refers to excessive use of drug (e.g. alcohol and other illicit drugs, such as Heroine, Marijuana, Cocaine, Ritalin, Inhalants, Anabolic Steroids, etc) (NSW Health, 2012). This was meant to be in line with the new Mental Health Act 2007. The legislation was perhaps part of the government’s response to calls for reforms in the mental healthcare services. In 2005 alone, several articles were published, calling for the government’s response to the increasing calls for changes (AAP, 2005; Wroe, 2005; Wroe & Nader, 2005; Hodge & staff reporters, 2005; Price, 2005). AAP (2005), for instance, cited a Mental Health Council of Australia report, argued that Australia’s system for mental health care was “broken and failing” and proposed, among other things, that the government increase its funding. Wroe and Nader’s (2005) article in The Age was explicitly titled Urgent action call on mental health, going further to cite what they called Stories of injustice and despair from a consumer and a carer. And Frenkel (2005) did not mince his words in his Herald Sun article Mental health system damned. Finally, the government responded with the Mental Health Act 2007. Although the Act was welcomed with a relief from carers and other consumers, many have since criticized it on the claims that it is a ‘misapplication’ of health resources. According to The American College Dictionary (1954), to misapply is ‘to make the wrong use of’ (pp. 776). The criticism does not attack the act per se, but the implementation of the policies that it lays down. The paper aims is a debate on the validity of this claim, focusing on the use of the NWS ambulance system. In this effort, the paper will seek to answer, amongst others, the questions: how are they used? Is there evidence of success and achievement since the act came into force? And what do consumers of mental health service and other carers in NWS think about the services? Legislation Following a major public outcry for a review of the health care system, with focus given mainly to mental health, the Australian government undertook necessary steps in that course. The Mental Health Act 2007 was the result. As stipulated in the document, the new changes aimed to: provide for better care, treatment and control of mentally ill persons; facilitate the objective above through community facilities of care. Also, it aims to provide both voluntary and involuntary hospital care for the mentally ill; offer the patients access to health care as part of protecting their civil rights; and facilitate the involvement of the patients and their carers in making vital decisions in relation to care, treatment and control (Mental Health Act 2007; Dineen, 2009). But as mentioned, this step has been criticized as a misapplication of health resources. One possibility for this criticism is that no achievements of successes have been attained even as the resources are utilized. But it could also be a manifestation of stigma against those with mental illness and substance abuse problems. According to NSW Consumer Advisory Group [NSW CAG] (2012), stigma broadly refers to the negative, stereotypical thoughts and attitudes, and feelings toward a group of people on the basis of specific traits, i.e. mental illness and drug abuse, in this case. As such, they are considered “as less worthy of respect and care than others” (NSW CAG, 2012). In the end, stigma causes people to feel alienated; case people not to seek help for fear of stigma; also affect the carers or family members of the mentally ill; cause discrimination in the society; and ultimately hinder recovery (NSW CAG, 2012). Evaluation According to NWS Government (2005), a number of processes and measures of outcome have been put in place to help evaluate the level of success of emergency services, i.e. indicators for the measure of the extent to which people with acute mental illness and/or behavioral disturbance (e.g. substance abuse) receive appropriate services and care, and thus safe. This evaluation focuses on the number of factors: the number and frequency of adverse events that happen to patients and/or their communities during emergency responses, and from the moment a patient is admitted to an emergency department to the time the patient is discharged. Other factors include the number of patients (in percentage) who face an emergency service transport period of over an hour; the percentage of patients who are brought to emergency departments by the police, kept waiting for over 30 minutes, admitted, and in comparison to overall mental health admissions in emergency departments; and how much the police are involved in overall inter-hospital transports, including the long-distance transports (NWS, 2005). Despite a number of evident national achievements as a result of the 2007 Act, many people maintain that the resources allocated to mental helath are being misapplied. For instance, citing the thoughts and opinions of patients, carers and families, and other support groups, Morris (2012) argues that mental health service has become a ‘disgrace’. He further cites reports on the nationwide state of mental health. According to the NWS Health website, the NWS government conducts more than 200,000 patient surveys- for both inpatients and non-patients- annually. This survey is based on a number of indicative parameters, such as access to care, care coordination, preferences of patients, emotional support, etc. But for the sake of this work, we will focus on response to emergencies- as part of timely access to care. Instead of looking at the emergency ambulance system as an isolated service, one must assess it essence. In other words, the ultimate goal of emergency ambulance services is to facilitate quick response during health emergencies. If, for whatever reason, a patient forwarded to Emergency departments by ambulances do not get that fast response- dying or not in the process besides the point- then the role that ambulances a have played become obsolete. Ambulances are supposed to drop people at Emergency departments. The response of the EDs gives credibility to the ambulance services or takes that credibility away. Unfortunately, EDs in NSW have not done the ambulances much justice. In her analysis of a 2009 NSW Health patient survey, Dougan (2009) takes note of the majority dissatisfaction with EDs amongst the population. Actually, 77 percent of the non-admitted emergency patients thought they were kept waiting for too long before seeing a doctor (uncited Newspaper articles cited in Dougan, 2009). And while just about 31 percent felt they got positive care, over half of them claimed they were kept waiting for over three hours, and only 54 per cent of the total number of emergency patients felt the response was good (uncited Newspaper articles cited in Dougan, 2009). Although this number 54 percent may seem big- atleast by virtue of representing more than half the emergency patient population- the actual figures can be very shocking. One of the uncited articles (cited in Dougan, 2009) shows that in 2009, about 80,000 patients specifically pointed at emergency services as ‘struggling’, this despite the government investing $14.8 million in recruiting more nurses. Part of this problem may be attributed to what Morris (2006) referred to as the government’s attempts to mainstream mental health care, i.e. integrate mental health service into the general system of health, rather as a different service (i.e. psychiatric illness). The consequence of this has been that the unique problems and needs of the mentally ill have not been appreciated fully as well as provided for. Thus, the mentally ill patients have suffered secondary marginalization in the general health system. Such marginalization can be witnessed in the treatment mental and substance abuse patients in the emergency departments of public hospitals. Even further, this has led to increased pressure on the health resources. Due to lack of sufficient resources that can meet the overwhelming needs of patients, the medical facilities have taken to rationing. As a result, it is only those who are considered to be ‘severely’ ill who are offered treatment. Thus, other who are equally ill do not get as much attention because they do not meet the limit for what is perceived as ‘severe’. This rationing, says Morris (2006), as seen above, becomes more pronounced at the moments when patients are seeking admission into emergency departments, when making decision for the discharge of patients from inpatient care, and when decisions have to be made with regard to patients who need intensive case management. Ultimately, people who should be admitted do not get it, patients who should still stay in the hospital are prematurely discharged, and those who need intensive case management plus follow-up do not get it. A The Australian report (Kate Legge, 2005 cited in Morris, 2006) linked 42 suicide deaths in Victoria of people under 30 over a period of two years to inadequate treatment. Some of the problems cited included lack of bed spaces for high-risk patients, premature discharge-as a result, and lack/absence of intensive treatment. Indeed, these statistics raised questions on the effectiveness of psychiatric services at Queensland Health, and by extension those in other health facilities. The report cited an acute lack of psychiatric beds that made it very difficult to admit very ill people, while also prompting premature discharge of other patients. Indicative of this deficiency is the fact that psychiatric inpatient units are ever 100 percent full, when the conventional capacity is expected to be a maximum of 85 percent, and without rationing (Morris, 2006). Lack or the absence of intensive follow-up management means that patients are at risk of self-harm. In the end, and quite ironically, Morris (2006) attributes some of these inadequacies and poor service provision to the very mental health policies and acts in the sense that they provide loopholes for the justification of such limitations. For instance, many patients may be turned back for not meeting stipulated admission criteria. Pirani (2005 cited in Morris, 2006) links tighter policies- that make accessing healthcare even more difficult- to increased suicide rate for the mentally ill people. Rurality (Hills, et al., 2011) is also thought to be a problem for the Ambulance and other emergency services. In a twelve-month period until June 2007, (2007 being the year that the new mental health legislations were put in place) there were over 50,000 hospitalizations related to mental diseases, including 10,000 intentional self-harm hospitalizations, i.e. acute mental distress making up about 12 percent of total NSW population (Population Health Division, 2008). Further, there were over 2000 beds in more than 450 specialized mental health facilities in the public sector (Australian Institute of Health and Welfare, AIHW, 2008). Even more, there were EDs in over 200 public hospitals for the purpose of serving acute mental health cases (NSW Health, 2009). However, even as the new legislations recognized the need to improve responses in emergency cases, it overlooked the differences in infrastructure, access and cultural factors between the rural and urban centers. In the end, it overlooked the need to support even greater and relevant response for specific social and geographical characteristics of the rural contexts (Hills, et al., 2010). By extension, related to this is the issue of culture. Culture has to do with stigma toward mental illness, language and lack of sufficient knowledge on available services, as well as differences in perceptions and explanations of mental health. Indeed, culturally-based discrimination holds a significant spot in mental health, especially in how depression and anxiety are experienced, i.e. symptomatology and how symptoms are perceived, and the ways that these perceptions affect help seeking behavior and access to health care and treatment (NSW Health, 2009). Some of the criticism against the emergency services for the mentally ill in NSW may be based on its lack of adequate multicultural considerations in its operations, as well as the incapacity of the adopted multicultural strategies to successfully overcome cultural obstacles to mental health care. Unfortunately, mental healthcare in NSW generally takes a monocultural approach. Minas (1990 cited in Schizophrenia Fellowship of NSW Inc., 2008) noted that the system for mental health care in Australia, including the very education system that trains health professionals, is basically monolingual and monocultural, i.e. the system’s structures, programs and priorities do not adequately represent the diversity of the Australian population. In recent times, the NSW has introduced the use of translators in multilingual settings. But the implication here is that culture is mainly considered from a language point of view, failing to take into account other culturally related issues surrounding mental healthcare, e.g. the use of indigenous healers, religion, shame associated with mental illness, etc. Equally, there are certain emergency cases when family members are used as translators. The risk here is that family members may filter information, and discussing issues to do with confidentiality may be difficult (NSW Health, 2009). Another section that concerns patients and their carers involves the mental health inquiry system. The inquiry follows the mandate given to emergency response units, Ambulance personnel for instance, to involuntarily detain people suspected of being mentally ill (sometime in collaboration with Australian Police, who use tasers to maim suspected mental cases). The inquiry therefore is meant to ensure that the people detained meet the criteria for ‘mentally ill’, as well oversee the care provided in the health facilities. ‘Involuntary’ here means that the Ambulance officers are explicitly mandated to take a person suspected of being mentally ill to a psychiatrist unit or hospital against his/her will (NSW, 2011). One question here is the criteria by which a person is suspected to be mentally ill (Communio, 2012). And again, like is the case of EDs above, the question is how long it takes from the time a person is involuntarily detained and the time mental health inquiry is conducted, and whether a patient can seek to be discharged (Cain, et al., 2011; Communio, 2012). See figure 1 and two below. Figure 1: Adopted from Communio (2012) Figure 2: Adopted from Communio (2012) Again, these aspects focus on the essence, i.e. the final objective for which ambulance services are put in place. Conclusion It is noted that this paper paint the picture that the Act, or the ambulance services- being a part of it- have totally failed. On the contrary, the Act and the ambulance have generally had successes that have made things better for mental health care. However, the question here, at least as far as this paper is concerned is not whether, the advantages trounce the limitations, or otherwise. Instead, the question is whether there is enough basis on which the claims that the emergency ambulance services for mental health care are a ‘misapplication’ of health resources. Along these lines, this paper mostly sought to isolate evidence that facilities these claims. The essay should not be used as evidence that the Act has failed. It is merely a framework upon which important changes can be made. In recognition of the elements of time, the act and the poise are still relatively young. Experience will eventually inform appropriate and relevant changes. Bibliography AAP. (2005). 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