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Emergency departments ‘ground zero’ for a stretched mental health system

Psychiatrist Anne Doherty on how increased demand during Covid-19 has left already stretched services ‘drowning under the additional pressure’.

Dr Anne M Doherty

WHEN OTHER MENTAL health services are closed during Covid-19, the mental health services provided by specialist liaison psychiatry teams of doctors and nurses based in EDs remain open.

In the ED, we treat people with mental health emergencies, including those presenting with self-harm and attempted suicide. It can be distressing work, with high risk of burnout, even where there is adequate staffing.

Emergency departments are busy places where ambulances bring the sickest people, and where GPs send people if they feel they need admission or cannot secure an emergency appointment with a community mental health team. 

Such services were stretched before Covid-19, but with the reduction in face-to-face appointments in the community, and rising need for services, EDs are now busier than ever.  

They have become ‘ground zero’ in the post-Covid world of increased mental healthcare need. 

In the Mater Hospital, where I work, the number of people coming in with serious mental illness in need of urgent attention has risen, and stands at 120% compared with last year.

  •  The Noteworthy team wants to investigate the measures being taken to tackle a pandemic-induced mental health crisis in Ireland. Support this project here.

‘Severely underfunded’ service 

Irish mental health services are severely underfunded compared to other developed countries and receive 6% of our total healthcare budget compared with 10-13% in the UK, France, Germany, Sweden and the Netherlands.  

We have one of the lowest proportions of hospital beds for psychiatric care in the developed world, and bed numbers drop each year. The Joint Committee on the Future of Mental Health Care reported a drop from over 12,000 in 1984 to just over 4,000 in 2004. This was down again to just over 1,000 in 2016. 

Today, we have lost over 75% of our 2004 capacity, and we have just 22 acute public mental health beds per 100,000 population, compared with the EU average of 70 per 100,000.  

In 2018, the Joint Committee on the Future of Mental Health Care recommended increasing beds to 50 per 100,000 within three years, but this has not yet been adopted as a policy. This is  infringing on our patients’ right to treatment.

Patients need to be sicker and sicker to access a bed

With every bed we lose, our threshold to admit someone to hospital must rise. Patients need to be sicker and sicker before we can justify an admission to hospital. 

These are hard decisions to make, and we triage for beds every day. It is unbearably unfair on vulnerable patients and their families.   

Beds are not the only component of mental health care, but they are needed for the sickest patients. As with other illnesses, people need different types of care depending on how ill they are. 

Someone with cancer, for example, may need some of their care as an inpatient, some attending a day services and at other times attending consultant outpatient clinics. We need enough beds to admit people who need it 

What ultimately happens when we don’t have enough beds? The people who need them end up homeless, in prison, and in the ED. We read with horror, a report published in November by the Council of Europe that detailed inhumane conditions endured by mentally ill prisoners, who cannot be transferred to hospital because there are no beds for them.

The impact of Covid-19

Covid-19 has resulted in changes to our lives that we could never have imagined. With the measures required to limit the spread of infection, social engagement has dropped and we have missed out on seeing loved ones, especially those at high risk (including older people) who have spent the last 10 months in almost complete isolation.  

Community-based mental health services have had to radically change their way of working, shifting from face-to-face interactions to remote consultations. Group-based therapies have been reduced or stopped. 

These have been the mainstay of treatment for certain patients, including recovery interventions for severe mental illness, and groups like dialectical behaviour therapy, a life-saving treatment for borderline personality disorder that relies heavily on weekly groups. 

For many people for many months, the ED has been one of the few places possible to have a face-to-face meeting with a psychiatrist. However, with the current situation of rising need, on reducing beds, liaison psychiatry services are drowning under the additional pressure. 

No liaison psychiatry teams in Irish hospitals are resourced to the minimum standards in the HSE’s A Vision for Change policy report published when we had 400% of our current number of beds. Many hospitals do not have psychologists or social workers on the teams. 

In University Hospital Galway, for example, the liaison psychiatry team is staffed at 30% of the recommended level in A Vision for Change.

During the first wave of COVID, liaison psychiatry services did not stop. Teams continued to work in hospitals and EDs, seeing patients face-to-face and caring for the mental health of patients who developed the neuropsychiatric complications of Covid-19

Patients need to have options

Patients need good mental health services in the emergency department and inpatients with physical illness needs also require mental healthcare. For instance, as many as 34% of medical inpatients have depression. 

Emergency department services alone are not the answer. Patients need to have access to beds and community-based crisis services: whichever the person needs at a given time.  The policy of continually reducing bed numbers needs to stop now.

We need to implement the recommendations of the Joint Committee on the Future of Mental Health Care and ensure adequate bed provision. Properly resourced specialist teams are urgently needed, and mental health services need adequate funding. 

As a nation we need to invest properly in evidence-based treatments and solutions. As Peter McVerry said recently: “We need action, not talk. We don’t need more reports.” 

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Anne M Doherty is consultant liaison psychiatrist at the Mater Hospital and associate professor of psychiatry at UCD. She is also chair of the Faculty of Liaison Psychiatry at the College of Psychiatrists of Ireland.

COVID CONSCIOUSNESS Investigation

Do you want to know what can be done to prevent a pandemic-induced mental health crisis in Ireland?

The Noteworthy team wants to talk to mental health professionals working on the frontline about their experience in supporting patients during and after the restrictive phases of the crisis and what can be done to better support them after the pandemic.

Here’s how to help support this proposal> 

About the author:

Dr Anne M Doherty

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