Having to present at the ED in a crisis is demeaning and traumatising. This experiment has run long enough.
I wasn’t around in the 1960s when the concept of “de-institutionalisation” swept the globe as the best way to care for people with psychiatric illness in society.
My psychiatry lecturers taught me it was a fabulous idea to open up the asylums, sell off the real estate and allow those with mental illness to live in the community when they had no skills or resources to do so. They knew a life where, if they were unwell, a doctor or a dentist would visit them at the asylum.
They were seen to be better off in society, and not because asylums as a concept were awful, although the asylums were so run down that by the time they left they were glad to see the back of them.
In the 1990s I was a medical student studying psychiatry while working as a community pharmacist in a nice leafy area in Melbourne, Australia. As patients left the asylums to live in the community, and we began to look after them in the pharmacy, the concept of mainstreaming was introduced. Mainstreaming was a term that defined the process of moving acute psychiatric services on to “mainstream” hospital grounds, with patients presenting for admission via the emergency department. (It occurred at a time when emergency departments were perhaps not run the way they are now, beholden to state government penalties, bed block, and hospital administration budgets. There was no pandemic either.) Even the term mainstream smacked of stigma, but it is still spoken of now as a relatively new concept that is all about improving the care of the patient with mental illness.
At the same time, the most up-to-date psychiatrists were aware of the terrible comorbid health outcomes that many psychiatry patients endured, including the comorbid mental health outcomes they indirectly caused by prescribing newer-generation antipsychotic medications and mood stabilisers. The concept hung on the pretence that if the patient saw a medical doctor on the way in for a quick “medical clearance”, these problems would be detected and alleviated.
Mainstreaming was also expected to reduce marginalisation and improve the quality of life for many who had been ignored and discarded from society.
It was all one very large catch-up operation, reactive by nature, and 60 years later, there is really nothing to show for it.
Fast forward to 2023, and we still have mainstreaming. We also now have three years and counting of a covid-19 pandemic, worsening climate change that will likely lead to further pandemics and outbreaks of diseases, and a country pelted by natural disasters during most seasons. We have dwindling funds to pay for expensive health solutions and a declining medical and nursing workforce. Our psychiatric patients still experience tremendous health adversity, which is shameful in a modern society that should know better and can definitely do better.
Patients requiring acute services is a given. Mental health conditions relapse and remit despite what we wish to believe about measures such as recovery-orientated models of care. They just do. Their presentations haven’t changed at all.
But what of organic diseases that present as psychiatric conditions? The foundation of teaching in psychiatry is still based on the understanding that mental illness can affect mind and body. Yes, tertiary syphilis can present as an acute psychosis. But given that psychiatry registrars studying for their fellowship exams are all over these most bizarre and unusual presentations we see in psychiatry, like every other discipline of medicine, it is my guess they would be the best experts in the hospital system to assess, manage and refer out. That’s after these registrar worker bees have finally caught up with admitting and discharging patients from the psychiatry ward who came in intoxicated by substances and weren’t given the chance to sober up in emergency department, to be discharged because there is simply no space. And I have yet to be educated about what “medically cleared” really means in a person who has possibly not seen a GP for years and is frankly psychotic or suicidal.
I have heard countless times that psychiatry wards are not equipped for medical presentations. I have said it countless times myself. Yet I wonder, why not? when they are staffed by hospital medical officers, psychiatry registrars and specialist nurses who can work as part of a team that delivers general anaesthetic and manages patients having ECT.
The poorly veiled argument I have heard is that IV poles can be used as weapons, and IV cannulas can be used to inject illicit drugs. No stigma to see there … wander through an emergency department anywhere, any time, where any patient with a delirium or other non-psychiatric presentation could also brandish an IV pole as a weapon if they are confused and agitated.
It also doesn’t seem to make any sense that mainstreaming ends when the patient leaves the emergency department. Mainstreaming psychiatry wards shouldn’t be such a controversial idea; after all our medical and surgical colleagues continue to ask us why we can’t manage people that are referred to them without transferring them out to medical or surgical beds. After years of fighting for transfers I have decided to see their point. We have consultation liaison services to manage patients on medical and surgical wards – perhaps this could just be an extension of their role.
And what about the perspective of the patient? Modern psychiatry has embraced the concept of the lived experience and interventions are based on another buzz phrase, “patient-centred care”. How is it to be a patient subjected to mainstreaming when also ravaged by symptoms of acute mental illness? And how is it different for patients without mental health symptoms, also acutely unwell, who are also participants in the mainstreaming process?
When you can see a patient in an emergency department who is acutely short of breath, their work of breathing is through the roof, they are panting and begging for air, they are distressed and frankly believe they may die, it evokes every reaction in you to move and move fast. A code blue is called, people come running, and a ventilator is found, somewhere, inevitably. If that same person re-presents in the same way, they will be no doubt terrified that they will experience this near-death experience again. They will become phobic of the smell and sound of the emergency department as it triggers the sensation of potentially taking their last breath before they become unconscious. The least that they would expect is support from nursing staff, and reassurance for the doctors treating them by helping them to breathe.
How much worse, then, is the emergency experience for the mind ravaged by schizophrenia? We describe their minds as “persecuted” and their behaviour stems from that. In these moments they can be literally convinced that they will also die at the hands of the people in the emergency department, people who are not only strangers but potential impostors also. They will not expect to be supported or managed by these people, the doctor, nurses and security guards. While responding to the voices coming through the walls, experiencing heightened sensations that they cannot decipher, their one motive could be to escape. Their facts and their reality are not the same as the person they are mainstreamed alongside.
Patients who are experiencing a psychiatric crisis are often exposed to faces that portray disdain and often disgust. People that challenge them with:
“Why. Are. You. Here? We are busy today. We have no time for you.”
Then in stark contrast to the resuscitation and emergency procedures for the non-psychiatric patients, performed by dedicated teams of intensivist nurses and doctors, they experience the opposite.
Nothing happens.
Nothing happens until they make a run for it and a different colour code is broadcast to muster attention: code grey. Burly security guards turn up, faces also expressing disdain and disgust. Conversations happen but nobody talks to the patient. They are held down on the floor, spitting and trying to bite and fight. They are also facing their near-death experience. There is no place for them. They are held down until the syringe is drawn up. They know what is coming: the trauma of the last time and the time before and the time before that blends with the terror that they will die, succumbing to the effects of the medication they had no say over. Sensations are dulled, making it hard to interpret the persecutors actions. Duller and duller until they wake up in a room with locked door and a small window. A room that they may spend their whole admission in.
Patients in crisis with mental health conditions do not need “mainstreaming”. They need the opportunity to be moved to the correct part of the mental health system that gives them immediate treatment and relief by people who understand how to do it. The Mental Health Act enshrines our obligations to achieve this.
The patients don’t need brand new parts of the sector, more add-ons that will confuse and fragment rather than align, add-ons that are underfunded and understaffed. They need the psychiatric wards to be better equipped and upgraded; they need direct admission when a medical professional deems they need it, without a protracted mainstreaming approach that totally inhibits their medical, physical, emotional and culturally focused care.
We have an alternative to continuing on a path that was thought of as being revolutionary at the time, but which has been shown to lead nowhere good. It’s time to propose a radical change back to what we had decades ago, improved with those decades’ worth of experience and legacies. And we can use a more compassionate term to describe it.
Dr Helen Schultz is a consultant psychiatrist and author; she tweets @drhelenschultz.
