Compassion fatigue
The Government has launched a $6.5 million inquiry into mental health and addiction. Health professionals and patients tell Sally Blundell what needs to change.
Kelly Pope was alone and homeless, experiencing massive anxiety and struggling to control her behaviour and interact with others. The 21-year-old Christchurch woman was terrified of sinking back into the mood fluctuations, self-harm and eventual bipolar disorder that had marked her highschool years.
Desperate, she went to her GP, who referred her to the specialist mental-health services at the hospital. The specialist mental-health services told her she was not “unwell” enough for ongoing therapeutic support and referred her back to her GP. Three times she was assessed; three times she was bounced back to her doctor.
Pope says her experience is not unusual. “People talk about the John Kirwan effect – we have these great mental-health campaigns telling people it is okay to reach out, but where is the help?
“You have mental-health [services] saying your doctor should be able to handle it, your doctor saying, ‘It is out of my hands.’ You go into crisis services, but if it can be explained as a psychosocial issue rather than a mental illness, you are screened out. You can be suicidal, but if that is because of a job loss or relationship breakdown and not because of mental illness, they say try somewhere else. Sometimes there is not a somewhere else to go to. It seems like the whole system has a bit of compassion fatigue.”
Putting an end to that sense of fatigue is the job of the Government’s new $6.5 million inquiry into mental health and addiction, chaired by law professor and former Health and Disability Commissioner Ron Paterson.
Due to report back to the Government by the end of October, the inquiry has a wide, “ground-breaking” scope, wrote Warwick Brunton, a retired senior teaching fellow in the Department of Preventive and Social Medicine at the University of Otago.
It will cover the full spectrum of mental illness, from mental distress to enduring psy- chiatric illness and suicide prevention. It will also look at early intervention – half of all lifetime cases of mental disorder begin by age 14 – equity of access to services and risk factors, including poverty, inequality, social and cultural isolation, and ease of access and attitudes to alcohol, which is implicated in over half of youth suicides.
It will look at the role of agencies in the health sector, the make-up and brief of a new Mental Health Commission and the responsibilities of other government portfolios: education, justice, workplace relations and social welfare.
WIDE AND DEEP
As a once-in-a-generation opportunity, says Paterson, it will go wide and deep.
“So many people in this country are affected by mental illness and addiction. We also have a very large workforce working in mental health and, beyond that, all sorts of community initiatives trying to tackle some of these problems, so we have been asked to look very widely. And in doing that, in the short time we have, we want to engage as widely as possible with the community, with people working in mental health, with family and whānau.
“We are particularly interested in looking at how we can have a more integrated system focusing more on promoting well-being and on early intervention and prevention. We are not here to tinker around the edges.”
When Paterson was asked to lead the inquiry, he called on former district court judge Ken Mason, head of the inquiry into mental health that resulted in the pivotal 1996 Mason Report and a former neighbour of Paterson’s parents in Papakura.
“Ken said, ‘Go and listen to the voices of the people – they will tell you the answers.”
This the inquiry will do, combining town hall meetings, kicking off in Palmerston North in May, with calls for submissions in writing, online or through an 0800 number.
“We have been asked to stand back, talk to the community and people working in
“People talk about the John Kirwan effect – we have these great mentalhealth campaigns telling people it is okay to reach out, but where is the help?”
mental health, hear their views, build on what we know already and then focus on solutions,” says Paterson. “So we are looking at quite novel and multiple ways for people to interact with the inquiry, so they can tell us their stories and give us their ideas. We’ll be asking people, ‘What do you think would have made a difference for you?’ And to groups working in these areas, ‘Where do you think the solutions lie?’”
Yes, it’s a tight timeline. It could take two to three years, Paterson agrees, “but people out there are asking for answers now.”
Mason recalls a similar mood for change, a general sense that things “weren’t going too well”, when he began his second inquiry in 1995. By then, the big old psychiatric hospitals – which at their peak housed more than 10,000 inpatients at any one time – had been replaced by a mixture of community support and inpatient hospital care. But the new system was struggling: leadership was seen to be lacking; crisis support and assessment services were fragmented and under-resourced.
Mason, now retired, says from his home in Nelson that care in the community “won’t work unless there are services, facilities, people and funding to do it. These things need to be sorted through, so the vision becomes a practical vision – not just something that sounds nice.”
The Mason Report ushered in a new funding regime for mental health, a national anti-stigma initiative – the forerunner of the Like Minds, Like Mine campaign – and a new Mental Health Commission to lift the priority given to mental health. The commission was disestablished in 2012, and now a new mood for change, a similar belief that things aren’t “going too well”, is taking hold.
Over the past eight years, the number of people using specialist mental-health services has jumped from 96,000 to 168,000 a year. From 2016 to 2017, the annual number of calls to crisis phone service Lifeline Aotearoa leapt from 48,000 to 159,000. According to last year’s World Health Organization (WHO) health estimates, New Zealand has one of the highest rates of anxiety disorders – fourth after Brazil, Paraguay and Norway – and a relatively high prevalence of depression. Our adolescent suicide rate, according to a recent Unicef report, is worst of all 41 EU/OECD countries measured.
In the past three years, there have been petitions, protests and public pleas. Last year’s People’s Mental Health Report painted a dismal picture of underfunding, overworked personnel, staff shortages, long waiting times, limited treatment options, ineffective responses to crisis situations and a general underfunding of mental-health and addiction services in the face of rising demand. Major concerns are stubbornly high suicide rates, growing substance abuse and poorer mental-health outcomes for Māori.
Those unwell enough to get immediate treatment are grateful – a 2015 national survey shows an 82% satisfaction rate with mental-health services by those who have been able to access them – but there are warnings that of the 47% of New Zealanders who will experience a mental illness and/ or addiction during their lives, many, like Pope, may struggle to find adequate and timely support.
FEELING THE PRESSURE
“This is an issue that affects everyone,” says Mental Health Foundation chief executive Shaun Robinson. “At least half of all New Zealanders experience a diagnosable mental-health problem at some point, and when mental-health problems and suicide occur, they can affect whole whānau and wider communities. But we know we don’t have things right – there are many signs of a system under pressure.”
District health boards are feeling that pressure as frontline mental-health services struggle to meet growing demand. Although brochures reiterate the value of wrap-around psychosocial support, the reality, according to family members spoken to for this story,
“We know we don’t have things right now – there are many signs of a system under pressure.”
is often a scaled-back service from overworked care workers and brief outpatient appointments with a psychiatrist. Outside the hospital system, for those unable to afford a GP visit, let alone a private counsellor or psychologist, the options are few, as community services face funding cuts, funding freezes and contract cancellations. Some are running waiting lists, some are closing their doors to new clients, some are closing down altogether.
Last year, when the National Government allocated an extra $224 million for mental-health services over four years, critics pounced, saying this was nowhere near enough to address population growth and increasing demands. The new Health Minister, David Clark, quotes a post-Budget analysis of Government health expenditure by the Council of Trade Unions and the Association of Salaried Medical Specialists estimating a further $2.3 billion is needed to restore health funding to 2009/10 levels.
“There’s been a 70% increase in people using mental-health services over the past decade and funding simply hasn’t kept pace,” he told the Listener. “You can’t strip that much out of the health system without losing the level of service you have been accustomed to.”
This year, the Government will begin rolling out its election promises to put a mental-health nurse in every public secondary school, to pilot primary-care mental-health teams at eight sites around the country and to make staff available to primary and intermediate schools in Canterbury. Clark says he is also keen on a pilot scheme for free GP visits for patients suffering from mental illness.
But is throwing more money into a creaking system the answer? The new inquiry will not shy away from looking at new fiscal approaches and funding models, says Paterson. Overseas, some countries are “desiloing” funding to better integrate mental health within primary health and community services. Elsewhere, mental health has been decoupled completely from the general health pot and handed over to a separate commissioning body.
Such moves reflect a realisation that demand for healthcare services won’t fall any time soon. The WHO predicts depression will be the second leading cause of disability in the world by 2020. Health Workforce New Zealand says by the end of this decade, demand for mental-health and addiction services will have doubled from 2010. Why? Some say it’s now more acceptable to seek help; some say our tolerance for emotional pain is decreasing and we are more likely to medicalise mental anguish. Others point to new psychological stressors from technology, social media and inequality.
“I don’t know why everyone is so stressed or anxious, but they are,” says New Zealand Medical Association president and Christchurch GP Pippa MacKay. “The earthquakes and the stresses around them undoubtedly are playing a significant part in Canterbury, but they are not the only thing – it has increased everywhere. Anxiety is a several-times-daily
thing, and in mental health, there are simply not enough public psychologists, not enough public counsellors and not enough psychiatrists, public or private.”
The big old institutions of the past may have been “truly awful”, she says, “but they were secure. A lot of people have been deinstitutionalised, but it would be wrong to say the funding has followed them.”
TICKING THE DIAGNOSTIC BOXES
Seven years after she found her life sinking into psychological chaos, Kelly Pope is now stable. After being bounced between her GP and specialist mental-health services, she says, a diagnosis of borderline personality disorder finally opened the doors to specialist mental-health treatment.
“But you do have to have a lot of heart to keep persevering, enough confidence in the system to go down that route again. If you do persevere, if you can put what you are experiencing into language that matches what the system is assessing against, then you can get some support.”
Even then, she says, that support may be limited to a combination of case management and medication. “Medication often becomes the first port of call – if it works, it becomes the only port of call and sometimes people have to stay on it because nothing else is being offered to help address what is underneath. But research shows medication and therapy in combination are the best way to go, if not therapy by itself.”
Now, in her job as a mental-health coordinator in peer support, she helps others find a safe place to talk through their pain. “Peer support for people in crisis is really important. It has a non-medical focus that says if you feel anxious, you can come in and talk about it. This is the big issue in the clinical system – there are many people struggling but they are not necessarily ticking the clinical medical diagnostic boxes or they are showing up at crisis [emergency services] when the focus is ‘are you going to walk out of here into the middle of the road? No? Okay, that’s all right then.’”
The WHO predicts depression will be the second leading cause of disability in the world by 2020.