Abstract
James Hundertmark, Adelaide, South Australia:
Mainstreaming is one of the central principles of the National Mental Health Plan, that is; ‘Mental health services will be delivered and managed as an integral part of mainstream health services so they can be accessed in the same way as other health services’[1]. Schrader concisely describes some of the diverse impacts of recent mental health reform on general hospital units [2]. Another by-product of mainstreaming has been the increased psychiatric load for general hospital emergency departments (EDs).
Between 1996 and 2000, the number of adult presentations to the Flinders Medical Centre ED rose from 244 to 780, an increase of 320% with a steady rise of about 35% per year. In our region, the emergency section of the psychiatric hospital closed at the end of 1996 community services were strengthened in line with the National Mental Health Plan. The 320% increase was not accounted for by a change in drug overdose presentations; the figures indicated a uniform rate of overdose over the period. On analysing the data for the groups which did contribute to the change, no conclusions could be drawn due to loose usage of diagnostic categories in the ED. However, affective and anxiety disorders increased three times and these two groups accounted for 60% of the total. Patients with psychosis accounted for 20%, an increase of three and a half times. Interestingly personality disorders and drug/alcohol problems did not contribute significantly.
More prominently than noted by Cannon et al. [3], we have observed an increase in the use of physical restraints. Long waiting times for beds and an inadequate physical environment in which to contain psychotic patients has lead to the use of both chemical and physical restraint.
In 1996, Tobin [4] wrote that with mainstreaming, management of ‘psychosomatic’ conditions would become a key role for psychiatrists and any reduction in funding of liaison psychiatry would be short-sighted. Historically, the ED in our hospital has been serviced by the consultation–liaison service. Not surprisingly, with the increase in demand for psychiatry services in the ED, the general wards have become starved of input and no additional funding has been obtained. As pointed out by Smith [5], consultation–liaison psychiatry already is mainstream. Physical/psychiatric comorbidity and somatization are the most common forms of psychiatric presentation in primary care and in the community. Liaison psychiatry may need to refocus on the comorbidity/ somatization group with the formation of a separate emergency psychiatry workforce to assist EDs.
As other avenues for handling emotional distress are becoming constrained, EDs are seen by the public, general practitioners and police as the best alternative resource. In a similar way, restraint of patients in EDs may be used increasingly as a result of mainstreaming. It is important that the increased psychiatry demand on EDs is recognized and adequate resources allocated.