Stigma must not stop investment in mental health services, says the president of the Royal College of Psychiatrists
I said this after the case of a 17 year old girl, named X for anonymity, for whom no hospital bed with necessary facilities could be found despite warnings that she would die by suicide within hours of discharge, was heard in high court.
I was relieved when an appropriate hospital was found for her, but remain intensely worried about the dearth of health services for young people and adults suffering from serious mental disorders, which cause profound suffering and may lead to death.
The judge, Lord Munby, said: “I cannot escape the powerful feeling that, but for my judgment, the steps subsequently taken would have been neither as effective nor as speedily effective as appears to have been the case. This however, is not a matter for congratulation; on the contrary, it is, of itself, yet further cause for concern . . . X’s is not an isolated case.”
So what will happen to other young people who are in similarly impossible situations, but whose cases don’t make it to the high court or news headlines?
X needed a bed in a low secure mental health ward, which England currently has only 124 of for under 18s. There should be sufficient beds to ensure that these young people can be admitted to hospital rather than “contained” in a penal institution or police station—or even abandoned altogether. It is also vital that they keep in close contact with their family, friends, and community team. This is impossible if the admission is far away from their home, which is currently not uncommon.
Work on expanding and improving the availability of children’s inpatient services is long overdue and needs prompt action. Equally important is ensuring that there are enough trained staff and other community resources to ensure that there is support and treatment available to prevent admission.
There are few transitional services as these children become adults. Teenagers often find themselves treated differently when they reach the age of 18 or have their treatment abruptly cut. This is because the health service’s resources available for adults with similar complex needs to girl X—the International Classification of Diseases uses the term personality disorder—is no better than the provision for children and adolescents, with fewer than 60 beds funded by NHS England specifically for adults with personality disorder.
While the diagnostic terminology may be criticised, we know that trauma and abuse in childhood often leads to serious psychological problems in adulthood. Our scientific understanding of the mechanisms isn’t clear, but it’s beginning to look as if negative childhood experiences disrupt the formation of brain circuits and lead to the symptoms we see in adults. What is important, however, is that we do have a range of treatments, which can reduce patients’ suffering and save lives.
People are justifiably horrified when they read or hear about child abuse. Yet there is a gross lack of funding to provide the medical care needed to address the harm it causes.
Fourteen years after the report Personality disorder: No longer a diagnosis of exclusion, mental health services often don’t have the resources to follow NICE guidelines for people with this diagnosis. Staff lack confidence in dealing with them. Many patients feel shut out from both mental and physical health services. Due to the lack of appropriate beds, patients are often left in locked rehabilitation wards, without necessary treatment facilities. The Care Quality Commission’s review of mental health services highlighted the existence of 3500 patients in such wards as a major concern: “We do not consider that this model of care has a place in today’s mental health care system.”
Now that the media furore around girl X’s case has moved on, I hope that the attention brought to this area will lead to significant improvements in children’s mental health services. While the plight of adults diagnosed with personality disorder is unlikely to garner the same level of emotional outrage as that of children, their situations are no less shameful. As I have said, their difficulties are often due to being traumatised. To be seen as undeserving or responsible for their own difficulties is just wrong. Stigma must not stop investment. Apart from the personal suffering it inflicts on individual patients, the current approach makes no financial sense. A £1.5 million investment in a personality disorder service in the South West led to savings of £6 million.
We need a national strategy for this group of patients. Establishing the resource deficit would be a good start, with a review of all available models of intervention and their cost effectiveness. There then needs to be a coherent and coordinated plan to ensure that these people get the help they deserve.
Wendy Burn is the president of the Royal College of Psychiatrists.
Competing interests: I have read and understood BMJ policy on declaration of interests and declare the following interests: None.