While I have written elsewhere (here and here) about the experience of depression and treatment, as well as the importance of seeking help, I want to address overcoming the barriers that clinicians may encounter in hospital admission and the role potential of mandatory mental health treatment. .
I am a psychiatry trainee near Fellowship and a resident of regional Victoria. I have worked in a few different metropolitan and regional services in different states over the years and know a lot of people in medicine and related fields.
I have also been battling depression for most of the past year. I have engaged with a variety of psychotherapy approaches to address particular issues with mixed success. Medication options for me are limited due to tolerability, but I have a combination that works as well as it can. I have had acute and maintenance transcranial magnetic stimulation (TMS) to target residual overreactivity to negative events and intrusive suicidal thoughts, as well as residual physical symptoms (mainly reduced appetite).
Initially, all my treatment had been outpatient. I had chosen to have outpatient TMS to reduce the impact on my daily life. I didn’t know how much TMS would affect my energy levels – I get absolutely exhausted and spend a lot of my free time sleeping during a course. I decided that if I needed TMS again, I would opt for an inpatient setting so that it could be over faster (and actually have less of an impact on my daily life).
There is also the issue of health fund coverage for outpatient TMS; I know of only two funds that cover this, to a very limited extent. So I recently had a voluntary, private mental health admission for the primary purpose of maintaining TMS. I decided to be admitted earlier than originally planned due to increased suicidal ideation and crying.
For me, I knew it was time to go to the hospital when I started getting angry because I had protective factors, resenting having obligations to others in my life, and wishing I could die without hurting anyone else. It is a very disturbing place.
Most doctors have some impression of inpatient mental health wards, especially in the public sector, which is based on personal experience as a specialist in psychiatry or as part of hospital rotations.
In the public system, we treat patients who are sickest and least able to provide care in any other setting. We also serve people who may have serious substance use disorders or severe personality disorders.
I wouldn’t be surprised if my colleagues reading this have images of psychiatric inpatient wards that aren’t as different as we’d like to think, a view that has been influenced by often negative depictions in popular culture.
In my clinical experience, public psychiatric wards can range from chaotic and scary to pleasant and social, and I do not intend to malign public mental health in any way. We work with what we have, and some services have done absolutely amazing things with very limited resources. Think though, as a doctor, would you want to be a hospitalized patient where you worked? If you had to choose between managing precariously at home or sending a close family member to your neighborhood, where would you feel most comfortable?
I’m under no illusions that it’s as nice as my private admission, but sometimes you need to be somewhere, anywhere, safer.
My admission has been a transformative experience. Even though it is a private facility, I still had many concerns.
Confidentiality was at the top of my list (both colleagues and co-patients included). While I’m very open about my experiences with mental health issues, of course there are some things I’m very private about. I was also worried about being asked to go to group sessions, the expectation of socializing in the ward, the act of giving up a lot of control over my daily routine and comfort and maintaining my religious observances while in hospital.
It took me many months to get to the point of accepting hospital care. I had planned an admission to Preventive and Recovery Care (short-term physician-led residential psychiatric rehabilitation) during a period that would be particularly stressful in my life, but in the end I made alternative arrangements.
I have also considered crisis admissions when the suicidal ideation was particularly severe, but I always found an excuse not to go to the hospital. I often told myself that my risk wasn’t high enough for admission to the public system, that I had work to do, or that I couldn’t justify paying the excess in my health fund.
There was always an excuse not to check in when I should have. While my psychotherapist pointed out the ridiculous nature of my reasoning, it was TMS that gave me what I perceived as a legitimate reason to go to the hospital.
Being an inpatient has given me the confidence to be a regular inpatient for maintenance TMS, but it has also given me the confidence to seek admission when my risk increases or my mental health deteriorates.
I am still very concerned about confidentiality and avoid other patients (who may one day be my patients or at least know my patients). I want to maintain some degree of separation in this regard. However, I am able to take a break from my stressors and work on myself without the distractions of work and home. I can also know for sure that I am safe while I recover.
I guess I was also somehow afraid of peer judgment that prevented me from applying, but the reality is that I have experienced nothing but care, respect and even admiration. A nurse said that I set a good example for other doctors when I entered the hospital. This is what I hope to do by being open about my own experiences and writing about them to reach a wider audience.
There was a point, looking back, at which, if he had been evaluating me, I would have become an involuntary patient. Somehow, I made it to the other end, but it was a very dark time.
I think it’s important to address mandatory treatment, as this is a fear that many have, both within the profession and among lay people. Each country, state and territory has its own legislation on compulsory mental health treatment, but there is a general movement in mental health in Australia and New Zealand to be as restrictive as possible.
When we are affected by mood disorders, substances, or psychosis, we begin to lose our ability to make sound assessments and decisions about our own mental health, risks, and treatment, even if we retain our judgment about the ‘evaluation and treatment of our patients. As much as we trust them professionally, safety plans may not be followed when someone is very distressed.
I strongly believe that being a health care professional should be taken at the same risk as things we take very seriously, like access to firearms. Relatively recent Australian research tells us that:
“Suicide rates for female health professionals were higher than for women in other occupations (Medical Professionals: Incidence Rate). [IRR], 2.52; 95% CI, 1.55–4.09; P<0.001; nurses and midwives: TIR, 2.65; 95% CI, 2.22–3.15; P<0.001). The suicide rates of male doctors were not significantly higher than those of other occupations, but the suicide rate of nurses and midwives was significantly higher than that of men working outside the health professions (IRR, 1.50; 95% CI 1.12–2.01, P = 0.006). ). The suicide rate of healthcare professionals with easy access to prescription drugs was higher than that of healthcare professionals without such access or in non-healthcare occupations. The most common method of suicide used by health professionals was self-intoxication."
Data from abroad tells us that healthcare workers, especially those working in mental health, die by suicide at rates far higher than the general population. Healthcare professionals (especially doctors and pharmacists) also know too much about anatomy and pharmacology, as well as what “works” and “doesn’t work” based on what we’ve seen clinically. First attempts can be lethal on this basis. We also know what to say to reassure people and how the system works.
Although I can’t speak for others, my experience is that doctors tend to be determined and motivated people. We carry our decisions one way or another. When the decision is to die, this is a very dangerous situation.
There is absolutely no shame in requiring mandatory mental health treatment. Mandatory treatment is designed to override the inaccurate perceptions we have of our own risk and needs that I described above. Mandatory treatment also does not warrant a notification from the Australian Health Practitioner Regulation Agency (AHPRA), which requires that practicing your profession would pose a significant risk to the public.
I have stipulated in my own management plan that mandatory treatment should be considered if hospitalization is indicated or if I cannot carry out a very strong safety plan. I hope that sharing this will be an example to others who may be worried about seeking help or being forced into treatment.
My message is fundamentally: seek help, either inpatient or outpatient, within or outside the area, formally or informally. If you find yourself in need of mandatory care, it’s not a failure or something to be ashamed of. Recovering means being able to overcome our difficulties and be better able to get there sooner in the future.
Dr. Israel Berger is an Advanced Fellow in Child and Adolescent Psychiatry at Goulburn Valley Health and is involved in medical and public health education at the University of Sydney and Monash University.
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