Place of refuge as psychiatric health system buckles

What it’s like inside the emergency psychiatric ward at St Vincent’s Hospital in Sydney, as troubled patients seek a refuge they desperately need.

Psychiatrist Jacqueline Huber at St Vincent’s Hospital in Sydney: ‘A huge part of what we do here is to try to help people find meaning and purpose’. Picture: John Feder

Inside the emergency psychiatric unit at one of Sydney’s busiest hospitals, there is a genial atmosphere as patients walk the halls in pyjamas, sometimes stopping for a chat at the open curtain of fellow inpatients.

The calm atmosphere belies the constant stress this hospital is under: this is supposed to be a short-stay unit, but many patients spend much longer here, with beds in the inpatient mental health ward perpetually oversubscribed.

The director of Emergency Psychiatry at St Vincent’s Hospital, Jacqueline Huber, is soon to discharge a patient to temporary accommodation. He’s an articulate, friendly man with an obvious sensitive and curious temperament, but she fears this admission won’t be his last this year.

Worse, Huber worries she’ll soon run into him in a nearby Darlinghurst park, or in the streets of King’s Cross, like many of her patients, where he might be sleeping.

“I walk through the parks and it’s just ‘G’day doc, G’day doc’,” Huber says. “It feels like it’s harder and harder to get supported ­accommodation for people. This is just such a wicked problem.”

Homelessness is endemic among those suffering mental illness who decades ago were cleared out of asylums and locked hospitals but have not been given proper community support. Victoria admitted during the week it did not have the money to implement key recommendations from a mental health royal commission as hospitals buckle under the strain.

With virtually all Australia’s mental health inpatient units at absolute capacity, an escalating staffing crisis and constantly rising costs to the health system, doctors say the solution is not just pouring money into hospital beds and new wards. Many of the reasons for the steeply rising rates of mental health presentations arise not only from diagnosed illnesses but as a result of loneliness, isolation and poverty. Many people need houses and community connection, but they’re so hard to find that instead, they end up in crisis in a hospital bed.

Inside St Vincent’s ED’s psychiatric emergency care centre, it’s not lost on Huber that many of her colleagues are still traumatised from events last month when 18 people were stabbed by an ­offender living with schizophrenia in nearby Westfield Bondi Junction, many of the injured brought to this same hospital fighting for their lives.

A renewed national focus on mental health was triggered by the events, and this is one reason the hospital has granted The Weekend Australian extraordinary access to its innovative six-bedded psychiatric emergency care ward, a place of low light, low stimulus and peace and quiet. The unit, with the hospital’s inpatient mental health unit, Caritas, will also be featured in an SBS series, The Hospital: In The Deep End, screening early next month with actor Samuel Johnson.

“I have a colleague who said something poignant to me ­recently: that the health system has become the only available community for some people,” Huber says as she stands inside the glass nurses station watching the hubbub in the ward. “I thought that was really spot-on.

“Our patients report a loss of a sense of community, and isolation, despite being in middle of a city. There’s also an escalating sense of ‘where’s my community? I’m surrounded by people. But where’s my community?’ ”

Psychosis, whether induced by underlying schizophrenia or bipolar disorder, or abuse of methamphetamine, remains a common reason for psychiatric presentations to emergency departments.

Domestic violence presentations have also increased dramatically, and no one really knows why. The minds of desperately stressed and abused victims frequently crack, but male perpetrators also present to hospitals in states of acute illness. It’s one of the little-discussed factors driving the nation’s DV crisis.

But it’s also social phenomena that is driving the large increase in psychiatric presentations to hospital in recent years. Psychosocial presentations, often with suicidal ideation among those without an underlying diagnosis, are rising. It’s not only poverty and loneliness, it’s also the sense of being overwhelmed by the problems in the world, including wars.

“We definitely see people who describe a heavier load of emotion,” Huber says. “Their well is sort of shut off. There’s more to worry about. If you pour more distress in, it’s much harder to manage.

“A huge part of what we do here is to try to help people find meaning and purpose in their lives.”

The Victorian royal commission five years ago emphasised the need not only for investment in hospitals and frontline services, but support in the community including early intervention that could prevent mental conditions from escalating to crisis levels. But the Victorian government this week said a workforce crisis was hampering its ability to staff services. As many as one in four public sector psychiatry positions are ­vacant in some states, with governments forced to heavily rely on locums, and The Royal Australia New Zealand College of Psychiatry estimates 30 per cent of NSW’s psychiatrists are considering leaving the profession in the next five years and 43 per cent of the workforce ­intends to retire in the next decade.

Simon Stafrace, chair of the Victorian branch of the RANZCP, said it was “crunch time” for governments to acknowledge how ­severe the public sector psychiatry workforce shortage was.

“Post pandemic, we’ve had a lot of pressure on people on families, the increased cost of living, escalating housing costs as well,” Stafrace said. “I do think that they’re coming to bear on the on the system itself.

“Putting a roof over people’s heads is probably the most important and significant contributions that government can make to improve people’s mental health and prevent them being readmitted to hospital.”