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Ongoing care, guidance and benevolence – fundamentals lost in the budget

Severe psychiatric illness can present medical professionals with a variety of management challenges. What additional impact will the implementation of co-payments have? Many thanks for Dr Helen Schulz for this piece examining the impact of the federal budget on those with severe mental illness. 

Dr Schulz writes:

It’s time to address how the proposed budget changes will affect patients with severe mental illness. Those often experiencing delusions and hallucinations, those who go missing to services due to paranoia, and those who are often treated as ‘bed blockers’ when finally brought in by emergency services for acute care under the Mental Health Act.

In 2014, we still have patients in society who suffer every day due to their psychiatric symptoms. They are often not the exception, but the rule in illnesses such as chronic schizophrenia, but due to their symptoms they hide from care, avoid care or fail to recognise they need care.  They deserve and should receive the best care they can, both from doctors and the teams that exist to help them.

It’s also time to face facts about prognosis and outcomes. Many patients with schizophrenia will have more than one episode in their life time. Not all are protected by intervention in their first episode, and not all are able to access diagnosis and treatment when acutely unwell for the first time. Some live in residential accommodation, or in continuing care units that were originally designed to serve as rehabilitation facilities, but due the overwhelming demand for acute treatment stay for long term care.

With the hindsight and experience of working in many areas of acute psychiatry, I can say that these most vulnerable patients will be hit hardest and remain among the most disadvantaged members of society. A society that I believe still has a social conscience. But governed by politicians that plans to cut funding for the National Disability Insurance Scheme, still in its infancy, reduce funding to public hospitals and now poised to dismantle Medicare as we know it.

It is of great concern that proposed co payments will not only affect GP services but also pathology services. Services that doctors order to ensure their patients are monitored for side effects and co morbid physical illnesses. Services that doctors would have to consider worthwhile given that the patients may be unable to part pay for. Under these proposed budget changes, a doctor will have to decide what is more serious, imposing a patient to potential side effects that are undetected without pathology services, or imposing severe financial hardship.

Even more concerning is that doctors will be forcing patients with severe mental illness, who are cared for under the Mental Health Act, to meet the cost of co-payments for medical and pathology services when they are involuntary and unable to consent to treatment.

Take for example a patient with treatment resistant schizophrenia, who improves using a medication such as clozapine, which is very effective but has rare but potentially fatal side effects. The patient has no family, lives in a boarding house, and as part of his treatment must undergo weekly blood tests and heart monitoring in order to get the next week’s supply of medication. Imagine this same patient improves and is well enough to live independently. He then cannot afford to continue with weekly blood monitoring and is unable to receive the medication for the following week. Within 72 hours he notices his symptoms return, worse than ever, and is found and brought into a crowded emergency department, blamed for being ‘non-compliant’ and not taking responsibility for his health. When the very doctors that care for him placed him under the Mental Health Act because they knew the patient was unable to in the first place.

Imagine another case whereby a patient has bipolar disorder and responds well to lithium. So well that they contemplate returning to work. They need to have regular blood monitoring for the levels of lithium in their system, ranging from twice a week at the outset, to monthly when stable. The same patient doesn’t have the blood tests because they can’t afford the co-payment, and the levels rise to dangerous levels. They develop toxicity and require an admission to an intensive care unit for two weeks, lithium is ceased and they then develop a manic episode. It takes them 18 months to finally get to work.

These are not outrageous stories. These events happen already, and would be familiar to anybody working in the mental health system. Impose a co-payment to pathology services and the numbers will rise. Not just for psychiatry but for any time a patient requires drug monitoring or review for side effects. Patients undergoing chemotherapy, taking warfarin, or needing an organ transplant. The undoing of months of time and resources with implications for the patient and their families, all for a grab for cash up front.

It would be nice to believe that patients recover quickly and don’t need ongoing care. It would be easier for administering budgets. But medicine isn’t like that nor is psychiatry. Some patients need our ongoing care, guidance and benevolence for years. It’s always been that way. Always.

Dr Helen Schultz is a clinical psychiatrist working in private practice in Melbourne, Australia. Prior to entering medicine in 1995, she graduated with a bachelor of pharmacy, and worked as a community pharmacist. Dr Schultz obtained her fellowship with RANZCP in 2010. She is also a coach and mentor of doctors in training, and is passionate about the future of psychiatry. She blogs regularly under the title “howshrinksthink’.

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