Are drugs replacing care in our mental health facilities?

BRIDIE COX knows all about the dangers of inappropriately prescribing sedatives to vulnerable patients

BRIDIE COX knows all about the dangers of inappropriately prescribing sedatives to vulnerable patients. After working in the disability and mental health sector in the UK for 30 years, she returned home to work in the midwest several years ago. She was shocked at what she saw, writes CARL O'BRIEN

Cox says she witnessed on several occasions the over-sedation of patients with challenging behaviour. Rehabilitation of residents was virtually non-existent, she said, as there was no meaningful therapeutic intervention.

Worse still was the attitude of senior management. While there was some good care, the main problem she said was a culture which did not place sufficient value on proper rehabilitation and multi-disciplinary care.

“As I saw it, people didn’t have the education or training to do the therapeutic intervention. There wasn’t enough focus on empowering people, helping them becoming more independent, building up therapeutic relationships,” she told this newspaper last year.

The latest findings of the inspector for Mental Health Services appear to provide grounds for even deeper concern.

For the first time, it has been collecting detailed information on prescriptions for in-patients and residents. Of the 22 hospitals or care facilities it has visited to far, it has expressed concern over the level of sedative use in half of them.

In some hospitals as many as 80 per cent of long-term residents were on sedatives – or benzodiazepines – prompting inspectors to call for an “urgent review” of the drugs use. In addition, many patients were often placed on a combination of sedatives and anti-psychotic medication; night sedation was also particularly common in some hospitals.

Benzodiazepines are prescription drugs which are legitimately used to treat a range of conditions such as anxiety, insomnia and seizures. While they are considered safe for short-term use, the risk of overuse, abuse and dependence is well documented.

In addition, over-reliance on this kind of medication often reflects a lack of access to valuable therapeutic interventions. These alternatives to drugs are highly effective in tackling underlying causes of anxiety or challenging behaviour.

Mental health inspectors have so far published reports for about one-third of psychiatric in-patient facilities, but already a pattern of high sedative use is clear.

St Joseph’s Hospital in Limerick is one of the psychiatric facilities visited recently by inspectors. They found that some 80 per cent of residents at the 55-bed hospital had a prescription for a benzodiazepine, while over half were using them on a regular basis, which prompted inspectors to recommend an “urgent review” of all medication at the hospital.

Over at An Coillin, Co Mayo, a 29-bed unit, inspectors said a review of the prescription of benzodiazepines should take place; it found 78 per cent of people on them; 33 per cent on more than one.

At St Edmundsbury Hospital, Co Dublin, – a private facility – inspectors found high numbers of people on night sedation (82 per cent), as well as on benzodiazepines (73 per cent).

Inspectors said these figures were “very high” and noted that medication sheets were of poor quality.

It is of little surprise that many of these facilities also have gaps in multi-disciplinary teams – the people who could provide the kind of therapeutic intervention that is so badly needed. For example, inspectors found benzodiazepine use at St Camillus’s Hospital in Limerick was high and called for a review. They also found that there was a lack of meaningful disciplinary care to underpin the “recovery ethos”, which is at the cornerstone of public policy on mental health care.

“Residents had very little to occupy themselves with during the day . . . ” the report found. “The service was introducing individual multi-disciplinary care plans to the wards but without them and an occupational therapist, therapeutic services and programmes could not be individually directed to the needs of the residents.”

Most observers agree that the answer to an over-reliance on medication lies in training and investment in mental health services.

A Vision for Change clearly sets out what needs to be done to achieve mental health reform. It envisages a national network of comprehensive, community-based, multi-disciplinary mental health teams. The voice of service users would no longer be ignored and quality alternatives to institutional care would be made available. Yet, almost five years on we are still waiting for meaningful signs of progress.

In three successive reports, an independent monitoring group – established to assess progress on the implementation of A Vision for Change – has expressed serious concern at the slow progress of the plan.

Spending on mental health has fallen from 11 per cent of overall health spending in 1991 to 5.3 per cent in 2010. The moratorium on recruitment has had a devastating impact, with at least hundreds of staff leaving the sector without being replaced.

The more time passes without convincing evidence of its implementation, the more disillusioned and disenchanted the champions of A Vision for Change become. The challenge for policymakers and campaigners will be to transplant the philosophy at the heart of Government policy into meaningful action in the day-to-day running of services.

We need a plan with real and detailed targets, time-lines, resources and assigned responsibility. People with mental health problems have waited far too long for a service which respects their dignity and rights. The least they deserve is a service which gives them the best possible opportunity to recover and to reach their full potential.

Carl O’Brien is Chief Reporter