System failure, under resourcing or impossible to prevent? GPs weigh in…

News that the 40-year-old man who stabbed six people to death at Westfield Bondi Junction on the weekend had been diagnosed with schizophrenia at the age of 17 – but had gone off his medications and been sleeping rough in recent years – has led many to speculate on the extent to which a systemic failure of mental health and social support systems contributed to the tragic event.

Writing in the Conversation, Swinburne University of Technology behavioural science Professor James Ogloff says there is good evidence that providing psychiatric and psychological care can help manage mental illness and reduce the likelihood of violence, but it’s also important to address the broader social factors.

Majority of GPs believe fractured mental health system likely played a role

Results from more than 1200 responses to Healthed’s 16 April survey suggest a majority of GPs sympathise with the sentiment that better resourcing would reduce violent incidents, if not eliminate them.

When asked which statement best reflected their views, 58% of surveyed GPs selected “If the current mental health system was better resourced, this could probably have been prevented.”

By contrast, 42% chose “This incident was very unfortunate, but unlikely to be preventable from a health care perspective.”

Many GPs elaborated on the nuance in free text comments.

“I don’t agree with either statement. The mental health care system is very poorly resourced but even an outstanding, well-funded system will not necessarily reach all patients and be able to engage them with treatments available and on a long-term, ongoing basis,” one GP commented.

“These incidents would be reduced with better resourcing and focus on mental health, but not completely prevented,” another agreed.

Others highlighted the focus on allocating resources for those with more common and often less serious mental health disorders, compared with more severe mental illness, despite the outsized burden of the latter.

“The mental health system for people with serious mental illness is abysmal, putting impossible pressure on family members.

This contrasts with the Better Access program where huge amounts of money are spent helping the distressed but mostly worried well of the upper socioeconomic strata of society, and the ridiculous increase in treatment and diagnosis of ADHD by psychologists and psychiatrists which is blocking access to seriously mentally ill patients.

I have found it near impossible to find psychiatrists who will see acutely and chronically mentally ill patients who are a danger to themselves and possibly others.

As a society we should be ashamed.” – Surveyed GP

Multiple factors contribute to risk of violence

In an article published in the Sydney Morning Herald this week, psychiatrists Olav Nielssen and Matthew Large make the case that “while homicides of strangers by people with schizophrenia are extremely rare, homelessness is a known risk factor for continuity of care for stranger homicide.”

“People experiencing both homelessness and mental illnesses often have trouble accessing treatment,” Nielssen and Large write.

“Stable housing is a fundamental requirement for the continuous treatment of people with chronic forms of schizophrenia,” they explain, adding that community services are often unable to locate those without a fixed address to check on them, administer treatment and offer other support.

Behavioural scientist Professor James Ogloff notes that 10% of people with schizophrenia have committed a violent crime, compared with 2.4% of the general population. Of those who do become violent, an overlap with social factors is often at play.

“People with serious forms of mental illness who have backgrounds characterised by social and family disruption and disadvantage together with abuse, behavioural disturbances, substance use and educational failure and disengagement are significantly more likely to offend than people with mental illnesses who do not have such disturbances in their backgrounds,” Professor Ogloff writes.

Exposure to trauma and violence, and poor family and professional support are also risk factors.

Layers of complexity

A number of GPs felt it was unrealistic to expect that patients with such complex needs could all be well-managed in the community. Some suggested a more comprehensive system for monitoring treatment compliance and following up patients known to be at high risk of violence.

Others noted the detrimental impact of the shortage of psychiatrists and psychologists, with the most vulnerable patients often unable to access adequate care in a timely manner.

“Living in the same area where the poor young man came from, I understand the frustration and horror his poor GP must feel as patients are discharged into our care from the public system when we have no access to private psychiatric care — and if you can find someone, then the appointment is over 12 months away and psychologists are equally as hard to find and both charge exorbitant fees which is beyond the capacity of these patients to afford,” one surveyed GP opined.

‘There’s only so much we can do’

While most surveyed GPs believe better resources would improve things overall, many felt that there will always be some who fall through the cracks.

They pointed to the challenge of monitoring patients with severe mental illness, especially if they don’t want to cooperate – or when they stop taking their medication because they feel well, and then choose to avoid the health system.

“If patients don’t take medication and are not compelled, as they have a ‘right’ to refuse treatment, it is very difficult… Better resourcing would definitely help as early discharge would be less, treatment in private system is expensive and there are long waits in the public system,” one GP summed up.