In three months, three men committed suicide in custody. The latest incident occurred in the Mount Carmel Hospital forensic unit. Maltese Association of Psychiatry president Etienne Muscat highlights the gaps in the mental health system and tells Kim Dalli nursing staff should have more say in determining a patient’s level of risk.
“Every time a psychiatrist hears somebody has committed suicide, it’s as if time stops as we wait to hear the name. We always worry it’s our patient,” Dr Muscat says.
This is the situation psychiatrists and the families of patients live with, as suicide is the ultimate negative outcome of a serious mental health illness.
“Hospitals and units housing people who are in a crisis are constantly having to reassess their structures and safety procedures,” he adds.
Even the best professionals cannot tell whether a person will or will not commit suicide, Dr Muscat continues. What a professional can do, however, is assess how high the risk is and take the necessary steps to ensure the patient’s safety.
“Where we are perhaps failing patients in psychiatric services and in police lock-ups is that the assessment done upon admission needs to be more nuanced and ongoing, rather than a black and white decision.”
The mental health landscape in Malta is a complex and multifaceted one – and the answer does not always lie in implementing new regulations.
“When something goes wrong, there’s usually an internal inquiry which determines whether or not the system which should have been in place was implemented.
“If the system was implemented and the outcome was still negative, then we have to see what went wrong with the system. If the system was not implemented, then the unit in question has to decide on the solution.”
Qualifying that he is not familiar with the specific workings of the forensic unit, Dr Muscat explains that suicide watch is a “hierarchised approach”.
What we’re doing is providing social support but diluting the psychiatric care we can give
Depending on the level of supervision the patient requires, there are standard pre-set levels. The psychiatrist requests the adequate level and it is the hospital’s responsibility to provide that level of supervision.
At its most basic level, patients would be admitted to a locked unit, which limits their range of actions and exposure to danger. Patients under heightened risk will be observed every 15 minutes, placed under constant watch and – in the most acute cases – observed by a staff member at arm’s length.
Yet the demand always overwhelms the available resources.
“The first step we need to look at is: who is being admitted to Mount Carmel Hospital? Are we reserving the hospital for those who are severely ill? Or are we admitting people on the basis of them being homeless or because they feel safe?
“What we’re doing is providing social support but diluting the psychiatric care we can give. And this is something we have been guilty of doing throughout the years.”
Dr Muscat strongly believes that nurses and other staff who work with the patients on a daily basis need to be given more of a say in determining patients’ risk and danger.
The current system depends solely on the psychiatrist’s assessment. This was especially crucial in view of the fact that a patient’s condition could be highly volatile and suicide watch is extremely labour intensive.
“The more the staff providing supervision are able to make their own rapidly shifting determination of a patient’s conditions, the more reactive a system will become.”
Malta’s current services also heavily revolve around inpatient settings. The country has to transition to an outpatient setting, which is more economically viable, less restrictive and more tolerable for the patient.
“The whole country says it wants change but is reluctant to go through the pain of change,” Dr Muscat notes.
Malta requires a service specifically targeting those who are just developing mental health problems. New patients are entering an overburdened system, where specialists are seeing too many patients who can be tended to by non-specialist doctors.
There is also a chasm between inpatient and outpatient services, and people are falling through the gap, Dr Muscat points out. There has to be a specific service to help those patients who no longer need an acute level of treatment but still require regular follow-up.
The psychiatric outpatient department in Mater Dei Hospital is also an issue for many psychiatrists and patients alike.
The area originally earmarked for the outpatient department is taken over for necessary ward space and its current location is darker, less welcoming and more crowded, and thus a less positive experience for patients, families and staff.
The outdated and stigmatised buildings that make up Mount Carmel Hospital were similarly not conducive to a positive, healing and therapeutic environment.
The first step we need to look at is: who is being admitted to Mount Carmel Hospital? Are we reserving the hospital for those who are severely ill?
“If doctors are reluctant to admit patients to the one place where they can receive care because of its structure and set-up, then we are failing people,” Dr Muscat says, adding that the association has raised the issue with the government, which is promising to give the sector due attention.
From his point of view, Dr Muscat adds, the sector always needs more staff. However, from the point of view of what a country or a hospital can afford, it is not always possible to obtain more staff, he acknowledges. The sector therefore has to rethink the way it organises and provides safety observations.
“We can sense that the set-up in Malta has become rather turgid and stagnated. But, on the other hand, we have a lower number of staff per capita than in other countries and yet we have incredibly easy access to medical and specialist care.
“But to provide for this, we end up seeing vast numbers and we are therefore unable to provide the time necessary to the patients most in need. If I am struggling with an emergency situation, I need more time. But if my outpatient clinic hosts 40 people, I cannot give that patient the time he needs.”
The Maltese Association of Psychiatry will be organising a conference entitled ‘Standards and Models of Delivery of Psychiatric and Mental Health Care’ on January 29.