After the devastating February 2011 earthquake, community mental health nurse Denise Coots was terrified.
She was “extremely anxious” working on Christchurch Hospital’s fourth floor, scared of going out on her own and feared something would happen to her family while she was out on-call at night.
“You had to manage your own fear while supporting people.
“It’s real, you’re human just the same as they’re human … but you do have to maintain control over your emotions.”
After each aftershock, colleagues knew to check on her right away.
“As a team we’d all been through it … some people lost family members and friends.”
By the time the November 2016 quake hit, Coots was coping better and managed to reassure people around her.
City specialist mental health nurse consultant Joan Taylor says staff have faced their share of post-quake hassles while looking after an unprecedented number of vulnerable people.
Demand started rising about a year after the February 2011 tremor and had plateaued near or above capacity for the past three years.
Comparing 2010 and 2017 figures, there was a 72 per cent increase in mental health presentations to Christchurch Hospital’s emergency department, a 100 per cent increase in children and youth referrals to community mental health services, and a 36 per cent increase in adult referrals.
‘HALF A SHOESTRING BUDGET’
International research suggests disasters can have long-term mental health impact and that policymakers allocate resources towards the most vulnerable in the five to 10 years post-disaster.
Yet, more than a dozen people working in Canterbury’s wider mental health sector interviewed for this series agreed Government funding had not stayed in line with demand.
The funding issue is at the heart of a public spat between the Canterbury District Health Board (CDHB) and the Ministry of Health (MOH) that has been simmering since 2012.
The CDHB says the Government’s post-earthquake support has been inadequate and has resulted in a ballooning deficit.
Canterbury’s three primary health organisation bosses and a group of 500 senior doctors publicly backed the board in July and called for an independent review of the region’s funding.
Medical officer of health Alistair Humphrey says the region’s mental health services are “doing incredibly well on half a shoestring budget”.
Community and mental health services have been “chronically underfunded for several years now”, he says.
“Even if the Government decided to fund us to the right level, we still have five years to somehow catch up with.”
The MOH and Treasury officials have roundly dismissed these assertions.
They say the CDHB was well supported with an extra $106 million since 2011 to help cope with post-quake pressures on top of normal funding. To put this figure into context, it represents about 1 per cent of the board’s funding over that period.
‘WE’RE NOT ABLE TO SEE EVERY SINGLE PERSON’
Several years working under strain has taken its toll, with CDHB staff taking one extra sick day on average across the board.
Despite the pressures, Taylor says the services have responded to the demand.
After the quakes the psychiatric emergency service, community and inpatient teams came together at Hillmorton Hospital to form the crisis resolution team.
The triage process was simplified so the team could assess more people in-person or on the phone. Staff prefer to visit people in their homes, Taylor says, but it is not always possible.
The move was hard for some and, at first, Taylor was not sure it was in the patients’ best interests. A few years on, she says it has turned out to be “a very good decision”.
“Not everybody gets the response that they want and unfortunately we are not able to see every single person.”
She says the service could not have coped without the changes, but it is getting more difficult to manage by the day.
“If it keeps going the way it’s going, we’re going to have to come up with some more ideas.”
MENTAL HEALTH CONSEQUENCES CAN PERSIST FOR YEARS
There is little research measuring the long-term impact of disasters on mental health specifically – most studies focus on the the first two years of recovery.
But a paper published in the Australian & New Zealand Journal of Psychiatry in June sheds some light on the matter.
Researchers looked at the mental health impact of the 2009 Black Saturday bushfires in Victoria five years on. They interviewed 1017 people and assessed their rates of post-traumatic stress disorder (PTSD), depression, anxiety and alcohol use.
The paper concluded that, although rates of mental health problems diminished over time, they remained higher than national levels five years post-disaster.
Findings suggested policymakers needed to “recognise that the mental health consequences of disasters can persist for many years after the event and need to allocate resources towards those who are most at-risk as a result of substantive losses and ongoing life stressors”.
Psychiatrist and University of Otago, Christchurch, associate professor Caroline Bell ran a service for people with PTSD for four years post-quake.
“We didn’t anticipate it going on that long, but we were still getting people referred to us.
“People carry on until suddenly they realise they’re not doing well.”
Canterbury’s recovery is hard to compare with other places that have suffered disasters, with the impact of several major quakes and thousands of aftershocks causing “constant retriggering” and “long-term persistent strain” on people and mental health services.
“We don’t have a map that’s going to tell us that’s where we are expected to be at seven or 10 years [post disaster],” Bell says.
AN EXHAUSTED WORKFORCE
It’s hard to pin down Christchurch Primary Health Organisation (PHO) mental health GP liaison Georgina Jardine. Her workload is such that we reschedule the interview twice, in between a staff meeting and patients waiting for her call.
Demand for primary mental health in Canterbury has almost tripled post-quake, according to internal data from the region’s three PHOs.
Jardine’s job is to help city GPs triage patients who need extra mental health help and direct them to services, including brief intervention counselling and access to nurses, psychologists and social workers.
Resourcing has increased, including a full-time intensive GP liaison role, a brief intervention counsellor and a couple more part-time staff. But she says it’s not in line with demand.
GPs play a key role in catching situations early before a patient deteriorates and ends up in a psychiatric ward, she says. Working under strain comes at a price.
“There’s a lot of goodwill coming from the staff, often to their own detriment healthwise,” Jardine says.
“A lot more people become unwell, but they still keep working because we don’t have any backup.
“The workforce is exhausted, but they do provide above and beyond what they’re paid for. There’s such a need in the community.”
It means some people “are falling through the gaps because GPs know teams are overloaded”.
In other words, GPs might do their own triage and the unmet need resulting from this is not measured. And some people cannot afford a GP visit in the first place.
‘WE’VE MADE IT LOOK TOO EASY’
CDHB chief executive David Meates has an unrelenting message. Over an hour-long interview, he mentions several times that Canterbury’s population growth “has been way beyond what was projected” post-quake, which has resulted in the region not getting its fair share of Government funding.
He says the complex formula determining how much funding each DHB gets annually works well in a stable environment, but more flexible mechanisms are needed after a disaster.
The CDHB has diverted tens of millions of dollars to top up mental health services since 2011, putting “significant additional pressures on all services”.
Staff have worked under constant disruption, with thousands of hospital rooms damaged, 44 buildings demolished and half of all Christchurch Hospital clinical services shifting, on average, four times since the quakes.
RICKY WILSON/FAIRFAX NZ
Since 2011, the CDHB has increased investment in staff counselling support programmes by 40 per cent.
“People have gone way beyond what you would reasonably expect.”
Meates says services have been able to deal with the demand thanks to a complete transformation that started in 2008.
Health services, not-for-profits, GPs and other agencies – which tended to work in isolation – were working together to care for people in the community instead of the hospital.
Without the shift, Meates says, “health services would have imploded quite a number of years ago in Canterbury”.
“Because we didn’t implode there is a clear sense that the impact of the quakes wasn’t that bad … I think we’ve made it look too easy sometimes.”
Meates anticipates demand for mental health will plateau over the next 12 to 18 months.
“We are at capacity now … it is literally one patient in, one patient out.
“The difference between continuing to be able to do that and grinding to a standstill is starting to get close.”
‘NO-ONE CAN SAY THERE’S TOO MUCH MONEY IN HEALTH’
Minister of Health Jonathan Coleman acknowledges the relationship between the CDHB and the MOH “has clearly been strained”.
“I’ve said to both of them ‘Look you’ve got to get on and work constructively and put the health of the people in Canterbury above and beyond’.”
Canterbury is “right around that peak time” for mental health need post-disaster, he says.
“The effects [of the quakes] are far reaching and over a long period of time and it’s important … that we have a framework for responding to it.”
Coleman denies the MOH has taken a business-as-usual approach to the region.
“The population-based funding formula allocates funds around the country, but on top of that, for events of this nature, there are other mechanisms.”
WHERE TO GET HELP
Lifeline: 0800 543 354 – Provides 24 hour telephone counselling.
Youthline: 0800 376 633 or free text 234 – Provides 24 hour telephone and text counselling services for young people.
Samaritans: 0800 726 666 – Provides 24 hour telephone counselling.
Tautoko: 0508 828 865 – provides support, information and resources to people at risk of suicide, and their family, whānau and friends.
Whatsup: 0800 942 8787 (noon to 11pm).
Kidsline: 0800 543 754 (4pm – 6pm weekdays).
The Lowdown: thelowdown.co.nz – website for young people aged 12 to 19.
National Depression Initiative – depression.org.nz (for adults), 0800 111 757 – 24 hour service.
If it is an emergency or you feel you or someone you know is at risk, please call 111.
For information about suicide prevention, see www.mentalhealth.org.nz/suicideprevention.