Open up mental health system to avert crisis

This week the Swedish Supreme Court is reconsidering the Appeal Court's decision to reduce Mijailo Mijailovic’s life sentence for murder to closed psychiatric care. This will no doubt serve to re-open the debate on a sequence of events in 2003 that shook up the Swedish mental health system.

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In May last year a 50-year old man obeyed the voices in his head and sat himself at the wheel of his rental car. He then drove at high speed down a pedestrian street in Stockholm's Gamla Stan, killing two and wounding sixteen. He had been in and out of psychiatric care for the past couple of years.

Earlier that month a 34-year old young man had run amok in Åkeshov, violently chasing innocent rush hour travellers with an iron bar. He killed one, and wounded many others. An hour before the attack he had asked the police to drive him to a drug dependency unit, but he was denied treatment because of staff shortages.

Then on September 10th a young Serbian immigrant stabbed Sweden's foreign minister Anna Lindh, who, after a night of extensive surgery, died in the early hours of September 11th. Lindh’s attacker, Mijailo Mijailovic, born in Sweden of Serb immigrant parents, also had a long history of psychiatric problems.

Swedes, whose faith in 'the system' is usually unwavering, were by now asking themselves, "Who is taking care of people with severe psychiatric needs?"

But for each violent attack there are many hundreds of patients suffering in a system that seems to have lost the plot.

More money is only part of the solution

The Government reacted to the nation's outcry by appointing Dr. Anders Milton, President of the Swedish Red Cross, to lead a special task force on psychiatry. One of the key issues in Milton's enquiry is the role that mental health services play in the prevention of violence and the protection of third parties.

Patients such as Mijailovic and the Gamla Stan and Åkeshov attackers are often stuck in a downward spiral where they find themselves batted between different health and social services, without any one agency assuming the main responsibility. In Sweden the basic responsibility for all health and medical care, including those with slight or moderately serious mental disturbances, lies with primary care.

Patients who primary care does not have the resources and skills to diagnose and treat, in a country where it can take up to a week to make an appointment for a common ear infection, are referred to specialist psychiatric health care. Thus the bottle neck is created.

Upon Milton’s recommendations the government quickly promised an additional 500 million Swedish crowns for 2005, although for 2006 there will only be 200 million available. Milton expressed his opinion in the Swedish press that he does not think this is enough.

A recent survey by Dagens Nyheter showed that despite the additional funds, one third of the country’s district councils are still planning to cut back their psychiatric services.


Healthy neurotics

Some 300,000 people seek help from a psychiatric unit in Sweden every year. In 1999 18% of people on sick leave named psychological distress as the main cause for their troubles, and by 2003 this had increased to 30%, with most patients suffering from depression and anxiety.

There are different levels of psychological pain, and there is a large group of people that currently make a demand on the mental health services, whose needs could just as easily be met by other supporting therapies. These are the so-called 'healthy neurotics', a term coined by Freud.

Burn out, depression, anxiety, and stress are not psychiatric problems as such, and yet the only place that people suffering from these conditions can go to is the open mental care system. But according a recent SVT documentary, Uppdrag Granskning, some patients have to wait for up to a year and three months to get help, if they’re lucky enough to be assessed as ‘sick enough’ in the first place.

In short, mental health resources are currently stretched across the whole range of needs from a light bereavement to serious personality disorders.


Increase the access to individual psychological care

Anders Milton has so far managed to get more money into the system. Now he is planning a better process for recognising potentially violent psychiatric patients and he wants to streamline the intake procedures at primary level.

But what's really needed is a restructuring at the intermediate level of care to enable more of the 'healthy neurotics' to be supported through times of crisis, relieving the burden on the psychiatric clinics.

If Sweden were to remove its conservative ‘old boys club’ mentality regarding licensing of psychotherapists and begin to license a greater variety of training centres, the country would increase the amount of licensed psychotherapists and, importantly, be able to offer patients and clients a wider choice of theoretical approaches.

Under the current system, art therapists, music therapists, existential and transpersonal therapists, gestalt therapists and psychodrama therapists are left out in the cold. These are not fly-by-night, superficial approaches. In fact, the majority of countries in Europe have already licensed such therapeutic approaches that are at the forefront of psychological development.

Because these therapeutic approaches do not fall under Sweden’s current licensing practise, but are relegated to the law on "quackery", desperate patients who are being failed by the state system have no way of knowing whether the help they are seeking outside the mental health system is of a good quality or not.

More importantly though, the system deprives an increasingly stressed and needy population from the care and support that the state system is no longer able to offer. If the burden of taking care of so-called ‘healthy neurotics’ is taken away from the state mental care system, there will be more resources available for those who need the system most, the severe mentally ill patients who need care, not condemnation.

A good start would be a second level of competence, similar to the level of a registered counsellor in the UK. Most GP surgeries in the UK now have a resident counsellor, or access to one, bringing primary mental health care back to the general primary care field.

As a Swedish doctor working in a local Vårdcentral once said to me, "I can’t spend an hour with each patient, even when I know that an hour of talking will do them more good than all the anti-depressants in the world. I have nowhere to send this patient, because despite her recent bereavements and integration problems, she is not sick enough to be referred to psychiatric care. She can’t afford to pay to see someone privately, and so she ends up coming to me every few weeks for the barest minimum of personal support and contact."

It is time for Sweden's health care system to recognise that not only do they have a great need to meet, they are actually sitting on a huge resource of unlicensed but extremely competent health care professionals that would relieve the state system of its great burden.


Lysanne Sizoo

Lysanne Sizoo is a certified Counsellor, specialising in bereavement, fertility and cultural assimilation issues. She also runs a support and discussion group for English speaking women. You can contact her on sizoo@swipnet.se, or 08 717 3769. More information on <www.sizoo.nu.