Medical Services in New Zealand and The Pacific
VIII: The Management of the Psychiatric and Psychoneurotic Cases
VIII: The Management of the Psychiatric and Psychoneurotic Cases
In New Zealand at an early stage of the First World War – in 1915 – it was anticipated by Sir Truby King, then Medical Superintendent at Seacliff Mental Hospital, that a number of men would return from overseas suffering from nervous disorders, and he offered his house at Puketeraki to the Defence authorities for the duration of the war as a hospital for such cases. It was contemplated at this stage that the mental and nervous disorders of soldiers would be relatively mild and transitory, and there was a popular sentiment that a man suffering from mental disorder produced by his patriotic efforts for his country should not be ‘stigmatised’ by committal to a mental hospital.
Sir Truby King's offer was accepted and for some time all went well – the cases which first came to Puketeraki were mild and amenable, and under the care of Seacliff nurses, attendants and doctors, most recovered and were quickly reabsorbed into civil life. These were mainly cases of true neurasthenia and similar functional nervous disorders. 'As time went on, however,' said a report by the Director-General of Mental Hospitals (Dr T. G. Gray), ‘we got many mental cases which were in no respect different from those we are accuWH2PMe to see in Mental Hospital. We received epileptics of dangerous tendencies, cases of delusional insanity, depressed cases who were suicidal and not a few feeble-minded men who had eluded the recruiting medical examiners and had got as far as England before the rigorous training disclosed their weakness.’
Under these circumstances a very difficult and at times dangerous situation arose at Puketeraki. In many instances removal to a mental hospital became an urgent necessity, and it was found that neither the relatives nor the military authorities were available or willing to make the necessary application for certification. General Henderson, the then Director-General of Medical Services, gave the Mental Hospital Department what purported to be a legal authority to hold such cases in a mental hospital and many cases were transferred to Seacliff; but this authority was later found to be illegal and for several years after the war the Department was attacked by the Returned Soldiers' Association and by individuals for its action, although this was dictated entirely in the interests of the soldiers and certainly was not harmful in any individual case. 'During the period between the outbreak of hostilities and 4 August 1919, the number of soldier patients in our care was 334, but these were not all dealt with at Puketeraki or Seacliff. We had urgent page 399 representations from relatives that the men should be located nearer their homes and so some were transferred, and others were admitted directly, to Auckland, Porirua and the other Mental Hospitals.'
Between the wars there was a very marked advance in the knowledge and treatment of mental disorders, and especially in the appreciation of psychoneurotic conditions.
At the onset of the Second World War the importance of the problem was stressed by the Director-General of Mental Hospitals to the DGMS. Dr Gray stated:
During the war of 1914-1918, quite an appreciable number of persons who were feeble-minded or who had suffered from mental disorders, managed to enlist and, whilst some were eliminated at the camps in New Zealand, a proportion went overseas and their disabilities were discovered through the rigours of advanced training or service in the field….
At the end of 1918, a review was made of the military patients who came under the care of this Department during the actual period of War, and it was found that out of 303 soldiers, 35 were definitely feeble-minded or had had a previous mental breakdown, whilst 59 had shown a previous predisposition to mental disorder. In other words, of the 303 persons who came under our notice during the war, no less than 31 per cent were unfit for active service before they enlisted. These figures, which I have taken from a review published in our Annual Report for the year 1918, are certainly minimal and from my personal experience I have no hesitation in stating that the percentage should be much higher. Except in those cases committed by a Magistrate, and they constituted only about a half, the familial and previous histories were very cursorily ascertained, owing to the conditions then obtaining. Furthermore, these statistics did not include cases sent to Mental Hospitals in England, nor those who were found untrainable in the various camps abroad and returned to New Zealand, nor the cases returned in the years following the war…. I feel that some routine procedure should be devised to prevent mentally defective persons from being sent abroad.
Arrangements were made during 1940 for nominal rolls of those called in the ballot to be circulated to the medical officers of the Mental Hospital Department, and for the names of all those who had come under official notice at the mental hospitals, in homes for defectives, or at the clinics conducted by those officers, to be reported through their head office to the DMS.
This system did eliminate many psychotic and feeble-minded persons, but it failed in many respects. First, it was brought into operation too late, after many mentally unfit soldiers had gone overseas. Again, such a check could not be expected to be complete and schizophrenics, who had been satisfactorily treated in our mental hospitals, joined the Army and sometimes broke down and were punished for offences due to their unrecognised mental defect. The many feeble-minded persons who had never been in an institution were also not covered. They had been filling a lower grade position in civil life satisfactorily but had been unable to page 400 adapt themselves to army life. Many of them broke down in camps in New Zealand, and at one stage the Mental Hospital Department had more psychotic cases from camps in New Zealand than from the Army overseas. During the war no provision was made for the utilisation of the services of psychiatrists on the medical boards throughout the Dominion. There was also no arrangement made for psychiatrists to be available as consultants either to the boards or to the Regional Deputies.
Consultations by psychiatrists, however, were arranged for in the case of psychotic and feeble-minded men referred from camps in New Zealand. A special psychiatric board was also set up to examine and arrange the disposal of men arriving back in New Zealand who were medically boarded as unfit by 2 NZEF. These arrangements were based on decisions made by the National Medical Committee on 20 November 1940.
On 24 October 1940 a conference of the Organisation for National Security was held at which there was present the Director-General and two officers of the Health Department, the Director-General of Mental Hospitals, the DGMS and Adjutant-General from the Army and a representative of the Treasury. The conference elaborated a decision of Cabinet made on 18 October ‘that early provision be made for the reception and treatment of neurasthenics and cases of a like nature on their return to NZ.’ The conference agreed that the following arrangements should be made:
Case Histories to be adequately prepared overseas.
Specialist Boards including at least one psychiatrist to be set up to examine cases immediately on arrival in NZ.
Cases deemed suitable to be admitted to the psychiatric wards in the four main hospitals. Other cases to be referred to the clinics, where available, at local hospitals. In all cases the relatives should be notified and asked to concur in all steps taken on the disposal of the soldier. As regards treatment, facilities were available—
Discharge from the Forces: To be the same procedure as in any other soldiers in that all cases should be discharged if not likely to become fit in 3 months and if not discharged to be reviewed by medical boards at least every 28 days.
Establishment into Civil Life: A special committee closely associated with the Rehabilitation and Social Security Depts. should be set up to ensure that a man gets suitable employment when fit.
Economic independence is the main objective, not compensation.
Institutional treatment: Should not be in separate Army, but in ordinary civil, hospitals.
The War Cabinet on 19 November 1940 approved of the recommendations of the conference and a copy of the report was despatched to HQ 2 NZEF. Instructions were then drawn up by the Director-General of Health to implement the proposals.
A prolonged argument took place later as to the responsibility for the certification of service patients in the civil hospitals, but no change was made and the responsibility remained that of the Hospital Superintendent. Difficulties arose from time to time concerning the provision of attendants for service patients in the public hospitals, but finally the hospitals were only too content to obtain the services of the admittedly untrained army personnel from the camps.
In August 1944 the Secretary of War Pensions, Social Security Department, furnished to the DGMS a valuable report on the boarding and after-care of returned soldiers in regard to matters raised by the National Patriotic Fund Board. The following is an extract from this report:
There are three types of cases to be considered:
(a) The psychotics.
The neurotics diagnosed as such and having no other disability.
Cases of men discharged either as 'fit' or on account of a physical disability who at a subsequent period in their rehabilitation exhibit some evidence of neurosis.
The psychotics are, if institutional treatment is required, first treated in a public hospital and only subsequently removed, when necessary, to a mental hospital. The matter of a special institution for these patients is one for the Mental Hospitals Department, but it would appear that:
There are too few patients to warrant it.
A separate institution could not be staffed at present.
The next-of-kin would object to one central institution for the whole of New Zealand.
Regarding the neuroses I would like to comment as follows:
If Medical boarding were postponed for four months the incidence of neurosis would be greatly increased. Experience has already proved that 'delayed boarding' does infinite harm.
Neurosis cases are followed up regularly and as often as appears indicated. Records show that 90% are returned to regular employment.page 402
The welfare societies, etc., could help by notifying the local War Pensions Officer of any particular case who was considered in need of medical advice or by asking the man to report himself. A medical examination could then be arranged.
The suggestion that each man on his return should be asked to report to his own doctor is to be wholly deprecated. Medical histories are already supplied confidentially to local practitioners on request.
The number of servicemen admitted to mental hospitals in New Zealand from the beginning of the war to 31 May 1944 was 142, of whom 72 were discharged and 3 had died. A large proportion of the 67 remaining were later discharged.
In New Zealand throughout the war there was a close liaison between the Director-General of Medical Services (Army and Air) and the Director-General of Mental Hospitals, and there was little difficulty in carrying out the arrangements decided upon in October 1940. The psychiatric control in New Zealand during the war was reasonably effective and the results of treatment very creditable.