Abstract
Bermuda comprises a group of small islands in the Atlantic Ocean, situated approximately 1000 km east of the USA. It is a self-governing crown dependency of the UK. It is the third richest country in the world, with average wages per head of US$41 495 in 2000. Its economy is based on a flourishing offshore insurance industry and tourism.
Psychiatric services
Bermuda’s health care comprises both private and public initiatives. Employees are required to obtain health insurance for themselves and their dependants. For those who are not insured, the government provides through the public system.
The island has two hospitals, King Edward VII Memorial Hospital, a general medical hospital, and a separate psychiatric unit, St Brendan’s Hospital. The latter provides mental health care for the majority of the islanders and receives a budget of over US$28 million per year.
Human resources
St Brendan’s Hospital employs three adult and one child and adolescent psychiatrist. Each adult psychiatrist takes on the responsibility for providing one specialist area of service. The majority of staff in the hospital are Bermudian, although, given the global shortage of suitably qualified mental health staff, Bermuda recruits actively for doctors, nurses and allied staff in jurisdictions such as the UK, Canada, Australia and the USA. The cultural diversity of the staff produces an interesting mix of perspectives and ideas about health care policy.
Overview of services
Since the early 1980s, mental health policy within Bermuda has focused on making services more accessible, more community oriented and less stigmatised.
The closure of two long-stay wards in the 1980s provided the momentum for the development of community mental health teams. Teams are multi-disciplinary; individual members case manage up to 50 patients. Bermuda’s small size facilitates assertive outreach.
There is a housing shortage for people with severe mental illness. The high cost of real estate due to the expansion of the business sector makes accommodation costs prohibitive for those on a low income and finding cheaper accommodation, such as at the island’s Salvation Hostel, can be difficult. Many individuals with severe mental health problems live with their families, despite the high level of burden this frequently places on carers.
Shortage of beds is unusual and this reduces the pressure to discharge patients before recovery is complete. A small rehabilitation unit offers a comprehensive package of psychosocial interventions for patients with complex needs; it has a philosophy of engagement for up to 2 years.
There are 25 acute hospital beds, including 5 on a psychiatric intensive care unit. Shortage of beds is unusual and this reduces the pressure to discharge patients before recovery is complete. A small rehabilitation unit offers a comprehensive package of psychosocial interventions for patients with complex needs; it has a philosophy of engagement for up to 2 years.
Two learning disability wards remain within the hospital but a government initiative aims to provide one new group home each year and a community learning disability service.
Consumers of mental health services
The population of Bermuda is some 65 000, approximately 60% Black and 40% White. The population is relatively wealthy and well educated.
Despite the turnover of expatriates employed in the business sector, the population is relatively static and this allows for an accurate and up-to-date case register of clients who use the service.
Education and research
St Brendan’s Hospital is currently accredited for training by the Royal College of Psychiatrists. This is important to the hospital, as it helps to maintain standards of care and benchmarks training against UK standards and practice.
A recent community survey commissioned by the hospital board highlighted the need to improve the awareness of mental health issues in Bermuda; a campaign to reduce stigma and provide education is under way.
The relative stability and small size of the population of Bermuda facilitate genetic and epidemiological studies into mental illness. In particular, there appears to be a strong line of schizophrenia and bipolar affective disorder among the St Davids islanders. Collaborative research projects are currently being explored. One study is currently looking at the effect of cannabis on the presentation of psychosis.
Mental Health Act
The Mental Health Act is largely based on the English Act. There is an assessment order and a longer treatment order that lasts for up to 1 year. Two consultant psychiatrists make a recommendation to either a nearest relative or a mental welfare officer. Appeals are allowed and there is a tribunal which hears cases, presided over by a lawyer.