Content Warning: This article touches on the topics of mental health issues, suicide, and cyberbullying, which may be triggering for some readers.
At some point, every single Australian will experience mental ill-health or know someone who has. This investigation by The Weekly exposes the flaws of a mental healthcare system. A system that is under-resourced, understaffed and underappreciated.
Dr Ashwini Padhi speaks solemnly. “The system is in crisis,” he tells The Weekly. He is not prone to alarmism. Dr Padhi has spent his life juggling the needs of vulnerable people, finding beds in wards where none exist, stretching human and financial resources almost to breaking point. A psychiatrist who has worked in the UK and Australia (he was, until recently, a Clinical Director in Mental Health for the vast Western Sydney Local Health District and is now Medical Superintendent at South Pacific Private), he has seen it all. But, he says, he has never witnessed the system buckling as it is now.
It’s buckling for myriad reasons. But prime among them is a surge in people experiencing mental ill-health, particularly younger people, especially since COVID. That coupled with a system that is under-resourced, understaffed and fragmented.
In short, says another concerned psychiatrist, Dr Mark Cross, “the system is broken, not fit for purpose. We simply can’t keep going in the same business-as-usual manner.”
The human toll is immense. In the course of our investigation, The Weekly has interviewed psychiatrists, psychologists and mental health-care consumers from across the country. We’ve read first-person accounts – including coroner’s reports – of people in need who were unable to access appropriate care, and of people discharged from the system into trauma, homelessness and danger.
Six years ago, Katerina Kouselas’s husband died by suicide three days after he was discharged from the hospital. “I believe the mental health system failed him,” she told the Victorian Royal Commission. “And it might be failing lots of other people we don’t know about.”
It is still failing people daily. In January this year, 206 NSW psychiatrists threatened to resign in protest against poor wages and conditions. Many made good on their threat. One of them, Dr Prachi Brahmbhatt, told the Industrial Relations Commission: “I could no longer be complicit in a system that was actively harming my patients and colleagues. I should have perhaps resigned a lot earlier.”
Is Australia in a mental health crisis?
We need to do better because, in some form or another, mental illness affects every Australian. The Australian Institute of Health and Welfare’s most recent national survey (2020-22) tells us that more than 43 per cent of Australians (8,514,700 people) aged 16 to 85 have experienced mental illness. And 22 per cent (4.3 million) had experienced mental ill-health in the 12 months prior to the survey. Far and away, the most common conditions were anxiety disorders, experienced by 17 per cent of us (3.4 million people).
Georgie Harman, CEO of Beyond Blue, explains that the national incidence of mental health-related conditions has largely been steady for about two decades. “What is shifting, though, and shifting absolutely in the wrong direction, are the prevalence rates of mental health conditions in young people – especially young women.”
Data collected by Beyond Blue has shown a 15 per cent increase in reported mental health conditions among young women over the past 15 years.
Mental health in an increasingly complex world
“Life is getting more complex,” Georgie says. “People’s distress is rising. We talk about the VUCA environment: Volatile, uncertain, complex and ambiguous. That’s the world we’re living in, and that was exacerbated during the pandemic. There are impacts from social media, increasing loneliness, and global conflicts. Political discourse is more divisive, and the effects of the cost-of-living crisis are absolutely real.”
There is also the effect of family violence and of violence against women in the community. “Life feels hard and heavy, and that’s what’s coming through in all our conversations with the community,” Georgie adds.
Simultaneously, what she calls our “mental health scaffolding” has been collapsing around us. “Let’s be really clear,” she says, “most mental health support happens outside of hospitals and mental health clinics. It happens in footy clubs, walking groups, choirs, around kitchen tables – in community. It’s about our social connection as human beings. Those social scaffolds – churches, RSL clubs, things that have in the past bound us together – are deteriorating. We’re increasingly divided and retreating inward. We’ve forgotten the power of connection.”
Decades of underfunding have pushed the system to breaking point
In recent years, we’ve seen a greater need for mental health services, yet neither private nor public funding has risen proportionately to demand. The impact of mental health issues accounts for 13 per cent of Australia’s total disease burden but receives only 7 per cent of healthcare funding.
“To put it very bluntly,” says Dr Padhi, “let’s say I’m CEO of a wealthy corporation and I have a choice between opening up a swanky cardiology unit with robotic surgery, or opening up a mental health unit for people who are homeless and socio-economically deprived. Far more publicity is garnered through the swanky cardiology, robotic surgery unit. I have been a victim of that, fighting for funding, advocating for mental health. Sadly, there’s not much support there.”
The results of this underfunding, says Dr Cross in his book, Mental State: Navigating Australia’s insane mental-health system and how to fix it, include understaffing and underpayment. So “those who work in the public health system are exhausted and leaving in droves”.
Meanwhile, the fragmentation of the system (between federal and state government departments, private enterprise and community NGOs) coupled with financial pressure, also leaves cavernous treatment gaps through which patients inadvertently but regularly fall.
Monique’s care fell through a gap in the system
Monique*, who lives in Melbourne, has struggled with a serious depressive disorder for decades. It’s why, even when times have been tough, she has kept up her private health insurance. But recently she realised this wasn’t the guaranteed safety net she had hoped it was.
“I’d taken a lot of medication a few times in a row,” Monique explains. “Sometimes I will take too many pills when … I don’t exactly want to end my life, but I don’t want to be here. Sometimes I can’t control the impulse, and then that can put me into a state of delirium.
“My psychiatrist was away, so couldn’t admit me to the private hospital where she practises. There was another hospital where she had a colleague, but they had a waiting list of 13 people. So, my psychiatrist sent me to a public hospital because, she said, ‘you can’t be on your own right now’.”
“I don’t know what would happen to someone like me if I didn’t have private health cover. They obviously didn’t have a place for me in the public system. How many people like me are just sent back out the door?”
Monique*
Monique went with a family member to the Emergency Department (ED), where she waited for 13 hours. When the triage nurse finally assessed her, she told Monique she was not sufficiently ill to be admitted. Monique certainly felt unwell, and when her psychiatrist called, she said, “You have to push.”
Monique was eventually sent home with a family member who was told to lock away her medication. A member of the Crisis Assessment and Treatment Team (CATT) phoned her every two days for a safety check.
“It was a scary week,” she remembers, with no access to residential psychiatric care. “I don’t know what would happen to someone like me if I didn’t have private health cover. They obviously didn’t have
a place for me in the public system. How many people like me are just sent back out the door?”
Waiting 72 hours in Emergency
Monique’s story raises a volley of questions. To begin with, why did a mentally unwell person have to spend 13 hours in the frantic environment of the ED?
Emergency presentations for mental health conditions have more than doubled since 2011. The Australian Medical Association’s most recent Public Hospital Report Card reveals that patients with mental health conditions are spending an average of seven hours in the ED. Ten per cent wait more than 23 hours before receiving a hospital bed.
Monique’s inability to access either public or private residential care is not uncommon. The private system carries a financial cost and often has long waiting lists. “The public system requires a certain severity,” Dr Padhi says. He and his staff were regularly required to draw that line.
Every day in the Local Health District, he explains, “there is an Executive Huddle which is attended by top management, senior doctors and department heads. Sometimes these huddles happen three to four times a day. What is discussed is bed occupancy and the number of people waiting in the ED.
“Often, people have been waiting in emergency departments for 72 hours or more. These are vulnerable people with mental health issues, spending 72 hours in the chaos of an emergency department.”
Doctors are under pressure to discharge
There is an urgency to finding places for people. However, admitting someone from the ED requires discharging someone from the ward, and again, decisions are made under pressure.
“Nowadays,” in NSW public hospitals, Dr Padhi explains, “we are mandated to put an expected date of discharge against each person’s name. There are key performance indicators, and managers are held to account. The endeavour should be to ensure that all patients get timely care and spend as little time in hospital as possible. However, often the expected dates of discharge are used to pressurise premature discharges to make room for patients waiting in the ED.
“One of the challenges of my job was calling the directors of every single unit saying, ‘How many discharges? Can you do one more? Can you do another?’ And the pressure goes on.”
Dr Ashwini Padhi
“One of the challenges of my job was calling the directors of every single unit, saying, ‘How many discharges? Can you do one more? Can you do another?’ And the pressure goes on. Sometimes, yes, there is a possibility of safe discharge. But sometimes, under pressure, there may be a possibility of unsafe discharge.”
Often, people are discharged into the care of a Home Treatment Team. These clinicians should ideally be able to conduct home visits daily. But, says Dr Padhi, “they can only do that if they have a reasonable caseload. Nowadays, most crisis teams in NSW have at least three times more cases than they can comfortably care for. So that system is breaking apart, too.”
A chronic shortage of carers
Recent inquiries have recommended the addition of over 2000 mental health beds in Australia. This would go some way towards easing the ED logjam, but at present, there are nowhere near enough psychiatrists to oversee those beds.
Better pay and conditions would encourage brighter, young med students to specialise in psychiatry. But even if this year’s top high-school graduates all chose a career in mental health, it would take the better part of a decade for them to enter the system, and the problem of distribution would remain. It’s proving near impossible to entice psychologists and psychiatrists beyond the affluent inner suburbs of capital cities.
Regional and remote NSW has fewer than one psychiatrist per 100,000 people.
In inner Perth, in 2022, there were 107 psychiatrists per 100,000 people. In inner Melbourne, there were 68 per 100,000. Yet there were just four or five psychiatrists per 100,000 in north-east Perth and north-west Melbourne, and best of luck finding a local psychiatrist in the regions. Regional and remote NSW had fewer than one psychiatrist per 100,000 people.
Even in inner-suburban capitals, finding a private psychologist or psychiatrist often involves joining a months-long waiting list and paying as much as $200 to $350 per session for a psychologist, or $350 to $500 for a psychiatrist (after Medicare rebate).
Medicare Mental Health Centres are an attempt to address both distribution and affordability. They are free services, strategically placed where need is acute, offering three months of care and help in navigating the mental health system. But we need so many more of them.
Telehealth has enormous potential, particularly in the bush, as do online portals such as Headspace and Beyond Blue. We could also expand our mental health workforce to include more carers with lived experience.
Post-natal mental health support changed Susan’s life
Susan Boden was 43 years old, the mother of an 11-year-old and a newborn baby, when she says, “I fell apart. I was tearful. I just felt like a ghost in my own life … My husband was incredibly supportive. I had family support and I had friend support, but I felt so lost. It was such a physical sense of overwhelm.
“I said to my husband, ‘let’s go for a walk’, and we walked around the block, and I just said to him, ‘I don’t think I can manage’. So we rang the GP – this was on a Saturday – and he said, ‘You need to go to hospital’.”
Susan was in Canberra and, by some small “miracle”, there were two postnatal rooms in the mental health unit there, where a mother could bring her baby and even her partner. There are none in the ACT now.
“I’ll never forget,” she says, “that my husband took me to the hospital and then I was terrified he was going to leave. But the head nurse said to me, ‘Don’t you understand? He can stay with you.’ And he did, and our daughter, Imogen, was cared for by family.” And slowly, Susan found herself again.
“Honestly,” she says, “I don’t know what would’ve happened to me had that not been available. And I know it’s not available to most women, even in big cities.”
Help from those who know
Fast forward 20 years, and Susan has completed postgraduate training in mental health case management. She is a spokesperson for Beyond Blue and is working as a mental health lived experience practitioner for the very same GP who suggested, on that Saturday afternoon, that she admit herself to hospital.
If a patient comes in with a mental health issue, the doctor will book them in for a follow-up appointment with Susan, free of charge. The practice pays her fee.
“It’s my job to offer whatever support they need,” she explains. “That might be simply saying, ‘Can I ring around and make some appointments for you?’ It might be asking them, ‘Would you like me to drive you? Would you like your family to come in so we can explain what’s going on?’ If they go into a hospital, we have a policy that we always visit, if they want that. We just go, ‘Hi, we’re here for you and we’ll be here for you when you come home.’”
“People with lived experience are worth their weight in gold.”
Dr Ashwini Padhi
Dr Padhi was involved in the introduction of “peer navigators” to emergency departments in the Western Sydney Local Health District.
“People with lived experience are worth their weight in gold,” he says. “Sometimes, having a friendly chat, offering a glass of water, just providing reassurance and sharing lived experiences can be calming
and therapeutic. The difference it made and the feedback we received was amazing.”
Dr Padhi introduced an initiative where a mental health nurse was embedded in the ED team to facilitate prompt mental healthcare, and subsequently, “mental health cubicles” were introduced at Westmead Hospital, where vulnerable individuals could find respite from the frantic emergency department environment.
How to solve our mental health crisis
Ideally, Dr Cross and Georgie Harman would like to see fewer people with mental health issues presenting to the ED. They’d like to see more funding for the sector altogether, and greater balance in where that funding goes. They would like to see an increased emphasis on prevention, reducing stigma, and addressing social inequalities that mean culturally and linguistically diverse people, Aboriginal and Torres Strait Islander people, those living in poverty and without secure housing, people with disabilities and LGBTQI+ people, as well as women, all experience a greater burden of mental ill-health.
“We’ve had lots of inquiries and reviews, and we’ve got lots of documents,” says Georgie. “Now we actually need a long-term vision and plan of where we want to get to as a country in terms of mental health.
“We need a plan that isn’t about electoral cycles, that is bipartisan and sets out the changes and reforms that need to be methodically worked through. It’s going to take a long time, but at the moment we don’t have a plan at all. We don’t even have a system. What we have is a loose confederation of confetti.
“We actually need a long-term vision and plan of where we want to get to as a country in terms of mental health.”
Georgie Harman
“So that’s where we could start — with governments sitting down, designing that plan and committing to fund it. And designing it with the community, because the people who use these services are often the experts.”
Dr Cross would also like to see a positive vision for the future and a plan to get there. “What an aspiration,” he says, “to be a mentally healthy country.”
He believes that, in spite of the gaps, stigma and hurdles, it’s achievable.
Where to find help if you need it:
You can find your nearest Medicare Mental Health Centre here. Or talk to your GP. For mental health support, contact Beyond Blue; Headspace; or call Lifeline on 13 11 14. Young people can also contact the Kids’ Helpline on 1800 55 1800. Aboriginal and Torres Strait Islander people can contact 13YARN on 13 92 76.
*We have changed Monique’s name to protect her privacy.
This article appears in the July issue of The Australian Women’s Weekly. SUBSCRIBE so you never miss an issue!
