Guardian Australia: “It’s rare to be able to tell the truth– here’s what’s wrong with Australia’s mental health system.” Dr Adrian Plaskitt (2021) on our mental health system: “Over two decades as a GP I’ve witnessed the decline of mental health services. 1/40 #Justice4Australia

Don’t get me started on psychiatrists. I am a GP who has worked in the Hunter region since 1999. This may be longer than you anticipated, but it is so rare to be given an opportunity to tell the truth as I see it that I thought I would make the most of it. 2/40

First of all, I want to talk about the general level of service as I have observed it. During my career there has been a general reduction in service for the severely mentally ill, while the provision of service for mild illness has probably improved. 3/40

General awareness of mental health has improved, but it is increasingly defined as an illness that effects an individual, which may obscure some societal drivers of mental illness – but I’ll come to that later. 4/40

At the beginning of my GP career there was a local mental health service that would do outreach for severely ill people. I could make a call to a clinician that I had a relationship with and together we could, if necessary, organise a psychiatry registrar, an ambulance and 5/40

a police officer to attend a person’s home and make decisions about the best course of action, which might involve an involuntary admission if needed. These days I have no direct way of contacting the local mental health team – instead, there is a statewide 1800 number, 6/40

and the problem is allocated by an “intake manager”. The decisions about scheduling people involuntarily are essentially outsourced to the police. It should not be their job. There is no community outreach service, so people tend to get further into a crisis 7/40

until someone calls the police and then they go to hospital. I imagine this service is far cheaper to run, but it means problems are more likely to get out of control before they are dealt with. When people are severely mentally ill they are placed on the “acute list”. 8/40

I used to get calls about this and be actively involved with the local mental health unit. Now when the crisis has passed they drop off this list, and there is no ongoing follow-up with a clinician who knows them and who has an established relationship with them. 9/40

In general people with severe mental illness such as schizophrenia in Newcastle who are stable do not have any ongoing contact with a psychiatrist (unless they have money). Also in the past there were community health centres. This was great for poor people 10/40

with severe but not life-threatening illness. If I had a patient – for example, I remember a young woman with a severe anxiety disorder, not suicidal, not psychotic but really unable to fulfil her potential in life because of disabling anxiety – I could refer them for 11/40

ongoing cognitive behavioural therapy. This service no longer exists; Headspace is the closest replacement but caters only for the young and has a four-month wait at present, and these people are left to work it out for themselves. (Call Lifeline – that will fix you!) 12/40

This is one of the reasons there is a high rate of antidepressant prescription for mild mental illnesses that really would be better treated in the young with talking therapy. It’s because GPs and drugs are far easier to access than psychologists and therapy. 13/40

Instead, there has been an emphasis on private psychologists receiving referrals under “mental health plans”. This is a Medicare structure where we (the GP) write a plan that allows the patient to get subsidised visits to a private psychologist. 14/40

When these were introduced, the psychologists immediately raised their fees, so there is almost always a gap. There is no free service like there used to be. The overall effect is an abundance of psychology services for well-heeled patients in wealthy areas, 15/40

and the five or 10 sessions available are very helpful for problems like mild anxiety or difficult grief. However, patients with severe and ongoing problems like psychotic illneses, victims of childhood sexual abuse (of which there are huge numbers), 16/40

entrenched personality disorders, perpetrators of domestic violence, dual and complex diagnoses between drugs and mental health, and so on, for these people five sessions at $60 or $80 a pop are just not going to help. 17/40

And these people do not in general have the personal resources to access the private service. So we have the paradox of increased funding to areas where there is already capacity to pay, and reduced services among those who are really struggling. 18/40

(That is not to belittle the very real problems that can befall anyone in all walks of life – it’s just that the balance is clearly skewed away from the poorest and most severely mentally ill.) And don’t get me started on psychiatrists. 19/40

There is a chronic, marked undersupply of psychiatrists, and so they tend to be concentrated in large metropolitan centres and focus on motivated private patients. Even in a city the size of Newcastle, I have given up trying to get patients to see a psychiatrist here 20/40

as their books are closed or their prices are so expensive that they have clearly made a decision to only serve the wealthy. As for rural areas, I think most of the psychiatrist workforce is fly in, fly out rather than part of the local community. 21/40

‘We all break eventually given enough stress’ One of the things I have noted over my lifetime is the general increase in awareness of mental health as a personal illness. All the R U OK movements and the men’s health month and so on are great and commendable and aimed 22/40

at destigmatising mental illness and encouraging people to seek help. And while this is commendable, it places emphasis on the idea that mental illness is a condition that can strike any individual in a personal way; it’s like a bolt from the blue and we are all at risk. 23/40

I agree with all that, and yet it is kind of like saying lung cancer is an illness that is terrible and we should all come forward if we have a cough, and we should acknowledge our tobacco addiction and get it treated, while ignoring the effect of the regulatory regime. 24/40

The most effective preventer of lung cancer has been proven again and again to be tobacco taxes. Increase the price of tobacco, and the lung cancer rate drops. So it’s a good example of how individual choices, personal biology and societal structures interact. 25/40