Meeting needs for mental health
3.1
There is a great deal of knowledge as to the treatments and supports people will likely need when experiencing mental health problems or to prevent suicide. However, treatment and supports are not always accessible for a number of reasons.
3.2
Accessibility is a multi-facetted concept. It encompasses the availability of mental health and suicide prevention services, the appropriateness of the services and their delivery, and the barriers impacting entry and navigation of the system.
3.3
If there are no services available then there is no accessibility. However, having services and supports available does not mean they are accessible. If services available do not offer the broad multidisciplinary care and social supports as and when required, if staff do not have training in caring for particular groups of people or particular illnesses, if services are too expensive, if it is too difficult to figure out where to go for help, if there are no options for early intervention, and if services are not culturally appropriate, then treatment for mental health problems, mental illness and suicide prevention is not accessible.
3.4
This chapter discusses a number of accessibility issues and at the same time examines suggestions for making services more accessible. Much of this is well recognised and recommendations in evidence to the inquiry included better funding for a diversity of services and supports, expanding the workforce, addressing bias, training staff, incorporating lived-experience and co-design, combatting stigma, developing community partnerships, and improving affordability.
Availability of services
3.5
The Committee has heard that across the board, there are insufficient services to treat people, whether with preventive interventions, low-level care, or high level interventions.
3.6
As a consequence, Professor Perminder Sachdev told the Committee:
… only about one half of people, adults with mood or anxiety disorders, are being given optimum quality care. In children, the evidence is that only 10 to 15 percent are getting adequate care. So there is a big quality gap in our care. This would not be acceptable in any other field of medicine.
3.7
Beyond treatments for people with mood and anxiety disorders, there are shortages for a range of other interventions, including high acuity care, care in rural and remote areas, and care for particular populations.
High acuity care
3.8
The Australian Medical Association (AMA) stated there is an absence of high acuity care that sees patients spill over into emergency departments, particularly after hours. ‘These are the people who have the most complex needs, and they are least available to access alternative models of care, such as the private system.’
3.9
Treating people with mental illness and people at risk of suicide in hospital emergency departments because there is no-where else for them to go is, according to witnesses, incredibly expensive and not appropriate. According to the Australasian College for Emergency Medicine:
If you put somebody who doesn't actually need emergency care in an emergency department, that not only adds to the cost of care for that patient but adds to the cost of care to the system. It also increases morbidity and mortality in patients.
3.10
This situation is compounded by the fact an unknown number of patients who present to emergency departments with a mental illness or disorder are being refused admission or are leaving due to the lengthy delays in assessment. Orygen suggested:
A mental health life is not valued so highly. We're still happy to turn people away from EDs [emergency departments], many of whom are at risk of dying…People never would imagine that you would redeploy people away from physical health into mental health, even though the need was greater in the mental health side.
3.11
While identifying a clear need for an increase in community mental health services, the Queensland Nurses and Midwives’ Union called for additional mental health qualified nurses and separate assessment areas in hospital emergency departments to triage mental health presentations and avoid the risk of walkouts and adverse outcomes. The Queensland Mental Health Commissioner advocated for crisis stabilisation units as an alternative to emergency departments for people with mental health and drug and alcohol problems. The Australasian College for Emergency Medicine called for after-hours care in the community.
Care in rural and remote areas
3.12
The barriers to accessible care in rural and remote areas were raised. Western Sydney University identified particular challenges in treating people with longstanding difficulties who had not previously received care:
[Students from rural Australia] haven't necessarily had a lot of interventions to manage their wellbeing needs prior to coming to university, so, when they do come to university, often it's one of the first times they've actually presented to a support service. The reason I'm saying that is that they present with longstanding difficulties that haven't been addressed, so the difficulty lies in how we begin to address something that's been there for some time. They often haven't had any support. They haven't talked to anyone about it. They've been quite isolated, perhaps, in how they've actually engaged in life, their schooling, their support networks and so forth ... A lot of the time, it was building up that relationship with the student and supporting them there.
3.13
The Queensland Mental Health Commissioner suggested more flexible models of service delivery need to be explored that ‘provide a combination of centre based services, supported by hospitals that integrate public, private and NGO [non-government organisation], fly-in fly-out services’. This would be complemented by a range of digital mental health supports.
3.14
Other stakeholders suggested variations of a hub-and-spoke model using regional contact centres and a central hub.
Suicide prevention and aftercare
3.15
The Committee heard that in suicide prevention, a combination of mental health services and psychosocial supports – including early intervention, wrap-around aftercare, and support by family and friends – are required to achieve reduced suicide rates.
3.16
According to the Zero Suicide Institute of Australasia, it is the complexity of suicide that requires a multilevel, multipronged approach—inside and outside of the health system.
3.17
The existing siloed mindset is working against achieving optimal care, where according to the Brain and Mind Centre at the University of Sydney:
We still have a much greater focus on what each professional group does, what that activity does, whether there is a Medicare number and whether there is a state system—not actually the person's set of needs as they move through the system and what they require in a timely fashion, with a strong emphasis on early intervention and secondary prevention, to achieve the maximal outcome. So we often have delayed care, which is costly care, and we very much have siloed care.
3.18
A range of interventions were discussed by witnesses to the inquiry, including peer support. Crisis centre hubs that encompass a call centre and various support teams were also suggested. According to the Zero Suicide Institute of Australasia, crisis hubs have a demonstrated 40 to 45 per cent reduction in cost to health services. Through the hubs, telephone support can de-escalate about 90 per cent of crisis calls:
For the 10 per cent who require some further support, mobile crisis teams that can be dispatched to the person in a location of their choosing, and they can connect with the person and their family or carer and put them in touch with ongoing services. This also avoids bringing in the police and the stigma that is often experienced due to police turning up at the front door. Seventy-five per cent of the 10 per cent have been resolved in this way, and the remaining 25 per cent have the opportunity to go to a stabilisation centre. And this stabilisation centre is able to provide comprehensive support and mobile crisis workers. They can assess the person to determine whether there is any need for inpatient care.
The model has shown that only three to five per cent of that original cohort that came into the mental health crisis had in fact needed to go to inpatient care. The final element is that all of these services are underpinned by evidence based practices like zero-suicide health care and supports that are available 24 hours a day. These high-tech, high-touch services have demonstrated that they divert people away from emergency departments and from jail.
3.19
The Committee was reminded by Gayaa Dhuwi (Proud Spirit) Australia that any service provision should be underpinned by an ‘equity approach’ that provides targeted responses. This was recommended by the National Suicide Prevention Adviser to the Prime Minister and acknowledges the disproportionate impact experienced by some population groups, including Aboriginal and Torres Strait Islander peoples.
3.20
The Zero Suicide Institute of Australasia suggested requiring a suicide impact statement in regard to all policies that arise out of legislation would be one way to get the community to think about and engage in providing suicide-safe environments. The Institute contended that suicide impact statements are already regularly completed for a range of other factors, including economic, multicultural, and regional and rural impacts.
3.21
An additional suggestion to support help seeking in a time of crisis was for the implementation of a 3-digit number for a mental health crisis line:
A simple and fast number that everyone can remember, no matter what state of mind.
If we have a simple 3-digit number, children can learn this number (as well as the 000 number) in school at an early age. Therefore perhaps finding instant help for themselves, a friend or a loved one when required.
Every second counts for those contemplating suicide, let us make access to help simple.
Justice system services
3.22
The links between the mental health system and the justice system were pointed out by Forensicare, who explained that people coming into prisons and people on community corrections orders are ‘among the most vulnerable people in society … almost two-thirds of people who enter prisons have a mental health diagnosis’. Orygen agreed, stating ‘there’s a huge overlap between offending and the onset of mental illness’.
We found that the people who have illness, whose needs are met—that is, they're actually being treated, have not only increased health outcomes but also lower rates of re-offending. So there's a real benefit to society in terms of meeting the mental health needs that often are factors that brought them into custody in the first place.
3.24
In particular, Forensicare noted the manifestation of symptoms and illness varies by culture:
In my experience in particular, with Aboriginal and Torres Strait Islander people, they oftentimes won't present or request care in the way that non-Indigenous people do, and are often overlooked for care. So it's typically the case around the country that, while we have a significant overrepresentation of Aboriginal and Torres Strait Islander people in our prisons, they're often underrepresented in the mental health services within the prisons, and even sometimes forensic mental health. I think it's both potentially ideologically driven but also the practical reality of limited resourcing.
3.25
Forensicare said the absence of the Medicare Benefits Schedule (MBS) for people in prison has consequences for the care received by people in the justice system:
Because Medicare is not available in prison, we typically have a very small workforce of psychologists, particularly clinical psychologists, and there's a large unmet need among people with higher prevalence disorders. It's simply the case that the majority of people with high-prevalence disorders wouldn't be receiving any care. Some would be receiving medication typically prescribed by a GP [general practitioner], and they would receive ad hoc care or sometimes crisis care, but typically not ongoing care.
3.26
It was pointed out that there must be continuity of care across the justice system and ‘more particularly on release’.
3.27
Forensicare and Orygen made a number of suggestions for recruiting, retaining and developing an appropriate workforce including, promoting forensic mental health as a profession, creating job appointments that allow for research and clinical work, delivering appropriate clinical supervision, and improving opportunities and incentives for staff development. They also noted growing evidence supported a peer workforce as a key element of any effective and comprehensive forensic mental health workforce.
Services for people with autism
3.28
The Committee heard of high rates of diagnosed mental health conditions and difficulties in accessing services experienced by people with autism. For instance, Amaze told the Committee:
75 per cent of autistic respondents had a diagnosed mental health condition and a further eight per cent had an undiagnosed condition. The majority reported that they had been previously diagnosed with a mental health condition that was not related to autism. And 69 per cent of respondents experienced significant difficulties finding mental health supports that were autism responsive and they expressed low confidence in health professionals' understanding of autism. Over 90 per cent of adults reported challenges in accessing health care due to anxiety caused by the environment, 84 per cent of adults reported access challenges related to their sensory sensitivities and over one-third of our respondents reported not being able to access mental health support at all.
3.29
In particular, the Committee was told ‘being female and autistic is a significant risk for anxiety, depression and poor sleep quality. Being female and autistic is one of the strongest risk factors for those’.
3.30
Yellow Ladybugs called for investment for autistic-led organisations where people can connect with their peers and not experience ‘autistic burnout’. Yellow Ladybugs explained ‘autistic burnout’:
… its link to mental health and how important it is that we connect autistic people with their peers so that they know that there's nothing wrong with them and that they grow up as happy, content, neurodivergent people and not second-rate neurotypical people.
3.31
Amaze called for people with autism to be identified as a priority group in the next National Mental Health and Suicide Prevention Plan. The Olga Tennison Autism Research Centre urged more extensive professional development for clinicians, stating ‘it’s often a two-hour lecture on autism, and that isn’t enough’.
Perinatal services
3.32
The perinatal period covers the time from conception to the end of the first year after birth. The Committee was told maternal suicide is the leading cause of death amongst expectant and new mothers.
3.33
While the Australian Government has recognised this and introduced universal screening for new parents, the Gidget Foundation told the Committee this will lead to increasing diagnosis and there are insufficient referral pathways—there are many help lines, many triage services, but few referral pathways.
3.34
According to PANDA – Perinatal Anxiety and Depression Australia the supports are not always easy to find. Women have reported they do not know how to navigate the system and become overwhelmed.
3.35
Early intervention is crucial. The Women’s Mental Health Service at the Royal Women’s Hospital stated:
Attachment takes place in the first year of life, but actually the mother begins to attach to her infant right from pregnancy onwards. So we want to optimise her mental health right from that point in time. We don't want to wait for the postnatal period when everything goes awry.
3.36
Early intervention was also supported by Prevention United:
… [promotion and prevention] needs to start in the perinatal period, in infancy and in childhood. That's where, unfortunately, we start to accumulate risk factors and it's where we need to build protective factors. Because by youth it is almost a bit too late. The underlying causes have already happened, and then we're just responding.
3.37
Early screening and intervention can allow for targeted and appropriate services to be provided that can have positive outcomes. According to the Women’s Mental Health Service:
… what it does, if it is being used, is identify very early on in pregnancy what the woman brings in terms of vulnerabilities and allows us to put programs of care in place at that point in time, rather than waiting for the post-natal care when things might fall apart. That has been a part of capacity building. So we have trained midwives who are doing antenatal care to undertake that screening. That is a two-way thing in that they learn about the women's mental health and they feel empowered to assist with that from an early stage. As you may be aware, midwives are extremely focused on holistic care.
3.38
Appropriate care at this time, according to Mental Health Australia, has the ability to embed strong relationships and provide parenting support that builds resilience in families.
3.39
Like other areas of the mental health system, the workforce is stretched. The Women’s Mental Health Service at the Royal Women’s Hospital explained that in perinatal and women’s mental health there are no problems recruiting female psychiatrists, but there are concerns with ‘the ageing workforce and recruiting and retaining that workforce in the public health system’.
3.40
As noted in Chapter 2, the COVID-19 pandemic has had particular impact on perinatal care—some women have been separated from their mothers and family supports, whether in Australia or in other countries. Others have experienced stress through the loss of employment within the family.
3.41
Noting the impact of lockdown on the ability to access traditional services, Mama You Got This advocated for expansion of its ‘virtual village’ to support connection for new parents and provide ready access to masterclasses and expert video series.
3.42
Further discussion on the role of digital services in mental health is included in Chapter 4.
Service capacity
3.43
The Committee heard that many mental health services have long waiting lists. batyr told the Committee there can be waiting times of up to six months after a young person takes the first step to reach out for help.
3.44
The Mountains Youth Services Team told of similar experiences:
… all of the services are at capacity and are referring on to everybody else, and everyone else is saying they're full … we're seeing such an increase in young people wanting services and we don't have the additional resources to be able to provide that service.
3.45
The pressure on services makes it hard, according to AMA, to ensure referrals meet the needs of the patient:
The system is just so strained that accessing private psychology or psychiatry is about getting in where you can. And that's not an ideal way to be doing mental health, in particular, where, as you said, building rapport and therapeutic relationships is key. I have a number of patients for whom we'll go, 'Look, let's just try this.' There are patients sitting around in what might not be the best therapeutic relationship—through no fault of the provider; it's just not a great fit—but there just isn't another option at the moment.
Rigidities in the service provision model
3.46
The Committee heard that there are various barriers to access in the current service provision model meaning people are not receiving the care they need, when they need it—there are rigidities in accessing particular services, and in obtaining wrap-around care.
Accessing particular services
3.47
In terms of service access rigidities, the Australian Association of Psychologists Inc called for improvements to make accessing a psychologist easier:
At the moment there's a lot of red tape. There are appointments with GPs you need to access. There are review appointments. There are letters going back and forth to unlock access to more sessions. This impacts on the consumer, especially at the moment, when it's really hard to get appointments with GPs. A lot of people are also not wanting to go out, or might not have access to telehealth services in order to access their GP.
3.48
The difficulty of referring patients to inpatient psychiatric units was raised as another issue that puts pressure on hospital emergency departments. Professor Sachdev told the Committee:
At the moment it's impossible—at least in our hospital, and I hear it's the same in many other hospitals as well—to admit someone directly to an inpatient psychiatric unit. They have to go through an emergency department. So you have to be either very seriously unwell or in a crisis. That's the only way you can get into a psychiatric ward. Even if a psychiatrist says, 'You need to be in hospital,' there's no way a psychiatrist can actually admit someone to a hospital, unless they go to an emergency department. And often there is pressure on emergency department assessments to discharge people because there is a dearth of beds.
Wrap around services that go to those in need
3.49
An accessible, person-centred approach to mental health services means providing for a range of integrated services that meet the specific needs of the person, across care settings—siloed health systems do not make this type of care easy.
3.50
The Salvation Army told the Committee a service model that combines mental health with other allied health services and that goes to the person who needs assistance rather than the other way around is ‘more successful and has a better chance of being successful’.
3.51
Jesuit Social Services agreed:
For instance, for a service like ours, where people are significantly traumatised and distressed, if they have to travel at all or travel a long way to receive a service, that is a significant barrier. Sometimes the way services see themselves, the culture of them, that 'people need to come to us', is a barrier. It's not a welcoming way of functioning, but also it simply doesn't take into account the state that people are in.
3.52
As a principle, Jesuit Social Services emphasised that system and service design have to acknowledge the needs of the people they are trying to assist. Designing services in this manner, according to the National Mental Health Consumer and Carer Forum (NMHCCF), requires ‘shared understandings of person-led approaches to care and support and their implementation in a participatory environment’.
3.53
The National Mental Health Consumer Alliance agreed:
Many consumers are saying, ‘We just don't have choice and we don't have control.’ … it's about trying to find the balance in how consumers have choice and control, how they have autonomy and how they are able to pick and choose what services may be useful for them, because we seem to be going straight from very few services in between to crisis intervention, really. Where are the services that are pre crisis? What services do individuals access before they get to that crisis stage?
3.54
The disconnect between service-centred and person-centred care was explained by the Matilda Centre for Research in Mental Health and Substance Use at the University of Sydney:
When people come to us with their challenges or problems, they don't see it as having an addiction or a mental health concern. What they have are their problems. Yet, our system sees those things differently, and that keeps being perpetuated if we don't form links and don't share knowledge across different areas … How do we build those bridges across those knowledge bases so that we've got a person centred care for the individual in front of us? It won't happen by accident. It needs to happen by design and by bold design.
3.55
The Blackdog Institute concurred with the need for integration:
One of the biggest challenges for a person entering the mental health system is the confusion that there is in how the different services interact together and, to be frank, the fragmentation, where you start in one system and then fall out before being able to enter into others.
3.56
headspace stated what is required is a system that combines:
… the face-to-face, the place based, the physical space, the digital space and the consumer at all points along the continuum. They will have those touchpoints where the culture of care is there and the connection and opportunity for further collaboration is there. Shared systems, shared electronic records and a real consumer focus has to be at the forefront of any reform.
3.57
AMA outlined any workable system has to connect at both ends:
… we're keen to ensure that we don't end up with programs that don't click in and link in with both ends of the spectrum—the primary care end with the usual general practitioner, who is that gatekeeper to care, but also making sure that at the more severe end of the severity spectrum, where patients are accessing public hospital services, there is integration.
Early intervention across the lifespan
3.58
The Committee heard services to promote mental health, treat mental illness and prevent suicide have to be available across the lifespan—and they have to be offered early. While it is not the case that all people within a particular group will have the same needs, a range of services must be available and easily accessible for those who do.
Children
3.59
Witnesses to the inquiry spoke of early diagnosis and treatment having a positive and protective effect that can prevent cumulative effects. Some issues raised included the early diagnosis of gut issues that can lead to anxiety, and communication difficulties that correlate with later mental health concerns.
3.60
The Committee heard that children are increasingly showing signs of anxiety yet there are insufficient services available, and where services are available, referral times can extend to nine months for the first interaction.
3.61
For services that exist for children, the Committee was told it is important they are informed by children and young people with lived experience, and co-designed with children and young people. In this way, service providers can gain a unique insight into the mental health and wellbeing of families, children, and young people, and the reforms needed.
3.62
Additional discussion on promoting wellbeing in schools is included in Chapter 8.
Youth
3.63
Young people are regarded by Orygen as ‘the crucial group across the whole lifespan’ because ‘a big surge of new cases occurs in the period between puberty and the mid-20s, and 75 per cent of mental disorders have already appeared by the age of 25’.
3.64
The Queensland Mental Health Commissioner spoke of rising presentations for psychological distress, particularly depression, anxiety, suicidal ideation, self-harm and eating disorders and expressed concern ‘people are not accessing services early enough, which results in delayed presentations with more complex and severe symptoms’.
3.65
As in other mental health spaces, services for young people are under significant pressure. Although highly regarded, concerns were raised about the accessibility of headspace for those who require support:
Headspace is under dire pressure around the country. The waiting lists have blown out to two months in most places, I would say, and it's closed; we can't get people in …
Headspace has been scaled up superbly across the country, but it's much too thin a green line. You can get in, you can engage but then you're marooned if you've anything more than something very simple. We definitely need this missing middle problem in youth mental health to be addressed in an equitable way, in comparison to what's planned for adult mental health.
3.66
Providing appropriate services, according to headspace, requires a boost in workforce capacity with a mix of professionals in multidisciplinary teams, including clinicians, allied health professionals, peer workers, and Aboriginal and Torres Strait Islander health workers. All workers must be experienced working with young people.
3.67
A number of suggestions were put forward by witnesses to the inquiry to improve accessibility for young people:
educating young people before they get to the point where they are quite mentally unwell
addressing feelings among young people that what they’re going through isn’t actually help-worthy
having non-judgemental relationships between members of the mental health multidisciplinary team and young people
empowering young people to become agents of their own development using a place-based approach that provides local solutions to local issues identified through community consultation and local knowledge.
Women across the lifespan
3.68
Ms Mischa Barr from the Women’s Mental Health Alliance and Women’s Health Victoria told the Committee women are around twice as likely as men to suffer from mental illness and make up the majority of people seeking mental health services, yet a gender bias means ‘most mental health services are designed on a male-centric model that does not recognise the specific needs and experiences of women and girls’.
3.69
The University of Sydney Brain and Mind Centre contended that women are preferentially discriminated against in healthcare services, in terms of purchasing power, diagnoses, and thresholds of care. In particular, there is a ‘failure to connect young women in trouble with continuing appropriate care, even though they are in life-threatening situations’. The Centre explained:
Ongoing care needs for women at critical stages in their life, such as adolescence, the postnatal period and the perimenopausal period, with the associated health conditions, are not well dealt with. What we've highlighted is that the gender gap continues. We note the particularly deteriorating situation for young women with regard to self-harm and suicidal ideation, with presentations at younger ages and increasing reliance on other emergency services. But, very importantly, there is the failure to sort those problems out or connect with ongoing care from emergency services.
3.70
According to Ms Barr ‘there are few examples of good practice here in Australia or internationally in terms of gender responsive approaches that respond to women's and girls' mental health needs’.
3.71
Professor Jayashri Kulkarni, also representing the Women’s Mental Health Alliance and Cabrini Health, spoke of the consequence of this situation:
I've worked in psychiatry for all my life, nearly four decades now, and over time I've seen some terrible things happen because women are not recognised as having special needs and special presentations of mental ill health.
3.72
The Brain and Mind Centre emphasised ‘the needs of women need to be addressed, and particularly those that sit around social support—that is, child care and the capacity to participate in employment, home care and support for other services’.
3.73
Professor Kulkarni called for tailored treatments:
What we need to do is get to that first base of almost saying that women's mental is different, so think differently, listen differently and then act differently. Then I think we're going to get some more runs on the board.
Men across the lifespan
3.74
The principles that underlie accessible care for children, young people and women are the same that should inform care for men. This approach was aptly summarised by the National Suicide Prevention Adviser to the Prime Minister who told the Committee how to design after-care services for men that are accessible:
If I were running a service for after-care and I was seeing two per cent participation by guys, I would ask that question and I would be looking at those issues. I would be looking at the time I'm making it available, how I'm making it available and whether I'm making it available in a way the guys feel is easy to engage with. I'd probably look across at Men's Sheds and say, 'Why are men's sheds such an easy thing for guys to do, relative to others?' I'd probably then look at: are there any particular language barriers? By that, I don't mean can somebody speak English? I'm talking there about are we trying to ask somebody who's got no innate language to translate their own mental health challenges into a conversation they can have. Is that the issue? Is it the resources we're using? Is it the fact that it's all women who are providing the service? It's not inappropriate, but we do have a workforce where often the front-facing person is female. Does that act as a bit of a barrier for a guy? Then we also need to look at: are there any particular cultural barriers? So, for men from different culturally and linguistically diverse backgrounds, are there challenges there? What is taboo? What is not? Do we need to look at some of those concepts around masculinity? Are there some of those challenges about: 'This is a weakness to do it'? So I think there's a range of complexity … we really do need to start looking at our services to say, 'Why aren't they being accessed by men?' Yes, we could do what I think intuitively we often do, which is to say, 'Let's go and design men's services.' No, actually, that may be required for some, but all of our services should be accessible.
3.75
MATES in Construction’s (MATES) submission argued the importance of the interim report conclusions of the National Suicide Prevention Adviser, that services should be targeted and meet men where they are. MATES explained that:
We know suicide rates amongst construction workers in Australia are 71% higher than amongst other employed men (Milner, 2016). Further, workers in the mining industry are at risk due to shift work arrangement, remote work locations and higher than average mental stress and alcohol consumption (Kelly, Hazell, & Considine, 2012).
For this reason, MATES developed the workplace suicide prevention and evidence-based program to deliver specific services to the male dominated construction, energy and mining industries. At the core of the MATES Program is the delivery of tailored training and support, onsite, where it is needed most, backed up by a 24/7 helpline and Case management services.
3.76
Appearing before the Committee, MATES explained that men are not particularly good at help seeking behaviours, noting that this often results from stigma and broader societal roles that men can often emulate. MATES clarified that its services are trying to develop these strengths and improve mental health for men, arguing that:
… if we can remove the stigma within individuals about how they view, then they're more likely to step forward and offer help to those people in need… the reality is you can address the stigma in practical ways, and big burly blokes that traditionally might be associated with needing to be bullet proof and 'toughen up, princess' so to speak can be the ones that genuinely reach out and offer help to someone in need.
3.77
One of the critical aspects of understanding mental health, suicide and comorbidities is how different genders present to, and interact with health services. MindSpot discussed that for example substance use and suicide are more prevalent within men, in lieu of anxiety or depression. It elaborated that:
… what we know is that, when people are referred by general practitioners, they're more likely to be male than female. What I mean by that is about 36 per cent are male in those instances. I think that actually speaks to the way males engage with health services, not just mental health services but health services more broadly. If they are referred by someone they trust—for example, a general practitioner—they're much more likely to engage. In terms of strategies and solutions, we're developing a number of new service options which we believe will be much more acceptable to males, and we're hoping to roll those out in the next six months or so.
Affordability
3.78
The Committee received a range of views on the extent to which affordability is a barrier to accessing care. Whether it is the only barrier, or one barrier among many, there was little disagreement from witnesses that it impacts access to appropriate care for some people with mental illness and at risk of suicide.
3.79
The Salvation Army stated that people living with a mental illness often cannot afford private professional mental health services and have to prioritise other expenses, such as rent, over medication and medical support:
… honestly all the fat has been trimmed from the budget already. They're making decisions about things that we would consider necessary, like medication—absolutely—psychologist appointments and even GP appointments.
3.80
Jesuit Social Services agreed, ‘the reality is that psychiatrists and psychologists sometimes have a gap [fee] which does mean that their services are out of reach for many’.
3.81
batyr was of the view the primary barrier to accessing care is waiting lists, with affordability an exacerbating factor in young people being able to access appropriate and timely care.
3.82
ReachOut suggested the larger issue was getting young people started and understanding they may need to seek help; but affordability ‘is of course an issue for young people … it comes up in any of the research and focus groups that we do and conversations that we have with young people’.
Stigma
3.83
The Committee heard services are not accessible if there is stigma surrounding a mental health diagnosis or obtaining treatment from a service. In some cases, services can also stigmatise certain populations.
3.84
Some organisations have recognised stigma associated with asking for help and developed innovative approaches. For instance, Jean Hailes found the anxiety section of their website was very popular with both men and women because there was a lack of stigma about a women’s health organisation website, rather than a particular depression or anxiety website. By focussing on prevention, it was not labelling people with a disease; and as part of a website focussed on whole health, it provided a more approachable environment.
3.85
Other suggestions to deal with a reticence to visit services due to stigma included allowing people to access services in their home environment including through telehealth, and health promotion messages to destigmatise mental illness.
3.86
The Committee heard services may stigmatise people with certain mental illnesses or certain populations. Professor Brin Brenyer, Professor of Psychology at the University of Wollongong and Director of Project Air Strategy for Personality Disorders stated:
But what we hear from people with personality disorders time and time again is their biggest challenge is access to trained and skilled practitioners who hold positive and hopeful attitudes about them, because stigma is one of the big problems in personality disorders.
… The old, stigmatised message about personality disorder was: 'You don't want to treat these patients. There's nothing we can do about them. They're just annoying and attention seeking—a 'not for service'—and we should send them away.'
… So training is really critical. One of the things that we do in Project Air is train about a thousand mental health practitioners a year, and our online training attracts another thousand, so we're really pushing the message of hope and treatability.
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SAGE Australia’s submissions identified legislative change as critical to reducing structural stigma, community discrimination and improving access for SGD individuals, further recommending:
Legislation to ban non-medical emergency, unnecessary surgeries and treatment on intersex children, allowing them to make their own decisions about their bodies when they are educated about their choices.
Reviews of legislation to support people from sex and/or gender diverse (SGD) groups in changing their identity documents when needed to reflect their identities.
Reviews of legislation to remove all discrimination against people from SGD groups to dramatically reduce social disadvantage, minority stress and suicidation.
Attention to Commonwealth bills that risk increasing discrimination:
Sex Discrimination and Fair Work (Respect at Work) Amendment Bill 2021
Education Legislation Amendment (Parental Rights) Bill 2020
Religious Discrimination Bill 2019.
Delivering accessible services through community access and partnership
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The Committee received significant evidence outlining co-design and community partnership as being critical to the effective delivery of mental health and suicide services and interventions, in addition to being crucial for resolving community access issues.
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Appearing before the Committee, the National Mental Health Consumer Alliance identified that in the delivery of services:
Consideration also needs to be given to the diversity of our communities, to include the multitude of CALD [culturally and linguistically diverse] communities, LGBTI youth, older adults, forensic services as well as our rural and remote communities—we mustn't forget those, particularly off the back of drought and also the bushfires.
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This was supported by the National Suicide Prevention Adviser to the Prime Minister’s final report, which recommended that suicide prevention planning and funding needs to be targeted with an equity approach, to engage communities that are disproportionally impacted by suicide.
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Action Area 3 of the National Strategic Framework for Aboriginal and Torres Strait Islander Peoples’ Mental Health and Social and Emotional Wellbeing 2017-2023 also focused on building the capacity and resilience of at-risk groups. It called for equality of mental health outcomes for the Aboriginal and Torres Strait Islander population by recommending the government develop strategies with community to support the mental health, and social and emotional wellbeing of:
members of the stolen generations and their families
those with chronic health conditions and/or disabilities
lesbian, gay, bisexual, transgender and intersex people
prisoners and young people in detention
people with co-morbidities, including alcohol and other drug issues and mental health issues.
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The Trans Health Research Group stated that for mental health services to appropriately meet demand and deliver on outcomes, they need to be co-designed with community. This involves services:
… speaking to leaders of community, speaking to people who are trans who are also people living with disabilities, who are neurodiverse, who are immigrants, who are people of colour, who are First Nations people, and making sure that any service is accessible to them, that it feels safe and it feels appropriate and is fulfilling their needs.
Aboriginal and Torres Strait Islander communities
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Forensicare contended that community partnership is particularly important for Aboriginal and Torres Strait Islander communities, noting the effectiveness of interventions is specifically tied to ‘local engagement from community, community leaders and community elders’.
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This was further identified by Wesley Mission through work completed in the Kimberley region of Western Australia:
That community knew firsthand what the community needed. Those community members had been individually impacted and so they were able to provide a responsive, community-led initiative. Too often we might purely look at the evidence or the different types of rhetoric that we're hearing in the media and look to respond there. But, if we're looking to have that real and timely impact, we need to have a relationship with people with lived experience at the local level to be able to empower them to take action.
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The Queensland Aboriginal and Islander Health Council (QAIHC) recognised the value of the health equity frameworks within Queensland, which effectively hold chairs and chief executive officers of Hospital and Health Services (HHS) accountable to co-design and effective community partnership through Close the Gap reporting. QAIHC stated:
They have to have the plan they provide to the minister and to our deputy director-general for Aboriginal health signed off, and it has to be co-designed by community controlled organisations, by community, by traditional owner groups, by Indigenous staff, and by a whole range of other stakeholders listed in that regulation.
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QAIHC further highlighted that where this reporting is not completed, it impacts on HHS funding allocations, identifying that ‘[f]or once I see a light at the end of the tunnel, because they have to get the sign-off from community and community controlled organisations for that plan to be submitted to the minister for approval’.
It's about engaging locally with traditional owner groups, the schools, the police, the men's groups, the women's groups and the mainstream non-government organisations, and having a place where they can sit down around the table and look collectively at what they're going to do and what role each of them will play.
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Operationalising a co-design approach was exemplified within Lifeline Australia’s submission, where it highlighted its partnership with Gayaa Dhuwi (Proud Spirit) Australia to develop and deliver a helpline by and for Aboriginal and Torres Strait Islander peoples.
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Gayaa Dhuwi noted that in addition to the shortage of mental health and suicide prevention services in rural and remote areas, not every service is culturally safe or trauma informed for Aboriginal and Torre Strait Islander peoples.
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The National Aboriginal Community Controlled Health Organisation stated that the recent reports have identified what Aboriginal groups have been continually telling government for decades, that ‘the key to improving mental health outcomes for Aboriginal and Torres Strait Islander people is through empowerment and self-determination’.
Cultural and linguistically diverse communities
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Wesley Mission identified a range of barriers for culturally and linguistically diverse (CALD) communities in accessing mental health services, including: low social support; immense community stigma or completely different beliefs on mental health and suicide; transient metropolitan communities; issues with service navigation and coordination; personal trauma in an overseas environment; and English as a second language.
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Further barriers were identified by the Centre for Multicultural Youth (CMY) to include intergenerational conflict, cultural adjustment, barriers in education and employment, and experiences of racism and discrimination.
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Noting that current mainstream services are not working for young people in CALD communities, the Multicultural Youth Advocacy Network advocated for recognition of community solutions and supporting community partnerships. CMY explained that building trust and engagement, and providing services that feel safe, has been fundamental to the successful delivery of services for this demographic:
… whether that's embedding mental health professionals within multicultural youth services or working alongside the cultural community based organisations, anything that brings services out to where young people are and to communities.
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Similarly, NMHCCF outlined that what is required to improve health service access for CALD communities:
… is increased and targeted engagement with CaLD communities through spiritual and community leaders to improve mental health literacy and awareness, support community resilience, enhance coping strategies and combat stigmatisation.
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Additionally, CMY argued for recurrent, co-designed mental health literacy programs with young people and communities from migrant and refugee backgrounds. Community partnership in delivering these programs would effectively create trust and dialogue around transcultural understandings, reduce stigma, and promote help-seeking. For example, CMY identified that within the South Sudanese community:
… we have a lot of mental health issues or mental illness and things like that, but we don't have a word for it per se in English or we can't explain all these things in English. So understanding what it is in our own language or our own way of dealing with everything that we are dealing with and the way we approach it is a bit different from the mainstream.
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This reiterates the importance of developing models with CALD communities, to build common understanding and work collaboratively to find and deliver on outcomes.
LGBTIQ+ and SGD communities
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The Trans Health Research Group advised that 70 per cent of LGBT individuals avoided mainstream services because of fears of discrimination. LGBTIQ+ Health Australia argued that this could be resolved by mainstream services showing ‘a demonstrated commitment to collaborate with LGBTI communities’. This is to ensure that:
… services are co-designed and co-delivered with people with lived experience and the knowledge [community understanding] is embedded in all programs and service design and funding arrangements.
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LGBTIQ+ Health Australia also argued for wider community partnership to support intersectionality, stating that ‘having a more integrated holistic approach is really important when we look at designing programs to appropriately support people’.
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The Trans Health Research Group explained that transgender Australians are one of the most socially and medically marginalised communities in Australia, with over 70 per cent having depression and 43 per cent having attempted suicide. Overall transgender individuals have significantly higher risks of unemployment, poverty, physical assault, and both social and medical discrimination.
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This was further supported by SAGE Australia, who noted:
… there are major problems with trans people getting help. In some quarters that provide help to this group of people, they have to wait six months for an appointment—six months! If you're suicidal, you need attention immediately…
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SAGE Australia recommended community partnership between suicide prevention services and community in the recruitment of SGD individuals for specialist positions. It identified that SGD mental health practitioners can give a higher quality service due to a higher level of community knowledge.
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The Trans Health Research Group also advocated for an expansion of tailored services for the trans community:
There is an urgent need for expansion of services tailored to the trans community, such as QLife and DISCHARGED, and a need to consider novel interventions that are co-designed with the community. We as a society need to reduce discrimination. Additionally, research in trans health and suicide prevention must be prioritised to reduce the health disparity and measure the success of targeted interventions to reduce suicide.
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The Committee heard mainstream services do not receive sufficient training and do not understand particular trans and gender-diverse experiences, and other experiences within the LGBTIQ+ community. As a consequence:
… people who are trans or gender diverse or other members of the LGBTIQ community turn to LGBTI-specific services because that's where they're going to feel most safe, and in a moment of crisis the last thing a person wants is to be misgendered or to be asked inappropriate questions because the person that has picked up the phone simply doesn't understand what it means to be trans.
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SAGE Australia called for specific training in SGD issues across the board for healthcare professions:
En masse, intersex people do not use gay access health services, and many trans people do not use gay access health services, because an intersex woman does not want to sit before a gay counsellor who doesn't understand anything about her issues.
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The Trans Heath Research Group told the Committee of progress in delivering training for health professionals, and advocated for expansion across Australia:
In Victoria we've seen investment in a statewide training program for health professionals in trans health, so that's run by a community-controlled organisation, Thorne Harbour Health. They've been operating for 12 months. Their goal is to train GPs and psychologists and all health professionals in providing safe, gender-affirming care, and it's these sorts of initiatives that should be rolled out across Australia to try to improve services for the trans community.
Committee comment
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Within the current mental health and suicide prevention sectors, vital services are not accessible for all who need them, potentially resulting in dire and long running consequences for individuals, their families and friends, and the broader health system.
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The Committee is particularly concerned with evidence delivered by the National Mental Health Consumer Alliance, who stated that:
Many consumers are actually saying: 'I'm not traumatised by my mental health issues. I'm actually traumatised by the services that I'm accessing that are supposed to be there to assist me to heal.'
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The Committee recognises the tireless work of dedicated professionals who provide support for people with mental illness and those at risk of suicide. These professionals are skilled and compassionate. Similar to people in need of care, the mental health and suicide prevention workforce requires the right supports, structures, knowledge, and experience to provide accessible care. Chapter 5 examines the mental health and suicide prevention workforce.
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The Committee has received significant evidence that services must be available when people need them. Services must have the capacity to treat those who need assistance, and service provision models must be developed so rigidities do not prevent people receiving multidisciplinary care.
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Services must cater to different populations, especially those who require acute care, live in rural and remote areas, or are at risk of suicide. Service delivery also needs to support the unique needs across the lifespan and the gender spectrum to ensure everyone has access to mental health and suicide prevention services in a way that caters to Australia’s diversity.
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System gaps that need to be resolved include:
The lack of suitable supports and specialised mental health services or practitioners for autistic individuals with mental illness.
The lack of available perinatal services, noting the impending increase in demand as a result of lockdowns lifting and escalated diagnosis following the Productivity Commission Inquiry Report on Mental Health’s recommended increases to perinatal screening.
The lack of tailored mental health services for delivering higher intensity supports for men.
The lack of MBS options for complex and specialist mental health treatments (Chapter 6 discusses funding in detail).
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The Committee is also concerned in the forensic space by the overlap between offending and the onset of mental illness, which is coupled with difficulties in accessing mental health services and an absence of MBS-supported health care within prisons.
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The Committee recognises consumer co-design and community partnership as intrinsic to the equitable access to services by priority populations. This approach ensures both the effectivity of services, programs and interventions, as well as the delivery of desired outcomes.
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The priority populations of concern include Aboriginal and Torres Strait Islanders, LGBTIQ+ and SGD individuals, and the CALD communities. The Australian Government needs to sufficiently support these communities through equitable representation in governance and specific allocation of funding.
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The Committee supports the recommendations of the National Suicide Prevention Adviser to the Prime Minister and the National Strategic Framework for Aboriginal and Torres Strait Islander Peoples’ Mental Health and Social and Emotional Wellbeing 2017-2023 on equitable responses in mental health and suicide prevention.
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The Committee is of the view that funding has to be increased to meet the needs of people wherever they are and for whatever they need. Absent of such a commitment, it is hard to argue with the proposition that the health system treats some lives as less valuable than others.
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The Committee recommends that the Australian Government ensure the principle of accessibility is at the forefront of all policy and funding programs for the mental health and suicide prevention sector, with a focus on:
increased funding for specialist services, such as forensic, perinatal and autism services, to innovate, expand and meet demand
frameworks that include consumer co-design and community partnership requirements to ensure equitable access for priority populations
Indigenous-led and culturally appropriate models improving Aboriginal and Torres Strait Islander experiences with mental health and suicide prevention services.