- Professor Patrick McGorry AO on Victoria's mental breakdown
Patrick McGorry: Now tonight, I'm not going to just talk about youth mental health tonight. I'm going to talk about the whole situation of mental health care in Victoria, which I've been really concerned about probably for about ten years.
And I'm going to show you some pretty disturbing figures. And I'm going to also try and convey an air of optimism as well, because I think we're about to really turn the corner. And I'll explain that a bit more later as well.
So now, I'll just start off with a couple of stories. This should be playing automatically.
Jon Faine: The other day I accepted an invitation from a listener to sit down, have a cup of tea, and a bite, and talk about what's happened in his family. He wants to be known by the name of Tony. And he told me a tale across the table that left me very distressed and feeling somewhat, well, inadequate and useless, I might say.
Tony wants his story to be heard by a wider audience, and I'm more than happy to provide the microphone for it.
And good morning to you, Tony.
Tony: Good morning. Thanks, Jon, for having me.
Jon: Let's start at the beginning. Tell us, what happened?
Tony: I guess the best place to start would be, nearly on three years ago now, my wife and I received two distressing calls from two of our older sons.
Jon: You have how many children?
Tony: Altogether. We've lived in our community for over 30 years. Like all parents, we've always wanted to do the right things, and we're very connected in that community, a loving family, grandparents who adored the grandchildren in that respect.
But on this particular day, we received two distressing calls separately – one to me, one to my wife. And it was basically screaming coming over the phone, and there was the mention of, ‘he's going to shoot me’.
I grabbed my wife, we jumped in the car, and we went to this place, which happened to be my parents' house about ten minutes away. We got there, and as we were rounding the corner, there was over 30 police cars. There were helicopters. It was like a scene out of some sort of movie, and there were the tapes that they put across the road. Well, I disregarded the tapes and I drove through them. And I could see my younger of the two older boys lying on the ground.
Jon: He's how old?
Tony: At the time he was approximately 25. As with anything like that, of course, what you're hoping for is to see some kind of movement, because he was just lying there. And so we had no idea whether he was dead, or alive, or whatever.
Jon: Were there police nearby?
Tony: There was over two dozen police–
Jon: No, no, nearby, specifically, him on the ground?
Tony: Yeah, there were police literally covering the whole street. It was literally like a scene out of some sort of movie. I saw a movement in him, which sounds stupid, but it was kind of a relief. At least he was alive. But we still had no indication of what condition he was in.
Jon: Were the police attending to him at the time?
Tony: The police were standing around. At that point, there was no ambulance. At that point, I jumped out of the car. The police tried to stop me from going to him, but I decided that I would do so anyway. My wife was really distressed, of course, that kind of thing.
Jon: Your other son?
Tony: My other son, there was no sign of him, but the police that were in the area were standing outside the gate of this particular home, and they had their guns drawn. And so, of course, we were fearing the worst. I guess I summed up the situation by recognising that he had fired the gun and–
Jon: So one of your sons had shot one of your other sons?
Jon: And all of this is because …?
Tony: They'd had an altercation. Both of them had been, for some time, using ice. And we had tried virtually everything. We had – plenty of times we'd had the CAT team around, we'd had police officers around, we'd had smashed up rooms, smashed up house. We had tried everything in our power. We'd been in rehabilitation places, all sorts of things that had gone on, none of which really addressed the issue with regard to it. And there's plenty that I can say about that particular thing.
Jon: So a prosperous family, thoroughly Melbourne middle-class, find their world turned upside down because of this particular substance and the grip it's got on your two eldest children.
Tony: That's right. And these young men had not had any bad upbringing or anything else like that. I don't think we're terribly bad parents. I think we’re average parents. We had always given them the opportunity to speak freely with us and communicate with us.
Jon: Good educations and all the rest of it.
Jon: So, Tony, let's avoid some of the issues here, but not avoid others. One of your sons is now in jail. The other one is not.
Jon: One of them, the one in jail, is no longer using. The one who's out is–
Tony: Possibly, possibly still.
Jon: May still be using.
Jon: And your frustration, the issues to do with ice use and take-up in our community have been discussed now for years.
Jon: But your specific frustration is directed at what part of what's going on?
Tony: I think it's important to say too, Jon, that I'm not saying that what the authorities are doing is wrong. I'm not saying they're being bad, or wrong, or otherwise. What I'm saying is that the current way that we deal with this doesn't work. It just doesn't work.
Patrick: So that's one story. And I just want to say that I've met that father on many occasions since then. I've seen his son in jail, and the son is absolutely 100 per cent recovered now. An incredibly good young man, actually.
But that story – and there's more in the interview where the father – by the way, the father's given me his permission to play this story tonight, because it's so graphic. When I heard that on the radio, I just stopped the car and just listened to it. And it made me feel very emotional, actually, because I've heard those stories so many times.
And he had to stand in between police and his son on several occasions to protect the son's life. So his son could easily have died. And we hear this story, I wouldn't say every day, but very, very commonly, increasingly commonly, in this state in the last five or ten years.
Another story is of a young colleague of ours, whose brother has schizophrenia. I saw him, actually, when he was first diagnosed, and he's now been treated for about ten years in a very, I would say threadbare way, by a mental health service in the eastern part of Melbourne. Long delays in getting treatment in the first place, languishing for years with severe symptoms just with the GP, and if he gets a little bit more sick then he ends up in hospital for a few days and then back out again – revolving door. And that was bad enough.
But this young colleague of ours told me last year about his sister who was diagnosed with lymphoma. She was in her 20s as well, diagnosed with lymphoma, a form of blood cancer. Treated in exactly the same hospital system, and you would not find better treatment anywhere in the world than that girl received for her physical illness, her life-threatening physical illness, just like schizophrenia is a life-threatening mental illness.
And the family were just completely gobsmacked with the contrast in care. It's like a form of apartheid, actually, the difference in access and quality that you see in the treatment of mental illness, in the same mainstream hospital system. I'm going to come back to mainstream in a minute.
And I could go on and on about stories of people let go from emergency departments who have died within days. Probably at least over 100 people in that situation in Victoria each year. I'll come back to the figures later. So the stories are just piling up.
So what is a mental breakdown? Well, a mental breakdown is an acute time-limited mental disorder that manifests primarily as a severe stress-induced depression, anxiety, or dissociation in a previously functional individual, to the extent that they're no longer able to function on a day-to-day basis until the disorder is resolved. They don't happen overnight. Human beings are intrinsically resilient, and it usually takes multiple forces operating over a sustained period to overwhelm us with emotional pain and compromise our ability to function.
There are nearly always warning signs. They don't happen overnight, and these are usually ignored, or often ignored.
So can a state system, can a mental health system have a breakdown? Well, we often hear claims about the system being broken, don't we? Or that there's no system.
And I think we've been warning now – not just me, but many other people in the mental health field in Victoria – have been warning for over a decade that we've been drifting and accelerating towards a breakdown. We've written quite a number of opinion pieces in the paper, interviewed on Jon Faine, and many other sort of outlets trying to get the governments to listen.
Both sides of politics are responsible here. And I'm not talking about this to blame anyone, actually. I think you'll see why this has happened. There's no individual person or even political party is actually to blame here.
And I think I'm optimistic, because I think the present Victorian government has late last year acknowledged this disastrous sort of situation, this crisis. And it's reached a point of breakdown. And I really believe they're shaping to do something serious to fix it. How serious? That's actually the big question for the next 12 months.
So this picture here is the pessimism that was kind of ingrained in mental health care when I first started working as a trainee psychiatrist. It's a picture from the 19th century, actually, which is where all our thinking about mental illness was sitting until about maybe 20 years ago, really. In 19th-century thinking about incurability: out of sight, out of mind, all that kind of stuff.
And this is the mental hospital I trained in Newcastle – Newcastle Psychiatric Centre. And this is The Royal Park Hospital, which is now closed. When I first came to Victoria 30 years ago, it's where I worked, and that's our inpatient unit there.
And that's our special inpatient unit, where all of our youth mental health work originated from, actually, from that inpatient unit with young people with their first episode of psychotic illness like schizophrenia. So that's the sort of setting that we were starting off from, a very low base – pessimism, no hope, very, very demoralising.
Around the time I came to Victoria, actually the year before, in 1983, this paper was published in the Australian New Zealand Journal of Psychiatry, by George Lipton, who was then the state director of mental health. And he was talking about the politics of mental health. And does it just go around in circles or could we actually spiral out of this and get to a better place?
And he talked – it's actually an incredibly wise paper, analysing all the issues that we're still grappling with, but in a very pessimistic way. And he would have been pessimistic to see, actually, what has happened since. But just a couple of quotes from there.
He says, ‘The politician is severely constrained by the attitudes of his constituency and he leads or lags at his peril.’ Well, I think we've still got that problem with politicians, not just on mental health.
‘He has two major tools which enable him to pursue philosophies that are at variance with public demand. The first is convince the public that some policy or other will rebound to their personal advantage. This often has severe cost implications.’ And that's definitely true of mental health care. That is absolutely true. The cost implications are very significant for the state government.
‘The second is the vehicle of public fear or guilt. This leads to law and order issues …’, as you just heard from that story, ‘… to increasing regulation and occasionally to improvement of services to the disadvantaged when this has become a public scandal.’ And we've had many other examples of untreated mental illness leading to public tragedies, even in the last 12 months in Victoria.
So another quote, ‘How can a politician effectively give priorities to an area whose problematic status is denied by his own constituency?’ Now, certainly in the 1980s that was definitely the case. The public did not want to hear about mental illness, not at all.
You might think they do want to hear a bit more about it now, and I'll come back to that. But I guess you're all here because things have improved a bit, but still. ‘Can he afford to confront them with their denial?’
We might be really great at talking about mindfulness, and having the conversation about mental illness and being aware of depression, but are we willing to talk about more serious forms of mental illness?
‘Can he dare to overly expose the community's guilt and the resentment that this inevitably brings?’
So this is why it's much more challenging than cancer or heart disease, what we're talking about here. It's more complex. There's more – every person has got issues with it.
Mentally ill people are difficult to be with quite often, and it's a challenge. And I think that's one of the things we always underestimate.
So those institutions, as you probably know, were swept away in the 1990s. And there's a paper by Valerie Gerrand describing that process. That happened during the Kennett government. Notice that Jeff Kennett actually opened this theaterette, and I think – well, we can analyse his legacy a bit later on.
But you do get the sense, even now, that mental health, mental illness, it's an awakening giant. This is a cartoon from the age a couple of years ago.
And it's incredibly important to our society, and it is starting to wake up, you can see.
And as we've had Beyondblue, lots of awareness. We've had R U OK? Day. And in 2010, it was probably the top, or third top, Australian issue. You had the economy, you had climate change, and then you had mental health in terms of what the Australian public thought was important.
And the ABC helped us to raise money for mental health research two years in a row. That was fantastic. The whole Mental Health Week, they had programs on mental health.
But they still talked about ‘having the conversation’. And the problem is that none of these changes in atmosphere have led to improvement in investment in mental health care. Which we all assume that if you had better knowledge, better public education, that would be the stepping stone to then people supporting governments or encouraging governments to invest, but that absolutely has not happened.
And that's led Helen Razer, who gave me and the ABC a pretty hard time about Mental As, because she said, that's a complete waste of space. What are you doing? Awareness is just a distraction, actually. It's actually taking the pressure off. It's making the politicians think that something is being done just because people are talking about it.
So I hadn't thought about that before. And at first I was a bit defensive. But then I actually talked to her, and I could see what she was actually saying.
And we're not knocking Beyondblue. They do a lot of great work. But it's this idea that somehow ‘having the conversation’ is enough. And again, not knocking R U OK? Day, because it is the first step. But what if there's nothing beyond that? And in America, there is nothing beyond that.
This is a book by Fuller Torrey, who's been one of the complete leaders of schizophrenia research and serious mental illness research in the US, with the Stanley Foundation. And he's written a book describing what happened in America from the early 1960s through to now.
And basically the federal government decided to invest in community mental health centres, but the intention wasn't to look after people, really, with mental illness. It was to do something preventive, psychoanalytically-based, vague, non-evidenced-based; over-promising that they could actually prevent mental illness through this program.
So what happened was, they closed all the services, all the old hospitals, and they excluded those patients with mental illness from these centres. And gradually, the state governments, they just completely stepped aside from providing care to the mentally ill. And the federal government really didn't do anything effective in its place.
They spend quite a lot of money, in many ways, on mental health care, but the vast majority of people can't access it and it's incredibly limited. So he describes all the consequences of that in the book. You can see the subtitle: ‘How the federal government destroyed the mental illness treatment system’.
And if you have ever been to America, you have to step over homeless people along the pavement wherever you go in the big cities. The jails, the prisons, are full of mentally ill people. And there are homicides and suicides directly attributable to untreated mental illness every single day in large numbers. So it's an absolute war zone, you could say, in terms of what they've created.
They should be thoroughly ashamed of themselves. They hold themselves out to be the leaders of the international psychiatry, with their DSMs, and all these other sort of things. And their country is a joke when it comes to the treatment of the mentally ill. And we are catching that disease. We are catching that problem, and I'll show you the figures in a minute.
Here's another book along the same lines.
That the consequences of the – moving into the shallow end of the pool without hanging onto the deep end. And I'm not saying that our Headspace reform is totally about having a soft entry for anyone who's even got a mild problem. That's absolutely their right with primary care. But we've got to actually make sure the whole spectrum is looked after.
And these countries – the US has not done that. So here are some of the pictures. Some of them are American, some of them are Australian, actually, these pictures. And it's probably getting worse – well, it is getting worse here too.
And in Australia too, there are many more mentally ill people in beds in prisons than there are in hospitals, and it's increasing. And Tony's son, the father in that interview, is one of them.
And it actually took him being admitted to – being incarcerated in prison to get effective treatment for his mental illness and drug and alcohol problems, of which he had both. It wasn't just an ice thing. It was a combination of ice use in a self-medication way with poorly treated mental illness.
And this was in the Herald Sun earlier this year. It's a story. We don't like to talk about this in mental health. But while the vast majority of people with mental illness are safer than the general population, and much less likely to be involved in violent or criminal activity, there is a subset, if they are not treated – like Tony's son – who will end up in conflict with the law. And will be dangerous in that situation, as you just saw, where someone got shot. And if he'd been treated, there's no way that would have happened.
We know that 60 per cent of murders that are committed by psychotic patients – and they're by far the tiny minority of murders, by the way, the vast majority of murders are committed by people without mental illness – but of the ones that are, the small number, 60 per cent of them, are committed by people who have never been treated. So it takes a violent incident to actually bring the person to attention, and these are preventable deaths.
So, obviously, it's not great to have the Herald Sun with these sort of headlines, but community safety is an issue here.
In Orygen, we never saw any murders committed by young people in our region for probably 20 years. I can't remember a single one. But as we've been overwhelmed by population growth and custody services several years ago, we've now seen probably five or six people who have been untreated or poorly treated, and have actually killed people. So this is something we've really got to be honest about as well, while not stigmatising the vast majority of people who wouldn't even ever be anywhere near that.
So this is still part of the whinge part of the lecture. So this is another quote from a paper in the mid '70s. And obviously, what happened in the '90s was we got mainstreamed into acute health care. So all the beds got moved into general hospitals, and we got managed by places like The Royal Melbourne – by the way, also founded by Sir Redmond Barry.
And so that mainstreaming seemed like a good idea, but it really hasn't worked that well. We've been done over, really, by having been mainstreamed into the powerful teaching and acute hospitals. And that's why I think that phrase ‘the battered child of medicine’ is very apt, having worked in that system for the last 20 years or so.
As we look back, we view the battering that psychiatry has taken as the price of painful acceptance of the young child in the family of medicine. But we also see that even in its youth, psychiatry has brought about a revolution of thinking, feeling, and behaviour of the family of medicine as a whole. And in doing so, has profoundly affected the collective consciousness of society regarding its mentally ill.
Well, that's the upside. You might think that that is the case, and that is true to an extent. But we have really suffered through this mainstreaming, and I'll show you why in a minute.
So this is just an example of just one of the many op eds that we've written over the years about this problem. It's a national problem. It's not just a Victorian problem.
The problem with Victoria is that it was the actual jewel in the crown, nationally, of mental health care. I'll show you some figures on that. But we've slipped badly. But all the other states are equally problematic.
That's the MJA editorial, and this is WA. So it's just to show that Victoria isn't the only one. The AMA magazine in Western Australia is actually showing the broken state, and it's all about the mental health services in Western Australia too.
So it's a national pattern. It's the same pattern that happened in the US, but not as bad. But it's heading in the same direction from the state government point of view.
So this is the experience that we feel. This is a Scandinavian slide, actually. But this is us, the mental health workers down here on the right. And we're coming on the scene late. And people have been badly hurt by the time we come in contact with them, like Tony's son.
And there's not much of a safety net. This is part of our argument for early intervention for youth mental health, to build up the system at the front, which I'll come back to, too.
So now, the cavalry arrived last year. I think that the Andrews government, to be fair, when they took office, they recognised there was an issue. And it had been a long time coming, probably at least 15 years. So again, both sides of politics are responsible.
But Stephen Duckett was doing an inquiry into the obstetric deaths out in Bacchus Marsh. And fortunately, and I think he deserves the credit for this, he argued that we should have a look at mental health in terms of safety, in terms of the health system. Because anecdotally people were very aware about all these preventable deaths from suicide. That's probably much more numerically important.
I've got friends that work in the EDs around the city and they're traumatised. Every couple of days there'll be someone that they've seen in the ED, and sent home, and that person will be dead. And that was becoming a thing.
And so I think Stephen Duckett then thought, let's have a look at it. He did. And the department, I think, supported him in this. I think the Department of Health now has some really great leadership and is really looking seriously at these issues.
‘The department has also failed to act on red flags, signalling more systemic problems in care. No way has this been more apparent than in mental health care. Significant degradation in funding, relative to needs and quality and safety, has occurred over the past decade and has not been acted upon,’ he says by the department, but it's really the ministers and the government at the time that were responsible for this. I think we can't blame the people in the Health Department.
‘Our strength and focus on improving care in mental health will be insufficient. However, when the overwhelming threat to safety and quality of care in mental health is the significant rising pressure on services, this will need to be addressed through funding.’
So we've had 500,000 people come into Victoria in the last six years. So this massive population growth, especially where we work in the northwest of Melbourne and the southeast of Melbourne – growth corridors – and we're just getting overwhelmed in these front line services.
So I think here's some figures of what's actually happened in Victoria. If you look at the spending it looks like it's gone up, but that's not in real terms, and it's certainly not in proportion to population increase.
In real terms, there has been a serious cut or failure to keep pace. If we put up the figures for general health care – now, you might think general health care in the hospital system is under pressure too, and it probably is. But it has increased much more rapidly than what we're seeing here, so much so that nationally we're down to about five per cent of the total health budget in Australia is spent on mental health. It's 14 per cent of the burden of disease. So a huge mismatch here.
But the interesting thing is that Victoria has gone from being the highest per capita spender over 20 years to the lowest. I'm going to show you in more – so this shows it more accurately.
The national average – two per cent of the population are covered by state-funded mental health services nationally. Now, we know that the convention is that three per cent of the public suffer, at any given time, from a serious mental illness. So two per cent you could say is not too bad. It's still only two-thirds of people being covered at all.
But in Victoria, we've slipped down nearly to one per cent. So it's about half the level of the national average. And you can see, some states and territories are doing extremely well, like ACT and Northern Territory, surprisingly.
But Victoria used to be, as I say, the jewel in the crown. We used to have hundreds of visitors coming from all around the world, all year, to visit the state-of-the-art community mental health system that was built in the late '90s, and used to come to visit our early-intervention services for psychosis. And they still come to visit our youth mental health reform services. But they're not coming any more to look at our community mental health, because it doesn't exist. It's been dismantled.
If you look at the beds in blue, the number of beds in Victoria are well below New South Wales, and probably on a par with Queensland. So we don't have enough beds, but that's not the main problem, actually. The main problem is the community.
Now, this is emergency department presentations. As the assertive community treatment and the systems have been shrinking in real terms, we've seen this rise. I think it's 42 per cent over the last six years in emergency department presentations.
So that's why everyone's ending up in the ED, because there's no other option. And the CAT teams, such as they remain, are overwhelmed and don't do what they once did.
And it's particularly an issue for young people and people in the prime years of life. It's their main problem, it's their main health problem. Mental health is the main problem of people in the prime years of life. You can see in older people and in little kids, mental health problems are not the main problem that's driving them into the emergency department.
So our emergency departments are incredibly poorly equipped to deal with it. Their mindset, their whole battle plan is about responding to car accidents and heart attacks, and that kind of stuff. They're not calm, relaxed, therapeutic type people. They can't really do it. It's not their fault.
And even when you put mental health people in there, it doesn't really work either that well, despite the best efforts of the people that are doing it. I'm not criticising the staff. It's just a bad model. It should be reserved for absolutely extreme situations, not the first protocol.
And the police shouldn't be the first protocol either, as you can see from that story. Neither should the ambulance service. It should be mental health people. There should be a really strong proactive mental health system with experts in that front line.
So now here is probably the key slide, which is our community context, the amount of community activity that's happening. And it's the worst. It's a disgrace. We were the best and now we're the worst, in terms of the support and funding.
Also, the waiting times for people with mental illness have gone up. The severity of the presentations has increased. All of this is in the Australian Institute of Health and Welfare data. And the amount of time that people spend with these people when they present is shorter as well.
So everything is under massive stress. So it's no wonder that there are so many preventable deaths.
And this is where we need to go. We need to catch up with these other jurisdictions. And we've got to do it fast.
I think the Health Department's modelling might be thinking, well, it took ten years, 20 years, to get like this, so it's going to take ten or 20 years to really fix it up. Well, no! We have to work much more rapidly, and we have to invest very, very heavily to fix this.
And that's going to involve, obviously, creating new workforces as quickly as we can as well and scaling it up. We can't do it overnight, but we’re not going to take ten years. We've got a ten-year mental health plan – that's a joke. A ten-year mental health plan won't even have the same government in ten years. So we should be planning for reasonable time frames, like three to four years, with these sort of things.
So we call this ‘the missing middle’. So what we have, and Frank Quinlan from Mental Health Australia presented this to Greg Hunt last Thursday when we had a big roundtable. And he showed figures.
There's quite a lot of activity at primary care level in general practice, and then there's all this activity at the bottom of the cliff in the emergency department, and the police and everything. But in the middle – experts, specialists, specialists in multidisciplinary care – is in incredibly short supply. It's like a tiny little piece on the graph. Everything else is much bigger.
So we call it ‘the missing middle’. And in Headspace, we can get lots more young people into the bottom step on the ladder, through Headspace, which is fantastic there. And then we can treat a lot of problems in Headspace, but there's about a third of those young people that need more complex care and there's nowhere for them to go. I'll show you in a minute, we're turning three out of four of these young people away from Orygen, which is designed to look after those more complex patients.
So these are the missing steps. The National Mental Health Commission in 2015 said we have to bring in step care for mental health care across all age groups. But the trouble is there's a bottom rung, there's a bottom step, and there's a top step, but there's nothing much in the middle.
And anyone, whatever age you are, if you've tried to seek mental health care in the community, to see an expert or see an expert team, you almost have to invent your own team. And it's very, very hard to find the people, even a city as big as Melbourne with lots of psychiatrists, it's very badly designed, badly organised, and financial barriers exist as well. So those steps are just not in place.
Now, luckily apart from some new leadership in the Health Department and the state government that's at least acknowledged the problem and shaping to do something about it, we do have some other friends and allies who are going to help us, and that's the economists. And this is the reason.
In the hard world of economics, if you are going to invest in non-communicable disease on a logical cost-effectiveness basis, you wouldn't be putting all the money into cancer. We're putting a fortune into cancer in this country, and we're getting a few more months of life expectancy at the end for huge investments.
I'm not saying we shouldn't do it, because that's a value judgement the community will always make. And if I get cancer I really hope that there's really great treatment available. So I'm not knocking it.
But look at what's happening with mental illness. It's incredibly underfunded and yet it has a massive effect on the economy. So if you start treating people in the prime of life, young people and people going through those productive decades of life much more effectively – because only a minority of them get any kind of evidence-based treatment at the moment, even in rich countries – if you did that, it would pay for itself many times over because the economic benefits would flow from it.
We know that. We've done that with psychosis and we've done the cost-effectiveness studies. If we extend that to the other range of mental illness, we will see it there too.
So it's just like a form of self-harm by the country not to actually do this. And it doesn't have to be at the expense of cancer or heart disease. We just have to catch up and do the same things that they do: prevention, early intervention, sustained treatment, and looking after people who've got more long-term conditions properly. That's what they do in those areas. They do that mostly.
And this is some other data from my colleague, Eóin Killackey, showing that the biggest growth in the disability support pension is people with mental illness. That's one of the drivers of these costs.
And once you get on to that DSP there's only two ways out of it. One is dying, and the other is the old age pension. You're not going to go anywhere once you get on that DSP. So it's like a death sentence for our young people if they don't actually recover and they end up in that. Not to say they shouldn't be supported financially but we do everything we can to get them back to work, back to education, back to school.
And if you look at the amount of money in the national economy that's being spent on mental illness, a big chunk of it is on the costs of failure, the cost of failure to treat effectively – welfare costs, prison costs, a whole range of costs increasingly. So we're spending money that – we're actually wasting money by not actually spending it in the right places.
And this is where this term ‘mental wealth’ comes from, from this paper. You've probably heard Malcolm Turnbull using this term ‘mental wealth’, because Ian Hickie inserted it into his brain and he says it quite often now. But basically it means the build-up of social capital across the life span.
So if you have a small child, have a baby, and you bring that child up, you know how much it costs financially and emotionally to bring that young person to the threshold of adult life. And if they break down, if they have mental health problems, which may risk putting them on welfare or possibly dying, even, from suicide, or – obviously that's the most tragic and terrible outcome.
But even if they under-achieve, even if they don't fulfil their potential, then there's a loss of social capital which extends across decades. And that led to the World Bank to value the life of a 22-year-old most highly across the whole lifespan, which is what this diagram actually shows too, that it's the worst thing to happen if you've done all that and the person doesn't actually become productive in society, become self-sufficient, and leads a fulfilling life.
So mental illness is quite different from physical illness in many ways, but especially – we kind of shoehorn it, we've tried to shoehorn it into our clunky, acute system of both general practice and acute hospitals.
But the one thing we didn't do when we were doing that in the '90s was look at the pattern of onset of these illnesses. So it's the mirror image of what you see in physical illness.
In physical illness it's in younger children and it's in the over-50s, pretty much. In the middle years of life, adolescence and middle years, we've never been physically healthier than we are now. We don't need big hospitals for that stage of life. We don't need all those things.
But we've actually forced mental health into the same age ranges, and we've under-invested – particularly in that surge in adolescence and emerging adults, peaking in the early 20s, the system's weakest where it should be strongest. And we've tried to do something about that with some support from government in recent years. And that means building a system of care for emerging adults, basically, teenagers and young adults, which is where all the action is. You can see that surge of morbidity there in that age group.
So Australia has actually done a great thing going by innovating around that in terms of reform for youth mental health. But it's still base camp. We're still nowhere near where we need to be.
And part of the argument is about how young people develop. It's not a ‘one size fits all’, they don't suddenly become adults at 18. It's a transition, and it's particularly a transition that's affected by having mental health problems, and slows things down, makes it much more challenging to make that developmental transition to being an adult.
So early-intervention, Headspace, models like Headspace were backed up by models like Orygen: more specialised, complex care are what we need. It's a process, this sort of reform process.
So starting at the top, it's the former Governor General visiting us a few years ago. We've got a collection of prime ministers – we have to keep updating this collection – but they've all been out to visit us, out in Sunshine in the western suburbs of Melbourne.
And Greg Hunt, we had a meeting with him last week, as I said. See where his hand is? He actually does care about mental illness. His mother had bipolar disorder. He is the first Health Minister that we've ever met who actually really gets what it's really like living with a serious mental illness.
And the Victorian Government, as I say, has commissioned a report, which has been leaked about 100 times by now. And so we know what they think and we know the facts. What we don't know yet is what they're really going to do about it.
But the signs are good. They've got some really serious experts in the health department that have been recruited in to work on it, and hopefully we'll be able to influence it too.
So, what are the things we have to do, what are the pillars of investment? The first one at absolutely top of the list is rebuilding this under-investment in community mental health. I didn't put any numbers on this, because I didn't want to frighten any government people that might be in the audience. But we have to go, broadly speaking, from an annual budget of about $1.1 billion a year, which is spent currently on mental illness in Victoria, to a budget of about $2 billion. And we need to do it in the next five years or so. We've got to build it up in a step-wise way.
So we're talking about hundreds of millions of dollars extra to fix this problem, and that will bring us up to a level where we're covering closer to the full number of people with serious mental illness that need expert care. It still won't get us there. And there will be many savings arising from doing that, actually. So it's not going to, in the end, going to cost the community that much. But if we can find billions of dollars for children's hospitals, and cancer centres, and new freeways, this is our investment in the fabric of Victoria, the human fabric. And we have to do it.
The next pillar is the youth mental health system, and that has to be an absolute centrepiece as well. We have building blocks here in Victoria, but look how weak they are. We cover a million people in the west of Melbourne, and we get 4,000 complex referrals into our front end at Orygen, which links to the four Headspaces that we run.
These are people who seriously need expert, multidisciplinary care. We're turning three out of four of them away, and they're dying in bigger numbers. This is something that makes me absolutely furious when I hear of a death every few weeks. A person that should have been – they don't have terminal illnesses, in a few weeks they'd be better and they'd be alive, and they die unnecessarily. This is happening.
So it's worse than turning away two out of three. We're turning away three out of four.
And the final thing – actually, I should say what we need to do there. First of all, the State Government has, in an incredibly positive move for us, and we're very grateful for this, they're rebuilding our facility, our research/clinical facility at Parkville. So there's an opportunity for a state-wide reform built around that new facility.
And we would like to see much stronger mental health services across not just the north-west, but also the eastern area and the south-eastern area, especially in these growth corridors. And that can be done, and that should be between 12 and 25, strengthening the system, so right in that peak zone. And that will take the pressure off the rest of the adult system too.
So that is something that we've been working on for ten years, and it just hasn't really been nailed. It hasn't really been properly funded. So we really want to see that.
And the final thing is mental health research. Mental health research is incredibly poorly funded in this country. The minister today, Greg Hunt, announced some improvements to that, which are very welcome. But if you look at what the State Government is putting into research apart from this new facility, it's really much less than what you see in the rest of medical research. So a fair deal there too.
And this is the situation nationally, where even though it's the major cause of burden of disease in the prime of life, it's funded much less than cancer and cardiovascular research. Same pattern as within the service system.
And in the UK, and it's probably the same here, if you look at the corporate and philanthropic sectors, for every pound spent by the government on mental health research, the general public donates only zero point three of a pence whereas for cancer, they donate two-pounds-75.
So the situation's worse in the corporate philanthropic public domain than it is for the government. We're getting a raw deal from the government. We're getting a very raw deal from the community in terms of support for mental health research.
And where are the new treatments going to come from? Where are the improvements? Where is the new knowledge? Where is the prevention going to come from if the research is not supported? So that's another thing.
So I do want to acknowledge what the state government has done for us, and I also want to acknowledge Lynne Kosky and Jim Williamson, who's in the audience tonight, for the tremendous effort they put in to help us get to that point when the government was coming in. And they've honoured that pledge. The building is being built.
So this is a huge opportunity for us to really revive ourselves, and move forward, and really deliver, especially in the youth mental health area. But we want to see it happen across the lifespan, because we care about all of the Victorians with mental illness.
So that's what the new facility is going to look like. As well as the functionality, it's like a statement. It's like saying mental health, mental illness, is as important as cancer and heart disease if you have a state-of-the-art facility like this. It's incredibly important for the patients, for their families, and for us as people in mental health.
We suffer from what's called structural stigma. Not just the patients are stigmatised, and the families, but we are for working with them, and within medical research, all these areas. We're underfunded because of the structural stigma. That's an antidote to stigma when you do something like that. So we're very grateful to the Premier.
The other side of the coin, we talked about the prime ministers, and the health ministers, and all of that. They're dependent, like George Lipton pointed out, on the public. The public has been too passive, way too passive on this.
We've managed to mobilise 800 people, going back 13 years, which really was the kind of groundswell that got Headspace funded, that kind of activism that was happening then. And in other countries, they're starting to do that. This is in Ireland. There's a mental health reform movement there.
Grassroots activism is what we need, probably at this level, I think. This is in Poland, actually. They managed to get rid of the Iron Curtain, so surely we can do that for mental health.
And so we have been working, a group of people, including me, who are affected, who've got lived experience of mental illness in their families or personally. And this is a small group. And Lisa Sweeney, I'll mention her, she's here tonight too. She's been a great force getting this off the ground.
We set up something called Australians for Mental Health. We want to raise a lot of money to support this campaign. It's going to be a standing campaign. It's going to move from one state to the other – a campaign for a fair deal for people with mental illness, and it's going to campaign in federal elections as well using the GetUp! sort of model, but we've focused on this issue with a bipartisan target.
So that's the missing ingredient, that we haven't done that yet, and we need to do it. It will help the politicians, it'll help the genuine politicians that do want to do something positive. And I think Martin Foley, the current minister, I think he genuinely wants to address this. But he needs us to create the environment where enough money will be freed up to do it.
So I'm going to stop. I thought I had picture, one slide which – I had a ‘thank you’ slide, actually. I just wanted to thank everyone affected by mental illness who's shared their stories and helped us to get this issue on the agenda.
I want to thank all my colleagues. I want to thank the State Library. I want to thank the politicians that do support us and both sides of politics.
And I mentioned Jim. I want to thank Jim. He gave me lots of really good advice for the lecture, including one thing I forgot, which was we spend about $23 million at Orygen on the western suburbs of Melbourne for a million people, and 50,000 young people with mental illness live there, and we treat about 1000 a year. A high school – I think he showed me the budget for Glen Waverley High School in the eastern suburbs – is about $23 million as well. One high school. And that's all we've got for the whole mental health problem in the whole western suburbs. We need to triple that if we're serious. That's the sort of scale we're looking at. And I thin – thank you, Jim, for that very good comparison. We're looking for that.
We spend $22 billion a year now on the NDIS for 400,000 Australians. We spend $8.5 billion a year for the four million Australians with mental illness. So you can see the mismatch, and those are the sort of figures we've got to turn around and we will be hoping that our government, and with an election year, we are looking for a bit of a bidding war between the two parties in terms of who's going to fix it.
So I'll stop there. Thanks very much. Sorry it went on too long.
'It's a form of self-harm for the country not to [intervene early]. It doesn't have to be at the expense of cancer or heart disese, we just have to catch up and do the same things they do: prevention, early intervention, sustained treatment and properly looking after people who have more long-term conditions.'
– Professor Patrick McGorry, AO
About this video
In the 2017 Redmond Barry Lecture, Professor Patrick McGorry AO discusses the breakdown of Victoria's mental health system – once the 'jewel in the crown' of the national system – and what is required to fix it.
Patrick credits Australians for 'having the conversation' about mental health but with community treatment systems shrinking and population growing, there has been a 42 per cent rise in the last six years in Victorian hospital emergency department presentations.
He warns that the integration of mental health within mainstream health system since the 1990s is taking Australia in the direction of the USA, where prisons and hospitals are filled with people with untreated mental health issues.
Patrick discusses the 'missing middle' in the mental health system, where there is a high level of pressure on general practice and with emergency departments and police 'at the bottom of the cliff', but inadequate specialist, multidiscplinary care in the middle. The cost of failing to effectively treat more complex patients is borne in welfare costs, prison costs and the loss of social capital across a person's lifespan.
Patrick proposes three pillars for investment and reform of the mental health system in Victoria:
- invest $2b per year in community-based mental health over the next five years to help people with serious mental illness who need expert care
- strengthen the mental health system for young people aged 12-25
- fund mental health research.
Patrick expresses gratitude to the Victorian Government for funding Orygen's research/clinical facility in Parkville.
He says there is a need for more corporate and philanthropic funding, and for grassroots activism for mental health reform. With others he has formed the not-for-profit Australians for Mental Health to campaign on the issue of mental health.
About the Redmond Barry Lecture
This free Redmond Barry Lecture was held at the Library on 29 November 2017.
An annual lecture, it honours the work of Sir Redmond Barry – founder of the State Library and a key figure in the development of Australia’s cultural and intellectual life.
Professor Patrick McGorry AO is a world-leading researcher in early psychosis and youth mental health. He’s the Executive Director of Orygen, the National Centre of Excellence in Youth Mental Health; Professor of Youth Mental Health at The University of Melbourne, and a Director of the Board of the National Youth Mental Health Foundation (headspace). His work has played a critical role in the development of safe, effective treatments and innovative research into the needs of young people with emerging mental disorders, notably psychotic and severe mood disorders. He has also played a major part in the transformational reform of mental health services to better serve the needs of vulnerable young people.