Written notes for the speech by Dr Molly Shorthouse Rural Generalist practitioner, Nhulunbuy, NT At the Rural Doctors Association of Australia's Breakfast Briefing for Federal Politicians Parliament House, Canberra 1 March 2016 As 1 in 5 Australians have had an episode of mental illness in the past 12 months, it is likely that every person who reads these words has either experienced, or been close to someone with a mental illness. I write this for that person today, the one who may know themselves how debilitating mental illness can be, or to the mother or father, brother or sister, child or close friend, who has helped care for a person with mental illness. Because it is you that knows, mental illness never, ever affects only the individual. It always affects those closest to them, and as we now know, it reaches further than that — it affects the very fabric of our community and society. Consequently, we are all one of those people, and so it is for all of us that I write today. I am a doctor who works in primary care mental health — ‘Primary Care’ simply means the first contact in health, the frontline of health. For me, I am at the frontline as a Rural Generalist, a remote GP Specialist in Mental Health. But primary care also includes, especially in remote areas, Nurses, Allied Health Professionals and Aboriginal Health Workers. It is an exciting time to be a rural doctor, thanks to the Rural Generalist approach to training and to the Rural Doctors Association Australia (RDAA). And it is an exciting time to work in Mental Health, that is, if we follow the advice of the recent report from the National Mental Health Commission’s Expert Reference Group on Mental Health Reform. Currently I live in East Arnhem Land, which is Aboriginal-­‐owned land in tropical north Australia that is about a third the size of Tasmania, but with a population of only 18,000. Its people are the Yolngu, and there are many great leaders, musicians, sportspeople, artists and educators whom are Yolngu; such as the Yunipingu’s, Marika’s, Gumana, Ganambarr, Wurramurra’s, Marawili’s and Munungurr’s. They are an inspiring group, and if you do not already know how sophisticated and wise our First Australians are — can I recommend you visit Arnhem? However, East Arnhem also has a white community of about 3000 people, and they too are a resilient and courageous group, as are most rural and remote Australians. So, I travelled the 4,500 kilometres from East Arnhem to Canberra to speak for all rural and remote Australians that mental illness has affected. Every doctor will tell you that patients alter us, they affect us, forever change us. Today I want to tell you some of these stories, they are personal stories, but ultimately they are stories about the value of local knowledge in mental health, and the value of person-­‐centred and community-­‐based care which, I believe, is best provided by the local and community-­‐based clinicians…the GP, Nurse, Allied Health Professional and Aboriginal Health Workers. My first story starts in late wet season in 2011 — 3 crows stood at the top branch of a dying eucalypt at the fringe of a remote aboriginal community…and they did something odd. I cannot tell you what it was that was so odd about these three crows. Perhaps it was the way they sang? The way they moved upon the branch? Perhaps it was something that they did not do, when usually they do. To the Elders of this remote community of 1000 people, the behaviour of the crows was a very serious sign indeed, called Galka, which a Yolgnu friend tells me means “black magic”, though I know she is simplifying it for me. It was so serious, it set off a cluster of youth suicide and by the time I heard of it, 2 young women had lost their lives. There was a third teenager who would have been next, if it were not for the Aboriginal Health Worker and a very experienced Remote Nurse in her community. They urged me to arrange an aeromedical transfer for her, to our little hospital hundreds of kilometres away. I was, at least geographically, a local, and so I trusted their assessment and arranged the transfer. I did not know what Galka was, but as a local, I knew that it mattered. And I will never forget the look in her eyes, when I entered her room on the ward, of sheer terror. And my awareness that my years of training in psychiatry and primary mental health had no meaning then, she had no mental illness that I had been taught to treat. All I could do, was listen…to the experts, the Yolngu experts. But when I looked into her beautiful, almond, dark eyes, all I could see were the eyes of the other two girls, in the hospital morgue only a hundred metres away. In fact, at that time I was still having flashbacks of a man’s face that I had to ‘declare’ deceased months earlier, frozen in distorted terror, after hanging himself from a tree on the main road out of town. And before that, 2 white boys, teenagers of our small community, who within months of each other had violently ended their own lives too. At that time, our remote community of East Arnhem had one of the highest suicide rates in the world, and did you know the number one cause of death in Australians aged 15 to 44 years old is suicide? Studies show that in rural/remote areas the rate of suicide is 66% higher than urban areas, it makes you shudder to think, yet only 1% of psychologists and Psychiatrists work in these areas. But, we have Rural Generalists, GPs, Nurses, Allied Health Professionals and Aboriginal Health Workers in remote areas, many of the latter whom I would call the “experts”…perhaps strengthening our resources at the frontline is what really matters? At that point, I was a sort of hybrid of GP, psychologist and psychiatrist — having completed some training with the Royal Australian College of Psychiatrists and then Cognitive Behavioral Therapy, then rural emergency medicine and general practice. But I was also a mother, a wife and a woman…who now found herself too often working in traumatic situations. And after the crows, and the girls, I resigned, and I moved with my family to Hobart, to what I thought was as opposite a place could be. I now realise, in part due to the recent release of the Black Dog Institute’s Guidelines on Post-­‐Traumatic Stress in Emergency Workers, that perhaps I was a little more than just 'burnt-­‐out’. On reflection, I had underestimated the intensity of providing mental health services to rural and remote communities. You often hear things that no-­‐one else hears. In the case of childhood sexual abuse it can be descriptions that are so distressing you need to open the door and stand outside when the patient leaves the room, trying to stop the waves of nausea flow over you. And you see and hear trauma where it is hidden from others. People’s "game-­‐
faces” drop and those whom can seem community stalwarts to all, are desperately sad to you. You see children on a pathway of intergenerational trauma and neglect and their parents yearning to break the cycle too, but not being given the opportunity to do so. And then, you begin to realise that with the right questions, almost every patient who presents to you will start to tell you their mental illness, not their physical one. Because, for most people and their families, it is their mental health they value and require, above all else. And then one day in Hobart I was reading about kintsukuroi, the Japanese art of repairing broken pottery with powdered gold, so that the bowl becomes more beautiful for having been broken. And it reminded me of every person I had seen come through the journey of mental illness, and how so often, that journey changed them, even strengthened them…and so it reminded me how much I valued working in mental health, above all else. So in 2014, around the time when the National Mental Health Commission released its report, I returned to East Arnhem with my family, armed with further training in Emergency and Child and Adolescent Psychiatry and a new determination. It is a new determination, but the same one I have had for a decade. I want to see Australia’s mental health system turned around, and upside down, and inside out. I want the dirty laundry out on the line and for advantaged people to know what is happening to the disadvantaged in Australia. Because no-­‐one chooses disadvantage. Often it starts before they are born, often before their parents are born. It is intergenerational; trauma, poverty, poor health, housing and education create it, propagate it. And though mental illness can affect any person at any time, at a population level mental illness disproportionately affects those who are disadvantaged, whether remote or in an outer urban suburb. I say this because I have recently worked as a locum in a GP Practice in an outer urban suburb, and to my surprise, I found that not only did this population face many similar challenges and sadness, as Arnhem, but the level of unmet need in their mental health care was equally as high. It was a bulk-­‐billing practice in a disadvantaged area and day after day, simple appointments turned to complex ones, physical illness to mental illness. What began as an appointment for a simple script for blood pressure medication turned to a risk assessment for suicide, as the tattooed and tough man before me began to cry about finding his closest mate weeks earlier, a suicide by shotgun. Then a child’s sore throat became a diagnosis of anxiety secondary to learning disorder, when I asked more questions about why he did not like school. And a pap smear became an admission of a childhood of sexual abuse, not previously revealed, let alone treated. They were hard and long hours, and as I mentioned it was a bulk-­‐billing practice…unsurprisingly there are very few GPs who can afford to work in these places anymore, yet these are the patients who need GPs, who listen, the most. It is understandable that many GPs avoid mental health in their consultations. Most of my colleagues admit openly to me it is their least favourite part of the job. One colleague, an experienced and exceptional GP, so drained after a year as the only female GP in a remote community, once said to me she can no longer say, at the end of a consultation, “is there anything else?” But why should GPs spend time in mental health? As I have mentioned above, it is an immensely draining and time-­‐consuming part of the job. Well, GPs must feel comfortable working in mental health because in rural and remote areas, they are often the only choice. But even in urban areas, the great majority of Australians seek help from their GP first, and many never go on to see a Psychiatrist or Psychologist. But more importantly, GPs must feel comfortable working with mental illness, because ultimately, they are in the position to make the greatest contribution to improving the mental health of all Australians. While it may be hard to imagine how an individual’s mental health can ultimately affect Australia’s productivity and growth, think back to someone you know who has had mental illness. Did they isolate themselves from family and friends? Did they lose motivation and stop participating in work and family? Did they lose belief in their own value, their own capacity? And, as is common, did their irritability and low mood cause them to start lashing out at those around them, thus hurting their families, friends and workplaces too? With mental illness affecting 1 in 5 Australians that is almost 5 million people who may be not realising their own potential, and impacting those around them also. Imagine for a moment if every person with mental illness suddenly had a broken leg, a cast and crutches hindering their lives. We would notice if 5 million Australians were hobbling around like that wouldn’t we? But we don’t with mental illness — our women, our men, our returned servicemen and women, they are very good at the “game-­‐face”. There is no health without mental health, so let’s value it. The Rural Doctors Association of Australia's soon-­‐to-­‐be-­‐released Position Paper on Mental Health is a blueprint for how Australia can develop a long-­‐term strategic plan to address the mental health needs of rural and remote Australians. It is about the value of the Primary Care Clinician, which means the local one, and the value of community-­‐based mental health care, because, for all rural and remote Australians with mental illness……………if you want to close the gap, first you must close the distance. In East Arnhem, we have a vision. We would like to develop a Primary Mental Health Network between our small local hospital; the East Arnhem Mental Health team; our Aboriginal Medical Services, Miwatj and Laynhapuy; our private GP practice; Anglicare; the Yolngu Social Emotional Wellbeing Team (Raypirri Rom); the Healthy Minds Team at Galiwinku; Aboriginal Health Workers; and community leaders such as Gayli Marika, who almost single-­‐
handedly turned the suicide rate in her community from highest to none…(and hers is an amazing story, if you have not heard it — please do). We also have Arts Centres, schools, sports academies, traditional healers and Learning on Country programs for rangers, all of whom we would like to include in person-­‐centred holistic treatment plans. We would like to use our GP Management plans for diabetes as a conduit to mental health screening, so that everyone with diabetes and pre-­‐diabetes is screened and mood disorders are identified and treated early. We want to catch them, before they fall. Can you imagine the financial and health implications of preventing deterioration of both diabetes and mental illness? In East Arnhem, many of our children and teenagers are suffering mental illness. And nationally we know that up to 50% of mental health conditions begin by age 14. Specific learning disorders, bullying, trauma and conflict in the home environment all contribute to the early development of anxiety and depression in children. We would like to develop a coordinated and local approach between our schools, parents and health services so that we can catch our children, before they fall. Today, I urge you to value those already on the frontline — GPs, Nurses, Allied Health Professionals, Teachers and Aboriginal Health Workers, who are providing a service despite its challenges. And by valuing mental health and those who wish to provide that service, we can hopefully attract more Doctors, Nurses, Allied Health Professionals and Aboriginal Health Workers into the field. We need more of them all. As it stands currently, our workforce is at crisis point, our community is at a crisis point. We must make it attractive to work in mental health, and to cope with the challenges of this area of health we desperately need more training opportunities. We need to build and formalise the relationship between the College of Psychiatry and the GP Colleges like that which exists in Anaesthetics and Obstetrics. This is the only way that Rural and Remote GPs will receive the training, supervision and support they require to face the challenges of remote mental health. Furthermore, this will ensure that clear referral pathways exist for the safety of both patient and practitioner. We need funding support for upskilling and training, such as the Grants that GP Obstetricians and Anaesthetists receive. Funding matters — I would not be here today without the government support of a RAMUS scholarship for medical school and the GP Registrar Incentive Program and I am most grateful for both. And it is essential that we see a National Rural Generalist Training Pathway be adopted as a policy by the Federal Government. Because at RDAA, we believe that it is the right funding, for the right skills in the right places, that will save our health system money, not spend it. And while there have been excellent and crucial developments in tele-­‐health and online Psychology programs — and I am immensely supportive of both — a patient once said after trying an internet CBT program at home and not engaging, “I may be mentally ill, but I do know that a computer does not feel bad for me.” Central to most therapy in mental health is the notion of relationship…in almost all people, but especially in a population such as the Yolngu, which is a kinship system, meaning they must know you and have a place for you before any meaningful health interaction can occur. And that takes time, a lot of time; I am still far from it. Tele-­‐health and internet psychology programs do not work for everyone, so please do not replace those of us who love to live remote and work in mental health in remote areas, let alone those who have been in these areas for 40,000 years, with computers and distant experts. Because closing the distance is about realising the distance, understanding the vast scale of difference; between indigenous and non-­‐indigenous, between city and country, advantaged and disadvantaged, between GP and Specialist and between policy and practice. It is time we value mental health, and rural and remote Australians, no matter what the challenges.