As my contribution to Mental Health Week, I’d like to talk about suicide and mental health care in Australia. A confronting topic, but important to discuss. As a doctor and also someone who has experienced a number of episodes of depression, it’s something I can talk about from both sides of the bed, as it were.
R U OK? Day last month drew a lot of attention to identifying people at risk of suicide. I found the campaign very frustrating for two reasons. Firstly, what they’re not saying is that you really shouldn’t be asking the question unless you’re prepared to deal with the answer. Secondly, no-one is talking about what happens next. I think many people assume that in this situation it’s a tidy little sequence: you get admitted to hospital – where you’re safe – they treat your mental illness, you get better, then you are discharged and go on your way with the medications which will keep you well. The reality is not quite so simple.
Suicide is NOT just about mental illness. People commit suicide because they feel trapped and in pain, believing that things will never get better and that there is only one way out. Everything except that pain becomes less real – people, memories, the sense of hope. And because those things are less real, leaving them behind doesn’t really seem to matter. Mental illnesses such as depression may take you some of the way to that point, but other factors are nearly always involved: personal loss, social isolation, poverty, trauma, violence, substance abuse, lack of meaningful employment – in its broadest sense – and sometimes, really not having many options in life. Sometimes mental illness is the least of the problems.
Hospitalisation can be truly helpful, but … there are a lot of buts. It’s a lot harder to get admitted to a psychiatric hospital than you might think. And if you are admitted you’re thrust into a highly stressful situation away from familiar surroundings, subject to an externally imposed schedule of mealtimes, sleep times, medication rounds and treatment sessions, alone among strangers – often quite disturbed strangers. Hospitalisation can be helpful if you can’t take care of your own basic needs. It can provide a respite from the stresses of work and family pressures, give you access to more intensive treatment and allow you to be monitored more closely. But it’s not a guarantee of safety. People do sometimes commit suicide in hospital. Equally disturbingly, a 2013 report by the Victorian Mental Illness Awareness Council (VMIAC) revealed that 45% of women in the state’s psychiatric hospitals had been sexually assaulted or harassed while in their care.
If an adequate level of outpatient care is available, there’s a lot to be said for being around healthy people, sleeping in your own bed, eating familiar food, seeing familiar faces and keeping to something like your normal schedule.
As for medications: yes, they play a role in treating underlying mental illnesses, and when they work they can produce amazing results, but they don’t work immediately, they don’t work for everybody, and they can have nasty side effects. Antidepressants in particular can sometimes make things worse, either by triggering a manic episode if you happen to have bipolar disorder, or by making you more suicidal or even violent or homicidal.
The things that really make a difference are having (or building) a life worth going back to, one where you feel you belong and are truly valued; and, whether in or out of hospital, individual support – a person or people who will really listen, who will help you find better ways of coping with your problems, who will remain calm and hopeful for you even when you are in crisis, who are able to mobilise extra help for you if necessary. And who can do all this for as long as it takes. Support for a suicidal person is not a one-time thing. Suicidal thoughts and feelings and the desire to act on them wax and wane in intensity, often over quite a long period of time. The level of support that is needed is above and beyond what can be asked of friends and family.
Our society is increasingly fostering a culture of divisiveness, fear and xenophobia and a mentality of scarcity, marginalising and isolating anyone who is different or who is judged undeserving. We are systematically destroying opportunities for people to build lives worth living by our failure to provide individuals and communities with equity of access to basic infrastructure, education, employment and an adequate welfare safety net.
And we are not funding the necessary levels of psychological treatment and support for the people who need it. Medicare and private health funds will cover part of the cost of treatment by a psychologist for a limited number of sessions per year, however not all psychologists are prepared to manage actively suicidal patients. Medicare funds a higher number of sessions per year for a psychiatrist, but those who offer psychotherapy are few and far between and the out of pocket costs can be far greater (and will be even more so with the impending cuts to the Medicare Safety Net). Even highly successful publicly funded programs, such as the Perinatal Depression Program and various youth mental health initiatives, struggle with chronic under-funding or the withdrawal of existing funding. Lifeline, the telephone crisis counselling service which is advertised in nearly every single news article about suicide, relies predominantly on volunteer staffing and private funding.
My own experience was that treatment with antidepressants only worked for some of the symptoms, some of the time, and on one occasion I became much worse while taking them. However, I’ve been very fortunate in being able to access good quality psychotherapy over an extended period of time and in having considerable educational, employment, financial and social resources in my life to fall back on. I am well aware that my situation is the exception rather than the rule.
If we’re serious about reducing suicide in Australia, we need to work on building a society worth living in, and on providing appropriately funded and accessible services that address ALL the issues relevant to suicide.
(originally published 8 October 2015. The artwork is Paint your own sunshine, one of my previous Mental Health Week poster competition entries)