No, we are not OK

Recently, Australia had an ‘R U OK? day’, where we have been encouraged to ask our colleagues, friends, and family about their mental health to stem the tide of mental illness and suicide.

As a GP, it is very clear to me that we are not close to OK. Day after day, my clinic is full of people struggling to cope with their mental health needs. Despite increasing investment in mental health and report after report showing what we need to do to address this epidemic, we are clearly not doing enough. So what is going wrong?

At the moment, we are pouring resources into bolstering resilience. The resilience narrative shifts responsibility to the individual. Resilience, they say, is the ability to bounce back from adversity. However, you can take the most resilient superball in the world, but if you ask it to bounce in a muddy pool of poverty, disempowerment, violence, and shame, it will drown. Some of the surfaces in our world are impossibly soggy.

FLOUNDERING

In medicine, we see this with our junior doctors, asked to ‘bounce’ in environments where bullying and harassment are endemic, long hours are expected, and admitting to mental illness is shamed. The result is an unacceptably high rate of suicide in our best and brightest. My patients who live on the edge of homelessness, or survive domestic violence, or endure systemic racism, poverty, and isolation, live in a world where safety and security are a myth.

Internationally, a shocking one in three women (30% of women worldwide) live with the memories of sexual or intimate partner violence,¹ and we estimate that at least one in six men (in Australia) survive childhood sexual abuse.² These experiences leave survivors with a pervasive sense of worthlessness and shame, none of which should be theirs to carry. My patients who lack the birthright of privilege work much, much harder to obtain the safety and security they need to flourish. Needless to say, they are not bouncing. And resilience is not the problem. Instead, the mud they are floundering in is getting deeper by the day.

And yet, our response is often to shift the burden of mental health care to the health system, which is designed to deliver individual care to those with diseases and disorders. There is nothing wrong with treating individuals or instituting awareness campaigns and prevention strategies. But as a clinician, it feels like we are taking resources from social security for everyone and pouring the money into treatment for a few. Frankly, it’s not working. Mental illness is rising.

THE MENTAL ILLNESS EPIDEMIC

It seems obvious that the most unwell patients should receive the greatest support, and yet people living in the poorest quintile in Australia have three times more mental illness and use mental health services three times less, when compared with those living in the richest quintile.^3,4 The wait for inpatient care for eating disorders is months long in the private system and often over a year in public facilities. Keeping these patients safe is a constant, worrying challenge — just imagine what it’s like for the parents of these young people. For the young people themselves, our inability to provide care is cruel. No investment in brief cognitive behavioural therapy (CBT) is going to address the problems experienced by people who have nowhere safe to sleep, nothing to eat, and who face relentless discrimination and harassment. No amount of awareness-raising helps a person unable to afford care, because they don’t have access to a living wage. No online initiative will support a person with lower than average literacy, or no access to Wi-Fi or phone credit. We know epidemics flourish with poverty, and our mental illness epidemic is no different.

Our current system is not OK. Until we get a roof over everyone’s head, food on the table, and a safe refuge for those living with violence, mental illness will flourish. At the moment, the muddy pools of disadvantage are getting deeper. We shouldn’t be surprised that people are drowning in them. Sprinkling a little bit of light CBT on the surface of the problem gives an illusion of care, but little real support. It’s time for some frank planning about how to drain the swamp before we GPs drown as well.