Lobbyists dominate mental health sector
A month ago, the town of Derby in the West Kimberley held a basketball carnival and hoop-shooting contest on what happened to also be World Suicide Prevention Day.
In a region with one of the highest suicide rates in the world, where primary school-aged children have taken their own lives in the past two years, Derby’s community leaders work hard to organise events that will have a positive impact on the children in their care.
As the carnival wound up, the children were seated to listen to a visiting government-funded social worker.
The fun had ended so people as young as six could be lectured about self-harm.
Professor John Mendoza, a suicide prevention consultant who happened to be in Derby, was appalled. Giving evidence a week later to a Senate committee investigating mental health issues and suicide in rural and remote Australia, Mendoza said the event had been “hijacked”.
“It was just entirely inappropriate,” said Mendoza. “I just thought, ‘Wow, that program was funded by the federal government’… It was completely out of context and disconnected to what the community needs.”
Mendoza is among a number of experts working in the health sciences and on suicide prevention who are concerned governments are spending money on programs they allege haven’t, by any rigorous scientific evaluation, been proved to work.
Their concerns appear to extend beyond the professional jealousies and competitive tensions that affect many corners of the community sector.
Some say funding decisions are influenced more by the lobbying of high-profile organisations than by scientific research. And a few believe the current national approach to combating suicide in Australia may in fact be making the situation worse.
It’s an allegation the federal government and organisations it funds, including beyondblue and the Black Dog Institute, reject. They insist programs are being evaluated thoroughly but that after they are designed based on research, they need to be implemented and then tested in the field.
What all agree on is that the latest figures on Australia’s suicide rate published on September 26 tell a grim story.
Last year, the number of suicides rose 9.1 per cent, from 2866 in 2016 to 3128.
That is 12.6 deaths per 100,000 people, equalling the 2015 rate as the highest in a decade.
Tasmania, Victoria and South Australia were the only jurisdictions that did not record an increase.
The percentage increase was biggest in the Australian Capital Territory, where the numbers climbed from 28 to 58 in a single year – a rise of 107.1 per cent.
But on raw numbers, Queensland’s increase was greatest, from 674 deaths in 2016 to 804 last year.
Nationally, the rate remains higher for men than women, and the rate among Indigenous Australians is more than double that of the rest of the population.
While the national figures have fluctuated in recent years, during the past decade the overall trend is upward – a dreadful indictment in a country that ploughs hundreds of millions of dollars into suicide prevention.
The question nobody can answer with certainty is: Why?
The causes of suicide are hugely complex – a mix of mental ill health and other factors, including financial and relationship stress, isolation, addiction, bullying or other persecution, and situational circumstances, such as living in areas of drought, high population growth, low income or inadequate services and infrastructure.
A spokesperson for Health Minister Greg Hunt said the national figures, while fluctuating, were of deep concern. The minister has written to the Queensland government seeking a joint approach to the particular challenges in that state.
“The data highlights that there is no single reason for the rise in Australia’s suicide rates, and no simple one-size-fits-all solution,” the spokesperson told The Saturday Paper.
“Suicide is a complex issue … It is therefore important that approaches to suicide prevention provide the right interventions, at the right time, in the right locations, for the right groups. In establishing suicide prevention initiatives, the government considers a range of evidence, including outcomes from evaluations, scientific research, evidence of best practice and feedback from mental health and suicide prevention experts and people with lived experience.”
He said the services and programs offered by organisations such as Lifeline, headspace, Orygen, and the Black Dog Institute were “all already well-supported by evidence”.
But some suicide-prevention experts are querying the government’s funding priorities and suggesting they are addressing only part of the problem.
Professor Ian Hickie, who has recently finished six years’ service on the National Mental Health Commission, told The Saturday Paper he believes too much is being spent on raising awareness and informing people about how and where to seek help, but too little is going to the services to treat them when they do.
The numbers, especially of young people, presenting to hospital emergency departments experiencing mental health crises and talking about suicide has risen dramatically in recent years.
But Hickie says there is not enough effective support being offered in response, and that hospital workers aren’t well enough trained to deal with them.
He and others believe the health system’s structure puts time pressure on GPs, which can result in inadequate treatment of psychological problems.
Hickie believes there is a risk that people who have tried once to end their lives might be discouraged from seeking help in any future crisis.
Emeritus Professor Robert Goldney of Adelaide University expressed similar views in an opening address to Suicide Prevention Australia’s yearly conference earlier this year, saying he saw no proof the non-government organisations receiving large amounts of funding were actually achieving results.
“They’re not preventing suicide,” Goldney told The Saturday Paper this week. “There’s no evidence they are.”
Melbourne University Professor Anthony Jorm suggests those with the loudest voices have influenced funding priorities. “I think we’ve been driven by lobbyist-led reform rather than evidence-led reform in the mental health sector,” Jorm told The Saturday Paper.
Privately, some others agree.
Jorm queries the speed with which some programs are rolled out nationally. He says there is often too little evaluation of the pilot stage.
“The concept looks great and then when the data comes in years later, it doesn’t look very good at all,” Jorm says.
“We need to rigorously evaluate how they work in practice … We need to rigorously evaluate things rather than say, ‘That’s a good idea.’ ”
The director of the Black Dog Institute, Helen Christensen, rejects the criticisms. She suggests some experts in the field are stuck on old ways of doing things that don’t reflect contemporary needs or response requirements.
“The way people are working now using implementation science we think is a really good way to go,” Christensen says. “Let’s evaluate in the wild, while it’s really happening. We actually have to do it. It’s about development.”
Beyondblue’s chief executive Georgie Harman, says rigorous work goes into research for her organisation’s programs and it is currently undergoing an independent evaluation, the results of which will be made public. She rejects criticism from others in the sector.
“Now is not the time to be launching an attack,” says Harman. “It is a time for the sector to be pulling together as never before. The #YouCanTalk suicide prevention campaign launched in August was the first time so many organisations had come together to drive the message that everybody has a role to play in suicide prevention.”
Harman says funding has been increased at federal, state and territory and local levels. “It is a long-term strategy,” she says. “It will take time for the impact of that funding to be felt and for the services to be fully implemented.”
Professor Patrick McGorry, the 2010 Australian of the Year who now heads Orygen, the national centre for excellence in youth mental health, takes a middle-ground position on the critical assertions.
“I think the figures really show that what is being done is not working,” says McGorry. “But that is because it’s only being done in a partial and a threadbare way.”
McGorry argues the current system works to support the low-level and the most acute cases but that the “missing middle group” is not well served.
“It’s the foundations of a house but we’ve built the front room,” he says. “We haven’t built the rest of the house.”
Similarly, Ian Hickie praises the concept of the network of 30 primary health network centres, or PHNs, that the Abbott government introduced and the Turnbull government boosted by introducing 12 suicide-prevention trial sites within them.
But Hickie says they still lack centralised coordination. “There’s no serious national implementation plan.”
Hickie says the trials also aren’t informed by predictive modelling that could tailor them better to the specific needs and stresses in their communities, although beyondblue and the Black Dog Institute dispute this.
He says that would require the collection and central availability of up-to-date detailed regional data on suicide and attempted suicide because, as Hickie says, while the national figures accurately reflect an alarming trend, the detail of them and their state breakdowns can be misleading.
“You can’t imagine any other area of public health where you don’t know the data accurately,” he says. Others say if it was a drug being tested, the trial would be cancelled.
John Mendoza, who runs private suicide-prevention consultancy ConNetica, concurs.
“If we are serious about tackling suicide, first things first: let’s learn to count and a lot quicker,” says Mendoza.
“The only complete data available at present in the public domain is 2014. That is hopeless for action by all the relevant players.”
But the Black Dog Institute rejects that assertion. The institute is conducting four trials of its own program at sites across New South Wales.
Helen Christensen told The Saturday Paper there is enough regional data on which to model programs and that her organisation both collects and holds it. She said, however, she supported “the idea that we need more national implementation into that process”.
Some who work specifically on prevention in Indigenous communities are also questioning funding priorities and suggesting the focus needs to broaden beyond health services to address deeper systemic disadvantage, noting the statistics are worst in the most disadvantaged communities.
Darwin-based Indigenous suicide prevention worker Dameyon Bonson believes funding priorities are wrong.
“Can we just see the evidence that what is actually being funded reduces the rates of suicide?” asks Bonson, adding that the question is valid in the whole sector, not just in Indigenous communities.
“The approach needs to shift away from a mental health paradigm and start treating suicide as a behaviour, which it is, not a disease or an illness.”
The minister’s office points to a federally funded centre of best practice on Indigenous suicide prevention and a range of broader programs supporting research into “what works” across the whole population.
The views emerging from Derby and the surrounding region about what would help alleviate the Kimberley’s elevated suicide rate – the subject of a Western Australian state coronial inquiry whose findings are due next month – goes beyond just health services.
The Kimberley region’s PHN suicide prevention trial oversight committee met this week.
The spokesman for the Kimberley Aboriginal Law and Culture Centre, Wes Morris, advocates greater support for preserving culture as part of it. He says that would emphasise the community’s strengths, not dwell on its weaknesses.
Some of Derby’s medical staff and health workers gave evidence to the Senate committee earlier this year, calling for more support.
Community leaders say other changes are needed, too.
After his working visit, John Mendoza told the Senate committee that the basketball carnival organisers in Derby had told him what they needed to help address the suicide risk among the town’s children was a covered court they could use through both the wet and dry seasons, not just half the year.
“When it comes to Christmas holidays and so forth, that is when the suicide rate goes up – and leading up to it,” says Mendoza.
“They need facilities which can enable them to keep young kids engaged in some form of community activity. That is suicide prevention. It is not about a bunch of whitefellas, like me, flying in and delivering some message to eight-year-olds about suicide. That does not work, full stop. But this is what I see around the country.”
Ian Hickie predicts that if governments don’t grasp the political potency of the rising national suicide rate already, they will as the election approaches.
“When the prime minister and leader of the Opposition start to tour the country … guess what?” says Hickie. “They’re going to have the same questions asked again: ‘What have you done since the 2016 election? What are you going to do going forward?’ ”
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This article was first published in the print edition of The Saturday Paper on Oct 6, 2018 as "Lobbyists dominate mental health sector". Subscribe here.