This month marks 10 years since the Australian federal Human Rights Commissioner Brian Burdekin issued the Human Rights and Mental Illness report, documenting “enormous” suffering and systemic “violations of the most fundamental rights of Australians affected by mental illness”. The Burdekin report, released on 16 September 1993, called for “an urgent, concerted and effective response”.

A decade later, despite two five-year National Mental Health Plans jointly implemented by federal and state governments to address the mental health crisis, the situation has dramatically worsened. A recent report by the Mental Health Council of Australia—entitled Out of Hospital, Out of Mind!—has documented the human toll produced by chronic under-funding of mental health facilities, both institutional and community-based.

The report’s title aptly refers to what has happened since the early 1980s, when governments began to close psychiatric hospitals and traditional residential institutions, claiming that they would be replaced by more humane forms of community-based care. These promises have never been kept. All that has happened is that those needing treatment and care are no longer as visible, and are therefore “out of mind” as far as the authorities are concerned.

Families and carers of the mentally ill cry out in the report about the lack of support for their loved ones. Mental health workers, nurses, general practitioners and allied health workers declare their frustration with a system that ignores their plight and the fate of those they are meant to treat.

Among the report’s findings are that levels of psychiatric illness in Australia have risen sharply over the past five years, yet most people with mental disorders are unable or unwilling to obtain adequate treatment.

Rates of severe psychological distress among adults have increased by more than half—from 8.2 percent in 1997 to 12.6 percent in 2001. Rates of illness continue to increase among young people in particular, although the report provides no estimates.

Broader numbers of people—20 percent of adults and 14 percent of children and teenagers—experience a mental health problem each year. Many of these cases are not simply episodic. In the 2001 National Health Survey, 10 percent of adults reported they had a long-term mental or behavioural problem.

However, an estimated 62 percent of people with psychiatric disorders do not utilise mental health services. The reasons given include the poor distribution and costs of specialist services, inappropriate public services, stigma associated with mental disorders, and fear of medical treatments.

Less than one in six people with depression or anxiety receives care that meets international standards. An estimated 38 percent of people seeking assistance rely on general practitioners. Even this basic treatment is under pressure because successive federal governments have frozen Medicare rebates to GPs, resulting in a rising proportion of local doctors charging up-front fees. GPs report that they are poorly supported by specialist care services.

The personal and social costs are immeasurable: educational problems, unemployment and immense strains on families. In 2001, 2,454 people died by suicide, representing 4.4 percent of all deaths among people aged less than 75. According to the report, the vast majority of those committing suicide had untreated mental disorders, particularly depression and alcohol or drug abuse.

Anguished responses

To gauge the depth of the problems, the Mental Health Council conducted three national surveys from August to December 2002, in addition to face-to-face consultations. Responses were received from over 400 different agencies and individuals.

Their comments highlight the broken promises made by governments to justify de-institutionalisation. Under the guise of overcoming the inhumanity of the old under-funded asylums, governments have effectively re-created their abuses on a wider scale by refusing to provide adequate funding for community care.

One parent pointed out that the lack of genuine community facilities was reproducing the worst features of the old institutions. “My son sits alone in a unit with nothing to do, no motivation, no energy and doped up on a tranquiliser. I see other people like my son around where I live, who appear lost and lifeless, who roam aimlessly all day.”

Another carer commented: "I do all the caring for my boy. But nobody wants to help me. I’m tired, really tired and there’s no end in sight—no help—nothing.”

Families expressed frustration at not being able to access services. “Psychiatrists won’t take my son if he is not aggressive, yet the next day he is more than aggressive and gets admitted,” one parent wrote. Another commented, “you almost need to throw a brick through a window to get admitted—but when you do that you end up being admitted to the wrong service!”

Because they cannot obtain timely and appropriate treatment, increasing numbers of people with mental illness end up being criminalised and jailed. In the meantime, they can pose a danger not only to themselves but also their families and others.

Carers noted with disgust that private psychiatric services were available for those who could afford them, while access to public specialist psychology and other allied health services was restricted by lack of government funding. Public systems were described as chaotic, under-resourced and overly focused on providing brief periods of medicalised treatment, largely within acute care settings.

Among mental health workers, there was a broadly held view that the system is driven by economic rationalist notions of cost saving and “more for less,” rather than quality of care. Many reported feelings of hopelessness and expressed concern about “burnout” due to lack of support and resources.

One wrote: “Many of the good staff leave because they become depressed with the system—they can’t tolerate the substandard level of care that’s dished out.”

Respondents repeatedly mentioned the high levels of homelessness among the mentally ill. Federal and state government cuts to public housing over the past 15 years have made affordable accommodation harder to obtain. The mentally ill have to compete with other disadvantaged groups for ever-more scarce subsidised housing.

Mentally ill people are left to languish in jails in alarming numbers. As prisoners, they are often locked in their cells for 11 hours a day, without treatment. NSW and Tasmania are among the few states in the Western world to also incarcerate “forensic patients”—those found guilty by reason of mental illness or ruled unfit to plead, and long-term prisoners who are later found to have a mental illness.

Worsening crisis

The report predicts rising levels of unmet demand for mental health services. “Increasing demand will be driven by the significant stress placed on Australian families from war, threat of terrorism, ongoing drought, more young people developing mental disorders.”

These references are significant, but the report does not elaborate. They point to the insecurities, anxieties and trauma created by the increasing resort to war and military interventions, and the Howard government’s frontline involvement in the Bush administration’s “war on terrorism”.

An atmosphere of constant fear and suspicion has been deliberately created to justify military aggression and the erosion of democratic rights. At the same time, as a result of these policies, ordinary Australians have become potential targets for terrorist violence.

These pressures have added to the stresses already produced over the past two decades by declining living standards, deteriorating health, education and other public services and growing job and economic insecurity, especially for young people.

Out of Hospital, Out of Mind! is not the first report to sound an alarm. SANE Australia’s Mental Health Report 2002-03 concluded that “mental health services are in disarray around the country, operating in crisis mode”. It warned that “effective treatments ... are not routinely available” and “untreated mental illness is a leading contributor to Australia’s suicide rate”.

Last year’s NSW Upper House Inquiry pointed to the inadequacy of community-based resources. NSW Select Committee on Mental Health chairman Brian Pezzutti commented: “Deinstitutionalisation, without adequate community care, has resulted in a new form of institutionalisation: homelessness and imprisonment.”

The lack of care facilities is an indictment of both the federal Liberal-National Party government, which holds most of the purse-strings, and the state and territorial governments, all controlled by the Labor Party, which are responsible for providing health services.

NSW, Australia’s most populous state, which led the way in de-institutionalisation, spends only $77 per capita on mental health services annually, compared with $85 in Victoria, $86 in South Australia and $96 in Western Australia.

While Out of Hospital, Out of Mind! brings together useful information, its thrust is that increased funding be directed to non-government organisations (NGOs) to provide community services. This is in keeping with the official drive to re-direct responsibility for mental health services away from government and the public health systems to individual families and private organisations. The NSW Upper House inquiry made similar proposals.

Most NGOs are religious-based groups, including large corporate organisations such as the Salvation Army, St Vincent de Paul, the Uniting Church and Bernardos. Together with other NGOs, they employ less trained staff, or rely on volunteers, saving themselves and the federal and state governments millions of dollars.