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21:45  20 april  2021
21:45  20 april  2021 Source:   starsinsider.com

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Dr Katherine Graham has been a GP in Horsham for 12 years now. It’s a market town in the Wimmera region, about halfway between Melbourne and Adelaide; one of those larger-sized rural towns where people within a two-hour radius come to do the big shop. It’s surrounded by agriculture: cropping, sheep, cattle.

There are about 20,000 people in Horsham, but tens of thousands more from surrounding areas use the town as a hub for their health care. For those people Horsham does not offer much if their mental health requires care.

Here, the hurdles to accessing mental health care – particularly for children and young people – begin at the very first step.

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“You start with things like whether you can access a GP,” Graham says. Access to ones that bulk bill, and with whom one is familiar or comfortable, she says, is “really limited”. GPs in general have limited training in mental health, but they are typically the first port of call for mental health concerns and can help manage some mental health issues.

Graham’s waitlist for appointments is about four weeks.

For many children and young people with mental health or behavioural issues, a GP may refer them to a paediatrician for more specialist treatment or assessment. Until last August, and the arrival of Dr Niroshan Amarasiri, there had been no paediatrician based permanently in Horsham for as long as Graham could remember.

Just over six months into his tenure, Amarasiri now has a waiting list of three to four months.

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The paediatrician estimates that 20-30% of his outpatients are presenting with mental health, developmental and behavioural issues. “And I see outpatients every day,” he says.

But Amarasiri can not treat all mental health and behavioural issues. For more targeted support, he needs to refer to a psychologist or psychiatrist ideally specialising in children and adolescents, or at least who will see them. There are no private or public child psychiatrists who treat children in the town. Locally, there are a few general psychologists who will see children. They are private, and have a couple months’ waiting time.

Amarasiri can refer children to the public mental health service in Ballarat, two-and-a-bit hours away by road – often a whole day trip for a half-an-hour appointment. Depending on the severity of the issue facing the child, it can be a few months to be seen by a public child mental health clinician there. “Or it may be more.”

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Some private psychologists he refers to in Ballarat, he says, are not taking any new patients at all.

Sometimes the families of the children and young people who see Niroshan and Graham cannot afford the private psychology fees. Sometimes they cannot afford the petrol or bus fare to Ballarat.

“In that case, some sort of frustration happens,” Amarasiri says. “We have to have some solution rather than sending everyone to the private sector.”

Graham is frustrated too. She has undertaken extra study on focused psychological strategies “but even still, it’s such a different world managing kids and adolescents. You wonder if you’re doing enough for them.” She knows it’s not the same as a post-grad degree in psychology, but it’s something. When she knows a patient is waiting for treatment, she tries to squeeze them in for more appointments. It can push her own waiting times back even further.

“Or you just work longer,” she says.

‘Children have been forgotten’

Prof Harriet Hiscock of the Murdoch Children’s Research Institute says that a child not in crisis should be seen by an expert in child mental health after presenting to a GP “ideally within four weeks”. As they wait long periods, she says, “typically they get worse”. Research by the institute found that three in four children did not get the help they needed, and that there needed to be great focus on and training in child-specific care.

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“Children have been forgotten,” she says. “And anything that’s happening in the metro areas is amplified in the rural areas.”

In the Guardian’s recent call-out for readers to share their experiences with the mental health care system, many said it took getting to a crisis point and being admitted to emergency for excellent care to kick in.


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a tall building in a city: A historic building in Horsham. Attracting and retaining GPs, or any specialist clinician, to regional and remote areas can be difficult. Photograph: Alizada Studios/Alamy © Provided by The Guardian A historic building in Horsham. Attracting and retaining GPs, or any specialist clinician, to regional and remote areas can be difficult. Photograph: Alizada Studios/Alamy

But in Horsham, there is no such acute care available, says Rob Pegram, the medical services director of Wimmera Health Care Group. “If we had a child, say 12 or 13 years old, with a significant mental health problem – say an eating disorder or something of that nature – I don’t see that at any point in the future that we would be able to manage those children here, even if we had the appropriate staff. They need to go to a specialised unit, so there’s always going to be a need to ‘ship out’ – to put it bluntly – people who need more specialised care.”

Which is what happened on a Friday in March. A young person came to the Wimmera emergency department having taken an overdose. The person demonstrated, Pegram says, “disturbed thinking”. The small hospital could not admit the person, but detained them for a while with parental consent; and then transferred them, by ambulance, to Melbourne. Four hours away.

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‘The numbers don’t look very good’

Pegram has worked as a locum in four different states over the past few years. The situation in Horsham, he says, “is consistent with my experience elsewhere”.

The most recent Australian Institute of Health and Welfare figures show that the number of general psychiatrists, psychologists and mental health nurses per capita rapidly decline the more regional and remote an area. In major cities there were more than 13 psychiatrists per 100,000 people; in very remote regions that figure was 3.5. More than three-quarters of mental health nurses work in major cities, where the proportion of these nurses compared with the general population is nearly three times higher than in very remote areas.

Eighty-three per cent of psychologists work in major cities. Twenty-eight per cent of people in Australia live outside the major cities.

“You see the numbers and they don’t look very good,” says Dr Hazel Dalton, research lead at the Centre for Rural and Remote Mental Health, run by the University of Newcastle. However, even those numbers belie the severity of the under-servicing.

“In theory you have access, but in practice it doesn’t happen and in practice less is spent,” she says. “Which can lead to a perception that there is less need, but actually there’s a higher need.

“We know from our research that there’s a proportion of people – up to a third of rural cohorts we looked at – that had clinically diagnosable distress that didn’t even recognise they were unwell.

“People are walking around with really high levels of distress and mental health problems that don’t actually see they need help, and if they do need help they may be worried about confidentiality, they may be worried about cost and they may not be able to access services when they finally do decide that something needs to happen.”

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Rates of mental illness are generally similar across cities and regional areas, but the rate of suicide is vastly higher outside major urban centres. The latest figures show the suicide rate was on average more than 50% higher in inner regional areas than in cities. In very remote areas, the rate is triple.

Doctors become flooded with demand and leave

When there are child and adolescent mental health practitioners in regional and remote areas, outcomes can be better than in the cities, says Prof Hiscock. Practitioners are often better connected to one another, and know each other.

Attracting and retaining GPs, or any specialist clinician, to regional and remote areas can be difficult, particularly in a context of a national shortage of specialisation. Rob Pegram of the Wimmera says that if a specialist is able to be recruited, the risk is they quickly become flooded with demand and leave. Clinicians in regional areas can find themselves feeling under-supported, unable to develop their skills and confidence, and overwhelmed. Burnout is a problem.

a tree on a dirt road: Farmland near Horsham. The hurdles in accessing mental health care in the area can begin with trying to find a GP who bulk bills. Photograph: Excitations/Alamy © Provided by The Guardian Farmland near Horsham. The hurdles in accessing mental health care in the area can begin with trying to find a GP who bulk bills. Photograph: Excitations/Alamy

However, both Hiscock and Dalton say the solution to the under-provision of mental health services for children and young people outside the cities can not be solved by simply boosting the numbers of specialist clinicians.

“When we insist on the specialisations, the sheer cost of that can be really hard on the system,” Dalton says. “It’s broader than we just need more child and adolescent psychologists and psychiatrists – which we do – but we also need primary care that’s well-equipped to support them in an ongoing capacity.”

Both Dalton and Hiscock’s organisations are engaged in programs and trials which seek to support primary care providers in delivering and managing mental health support for children and young people, and those in remote communities generally. Those models can include hubs that house general practitioners, nurses and specialists, or having generalists supported in person or remotely by clinicians with expertise in child mental health.

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Telehealth is often seen as a critical lifeline for people living in rural and remote areas, however Medicare rebates for telehealth psychology appointments finished at the end of March. However, Prof Hiscock says that telehealth, while sometimes preferred by teenagers, is not particularly effective for dealing with children, assessing new children and young people, or in determining suicidality.

“Technology is a really important part of the solution, but telehealth alone is not the answer,” Dalton adds. “You can actually kill the local services entirely and really mess with things. If you just supplant care and say, ‘Here, you can have it all by telehealth,’ you risk denuding the skills capability and presence of local services. That would be disastrous.”

Problems that could be preventable

For regional communities, the under-provision of mental health services can impact their sense of value, Dalton says. It can also lead to systemic and inter-generational poor mental health that goes unchecked and drifts into other problems. “It’s part of the cycle of inequity.”

For the children and young people who live in those communities, the threat is yet more urgent. Without timely and appropriate treatment, engagement with school can suffer, and pressure on families increase. There is stress. There is suffering.

“We know that 50% of all mental health problems begin before the age of 14,” Prof Hiscock says. But those issues do not suddenly appear at 13-and-a-half, she says. Those issues are often seen in children in primary school and younger. “We can see the trajectory they’re on, and if they can’t get help and support then, then at least half of them will progress to a mental health disorder that could have been preventable.”

Meanwhile in Horsham, Graham still does not always know which specialists will be able to see the children and adolescents that need help. She fears they’ll make that call for help and be told they can’t get it – not for a while at least. And she’s worried what that means for them.

“Some of these people won’t engage with the system again,” she says. “And you’ve kind of lost them.”

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