A young man sits under a jacaranda in the remotest corner of Victoria. He's at a concrete picnic table. This is in Weman near Robinvale, on the Murray River. The tree and the table are outside a roadhouse selling fried food and fish hooks, one of the few buildings around.
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Hayden Parkyn is 23 and he sits here waiting for Michael Oates, a gentle 64-year-old with a long white beard, who was born in Claremorris on the west coast of Ireland but for 26 years has driven through this arid part of the world to help the mentally ill.
Some of his current clients are the third generation of their families to know him. He has clocked up 1 million kilometres driving between Mildura, Robinvale, Manangatang, Ouyen and Boundary Bend since he started in the job, doing home visits to administer care for those across the entire mental illness spectrum.
This is a region in the grip of a mental health crisis. Not a new crisis but an acute ongoing crisis, vulnerable to tiny shifts in the economy, the weather and also to cultural and demographic changes in its towns with itinerant populations.
Medical data shows the area – the Lower Murray Medicare Local – has among the highest rates of antidepressant use in Australia. Last year the prescriptions were issued at a rate of just over one (1.004) for every person, making it the fourth-highest Medicare Local in the country behind Far West NSW, Wide Bay in Queensland and Central Adelaide and Adelaide Hills. This does not mean that every person in the area has a script, because patients may receive a number of scripts over the year, but it is still a figure that has shocked even those who run the health service. Based on population projections, by next year the area will rank third.
The newest challenge up here near the river is the drug methamphetamine, or ice. Mildura is reeling from seven Aboriginal suicides in seven months, all linked to it, according to sources close to the community.
Hayden Parkyn never did the stuff, even when he was at his worst last year. But he was smoking truckloads of marijuana and drinking heavily, living alone in a portable cabin on a grape and sultana farm beyond Weman, isolated, depressed, anxious and medicated but also enthusiastically self-medicating.
He meets Oates under the jacaranda for "mental health mobile outreach" – bush therapy – every Wednesday at 2pm. Parkyn comes in his unregistered car down farm tracks and Oates via Robinvale through the grapes and almonds and carrots upon which the region depends. They buy chocolate milk from the roadhouse and then talk right there partly because there is nowhere else but partly also because Parkyn prefers it.
"It looks normal," he says. "It doesn't look like I have problems." Among the great challenges in mental health care in remote Australia is overcoming the significant stigma around mental illness, which leads to sufferers preferring to stay invisible. Says Parkyn: "If we do it this way we're just two people sitting under a tree."
To Oates, his young client is a "perfect case study for social isolation". This is the other crushing problem in remote mental health – the distance from other people, coupled with the chronic lack of specialists. According to the National Rural Health Alliance, regional and remote suicide is up to 2.4 times higher than in big cities. Yet 91 per cent of Australian psychiatrists are in big cities.
In Tooleybuc, between Robinvale and Swan Hill on the NSW side, with known mental health concerns, there is a typical proxy method known as "telehealth". A psychiatrist from Sydney does four hours on Skype a week and then visits for half a day four times a year. The area does have a 24-hour telephone triage service and health outreach from Mildura and Dareton but residents can feel prone.
"People literally don't have anyone to turn to," says Oates. "No social connections, very isolated, very transient." Parkyn has been taking antidepressants since he was 15. He has lived in Tasmania, Queensland and Western Australia. Under the tree, Oates makes sure he has been taking his medication and talks him through ways to control chronic anxieties. To put these in perspective, when Parkyn was rock bottom only a few months ago – suicidal, not sleeping – he would shake and sweat uncontrollably even contemplating leaving his cabin to work. "Walking up and down the vines, 45 degrees, by myself, not much fun," he says. "You get cabin fever out here." Oates respects the young man's tenacity. "We have done some good work together. I think he's less vulnerable now. I think and I hope he will go on to better things soon."
Forty per cent of Oates' clients in Robinvale are indigenous even though they only make up 15 per cent of the population. His turf is deeply multicultural, like Shepparton; Robinvale has more than 40 nationalities. Many of these new Australians can be sceptical about mental health issues and "officialdom" trying to help.
"The main challenge we have is to deliver the best service we can and keep the doors open to all the communities in our area," he says.
Oates' employer is the Mildura Base Hospital's mental health department: it is the only hospital in the north of the state with a psychiatric ward. Swan Hill – where youth self-harm has been reported to be seven times the national average – has a community health team only. Ouyen has next to nothing but is suffering through suicides of farmers and young people over the past three years. Mallee Family Care, a large organisation based in Mildura, offer community mental health support. There are no Community Care Units (CUU) or Prevention and Recovery care (PARC) units north of Bendigo. These state-funded facilities offer housing, therapeutic intervention and monitoring for those not mentally ill enough for hospital. Patients typically have bipolar disorder, anxiety, depression, psychosis or schizophrenia.
Mildura and Robinvale both have high rents and long waits – up to two years – for public housing. We meet Justin Chilcott, 37, who has been diagnosed as bipolar with schizophrenic tendencies, and who came to Mildura from a psychiatric ward in Tasmania. His brother lives locally but Chilcott can't live there so he has been taken in by the generous family of a friend.
He worked at a recycling plant but was sacked after catching gastro and hasn't found another job even though he is monitored by Mallee Family Care.
"I have been stable for about a year," he says. Case-worker Garth Boyd says: "We try and get people in employment because then they are socially engaged." Still more rural and remote mental health narratives come from the pressures of drought-prone farming. Succession plans for the farm can be unclear as younger generations opt out. Says psychologist Judith Gullifer of Charles Sturt University, who has studied older farmers: "The farm is the farmer's sense of self, so in times of drought everything is dying and they're selling stock to survive and what they put up with is a barren property.
"The more west you go in any eastern state the more you find depression, anxiety and suicidality."
Dr Keith Miller of Flinders University, a senior lecturer in social work and social planning, says as farms become larger and more mechanised – and drier – less labour is employed so farmers have less human contact. In the surrounding district, meanwhile, "the economics of being able to provide a good range of health services to small rural communities do not have critical mass". The federal government announced a new drought assistance package for western NSW and Queensland at the end of February. It included $10.7 million for family support and community care. Meanwhile, the north-west and central-west of Victoria has had a "serious deficiency" of rain in the past 16 months, according to the Australian Bureau of Meteorology.
Much of the good research being done now into remote mental health is to do with resilience. That applies to resilience from disasters such as fires, floods and drought but also how to build resilience in advance to protect families from mental health issues. "We want to help people to understand mental health as opposed to mental illness," says associate professor David Perkins, the director of Sydney University's Centre for Remote Health Research. In remote suicide, research is around the idea of postvention – how to cope afterwards. The federal government is funding a trial program in South Australia to allow Anglicare volunteers to support country people who have lost loved ones.
The Victorian Department of Health also has a regional suicide postvention service StandBy Response, which is active in Mildura.
Meanwhile Oates keeps driving and administering his bush therapy. He and his colleagues have a new challenge – a rise in what they see as "borderline personality disorder" in people in their towns, in those aged from the mid-teens to middle age. With this, they say, comes self-harm, suicidal gestures and emotional instability.
Oates has a case-load now of 26 people. Parkyn is not one of them; he is OK for now. "We have to make this work," says Oates. "We have to bring the service to the people wherever that is. We have to get it right in the time we have and in the place we happen to be."