Tamworth mother of two Leah Dryden still can't believe she found the strength to ask for help. But one day, the voices got too much.
"It is just this constant voice saying 'Kill yourself, hurt yourself', and I wanted to just take off, to just leave, it was the only physical response I could have, because the next step was to physically hurt myself," the 29-year-old artist says.
So instead she dropped her kids off at school, and drove to the hospital.
Living with one of the best health systems in the world, you might think that Dryden's panicked trip to the hospital emergency room would at least trigger the kind of long-term, structured response you would expect for a life-threatening medical condition.
But the healthcare system experienced by Australians with a mental, rather than physical, illness is very different.
The truth is, the system has been failing Dryden since she was in year 10, when she dropped out of high school under the severe lows of bipolar disorder. She couldn't leave her room for days at a time, and was self-harming.
Her local doctor had told her parents she just had the "puberty blues".
Years later, after a miscarriage, she waited weeks for mental health services to return the call her husband had begged her to make.
And now, here she was in the hospital emergency room, being told to go home.
"If I didn't have my family and my husband, without a doubt I would not be here," she says.
"The system is not working. There just aren't enough people, there aren't enough case-workers, there aren't enough psychiatrists, psychologists.
"You feel like you are being timed, you have only got this really small amount of time – and it's not their fault, they don't have the money or power to do what needs to be done."
Dryden survived this lowest of lows. But many don't. Seven Australians every day, in fact.
"We hear a lot of stories about people who are suicidal ... being discharged from hospital with inadequate or no follow-up"
Last week the National Mental Health Commission released a massive review of our mental health system, which recommended a goal be set to reduce the suicide rate by 50 per cent over the next decade.
It is part of a radical overhaul everyone agrees needs to be made to the way we deliver mental health care in Australia. The only problem is that "it needs to happen" is pretty much the only thing they agree on.
The Commission's report has triggered equal parts praise and criticism, in part because the commissioners were set an impossible task: to figure out what needs to change within the existing budget, despite the fact mental illness is thought to cause about 13 per cent of health problems yet receives only 5 per cent of health funding.
Allan Fels was well known as the Australian Competition and Consumer Commission chairman. But behind the scenes he had an equally important role: father to a daughter with schizophrenia.
"It has been a very heavy burden on my wife especially, and on me and my other daughter," he told Fairfax when he was appointed.
Fels has seen first-hand the shortfalls in our system of care. He says it is just not acceptable that people are left without treatment until they are at their sickest (imagine if that happened to people with cancer, he says), or turned away without support when they feel suicidal.
"We hear a lot of stories about people who are suicidal or have suicidal thoughts being discharged from hospital with inadequate or no follow-up," he says. "The suicide rates aren't going down, in fact the suicide rate in Australia has not changed dramatically in the past 10 years."
In essence, the commission's report says we need to get support to people as early as possible, and get it to them in a way that suits them. Many of its recommendations centre on the "missing middle" of care, training up nurses and other clinicians to work in the community sector, and improving services for people who are suffering but aren't so unwell they need to be in hospital.
At the moment, we have a "crisis-driven system," it says.
The report also identifies deep and systematic shortcomings in the support available for Aboriginal Australians, and people in regional and rural areas.
"Indigenous people have significantly higher rates of mental distress, trauma, suicide and intentional self-harm, as well as exposure to risk factors such as stressful life events, family breakdown, discrimination, imprisonment, crime victimisation and alcohol and substance misuse," the report finds.
And there's the rub. These problems often can't be cured just by a doctor's care or the right medication. They are linked to the type of embedded, structural disadvantage that so far appears to have rendered governments impotent.
Fels says any response needs to be multifaceted and involve housing, employment and other factors.
"The best response to this is to pick up on what are the concerns of the person, and more often the concerns are wider than might be suggested by a narrow medical focus," he says. "Often we are talking with them and we find out their problem is accommodation, or they don't have a job."
Everyone who works in mental health agrees there needs to be more support in the community, and a broader range of support available to prevent suicides and give people the help they need to live their lives.
And every doctor has their story of being unable to discharge someone because of a lack of accommodation or medical support.
But it gets controversial where the report appears to recommend money should come out of acute care and towards those of us with more mild or moderate conditions.
If more than 3.6 million people experience mental health problems that are painful and difficult, but common, should the health system be trying to reach all of them?
Take the example of the flu vaccine. The government pays for it to be given to people aged over 65, because it knows the flu will be most dangerous and costly for them. But we expect individuals and workplaces (who largely bear the cost of the disease) to pay. Research consistently shows that high-stress, high-demand workplaces can increase or even precipitate mental ill-health, so perhaps workplaces should be responsible for funding the mental wellbeing of their staff.
"There are many good things in the Commission's report, but there were a couple of things that probably did take us a bit by surprise to be honest, and the taking of money from hospital care was one," says Professor Malcolm Hopwood, the president elect of the Royal Australian and New Zealand College of Psychiatrists.
Hopwood says the "battle for crumbs" in mental health often leads to infighting, but there are also philosophical differences about whether focus is better placed on early intervention, or treating existing problems.
"Early intervention is a great thing, and if you can reduce disability that's a great thing, but if you stand back you end up saying, 'Realistically at this point we are not going to be able to prevent all disease'," he says.
Hopwood agrees that something urgently needs to be done about one of the key problems identified in the report: the preponderance of smaller, non-government organisations that rely on federal grants to provide their services. They often duplicate other services, or aren't integrated into the wider system, and each level of government operates almost independently from the others.
"The Commission's mapping exercise demonstrates something we already knew, that the community sector contains a lot of different organisations and professionals, and is often disjointed," he says.
But he maintains that shifting money out of the acute end of care is not the answer.
"It's true that in severely acute psychiatric units there are always a number of patients who you can identify who don't necessarily need acute psychiatric care ... people with very complex, enduring disability and a combination of problems," he says.
"If these beds were empty, do I think they would be filled very quickly by people who are only slightly less sick than the people who are in them? I think they would be."
How John Howard may have inadvertently helped reduce our suicide rate
John Howard probably didn't realise how many lives he was saving. Twelve days after the brutal murders of 35 people in Port Arthur, he fronted the media to announce a crack-down on gun laws.
"We resolved as a community to send a very strong message … that violence as a method, particularly through the use of firearms, of settling disputes, of playing out emotions and then getting rid of pent-up passions with something, that is unacceptable to us in Australian modem society, irrespective of our political or our religious beliefs," he said at the time.
The resulting gun buy-back scheme is estimated to have saved 200 lives each year – but not so much by preventing mass murders, as by preventing suicides.
"The rate of suicide in Australia declined in the mid-1990s, and the factors that were almost certainly responsible for it were reductions in access to methods," says Matthew Large, a UNSW researcher and psychiatrist in a major public hospital emergency department, and one of the world's top experts in suicide risk.
It turns out that for some people, when you remove the method they would have used to kill themselves – such as guns, leaded petrol, large amounts of medication – they don't go ahead with their plan.
"The majority of people who suicide have no contact with the hospital system" says Large. "The majority are not in treatment and many of them are not severely mentally ill, although I think it's likely they are mostly irrational.
"If someone survives a suicide attempt and you ask them how long they have been thinking about it, some will say 'for years', but others have only been thinking about it for minutes."
"People present feeling suicidal who have taken overdoses, and when they are sober they can't recall why."
And Large says this raises some uncomfortable questions if we want to make the type of changes that might help lower suicide rates.
"If you consider what you would need to do to reduce the suicide rate by half, one way might be to try to make the male suicide rate the same as the female rate, and really to do that you would need to stop men doing a lot of the things men do. You would have to have them drinking a lot less, and have to have them having better relationships with the important people in their lives, and you would have to further reduce their access to firearms," he says, noting the particular need for a change in the drinking culture.
"It seems to me that our politicians at the highest level have very little interest in attempting to tackle our social attitudes towards drinking, as evidenced by our Prime Minister sculling a beer the other day," he says.
Large agrees that psychiatric hospitals, which are often far more run-down and over-stretched than other hospitals, are not always the best places for people feeling suicidal.
"We do need better community resources, but I'm sure we need better hospital care," he says. "We need to create more human environments, with more care and less exertion of control."
In the meantime, the system rolls on. It's heartbreaking for advocates like John Mendoza to see more talk while watching quality services close down.
Mendoza, who recently lost a much-loved nephew to suicide, says economic indicators and rates of self harm signal the risk of more suicides in the years to come.
"We have the makings of a very serious problem and we just have to get assertive, we have to get active and we have to stay focused. Otherwise things could get very nasty."
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