Note: This article deals with confronting mental health issues. If you are concerned by your well being - or someone else's - please refer to the contact information at the end of this article.
An exasperated Levin GP says a big chunk of what he deals with are mental health issues, and in his experience, suicide is the tip of a distress iceberg which is growing.
Glen Colquhoun said suicidal thoughts are not an uncommon disclosure by patients at Youth One Stop Shop (YOSS), a free youth health care clinic based in Horowhenua where he works.
After digging deeper and asking questions, many have emotional, spiritual or mental health issues - often affecting their physical health as well.
"Just about everyone at some point would have considered suicide, from a fleeting thought through to planned out actions or attempts," he said.
"It's always tricky because there are some things in medicine that are black and white, it is or it isn't, it's a broken bone or it isn't."
Colquhoun said that in his experience suicidal risk comes in waves, which also makes it difficult for him to predict.
"You have to make fine judgements. It's much more of an art than a science.
"When people are fragile around depression, sadness, anxiety, fear, or people who have been through trauma and carry horrible memories all the time, they get overwhelmed sometimes, and have a bad few hours, they can act impulsively and kill themselves," he said.
Colquhoun said his response is to take it all seriously and to talk about it openly with the patient, to bring it out of the closest.
"It soon becomes apparent for those young people whether or not it's a fleeting thought or they think sometimes it's a way of expressing their unhappiness, they just want the sadness, the frustration or fear to stop," he said.
"Then there are those who have a strong desire to die, or very little strength left to fight that and feel like they are going to be overwhelmed."
He said it was the act of talking about it that brought about understanding to both patient and doctor.
"Talk about it, maintain contact with somebody, create plans of what to do if they get the wave going through, put small teams of connections around them, embedding them in a soft cushion so if they fall they get caught and they know what do to," he said.
"Talking is a way of putting a cushion around people."
Colquhoun said a cushion should be a long-term thing and it's important to keep eyes on that person.
"Put cotton wool around somebody and keep it there for a long time, not for a week or three months, but a couple of years sometimes, or for longer," he said.
"Most of us survive because of our cotton wool, but we often take that cotton wool for granted. Take it way and we rapidly get unhappy."
Colquhoun said the problem is too often people who are at risk of serious suicidal thoughts are coming from families which are disconnected.
"Not always. I wouldn't rush to that generalisation but probably most of the time they are coming from backgrounds where they are not connected and this is part of the reason they are feeling as bad as they are," he said.
"It's painstaking. We will try really hard to maintain connection with them if we think they are really at risk, then we are obliged to break confidentiality to put people around them and refer them acute to mental health services," he said.
Colquhoun said from what he sees, suicide is the tip of the distress iceberg, though many people are not committing suicide but are still ending up in really bad situations, entrenched in dysfunction and failed by a broken health system.
"[Suicide is the] most dramatic and distressing to our society but there are plenty who end up in the criminal justice system, or who end up with chronic drug and alcohol problems, or having children they hurt and don't support."
He said most of New Zealand society ticks along well and it's not all doom and gloom, however he sees society becoming more and more a tale of two cities.
"There is a body of dysfunction, families badly, badly broken, and in pain ... generating children [and that] pain is sewn back into them, sexual abuse, physical abuse, yelling and screaming at kids, little kids left alone to look after their brothers and sisters, party culture, kids having kids," he said.
"Intergenerational dysfunction is getting passed on, a sickness in the culture, people are part of a community of dysfunction.
"It's an illness in the western way of living. The culture is where the disease process lies.
"It's really hard because medicine is built on the disease being in the person, but this is a disease in society.
"People need to be loved by parents to develop or you are at risk of not growing and at risk of making poor decisions. It's a society illness and the problem with that is no one is to blame but everybody is pointing.
"Inflammation breeds inflammation. We need to deal with it painstakingly cell by cell, person by person. You get cotton wool around families and love them back - it's painstaking.
"I don't think it's really rocket science but to [heal the issue] requires lots of manpower and connections between people, within the community and within our health services," he said.
Therein lies the problem, as Colquhoun believes as a nation we don't have the man power, the capacity and health care services are run off their feet.
'Setting up GPs to burn out'
Colquhoun says there isn't a GP shortage, but rather a health care system that refuses to admit it's broken.
He said the system is setting up GPs to burn out and allowing at-risk mental health patients to fall through the cracks.
Through his experience the free youth health care clinic based in Horowhenua, Colquhoun said many acute suicidal cases he referred to mental health services often engage only briefly and patients end up back in the same situation.
"Mental health services are broken and don't work effectively. What's worse is they don't know they are broken, which is the most dangerous thing," he said.
"The services are not even scratching the surface. There is so much unhappiness, and difficulty out there."
He said patients often return from mental health services feeling like they hadn't been heard, only passed from one doctor to another.
"Those people survive for other reasons."
The dedicated GP finds it continually frustrating.
'Time to speak out'
While Colquhoun believes GPs are not building long-term enduring relationships, he does not blame his fellow practitioners.
He holds the managers responsible and believes they should speak up to say they are swamped and overwhelmed.
"The best thing they can do is speak up because then it becomes a political issue, and that is where it needs to be settled."
He even believes his own clinic is a "sinking life boat".
"With only three days in the community, one doctor and one nurse, it is now taking two to three weeks to get in to see us," he said.
Spending time getting to know his patients would be best practice, but he finds this harder and harder to achieve with a growing patient list and pressure on time and resources.
He said that even if a patient tells him about self-harming, getting kicked out of school or other traumatic experiences it can be up to four weeks before he can see them again.
"It's not best practice to wait that long between visits," he said.
These types of delays, along with relentless pressure on GPs, mean Colquhoun is worried they aren't as effective as they could be helping those with mental health issues.
"GPs are rushing so fast ... but then they slowly burn themselves out and leave medicine for something else. They are set up to be pressured out," he said.
Colquhoun said mental health criteria mean many youth are not receiving the level of care they need.
That care is limited to people who are suffering marked psychotic disorders, bad depression, bipolar affective disorders, so many cases considered too mild for mental health care are slipping through the cracks and committing suicide.
If a patient that was considered 'mild' commits suicide, Colquhoun said mental health GPs are protected through "perfect, defensively written notes".
He said in one day alone, there were six cases he had seen where young people were falling through the cracks.
"They just exist by luck," he said.
Colquhoun believes the solution ultimately is gearing finances to demand instead of having a health care system constrained by budgets.
For the changes needed, he said the public health system needs to speak up and admit the system isn't working.
We should identify the families that are struggling. It's a small enough place that we could name [them] and help them
He questions the need for District Health Boards. "We need to create one national health service and smash down the cost of going to the GP," he said.
He said this innovative restructure of the national health care system needs to see GPs work alongside social workers, youth workers, police, schools, mental health and the Ministry for Vulnerable Children, formally CYFS.
He said finding solutions to the mental health crises is hard because medicine is built on the disease being in the person, but mental health is a disease in society.
"It's not just about having response systems that work well, because all they do is fix things once they are broken," he said.
"All public services need to be at the same table to swap notes to better understand the backgrounds of mental health patients and their at-risk families," he said.
There should be capacity so people can be seen by a GP within a week and acute patients the same day. If this isn't affordable, there needs to be a national conversation about priorities.
With national suicide statistics on the rise, Colquhoun believes the solution lies in creating real and lasting connections with at-risk families, something that requires more time and resource to build a foundation of trust and relationship from which to better make decisions.
"Whatever it takes to put a set of eyes on every kid born into New Zealand."
'Work together or more will die'
Colquhoun says our national health services lack a co-ordinating body, and that if the country is to provide more comprehensive health care services a Whanau Ora model needs to be implemented - something he believes Horowhenua could pioneer.
A Whanau Ora model is where health, education, justice, iwi, as well as the Ministry of Social Development collate a body of information about struggling families.
"We should identify the families that are struggling. It's a small enough place that we could name [them] and help them," he said.
Colquhoun suggests psychological help, maybe assistance with housing, Work and Income NZ, employment, and education, "ensuring kids failing at school are having non-failing experiences".
"But let's only do that if we are committed to giving them the resources needed to help," he said.
Colquhoun believes every struggling family needs a committed case worker who spends more time with them to connect and discover why the cycle of dysfunction continues.
"We need to know who these people are, eyeball to eyeball, so they are not this nebulous 20 per cent of struggling families, but it's actually the Jones family and the Smith family," he said.
"Let's work together to go out into our communities and look at them from a health perspective, not a criminal perspective."
He said figuring out the role of addiction or childhood trauma plays in their lives was really important.
"[We need to] ask them what they want for their children, how we could help them and then commit to letting light into the undergrowth," Colquhoun said.
He said Horowhenua needs to get together and make a plan for health that is not so disconnected, and doesn't separate mental and physical health.
"I would start thinking about having our own local responses to those struggling with mental health. Let's have support teams on call instead of relying on overloaded crisis teams," he said.
"People with the ability and the time to form a connection and follow that person up, to be alongside them, [and] call them up two days later."
Colquhoun said young people struggling with mental health really needed someone to talk to so they know they were cared about.
"Sometimes all we do is send out text messages asking how they are going," he said.
He suggests that mental health patients would be better cared for and doctors' workloads would ease if there was a team of youth workers and other professionals around each GP to carry out this pastoral care.
Perhaps, he suggests, the answer to a more cohesive and comprehensive health care system would be to merge all practices into one.
"Somewhere we could all work together and practice medicine in its broadest sense."
Where to get help
If you are worried about your or someone else's mental health, the best place to get help is your GP or local mental health provider. However, if you or someone else is in danger or endangering others, call police immediately on 111.
OR IF YOU NEED TO TALK TO SOMEONE ELSE:
• LIFELINE: 0800 543 354 (available 24/7)
• SUICIDE CRISIS HELPLINE: 0508 828 865 (0508 TAUTOKO) (available 24/7)
• YOUTHLINE: 0800 376 633
• NEED TO TALK? Free call or text 1737 (available 24/7)
• KIDSLINE: 0800 543 754 (available 24/7)
• WHATSUP: 0800 942 8787 (1pm to 11pm)
• DEPRESSION HELPLINE: 0800 111 757