President's update: Does having a mental illness mean having to accept second-class health care?

The Australian figures are confronting. Around one in five Australian adults, approximately 4.3 million people, experience a mental health disorder each year. More people are presenting to emergency departments with mental health concerns and waiting longer for care.

Financial pressure is a major source of stress for one in three people with a mental health condition, compared with one in five without one. People with mental health conditions are twice as likely to experience discrimination, while the proportion of Australians avoiding mental health care because they cannot afford it has risen from 12% to 20% in just three years.

These findings sit alongside the 2026 National Stigma and Discrimination Report Card, which found that around 70% of people surveyed with mental health challenges had experienced discrimination in at least one area of their lives.

As a psychiatrist, I find these figures deeply troubling. But what concerns me even more is the risk that we become accustomed to them.

If comparable numbers of Australians with cancer, cardiovascular disease or another serious illness could not afford specialist treatment, were deteriorating while waiting for care, or repeatedly arriving in emergency departments because appropriate treatment was unavailable, would we accept it?

Why are we accepting it for mental illness?

We have known what the problems are

Australia has not lacked reviews, recommendations or reform plans.

The Productivity Commission’s landmark inquiry into mental health began in 2018, released its draft report in 2019 and its final report in 2020. It described a system in which many Australians did not receive the treatment and support they needed and called for affordable, evidence-based care, stronger community services, better access to psychosocial support, housing and employment, greater support for carers and much clearer accountability for outcomes.

It also made the economic case impossible to ignore. Mental ill-health and suicide were estimated to cost Australia between $200 billion and $220 billion every year, including direct economic costs, lost productivity, care provided by family and friends, and the enormous human cost of poorer health and reduced life expectancy. The Commission estimated that reforms could deliver improvements in quality of life worth up to $18 billion annually, with further benefits through greater economic participation.

Victoria then undertook one of the most comprehensive examinations of a mental health system in our history. Its Royal Commission heard from more than 12,500 people and produced 74 recommendations across its interim and final reports. The Victorian Government committed to implement them all and made an initial $3.8 billion investment in reform.

These were significant commitments, made with genuine ambition and considerable investment.

Yet five years after the Victorian Royal Commission, and more than five years after the Productivity Commission’s final report, we are looking at another national Report Card telling us that affordability is worsening, people are waiting longer for care and discrimination remains widespread.

Professor Patrick McGorry, who chaired the Victorian Royal Commission’s Expert Advisory Committee, reflected on this recently in The Age. After more than 40 years in psychiatry, he described repeatedly seeing mental health systems cycle between crisis and the promise of reform, and expressed his profound disappointment that the Royal Commission he hoped would break that cycle had not yet delivered the transformation envisaged.

That should give all of us pause.

The issue is no longer whether governments know what needs fixing. The question is whether our reforms and investments are reaching the people they were intended to help.

Treatment matters

Mental illnesses are treatable.

We have effective, evidence-based treatments, and psychiatry continues to advance through pharmacological and psychological therapies, neuromodulation and other biological treatments, alongside multidisciplinary and psychosocial approaches.

But innovation is meaningless if people cannot access it.

For someone living with schizophrenia, bipolar disorder, severe depression, an eating disorder or another complex mental illness, one assessment, one contact or one episode of care is often not treatment. They may need comprehensive psychiatric assessment, medication and psychological therapies, physical health care, multidisciplinary input and specialist care over months or years.

Our measure of success cannot simply be the number of services opened or contacts delivered. We need to know whether people receive the right evidence-based treatment, at the right level of expertise and breadth, where they need it – be it their homes or clinics or inpatient units or emergency departments or programs, rural-regional to metropolitan areas – for as long as their illness requires.

Our members see what happens when they do not.

Psychiatrists in public services see people arriving later and more unwell, often through emergency departments, while trying to provide care within systems facing workforce shortages and insufficient specialist community and inpatient capacity.

Private psychiatrists and private hospitals carry another substantial part of Australia’s specialist mental health care, often caring for people with serious and complex illnesses over many years. But when someone’s illness deteriorates and they need assertive community treatment, intensive multidisciplinary support or urgent admission, a private psychiatrist cannot create those services from a consulting room. The public system needs the capacity to step up and work alongside them.

A person’s illness does not distinguish between public and private systems. Neither should their care.

Recovery requires more than clinical treatment

The Productivity Commission understood something equally important: recovery does not occur within the health system alone.

It specifically identified housing, employment and services that help people reconnect with their communities as sometimes being as important as health care itself. It called for expanded psychosocial supports and better coordination between clinical and community services.

For someone living with severe mental illness and psychosocial disability, effective psychiatric treatment may stabilise their illness. But recovery also requires somewhere safe to live, support with daily life, opportunities to study or work, relationships and social connection.

This is particularly important as Australia reforms the NDIS. People with severe mental illness who lose access to the NDIS cannot be left waiting for a future system of foundational supports that does not yet meet their needs. Without properly funded alternatives, need does not disappear, it just moves to families and carers, emergency departments, hospitals and homelessness services.

And too often, it is families and carers who silently absorb the failure of the system.

When services are unavailable, carers become the crisis service, care coordinator, accommodation provider, advocate and safety net and frequently while trying to maintain their own employment, health and family responsibilities. The Productivity Commission specifically recognised the enormous contribution of families and carers and called for greater inclusion and support for them.

Psychiatrists see this firsthand. We see exhausted families trying to keep someone they love safe and well while navigating fragmented systems and thresholds for care.

We have to hold the system accountable where unmet need has been transferred from a funded service onto an unpaid family.

Investment must translate into outcomes

There has been substantial investment in mental health, and that should be acknowledged.

Victoria introduced its Mental Health and Wellbeing Surcharge to provide additional resources for reform following the Royal Commission; it raised approximately $1.26 billion in 2024–25 alone. Queensland also raises hundreds of millions of dollars annually through its Mental Health Levy. Australians contribute through taxation and Medicare, while many also pay private health insurance premiums and significant out-of-pocket costs for specialist care.

These investments were made with an expectation of change.

Accountability therefore cannot simply mean demonstrating that money was allocated or spent. We need to know what it changed.

Did people get specialist treatment earlier? Did community and inpatient capacity grow? Did access to psychiatrists improve? Are people receiving contemporary evidence-based treatments? Are psychosocial supports available? Are fewer families carrying unsupported care? Are fewer people reaching crisis and emergency departments? Are people recovering and participating in their communities?

The Productivity Commission explicitly recommended that governments and providers be held accountable through transparent monitoring, reporting and evaluation based on outcomes that matter to people living with mental illness and their carers.

These investments carry more than taxpayers’ dollars. They carry the hopes and aspirations of people living with mental illness, their families and carers, and a workforce that has repeatedly been asked to believe that meaningful reform is coming.

We should account for the return on those hopes and aspirations as seriously as we account for the money.

This is also about discrimination

Perhaps the most uncomfortable question raised by the Report Card is whether discrimination is reflected not only in attitudes towards mental illness, but in the systems we have built.

We have spent decades asking communities to challenge stigma. Governments and health systems should be willing to apply the same scrutiny to themselves.

When people with mental illness experience greater financial barriers, difficulty accessing specialist treatment, fragmented care, inadequate psychosocial support and thresholds that require them to become profoundly unwell before intensive services respond, inequity can become structural.

People living with mental illness should not have to become sicker, poorer or reach crisis before their health care system responds.

What the College will do

Following the Report Card, the RANZCP has called on federal, state and territory governments to act.

We will continue advocating for affordable access to psychiatrists, a sustainable specialist workforce, stronger public community and inpatient services, integration between public and private care, access to innovative and evidence-based treatments, properly funded psychosocial supports, and transparent accountability for outcomes.

I have also called on Federal Health Minister Mark Butler to lead the next stage of national mental health reform. Minister Butler has long prioritised Medicare and mental health, and substantial investments have been made. The challenge now is ensuring those investments translate into treatment, recovery and better lives.

While the evidence discussed in this column is Australian, access to specialist psychiatric care, workforce capacity, continuity of treatment and psychosocial support are priorities across both Australia and Aotearoa New Zealand. Our systems and policy settings differ, and our advocacy must reflect that, but the principle is binational.

People living with mental illness are not asking for preferential treatment. They deserve timely assessment, specialist expertise when required, evidence-based treatment, continuity of care and the practical supports necessary to recover.

Mental illnesses are treatable. With the right treatment and support, people can recover, participate in their communities, study, work, sustain relationships and live the lives they want and deserve.

Governments have known the problems for a long time. We have had landmark commissions, ambitious reform plans and substantial investment.

The next measure of success must be simpler and much more demanding: is life actually getting better for people living with mental illness and for the families who support them? Having a mental illness should never mean having to accept second-class health care. That is the accountability our communities deserve, and it is what our College will continue to advocate for.

Dr Astha Tomar
President