When Dr Graham Fleming heard that a local 15-year-old boy had hanged himself, he worried about who might be next. The GP, from the small isolated community of Tumby Bay, 600km from Adelaide, was already concerned about his huge crisis counselling load. And as the parent of teenagers, he was deeply disturbed by the young man’s senseless and unnecessary death.
“That death created a great deal of despair in the town,” says Dr Fleming. “I looked upon it as if it had been my kid and thought it was the most shocking thing.
“I knew the child. I wasn’t caring for him, but I did a psychological post-mortem and there was evidence to me that he had depression. I went out and said we need to get rid of depression, and [if we do,] we’ll get rid of suicide.”
That single-minded decision marked the beginning of a project that consumed Dr Fleming over more than 20 years and led to a dramatic reduction of suicides at Tumby Bay. The district of just 3000 people lost 12 people to suicide in the 10 years to 1996. In the following 16 years, to now, it has lost four.
Dr Fleming involved the school, hospital and community groups, and the project grew well beyond depression. In 2000, it dawned on him that his work had made a difference.
“I said, my goodness me, something tremendous has happened here,” he says.
He contacted Emeritus Professor Robert Goldney, a professor of psychiatry at the University of Adelaide, who is recognised as one of the world’s foremost researchers on suicide and depression.
“I asked, am I barking up the wrong tree, or is this relevant information?” Dr Fleming says.
“He said you’ve got to write it up.”
Two years later, after 13 rewrites, on top of working 70-80 hours a week, Dr Fleming had done just that. His peer-reviewed thesis, which received high commendation, gave him a postgraduate Doctor of Medicine degree and confirmed through rigorous statistical analysis that suicide rates in Tumby Bay had dropped below the national average.
Having tried, without success, to get better mental health support for Tumby Bay, the aim of his thesis was simple: “to determine whether suicidal behaviour in the Tumby Bay district could be reduced by enhancing and utilising community resources.”
Professor Goldney supervised the writing of Dr Fleming’s thesis. As he told Australian Rural Doctor: “It was good work. It was terrific.”
Professor Goldney says while many countries have pulled teams of experts together to formulate national suicide programs, Dr Fleming’s effort embodied all the broad-brush suicide prevention strategies those committees typically came up with. And he’d done it alone, based on common sense.
“It was a massive undertaking. I can’t speak too highly about what he has done,” Dr Goldney says.
“There is no doubt that it has made a difference. What he introduced has worked.”
Dr Fleming is pleased to have reduced his crisis counselling load and the trauma the town has experienced.
“The disappointing thing is no one has said this should be run as a broader trial.
“Part of that is my fault, because I probably should have written it up in something like the MJA (Medical Journal of Australia). But writing up that thesis exhausted me, mentally and physically,” he says.
Dr Goldney sees no reason why Dr Fleming’s approach couldn’t be replicated elsewhere, except that it would require another person like Dr Fleming.
“In some ways, it’s almost too hard, because there is an enormous personal commitment that goes into it – a long-term commitment. You have to have that fire in the belly, and it’s hard to maintain that over a long time. And it really has to be developed from within the community.”
After the teenager’s suicide in 1986, Dr Fleming started out in a very simple way. Although the term “mental health literacy” had not yet been coined, he started teaching community groups about depression’s causes, symptoms and treatment, aiming to demystify it and reduce its stigma.
“I went into every organisation in the town I could think of – church groups, school groups, the Parents and Citizens, Lion’s, everybody. I’d talk and try to get them to understand depression.”
He also ran an education program for teachers in the local school. Five other schools in the region took up his offer to run the program too.
Some mental health experts in Adelaide suggested his approach might do more harm than good, which concerned Dr Fleming, but didn’t put him off. He became a vigilant note keeper, which later proved a godsend in tracking the long-term impact of his work.
It helped him, for instance, many years later to see the difference his training and talks had made. Once a statistician had overcome the problem of working with small figures, Dr Fleming could identify that this was when the suicide rate started to level off.
“Probably dealing with depression alone had more of an effect than we thought it did at the time,” he says.
He noticed small but significant changes.
“We had farmers coming in and saying, excuse me, doc, I’m feeling stressed and I think I need some help, whereas in the past they’d probably have gone to the pub.”
However, the problem was a long way from solved, with another seven local people committing suicide after the teenager, in the seven years to October 1992.
He sought help from government and academics to address the alarming suicide rate, “but the answer was always that there was no money or resources”, Dr Fleming writes in his thesis.
“Furthermore, it was suggested any interventions should begin in the major centres where resources could be used more effectively, and lessons learnt could then be applied to the rural sector.
“It was also suggested that the situation seemed too dangerous for novices to dabble in, and perhaps the alarming suicide rate may have occurred because interventions had somehow produced a morbid community fascination and focus on depression and suicide. Overall the process had become very disheartening.”
He found some mental health workers in Adelaide who said they would come and assess what the town’s problems were, if he could raise a couple of hundred thousand dollars.
“We said we know what the problems are: people are killing themselves,” Dr Fleming says.
“I didn’t know what I was doing, but I’ve got a reasonable degree of intelligence and have lived in rural communities all of my life.”
Then, in 1993, another tragedy rattled the town to its core, and eroded Dr Fleming’s confidence. A high-profile, widely adored school teacher killed himself. He was friends with Dr Fleming and another GP at the town’s three-doctor practice.
“He was probably my GP colleague’s best mate and his wife worked as a receptionist in the surgery,” Dr Fleming says.
“He had gassed himself in the car. I was called to try and resuscitate him. It took me an hour to decide to give up, which was probably 40 minutes more than it should have.”
Dr Fleming was devastated he hadn’t realised his friend was so distressed, that his friend hadn’t called on him for help, and that he hadn’t been able to resuscitate him.
“I was hurting after that and probably still do hurt after that,” Dr Fleming says.
“I said, I’m getting out of general practice. I was going to specialise in obstetrics.”
Dr Fleming met at the pub with two concerned local people who were also grieving – the local hospital’s director of nursing, Pauline Kearns, and then school principal Kent Spangenberg.
“I said general practice is not for me anymore. Those people said let’s talk about it. What are our problems? What are our assets?”
Mr Spangenberg says they grappled with the concept of the teacher being so private in his suffering; that his suicide had come as such a shock.
“The teacher had just had a second child after 13 years of trying, and he’d just implemented a maritime studies course in year 12, which he’d wanted to do for a long time,” Mr Spangenberg says.
“Two weeks before, he’d taken his class away sailing for four or five days. That was his ultimate achievement. It appeared he was achieving, from a family and professional perspective, things he’d been aiming for, for years.
“His death really devastated the whole community.”
The pub discussion strengthened Dr Fleming’s resolve. And his most basic coping mechanisms gave him the drive to work longer hours.
“Being a country GP, you’re supposed to solve everybody’s problems and not your own. You tend to work harder to take your mind off it.”
He realised he needed a broader focus, beyond depression to what constitutes good mental health.
“Good mental health is not the same as an absence of mental illness,” he says.
“At the end of the day, healthy, happy people don’t commit suicide. So if people have mental health issues and are not happy, they are at risk.”
His research showed that many of those who had committed suicide had not had regular contact with
GPs, and that ultimately, suicide prevention was a responsibility the entire community would have to own. He also figured it was more likely problems could be managed locally if they were identified early.
Dr Fleming established a reference group, which he sat on, along with a nursing representative, a mental health patient and their carer, a minister of religion, school and community counsellors and a medical administrator.
He also persuaded retired professionals, including school teachers, nurses and social workers, to study mental health and counselling. Four registered nurses, and a retired school teacher – Dr Fleming’s wife, Gladys completed a postgraduate course in counselling. Gladys also achieved a graduate certificate in community mental health. Other retired teachers worked with an educational psychologist to help students with learning difficulties and improve their reading.
It was at a time when there were no models of depression, so Dr Fleming developed and then widely presented one. It explained six common causes of poor mental health, based on the conditions he had treated locally and what he thought the community could recognise and understand.
“Overall the community was taught to recognise poor mental health in their family and neighbours and a plea was made for early referral to well-known entry points,” Dr Fleming writes in his thesis.
The model covered “worriers”, which included people with anxiety disorders ranging from nervousness to panic attacks; mood disorders including depression and bipolar; schizoid disorders; personality disorders; substance and alcohol dependence; and grief reactions.
“The causes, symptoms and treatments were discussed, with emphasis on consequential secondary behaviours, of which suicide was the most dramatic,” Dr Fleming writes.
He emphasised that most mental disorders were reversible and, if they were identified early, they could be managed locally. And he outlined where people could access care and crisis resources.
When talking to nurses, he placed emphasis on somatisation and depression occurring with physical illness.
“As nurses were often the first points of triage, they were trained to assess presenting symptoms, and assess urgency and safety issues with regard to potential suicidality,” he writes. “A planned protocol of questions to ask … was devised to assist the nurses and ensure appropriate follow-up.”
Dr Fleming says the training had a huge impact on the nurses’ confidence, particularly when dealing with patients experiencing a psychotic episode.
“Instead of the [nurses] being terrified, they would calmly say to the patient, what are the voices telling you?
More importantly, we developed a protocol, so if anyone came into the hospital with a mental health problem then they would go through a list of questions. Patients knew the nurse was on their wavelength.”
When presenting to teachers, he covered psychological principles, learning disorders, signs of possible dysfunction and personality development.
“They were taught the main foci of assessment such as behaviour, progress in learning, psychiatric symptoms and social milieu.”
A senior educational psychologist presented an hour-long presentation on learning difficulties.
Dr Fleming and Mr Spangenberg also discussed how to approach children who had bad conduct or were refusing to go to school, recognising that poor mental health often started in children. They decided to focus on children who were more than one academic year behind, and were behaving abnormally or in a way that was different to their peers.
Teachers were trained to observe the students and identify those considered appropriate for assessment. With their parents’ consent, children were then assessed to exclude physical illness, determine their behaviour at home and with peers, their academic progress, social interaction and signs of psychiatric illness.
Of the 350 students at the school, 51 were regarded as dysfunctional and considered suitable for formal assessment. Parents of 49 students agreed to them being assessed, which revealed co-morbidity in many students and a significant psychiatric illness in 20. Twenty-six had psychiatric problems, 35 had behaviour problems, 20 had learning problems (19 significant) and 20 had social problems, which reflected dysfunction or disadvantage in their social environment.
Dr Fleming achieved grants which paid travel costs for a senior child and adolescent psychiatrist, and an experienced senior educational psychologist from Adelaide. The psychiatrist, who agreed to bulkbill, formally assessed children with frank psychotic symptoms, and the psychologist assessed those with learning difficulties.
Therapists, teachers and parents then addressed each child’s needs. Evaluations six months and then 12 months later showed they, and the students, universally agreed the interventions were worthwhile.
Dr Fleming couldn’t believe just how skilled teachers became at picking up subtle early warning signs in children.
“It blew my mind. The teachers were so good. They were on to it straight away, because it made their class management so much easier.
Initially they only referred the really difficult kids, but then they picked up more subtle signs.”
Before setting up the program, Dr Fleming had a joint meeting with the state’s ministers for education and health, who approved his work. Then, a year later, Dr Fleming tried to extend the program to a double-blind trial across the Eyre Peninsular, but a change in government had significantly dampened enthusiasm.
“The education department said we’d never let a program like that run in our schools,” he says.
Mr Spangenberg, however, did what he could to see the benefits push farther than Tumby Bay when he moved to Loxton, eight hours away.
He invited Dr Fleming to present his model and a session on risk factors to an extended staff meeting and established a new relationship with a Loxton GP who could refer to a visiting psychiatrist. But Mr Spangenberg hasn’t had the resources to employ an educational psychologist and paediatric psychiatrist in order to run the program rigorously.
Having arrived at Tumby Bay shortly after the teenager’s suicide, been “massively” affected by the suicide of the teacher from his school, having seen first-hand the impact Dr Fleming’s work had on the wellbeing of teachers and students at his school, Mr Spangenberg is resolute that the program deserves far more attention than it has received.
“What Graham has done has been truly outstanding and it needs to be picked up and run with throughout rural and metropolitan communities, throughout Australia,” he says. “There’s no doubt about that, as far as I’m concerned.”
Findings from Dr Fleming’s thesis
Model is ‘majestic’ but hard to replicate, academic says
Involving the whole community is the only way Dr Fleming’s initiative could be replicated in other parts of the country, says Dr Angelo De Gioannis, senior lecturer at the Australian Institute for Suicide Research and Prevention at Griffith University in Queensland.
He says that, even with broad community involvement, it would require a strong individual who was prepared to take ownership, get things done, and follow up outcomes – labour-intensive work that would come with limited rewards.
“It was wonderful to be able to do it, but I’m pretty sure the main reason we haven’t heard of it elsewhere is it’s probably very difficult to replicate,” says Dr De Gioannis, who is also a consultant psychiatrist at the institute’s Life Promotion Clinic.
“The principle, I fully agree with. That particular application was majestic, which is why it was so effective and is hard to replicate.”
He says there are some key aspects of the work that rural GPs could adopt, particularly Dr Fleming’s “hard-line approach to addressing any sign of distress”.
“I thought that was really valuable and can be done in different settings, regardless of how much time you have available,” he says. “If you see somebody who is struggling, you don’t just ignore it.
“We expect people to be stressed, depressed or angry, and so we have a very high level of tolerance for those things.”
He says there is plenty of research that shows that GPs make a huge difference when they have a five-minute chat with patients about cigarettes or alcohol. “If GPs did it also for anxiety and depression, it would also make a difference,” Dr De Gioannis says.