The most rewarding aspect of a career in mental health is that you get to spend time with truly inspiring people. My clinical work has focused on people whose lives have been affected by depression, bipolar disorder or schizophrenia. For any doctor who wants to connect with the most fundamental aspects of what it is to be human, nothing beats a career in mental health. However, the big frustration that I face on a daily basis is the impoverished mental health system in which we provide services. Too often have I run up against the comment, “That’s all true, Ian, but we won’t see any real change in our lifetime”.

I was fortunate to grow up in a large, academically oriented family. A rather strong Irish cultural legacy on one side and a printers’ union background on the other left me (and each of my siblings) at odds with the status quo. My early exposure to multiple perspectives, endless rounds of negotiation, and the need to come up with a collective rather than personal solution proved more valuable later in life than much of my professional training.

Given my father’s distinguished career in academic medicine, my own journey down that same path may seem to have been rather predictable. Indeed, it now appears that there are strong transgenerational elements at work (Box 1).1,2 Unfortunately, like other rather glib narratives that are common in psychiatry, it’s an interpretation that doesn’t really fit the data. Having a father in academic medicine actually seemed to result in a household with an oversupply of lawyers! Perhaps we all do share a common sense of social justice. However, from my parents’ perspective, having only one of their seven university-educated children pursue a medical career always seemed a rather poor return on investment.

While I enjoyed my early medical training at St Vincent’s Hospital in Sydney, the time I spent working for a bookmaker gave me a much better introduction to the more colourful aspects of everyday life. The real highlight of my undergraduate years was the time I spent in the Philippines during the later years of the Marcos regime. Not often can one so clearly experience the direct relationship between the impoverished state of a nation and the grossly inadequate health care that its citizens receive. The time spent with health professionals who took direct social actions to improve the lives of others also left a lasting impression on me.

On graduating, I jumped at the opportunity to be a resident medical officer at the still rather new and often chaotic Westmead Hospital. Here was a medical centre that was critical to the future of the community in which it was based. While working there, it became very clear to me that, although the rewards of procedural medicine were great and the challenges of internal medicine considerable, only psychiatry was really challenging from a personal and intellectual perspective. At that time, one training program stood out in terms of its academic rigour and breadth of teachers. Consequently, I moved to Prince of Wales and Prince Henry Hospitals to pursue my specialist training.

One of the difficulties that young psychiatrists face is the apparent drift away from conventional measures of pathophysiology. In the absence of clear laboratory markers, there is a recurring tendency to invoke more narrative accounts or other pseudo-sophisticated illness models. Fortunately, I was spared these distractions through my early research collaboration with two great physicians; namely, Andrew Lloyd and Denis Wakefield. Although our shared interest in post-infective fatigue syndromes has always aroused great controversy, it allowed us to work with a robust model for the onset of neurocognitive disturbance following a discrete medical event.3

Twenty years later, this work is now firmly based in more respectable models of cytokine-induced cognitive and mood disturbance.4 More importantly, very few psychiatrists ever receive the collegiate support that I have had from Andrew and Denis over the past two decades, and this collaboration put me in contact with a collection of international experts in medicine and psychiatry who share a much broader world view.

Towards the end of my registrar training, I was fortunate to work with the newly established Mood Disorders Unit at Prince Henry Hospital. The concentration of clinical researchers assembled under the leadership of Gordon Parker and Henry Brodaty was crucial to its success. While the work borrowed heavily from Leslie Kiloh’s earlier focus on the subclassification of depression, it used a range of neuroendocrine, neuropsychological and brain imaging technologies to develop a more specific fronto-subcortical model of severe mood disorders.5

During this period, I was lucky enough to lead projects that used magnetic resonance imaging. Although our neurological colleagues were aghast at our “waste” of such expensive tools, conveniently, the Professor of Radiology did not share their narrow view. Consequently, in partnership with Dr Liz Scott at Prince Henry Hospital, we were among the first groups internationally to demonstrate the clinical utility of these new techniques in people with severe depression.6,7 It kick-started a line of work that moved rapidly from detection of an underlying vascular abnormality in late-life depression to the development of large-scale preventive and early intervention programs.8,9

By its nature, the discipline of psychiatry is both philosophical and political. While many prefer the former path, I’ve always thought that Norman Sartorius was on the right track. In the early 1990s, I was very fortunate to win a Harkness Fellowship to pursue both my sociological and brain imaging interests at Duke University in North Carolina. Packing up a family with four young children and shifting continents proved to be quite an adventure. The Fellowship provided me with fundamental insights into the way in which communities could act collectively across a whole range of health and social issues. The emphasis on community action rather than government-based initiatives is central to social progress in the United States.

Throughout this period, I had the good fortune of being assisted by an eminent clinician and Dean of Medical Education at Duke University School of Medicine, Dan Blazer. Dan is not only an international leader in depression research but, more importantly, he is gentle, educated, spiritual and community-oriented. His ongoing contributions are thoughtful and particularly relevant to those of us who work at the interface of society and biological medicine.11 Too few medical schools promote role models of this calibre.

Soon after returning to Australia in 1995, I joined Dr Margaret Tobin at Sydney’s St George Hospital. She was determined to drag mental health services into the late 20th century. Margaret and I shared an ongoing joke over who would sustain this charm-free campaign after we had both moved on. Although the facilities were limited, the services were stretched, and the whole process appeared unnecessarily disruptive, it was a great learning experience. Margaret’s tragic death some years later robbed Australia of a person who was truly committed to changing the system. During my 5-year stay in southern Sydney, I learnt what it was possible to achieve with a small group of people who shared a common view of a better future. The deeply personal and broader collegiate relationships that I formed during this period continue to sustain me through tough times.

Around this time, my own interests moved rapidly to the substantive issue of the lack of adequate management of depression in primary care settings.12 Working with Liz Scott, Tracey Davenport and a team of young psychologists, we were able to roll out SPHERE: a major national educational and service evaluation program.13 We conducted an audit of over 46 000 consultations in primary care settings. The study emphasised the low rate of detection and active treatment of common mental disorders, highlighted the lack of access to skilled non-pharmacological therapies, and set in place an enduring national general practitioner training program. Over a decade later, that program alone has provided various forms of general practice-based mental health training to more than 10 000 primary care practitioners.

This work, in combination with my later advocacy work with beyondblue,14 provided the impetus to correct one of the major flaws in our Medicare funding system; namely, the lack of financial support for psychological services. By 2001, we had convinced the Australian Government of the need to provide specific payments for well trained GPs and clinical psychologists who provided psychological services.15 From my perspective, this was the first in a series of “not in our lifetime” predictions to be defeated.

In the late 1990s, the Kennett Government in Victoria had moved to confront major health and social problems such as mental illness and drug misuse. In 1999, Kennett’s proposal to establish a national depression research institute appeared to have died with his election loss. However, immediately after that election, the federal Health Minister, Michael Wooldridge, set about resurrecting the plan. In 2000, beyondblue: the national depression initiative was born and Jeff Kennett was appointed as the chairman. It was a credit to the Victorians involved that they were able to put together this very smart deal.

I jumped at the opportunity to become the inaugural chief executive officer of beyondblue (Box 2). Sadly, through a bizarre combination of state-based and professional rivalries, my home state of New South Wales refused to join. Despite the resistance, we set an ambitious agenda not only for improved community awareness of depression, but also for significant reform of primary care services, establishment of large-scale postnatal depression and secondary school-based preventive research, and investments in smaller-scale community-based and translational research programs. Importantly, we achieved major changes in other key industries such as life insurance and income protection.16 In the longer term, beyondblue has proven to be the major national driver of increased community awareness of depression and other common mental health problems.17 The wider significance of this to the field of mental health, and specifically the lives of those who live with depression, cannot be underestimated — we have seen major changes in community attitudes in our lifetime.

Some have described my relationship with Mr Kennett as a rather odd example of a very odd couple. I always preferred the description provided by a Victorian taxi driver — he thought we could easily double for the comedians Roy and HG! In truth, Mr Kennett has many skills that are invaluable to our field. He also respected the fact that those with technical or clinical skills needed to take the lead on illness-related issues. If not for the offer of a lifetime from Max Bennett and the University of Sydney, I would have been happy to have spent a much longer period in Melbourne.

There is no doubt that the lack of a solid evidence base, and the long periods between genuine breakthroughs in clinical therapeutics, discourages some young doctors from pursuing a career in mental health. By the end of the 20th century, it had become clear that a fundamental change in direction for psychiatry was possible. The opportunity to forge real links with other clinical and basic neurosciences was emerging. Thanks to the foresight of Gavin Brown, then Vice-Chancellor of the University of Sydney, and the unrelenting drive of Professor Max Bennett, the Brain & Mind Research Institute (BMRI) was created (Box 3).18 In 2003, I left Melbourne rather prematurely to become its inaugural executive director.

The BMRI is a unique campus, now combining over 20 major research teams that span key disciplines and technologies. I am proud that at least one major Australian educational institution has chosen to value mental health research so highly. The federal and state governments have responded positively to this movement, and we can now boast that the facilities provided for both patients and researchers are as good as any that one would expect for the management of cancer, infection or heart disease. This has been the third major “not in our lifetime” moment that I have experienced. Our ongoing focus on discovering how dysfunctional glial cell–neuronal networks give rise to the major mental disorders will keep us busy for some time to come.

The BMRI is now the home of my own interdisciplinary and clinical research program. From 2007, this has been supported by a National Health and Medical Research Council (NHMRC) Australia Fellowship for health and medical research. Some of those close to me suggested that the NHMRC would be unlikely to back a clinical and health services-oriented psychiatrist under this scheme — just another “not in our lifetime” prediction that proved erroneous. It has enabled my talented team of clinicians and scientists to pursue large-scale national and international collaborative research. In partnership with Pat McGorry and his team in Melbourne, and led by Liz Scott and Sharon Naismith at the BMRI, we are rapidly developing a world-leading program of youth services19 and clinical research.20,21 This is complemented by our academic (with Helen Christensen at the Australian National University) and community (with the Inspire Foundation) partnerships in developing relevant e-health services.

Twice in the space of a recent month I had senior political people say to me, “I know that needed to be said, but did you have to be the person who said it?!” One of the more obvious responsibilities associated with working in mental health is to speak out on behalf of those who are marginalised, neglected or abused. Fortunately, my peer relationships have grown to include a wider group of community and political leaders. Collectively, we have tried to push the political and social agenda. While the world of mental illness is no longer characterised by the more obvious abuses of human rights, it is still plagued by systematic failures in access to basic health care (only 35% of those with a common disorder receive treatment, and this has not improved in the past decade22), a lack of focus on early intervention for young people,23 too much reliance on the old restrictive ways,24 and disconnection from essential social, economic, employment, education and housing supports.25

As recently emphasised by the National Health and Hospitals Reform Commission,26 mental health continues to be an area of great inequity. Traditionally, politicians, health and educational institutions or philanthropists do not rush to identify with this form of suffering. At times, however, there have been notable exceptions. In 1993, the Keating Government responded positively to the findings of the Burdekin Royal Commission into mental health services and backed the first National Mental Health Strategy (1993–1998). This was continued as a second 5-year strategy (1998–2003) by the Howard Government. Sadly, leadership of that reform process was left under the control of a state-based committee that had little stomach for real change.

By 2002, the community’s frustration with the lack of progress was palpable, and my colleagues and I decided it was time to revisit the community’s experiences. Working through the Mental Health Council of Australia, and with the assistance of the Human Rights Commissioner, Sev Ozdowski, we were able to complete a national evaluation that once again highlighted the disastrous consequences of our fundamental lack of investment in key mental health services and related social supports.27

The launch of the resulting report, Not for service: experiences of injustice and despair in mental health care in Australia,28 at the BMRI in 2005 indicated that our new academic home was not only committed to fundamental scientific advances but would also continue to engage in the issues that affected the daily lives of those with severe mental disorders. Although the Health Minister of the day sought to lay the blame at the feet of the states, a few days later, Prime Minister John Howard made it clear that mental heath reform was indeed a major social and economic issue that demanded a serious response.

This rhetoric was matched by real action in mid 2006 when Prime Minister Howard and NSW Premier Morris Iemma enacted the Council of Australian Governments’ new National Action Plan on Mental Health 2006–2011.29 This national political action was a direct result of our 4 years of sustained campaigning. It was accompanied by over $4 billion in new investments and led directly to key structural changes. The most important of these was the introduction of new Medicare rebates for psychological treatments. Once again, this was a genuine “not in our lifetime” breakthrough. Prime Minister Howard went on to support the development of a new stream of youth services under the headspace initiative,23 while Premier Iemma backed substantial new infrastructure investments in youth mental health (Box 4) and research into the biological basis of psychotic disorders.

Since its election in 2007, the Rudd Government has promoted much discussion about the future of our health system and, importantly for mental health, the development of the concept of social inclusion. At this stage, we are still waiting to see whether the rhetoric will be backed by decisive action.30 Although I have been appointed to the Health Minister’s new National Advisory Council on Mental Health, it is clear we need a government that genuinely prioritises improved access to mental health care, as well as linking health with other key areas of social services and disability support. The struggle to achieve another “not in our lifetime” moment is ongoing.

Most of my own community and advocacy work has sought to develop new styles of social and political partnerships. The key roles that the media, the business world, industries, community organisations and other professionals can play in improving the lives of those with mental illness have been obvious. I’m now deeply suspicious of those who seek either a largely government-delivered solution or, on the other hand, promote a simplistic, laissez faire approach. As in other areas of health care, developing services that respond personally to the particular needs of those we serve remains the biggest challenge.

A sustaining influence for much of my academic and social advocacy work has been the intellectual prowess of my professional colleagues. When asked why I chose to pursue psychiatry, I remark that the most interesting people I met throughout my medical training were psychiatrists. Real characters and genuine thinkers like Neil McConaghy, Gavin Andrews, Issy Pilowsky and Scott Henderson stand out. While leaders in other areas of medicine are identified by their technical skill or their lifetime dedication to patient care, psychiatry thrives on the daily contest of ideas.

Although too few senior psychiatrists have engaged in the broader struggle to overcome the fundamental inequities that people with mental illness face, I have immensely enjoyed my work with the leadership of the Mental Health Council of Australia (and, specifically, the late Dr Grace Groom and then Mr John Mendoza). These days, I have the pleasure of the company of a new generation of Australian-based but international leaders in mental health such as Pat McGorry, Chris Pantelis, Helen Christensen and Nick Martin.

For my colleagues and me, the past two decades have really been about working with the wider community to set a clear reform agenda in mental health. While our collective minds remain firmly focused on key issues of health equity, promotion of early intervention and youth-specific services, protection of human rights, access to evidence-based health services, and provision of appropriate social, employment and housing supports, real progress will remain dependent on our capacity to engage genuine community and political support. From a personal perspective, there are many more challenges ahead.

1 Three generations of medical research

Ian Hickie (standing), with daughter Megan Hickie (left), partner Elizabeth Scott (right), and father Professor John Hickie AO (seated).

2 Launch of the beyondblue Victorian Centre of Excellence in Depression and Related Disorders, July 2002

L–R: The Hon Bronwyn Pike (Victorian Minister for Community Services), The Hon Jeff Kennett (Chairman, beyondblue), Ian Hickie (Chief Executive Officer, beyondblue), Professor Bruce Singh (University of Melbourne).

3 Opening of the Brain & Mind Research Institute research laboratories, 2006

Ian Hickie and Prime Minister John Howard.

4 Opening of the clinical and translational research facilities at the Brain & Mind Research Institute, 2007

L–R: Premier Morris Iemma, Professor Max Bennett AO, Ian Hickie.