Mental illness is currently one of the most challenging problems faced by Australian society. It is difficult because it is so widespread and destructive for all sorts of people, it can carry stigma, plus it can be hard to pinpoint and be even harder to understand when education and treatment are not sought. Mental illness also plays a role within many other conditions our population faces – crime, homelessness, substance abuse and interpersonal conflict. At a time when drought, fires, floods, and financial hardship have left many people in our communities vulnerable and isolated, the rate of mental illness is increasing. Mental illness will also surface when none of the above is present. However, like many conditions it is diagnosable and treatable, and people experiencing mental illness can recover and lead happy and successful lives.

This Cud piece won’t begin to solve such a multifarious problem, but merely argues that as citizens we can help by educating ourselves about the problem, for our own benefit and the benefit of others. The motivation for this piece is a growing sense that mental illness is of concern to all of us. Over the years the number of friends, family members and work colleagues I have seen seriously impacted by mental illness, some fatally, has accumulated to some sort of personal ‘critical mass’. In aggregate, to me it now seems that these are not random, isolated, or even infrequent occurrences. Sadly, for the most part, we are usually either absent or unaware there is a problem. This Cud piece humbly attempts to raise awareness.

How bad is the problem?

The ABS definition of mental illness includes depression, anxiety, personality disorder and substance abuse. Today, approximately 2.4 million Australians struggle with mental illness of some form.1 Furthermore, an ABS survey completed in 2007 revealed that one in five people Australia-wide are suffering from mental illness at any time.2 According to the ABS survey, incidence is concentrated in disadvantaged demographics. For example, people in disadvantaged social and economic groupings are 1.5-3.5 times as likely to experience mental health issues as those that live in relatively advantaged circumstances. Some of the ABS’ findings are staggering:

“of the 16 million Australians aged 16-85 years, almost half (45% or 7.3 million) had a lifetime mental disorder, ie a mental disorder at some point in their life. One in five (20% or 3.2 million) Australians had a 12-month mental disorder. There were also 4.1 million people who had experienced a lifetime mental disorder but did not have symptoms in the 12 months prior to the survey interview”.3

The most final, terminal expression of mental illness must be suicide. As ever, it often takes a publicised event involving someone in the public eye, to catch our attention. However, for the most part these stories quietly pass by, or are sad for a moment but we quickly shut them out and move on. More intense is the experience of losing a friend or family member through suicide. Those left behind are very hurt and usually have a permanently heightened awareness of mental illness-related issues.

ABS Statistics quote about 2,000 deaths from suicide each year – roughly equivalent to the annual number of fatalities from road accidents. Men account for about 75% of suicides – accordingly, nearly one fifth of all deaths of men aged 20-34 are from suicide. The demographics at higher risk of suicide are: men of all ages, the elderly, Aboriginal and Torres St Islanders, those living in rural or remote communities, and those who have been treated for mental illness or who have just been discharged from an institution. SANE (2008) identified the alarming trend that many people with depression lose their battle – with suicide the main cause of premature death among people with a mental illness. More than 10% of people with a mental illness die by suicide within the first 10 years of diagnosis. The same research also found that an attempt of suicide may also be a sign that a mental illness is developing. Amidst these saddening statistics, it is positive to note that the actual rate of suicide in the population is actually lowering, it fell from a rate of 15 suicide-deaths per 100,000 people in 1997 to just below 10 deaths per 100,000 in 2007 (ABS).

Treatment levels are low. One of the major findings of the ABS’ 2007 survey was that only a third of Australians who reported they were experiencing mental illness, were actually seeking treatment for their condition.

More qualitative learning’s from the ABS surveys include that depression is often triggered by ongoing stress or a particularly traumatic or stressful experience. Sadly, mental illness is found to be highly concentrated in the elderly or those experiencing a chronic illness or ailment. Furthermore, recent research has shown that cognitive impairment from conditions such as depression increases the risk of dementia.

In summary, the ABS statistics show that mental illness is widespread and can lead to serious health consequences. Mental illness is a live issue, and the statistics confirm that there are many people in our communities, in our families, social groups and workplaces battling it, every day. It can be triggered by ongoing stress or a traumatic incident including an injury, illness or relationship breakdown. These can happen to any of us at any time.

Looking forward, and globally, the World Health Organisation (WHO) believes that depression, one of the forms of mental illness, will be the primary cause of disability in the developed and developing world by 2030.4

Mental illness and crime?

The above figures are alarming in their own right, but there is also a growing body of evidence that mental illness is associated with a raft of societal problems. For example: crime, homelessness, relationship/family breakdown, and even terrorism. Many studies globally and in Australia have drawn linkages between mental illness and the criminal justice system. On mental health, a classic ‘chicken and egg’ situation presents: what’s cause and what’s effect? Risks of mental illness are linked to poverty, homelessness, unemployment, age and poor health. However, those experiencing the onset of mental illness may experience reduced capacity to maintain full-time employment and function as a healthy, normal person – leading to financial hardship. They may isolate themselves from friends, or may turn to drugs or alcohol in the process. A NSW Health report characterised this descent as “falling through the gaps – the gap is wide and the fall is hard”.5

While a precise root or causal relationship between mental health and crime, or violent crime, has not yet been established in Australian research, it is clear that people with mental illness are overly represented in the criminal justice system. The Australian Institute of Criminology has studied linkages between mental illness and the judicial system.6 Their studies reveal that mental illness and substance abuse are much more prevalent in people in incarceration than in the general population. White and Whiteford (2006) revealed similar findings in their paper entitled ‘Prisons, mental health institutions of the 21st Century?’.7 They also argue the need for a massive improvement in the provision of mental health assistance to people passing through the legal and judicial systems. For many, in the context of crime, mental illness is more about risk containment rather than support and management. Furthermore, mental illness is often perceived as a loophole to escape punishment for crimes committed. The sad reality is that those experiencing mental illness are much more likely to be a risk to themselves than they are to others, and this is borne by the literature findings.8 People experiencing mental health issues can become tangled up in the legal system, often with poorly informed law enforcement and legal and judicial practitioners, and this can make an initially trivial episode countless times worse, with serious, lasting implications for the individual involved.

Famous ‘outings'

Recently a number of high profile public figures, have voluntarily ‘outed’ themselves, by announcing publically their personal experiences with mental illness. Famous people are clearly no different from you and I and the average punter on the street. Andrew Robb, the Australian Government Opposition Finance Spokesman, at time of writing, is one such figure. At great risk to his own career and political future, Robb announced publically in 2010 that he had struggled with lifelong depression. Robb has ‘toughed it out’ for his entire professional life, functioning at the very highest cognitive and communicative levels as a senior Government minister and opposition figure. Robb’s messages are clear – it is a tough slog but you can take on depression and win, treatment is the answer, and you should never give up. Robb’s condition is managed by taking a pill in the morning that corrects his body’s natural chemical imbalance. As a result he has never felt better and regrets not seeking help earlier. Furthermore, Robb’s message is you can talk about mental illness, seek treatment and successfully get on with your life.

John Cleese is one of my favourite actors and funny men. Like many comedians he too has battled with depression, and bipolar disorder, for most of his life. While making us laugh for years as Basil Fawlty, the hapless and doomed hotel proprietor and husband of the snarling Sybill, the truth was that very little could make John Cleese laugh himself. He was diagnosed with depression in 1973 and has spoken openly about his experiences.

Winston Churchill, arguably one of the greatest leaders of the 20th Century and who reliably steered England through World War Two, was affected by depression. He famously would ‘chase away the black dog’, his now famous term for fighting off his depression, by painting at the family’s country estate.

These people were and are courageous, and their public struggles should be embraced and put to good use. Their message is that people can manage mental illness and lead successful and rewarding lives, but there were and are clear strategies put in place to manage their conditions. They didn’t go it alone.

Policy challenges

Mental illness affects millions of Australians, and not many seek treatment, as the statistics show. It is a problem because those experiencing the various conditions can suffer a great deal, in unimaginable ways, and they can lose their lives. Mental illness is also linked to poverty, crime, broken families and lost productivity. Placed in those terms it would seem it should be a priority of all governments. However, such a complex problem has equally complex solutions, and it appears that we are well short of a comprehensive and reliable mental health system that serves those affected.

At a policy level, recent government reviews of Australia’s mental health system9,10 revealed the usual suspects: not enough funds, not enough accountability, poor performance measures, and confusion over state versus commonwealth responsibilities. A recurring theme in government surveys is “the need for better services; and the need to serve more people”. Criticisms also include that the solutions are poorly coordinated in terms of funding and also in the coordination of who is providing the service (GPs, private psychiatrists, private psychologists, private hospitals, public hospital inpatient, and non government charitable organisations). Confounding the problem is that there is a multitude of stakeholders: carers, family members, consumers, law enforcement, medical professionals, lawmakers, the legal profession and the general public. An Australian Senate Committee inquiry into Australia’s mental health services noted in 2006 that "it is not often that a committee hears such a united chorus of criticism from such a diverse array of organisations and individuals,”.11 Many, including 2010 Australian of the Year Professor Patrick McGorry, are outspoken about the lack of progress towards an effective and fair mental health system.12

As with many public policy issues there is a clear case of market failure, or perhaps market confusion. Who benefits, who pays? The traditional cost-benefit policy framework makes it difficult to identify the costs and benefits of policy action. The general predicament has resulted in numerous non Government charity organisations that attempt to fill in the gaps – such as BeyondBlue, Lifeline, Suicide Prevention Australia, SANE and The Black Dog Institute.

Some progress has been made. Mental health is now one of the Government’s so called ‘National Health Priority Areas’. There is also a growing understanding on the behalf of Commonwealth and state governments that mental illness is related to many social problems, as discussed above – and is inextricably linked to the welfare, health and criminal justice systems.

Previous reforms include a shift from the old psychiatric institutions of “Shutter Island” fame to mainstream hospitals and community care. Partial Medicare rebates are now available for psychological treatment by registered psychologists under the Australian Government's ‘Better Access to Mental Health Care’ initiative. However, these are overly restrictive, smaller than other health-related rebates, and require ongoing GP referrals – it is clearly different from other supposedly ‘more normal’ conditions where claiming a specialist consultation is straightforward and mostly unrestricted. A mental illness patient is only allowed up to 10 ‘rebatable’ individual visits with a psychologist in a calendar year. There is the possibility of ‘exceptional circumstances’ which allows an extra six visits per year, but red tape needs to be cleared to secure additional visits. A maximum of 16 ‘rebatable’ visits to a psychologist per year (once every three weeks), demonstrates that there is a legitimate need to reduce the cost of psychologist access.

There is also the need for better education of health, legal practitioners, work place HR professionals, and law enforcement, about how to deal appropriately with mental illness situations. Clearly, cross-jurisdictional and disciplinary consistency and linkages are very important in order to ‘reduce the gaps’.

At the medical and scientific level, much effort is being spent on better understanding the causes, diagnosis and treatment of mental illness. Disciplines such as neuroscience are being brought to bear for mental illnesses that are now believed to have physical or biochemical manifestations in the brain or in the hormone systems. Major breakthroughs have been made in brain imaging, whereby the use of complex scanning equipment can pinpoint treatable brain irregularities related to a specific condition. Additionally, breakthroughs in the last decade have linked genetics to the onset of types of mental illness, and have led to innovative techniques to treat the problem. Obviously, more funding will always be required for this ongoing work that is undertaken in our hospitals, universities and independent research centres. Some recent Government activity is encouraging , but many research centres still rely on charitable donations and ad hoc fundraising.13

Ground zero: where it counts

The demands of mental health system reform are obviously proving to be a significant challenge for government. But it is easy to forget that part of the responsibility also rests with us to look after ourselves, and look out for our family, friends and colleagues, and thereby potentially reducing the burden on our governments.

Importantly, at ground zero, we are not helpless. Friends, family and work colleagues are usually the first line of defence when the going gets tough. By being more educated about mental illness, and being aware of how it can surface, and what to do when it does, we’re better placed to look after ourselves, and our friends, family members or work colleagues who may be doing it tough. Indeed, the World Health Organisation (WHO) found in 2005 that social relationships and networks can act as protective factors against the onset or recurrence of mental illness and enhance recovery from mental disorders. These safety nets are found in families, friends, sporting teams, clubs, and other community groups.

Failure to understand the causes and consequences of mental illness impacts us all. For those who are suffering, poor understanding and lack of awareness in peers, and failure to seek treatment by the individual themselves, often leads them to feel more isolated, stigmatised and discriminated against – making matters profoundly worse.

Part of the benefit of having an awareness of the signs of mental illness means you’re more readily able to identify that something may be going wrong inside yourself, or in someone around you, and you’re on hand to help that person take action and get help.
Organisations mentioned above, like BeyondBlue (http://www.beyondblue.org.au), SANE (http://www.sane.org), the Black Dog Institute (http://www.blackdoginstitute.org.au), Lifeline (http://www.lifeline.org.au), and RUOK? (http://www.ruokday.com.au), maintain counselling and education services that can feed into higher order assistance. They have websites that contain useful information on what you should do if you or someone you know is having a hard time of it. Lifeline maintains a free telephone counselling service manned by trained counsellors.

The growing number of these organisations and their websites, with high profile patrons, helps to reinforce that this is a mainstream issue. Most of the organisations spread the message that seeking help is very important, and that treatment offers excellent prospects for recovery. The message is - if you believe you are going under, or are struggling yourself, don’t muck about – talk to someone about it: your GP, a trusted family/friend member or a counsellor. It is surprising how many successful, professional people I know (young and old), who regularly talk to a counsellor or their GP to keep a routine watch on themselves and make sure they’re not ‘slipping through the gap’ referred to by NSW Health. They treat it as just as important as a physical check up – it is normal to look after your health.

In Summary....

Data shows that mental illness is much more common than you think. Chances are that more than one person in your circle of friends or family is affected. More likely, someone in your workplace is affected. Most certainly, someone you encounter in the street or in the course of business will be struggling with serious personal issues. At the very least we as regular punters could do worse than to keep an eye out for ourselves, our mates, colleagues and family. If they’re behaving oddly, falling off the radar or becoming distant, check in with them to see that they’re OK. If you’re worried about them consult an expert via one of the websites above or talk to your GP, or encourage them to talk to theirs. And if you feel you’re losing your grip, likewise check yourself to see you’re OK. Don’t go it alone.

ENDNOTES:

1 ABS, 2007. 4326.0 - National Survey of Mental Health and Wellbeing
2 Ibid
3 Ibid
4 World Health Organisation (WHO), 2008. The Global Burden of Disease
5 NSW Health. (2000). The Management of People with co-existing Mental Health and Substance
Use Disorder – Service Delivery Guidelines, NSW Health Department: Australia, p.2.
6 http://www.aic.gov.au/crime_community/communitycrime/mental%20health%20and%20crime/mental_health_offenders.aspx
7 White, P. And Whiteford, H. (2006). Prisons, mental health institutions of the 21st Century. Med J Aust 2006; 185 (6): 302-303.
8 Ibid
 9 Australian Senate Community Affairs References Committee, 2011. Inquiry into Commonwealth Funding and
Administration of Mental Health Services
10 Australian Government, 2011. National Mental Health Report 2010.
11 http://www.aph.gov.au/Parliamentary_Business/Committees/Senate_Committees?url=mentalhealth_ctte/report/index.htm
12 http://www.patmcgorry.com.au/
13 http://www.nhmrc.gov.au/media/releases/2011/understanding-mental-illness-through-better-research