Chapter 3
Depression and other mental illness
3.1
Mental health is a hugely significant contributor to the burden of
disease in Australia. In chapter 1 the committee described the concept of
'disability adjusted life years' (DALYs) which seek to measure the impact of
both fatal and chronic disease in Australia. DALYs measure both years of life
lost through premature death and loss of quality of life through living with a
chronic condition.
3.2
When these two measures are combined the full impact of mental health is
clearly apparent. As a general disease category, mental health ranks third
behind cancers and cardiovascular diseases as a contributor to the overall
burden of disease.[1]
When specific conditions are considered, anxiety and depression rank second
behind coronary heart disease.[2]
Mental disorders are the largest single component of the non-fatal burden of
disease comprising 24.2% of that category.[3]
3.3
Mental health issues show distinct differences between the sexes. Generally
men are less likely to experience a mental health problem than women.[4] However, in
specific areas and age groups men carry a greater share of the burden of
disease. This is particularly clear in relation to substance abuse which is
more common among men in all age groups. The incidence of suicide among men is
four times that among women.
3.4
Anxiety and depression are less common in men than women but within the
35-44 age group both occur at significant levels. It is estimated that, in this
age group, 8.3% of men experience depression or a related condition and 15%
experience an anxiety disorder.[5]
Surveys suggest that 18% of men experience a mental health problem related to
substance abuse or affective disorder (depression) or anxiety at any time.[6]
3.5
The identification and treatment of mental health problems, particularly
in men, are made more difficult by a range of factors. Firstly, there is a
widespread community perception that mental health is not an important issue
and in conjunction with this is a level of ignorance about significant mental
health problems. In each of the measures of knowledge of mental illness men
were significantly less likely than women to see mental health as a serious
issue or to be able to identify specific mental health problems, including
depression.[7]
In conjunction with research which suggests that men access health services
only when they consider it absolutely necessary, this low awareness of mental
health inevitably results in failure to seek help.[8]
3.6
Men's attitudes to seeking help and treatment for all health problems
are discussed in more detail in chapter 2. Specifically with regard to mental
health, the recently published Irish Men's Health policy states that,
There is considerable evidence to suggest that mental health
is highly gendered and requires a gendered focus at a policy and service
delivery level. Mental health issues can pose a threat to a man’s masculinity,
as evidenced by the way many men conceal symptoms, reject help‐seeking and rely on more
‘acceptable’ male outlets, such as alcohol abuse or aggression, to deal
with a mental health issue.[9]
3.7
As beyondblue has described, men are particularly reticent about
seeking help for mental health problems. Research,
...shows that over 70% of men with a mental disorder do not
access services for their mental health problem and that lower rates of men
(less than 20%) see their general practitioner for mental health issues than
women (30%).
and that a high proportion of men "would feel
embarrassed" to talk to their doctor.[10]
3.8
This is compounded by an apparently widely held perception that General
Practitioners are not supportive in dealing with depression. Approximately 50%
of respondents to a beyondblue survey did not feel that their GP would
take depression seriously, and significant though smaller proportions held
other negative views – that GPs are too busy; that they are likely to prescribe
medication rather than engage in a thorough consideration of the problem and
that GPs did not view depression as an issue of high importance.[11]
3.9
Male attitudes to health and seeking health care are exacerbated by the
perceived stigma attaching to mental health problems. This is particularly
important in regional and rural Australia. It was put to the committee that,
Both men and women in small communities often seek assistance
from health professionals outside of their local community, especially for
mental health issues, for fear of the reaction of others.[12]
This was supported by a number of witnesses to the inquiry.
3.10
Community perceptions of mental health also tend to reflect stereotypes,
often driven by media representations, which are unrepresentative of the true
situation:
...accounts of mental illness that instil fear have a greater
influence on public opinion than direct contact with people who have mental
illness. Mental illness is usually depicted through characters that are
physically violent toward self or others or people who are simple, lacking in
comprehension and appearing lost, unpredictable, unproductive, untrustworthy,
and social outcasts.[13]
3.11
Inevitably this leads to a widespread perception that the community at
large is unsympathetic to, or ignorant of, the realities of mental illness. The
Royal Australian and New Zealand College of Psychiatry (RANZCP) reports that
80% hold these attitudes and that one-third of people "... are unsure how a
friend or colleague would treat them after hearing they had a mental illness".[14]
3.12
In the context of men's health the College makes the important point
that, "...employment status is a key social determinant in men’s mental
health and wellbeing", and that fears of "...job loss, being
discriminated against at work and falling out with people they had close
business and personal relationships with"[15]
are major disincentives to seeking early treatment or acknowledging a mental
health problem.
3.13
In an area surrounded by so much misunderstanding and anxiety it is
perhaps inevitable that confusion also exists about the role of mental health
professionals and the treatments available. The RANZCP has commented that,
With the introduction of the Medicare items allowing access
to psychologists, there has never been greater confusion within the wider
community regarding the different practitioner roles and treatment options
available to consumers.[16]
The College went on to comment that psychiatry is particularly
poorly understood by the community, carrying with it images of "...asylums
and forced medication".
Funding and other support
3.14
Expenditure on the provision of mental health services is estimated to
be 7.8% of total allocated health expenditure in Australia, which ranks third
in terms of expenditure on broad disease categories.[17] This is
less than the proportion of the burden of disease which has led some submissions
to suggest that funding should be increased to that proportion.[18]
3.15
However as table 8.9 in the AIHW report shows, none of the shares of
allocated expenditure on broad disease categories matches the proportion of the
burden of disease – the expenditure on cancer and cardiovascular diseases are
similarly smaller than their share of the burden of disease, suggesting that
such a comparison is not a useful guide to expenditure. To adopt this approach
would imply an increase in expenditure on cardiovascular disease from its
current 11.2% to 18% and on cancer from 7.2% to 19 %.
3.16
The split of expenditure on mental health per capita between men and
women shows that whole of life expenditure on women is slightly higher than on
men ($209 compared with $196) but expenditure by age group shows that at some
ages expenditure on men exceeds that on women.[19]
As noted above, (paragraph 3.3), the incidence of mental health disorders in
women is slightly higher than in men.
3.17
However as the College of Psychiatrists commented, "...the pattern of
presentation and onset [with mental health disorders] does vary between males
and females and there is a marked difference in accessing mental health
services depending upon age and social factors".[20] Thus there
is a clear need for a better understanding of these patterns and the factors
that influence them so that services and interventions can be better targeted.
3.18
The committee received relatively little comment on research into men's
mental health. The RANZCP noted that, with regard to depression,
It is also widely accepted that the understanding of gender
specific symptomology of depression is not widely known or understood and could
also be promoted in terms of improving men’s health.
This conclusion would apply to mental illness generally. Thus
providing funding for research into "...gender specific prevention,
identification and appropriate treatments of mental illness"[21] should be
seen as a priority and would, of course, be of benefit to both men and women.
3.19
A specific area of concern which impinges disproportionately on men's
health is the use of alcohol and other drugs and the links to depression. It is
now generally accepted that the male brain continues to mature until at least
25 years of age or even older and that the maturing brain can be adversely
affected by alcohol. Research suggests that many of the behaviours identified
in adolescent males – propensity for risk taking, lack of inhibition and
judgement and heightened expression of emotion - which lead to significantly
higher rates of accidents and fatalities reflect brain immaturity and that
these characteristics are exacerbated by alcohol.
3.20
beyondblue's representatives emphasised the importance of
recognising and responding to these issues in young people arguing that,
...the things that affect men most are alcohol and drug related
issues, and relationship issues which are terribly profound...and the reason that
beyondblue was founded was young men dealing with the break-up of
relationships.
Drugs, alcohol and depression were described as the "axis
of evil' in mental health which imposed "the greatest weight on the
condition of men" and consequently needed to be accorded priority in the
distribution of limited resources.[22]
3.21
The RANZCP also commented on the need to address mental health issues in
young people which "...if unresolved will manifest in adulthood and will
become more difficult to manage" and,
...to ensure that boys learn more positive coping strategies
and that aggressive, externalising coping mechanisms are not reinforced in the
home or the community.[23]
3.22
The committee considers the mental health of boys and young men to be a
key area that must be addressed in the forthcoming national men's health
policy. Elsewhere in this report it has recommended the introduction of health-related
education programs for school age boys. These must include a component which
monitors mental health and identifies emerging problems, permitting early
intervention.
3.23
The committee received a large number of submissions about the specific
issue of family breakdown and its impact on fathers, who are denied, or have
only very limited, access to their children, particularly boys. Clearly,
judging from both the individual submissions and those from organisations such
as Dads in Distress and Dads4Kids Fatherhood Foundation, this has been a long
running issue which, despite reforms to the Family Law and to the procedures of
the Family Court of Australia continues to cause immense distress.
3.24
With regard to the health of men in this situation, it is clearly important
that they are provided with support after the finalisation of their matter
before the court. Many men will need to rebuild their lives, to make new living
arrangements, sometimes to find new employment and to adapt to the new
relationships with their children, no matter how unsatisfactory they may
consider their situation to be. These can be demanding and stressful
undertakings. It is very important, therefore that they have access to advisory
and counselling services that can help them through this period.
3.25
It is well understood that certain groups in society are at greater risk
of developing mental health problems. In Australia, in addition to men who have
experienced family break down and loss of contact with children, the incidence
of mental health problems rises in rural and regional areas, particularly among
Indigenous men, among men from low socio-economic backgrounds, and is also
particularly prevalent among Defence force personnel who have served in
conflict zones.[24]
3.26
With the continuing impact of drought in south-eastern Australia, the
impact of the global financial crises on employment, financial security and
retirement income and the continuing involvement of Australian forces in
conflict or peace-keeping roles in various theatres, the demands on mental
health services are likely to rise.
3.27
At the same time service providers need to anticipate this growing
demand by putting services in place in preparation. The impact of mental health
problems can be significantly reduced through early identification and
intervention thus it is vitally important that services are available when and
where they are needed. Where at risk groups are readily identifiable, such as
members of the forces or the unemployed it is incumbent on the appropriate
agencies of government to ensure that at-risk people are monitored or, at the
very least, advised as to the availability of mental health support services
should they need them.
Education and Awareness
3.28
Improving the community's understanding of mental health is central to
making progress in this area. As noted above, men are generally perceived as
being unwilling to access medical services and seek help for mental health
problems. A significant component of this unwillingness is the stigma attaching
to those suffering from such problems.
3.29
Changing community attitudes is extremely difficult as demonstrated by
the long term efforts in relation to tobacco use. However the work of beyondblue
with regard to depression does demonstrate that remarkable progress can be made
with well-designed programs. A key aspect of beyondblue's success
appears to be its ability to get highly visible public figures from a range of
backgrounds – politics, business, the theatre, sport - to talk publicly about
their problem, to demonstrate that a significant mental health issue can be
managed and that it is not a barrier to living a full, productive and rewarding
life.
3.30
The Director of Communications for the Mental Health Council of
Australia looked forward to the day,
...where, when we look at a football park and we say, ‘He
recovered from two broken arms and has got back on the field,’ we can also say
‘Well, that person has had a history of depression or anxiety,’ without a
stigma being attached to that, and we do it in the same laudatory way of: ‘Isn’t
that great; recovery and resilience.’[25]
3.31
A second component of beyondblue's success has been to take its
message directly to people where they work, live and relax. It has numerous
programs that target rural communities, sporting clubs, organisations and
workplaces where a combination of meetings, distribution of educational
material and training in how to identify and respond to depression has had
considerable success.
3.32
The success of these activities suggests that the generally accepted
view that men are not willing to talk about, or seek help for, health problems,
specifically mental health issues, needs to be modified. Mr Kennett described
to the committee participating in meetings of several hundred people in small
communities in rural Australia where there was considerable willingness to talk
publicly about problems.[26]
Clearly well designed programs which approach men in a manner with which they
are comfortable and provide information which they find useful will overcome
reticence.
3.33
While progress is being made in encouraging men to acknowledge that they
have a mental health problem and to seek treatment, advances in identifying and
addressing causes are more difficult. As noted above, the interaction of
alcohol, drug use and depression is a major problem, particularly among young
people. There is also evidence that drug and alcohol use is related to a high
level of 'self-medication' by those experiencing mental health problems.
3.34
Despite recent publicity surrounding alcopops and binge drinking among
young women, men remain significantly higher consumers of alcohol than women
and alcohol consumption is strongly linked to ideas of masculinity:
It is considered a masculine behaviour. I do not think I have
to provide a number of citations for you to realise this. Holding your drink is
considered to be a masculine accomplishment...it certainly is embedded in
Australian culture...men definitely have a cultural background, an impulse, to
drink more, to show that they can drink: to show themselves, not only their
friends.[27]
3.35
Research increasingly supports the position that alcohol has a
significant negative impact on the immature human brain, leading to
recommendations that no alcohol should be consumed before the age of eighteen
or even older. However, as has been the experience with changing behaviour with
regard to tobacco smoking and drink driving for example, it is extremely
difficult to compete with entrenched social and cultural attitudes to the
consumption of alcohol, (particularly where they intersect with attitudes to
typically 'masculine' behaviour) and the commercial interests that promote it.
3.36
As Dr James Lemon told the committee, attempts to change attitudes that
ignore the reality that in the short term drug or alcohol use can make the user
feel better will fail and that young people will respond much more strongly to
behaviours they see modelled by adults than to messages that are contradicted
by people's own experience.
As long as young men see an advertisement on television
telling them that getting drunk is not cool and their experience of getting
drunk is that it is cool...they
simply say, ‘This is a load of codswallop and I’m not going to listen to any of
it,’ even if the entire remainder of the content is quite sound and would be
helpful. [28]
3.37
Alcohol consumption is an area where conflicting messages undermine
efforts to educate users about safe behaviour. The known protective effects of
regular moderate alcohol consumption tend to confuse the debate about the
dangers of alcohol. This emphasises the point that, unless education campaigns
are carefully designed they will fail and in failing may discredit the
worthwhile messages that they are trying to promote.
3.38
Related to this, the committee heard much comment on the need for
thorough evaluation of health-related education and awareness campaigns in
general and specifically in the area of mental health. Dr Lemon commented, with
regard to advertising campaigns, that,
...the government does fund a lot of these efforts...It funds the
research that devises these interventions, it funds the interventions
themselves and it funds people like me. A lot of my job is looking at
evaluating these interventions. Very often I end up being a sort of coroner who
has to determine the reason the intervention died and explain this to the
bereaved therapist whose intervention has not worked ...[29]
The committee has commented further on this in chapter 2.
3.39
The final area of awareness that the committee wishes to emphasise is
the link between family breakdown and mental health issues. beyondblue
identified relationship breakdown as a major contributor to mental health
problems. The College of Psychiatrists similarly identified family
circumstances as one of the most important social factors affecting men's
mental health.[30]
3.40
The committee also received a number of submissions from individuals and
organisations specifically concerned with the impact of family breakdown on men
and on the children of a relationship who found themselves without regular
contact with their father. These submissions referred to both the damage to
men's mental health and the impact on boys of growing up without a father
providing a male role model. The committee has commented on the need to provide
support to men experiencing this process at paragraphs 3.23-3.24 above.
3.41
In terms of addressing the causes of depression and other mental health
problems, some effort needs to be put into educating young men (and women)
about the responsibilities that they will take on when entering into long-term
relationships, particularly where they become parents, with the object of
reducing the incidence of relationship breakdown. A second group that should be
targeted is parents whose relationship has failed, to assist them in minimizing
the adverse impacts on children of behaviours which inappropriately limit
contact between the child and both parents, or worse, involve the children in a
conflict with the estranged partner.
3.42
In terms of reducing the incidence of family breakdown and addressing a
source of depression in both men and boys the committee supports the proposals
put forward in the submission from the Family Action Centre at the University
of Newcastle on the need to increase awareness among fathers of the issue of
post-natal depression and also the related issue of the incidence of depression
in new fathers, which can have damaging effects on the whole family.[31]
3.43
The committee notes that the Commonwealth Government has announced the
National Perinatal Depression Plan[32]
which "...aims to improve prevention and early detection of antenatal and
postnatal depression and provide better support and treatment for expectant and
new mothers experiencing depression".[33]
The program will involve screening of all pregnant women for depression prior
to and two months after the birth of a child. The program will also include
some information and advice for men as to how they can help their partner and
also where they can get advice.
3.44
While the incidence of depression in new fathers may not be high enough
to justify a universal testing program, the committee suggests that the
screening program for mothers could be extended to include contact with the
father to ensure that he is fully aware of the issue and that he is given an
opportunity to raise any problems he may be having.
Improving the quality and accessibility of services
3.45
Removing the stigma attached to mental health, promoting open discussion
and encouraging men to seek help for mental health problems will not have
significant impact on morbidity if the services cannot respond appropriately to
demand.
Improving health professionals’ capacity and willingness to
recognise and manage depression and anxiety may be a key factor in improving
the help seeking behaviours of both Australian men and women.[34]
3.46
General practice is the first point of contact for the majority of men
seeking help for a mental health problem,[35]
despite the perception noted above in paragraph 3.8 that it is not a
sympathetic environment in which to discuss depression. The committee is aware
of the demands on general practitioners and does not wish to criticise them but
there do appear to be structural problems which militate against the men
concerned about their mental health seeking treatment from a GP.
3.47
The standard short consultation is not appropriate to the identification
of depression or anxiety. Yet reliance on the short consultation is largely
driven by demand (the doctor's waiting room is full) and cost (the gap between
the Medicare rebate and the GP's fee is obviously greater for longer
consultations).
3.48
There are also training issues in relation to general practice because
GPs may not be particularly well-equipped to identify a mental health problem, especially
where the patient presents with another complaint and does not volunteer the
information that they have an additional problem. Here again we see the interaction
of men's behaviour, a reticence to talk about mental health and a preference
for practical advice in relation to a visible problem, with the realities of
general practice. Research suggests that most GPs deal with only one problem at
a time.[36]
3.49
In recognition of this problem beyondblue is supporting research
to "...enhance general practice's capacity to identify depression and
suicidal risk factors".[37]
The committee has also considered this matter in chapter 2 and made
recommendations to improve the situation.
3.50
An important aspect of the incidence of depression is co-morbidity,
where depression occurs in conjunction with, and as a result of, a physical disease
such as prostate cancer. The committee has discussed this at some length in
chapter 4. There is a clear need for general practitioners and specialists to
consider the mental health implications of major physical diseases or trauma. The
committee notes that the Prostate Cancer Foundation of Australia (PCFA) and beyondblue
have collaborated in a number of activities to increase awareness of this
problem, particularly the successful Movember campaign which acts as both a
fund- and awareness raiser.[38]
3.51
A more general problem exists as a result of the rigid division between
services which are, in practice, often closely related. This is most apparent
in the areas of drug and alcohol problems which are often associated with
mental illness, particularly among men, given the incidence of self-medication.
beyondblue explained to the committee that there is a need for much
better integration of services to ensure that people are not turned away if
they approach the 'wrong' service.
...if you have a drug problem and an alcohol problem you may
not even get into the one service. If you have mental illness as well, you will
not; you will be turned away because ‘we do drugs here’ or ‘we do alcohol here’
or ‘we do mental illness’[39]
and concluded,
...there is an absolute need for identifying issues and working
together in an integrated way across drug, alcohol and mental health services.
Regardless of the point at which you come in, you should not to be turned
away...There is a strategy for everything, but they are not integrated. In fact,
the person is often excluded from services because of that. [40]
3.52
The College of Psychiatrists also commented on two aspects of service
provision:
- The variable standards of care across the various jurisdictions
in Australia, and
- the range of services which are often required in the treatment
of mental illness and the need to bring them together,
There is also a need to better coordinate and connect other
relevant community supported services needed by patients with severe mental
illness and complex needs with their clinical care (e.g. general health care,
financial support, housing, substance abuse, rehabilitation etc).[41]
3.53
This can be particularly true for patients from rural or regional
Australia who have had to move 'out of area' to receive treatment.
3.54
The importance of recognising the range of services that a person with a
mental health diagnosis may need cannot be over-emphasised. It is a common
occurrence, particularly for a person being released from institutional care to
be left without adequate support. The pressure on acute care beds is such that
many mental health units have to discharge patients somewhat earlier than is
ideal:
Adequate discharge planning and follow-up of patients should
become mandatory for all patients discharged into the community from hospital
settings. Acute inpatient units increasingly discharge people with severe
illness into crisis accommodation or “no fixed address”. In communities that do
not have the service structures and operating systems to support people with mental
illness to live safely or rehabilitate in the broader community, people with
mental illness will not receive adequate follow-up treatment and often end up
being readmitted following a worsening of their condition.[42]
3.55
There is overwhelming evidence of the interconnectedness of men's physical
and mental health issues. It is important that this be recognised in the
provision and conduct of treatment services. Therefore,
The committee recommends that the integration of health service
provision to recognise the interconnectedness of men's health issues be made a
central part of the forthcoming national men's health policy.
The committee recommends that the Commonwealth Government
investigate standardised service models for mental health to facilitate a uniform
standard of care throughout Australia.
3.56
Given men's attitudes to seeking help for mental health problems and its
higher incidence in rural and remote areas, and the lower level of trained and
specialist services in those areas, telephone counselling services play an
important part in providing initial contact and advice on mental health and in
providing crisis support.
3.57
The Commonwealth must ensure that services such as Mensline Australia,
SuicideLine Victoria and the beyondblue Information Line are adequately
funded and that the services they provide are widely publicised, particularly
to known at-risk groups. These services also have specific advantages for men
particularly in:
Providing services that allow men to access help without have
to confront perceived social obstacles; [and]
Devising gender‐specific information and
disseminating it through media that are appropriate for men;...[43]
and the potential to expand them should be investigated.
Suicide
3.58
Men are four times more likely to commit suicide than women. It is the
tenth most common cause of death for men, ranking above such things as melanoma
and land transport accidents.[44]
Suicide is highest in the 30-45 age group but is high, above 20 per 100 000, in
every age group from the late teens through to late middle age. It also
increases in older men above the age of 75.[45]
3.59
The reasons why men commit suicide are, perhaps inevitably, unclear and
there is no clear linear progression from a 'negative life event' to suicide.
It is known that having a diagnosed mental illness is an increased risk factor
for suicide and that relationship breakdown leading to anxiety and depression
is correlated with attempted suicide in men.[46]
The increasing incidence of suicide in rural Australia has been linked to
economic and social stresses related to the extended drought. It is also
conjectured that men are particularly ill-equipped to cope with the sense of
failure that may come from the loss of a property of or job.
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