EVALUATION OF FIRST NINE MONTHS OF THE NATIONAL DEPRESSION INITIATIVE PUBLIC HEALTH CAMPAIGN

Transcription

1 8 Normanby Road, Mt Eden PO Box , Auckland Telephone Facsimile EVALUATION OF FIRST NINE MONTHS OF THE NATIONAL DEPRESSION INITIATIVE PUBLIC HEALTH CAMPAIGN R E S E A R C H R E P O R T F O R MINISTRY OF HEALTH February 2008 Ref: R doc

2 CONTENTS 1 SUMMARY DISCUSSION AND RECOMMENDATIONS DISCUSSION RECOMMENDATIONS INTRODUCTION PROGRAMME LOGIC...23 INTRODUCTION CAMPAIGN LOGIC NDI PROGRAMME LOGIC PRIORITY AUDIENCES CAMPAIGN ACTIVITIES CAMPAIGN IMPACT ACTIONS TAKEN: USE OF FREEPHONE, WEBSITE AND RESOURCES WHO IS BEING IMPACTED: RESPONSE TO ADVERTISING AND CALLS TO LIFELINE MAORI AND OTHER ETHNIC GROUPS GENDER YOUTH LEVEL OF DEPRIVATION REGION CHANGES WITHIN PRIMARY CARE (INCLUDING GREEN PRESCRIPTIONS AND PRESCRIBING)...64 APPENDIX A: MEDIA COVERAGE...69 APPENDIX B: JOHN KIRWAN NZ HERALD ARTICLE NOVEMBER 28, APPENDIX C: INTERNATIONAL DATA ON IMPACT OF DEPRESSION CAMPAIGNS ON PRIMARY CARE...82

3 1 SUMMARY INTRODUCTION This is a limited evaluation of the first 9 months of the National Depression Initiative (NDI) Public Health Campaign, up to the end of June, The objective of this report is to bring together the available information to provide: Documentation of what has happened Information relating to campaign impacts Assessment of progress to date for the purpose of future planning PROGRAMME LOGIC Two logic models have been developed: A model for the NDI public health campaign A model for the whole NDI PRIORITY AUDIENCES The following priority audiences have been identified for the campaign: Youth (15 to 24 year olds) Adult males aged 25 to 44 years Adult females aged 25 to 64 years Maori, especially Maori women The most deprived (NZDep quintile 5) People experiencing anxiety disorders Pregnant mothers and those with new born infants (re post natal depression) At risk minority groups, namely: Refugees Gay, lesbian and bisexual persons Children who receive welfare care People in custody and incarcerated Those who are socially isolated or excluded The most notable exclusion from this list is Pacific peoples, which has been the source of considerable discussion within the provider group and Ministry. CAMPAIGN ACTIVITIES The campaign activities have included: Advertising campaign Freephone service Website (a mainstream site and a youth site under development) Project management and sector engagement Media coverage 3

4 Distribution of educational resources Research and evaluation CAMPAIGN IMPACT To assess campaign impacts with the public, a benchmark survey was undertaken in September/early October, 2006, just before the campaign began and a follow-up survey was undertaken in June/July, 2007, after eight months of the television and radio advertising campaign. Both surveys had samples of just under 1000 interviews, which were completed with the NDI priority audience of males aged 15 to 44 years and females aged 15 to 64 years. There was a weighted response rate of 70 percent in the follow-up survey. The data was weighted to reflect the correct proportions of the population by gender, age and ethnicity. Response to advertising A very high proportion (90%) recalled seeing the advertising, after prompting. People were generally very positive about the ads. When asked about message recall, two-thirds reported something relating to seeking help, although only three percent specifically mentioned phoning the 0800 Depression helpline. Sixteen percent made some comment that related to the message that it 'Can be treated/ controlled', while 12 percent said 'Talk about it/ be open about it'. Seven percent mentioned 'look for signs of depression' Sixty-two percent had discussed this advertising with someone else. Seven percent said they had heard advertising about depression on the radio. Contact with people with experience of depression While there was a slight increase in the proportion who volunteered that they had personally experienced depression (up from 13% to 15%), this was not a sufficiently large increase to be significant. Fifty-seven percent of respondents said that in the previous 12 months they had listened to, talked to, or supported someone who was experiencing depression. (There was no comparable measure in the previous survey.) Symptoms of depression There was a small but significant increase between the two surveys in the proportion of participants who were able to give at least one actual sign or symptom of depression, up from 92 to 94 percent. However, there was no change in the average number of actual symptoms respondents mentioned (2.7). The most mentioned individual symptom was 'withdrawal/social isolation', which showed a significant increase from 48 to 53 percent. Who to turn to for help There was one significant change in mentions of people they would be likely to ask for help if they thought they might be experiencing depression. This was a small decrease in the proportion who said they wouldn't seek any help (down from 5% to 3%). 4

5 When asked to rate the likelihood that, if they thought they might be experiencing depression, they would adopt certain behaviours, there was an increase in the mean likelihood of phoning a helpline. There was also an increase in the mean likelihood of 'seeking written information about depression, such as from the internet, magazines or books'. There was no increase in the likelihood of talking to a 'friend, family or whanau member or some other person you could trust', or a 'doctor or some other health professional'. Response to someone who might be experiencing depression Eighty-three percent (up significantly from 77 percent) gave a high rating (7-10) for the likelihood of going to the person and encouraging them to talk about it. There was a small improvement for the ratings for 'Seek advice or information so you could assist this person', with a decrease in those giving a low rating (down from 5% to 2%). There was no change in the level for encouraging someone with depression to see a doctor or seek other professional help (84%). Suitable treatment or assistance for someone with depression There was no significant movement in the proportion of participants listing at least one thing they could do to be supportive of someone with depression, although this was already relatively high (88%). There was an increase in mention of 'Counselling/psychotherapy/psychological treatment' (up from 41% to 46%). Attitudes relating to depression and its treatment Most statements showed significant improvements in the desired direction, specifically: It is important to recognise and act early on depression, rather than waiting (increase from 64 to 74% in the proportion 'strongly agreeing') If a close friend had depression, I would be able to recognise the signs and symptoms (up from 49% to 54% for those 'agreeing' 1 ) I would be able to recognise if I had depression ('agreeing' up from 53% to 60%) I would like to know more about depression ('agreeing' up from 36% to 42%) Depression can be successfully treated with medication ('agreeing' up from 43% to 49%) People with depression just need to stop feeling sorry for themselves ('disagreeing' up from 63% to 70%) ACTIONS TAKEN: USE OF FREEPHONE, WEBSITE, AND RESOURCES The graph which follows illustrates the close link between the level of advertising (TARPS) and the weekly calls to the helpline and visits on the website. There was high useage of both in the initial period of advertising in October 2006, but a rapid decrease when the advertising stopped. The advertising beginning at the end of December 2006 and running for the three weeks of the holiday period resulted in the highest use of the web during any period. The number of phone calls is more dependent on the advertising than the number of web visits. 1 'Agreeing', as reported in this summary, refers to those who said they either 'agree' or strongly agree' with the statement. 5

6 There was a peak in website activity (but not freephone activity) in response to an article in the New Zealand Herald on 28 November, 2006, where John Kirwan was inspiring men to reach out for help, but this was the only media coverage to cause any marked increases in website or freephone activity. Link between advertising, freephone and website sessions TARPS NZ Herald article "JK inspires men to reach out for help" Calls/Sessions Tarps Calls to freephone Web Sessions Oct 22-Oct 5-Nov 19-Nov 3-Dec 17-Dec 31-Dec 14-Jan 28-Jan 11-Feb 25-Feb Week Ending 10-Mar 24-Mar 7-Apr 21-Apr 5-May 19-May 2-Jun 16-Jun 30-Jun Just over two thirds of site visits last for less than three minutes, and it would seem unlikely that people are going to be getting any benefit from the site in this amount of time, except possibly getting an 0800 or other contact number. Therefore dividing site visits by three provides a better indication of numbers of site users. These numbers are comparable and sometimes less, especially in the early period of the campaign, with those using the freephone. The two dominant responses with freephone callers is to supply them with resources and provide information on self-help strategies. Lifeline offer freephone callers the opportunity to be called back to provide support, check on progress being made, and make sure they have received any professional help they needed. Twenty-seven percent of callers were initiating these "WeCare" callbacks, although approximately 47 percent of callbacks were abandoned with no contact after several attempts. Those reached had received an average of 3.2 calls over a three month data collection period. Lifeline reported that these follow up calls are highly valued by users. The Depression freephone had not reduced the number of calls Lifeline were receiving on their normal counselling phones. Monday was the day when the greatest number of calls were received, with the numbers decreasing as the week progresses. This decrease during the week was similar for the website, but the website did not have the markedly higher level for Monday. The most popular website page was 'Help me', followed by the survey. The freephone calls peaked between 10 and 11 am, but remained at relatively high levels until around 10pm. This was an earlier peaking than for the website, possibly indicating a more urgent need to address issues for the freephone callers

7 WHO IS BEING IMPACTED - RESPONSE TO ADVERTISING AND CALLS TO LIFELINE Maori and other ethnic groups The rate of Pacific peoples, Asian peoples and Other minority ethnicities calling the freephone was less than half their proportion in the population. Maori were also under-represented in the calls, but not to the same extent. Maori had above average recall of the campaign (96% versus 90% for the total sample). The main Maori feelings and impressions about the advertising, message recall and rates of discussion of the ads were at similar levels to the total sample. Maori had lower recall of symptoms of depression than did the total sample. Maori were less likely to mention turning to a GP/doctor/health service, or a counsellor/psychologist if they thought they might be experiencing depression They were also less likely to give a high rating for their likelihood of encouraging someone with depression to see a doctor or seek professional help and for their likelihood of 'Seeking advice or information so you could assist this person'. There was a significant decrease between the two surveys in the proportion of Maori mentioning 'Alternative/traditional/ spiritual/self help' as suitable assistance or treatment for someone experiencing depression Compared with the total sample, Maori were less likely to mention 'Counselling/psychotherapy/ psychological treatment and 'Medication/anti-depressants'. Maori showed significant changes consistent with advertising messages for three of the attitude statements, these being: It is important to recognise and act early on depression, rather than waiting Depression is becoming a major health problem in New Zealand People with depression just need to stop feeling sorry for themselves, for which there was a big increase in the proportion 'disagreeing' There was an increase in the proportion of Maori who disagreed that they would be able to recognise if they had depression (up from 6% to 11%). Compared with the total sample, Maori were significantly more likely to 'agree' that 'I would like to know more about depression' and that 'depression is becoming a major health problem in New Zealand'. Gender The proportion of males calling the freephone is a close match to their proportion of the population, which is much higher than the normal male freephone response to campaigns. Although men had lower recall of the advertising than women (83% versus 94%), this level for men was still relatively high. Men and women were similar in their response to the ads, including messages recalled and level of discussion. Women were more likely to volunteer that they had personally experienced depression (18% versus 10% for males), which was consistent with the epidemiological data. Women were much more likely to report that in the last 12 months they had listened to, talked to, or supported someone with depression. Women were generally more aware of symptoms than were men. Between the two surveys men reported an increased likelihood of seeking information about depression, such as from the internet, magazines or books. 7

8 There was also a reduction in the proportion of males who rated it unlikely that they would 'talk to a doctor or some other health professional' Compared with women, men were more likely to mention turning to friends/family/whanau if experiencing depression. Women were more likely than men to mention doctors (76% versus 50%) and counsellors/psychologists. Women were more likely than men to give higher ratings for the likelihood of taking actions if they thought they might be experiencing depression or if someone else was. Both men and women reported increased likelihood of going to a person who might be experiencing depression and encouraging them to talk about it. For men there was a decrease in the proportion mentioning 'Support/someone to talk to/social contact' as an appropriate form of assistance or treatment. Women generally had higher awareness than men of appropriate forms of assistance or treatment. Men showed changes consistent with advertising messages on six attitude statements compared with three for women. Youth The freephone data showed low levels of calls by persons aged 14 to 19 years. Youth recall of the advertising was below average, but at 79 percent this was still a relatively high rate of recall. Youth were much less likely to discuss the advertising They were similar to the total sample in saying that it was a good ad, although fewer youth went as far as saying it was 'very good/fantastic'. Youth message recall was generally at similar levels to the total sample. There was a significant increase since the benchmark survey in the proportion of youth who volunteered that they had personally experienced depression. Youth were now more likely to mention seeking help from a counsellor/psychologist if they thought they might be experiencing depression. Youth also showed an improvement on three of four measures for the likelihood of taking actions if they thought they might be experiencing depression, these being: 'talking to a friend, family or whanau member or some other person you could trust', 'talking to a doctor/health professional' and phoning a helpline. Compared with the total sample, youth were more likely to turn to their family/friends/whanau, or a counsellor/psychologist, and less likely to 'talk to a doctor or some other health professional'. They were less likely to mention medication/anti-depressants as suitable treatment. Youth showed no significant changes in attitudes between the two surveys. Compared with the total sample, they were: less likely to 'strongly agree' that 'It is important to recognise and act early on depression, rather than waiting' less likely to 'agree' that: 'If a close friend had depression, I would be able to recognise the signs and symptoms'; 'Depression is becoming a major health problem in New Zealand; and 'Depression can be successfully treated with medication' less likely to 'disagree' that 'I would like to know more about depression, which was indicative of a greater interest in knowing more. less likely to 'disagree' that 'People with depression just need to stop feeling sorry for themselves which was indicative of a less positive attitude towards people with depression. 8

9 Persons from high deprivation areas While level of deprivation data is not available from the freephone data, information is available to show that beneficiaries are over-represented among callers. This high deprivation group were similar to the total sample in their recall of the advertising, their feelings and impressions about it, their discussion of it, and their recall of the radio advertising. In terms of message recall, they were less likely to mention 'It is OK to be depressed', but on other messages they were similar to the total sample. There was a increase in the proportion of high deprivation persons who volunteered that they had personally experienced depression. There was a decrease in the proportion giving a high rating for the likelihood of 'seeking written information about depression'. Compared with the total sample, people from high deprivation areas were less likely to give a high rating for the likelihood of 'talking to a friend, family member', or 'seeking written information about depression' if they had depression. In terms of treatment/support options, this group reported increased mention of 'Counselling/psychotherapy/psychological treatment' and decreased mention of 'doctors/hospitals/ psychiatrists',but there were no differences of note compared with the total sample. There were attitudinal changes consistent with campaign messages in terms of: More 'strongly agreeing' that 'it is important to recognise and act early on depression, rather than waiting' More 'agreeing' that, 'Depression is becoming a major health problem in New Zealand' More 'disagreeing' that, 'People with depression just need to stop feeling sorry for themselves'. There were attitudinal changes demonstrating lack of uptake of campaign messages in terms of: More 'disagreeing' that, 'If a close friend had depression, I would be able to recognise the signs and symptoms' More 'disagreeing' that, 'Depression can be successfully treated in ways that don't need medication'. Compared with the total sample, those from high deprivation areas were more likely to: 'agree' that, 'I would like to know more about depression' 'agree' that, 'People with depression just need to stop feeling sorry for themselves' CHANGES WITHIN PRIMARY CARE (INCLUDING GREEN PRESCRIPTIONS AND PRESCRIBING) The graph below shows the number of new diagnoses of depression between October 2004 and March 2007, based on primary care data from HealthStat (from an unpublished 2007 report to MoH). Despite a marked increase in November, 2006, which was presumably a result of the launch of the NDI, there appears to have been no long term impact of the NDI on the established trend of increasing GP diagnoses of depression. The number of consultations per annum for those with depression were not yet showing any effects of the NDI campaign. Antidepressant prescription volumes 2 based on the primary care survey, showed a similar trend to that for depression diagnoses, except there was no marked increase at the time the NDI campaign began. This indicates that the new diagnoses of depression at the time the campaign began were 2 It should be noted that some antidepressants are also prescribed for reasons other than depression, primarily for chronic pain management and smoking cessation. 9

10 probably mostly already using anti-depressants, adding further confirmation that the campaign was not resulting in any marked increase in people presenting to primary care with depression. Pharmac prescription data also shows no indication of any marked change in existing trends that might possibly be attributable to the NDI. There is insufficient data as yet to assess the impact of the NDI on green prescriptions. However, the 2006 survey reported that 42 percent of GPs who were using green prescriptions, were using them to relieve patients' depression/anxiety. In a 2007 patient survey, 57 percent of those issued a green prescription for depression felt less depressed/anxious, with 54 percent feeling less stressed, 50 percent generally feeling better and 47 percent feeling stronger/fitter. 10

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12 2 DISCUSSION AND RECOMMENDATIONS 2.1 DISCUSSION This report draws heavily on the findings from the tracking surveys and therefore the discussion and recommendations have a lot in common with the corresponding section of the second tracking survey report. USEAGE OF FREEPHONES EXCEEDS EXPECTATIONS, BUT CURRENTLY QUITE DEPENDENT ON ADVERTISING In terms of the stages in the programme logic, calling the freephone is one of the actions that the campaign has been seeking to encourage. Lifeline report that the freephone calls have far exceeded their expectations based on previous campaigns. (We can't actually work out how many people have accessed the freephone, as we don't know how many are repeat callers.) Freephone useage does decrease a lot when there is no advertising (more so than the web visits), so it will be important to find ways of ensuring that people have access to the freephone number from other sources. Obviously ensuring it is listed with other personal help services in the front of phone books will be critical. It may also be that people will increasingly need to find the 0800 number via the website. The extent to which the freephone is promoted needs to be carefully planned. Obviously Lifeline are contracted to provide a certain level of service, so the number of calls needs to be matching this as closely as possible. It would certainly be possible to give the freephone a higher profile in the advertising than at present, where it appears on the final screen, but is not mentioned in the voice over. The tracking survey findings are consistent with this low profile, as it gets very little mention in the advertising recall and there was only a small increment in reported likelihood of using the freephone if the person had depression, with levels remaining quite low. VALUE IN INCREASING WEBSITE USEAGE It is difficult determining what is an appropriate level of useage of the website, in terms of measuring the success of the campaign. It is a lot less threatening for someone to visit a website than to call a freephone number, so one might possibly expect that there would be a lot more website visits than freephone calls. When only web visits of at least three minutes are considered, the number of web hits decreases to levels similar to the freephone use. This would seem to be quite low, even allowing for some households not having internet access. There would therefore seem to be a case for increasing the promotion of the website, in part because it does not cost anything extra to deal with increased traffic. The website currently has a low profile in the TV advertising, appearing on the final screen with no voice over. There was almost nil mention of the website in the message recall. While the website was not asked about specifically, seeking written information about depression, such as from the internet, magazines or books did show an increase as a likely action if people thought they might be experiencing depression. Obviously the promotion of the main website also needs to be considered in relation to promotion of the youth website. For example, should both be promoted on the TV ads? 12

13 NEED TO ENSURE WEBSITE IS WORKING EFFECTIVELY The previous discussion about the importance of the website does raise the question as to the quality of the existing NDI site and how well it is meeting the needs of the priority audience. This website was initially developed within a tight timeframe to mainly act as a portal, providing some information, but mainly ensuring people got directed to appropriate assistance. Consideration should now be given to further development of this site, which could provide a more interactive and dynamic experience for visitors Given the increasingly important role that it will need to play, especially when advertising spend is low, it would be appropriate to consider further research to inform future development of this site, beyond the on-line survey that is currently underway. This survey has had a poor response rate, plus only motivated people will answer a survey such as this, so it is only going to provide limited information. Some qualitative research, such as was undertaken as part of the development of the youth website, would add understanding as to how people are likely to be responding to the site. NEED TO BUILD A SUSTAINABLE APPROACH It is obviously important to seek to build an approach that, over time, reduces reliance on paid advertising. This will mean that people need to know where they can go to access information and contacts. This underlines the importance of the websites, especially as web useage in general is likely to continue to increase in its reach and importance within society. Primary care seems to be the other main option to focus on in terms of sustainability. This is because primary care is the place that people currently think of turning to most often, apart from family friends and whanau. Primary care is also likely to be having an increasing focus on mental health, building on the primary mental health initiatives. Working with primary care is already being addressed as a key part of the NDI, but mostly separately from the public health campaign. So it will be important that close links are maintained between the public health campaign and the specific initiatives with primary care. QUESTION OF HOW MUCH TO PROMOTE USING PRIMARY CARE Despite some media coverage at one stage suggesting that primary care services were struggling to deal with the increased demand resulting from this campaign, the data show that there was only a one month increase and that was probably compensated for by slightly lower levels in the following few months. The data also suggest that the increase was not due to new people presenting to primary care for the first time, as antidepressant prescriptions volumes did not change. The findings do raise the question as to whether the campaign should be resulting in increased cases of depression presenting to primary care. One of the campaign strategies is to encourage people to seek appropriate help. Given primary care is the main professional help option people are aware of, and it is in most cases the most affordable, it does seem that the NDI should be encouraging more use of primary care and that increased useage should be seen as a measure of success for the NDI. Given the campaign to date, which has had very little focus on help seeking options, has not produced any increase in demand on primary care services, greater promotion of primary care would now seem appropriate. 13

14 IMPORTANCE OF LIFELINE FOLLOW-UP CALLS The follow-up WeCare calls that Lifeline has initiated (which was beyond what they were initially contracted to do) would seem to be playing an important role, especially if people are not presenting at primary care. People who are experiencing depression are, not surprisingly, valuing this support and presumably the feeling that someone cares about them. Also knowing someone is going to be calling can assist in motivating people to take the actions they have undertaken to do. It will be valuable to obtain more detailed information on this follow-up, once Lifeline has their new data collection system operational. This data will also assist in our understanding of the paths people follow once they make the freephone call and how useful people are finding different helping options (eg primary care, self-help strategies). It may also assist in identifying some of the barriers to people seeking other forms of help. A GOOD BEGINNING FOR MEDIA CAMPAIGN, BUT MORE SPECIFIC MESSAGES NOW NEEDED TO COMPLEMENT JK ADS Overall, it would seem that the media campaign has made a good beginning. There were a lot of positive improvements evident in the second tracking survey, but at the same time there were some measures that hadn t moved as yet. The level of advertising recall was very high and similar to the levels that have been achieved by the 'Like Minds Like Mine' campaigns over recent years. The level of discussion of the ads was slightly better than the most recent survey for Like Minds, but similar to the best levels achieved by Like Minds in earlier surveys. When compared with the NDI strategies, as outlined in the Introduction section, there are good advances in terms of people strongly agreeing with the importance of early identification and intervention. This message is now at high levels among most groups, so there would seem to be no need to further prioritise this message. In terms of assisting people to recognise symptoms of depression in themselves and others, it is positive that there have been significant improvements in people agreeing that they could "recognise the signs and symptoms" of depression. However it is interesting to note that there has not been any significant increase in the overall number of symptoms mentioned when asked to specify symptoms. There have been some increases and decreases in mention of specific symptoms and perhaps people are now feeling they have a better understanding of these. The TV ads have not mentioned particular symptoms, except anxiety attacks, so it is not surprising that there is no overall increase in the number of symptoms mentioned. The pre-testing of these ads, which Phoenix Research undertook, identified that people were left wanting to know more. The research findings point to a need to now examine whether more can be done with complementary initiatives that provide this information. However it could also be that people have had a reasonable knowledge of symptoms all along and the campaign is now giving them greater confidence that they do know the "signs and symptoms" and could identify someone with depression. While there has been an improvement in the proportions who feel they could recognise depression in themselves and others, there are still not much over half the population who agree that they could do this, so there is obviously still a lot of room for improvement. This is particularly the case with some of the key audiences discussed below. 14

15 There has recently been discussion within the Ministry and provider group as to whether symptoms is the best way of approaching this or whether there should be more focus on risk factors. This is consistent with the NDI advertising pre-testing qualitative research, which indicated that people may be more likely to recognise depression via the difficult circumstances someone is experiencing (eg relationship break up) rather than via the recognition of actual symptoms of depression. In terms of encouraging people to seek appropriate help, there is a strong message coming through the advertising about seeking appropriate help. However the campaign doesn't seem to have got people thinking about any new options for seeking help, as there were no changes in who they mentioned they would seek help from. While there were small improvements in the ratings people gave for the likelihood of phoning a helpline or seeking written information, the lack of improvement for doctors or other health professionals was perhaps disappointing, given there are still only two thirds giving a high rating for this. The fourth component of the NDI strategy is increasing awareness of effective interventions for depression, including self help strategies. 'Counselling/psychotherapy/psychological treatment' did show increased mention. One of the John Kirwan ads mentions reaching out to "loved ones, doctors, psychologists, psychiatrists", so perhaps it might have been expected that there would be more categories showing increases. However, it is only mentioned in one of the five ads, so there could be a case for this ad receiving greater air time than it has to date (it has been one of three that has received more air time). Therefore the initiatives that are designed to complement the mass media campaign need to take a key role in making people more aware of the appropriate forms of assistance and treatment for someone experiencing depression. The one attitude measure that showed no change was the one relating to awareness of self-help strategies. Self-help strategies also remained low in mention as suitable options for assistance or treatment for someone experiencing depression, being mentioned by just one in five. The John Kirwan ad which addresses self-help only covers a few options (it mainly mentions "actively relaxing" and shows physical activity in the form of surfing), so more specific information may be needed to ensure people become better informed. Given self help strategies are options which may be low cost and possibly reduce pressure on primary care and other services, they would seem to justify greater attention in future promotions. One of the ads primarily addresses reducing stigma. The pre-testing identified that the 'don't hardenup' communication in this ad was particularly effective, especially for Maori. However, the ad is not directly addressing any of the four components of the NDI strategy; reducing stigma is not part of the NDI strategy, because it is covered by Like Minds. Therefore it would seem appropriate to reduce the air time given to this ad. As noted in the introduction, these ads were developed before the NDI objectives and strategies were finalised. It is increasingly apparent that there is a need for additional information to be provided to build on what these ads are delivering. There needs to be discussion within the campaign team as to whether a mass media approach is needed, in order to communicate this additional information in a manner that ensures it gets sufficient exposure. Perhaps some of the budget that was allocated for further screening of the John Kirwan ads could be redirected towards other forms of advertising. 15

16 POSITIVE INDICATIONS OF CAMPAIGN IMPACT ON YOUTH Despite the fact that the advertising campaign features someone who may not be known to a lot of youth and despite the known difficulty of reaching youth, this campaign appears to have been reasonably successful to date in this regard. The relatively high recall of the advertising by youth, positive feedback on it and good levels of message recall are all positive indicators. More important evidence of the campaign impact with this 16 to 24 year age group were the significant changes in likely behaviours if they thought they or a friend might be experiencing depression. Another positive sign is the fact that more of them were now willing to mention their own experience of depression. It is also worth noting that young people were more likely than the total sample to mention turning to 'friends and family' and also 'counsellors/psychologists'. The greater mention of counsellors/psychologists by youth may reflect them being used to having counsellors available at schools and tertiary institutions. The limited availability and cost of counsellors in the wider community may therefore be a barrier to young people obtaining help with depression once they have left school or tertiary institutions. The good news with youth has not yet extended to significant increases in any of the attitude measures. Youth are still less likely than the total sample to give the desired response on some of these measures, including the key ones of the importance of early intervention and being able to recognise the signs of depression in a friend. A point to remember in relation to youth is that they have not had as much opportunity to live with people with experience of depression, which puts them at a disadvantage compared with older age groups. The campaign focus on developing the youth website, to complement the mass media campaign, is still justified by these findings. However these findings do indicate that the media campaign may be having a greater impact on youth than had been anticipated. CAMPAIGN REACHING MAORI Despite the lack of Maori featuring in the advertisements, Maori had very high recall of this campaign and a positive response to the advertising that matched the total sample. Their message recall was a little lower on a couple of items, but was generally at similar levels to the total sample, as was the rate of discussion of the advertising and recall of radio ads. The fact that John Kirwan was a famous rugby player may be a factor in the appeal of the ads to Maori. There are indications of the campaign having a positive impact with Maori in that there were significant improvements on three of the attitude items, including the importance of early intervention. However, there were no changes for any of the measures relating to likely behaviours if they were concerned about someone having depression, so this is an area that needs to be developed in future communications. One area in which Maori appear to need more support is in knowing how to recognise the signs of depression, where their rating worsened. 16

17 SOME IMPACT WITH PERSONS FROM HIGH DEPRIVATION GROUPS It is positive that the improvement in 'strongly agreeing' that early intervention is important has extended to this group. There are also other positive changes in attitudes among this high deprivation group. However, as with Maori, this group appears to be feeling less confident now in their ability to recognise symptoms of depression, which is an important issue to address. There is an openness to more information, with over half wanting more, this being above the average. As might be expected, given their likely lower education levels, this group were less likely than the total sample to seek out written information, such as via the internet or magazines, which limits this as a vehicle for reaching them. They were also less likely to talk to a friend or family member. While the difference was not large, it may reflect poorer social support systems. A key question is how is the high deprivation group responding compared with the low and medium deprivation groups, in that it is the high deprivation group who are most at risk of depression. For the attitude statements, those from medium deprivation areas showed improvements in the desired direction on five of the attitudes versus three for the high deprivation group. However the low deprivation group improved on only one. These and other findings suggest that the campaign is certainly not having greater impact on the high deprivation group compared particularly with the medium group. There is therefore a need to consider what other strategies might be effective in reaching the high deprivation group, to complement the advertising campaign. GENDER GAP NARROWING Although women had higher recall of the advertising than men, the level for men was still relatively high. Men also showed more improvements on the attitude ratings in the desired direction, so this is a good sign of a reduction in the gap between men and women. However women generally still tended to give more appropriate responses than men on many of the attitudes and other measures. NEED TO ADDRESS POST NATAL DEPRESSION Women at risk of post-natal depression are a recommended priority audience. This audience has been added since the initial feasibility report, but the data on the prevalence of post-natal depression make a strong case for focussing on it. This is a very discrete priority audience, who should be relatively easy to reach, particularly via midwives, who tend to be the main lead maternity care givers. They have contact with pregnant women both before and after the birth, so are ideally placed to recognise symptoms of post natal depression and offer appropriate advice. NEED TO REVIEW ADVERTISING TIMING It is interesting to note the high level of calls to the helpline and hits on website during working hours. This does raise the question as to whether more advertising should be scheduled for day time television and radio. 17

18 The freephone and website data also shows that the need is greatest earlier in the week. If more advertising is placed at these popular times, it will obviously increase the demand on the freephone services at the time when they are already most busy. It would be necessary to discuss with Lifeline as to whether they can allocate more counsellors on the high demand shifts. LIMITATIONS OF PRIMARY CARE DATA CBG, who collect the primary care data noted that "the coding rates for mental health conditions have started from a low base", suggesting likely under-reporting. It is therefore possible that increasing trends in reporting of depression diagnoses may reflect improved reporting rather than actual increases in depression diagnoses. This is a serious issue that limits the ability of these data to accurately identify the impacts of the NDI. Unless the NDI results in a marked increase, any gradual increases will not be able to be differentiated from increases that are due to improved primary care reporting. The big concern of some in primary care has been that the NDI will lead to marked increases in demand that they will be unable to cope with. The CBG data shows that this has not been the case and there is value in continuing with the CBG surveys to see if there are any marked increases in the future. Given the CBG data is also monthly, it does allow us to see if changes are linked to the timing of advertising, which will give greater confidence that any changes are linked to the NDI. LEVEL OF REPORTING OF WEB AND FREEPHONE STATISTICS COULD BE REDUCED Some of the web and freephone statistics change very little between reports, so the amount of reporting could probably be reduced. A set of statistics and the required frequency could be agreed among the providers. 2.2 RECOMMENDATIONS There should now be more promotion of appropriate options of assistance and treatment, particularly: primary care self help strategies. The websites should be emphasised more in the advertising and other communications. The NDI website needs to be further developed to better meet strategic communication objectives. Further research should be undertaken to ensure the NDI website communicates more effectively with identified audiences. The helpline number could be emphasised more in the advertising and other communications, providing Lifeline can deal with the level of calls. The amount of air time given to each of the existing JK ads should be reviewed: It is recommended that proportionately more air time be given to the 'Seeking Help' (tree) ad, which makes specific mention of health professionals, along with 'loved ones'. It is recommended that less air time be given to the 'Overcoming Stigma' (mirror) ad There need to be increased efforts made to provide more specific information on how to recognise if someone has depression, especially for Maori and people living in high deprivation areas. 18

19 There needs to be consideration as to whether this is best addressed via information on symptoms and/or information on risk factors and circumstances that could indicate depression, such as a person seeming down for a lengthy time following a relationship break up. There needs to be discussion as to whether a mass media approach is needed, to ensure the additional information is communicated in a manner that provides sufficient exposure. There is no need to continue prioritising the importance of the early intervention message. There is a need to consider what other strategies might be effective in reaching the high deprivation group, to complement the current advertising campaign. There is a need to place greater priority on women at risk of post natal depression. The timing of the advertising placement should be reviewed in light of the findings, but also taking into account the ability of Lifeline to service the freephones if peak time calls are increased. Data from the Lifeline WeCare follow-up calls, when available, should be used to obtain information on call outcomes and to assist in planning for best meeting the needs of these people. The level of reporting of the web and freephone statistics should be reviewed. 19

20 3 INTRODUCTION EVALUATION OBJECTIVES This is a limited evaluation of the first 9 months of the National Depression Initiative Public Health Campaign. This time period is dated from the launch of the television campaign at the beginning of October, 2006, although activities were underway prior to this. The nine month period extended to the end of June, 2007, although some more recent data is also included, where it was available. The objective of this report is to bring together the available information to provide: Documentation of what has happened in the Public Health Campaign to date, including formative work to develop a programme logic and define priority audiences Information relating to campaign impacts, including: public response to the advertising; use of the freephone, website and resources; analysis of who is being impacted; and changes in primary care An assessment of progress to date for the purpose of future planning As this is not intended to be an extensive evaluation, no provider or other stakeholder interviews have been included in this report, although it is intended to include such interviews in the second report at the end of June NDI OBJECTIVES AND STRATEGIES The following are the objectives and strategies for the National Depression Initiative as a whole. The NDI objectives are: To strengthen individual, family and social factors that protect against depression; and To improve community and professional responsiveness to depression. NDI strategies are: 1. Identify and build on opportunities to create a social and physical environment that protects people from depression. 2. Encourage people to recognise and become more responsive to depression, including: (a) The importance of early identification and intervention; (b) Assisting people to recognise symptoms of depression in themselves and others; (c) Encouraging people to seek appropriate help; (d) Increasing awareness of effective interventions for depression, including self help strategies. 3. Improve the capability of health professionals to respond appropriately to people seeking help with depression. 4. Support co-ordination mechanisms between public health, primary health care and mental health care services, consistent with the objectives of the National Depression Initiative. 5. Support the above with research, monitoring and evaluation. 20

21 WHERE PUBLIC HEALTH CAMPAIGN FITS WITHIN NDI This evaluation focuses on the "public health campaign", which is one part of the wider NDI. The main focus of the public health campaign is strategy 2, but the other four strategies are also important to this. The diagram below shows that the NDI as a whole is focussing primarily on prevention/promotion and primary care, with limited focus on secondary care. Within the NDI, the public health campaign is focussing on prevention/promotion, with limited focus on primary care. Part of the public health campaign role is allowing people to make informed decisions about treatment. The Ministry team working on NDI has representatives from Public Health, Mental Health and Clinical Services (which is responsible for primary health care). Prevention/ Promotion Public Health Campaign 1º NDI 2º BACKGROUND TO CAMPAIGN DEVELOPMENT The television advertising has been the most high profile and resource intensive part of the NDI campaign. This particular TV campaign was developed in an usual manner due to the need to take advantage of a very generous offer from John Kirwan. John had featured on previous Like Minds TVCs and offered to contribute to a depression campaign. At that point in time the National Depression Initiative was only in the scoping stage, but the Like Minds national co-ordinator took the opportunity provided by 21

22 John Kirwan during one of his visits to New Zealand. This resulted in film footage that eventually became the NDI campaign. At the stage it was developed the NDI objectives and strategies were not finalised. However, the subsequent pre-testing of the near finished commercials indicated that they were effective ads to which people responded very positively. The five ads were seen to be more likely to address the first and third strategies (importance of identifying depression and seeking help), but it was felt the others would also be adequately addressed. While the NDI campaign has different objectives from the "Like Minds Like Mine" campaign to reduce stigma and discrimination associated with mental illness, the public will not necessarily be aware that they are different campaigns. REPORT OUTLINE The sections of the report are as follows: Programme logic Priority audiences Campaign activities Awareness of campaign Changes in knowledge, attitudes and likely behaviours Actions taken: use of freephone, website, and resources Who is being impacted - response to advertising, calls to Lifeline, web visits By ethnicity, gender, age, NZDep, Other demographics Changes within primary care (include green prescriptions and prescribing) An appendix includes details of media coverage. 22

23 4 PROGRAMME LOGIC INTRODUCTION Two logic models have been developed: 1. A model for the NDI public health campaign, which was developed by Allan Wyllie (Phoenix Research) from initial work done by the NDI campaign provider team, to assist with strategic planning by the different providers and getting clear how the activities of each linked in 2. A draft model for the whole NDI, which was developed by Candace Bagnall (Ministry of Health) 4.1 CAMPAIGN LOGIC EXPLANATION OF MODEL The model, which is shown on the following page, has had one change made since it was initially developed, which is the addition of another 'Desired Outcome' box labelled, 'family and friends recognise depression in others and respond appropriately'. This is in the central part of the model, which also includes the desired outcomes of people with symptoms of depression seeking appropriate help, or feeling supported by family, friends, whanau, employers etc. There are other intermediate outcomes, such as people recognising the signs of depression, but these have not been included, in order to reduce the complexity of the model. The top part, 'Initiatives for Public', are the key stages that the public will go through to achieve the desired outcomes. The most likely starting point is one or more of the campaign communications. This might lead directly to people seeking help or family and friends responding appropriately. Alternatively, it may lead to use of the freephone service or website, which will then lead on to help seeking or family and friends responding appropriately. The initiatives for the public also encourage the support of people with depression. The bottom part relates to 'Initiatives for (and with) Stakeholders'. This includes both promoting NDI to them, but also providing support to enable them to contribute most effectively to meeting the objectives of NDI. This will lead to a series of outcomes from stakeholders, which are shown in the rounded boxes. The broken line arrows depict weaker paths of influence. The coloured shading shows which provider is responsible for each component. It is intended that this logic model will be reviewed annually and updated where appropriate. Not included in this logic model is national co-ordination, undertaken by the MHF up until the end of December 2007, and research and evaluation, being undertaken by Phoenix Research. 23

24 NDI CAMPAIGN LOGIC INITIATIVES FOR PUBLIC Exposed to and respond to campaign communications Iwi radio ads TV ads Unpaid media/pr Booklet/pamphlets Posters Use freephone Access website Tape talk Counsellor Mainstream Youth DESIRED OUTCOMES Family and friends recognise depression in others and respond appropriately People seek help from: Primary care Mental health services Other NGOs (including Maori and Pacific) Counselling/ psychological therapies Self-help strategies People with depression feel supported INITIATIVES FOR STAKEHOLDERS Stakeholders communicate NDI messages/ promote NDI Stakeholders encourage people to seek help Promotion of NDI with stakeholders Support/encouragement of stakeholders Primary care, especially new initiative sites Secondary services Public health providers Organisations/personnel working with "at risk" people/priority audiences (e.g. school counsellors, WINZ/Income Support, ACC) Other professionals Stakeholders feel supported to address public needs/ demand NDI campaign components Outcomes Stakeholders encourage support for people with depression Agencies FCB MHF Lifeline INITIATIVES FOR SPECIFIC CAMPAIGN AUDIENCES While not able to be shown fully on the logic model, the provider group discussed initiatives for specific campaign audiences. Maori The initiative specifically for Maori is iwi radio advertising. It was noted that the MHF needed to work with Maori providers, to ensure there is on the ground support for the iwi radio campaign. There is a Maori version of a MHF pamphlet about depression, although the MHF noted that it is a direct translation and they would prefer to have something that was written from a Maori perspective. There was discussion as to whether there should be a Te Reo version of tape-talk, the tape that people can choose to listen to when they call the freephone, but this was not developed. Lifeline reports that although Maori speakers are available on request through the 0800 Helpline, they are rarely asked for. Youth A specific youth website was developed by DRAFTFCB and launched on 5 December

25 This website provides access to new online and text-based support services for young people, provided by Lifeline. Primary care/ PHOs Initiatives with Primary care/ PHOs are: Posters (A4 and A3), developed by DRAFTFCB and distributed by MHF Primary care guidelines on depression and other common mental disorders are being developed by the NZ Guidelines Group (NZGG) and will be finalised and implemented during NZGG also produced information for GPs and the general public on depression, available since the launch of the NDI campaign in October 2006, and have been distributed by Lifeline, MHF and the Ministry s distribution agent, Wickliffe It was noted that the focus needed to be on the 40 or so sites that received additional funding to address depression and other mental health issues as part of primary mental health new initiative funding, although it is expected that this approach will be extended over time to all PHOs and will become mainstream practice. 25

26 4.2 NDI PROGRAMME LOGIC Staff responsible for the various components of the NDI within the Ministry of Health have also been working on a programme logic for all of the National Depression Initiative. This is still at a draft stage, but is included below, to provide more context for where the NDI Public Health Campaign is seen to fit within the wider programme. THE NATIONAL DEPRESSION INITIATIVE ACTIVITIES OUTCOMES VISION A society that responds effectively to people experiencing depression Friends and family recognise depression in others and are able to respond effectively Contribute to a social & physical environment that protects people from depression Mental health promotion services PUBLIC HEALTH Improve recognition of, and responsiveness to depression NDI public health campaign People with depression seek and receive the information and help they need, including self-help Primary care services respond effectively in diagnosing and managing depression and referring where appropriate PRIMARY HEALTH CARE Primary mental health services developed E-therapy service options for primary care and individuals Depression guidelines review and implementation Workforce development for primary mental health service providers Mental health services continue to treat people with severe depression MENTAL HEALTH CARE Effective co-ordination of public health, primary health care and mental health services Support the above with research, monitoring and evaluation 26

27 5 PRIORITY AUDIENCES In the Public Health Depression Initiative: Feasibility Report (Phoenix, 2005), which was undertaken prior to the launch of the NDI, Phoenix Research made recommendations for key priority audiences based primarily on an analysis of the MaGPIe research, suicide research, and the Phoenix Research National Benchmark Public Health Depression Initiative (PHDI) survey. Since then, the findings from Te Rau Hinengaro: The NZ Mental Health Survey (2006) have become available. As this is the most comprehensive representative survey ever undertaken in New Zealand, the findings from that report have been given major emphasis in the recommendations for priority audiences. It does need to be noted that the Mental Health Survey measured 'major depressive disorder' 3, whereas the NDI focuses on mild to moderate depression, and could be seen as a preventative strategy for major depressive disorder. The Mental Health Survey also measured dysthymia 4 and bipolar disorder and grouped these together with major depressive disorder as 'any mood disorder'. However, it is interesting to note that the recommendations remain the same as those made in the Feasibility Report, except for the addition of pregnant mothers and those with new born infants, regarding post natal depression. This chapter summarises the rationale for the recommended priority audiences, which are: Youth (15 to 24 year olds) Adult males aged 25 to 44 years Adult females aged 25 to 64 years Maori, especially Maori women The most deprived (NZDep quintile 5) People experiencing anxiety disorders Pregnant mothers and those with new born infants (re post natal depression) At risk minority groups, namely: Refugees Gay, lesbian and bisexual persons Children who receive welfare care People in custody and incarcerated Those who are socially isolated or excluded The most notable exclusion from this list is Pacific peoples, which has been the source of considerable discussion within the provider group and Ministry (see Pacific section below). 3 4 Major depressive disorder consists of one or more episodes of major depression; that is, a period of at least two weeks in which the individual experiences depressed mood (most of the day, nearly every day), or a marked loss of interest in all or almost all usual activities, plus at least four of the following symptoms every day or nearly every day: Significant weight loss when not dieting, or weight gain or change in appetite; insomnia or oversleeping; psychomotor agitation (restlessness) or retardation (being slowed up); fatigue or loss of energy; feelings of worthlessness or excessive or inappropriate guilt; diminished ability to think or concentrate, or indecisiveness; recurrent thoughts of death or suicidal thoughts or plans. These symptoms should constitute a change from previous functioning in order to be criteria for a major depressive episode. Dysthymia was defined as "depressed mood for most of the day, for more days than not, for at least two years, plus at least two of the following: Poor appetite or overeating; insomnia or oversleeping; low energy or fatigue; low self-esteem; poor concentration or difficulty making decisions; feelings of hopelessness. 27

28 GENDER AND AGE As shown in the table which follows, females have higher rates of depression than males 5. This gender difference is also consistent with the earlier national findings of Oakely-Brown et al (1989) who reported a six month prevalence of depression among females of 12% compared with 6% among males. However, a different pattern emerges when suicide rates are considered (see graph which follows). Suicide data shows a much higher rate of suicide among males than females (for all ages, and therefore reversing the depression statistics). In 2002, males accounted for 76 percent of all suicides (Beautrais et al., 2005). This is in part due to males using more lethal means of suicide, as women make more suicide attempts than men (Beautrais, personal communication). The Mental Health Survey shows a consistent reduction in depression rates with increasing age, for both females and males. MaGPIe showed a similar pattern, except the rate for males decreased markedly after the year age group. However, as the MaGPIe study showed prevalence of depressive disorder among general practice attenders, the lower rate of males in the years age group may be explained by reluctance of older males to visit a GP if they feel they might be depressed. The inclusion of more moderate depression in the MaGPIe study may also be a possible explanation for the difference (which is also why the rates of depression are so much higher in the MaGPIe study, compared with the Mental Health Survey, which measured 'major depressive disorder'). The age patterns for suicide and depression are quite similar, with rates tending to be lower from age 45 onwards (see graph which follows, sourced from Beautrais et al., 2005). The most obvious exception is males aged 85 years and over, although presumably this high rate is affected by the small number in the denominator (i.e. there are very few males aged 85 years and over, so if a small number commit suicide they form a relatively high percentage). Beautrais et al (2005) identify "older adults" (55 years and over) as a high risk group for suicide and note that in this group depression is the main contributor and should be the main focus for efforts to reduce suicide rates among this group. While the suicide rates are lower in these older age groups, with the ageing population this group is going to account for an increasing proportion of the suicides. However, older adults are not being recommended as a target group because their current rates of depression are relatively low. Beautrais et al (2005) reported that suicide rates since 1950 had increased in youth (15 to 24 years) and young adults (25 to 44 years), and decreased among the two older groups (45 to 64 years and 65 years and over). They noted that much of the youth suicide is in fact in the 20 to 24 age group. There was a marked increase in male youth suicides from 1970, with it being most marked from the mid- 1980s to mid-1990s. It has since halved, but the rate is still high by international rankings. 5 This age within gender data was obtained by Kathryn Nemec on behalf of the MHF, as the survey report only provided separate age and gender findings. 28

29 Table: Results of the and Mental Health Survey and MaGPIe study showing twelve month prevalence by age and gender. Mental Health Survey Total 16/18-24yrs* 25-44yrs 45-64yrs 65+yrs Male Female Overall MaGPIe Male ** ** Female * This group was for the Mental Health Survey (2006) and for MaGPIe. ** Denotes need to interpret with caution due to high standard error. Suicide rates by age group and gender, Males Females Rate (per 100,000) Age group (years) Source: (Beautrais et al., 2005) 6 It was recommended that the priority audiences include youth (aged 15 to 24 years), males aged 25 to 44 years and females aged 25 to 64 years. This decision is based on the high female depression rates in the up to 64 year age groups and the high suicide rates in males up to age 44 years. The prevalence rates from the Mental Health survey are higher for females up to 64 years 6 Beautrais, AL. Collings,SCD, Ehrhardt,P et al. (2005). Suicide Prevention: A review of evidence and risk and protective factors, and points of effective intervention. Wellington. Ministry of Health 29

30 than they are for any of the male groups, so there is therefore justification in including females up to age 64 years. As noted above, the criteria for determining the cut-off for males has been based more on their suicide rates, although the declining depression rates with age also provide support for not including older males. MAORI The Mental Health Survey showed that the twelve month prevalence of major depressive disorder 7 among Maori (5.7%) was at a similar level to Other 8 (6.9%) and higher than Pacific people (3.5%). When any mood disorder is considered, the Maori rate is markedly higher at 9.3%, compared with 7.9% for Other and 6.4% for Pacific people. The MaGPIe study showed very high levels of depression for Maori (46%), especially Maori women (55% compared with 21% for Maori men) (Bushnell & Dowell, 2005). The authors concluded that while social and material deprivation may play a role in these rates, there were other ethnicity-specific factors involved. The Youth 2000 study ( identified 16 percent of Maori youth with significant depressive symptoms (measured using the RADS screening tool), compared with 12 percent among New Zealand European youth. The rate was much higher for young Maori women (23%) than men (10%), a gender pattern that was evident for all ethnic groups. Maori male and female suicide rates are higher than for non-maori, but there has been some convergence of rates since Beautrais et al. (2005) identified Maori children and youth as one of the high risk groups for suicide, noting that the rates are approximately twice those of non-maori (for both males and females). The Mental Health Survey showed that Maori are less likely than Other ethnicities (33% cf 41%), but more likely than Pacific people (33% cf 25%), to have visited a health service for a mental health reason. The Phoenix survey conducted as part of the NDI feasibility study confirmed Maori as being less likely than the general population to turn to a doctor/health centre for help with depression. It was therefore recommended that Maori be a priority audience. PACIFIC PEOPLE As noted above, the Mental Health Survey shows lower levels of 'major depressive disorder' among Pacific people (3.5%) compared to Maori (5.7%) and Other (5.8%). For 'any mood disorder' the levels were 6.4% for Pacific people, 9.3% for Maori and 7.9% for Other. For bipolar disorder 9, the pattern changes slightly and Maori had the highest prevalence (3.4%) followed by Pacific people (2.7%), and Others (1.9%). The Pacific Youth 2000 report 10 identified rates of depression for young Pacific women at 23 percent, and the Pacific males at 13 percent The prevalence figures reported have been adjusted for age, sex, educational qualifications and equivalised household income. Other included Asians and other ethnic groups. Bipolar disorder combines depression and manic episodes. 10 Personal communication from David Schaaf, one of the authors of the soon to be published Youth 2000 Pacific report 30

31 The Mental Health Survey (2006) also showed that Pacific people who had experienced a serious mental health disorder were less likely to have visited any health service for a mental health reason (25% cf 58% of the total population who had visited a health service). Other research supports this finding. For example, it is known that Pacific people present later to services (Gaines et al., 2003) and there is some evidence that they are less informed about mental health issues than other groups and that stigma and discrimination pose significant barriers to Pacific people using services (Pulotu- Endemann et al 2004). In addition, the Phoenix survey as part of the feasibility study showed that Pacific people are the least informed about depression and hold the least supportive attitudes. However they are the most likely to mention having become more supportive and less stigmatising of people with depression over the last two years. The Like Minds research also shows that Pacific people have made some marked gains in this respect, while still remaining at lower levels on some measures (Wyllie et al., 2005). Beautrais et al (2005) noted that the strong Pacific links with family and church provide protection against suicide. There were 18 Pacific people who died of suicide in 2002, which is a low rate. On the basis of prevalence of depression and suicide rates, there is little evidence to support their inclusion as a priority audience for the NDI, except for Pacific youth. With youth being a priority audience, it is suggested that Pacific youth be targeted in youth initiatives, an approach that may be supported by as yet unavailable Youth 2000 data. It was therefore recommended that Pacific people not be a priority audience. The Mental Health Foundation have argued strongly for inclusion of Pacific people on the grounds of their not getting early or appropriate treatment for depression. However, given the low prevalence of depression amongst Pacific people, we do not believe this is sufficient reason to make them a priority audience for the campaign. HIGH DEPRIVATION/LOW SOCIO-ECONOMIC GROUPS Beautrais et al (2005) noted that while there is a lot of research internationally linking higher suicide rates with lower socio-economic status, there is some evidence to suggest that much of this effect disappears after adjusting for possible confounding factors, particularly mental illness. In terms of the relationship between depression and level of deprivation, the Mental Health Survey did not shed much light. However, they did note a relationship between mental disorder and level of deprivation. The Phoenix survey undertaken as part of the feasibility report found that those in quintile 5 (the most deprived NZDep group) had lower levels of appropriate responses, in terms of what the campaign is seeking to address. Another important consideration is the Government s social policy goal of reducing disadvantage and promoting equality of opportunity for all New Zealanders. It was recommended that high deprivation groups be a priority audience, because of the Government focus on promoting equality of opportunity and the Phoenix survey findings. MIGRANTS (INCLUDING ASIAN PEOPLES) AND REFUGEES The growth of the population of Asian communities in New Zealand has meant that policy makers are increasingly turning their focus to the needs of Asian people. Statistics New Zealand identified that over a 10 year period, the populations of Asian groups grew by 140% (reported in Tse et al 2004). However, there is almost no mental health epidemiological data on Asian groups in New Zealand. The recent Mental Health Survey did not distinguish any ethnic group except for Maori and Pacific Island 31

32 (all others were categorised as Other). The Youth 2000 study identified that 19 percent of Asian young women were reporting significant depressive thoughts, which compared with 18 percent for all the women who participated in this large survey. Information from three DHBs shows an increase in Asian people attending mental health services. International studies show a pattern of delayed help-seeking by Asian groups for mental health issues, often until the problem is severe (Tse et al, 2004). Asian stakeholders interviewed as part of the Environmental Scan (that helped inform the Feasibility Report) reported that depression is a big issue in the different Asian communities. They described it as being silent and invisible. Abbot (1997) noted the following factors as being likely to contribute to higher risk of mental health problems for migrants and refugees: stress and trauma before, during and following the migration and resettlement process; unemployment and underemployment; diminished socio-economic status; and diminished social support. The Environmental Scan identified that the mental health issues for migrants (new settlers) and refugees are likely to be different. New settlers experience dislocation and loneliness from their country of origin, thus may be at risk of depression. Refugees may be at greater risk because of losing everything, home, belongings, family, and country for an uncertain future in a new land. Depression and Post Traumatic Stress Disorder (PTSD) and anxiety were seen as key issues for this group. Given the need to only identify priority audiences, it was recommended that only refugees be included as a priority audience, not migrants as a whole. CO-MORBIDITY The Mental Health Survey found a strong level of co-morbidity between mood disorders and anxiety disorder (specific data on depression was not reported). Half of those with a mood disorder experienced an anxiety disorder, compared with 15 percent of the population. MaGPIe also pointed to the co-morbidity of depression with anxiety. The 18 percent with depression included eight percent who also had anxiety disorders. It was therefore recommended that those with anxiety disorders be included as a priority audience. OTHER AT RISK GROUPS Fergusson et al (1999) found that people who were gay, lesbian or bisexual were more likely to report mood disorders. Beautrais et al (2005) noted that while these groups have higher rates of suicide ideation and attempts, there is not evidence that they have higher rates of completed suicide. However they note that this may in part result from the difficulty of knowing the sexual orientation of those who complete suicide. Beautrais et al (2005) also identified the following groups as being high risk for suicide: children who receive welfare care, people in custody and incarcerated; and those who are socially isolated or excluded (which in some cases is a reflection of their individual temperament and genetic predisposition to mental illness, while alcoholism is another contributor to social isolation). While there is no comparable information to identify whether they are also at high risk of depression, it 32

33 33 would seem likely that they are, so it was recommended that they be included as part of a "at risk minority group" priority audience.

34 POST NATAL DEPRESSION The most recent New Zealand study on the prevalence of postnatal depression was conducted in A postal survey of European/Caucasian women at 4 months postpartum, found that 30 percent were suffering from depressive symptomatology and only 13 percent of those were in treatment. The prevalence rate was estimated at 16 percent. They concluded that the prevalence rate of PNDS in urban New Zealand is slightly higher than the world-wide average, and goes largely untreated in the community. In terms of comparison to overall depression rates amongst females, the prevalence rate of 16 percent for PNDS is significantly higher than the seven percent rate reported for depression in the Mental Health Survey. A Christchurch study that was conducted in assessed the prevalence of postnatal depression as 20 per cent of mothers, with 13 percent being significantly depressed and seven percent having borderline level of symptoms. Importantly, only 6 percent of the women in the study recognised their symptoms as characteristic of depression. Both of the above studies highlighted that recognition of PNDS and early intervention is a significant issue for women with PNDS. It is therefore recommended that pregnant mothers and those with new born infants be a priority audience. 11 Thio, I. M, Oakley Browne, M. A, Coverdale, J. H., & Argyle, N. (2006). Postnatal depressive symptoms go largely untreated: a probability study in urban New Zealand. Social Psychiatry & Psychiatric Epidemiology, 41(10), McGill, H., Burrows, V., & Holland, L, et al. (1995). Postnatal depression: a Christchurch study. New Zealand Medical Journal, 108,

35 6 CAMPAIGN ACTIVITIES The campaign activities have included: Advertising campaign Freephone service Websites Project management and sector engagement Media coverage Distribution of resources Preparation of guidelines Research and evaluation ADVERTISING CAMPAIGN The most high profile component of the NDI campaign has been the John Kirwan television advertisements, developed by DRAFTFCB. These were developed with material that was filmed prior to the NDI beginning, although a feasibility study was underway at the time. This occurred because John Kirwan offered his services and it was decided to take advantage of this opportunity. The John Kirwan ads were pre-tested by Phoenix Research and found to be sufficiently meeting the NDI strategies, with people responding very favourably to the ads. The pretest also showed that the ads left people wanting know more about how to recognise depression. The TV campaign began on 10 October, 2006 and has continued to run with reasonable frequency throughout the evaluation period. FREEPHONE Lifeline provide the NDI 0800 freephone service, as a separate service to their normal Lifeline phone counselling service. The freephone number is included on the last screen of the television ads. The service provided by Lifeline is a listening and assessment service. They are not contracted to provide formal counselling; but if the caller is assessed as needing further professional help, they are provided with contacts for appropriate services in their areas. The average call duration is eight minutes, with calls in excess of 30 minutes being rare. Lifeline also offer callers "WeCare" follow-up calls at a time and date that the caller wants. These calls are designed to support people in addressing their depression, which may include access to helpful professional services. There is often more than one "WeCare" call, if it seems appropriate. Data on the calls received is reported in a later chapter. WEBSITES The main website was operational from the time the campaign began on television. A leading-edge youth specific website was launched on 5 December

36 The Mental Health Foundation, who managed the main website in consultation with DRAFTFCB and the Ministry, reported that feedback from users had ranged from highly positive to highly negative. They also reported that the site had featured prominently in many media articles. Data on the number of and types of visits is reported in a later chapter. PROJECT MANAGEMENT AND SECTOR ENGAGEMENT The MHF held the contract to provide public health campaign management since mid 2006 to 31 December A full time project manager was appointed in February, Activities that they have undertaken under this contract relating to project management and sector engagement are as follows: Project management and co-ordination: Providing a co-ordination role with other NDI campaign providers, which has included provider planning and update meetings, a monthly bulletin and other contact with providers. Formed a stakeholder reference group and held three meetings. Sector engagement, relationship management and co-ordination Made presentations to organisations working in the sector (four presentations in the first six months of 2007). Distributed the first edition of a stakeholder newsletter. Established an discussion group, which had 78 members as at 30 June, with 84 messages posted by the group between March and June, averaging 21 per month. Established relationships with a range of organisations, including some Maori organisations Circulated NDI information via a range of organisations Personal communications with a range of stakeholders Distributed resources (detailed in section below) Provided advice to the Ministry MEDIA COVERAGE The Mental Health Foundation subscribe to the Chong clipping service and therefore access media coverage from the following sources: TV news Radio news and national radio programmes (the MHF go on to the web and see if an audio is available) Radio talkback - brief descriptions, which are sometimes enough to rate whether the content is positive or negative (transcripts cost a lot of money) All national daily papers Most community papers New Zealand's top rating magazines The coverage identified and reported by the MHF for the first six months of 2007 is attached as an appendix to this report. There were 83 print articles that focused on or covered the national depression campaign. The Mental Health Foundation also generated five national TV and radio interviews which covered the national depression campaign. 36

37 75 items of media coverage mentioning the national depression campaign were positive. These items included coverage about the success of the campaign, John Kirwan s involvement and courageousness, and the Queen s Birthday Honour that John Kirwan received. 10 items of media coverage were of a neutral tone. These items tended to be stories, such as about cognitive behavioural therapy, that simply referenced the depression campaign support line and/or website. Three items of media coverage were negative. These items made specific reference to the national depression campaign in relation to demand on services, and in relation to the television adverts being too repetitive. DISTRIBUTION OF RESOURCES The New Zealand Guidelines Group prepared two publications providing information relating to depression, one for primary care and one for the public. All issues for the one for primary care were distributed. The Mental Health Foundation reported that almost one fifth of the queries to their Information and Resource Centre related to depression. The table below shows the number of resources for the NDI distributed up until the end of June 2007 by the MHF. In addition to this, the MHF were distributing their own "Out of the Blue" 13 resources plus other resources they have that relate to depression, as shown in the second table below. The number of NDI fact sheets distributed was very low given that 50,000 had been produced. In comparison, almost all of the 40,000 NDI postcards printed had been distributed, with the MHF accounting for just under a fifth of these. There are no ethnic specific printed resources that are part of the NDI. 13 "Out of the Blue" is a depression prevention initiative that the MHF had begun before the NDI began. 37

38 TYPE OF NDI RESOURCE Number distributed by MHF up to 30 June 07 NDI What is Depression fact sheet 9,982 NDI What is Depression postcard 9,455 NDI Poster A2 4,529 NDI Poster A3 3,838 NZGG Depression booklet for consumers 6,114 NZGG Depression booklet for primary care 34 OTHER DEPRESSION RESOURCES DISTRIBUTED BY MHF (THOSE WITH MORE THAN 500 COPIES) Number distributed by MHF up to 30 June 07 Postnatal depression 12,254 Fact sheet Mate Whanau Tamariki 3,138 Maybe its depression 2,487 Late life depression 9,16 Asian youth Feeling Sad/Depressed 3,76 Out of the Blue wallet card 86,266 Food and Mood leaflet 14,389 Men and Depression 31,657 RESEARCH AND EVALUATION Phoenix Research research and evaluation activities prior to this evaluation report have included: Pre-testing the John Kirwan TV ads Providing formative input into project planning with the MHF, including development of the programme logic (in association with all the providers) Undertaking surveys to monitor the response to the advertising (reported on in later chapters) Qualitative research to inform the development of the youth website A survey on the main website to obtain information about site visitors, for which data collection is still underway The level of response to the survey has been low, so it has been necessary to leave it on the website longer than anticipated, so findings were unavailable to inform this evaluation report. 38

39 7 CAMPAIGN IMPACT INTRODUCTION This chapter reports on the key findings from the national tracking surveys which have been undertaken to assess the impact of the campaign on the public. A benchmark survey was undertaken in September/early October, 2006, just before the campaign began. A follow-up survey was undertaken in June/July, 2007, after eight months of the "John Kirwan" campaign. Both surveys had samples of just under 1000 interviews, which were completed with the NDI priority audience of males aged 15 to 44 years and females aged 15 to 64 years. There was a weighted response rate of 70 percent in the follow-up survey. The data was weighted to reflect the correct proportions of the population by gender, age and ethnicity. RESPONSE TO ADVERTISING A very high proportion (90%) recalled seeing the advertising, after prompting. People commented that it was a 'Positive idea having a prominent person willing to talk openly about his depression' (39%). Thirty-two percent said 'Good ad/well put/effective/ gets the point across', while 17 percent were particularly positive in their response, with comments such as, 'The ad is very good / fantastic'. Others noted that it is 'Good/ positive idea to advertise depression' (15%) and that the ads 'Bring it out into the open/ talked about' (12%). When asked about message recall, two-thirds reported something relating to seeking help. This included mentions such as 'Seek help/don't hide (38%), 'Help is available' (25%), and 'No shame in asking for help/ no stigma attached' (14%). Only three percent specifically mentioned phoning the 0800 Depression helpline. The next most common response was that 'Depression can affect anybody/ all walks of life', which was mentioned by 30 percent. Other more prevalent messages included: 'It is ok to be depressed'(24%); 'Depression is quite common/ more common than you think' (17%) and 'Making people aware of depression' (17%). Sixteen percent made some comment that related to the message that it 'Can be treated/ controlled', while 12 percent said 'Talk about it/ be open about it'. Seven percent mentioned 'look for signs of depression' and four percent specifically mentioned 'there is hope'. Sixty-two percent had discussed this advertising with someone else, which included 31 percent who had done so 'once or twice', 24 percent 'a few times' and six percent 'more often than this'. Seven percent said they had heard advertising about depression on the radio. CONTACT WITH PEOPLE WITH EXPERIENCE OF DEPRESSION While there was a slight increase in the proportion who volunteered that they had personally experienced depression (up from 13% to 15%), this was not a sufficiently large increase to be significant. Fifty-seven percent of respondents said that in the previous 12 months they had listened to, talked to, or supported someone who was experiencing depression. (There was no comparable measure in the previous survey.) There was no significant change in the proportion who had ever lived with someone with depression (47% compared with 45% in the benchmark survey). 39

40 SYMPTOMS OF DEPRESSION There was a small but significant increase between the two surveys in the proportion of participants who were able to give at least one actual sign or symptom of depression, up from 92 to 94 percent. There was no change in the average number of actual symptoms respondents mentioned (2.7). The most mentioned individual symptom was 'withdrawal/social isolation', which showed a significant increase from 48 to 53 percent. Other symptoms with increased recall included: 'Change in behaviour / personality' (up from 18% to 26%), 'Mood swings: extreme highs or lows' (from 9% to 13%), 'Negativity/negative thoughts' (from 6% to 9%). Symptoms with decreased recall included: 'Sleeping difficulties' (down from 22 to 18%), loss of interest in food/eating too much food' (down from 20 to 14%). WHO TO TURN TO FOR HELP There was one significant change in mentions of people they would be likely to ask for help if they thought they might be experiencing depression. This was a small decrease in the proportion who said they wouldn't seek any help (down from 5% to 3%). When asked to rate the likelihood that, if they thought they might be experiencing depression, they would adopt certain behaviours, there was an increase in the mean likelihood of phoning a helpline. There was also an increase in the mean likelihood of 'seeking written information about depression, such as from the internet, magazines or books'. There was no increase in the likelihood of talking to a 'friend, family or whanau member or some other person you could trust', or a 'doctor or some other health professional'. For participants who volunteered that they had personally experienced depression there was a significant increase in giving a high rating for the likelihood of 'phoning a helpline' (up from 11% to 24%). RESPONSE TO SOMEONE WHO MIGHT BE EXPERIENCING DEPRESSION Eighty-three percent (up significantly from 77 percent) gave a high rating (7-10) for the likelihood of going to the person and encouraging them to talk about it. There was a small improvement for the ratings for 'Seek advice or information so you could assist this person', with a decrease in those giving a low rating (down from 5% to 2%). There was no change in the level for encouraging someone with depression to see a doctor or seek other professional help (84%). SUITABLE TREATMENT OR ASSISTANCE FOR SOMEONE WITH DEPRESSION There was no significant movement in the proportion of participants listing at least one thing they could do to be supportive of someone with depression, although this was already relatively high (88%). There was an increase in mention of 'Counselling/psychotherapy/psychological treatment' (up from 41% to 46%). 40

41 ATTITUDES RELATING TO DEPRESSION AND ITS TREATMENT Most statements showed significant improvements in the desired direction, specifically: It is important to recognise and act early on depression, rather than waiting (increase from 64 to 74% in the proportion 'strongly agreeing') If a close friend had depression, I would be able to recognise the signs and symptoms (up from 49% to 54% for those 'agreeing' 15 ) I would be able to recognise if I had depression ('agreeing' up from 53% to 60%) I would like to know more about depression ('agreeing' up from 36% to 42%) Depression can be successfully treated with medication ('agreeing' up from 43% to 49%) People with depression just need to stop feeling sorry for themselves ('disagreeing' up from 63% to 70%) There were two statements which showed slight, but significant, moves in a less desirable direction, these being: Depression is becoming a major health problem in New Zealand, which showed a significant increase for those 'disagreeing' with it (up from 2% to 4%) Depression can be successfully treated in ways that don't need medication, which showed a significant increase for those 'disagreeing' with it (up from 3% to 6%) The cost statement showed significant increases in both the proportions agreeing and disagreeing: 'Getting treatment for depression would be expensive' There was only one statement which did not show a significant change: 'There are activities and other things that people with depression can do themselves to help overcome their depression'. 15 'Agreeing', as reported in this summary, refers to those who said they either 'agree' or strongly agree' with the statement. 41

42 8 ACTIONS TAKEN: USE OF FREEPHONE, WEBSITE AND RESOURCES LINKS BETWEEN LEVEL OF ADVERTISING AND USE OF FREEPHONE AND WEBSITE As outlined in the programme logic, the direct actions that are being sought in response to the advertising and other promotion is for people to access the NDI website or call the NDI helpline. The graph on the next page (provided by DRAFTFCB) shows the link between the level of advertising and the weekly calls to the helpline and visits on the website. It can be seen that there was high useage of both in the initial period of advertising in October There was a rapid decrease when the advertising stopped. Following this decrease, for the rest of the eight week period of no advertising the website activity remained at a relatively steady level, while the freephone calls continued to decrease. There was a peak in website activity (but not in freephone activity) in response to an article in the New Zealand Herald on 28 November, 2006, where John Kirwan was inspiring men to reach out for help. On that day the daily number of visits went up from below 100 to just over 400 (note that the graph below provides weekly rather than daily data). The only single day that has been higher than this was at the time of the launch when it reached just over 500. The advertising beginning at the end of December 2006 and running for the three weeks of the holiday period resulted in the highest use of the web during any period. While freephone calls also increased, it was no where near as marked as for the website. This may reflect people having more time available during the holidays to visit the website. Both the web visits and the phone calls have continued to decrease during periods of no advertising and increase with further bursts of advertising. However, it is the phone calls that are the more dependent on the advertising. They have also shown a downward trend over time, whereas the general trend for website visits has held steady since February It is useful to also consider the period since the end of June, as this was the first substantial period of time without NDI advertising - nine weeks (Like Minds was running for much of this time). The second graph which follows shows that website activity declined slightly over this period (note this is daily visits, not weekly as in the previous graph) and then increased again when the advertising began again. The third graph shows that calls to the freephone were averaging about 30 a day (about 200 a week) during the period of no advertising in July and early August, but then increased to an average of about 80 per day (about 550 per week) during the period of advertising. These findings again reflect that the number of freephone calls is much more dependent on the advertising than are the visits to the website. 42

43 Link between advertising, freephone and website sessions TARPS NZ Herald article "JK inspires men to reach out for help" Calls/Sessions Tarps Calls to freephone Web Sessions Oct 22-Oct 5-Nov 19-Nov 3-Dec 17-Dec 31-Dec 14-Jan 28-Jan 11-Feb 25-Feb Week Ending 10-Mar 24-Mar 7-Apr 21-Apr 5-May 19-May 2-Jun Website usage 1/08/07-31/08/07 Average sessions per day 16-Jun 30-Jun TV advertsing begins Countrywide Northern feature Marketing Magazine feature Bay of Plenty Times article. Family Violence Radio NZ Auckland Youth Ati l Health TV coverage Sat4/0 8 Sun 5/08 Mon 6/08 Tue7/ 08 Wed 8/08 Thu 9/ 08 Fri 10/08 Sat 11/08 Sun 12/08 Mon 13/08 Tue Wed 14/08 15/08 Thu 16/08 Sessions Fri 17/08 Sat 18/08 Sun 19/08 Mon 20/08 Tue Wed 21/08 22/08 Thu 23/08 Fri 24/08 Sat 25/08 Sun 26/08 Mon 27/08 Tue Wed 28/08 29/08 Mon 30/08 Tue 31/08 43

44 Usage of freephone NDI inward calls 1 July 30 Sept /07/07 8/07/07 15/07/07 22/07/07 29/07/07 5/08/07 12/08/07 19/08/07 26/08/07 2/09/07 9/09/07 16/09/07 23/09/07 30/09/07 IMPACT OF MEDIA ARTICLES While the response to the John Kirwan article on 28 November was marked, as noted above, there was no evidence of any other media article generating a marked increase in number of website visits or freephone calls. Even articles about John Kirwan receiving an honour for his work in this field did not have a marked impact, which suggests it was the content of the article, no doubt coupled with his appeal, that made the difference. There was a strong focus on men reaching out for help and challenging traditional stereotypes of masculinity. It had quite a strong focus on the Lifeline freephone and also included the website address (a copy of the article is included as Appendix B). However, all the other media articles will probably have contributed to maintaining the overall profile of the issue, all of which contributes to the success of the initiative. ESTIMATING NUMBER OF SITE 'USERS' The Mental Health Foundation have been providing monthly reporting on website activity and these include the duration of the visit to the site. This duration is calculated as the difference between the load time of the first pageview and the load time of the last pageview of the session. Sessions with only one pageview are considered to be 0-10 seconds. It should be noted that visitors may spend more time looking at the last pageview of a session, but that only the load time is recorded. Therefore the durations may be slightly under-reported. As shown in the graph below for the month of June 2007, quite a proportion of the visits are 0-10 seconds (36%). If all the visits of 0-60 seconds are summed, they account for 49 percent of the total. If all those from 0 to 3 minutes are summed, they account for just over two thirds of the visits (68%). It would seem unlikely that people are going to be getting any benefit from the site, except possibly getting an 0800 or other contact number, if they are spending less than three minutes on the site. Therefore, if we define site 'users' as anyone who visits for more than 3 minutes, the numbers will be 44

45 comparable and sometimes less, especially in the early period of the campaign, with those using the freephone. Length of website sessions - June 01/06/07-30/06/07 2,500 2,000 1,500 1, sec sec sec 1-3 min 3-10 min min 30+ min Session Length 2, ,032 1, COMPARISON OF NDI and BEYONDBLUE SITE USAGE DATA The NDI rate of website visits per month was averaging at about 1300 calls per month at the end of the first nine months (ie the period preceding June 30, 2007). This equated with 0.178% of the population using the site per month (this includes those who visited for only a few seconds). After nine months the Australian beyondblue website was attracting visits at approximately twice the NDI rate (0.345%). The Australian site had an average time on the site of around 11 minutes over the first nine months. In more recent times it has reduced to around 8 minutes. While there is not data on average time provided for the NDI site, the high proportion of people being on the site for less than one minute (as shown in the graph above) suggests the NDI average is likely to be lower than 11 minutes. ACTIONS RECOMMENDED BY FREEPHONE COUNSELLORS A key issue in terms of the freephone service is what happens once people call. As shown in the graph below, the two dominant responses are to supply people with resources and provide information on self-help strategies. Supplying resources is in effect a specific means of encouraging self-help. 45

46 The information on self-help strategies that is provided is based on the information in the NZGG booklets. Between April and June ,344 resources were distributed by Lifeline counsellors. This material was obtained from the Mental Health Foundation and the Ministry of Health and are primarily the NZGG booklet. Females accounted for 52 percent of the resources, which was similar to their share of the callers. Referrals to GPs had decreased in the last few months, which Lifeline suspected might have been due to their counsellors seeing the media coverage on primary care being concerned about not having the capacity to deal with demand. 46

47 Counsellor Actions - April- June Resources Self help Ref GP Ref Therapy Ref Psych serv Ambulance Police FOLLOW-UP CALLS FOR FREEPHONE CALLERS Lifeline offer callers the opportunity to be called back to provide support, check on progress being made, and make sure they have received any professional help they needed. In November 2006 they implemented on-going monthly follow-up, whereas prior to that it had been less systematic, due in part to the unexpectedly high number of calls. In the three month period up to June 2007, 1,258 callers initiated these "WeCare" callbacks, which represented 27 percent of the 4,616 callers in that period. During that same time period 1,754 call backs were actually undertaken to 548 persons, which was an average of 3.2 calls per person, with many of these being with callers from earlier months?. The Lifeline manager reported that approximately 47 percent of callbacks were abandoned with no contact after several attempts. Lifeline reported that these follow up calls are highly praised by users. One counsellor who had been with Lifeline for 17 years noted that, "the most important aspect of the support we have been providing is the follow-up care call People have been overwhelmed by the real sense of being cared for, which for some has been a really important step in their recovery". It is planned to begin collecting data from these follow-up calls as part of the new CRM system Lifeline are currently introducing. OTHER FINDINGS RELATING TO USE OF FREEPHONE Lifeline, who provide the freephone service, have prepared detailed monthly reports on the use of this service and key findings, with some additional analysis, are included in this report. Lifeline noted that the Depression freephone has not reduced the number of calls they are receiving on their normal Lifeline counselling phones. Lifeline are not able to identify with any accuracy the number of first time callers. A high proportion of callers use cellphones and an equally high number block their caller ID on their landline phones. They also note that it is risky to assume that a call from a phone number in their database is from the same person it can be from another 47

48 member of the family, or if it is a payphone (Phone box) someone else in the boarding house. Lifeline have a strategy for addressing regular callers. If someone calls more than three or four times over a month, a management plan is introduced and they are worked with through Lifelines main service. Lifeline reported that there would usually be about six such people on any one month. They reported that there are also a few who call three to four times a month. This means the data is not being overly influenced by a high number of regular callers. Lifeline do not collect data on what prompted the call, but they did review the opening remarks for 100 calls over a three day period to see what this might tell us. Of these, 14 mentioned the John Kirwan ads, eight said they had seen an article in the newspaper and three said they were referred by Healthline. As at June 2007, 60 percent of the callers used a landline. Most of the rest used mobile phones, with occasional calls from pay phones. As shown in the graph which follows, Monday was the day of the week when the greatest number of calls were received, with the numbers decreasing as the week progresses. This decrease during the week was similar for the website, but the website did not have the markedly higher level for Monday. Freephone calls by days of the week April- June Sunday Monday Tuesday Wednesday Thursday Friday Saturday In terms of hour of calling, the call traffic peaked between 10 and 11 am, but remained at relatively high levels until around 10pm. This was an earlier peaking than for the website, possibly indicating a more urgent need to address issues for the freephone callers. 48

49 In the three months of April to June 2007, 91 percent of calls came in during the 8am to midnight hours that the service was operating. The out of hours calls had increased by six percent since the previous report. Time of freephone calls (April to June 2007) Ca ll tra ffic - tim e of da y Re port am 1-2am 2-3am 3-4am 4-5am 5-6am 6-7am 7-8am 8-9am 9-10am 10-11am 11-12pm 12-1pm 1-2pm 2-3pm 3-4pm 4-5pm 5-6pm 6-7pm 7-8pm 8-9pm 9-10pm 10-11pm 11-12am Most third party calls from females were regarding daughters, husbands/partners, and to a lesser extent, friends. For male third party callers, they were calling regarding sons and wives/partners. OTHER FINDINGS RELATING TO WEBSITE The most popular page was 'Help me', followed by the survey. These findings clearly indicate that people are seeking help for themselves much more often than for others. Given its appeal, there might be value in promoting the availability of the survey more widely, via articles in the media. 49

50 Popularity of Website Pages Visited By Number of Pageviews. 01/06/07-30/06/07 10,000 9,000 8,000 7,000 6,000 5,000 4,000 3,000 2,000 1,000 0 /HelpMe/Defau /Survey/Defaul /Default.aspx /Resources/De /HelpOthers/D /HelpOthers/In /Misc/Default.a lt.aspx t.aspx fault.aspx efault.aspx formation.aspx spx /Images/TVAD /MKRH _Broadban /Images/TVAD /MKRH _broadban Pages 9,918 8,282 4,628 1,968 1, The most popular days for visiting the site were Monday to Thursday, with rates being lower in the weekend. Day of week for web sessions 10/10/06-30/06/ Mon Tues Wed Thurs Fri Sat Sun Days of week

51 As shown in the graph below, people were accessing the website all hours of the day or night New Zealand time. However, there were 8 percent who could be identified as overseas and another 39 percent who were not able to be identified as New Zealand or overseas (.com,.net, or no entry), so this would be affected the time of day data. A lot of visits come during 'working hours', with the level by 9am being relatively high. Web Sessions by Time of Day 01/06/07-30/06/07 Hourly Average = am 1am 2am 3am 4am 5am 6am 7am 8am 9am 10am 11am 12pm 1pm 2pm 3pm 4pm 5pm 6pm 7pm 8pm 9pm 10pm 11pm Time of day Just under half the visits (45%) were via a search engine or some other website (33% were via google, the next highest being the Mental Health Foundation site at 1.6%). The remaining 55 percent would have required the visitor to type in the URL or have visited via a bookmark/favourite. It might be hypothesised that the visits via the search engines would be more prevalent among the brief visits. Almost everyone who used a search engine typed in "depression" as the key word or one of the key words. It would be useful to know what proportion of the website visits are repeat visitors, but the MHF advise us that this data is not available. 51

52 9 WHO IS BEING IMPACTED: RESPONSE TO ADVERTISING AND CALLS TO LIFELINE The survey data from the advertising tracking surveys, plus the freephone data supplied by Lifeline has been examined to see how response to the campaign and calls to the freephone are varying by key demographics that relate to priority audiences. There is currently no data available on the demographic composition of website users. 9.1 MAORI AND OTHER ETHNIC GROUPS ETHNICITY OF FREEPHONE CALLERS The graph below compares the ethnic split of callers to the freephone, compared with the 2006 Census data for all persons aged 15 years and over and persons aged 15 to 45 years (which approximates the age of the NDI priority audience). It can be seen that Maori, Pacific peoples, Asian peoples and Other minority ethnicities are underrepresented among the freephone callers. Ethnicity of callers % 100 Helpline callers NZ Census 15 + years NZ Census 15 to 45 years European Maori Pacific Asian Other Unknown 52

53 MAORI FINDINGS FROM TRACKING SURVEYS Because of the smaller sub-sample for Maori (299 in both surveys), changes between surveys needed to be larger to be significant, so there were fewer changes evident for Maori than was the case for the total sample. Response to Advertising Maori had above average recall of the campaign (96% versus 90% for the total sample). The main Maori feelings and impressions about the advertising were at similar levels to the total sample. In terms of message recall, Maori were similar to the total sample for some mention of a help seeking message (66%), but they were lower for mention that 'it can be treated/controlled' (9% versus 16% for total sample). They were also less likely to mention 'talk about it/be open about it' (7% versus 12%) and 'look for signs of depression (3% versus 7%). Maori rates of discussion of the ads were similar to the total sample, as was their recall of radio advertising. Contact With People With Experience Of Depression Maori did not report any significant change in their own experience of depression or contact with persons with experience of depression. They also did not differ significantly from the total sample on these measures. Symptoms of Depression While Maori showed no significant changes between the two surveys for recall of symptoms of depression, compared with the total sample there were significantly fewer Maori who were able to give at least one actual sign or symptom of depression (87% compared with 94% for total sample). Consistent with this, Maori recall of specific symptoms was often at significantly lower levels than in the total sample. Who to Turn to for Help Maori showed no changes between the two surveys. Compared with the total sample, Maori were significantly less likely to mention turning to a GP/doctor/health service (52% versus 66% for total sample), or a counsellor/psychologist (13% versus 19% for total sample). These findings were consistent with Maori also being more likely to give a low rating for their likelihood of talking to a doctor or other health professional (18% versus 14% for total sample). Response to Someone Who Might be Experiencing Depression Again, Maori showed no changes between the two surveys. Compared with the total sample, Maori were significantly less likely to give a high rating for their likelihood of 'Encouraging the person to see a doctor or seek professional help' (78% versus 84% for total sample) and for their likelihood of 'Seeking advice or information so you could assist this person' (72% versus 78% for total sample). 53

54 Suitable Treatment or Assistance for Someone With Depression There was a significant decrease between the two surveys in the proportion of Maori mentioning 'Alternative/traditional/ spiritual/self help' as suitable assistance or treatment for someone experiencing depression (down from 26% to 17%). Within that category, there was also reduced mention of 'church/spiritual help' (down from 5% to 1%). There was also a reduced mention of non-proven self-help strategies (down from 17% to 11%). Compared with the total sample, Maori were significantly more likely to mention 'family/friends/whanau' (11% versus 7% for total sample). They were less likely to mention 'Counselling/psychotherapy/psychological treatment (35% versus 46% for total sample) and 'Medication/anti-depressants' (30% versus 45% for total sample). Attitudes Relating to Depression and its Treatment Maori showed significant improvements for three of the attitude statements, these being: It is important to recognise and act early on depression, rather than waiting (increase from 65 to 77% in the proportion 'strongly agreeing') Depression is becoming a major health problem in New Zealand (up from 63% to 72%) People with depression just need to stop feeling sorry for themselves (a big increase in the proportion 'disagreeing' from 51% to 69%) There was an increase in the proportion of Maori who disagreed that they would be able to recognise if they had depression (up from 6% to 11%). Compared with the total sample, Maori were significantly more likely to 'agree' that 'I would like to know more about depression' (53% versus 42% for total sample) and that 'depression is becoming a major health problem in New Zealand' (72% versus 63% for total sample). Maori were significantly less likely to 'disagree' that 'getting treatment for depression would be expensive' (21% versus 30% for total sample). 54

55 9.2 GENDER GENDER OF FREEPHONE CALLERS As shown in the graph below, there have been almost as many males calling the freephone as females. As males only account for 48 percent of the population aged 14 years and over, the proportions calling are almost a perfect match with the population. The graph also shows that there was a small bias in favour of females when the campaign began, but that gradually disappeared, only to re-emerge in the final report, which covered April to June Lifeline note that this gender ratio is in such contrast to the one third male, two thirds female that they typically get when operating freephone services for campaigns. Gender of callers - 10 October 2006 to 30 June % of callers Male Female Reports GENDER FINDINGS FROM TRACKING SURVEYS Response To Advertising Although men had lower recall of the advertising than women (83% versus 94%), this level for men was still relatively high. Men were a little more likely (but not significantly so) to say that it was a good ad (36% versus 29%), but less likely to mention that it was very good/fantastic (8% versus 22% for females). There were no gender differences on the main messages recalled. Men were less likely to mention that depression can affect anyone/ all walks of life (21% versus 35%). There were no gender differences in levels of discussion of the ads. 55

56 Contact With People With Experience Of Depression Women were more likely to volunteer that they had personally experienced depression (18% versus 10% for males). Women were more likely to report that in the last 12 months they had listened to, talked to, or supported someone with depression (62% versus 49%). Symptoms Of Depression Women were generally more aware of symptoms than were men. Who To Turn To For Help Between the two surveys men reported an increased likelihood of seeking information about depression, such as from the internet, magazines or books (mean rating up from 5.9 to 6.3). There was also an improvement in the proportion of males who rated it unlikely that they would 'talk to a doctor or some other health professional' (down from 23% to 18%). Compared with women, men were more likely to mention turning to friends/family/whanau if experiencing depression (83% versus 77%). Women were more likely to mention doctors (76% versus 50%) and counsellors/psychologists (24% versus 11%). Women were more likely than men to give higher ratings for the likelihood of taking actions if they thought they might be experiencing depression. They were significantly higher on three of the four items, with the other showing a difference that was not large enough to be significant. Response To Someone Who Might Be Experiencing Depression Both men and women reported increased likelihood of going to a person who might be experiencing depression and encouraging them to talk about it. Women were more likely than males to give a high rating for their likelihood for all three actions asked about. Suitable Treatment Or Assistance For Someone With Depression For men there was a decrease in the proportion mentioning 'Support/someone to talk to/social contact' as an appropriate form of assistance or treatment (down from 47% to 38% for total mentions). Women were more likely than men to: Mention at least one thing supportive (91% versus 82%) Mention 'support/someone to talk to/social support' (50% versus 38%) Mention 'Counselling/psychotherapy/psychological treatment' (52% versus 36%) Mention self help strategies (23% versus 15%),including proven self help strategies (9% versus 4%). Attitudes Relating To Depression And Its Treatment Men showed improvements on six attitude statements compared with three for women. They both showed improvements for: It is important to recognise and act EARLY on depression, rather than waiting I would be able to recognise if I had depression Men (and not women) showed improvements for: 56

57 Depression can be successfully treated in ways that don't need medication Depression can be successfully treated with medication People with depression just need to stop feeling sorry for themselves (Disagreement that) getting treatment for depression would be expensive Women (and not men) showed improvements for: If a close friend had depression, I would be able to recognise the signs and symptoms 57

58 9.3 YOUTH AGE OF FREEPHONE CALLERS The freephone data shows low levels of calls by persons aged 14 to 19 years. The level is at its highest for those aged 30 to 39 years, but is still relatively high for 20 to 29 year olds and 40 to 49 year olds. The levels shown in the graph below are the percentage of the New Zealand population aged 14 years and over who have called the freephone number over the nine months the campaign had been running up to the end of June Age groups All callers / 3rd Party callers % of NZ population All callers rd party callers 0 14 to 19 years 20 to 29 years 30 to 39 years 40 to 59 years 50 to 59 years 60 years or over YOUTH FINDINGS FROM TRACKING SURVEYS Youth (16 to 24 year olds for the purposes of this study) are an important priority group because rates of depression are highest among youth and there has been some concern within the campaign team as to how effectively the campaign is reaching youth. Because of the smaller sub-sample for youth (174 in the second survey), changes between surveys needed to be large to be significant. 16 These figures are different from those in the Lifeline report, which simply show the percentage of callers in each age group. The figures in this report present the number of callers in each age group as a percentage of the number in that age group in the NZ population. 58

59 Response To Advertising Youth recall of the advertising was below average, but at 79 percent this was still a relatively high rate of recall. Youth were less likely to discuss the advertising (48% discussed it compared with 62% for the total sample). Youth were less likely to mention that is was a good idea having such a prominent person willing to talk openly about his depression (26% versus 39% for total sample). They were similar to the total sample in saying that it was a good ad (33% versus 32%), although fewer youth went as far as saying it was 'very good/fantastic' (8% versus 15%). Youth message recall was generally at similar levels to the total sample. They had 59 percent mention of help seeking messages, which was a little lower than for the total sample (67%), but the difference was not significant. The main significant difference was less mention of, 'Its OK to be depressed' (14% versus 24%). Contact With People With Experience Of Depression There was a significant increase since the benchmark survey in the proportion of youth who volunteered that they had personally experienced depression (up from 9% to 17%). Compared with the total sample, they were less likely to have lived with someone with depression (32% versus 45% for total sample), which is consistent with them having had fewer years to have such contact. Symptoms Of Depression Youth reported decreased mention since the benchmark survey of 'Irritability / grumpiness / short tempered / moodiness' as a symptom of depression (from 13% to 3%), while there was increased mention of non-symptoms (up from 7% to 14%). Compared with the total sample youth were less likely to mention the following symptoms: Lack of energy/tiredness (7% compared with 19% for total sample), irritability/grumpiness (3% versus 12%), negativity (2% versus 9%). Who To Turn To For Help Since the campaign began, youth were now more likely to mention seeking help from a counsellor/psychologist if they thought they might be experiencing depression (up from 17% to 27% for total mentions). Youth also showed an improvement on three of four measures for the likelihood of taking actions if they thought they might be experiencing depression, these being: An increase in the proportion giving a high rating for the likelihood of 'talking to a friend, family or whanau member or some other person you could trust' (up from 77% to 87%) A similar increase for 'talking to a doctor/health professional' (up from 41% to 58%) A decrease in giving a low likelihood rating for phoning a helpline (decreased from 54% to 44%) Compared with the total sample, youth were more likely to: Mention turning to their family/friends/whanau (90% versus 79% for total sample) Mention turning to a counsellor/psychologist for help (27% versus 19% for total sample) Give a high rating for the likelihood of 'talking to a friend, or family member' (87% versus 79% for total sample). 59

60 Give a low rating for the likelihood of 'talking to a doctor or some other health professional' (19% versus 13% for total sample giving a low rating). Response To Someone Who Might Be Experiencing Depression When dealing with someone else who they thought might have depression, youth reported an increase in high ratings for the likelihood of going to the person and encouraging them to talk about it (up from 69% to 78%). Compared with the total sample in the current survey, youth were less likely to give a high rating for 'Encouraging the person to see a doctor or seek professional help' (70% versus 84% for total sample). Suitable Treatment Or Assistance For Someone With Depression Youth showed no marked changes between the two surveys. Compared with the total sample, they were significantly more likely to mention: 'support/someone to talk to' (55% versus 46% for total sample) and 'family/friends/whanau' (11% versus 7% for total sample). They were less likely to mention 'Medication/anti-depressants' (28% versus 45% for total sample) and 'exercise/sport' (1% versus 5% for total sample). Attitudes Relating To Depression And Its Treatment Youth showed no significant changes in attitudes between the two surveys. Compared with the total sample, they were significantly less likely to 'strongly agree' that 'It is important to recognise and act early on depression, rather than waiting' (64% versus 74% for total sample). They were less likely to 'agree' that: 'If a close friend had depression, I would be able to recognise the signs and symptoms' (45% versus 54% for total sample); 'Depression is becoming a major health problem in New Zealand (54% versus 63% for total sample); and 'Depression can be successfully treated with medication' (32% versus 49% for total sample ). They were less likely to 'disagree' that 'I would like to know more about depression (10% versus 17% for total sample), which is indicative of a greater interest in knowing more. They were also less likely to 'disagree' that 'People with depression just need to stop feeling sorry for themselves (58% versus 70% for total sample), which is indicative of a less positive attitude towards people with depression. 60

61 9.4 LEVEL OF DEPRIVATION FREEPHONE CALLERS While level of deprivation data is not available from the freephone data, information is available to show that beneficiaries are over-represented among callers, as shown in the graph below. It should be noted in this graph that 29 percent of the freephone callers were unable to be categorised, so it is likely that the levels shown for the different categories are under-represented. It should also be noted that the best available Census match for the "senior/retired" category used by Lifeline was persons on superannuation, which will include some persons who are still employed. Employment status % 100 Freephone callers NZ Census Beneficiary - Sickness Beneficiary - Unemployment Employed Self-employed Senior/Retired Undisclosed TRACKING SURVEY FINDINGS FOR PERSONS FROM HIGH DEPRIVATION AREAS There were 357 people in the high deprivation group in the current survey. Response To Advertising This high deprivation group were similar to the total sample in their recall of the advertising, their feelings and impressions about it, their discussion of it, and their recall of the radio advertising. In terms of message recall, they were less likely to mention 'It is OK to be depressed' (18% versus 24% for total sample), but on other messages they were similar to the total sample. 61

62 Contact With People With Experience Of Depression There was a significant increase in the proportion of high deprivation persons who volunteered that they had personally experienced depression (up from 13% to 19%). The high deprivation persons did not differ significantly from the total sample on these measures. Symptoms Of Depression There were no significant changes between surveys for this group. Compared with the total sample, people from high deprivation areas were more likely to mention 'suicidal thoughts' (6% versus 3%) and less likely to mention 'change behaviour/personality' (20% versus 26%). Who To Turn To For Help For people from high deprivation areas, there was a significant decrease in the proportion giving a high rating for the likelihood of 'seeking written information about depression' (down from 61% to 53%). Compared with the total sample, people from high deprivation areas were less likely to give a high rating for the likelihood of 'talking to a friend, family member' (73% versus 79% for total sample), or for the likelihood of 'seeking written information about depression' (53% versus 60%). Response To Someone Who Might Be Experiencing Depression There were no changes between surveys and no differences compared with the total sample. Suitable Treatment Or Assistance For Someone With Depression This group reported increased mention of 'Counselling/psychotherapy/psychological treatment' (up from 35% to 43%). They reported decreased mention of 'doctors/hospitals/psychiatrists' (down from 32% to 22%). There were no differences of note compared with the total sample. Attitudes Relating To Depression And Its Treatment Persons from high deprivation areas, along with those from medium and low deprivation areas, showed a significant increase in 'strongly agreeing' that 'it is important to recognise and act early on depression, rather than waiting' (up from 62% to 75%). There were also increased proportions of this group 'agreeing' that, 'Depression is becoming a major health problem in New Zealand' (up from 60% to 67%). There was also a positive improvement in the proportion 'disagreeing' that, 'People with depression just need to stop feeling sorry for themselves' (up from 56% to 65%). They were now more likely to 'disagree' that, 'If a close friend had depression, I would be able to recognise the signs and symptoms' (up from 5% to 10%). There was also an increase in 'disagreeing' that, 'Depression can be successfully treated in ways that don't need medication'. Compared with the total sample, those from high deprivation areas were more likely to 'agree' that, 'I would like to know more about depression' (53% versus 42% for total sample). They were more likely to agree that, 'People with depression just need to stop feeling sorry for themselves' (17% versus 12% for total sample). 62

63 9.5 REGION Although region is not a key variable in defining the priority audiences, it is interesting to note that there were some regional differences in the location of freephone callers. The standard regional data provided by Lifeline has been reanalysed for this report, to provide rates based on the population aged 14 years and over in each region. As shown in the graph below, there were markedly higher rates in Auckland and Hutt Valley, but it is difficult to understand why this might be. Percentage of callers by DHB region % Northland Waitemata Auckland Counties Manukau Waikato Bay of Plenty Lakes Tarawhiti Hawkes Bay Taranaki Whanganui Mid Central Wairarapa Capital & Coast Hutt Valley Nelson Marlborough West Coast Canterbury South Canterbury Otago Southland Regional analyses have not been undertaken for the tracking surveys, because region is not a priority audience defining variable. 63

64 10 CHANGES WITHIN PRIMARY CARE (INCLUDING GREEN PRESCRIPTIONS AND PRESCRIBING) PRIMARY CARE CBG Health Research have a panel of primary health care practices which provide weekly data (called HealthStat). The Ministry of Health contracted CBG to use this panel to collect and report on primary care data to assist in assessing the impact of the NDI on primary care. Seventy-two practices were included in the NDI survey, with half being involved in primary mental health initiatives (as requested by the Ministry). Seventy five of the 103 practices on the CBG data base were invited to participate in this NDI project. The data base of 103 that CBG sampled from appears to provide a reasonable cross-section of primary care practices in New Zealand. They selected this sample stratifying by DHB and then randomly selecting within DHBs. They had an 83 percent response rate. CBG note that their sample does over-represent Maori and Pacific patients and patients from Access practices as their response rate was 100 percent. However, CBG do note that "the coding rates for mental health conditions have started from a low base", suggesting likely under-reporting. It is therefore possible that increasing trends in reporting of depression diagnoses may reflect improved reporting rather than actual increases in depression diagnoses. The CBG panel data collection is only complete from October 2005, so CBG extracted additional data going back to October 2004, to provide more baseline data for the NDI on prescribing antidepressants and depression diagnoses. CBG produced a progress report on 1 July 2007, which covered the period up until 31 March A second report covering the six month period April to September will follow. This second report will provide a better indication of the impacts of the NDI as the 12 month period will ensure that the results are not confounded by seasonal effects. New diagnoses of depression The graph below shows the number of new diagnoses of depression between October 2004 and March It can be seen that there was an upward trend over this period. There was a marked increase in November, 2006, which is presumably a result of the launch of the NDI. However the key point to note is that the increase did not last beyond that month. In fact the levels over the following three months were a little lower than might have been expected, given the general upward trend prior to the campaign being launched. It may therefore be that the campaign launch precipitated some people going to their GP about depression, but that these people would have done so over the next month of two anyway. CBG note that the increase in November may also be due to raised awareness of depression in GPs and perhaps practice nurses, as a result of the campaign. 64

65 65 The number of consultations per annum for those with depression were not yet showing any effects of the NDI campaign. However, given this is based on year long data, any effects of NDI are more likely to be evident in the next report. As shown in the graph below, the number of consultations per annum for those with depression continued the same upward pattern after the NDI began, as were evident in the year preceding it. This upward pattern for depression appears to be at a more rapid rate than for all consultations. There are a number of factors that may be contributing to this upward rate for depression. It may relate to improvements in primary care reporting of depression, as CBG noted in their report that "the coding rates for mental health conditions have started from a low base". Other possible factors contributing to increased depression rates are the Like Minds campaign reducing the stigma associated with mental illness and the pharmaceutical industry promotion of Prozac and other anti-depressants.

66 Consultations per annum ALL Depression Antidepressant prescribing volumes The graph below, from the CBG report, shows that there is general upward trend in antidepressant prescription volumes 17, which is a similar trend to that for depression diagnoses. However, the key difference between the two graphs is that the prescribing does not show the same marked increase that was evident for diagnoses. 17 It should be noted that antidepressants are also prescribed for reasons other than depression. 66

67 This indicates that the new diagnoses of depression at the time the campaign began were probably mostly already using anti-depressants. (There were far 3.4 patients receiving anti-depressants for every patient who was diagnosed as having depression.) This suggests that the campaign did not result in an influx of people who had never sought treatment for their depression. However, somehow as a result of the campaign, a group of people who were already using anti-depressants finished up with a diagnosis of depression. In line with the earlier reasoning, it may be that they would normally have come to primary care and got a diagnosis over the following month or two. Another possible explanation is that doctors became more inclined to diagnose depression as a result of the campaign. Whatever the explanation, the key point to take out of this is that the NDI campaign does not seem to have led to any marked increase in people presenting to primary care with depression. This is consistent with the experience in Australia, with 'beyondblue' showing no marked increase on demand for primary care (see Appendix 3). The graph below shows the upward trend also evident in Pharmac data for prescribing of antidepressants. There is no evidence as yet of any marked change in the existing trends, that might possibly be attributable to the NDI. 67

68 Anti-depressant prescriptions 3,000,000 2,497,965 2,500,000 2,000,000 1,982,477 2,044,071 2,128,391 2,266,254 Numer of items dispensed 1,500,000 1,000, , , ,058 1,007,109 1,132,628 Number of scripts 500, / / / / /07 GREEN PRESCRIPTIONS CBG Research found that green prescription data was not being recorded in the data they were obtaining. They plan to begin this from October SPARC have kindly agreed to supply copies of the annual green prescription surveys that they undertake with both GPs and patients. However the most recent GP survey had data collection in October/November 2006 and so there is not yet any post-campaign launch data to examine trends. The 2006 survey reported that 42 percent of GPs who were using green prescriptions, were using them to relieve patients' depression/anxiety. This was a similar rate to the previous two years. It was also noted that the rate was higher among female GPs (48% versus 35% for males) and those in Southern regions (56%), while it was lower among metropolitan GPs (36%). The most recent patient survey had data collection in April It was based on 1,377 responses to a self-completion survey, with a 32 percent response rate. Fourteen percent of patients believed that the main reason GPs issued a green prescription was to relieve depression/anxiety, which was similar to the 13 percent in the 2006 survey. This is obviously a lot lower than the 42 percent for GPs, however the GP figures tended to be higher for most conditions (e.g. the figures for weight issues were 93 percent for GPs and 59 percent for patients). It was also reported that 57 percent of those issued a green prescription for this reason felt less depressed/anxious, with 54 percent feeling less stressed, 50 percent generally feeling better and 47 percent feeling stronger/fitter. 68

69 APPENDIX A: MEDIA COVERAGE Media coverage details for first six months of 2007, as supplied by the Mental Health Foundation The highlighted areas are media releases that the MHF issued (yellow) and letters to editors they wrote (turquoise). DATE MEDIA TITLE SUBJECT Waikato Times Kirwan helps NZ to understand MHF Media Release Article about Kirwan s support with depression campaigns. Positive Beat the back to work blues Scoop.co.nz Beat the back to work blues Media release from the Mental Health Foundation about the back to work blues and how to reduce the likelihood of experiencing them. Includes information about the signs of depression, the depression support line number and the depression website. 7 Taken from the Mental Health Foundation media release. Mentions the national depression campaign support line contact details. Generated by the Mental Health Foundation communications team. Positive Radio NZ Live radio interview with Judi Clements about back to work blues for the Summer Report programme. Mentioned the national depression campaign support line number. Generated by the Mental Health Foundation communications team. Positive Radio Live Live radio interview with Judi Clements about back to work blues for the breakfast show. Mentioned the national depression campaign support number and website. Generated by the Mental Health Foundation communications team. Positive Dannevirke Evening News Bay of Plenty Times Everybody.co. nz Easing back into work after a break Article about the back to work blues. Quotes the depression support line. Generated by the Mental Health Foundation communications team. Positive Body clock rhythm has big hand in turning off the back to work blues Article about back to work blues. Quotes the depression support line. Generated by the Mental Health Foundation communications team. Positive Beat the New Year back to work blues Article about the back to work blues. Quotes the depression support line and website. Generated by the Mental Health Foundation communications team. Positive Plains FM Live interview with Judi Clements about back to work blues for the breakfast show. Mentioned the depression campaign. Generated by the Mental Health Foundation communications team. Positive 69

70 DATE MEDIA TITLE SUBJECT Waikato Times Fighting depression Marlborough Express Feilding Herald Lake District News Published letter to the editor from the Mental Health Foundation with regards to article Kirwan helps NZ understand. Quotes the depression support line and details high profile supporters of the campaign. Generated by the Mental Health Foundation communications team. Positive Boring TV choice The Herald Fighting fat Letter to the editor about the boring and depressing sport on TV at the moment and how it is no wonder there are adverts about depression encouraging us to overcome it. Neutral Beat the back to work blues Article about the back to work blues. Quotes the depression support line and website. Generated by the Mental Health Foundation communications team. Positive Blues need not be a grey area Rangitikei Mail Beat the back to work blues Article about the back to work blues. Quotes the depression support line and website. Generated by the Mental Health Foundation communications team. Positive Letter to the editor from a member of the public about downsizing reality TV programmes and how they actually might do harm, especially to younger impressionable children. Mentions that at least the government are doing a positive thing through promoting mental health and depression. Positive Article about the back to work blues. Quotes the depression support line and website. Generated by the Mental Health Foundation communications team. Positive Hutt News Beating the back to work blues Guardian (Palmerston North) Gisborne Herald The New Zealand Herald Article about the back to work blues. Quotes the depression support line and website. Generated by the Mental Health Foundation communications team. Positive Beat the back to work blues Article about the back to work blues. Quotes the depression support line and website. Generated by the Mental Health Foundation communications team. Positive JK even greater now Letter to the editor from a member of the public about John Kirwan signing a contract with the Japanese national rugby squad, and his courage in speaking out publicly about his depression. Positive The media s year ahead, from A to Z A to Z of what may be happening in the media over the next year. Letter M stands for Mental Health, and briefly talks about FCB and its health awareness clients being given kudos for the John Kirwan ads, however it then goes on to mention that the TV adverts are repetitive and may make us feel depressed. Negative. 70

71 DATE MEDIA Kapi-Mana News East & Bays Courier Feb/Mar issue Stella magazine Auckland City Harbour News Otago Daily Times Magazine The New Zealand Herald TITLE SUBJECT The Mental Health Foundation has the following tips to reduce back to work blues Article about the back to work blues. Quotes the depression support line and website. Generated by the Mental Health Foundation communications team. Positive Tips to beat the back to work blues Article about the back to work blues. Quotes the depression support line and website. Generated by the Mental Health Foundation communications team. Positive Stress and success An article about the stress and success of working your way to top. Tips from the Mental Health Foundation on how to reduce stress. Quotes the depression support line and website. Generated by the Mental Health Foundation communications team. Positive. Back to work blues Article about back to work blues. Quotes the depression support line. Generated by the Mental Health Foundation communications team. Positive. When in doubt, check it out, say experts Article about youth suicide, suicidal behaviour and how to spot potential signs. Refers to the National Depression Campaign as being part of the suicide prevention strategy. Quotes from Merryn Statham Director of SPINZ at the Mental Health Foundation. Input from the Mental Health Foundation communications team. Neutral Unpublished letter to journalist from the Mental Health Foundation regarding the article The media s year ahead, from A to Z published on , thanking him for the kudos that he gave to the depression campaign and stating that we are encouraged by the number of people that called in to the support line and website over the festive period indicating that there was a need for the repetitive TV ads. Positive Central Leader Take it easy to avoid the post holiday blues Taupo Weekender Waitomo News Article about the back to work blues. Quotes the depression support line. Generated by the Mental Health Foundation communications team. Positive Beat the blues back at work Article about the back to work blues. Quotes the depression support line. Generated by the Mental Health Foundation communications team. Positive Three year project aims to battle depression Article about depression and the National Depression Campaign with a local view. Positive TV3 Lillian Ng, health reporter at TV3, came to interview Janet Peters about the National Depression Campaign and its success so far. The item aired on Generated by the Mental Health Foundation communications team. Positive 71

72 DATE MEDIA Consumer Magazine This Week Hamilton TITLE SUBJECT The black dog of depression Article about depression which includes the signs and symptoms to look out for as well as a whole list of contact details, including the depression campaign website and support line. Also mentions John Kirwan. Positive. Claim simplistic Published letter to the editor sent by the Mental Health Foundation in response to an overly simplistic view about why people had died by suicide. The response mentions the national depression campaign in relation to its link with the suicide prevention strategy. Generated by the Mental Health Foundation communications team. Positive Sunday news Legend scores with kiwi blokes: JK throws a lifeline Taupo Times A hope worth having Fitness Life Moody Blues Plains Profile Depression Article about the success of the depression campaign and how John Kirwan s involvement has helped many people. Positive An article that starts off referencing John Kirwan s hope message from the national depression campaign and goes onto talk about hope in a larger sense and how god can be relied on. Neutral. Unpublished letter to the editor from the Mental Health Foundation about an article about depression which uses NZ and Australian statistics. The Mental Health Foundation communications team sent the editor an to say thank you for publishing/concentrating on such an article and provided some extra information about where she could go for information in the future, as well as information about the MHF involvement in the national depression campaign. Article about the national depression campaign and information taken straight from the depression campaign website. Neutral Plains Profile The Mental Health Foundation communications team sent a letter to Plains Profile magazine and to the GP who suggested the article on depression thanking them for publishing it. Mentioned the national depression campaign and the Mental Health Foundation s role in the campaign. (Unpublished) Keeping On Magazine Canterbury General Practice Link Depression campaign gets people talking Article about the national depression campaign with a point of view from a lifeline counsellor. Provides the support number, website and information on how to spot the signs of depression. Thank you response put together. Generated by the Mental Health Foundation communications team. Positive Depression ads show strong and positive results Article about the success of the depression campaign. Generated by the Mental Health Foundation communications team. Positive 72

73 DATE MEDIA The New Zealand Herald TV One Close Up Gisborne Herald Otago Daily Times Marlborough Express TITLE SUBJECT Kirwan all smiles Short piece about John Kirwan s visit to meet Jim Anderton in Wellington in order to discuss the success of the depression campaign so far. Positive Interview with John Kirwan about his involvement in the national depression campaign. Positive. Kirwan thanked for depression adverts An article about John Kirwan s visit to parliament to find out how the depression campaign is going. Positive Kirwan thanked for work in campaign An article about John Kirwan s visit to parliament to find out how the depression campaign is going. Positive Kirwan thanked for his efforts on depression An article about John Kirwan s visit to parliament to find out how the depression campaign is going. Positive All Blacks.com John Kirwan motivates men to seek help for depression Otago Daily Times Article about the success of the depression campaign and the ads fronted by John Kirwan. Generated by the Mental Health Foundation communications team Positive Depression Waikato Times Blacker than black Manawatu Standard Letter to the editor from a member of the public about clinical studies of depression which show that depression is associated with reduced rates of blood flow to the brain. Mentions John Kirwan and at the start of the article and says he has drawn attention to a condition that is usually hidden. Positive. Article about depression and the success of the depression campaign generated by the Mental Health Foundation communications team. Features two case studies of men who have experience of depression. Also included the depression support line phone number, website and the signs to watch out for. Well written. Thank you sent to the journalist. Positive Suffering silence Article about depression and the success of the depression campaign generated by the Mental Health Foundation communications team. Features two case studies of men who have experience of depression. Also included the depression support line phone number, website and the signs to watch out for. Well written. Thank you sent to the journalist. Positive Waikato Times (Unpublished) Letter to feature writer of Blacker than black from the Mental Health Foundation communications team, congratulating him on the positive article that appeared in the Waikato Times about the national depression campaign. 73

74 DATE MEDIA The Dominion Post March 2007 Public Health Perspectives MOH news magazine Marlborough Express Autumn 2007 ProCare Pulse magazine TITLE SUBJECT United front to universal enemy Article about suicide prevention moving to an all-encompassing strategy. Mentions the depression campaign and John Kirwan as being part of the Government s suicide prevention strategy. Provides a case study of peer support in Lower Hutt. Neutral. Depression ads show strong and positive results An article about the success of the depression campaign ads so far. Generated by the Mental Health Foundation communications team. Positive Facing the black hole of depression Article about depression and the success of the depression campaign generated by the Mental Health Foundation communications team. Features two case studies of men who have experience of depression. Also included the depression support line phone number, website and the signs to watch out for. Well written. Thank you sent to the feature writer on Positive Depression: A man s world Nelson Mail Escaping a black hole April 2007 Hauora Newsletter MHF Media Release Rugby News magazine Article written by Alex Dawber, a psychologist with ProCare Psychological Services, about depression. Mentions John Kirwan and the signs and symptoms of depression as well as the depression support line phone number and website. Positive Article about depression and the success of the depression campaign generated by the Mental Health Foundation communications team. Features two case studies of men who have experience of depression. Also included the depression support line phone number, website and the signs to watch out for. Well written. Positive Depression ads show strong and positive results Article generated by the Mental Health Foundation communications team about the success of the depression campaign. Positive. An invite to a special film Media release from the Mental Health Foundation about a charity preview screening of the Flying Scotsman, aimed at raising money for the MHF. The film has a storyline about depression. The media release mentions the depression support line number and website address for information on where to go for help. 2 Red Sun Rising Interview with John Kirwan with a couple of questions asked about the depression campaign. A sidebar of information about the success of the depression campaign with an accompanying photo was generated by the Mental Health Foundation communications team. Positive. 74

75 DATE MEDIA The New Zealand Herald MHF Media Release Howick and Botany District Times 25 April to 01 May Express newspaper TITLE SUBJECT Blokes learn to ask for help Article about more men contacting support lines for help with regards to all aspects of their lives. Mentions John Kirwan and the positive impact that he has had, as well as quoting Brian Wilshire from Lifeline. Positive Mental Health Foundation scores support of the Hurricanes Media release from the Mental Health Foundation about the launch of a partnership between the MHF and the Hurricanes. The release includes reference to the national depression campaign and John Kirwan s involvement. 5 Male forum breaks barriers Article about a male depression support group. Mentions the depression campaign ads featuring John Kirwan in a positive light. Positive. Depression Healthwise Men & depression The New Zealand Herald Express newspaper Healthwise Magazine Article about depression details the causes of depression, the signs and what people can do. Provides details of the depression helpline and the out of the blue website. Positive. Article about John Kirwan, the depression campaign and depression. Provides the signs and symptoms of depression and where to go for help, includes depression support line number, MHF website, and the Lifeline website. Positive. Mental health outlook improves Article about the Mental Health Commission s 10 year report of mental health in NZ over the past decade. Has a picture of John Kirwan and a caption about his involvement in the depression campaign. Positive (Unpublished) Letter to the editor from the Mental Health Foundation s communications team regarding the Depression article that was featured in Express on 25 April 01 May issue. The letter thanked the editor for including an article about depression, mentioned the MHF s involvement in the depression campaign and offered future help for similar articles. Editor responded and the MHF communications team generated another article about depression and reducing stress quoting the depression campaign website and support line. (Unpublished) Letter to the editor from the Mental Health Foundation s communications team regarding the article Men and depression that was featured in the April issue of Healthwise. The letter thanked them for including an article about depression in men, mentioned the MHF s involvement in the depression campaign and offered future help for similar articles. 75

76 DATE MEDIA TITLE SUBJECT Timaru Herald Mental Health Sunday Star Times A sensitive letter to the editor written by a member of the public who has recently attended the funeral of a man who experienced depression. Her point of view is that when open discussion and support is needed by those experience mental health issues, fear judgement and shame creep in and stop people's recovery. Talks about these views being ignorant. Congratulates JK for being open and upfront, and for the depression ads. Positive. Kirwan campaign success leaves GPs, counsellors stonkered by demand Article about the success of the depression campaign and how it has left services unable to cope with the demands of people who are experiencing depression. Negative Stuff.co.nz Kirwan ad reveals lack of resources Express newspaper Sunday Star Times Article about the success of the depression campaign and how it has left services unable to cope with the demands of people who are experiencing depression. Negative. Mind your mood Malvern News An open letter to John Kirwan Sunday Star Times Sunday Star Times Article about how to help protect your mental health. References the depression campaign website and support line. Generated by the Mental Health Foundation communications team. Positive. Letter to the editor sent by the Mental Health Foundation communications team about the article Kirwan campaign success leaves GPs, counsellors stonkered by demand that featured in the 13 May Sunday Star Times. The letter from the Mental Health Foundation took the point of view that the campaign has had a very good reaction throughout New Zealand and in particular from men, who traditionally respond to such campaigns at a much lower rate. It also stated that it is true that not everyone who would benefit from talking treatment or counselling will find ready access but generally those people who have contacted the support line are reporting benefits and improvements. An open letter published in the Malvern News by a man thanking JK for sharing his experience of depression, as it has helped him to realise that it is not something he should hide, and that John Kirwan has helped him through it. Positive. Depression Treatment online Follow up from last week s (13 May) article about how the success of the depression campaign has led to concerns about access to free counselling services. Focuses on CBT being offered online and alternatives to help people experiencing depression. Neutral Success story at heart Published letter to the editor from the Mental Health Foundation published with regard to Kirwan campaign success leaves GPs, counsellors stonkered by demand. Positive 76

77 DATE MEDIA TITLE SUBJECT Hutt News Canes throw weight behind mental health The Aucklander West The Aucklander Shore Article about the partnership between the Mental Health Foundation and the Hurricanes. Mention John Kirwan and his experience of depression. Generated by the Mental Health Foundation s communications team. Positive. Give the glums the elbow Sunday News Birthday Treats The New Zealand Herald The Dominion Post Bay of Plenty Times Article about depression and CBT. Focuses on a personal story. References the depression support line number and the depression website. Neutral. Therapy gives the glums the elbow Article about depression and CBT. Focuses on a personal story. References the depression support line number and the depression website. Neutral. Article about the Queens Birthday honours. The paper states that John Kirwan, among others, is likely to receive an honour for the work that he has done for mental health. Photo of John Kirwan, mentions the depression campaign. The Mental Health Foundation put forward the proposal for John Kirwan to receive a Queen s Birthday honour. Positive. Heroes in word and deed Article about the New Zealand Queen s birthday honours list. John Kirwan has received an honour for the work that he has done for mental health. Mentions the depression campaign ads. Front pages article with photo of John Kirwan. The Mental Health Foundation put forward the proposal for John Kirwan to receive a Queen s Birthday honour. Positive. Queen s Birthday Honours Article about the New Zealand Queen s birthday honours list. John Kirwan has received an honour for the work that he has done for mental health. The Mental Health Foundation put forward the proposal for John Kirwan to receive a Queen s Birthday honour. Positive. Honours missing the mark Article about the Queen s Birthday honours. Talks about how some people of the list should not be given the honours questions what they have actually done for the country / community? Gives examples of well known people who do deserve such accolades, one being John Kirwan for his work in mental health as an example. The Mental Health Foundation put forward the proposal for John Kirwan to receive a Queen s Birthday honour. Positive. 77

78 DATE MEDIA TITLE SUBJECT The Daily Post Honours to those who earn them Wairarapa Times Age Wanganui Chronicle MHF Media Release Article about the Queen s Birthday honours. Talks about how some people of the list should not be given the honours questions what they have actually done for the country / community? Gives examples of well known people who do deserve such accolades, one being John Kirwan for his work in mental health as an example. The Mental Health Foundation put forward the proposal for John Kirwan to receive a Queen s Birthday honour. Positive. Law expert heads Queen s honours Article about the Queen s Birthday Honours. Mentions that JK received an honour. The Mental Health Foundation put forward the proposal for John Kirwan to receive a Queen s Birthday honour. Positive What have they done for NZ Article about the Queen s Birthday honours. Talks about how some people of the list should not be given the honours questions what they have actually done for the country / community? Gives examples of well known people who do deserve such accolades, one being John Kirwan for his work in mental health as an example. The Mental Health Foundation put forward the proposal for John Kirwan to receive a Queen s Birthday honour. Positive. Mental Health Foundation delighted at John Kirwan s honour from the Queen Media release from the Mental Health Foundation expressing delight at the honour JK has been given in light of his mental health work. The Mental Health Foundation put forward the proposal for John Kirwan to receive a Queen s Birthday honour Letter to editor Unpublished letter sent to editor of the New Zealand Herald from the Mental Health Foundation s communications team expressing MHF delight at John Kirwan s honour. The Mental Health Foundation put forward the proposal for John Kirwan to receive a Queen s Birthday honour Letter to editor Published letter sent to the editor of the Sunday News from the Mental Health Foundation s communications team expressing MHF delight at John Kirwan s honour. The Mental Health Foundation put forward the proposal for John Kirwan to receive a Queen s Birthday honour The Aucklander Papakura The Aucklander East Counsellors advise its good to talk Article based on the Home and Family counselling service who are promoting the fact that it is good to talk things through. The article mentions John Kirwan as being pivotal in getting people to talk. Positive Counsellors urge people to talk Article based on the Home and Family counselling service who are promoting the fact that it is good to talk things through. The article mentions John Kirwan as being pivotal in getting people to talk. Positive 78

79 DATE MEDIA The Aucklander Central The Aucklander South The Aucklander West The Aucklander North The Aucklander Shore Daily Chronicle TITLE SUBJECT Counsellors urge people to talk Article based on the Home and Family counselling service who are promoting the fact that it is good to talk things through. The article mentions John Kirwan as being pivotal in getting people to talk. Positive Counsellors urge people to talk Article based on the Home and Family counselling service who are promoting the fact that it is good to talk things through. The article mentions John Kirwan as being pivotal in getting people to talk. Positive Counsellors urge people to talk Article based on the Home and Family counselling service who are promoting the fact that it is good to talk things through. The article mentions John Kirwan as being pivotal in getting people to talk. Positive Counsellors urge people to talk Article based on the Home and Family counselling service who are promoting the fact that it is good to talk things through. The article mentions John Kirwan as being pivotal in getting people to talk. Positive Counsellors urge people to talk Article based on the Home and Family counselling service who are promoting the fact that it is good to talk things through. The article mentions John Kirwan as being pivotal in getting people to talk. Positive Quick comment Central Leader Talk uncorks Norma s blues Article about the queen s honours and why some of the people chosen should not be getting the awards. Mentions John Kirwan in a positive light saying that he has done much for the community in terms of services to mental health. The Mental Health Foundation put forward the proposal for John Kirwan to receive a Queen s Birthday honour. Positive. Counsellor reports positive impact of John Kirwan in relation to the national depression campaign in encouraging men to seek counselling for their depression. Positive Sunday News Kirwan deserves Queen s kudos The Press In a few words Published letter to the editor from the Mental Health Foundation published expressing the Mental Health Foundation s delight in John Kirwan s Queen s honour. The Mental Health Foundation put forward the proposal for John Kirwan to receive a Queen s Birthday honour. Positive Bite sized article about John Kirwan receiving a Queen s birthday honour. The item states that this is where John Kirwan s real courage has come from. The Mental Health Foundation put forward the proposal for John Kirwan to receive a Queen s Birthday honour. Positive 79

80 DATE MEDIA Auckland City Harbour News New Zealand Herald Hauraki Herald Diabetes magazine TITLE SUBJECT Big step breaks taboo Article about an older lady who has learnt how to deal with her experience of depression. She credits John Kirwan and the Mental Health Foundation for having a big impact on encouraging people to seek professional help. Positive In the sights of the behaviour engineers Article about social marketing campaigns. Mentions John Kirwan for the role he has played in raising awareness of depression and his Queens birthday honour. The Mental Health Foundation put forward the proposal for John Kirwan to receive a Queen s Birthday honour. Positive Thames group gets Waikato wide health contract Article about Te Korowai being awarded the contract to run the Waikato wide Like Minds contract. The Co-ordinator of this contract for the region attributes recent awareness campaigns especially those featuring former All Black John Kirwan are helping to take away some of the stigma attached to mental illness. Neutral. Diabetes and depression: improving quality of life Article about diabetes and depression how depression can have major implications for people with diabetes. Features depression symptoms and provides the depression support line number and depression website. Generated by the Mental Health Foundation communications team. Neutral Te Waha Nui Depressed still not seeking help Article about depression and the Government figures that 50% of New Zealanders will meet the criteria for a mental illness at some point in their lives. The article quotes Minister Anderton and mentions the depression campaign and John Kirwan s involvement in helping to raise awareness of the issue. Positive mention of the national depression campaign. 80

81 APPENDIX B: JOHN KIRWAN NZ HERALD ARTICLE NOVEMBER 28, 2006 John Kirwan inspires men to reach out for help 12:00AM Tuesday November 28, 2006 By Martha McKenzie-Minifie Former All Black John Kirwan speaks about his battle with depression in a series of television commercials. Former All Black John Kirwan speaks about his battle with depression in a series of television commercials. Former All Black John Kirwan's vivid description of his experience with depression in a series of TV commercials is being credited with a rise in men asking for help. Half the callers to the National Depression Initiative helpline had been men, bucking the trend of women callers to counselling lines outnumbering men two to one, said LifeLine chief executive Bryan Wilshire. "It's quite astounding," Mr Wilshire said. "It's had its moments when it's [the number of male callers] more than the female figure." Waikato University lecturer Richard Pringle, who wrote his PhD thesis on men's attitudes to rugby culture, admired the former winger for speaking out and said the ads challenged many people's view of footballers. "I think it is challenging some stereotypes of masculinity," said Dr Pringle. "I think the fact that he is who he is and is doing this makes it more powerful." The advertisements, by agency FCB, are part of a $6.4 million Government campaign to reduce the impact of depression. In the commercials, Kirwan speaks openly of the rapid on-set of his depression. "One day I was happy-go-lucky JK, the next morning I got up, looked in the mirror and there was this guy I didn't like looking back. "The biggest fear for me was that I was never going to be well again, I was never going to be the John Kirwan that went into this." Mr Wilshire said the ads were "genuine" and "gutsy" and touched previously hard-to-reach people. "People haven't realised beforehand that, say, their partner was actually suffering depression - they'd not believed it," he said. "Now they realise that they can do something about it." Mr Wilshire said Kirwan was thrilled with the response. "He encouraged them [people with depression] to keep on looking until they find someone who can give them some help and [remember] that there is a light at the end of the tunnel." Call attempts to LifeLine swelled from 27,500 in August to almost 60,000 last month, when the ads first screened. The three commercials in the five-ad series that screened last month will repeat during the Christmas and New Year period. The final two in the series are due to go to air in February. * Visit the National Depression Initiative website or call for more details. 81