The National Survey of Mental Health and Well-Being in Australia: Impact on Policy

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1 In Review The National Survey of Mental Health and Well-Being in Australia: Impact on Policy Scott Henderson, MD, Hon MD (UNSW), DSc, FRACP, FRANZCP, FRCP, FRCPsych 1 Objective: To provide a synopsis of the 3-part National Survey of Mental Health and Well-Being in Australia and to examine the yield in terms of policy and other changes in mental and general health services. Method: Published data are examined, and a commentary is provided on service-delivery issues that the data have revealed. Results: One-year prevalence estimates for the common mental disorders, defined according to ICD-10 criteria and assessed using the automated version of the Composite International Diagnostic Interview (CIDI-A), have indicated rates similar to those of other countries (17.7%). Alarmingly high rates were found for alcohol and substance abuse in young persons, especially among young men. The number of years of life lost owing to disability attributable to mental disorders exceeds the number lost owing to cardiovascular disease and cancer. Only 35% of persons with 1 or more of the common mental disorders had sought help in the 12 months prior to interview. The point prevalence for mental health problems was 14% for persons aged 4 to 17 years. The point prevalence for psychotic disorders was 4.7 per An encouraging finding is that 81% of affected individuals had been to their general practitioner (GP) in the last year. However, only 20% had participated in any rehabilitation program in the past year. Conclusions: The Survey results are based on a national population sample, not on individuals reaching services. They have therefore proved to be of great value in influencing policy at federal and state levels and may have contributed to increased funding for both services and research. (Can J Psychiatry 2002;47: ) See page 824 for funding support and author affiliations. Clinical Implications The profile of morbidity revealed by a general population survey differs importantly from that of the population reaching clinicians. Psychiatrists can more effectively contribute to mental health by spending some time in consultative work instead of engaging exclusively in 1-to-1 encounters. Much greater effort needs to be put into rehabilitation and recovery, particularly for persons with psychoses. Limitations Some important groups in the Australian population could not be adequately studied, either for financial or for administrative reasons. The validity of the prevalence estimates needs to be critically assessed. No information could be obtained on the performance of general practitioners (GPs), who were by far the most frequently used source of professional help. Key Words: psychiatric epidemiology, unmet need, prevalence estimates, children, psychoses, health policy Can J Psychiatry, Vol 47, No 9, November

2 The Canadian Journal of Psychiatry In Review In the mid-1990s, a National Survey of Mental Health and Well-Being was carried out in Australia. The purposes were mainly administrative: to inform policy at the federal and state levels and to provide information for advocacy at a time of major changes for mental health services (1). The success of the undertaking is probably largely attributable to the consortium of expertise that was assembled. This included senior administrators, consumer and caregiver spokespersons, psychiatric epidemiologists, and survey experts from the Australian Bureau of Statistics. Three aims were agreed upon: 1) to estimate the 1-month and 1-year prevalence of mental disorders and of significant psychological symptoms in the Australian population, 2) to estimate the amount of disability associated with such morbidity, and 3) to estimate the use of health and other services by affected persons. To achieve these aims, the National Survey needed 3 complementary parts: 1) a survey of adults in the general population, 2) a survey of people with low-prevalence disorders and psychoses, and 3) a survey of children and young people. This paper provides a synopsis of the main findings and retrospectively considers the utility of the National Survey for improving both mental and general health services. The Survey of Adults Some persons aged 18 years to late life completed an interview with the automated version of the Composite International Diagnostic Interview (CIDI-A), developed in Sydney by Peters and Andrews (2). This represents a response rate of 78% of the target sample. The CIDI-A algorithms give both ICD-10 (3) and DSM-IV (4) diagnoses, the former being used in this analysis. The sample was unable to generate stable estimates of the following groups: people living in rural and remote areas of Australia; the indigenous population; people not fluent in English; those in prison, colleges, and other institutions; those in the armed forces; and the very elderly. With this caveat, the National Survey showed that just under 1 in 5 Australian adults (17.7%) had an anxiety, affective, or substance use disorder in the 12 months prior to interview (5 7). Anxiety Disorders These are the most common disorders. They affect just under 1 in 10 adults (9.7%). Contrary to expectation, it was found that anxiety disorders are unrelated to education in Australia, that they cause much more disablement in people s lives than was realized, and that three-quarters of all affected individuals had not sought help from health services. Comorbidity is present in almost one-half of all cases. Depressive Disorders According to ICD-10, this refers to both depressive episodes and dysthymia. In the 12 months before the interview, 5.8% of the adult population had 1 or more depressive disorders. They were more frequent in women (7.4%) than in men (4.2%). For men, depression is a little more common in mid-life. In women, the highest rates occur in those aged 18 to 24 years, where 1 in 10 respondents had experienced depression in the previous year. Thereafter, depression gradually decreases with age. Comorbidity was again conspicuous: over one-half of the women and two-thirds of the men with a depressive disorder had at least 1 other mental disorder. Disablement was much higher than expected, leading to the conclusion that the depressive disorders cause considerable disruption to sufferers and to those around them. Regarding service use, 40% of persons with a depressive disorder had consulted their general practitioner (GP) for mental health problems in the previous 12 months, compared with 3% of people with no mental or physical disorders. The National Survey does not indicate whether GPs recognized that these subjects suffered from clinical depression. Contrary to the belief of many members of the general public and many health professionals, there is some evidence that, in the general population, the prevalence of depressive disorders is lower in persons aged 65 years and over than in younger adults (8,9). This finding applies to the elderly living in the community, not to those in nursing homes or other special accommodation. There, the prevalence of depression is known to be high. Again contrary to popular belief, depression is no higher in the capital cities than in the rest of each state and territory. Substance Use Disorders One in 13 Australian adults aged 18 years and older (7.7%) had a substance use disorder in the past 12 months. Cannabis use accounted for more drug use disorders than did any other illicit drug: 1.7% of Australian adults had a cannabis use disorder in the past 12 months. The prevalence of substance use disorders declined steeply with age for both men and women. One in 6 Australians aged 18 to 24 years had a substance use disorder, but only 1 in 90 Australians aged 65 years and over had such a disorder. As expected, comorbidity with anxiety or depression was high. Only about 1 in 7 individiuals with a substance use disorder had sought assistance from a health professional in the previous 12 months. This is one-half the rate at which people with an anxiety disorder sought treatment. Almost twice as many women as men sought such assistance. Most often, treatment was provided by a GP rather than by a psychiatrist, psychologist, or other mental health professional. Neurasthenia Formerly a common diagnosis throughout the world, this diagnosis was reintroduced to ICD-10 because of its utility and the need to reassess its status. Neurasthenia (F48.0) is characterized by persistent and distressing physical or mental fatigue, together with muscular aches, dizziness, tension 820 Can J Psychiatry, Vol 47, No 9, November 2002

3 8.125x /10/02 09:26 AM Page 3 The National Survey of Mental Health and Well-Being in Australia: Impact on Policy Figure 1 Years of life lost through disability (YLD), Australia, From Mathers and others (14) headaches, insomnia, inability to relax, or irritability. Because of its significance in primary care, the investigating team decided to include neurasthenia in the National Survey. Prolonged and excessive fatigue was reported by 13%of the sample (10). Of these, only 1 in 9 people met the ICD-10 criteria for neurasthenia. Comorbidity was associated with affective, anxiety, and physical disorders. Fatigue is frequent in the Australian community and is common in people attending general practice. Neurasthenia is disabling and places pressure on health services, largely because of its comorbidity with other mental and physical disorders. Personality Disorders Personality disorders are rarely included in general population surveys, but were included on this occasion. It was estimated that approximately 6.5%of the adult population of Australia have a lifetime prevalence of 1 or more personality disorders (11). They are more likely to be younger, male, and not married. They are also more likely to have an anxiety disorder, an affective disorder, a substance use disorder, or a physical condition. They are more likely to have greater disability. Smoking and Mental Disorders A strong relation was found between mental disorders and smoking (12). This association is age-specific, being much stronger in younger adults than in the elderly. It could be caused by a cohort difference in motivation to take up smoking. Public health efforts to reduce the prevalence of smoking need to take into account the strong relation between smoking and mental disorders. Disability and Service Use The disablement caused by the common mental disorders is considerable: on average, 3 days of disablement were experienced by affected individuals in the 4 weeks prior to interview, compared with 1 day for the general population (13). The National Survey made it possible for Mathers and his colleagues (14) to estimate the contribution of mental disorders to overall disability, expressed as years of life lost through disability (YLD) (Figure 1): YLD arising from mental disorders exceed all the other major categories. These researchers also found that mental disorders came third in terms of disability adjusted life years (DALYs), surpassed only by cardiovascular disease and cancer (Figure 2). Of those individuals with 1 or more of the common mental disorders, 65%had not used any form of health service in the 12 months prior to interview. Most who did use a service visited a GP. Well-Being in Australia During the Survey s planning, consumer and caregiver spokespersons urged that well-being be measured to complement measures of morbidity. This proved to be a valuable addition (15). Well-being was measured by the single-item Life Satisfaction Scale, expressed as a percentage, with 0%indicating terrible and 100%repesenting delighted. The mean score for the Australian adult population was 70.4%, which matches the proposed universal norm. Men and women Can J Psychiatry, Vol 47, No 9, November

4 8.125x /10/02 09:26 AM Page 4 The Canadian Journal of Psychiatry In Review Figure 2 Contribution to total burden of disease and injury in Australia, From Mathers and others (14) had very similar mean scores. Well-being was higher in persons with tertiary education and in those owning or purchasing their homes. It was lower in persons with physical or mental disorders, particularly depression. A U-shaped relation was found for alcohol use, whereby well-being was lower in both abstainers and heavy users. Multiple regression analysis showed that, when adjustment is made for confounders, women had higher life satisfaction than men and that, with age, high life satisfaction became less common in men but even more common in women. Life satisfaction was impaired for respondents with high psychological distress, especially among the unemployed, the divorced, and those with tertiary education, whether their symptoms led to a CIDI-A diagnosis of depression, or not. Of particular interest is the existence of a few persons with current anxiety or depressive disorders who reported having high life satisfaction. The Survey of Persons With Psychoses Jablensky and his team provide an account of this survey elsewhere (16 18). Cases known to public and private services, including GPs, were identified across 4 sites: Perth, Melbourne, Canberra, and Brisbane. The point prevalence of psychotic disorders in the urban Australian population aged 18 to 64 years has a weighted mean of 4.7 per No fewer than 60%of this population were found to be severely disabled in daily life. Only 30%were in self-care. Most lived in marked social isolation. Despite this, 60%reported satisfaction with their independence, and 44%felt satisfied with their life as a whole. Ten percent had been arrested in the last year, and 18% had been victims of violence. There was very high use of tobacco, alcohol, and illegal drugs. Some 50%had an admission in the previous year, mainly to a general hospital psychiatry unit. A remarkable finding was that 81%had been to their GP in the previous year. Predictably, 86%were taking medication; 75%said they were impaired by the side effects. Threequarters of the patients had no regular job, and 85%were receiving a government pension. Only 20%had participated in any rehabilitation program in the past year, a finding with a considerable impact on service planning. The Survey of Children and Young Persons Sawyer and colleagues (19,20) used the parent version of the Diagnostic Interview Schedule for Children (DISC-P) and the Child Behaviour Checklist (CBCL) to interview the parents of 4509 children aged 4 to 17 years. Adolescent respondents completed the Youth Behaviour Questionnaire. The findings identified 14%with mental health problems. Many had problems in other areas of their lives, including suicidal behaviour. Only 25%had reached any professional service in the previous 6 months. The point prevalence of attention-deficit hyperactivity disorder (ADHD) as defined by the DSM-IV was 7.5%, with the inattentive subtype being more common than the hyperactive-impulsive and combined subtype (21). ADHD was more prevalent among young male subjects and was linked to social adversity. The findings support the DSM-IV 822 Can J Psychiatry, Vol 47, No 9, November 2002

5 The National Survey of Mental Health and Well-Being in Australia: Impact on Policy view of ADHD subtypes as distinct clinical entities with impairments in multiple domains. One-quarter of the adolescents in the sample had used cannabis (22). There were no sex differences. Use increased rapidly with age. The association with depression, conduct problems, excessive drinking, and use of other drugs shows a prognostically malignant pattern of comorbidity. The Impact and Consequences of the National Survey Are these prevalence rates believable? The overall pattern of morbidity in adults is very similar to that reported for the UK by Jenkins and others (23). Our view is that having symptoms, even at case level, is necessary but not sufficient to justify treatment. In this regard, Andrews and Henderson offer a careful analysis of the need for treatment, including the reality of unmet need (24). It is irrational to suggest that 1 in 5 adults need treatment for a case-level mental disorder, and there are 3 possible interpretations for these statistics: first, the casefinding instrument may have too low a threshold, especially when used by nonclinicians. Second, some people s symptoms may be manageable by self and others; this is a group we need to know more about. Third, the relation between symptoms and disablement may be nonlinear. Whatever the validity of the estimates, the National Survey has yielded many benefits. Both training opportunities and expertise in epidemiology and health services research have advanced. Collaborations that did not previously exist have been forged between investigators or between them and administrators and policy-makers. Australia now has better estimates of the degree to which mental disorders contribute to the overall disease burden (14). Health inequalities have been shown to exist, particularly in relation to the availability of specialist mental health services the aptly-named inverse care law, whereby those in most need often get the least treatment. Population groups with conspicuously unmet needs have been identified, such as youth with alcohol-related problems. Also identified is the low rate of help seeking (62%) for treatable and common mental disorders. There have been some surprises. Anxiety, depression, and substance abuse are all less frequent in the elderly. No statistically significant differences could be found between metropolitan and rural populations. Foreign-born persons have somewhat lower rates than those born in Australia. (The reasons for this can only be speculative.) The disability associated with mental disorders is far greater than has been recognized. It accounts for 15% of the total burden of disability and is the third cause of disability after heart disease and cancer. For persons with psychoses, the findings are powerful. A debt is owed to Professor Assen Jablensky and his collaborators across 4 sites for the high quality of their methods and the administrative significance of the data they generated (16). People with psychotic disorders experience high rates of functional impairments and disability, decreased quality of life, persistent symptoms, substance use comorbidity, and frequent medication side effects. Although these individuals make high use of hospital-based and community mental health services, as well as of public and nongovernmental helping agencies, most live in extreme social isolation and adverse socioeconomic circumstances. Among many unmet needs, the limited availability of community-based rehabilitation, supported accommodation, and employment opportunities are particularly prominent. The so-called low-prevalence psychotic disorders represent a major and complex public health problem. They are associated with heavy personal and social costs. A broad programmatic approach to the recovery and rehabilitation of such persons is needed. It must involve various sectors of the community to tackle the multiple dimensions of clinical disorder, personal functioning, and socioeconomic environment that influence the course and outcome of psychosis and ultimately determine the effectiveness of service-based intervention. These data provide invaluable evidence for advocacy, to be used in policy decisions and in planning resource allocation. They also can be used to good effect by NGOs, by the general public, by consumers and caregivers, and by health care professionals. The findings are believed already to have influenced allocation of funds for mental health services, although the causal effect obviously cannot be proved. The National Survey has also contributed inter alia to greater resource allocation for mental health research. Some major banks, foundations, and the Australian Rotary Health Research Fund have now contributed considerable sums to mental health research. There have now been some 94 publications from the National Survey (Note 1). Within federal and state governments, the need to improve mental health literacy has become accepted (25), and intervention programs are now active. Their aim is to raise the level of knowledge about mental disorders, to inform people how and where they can seek help, and to reduce stigma not only among the public but also among health professionals. Parallel with this is a nationwide move to improve the contribution of family physicians to mental health care a continuing and demanding exercise. It will be part of the continuing National Mental Health Strategy in which a more effective deployment of limited resources will be pursued. Can J Psychiatry, Vol 47, No 9, November

6 The Canadian Journal of Psychiatry In Review Funding Support The National Survey was funded by the Commonwealth Department of Health and Ageing, Canberra. Note 1. This Publication List may be accessed on the Web site of the Mental Health and Special Programs Branch, Commonwealth Department of Health and Ageing, Canberra, at References 1. Whiteford H. Introduction: the Australian mental health survey. Aust NZJPsychiatry 2000;34: Peters L, Andrews G. Procedural validity of the computerized version of the Composite International Diagnostic Interview CIDI-auto in the anxiety disorders. Psychol Med 1995;25: World Health Organization. The ICD-10 Classification of Mental and Behavioural Disorders. Diagnostic Criteria for Research. Geneva: WHO; American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 4th ed. Washington (DC): APA; Henderson S, Andrews G, Hall W. Australia s mental health: an overview of the general population survey. Aust NZJPsychiatry 2000;342: Andrews G, Henderson S, Hall W. Prevalence, comorbidity, disability and service utilisation: overview of the Australian National Mental Health Survey. Br J Psychiatry 2001;178: Hall W, Teesson M, Lynskey M, Degenhardt L. The 12-month prevalence of substance use and ICD-10 substance use disorders in Australian adults: findings from the National Survey of Mental Health and Well-Being. Addiction 1999;9410: Henderson AS, Jorm AF, Korten AE, Jacomb P, Christensen H, Rodgers B. Symptoms of depression and anxiety during adult life: evidence for a decline in prevalence with age. Psychol Med 1998;28: Jorm A. Does old age reduce the risk of anxiety and depression? A review of epidemiological studies across the adult life span. Psychol Med 2000;30: Hickie I, Davenport T, Issakidis C, Andrews G. Neurasthenia: prevalence, disability and health care characteristics in the Australian community. Br J Psychiatry 2002;181: Jackson HJ, Burgess PM. Personality disorders in the community: a report from the Australian National Survey of Mental Health and Wellbeing. Soc Psychiatry Psychiatr Epidemiol 2000;3512: Jorm AF. Association between smoking and mental disorders: results from an Australian National Prevalence Survey. Aust NZJPublic Health 1999;233: Sanderson K, Andrews G, Jelsma W. Disability measurement in the anxiety disorders: comparison of three brief measures. J Anxety Disord 2001;15: Mathers C, Vos T, Stevenson C. The burden of disease and injury in Australia. Canberra: Australian Institute of Health and Welfare; Dear K, Henderson S,Korten A. Well-being in Australia: findings from the National Survey of Mental Health and Well-being. Soc Psychiatry Psychiatr Epidemiol. Forthcoming. 16. Jablensky A, McGrath J, Herrman H, Castle D, Gureje O, Evans M, and others. Psychotic disorders in urban areas: an overview of the Study on Low Prevalence Disorders. Aust NZJPsychiatr, 2000;342: Gureje O, Herrman H, Harvey C, Morgan V, Jablensky A. The Australian National Survey of Psychotic Disorders: profile of psychosocial disability and its risk factors. Psychol Med 2002;32: Castle D, Morgan V, Jablensky A. Antipsychotic use in Australia: the patients perspective. Results from the National Survey of Mental Health and Well-being. Aust NZ J Psychiatry. Forthcoming. 19. Sawyer MG, Arney FM, Baghurst PA, Clark JJ, Graetz BW, Kosky RJ, and others. The mental health of young people in Australia: key findings from the child and adolescent component of the national survey of mental health and wellbeing. Aust NZJPsychiatry. 2001;356: Rey JM, Sawyer MG, Clark JJ, Baghurst PA.. Depression among Australian adolescents. Med J Aust 2001;1751: Graetz BW, Sawyer MG, Hazell P, Arney F, Baghurst P. Validity of DSM-IV ADHD subtypes in a nationally representative sample of Australian children and adolescents. J Am Acad Child Adolesc Psychiatry 2001;40: Rey J, Sawyer MG, Raphael B, Patton G, Lynskey M. The mental heath of teenagers who use marijuana. Results of an Australian survey. Br J Psychiatry 2002;180: Jenkins R., Lewis G, Bebbington P, Brugha T, Farrell M, Gill B, Meltzer H. The National Psychiatric Morbidity Surveys of Great Britain initial findings from the household survey. Psychol Med 1997;27: Andrews G, Henderson S, editors. Unmet need in psychiatry: problems, resources, responses. Cambridge: Cambridge University Press; p Jorm AF, Korten AE, Jacomb PA, Christensen H, Rodgers B, Pollitt P. Mental health literacy : a survey of the public s ability to recognise mental disorders and their beliefs about the effectiveness of treatment. Med J Aust 1997;166: Manuscript received and accepted September Emeritus Professor and Visiting Fellow, Centre for Mental Health Research, The Australian National University, Canberra, ACT 0200, Australia. Address for correspondence: Dr S Henderson, 9 Timbarra Crescent, O Malley, ACT 2606, Australia as.henderson@bigpond.com Résumé : L enquête nationale de santé mentale et de bien-être en Australie : répercussions sur les politiques Objectif : Offrir un synopsis de l enquête nationale de santé mentale et de bien-être en 3 phases de l Australie, et examiner les conséquences en matière de politiques et d autres changements des services de santé générale et mentale. Méthode : Les données publiées sont examinées, et les questions de prestation de services que les données ont révélées sont commentées. Résultats : Les estimations de la prévalence d un an des troubles mentaux communs, définis selon les critères de la CIM- 10 et évalués à l aide de la version électronique de l entrevue diagnostique composite internationale (CIDI-A), ont indiqué des taux semblables à ceux d autres pays (17,7 %). Des taux alarmants d alcoolisme et de toxicomanie ont été constatés chez les jeunes personnes, surtout les jeunes hommes. Le nombre d années de vie perdues en raison d une incapacité attribuable aux troubles mentaux excède le nombre d années de vie perdues en raison d une maladie cardiovasculaire et du cancer. Seulement 35 % des personnes souffrant d un des troubles mentaux communs ou plus ont obtenu de l aide dans les 12 mois précédant l entrevue. La prévalence ponctuelle des problèmes de santé mentale était de 14 % pour les personnes âgées de 4à17ans. La prévalence ponctuelle des troubles psychotiques était de 4,7 sur Un résultat encourageant est que 81 % des personnes affectées avaient vu leur omnipraticien durant l année précédente. Toutefois, seulement 20 % avaient participé à un programme de rétablissement quelconque, l année précédente. Conclusions : Les résultats de l enquête sont fondés sur un échantillon de la population nationale et non pas sur des personnes recourant aux services. Ils ont donc été d une grande valeur pour influencer les politiques à l échelle fédérale et des États, et peuvent avoir contribué à un financement accru des services et de la recherche. 824 Can J Psychiatry, Vol 47, No 9, November 2002