Chapter 6 Mental health and wellness in Australia and New Zealand
Learning outcomes
Incidence and prevalence of mental health disorders
The worldwide burden of mental health problems and disorders is high and is expected to increase—for example, depression is expected to become one of the greatest health problems in the world by the year 2020 (Murray & Lopez 1996). Mental disorders cause considerable personal, social and financial distress to individuals, and have a huge impact on healthcare funding, implementation of service provision and community resources. In order to gauge the full extent of the problem, many countries have conducted research into the prevalence and consequent impact of mental disorders on the individual, society and healthcare funds. Both the Australian and New Zealand governments have conducted extensive research to determine the extent of mental disorders in the community and the impact this has had on the individual, community and government spending. A brief overview of the findings is presented below.
Australian National Survey of Mental Health
The National Survey of Adult Australians (aged 18 to 99 years) conducted by the Australian Bureau of Statistics in 1997 examined mental illness, anxiety disorders, affective disorders and substance abuse disorders. This survey revealed that 9.7% of all people (n = 10,000) who participated in the study suffered from an anxiety disorder (7.1% of men and 12% of women), 5.8% of all people surveyed suffered from an affective disorder (4.2% of men and 7.4% of women), and 7.7% of people surveyed suffered from a substance abuse disorder (11.1% of men and 4.5% of women) (Andrews et al 1999).
The overall results showed that over a 12-month period an estimated 18% of Australians were affected by one or more mental disorders. From this it is anticipated that one in five people in Australia will be affected by a mental health problem at some stage in their lives (Commonwealth Department of Health and Aged Care (CDHAC) & Australian Institute of Health and Welfare 1999). Results from the Child and Adolescent component of the National Survey of Mental Health and Wellbeing were published in October 2000. The survey included 4500 children between the ages of four and seventeen, with the results indicating that 14–20% of children had mental health problems (Sawyer et al 2000; Zubrick et al 1995). Interestingly, the prevalence of mental disorders drops to 6% among Australians aged 65 years and over. Dementia is strongly related to age, affecting 1.6% of those aged 65–70 years and 39% of those aged 90–94 years (Henderson & Jorm 1998).
Survey results for people living with a psychotic illness, undertaken in 1997–98, revealed that illnesses included schizophrenia, bipolar affective disorders and delusional disorders. The survey covered 3800 Australians aged 18–64 years who attended mental health services in four states of Australia (Jablensky et al 1999). The results of the survey revealed that approximately four to seven per 1000 adults living in urban areas suffered from a psychotic illness—that is, 0.3–0.5% of the population (Jablensky et al 1999). A further breakdown of these results indicates that 62.4% (approximately 34,000 people, or 0.25% of the population) had schizophrenia or a closely related disorder, 11.4% (approximately 6200 or 0.05% of the population) had bipolar disorder and 8.1% (approximately 4400 people or 0. 03% of the population) had a depressive psychosis (Meadows & Singh 2001).
Te Rau Hinengaro: the New Zealand mental health survey
Te Rau Hinengaro: the New Zealand mental health survey1 (Ministry of Health 2006) was completed in 2006. For the first time Māori and Pacific people were selected at higher rates, to allow estimates of acceptable precision for those communities.2 The survey had four objectives for all New Zealand, Māori and Pacific populations living in New Zealand:
Comorbidity
Comorbidity is associated with suicidal behaviour and increased service use (Ministry of Health 2006). The survey found that comorbidity of mental disorders was common, with 37.0% of those experiencing 12-month disorders having two or more disorders. In particular, mood disorders and anxiety disorders were the most likely to co-occur. In addition, the survey found comorbidity between mental and physical disorder. People with mental disorders have higher prevalences of several chronic physical conditions than people of the same age without mental disorders. People with chronic physical conditions are also more likely to experience mental disorders than those without physical conditions.
Suicidal behaviour
Of the population, 15.7% reported ever having thought seriously about suicide (suicidal ideation), 5.5% had ever made a suicide plan and 4.5% had ever made an attempt. In the past 12 months, 3.2% had experienced suicidal ideation, 1.0% had made a suicide plan and 0.4% had made a suicide attempt. Suicidal ideation in the past 12 months was higher in females, younger people, people with lower educational qualifications and people with low household income, and among people living in more deprived areas (measured using the small area descriptor of socioeconomic adversity, the New Zealand Index of Deprivation) and in urban areas. The risk of making a suicide plan or suicide attempt was more common among younger people, people with low household income, and people living in more deprived areas. The risk of making a suicide attempt was higher in people in urban areas. People with a mental disorder had elevated risks of suicidal behaviour, with 11.8% of people with any mental disorder in the past 12 months reporting suicidal ideation, 4.1% making a suicide plan and 1.6% making a suicide attempt in that period. Mood disorders, anxiety disorders, eating disorders and substance use disorders were all associated with suicidal ideation, suicide plan and suicide attempt. Of individual disorders, major depressive episode had the strongest association with suicidal ideation, suicide plan and suicide attempt (Ministry of Health 2006). Māori and Pacific people had higher prevalences of suicidal ideation, suicide plans and suicide attempts in the past 12 months than others. Even after adjustment for socio-demographic correlates, Māori and Pacific people still had higher prevalences of suicide plans (Māori 0.9%, Pacific people 1.0%, others 0.3%) and suicide attempts (Māori 0.7%, Pacific people 0.8%, others 0.3%).
Gender differences
There are unmistakable gender differences in the prevalence of mental disorders. The results of recent studies indicate that females are twice as likely as males to develop anxiety-related disorders and have a sub stantially higher incidence of reported affective disorders. Females report higher rates of depression across all age groups, the highest being those aged 18–24 years. Females were more likely than males to report a long-term mental or behavioural problem in 2004–05 (11.4% of females compared to 10% of males). Females are more likely to report high to very high levels of psychological distress than men (15% compared to 10%) (Australian Bureau of Statistics, http://www.abs.gov.au/ausstats). Males, on the other hand, have a much higher occurrence of substance-abuse disorders. Both genders have the same reported incidence of psychotic disorders; although males generally experience an earlier onset and have a poorer outcome, females tend to have more affective symptoms and generally have more periods of remission than males (Jablensky et al 1999). It is unclear whether the differences are a result of schizophrenia or the normal differences in brain structure and function between males and females (Meadows & Singh 2001). Women with children face greater problems than men for transportation, economic support and child care (Marsh, D’Aunno & Smith 2000).
The prevalence of depressive and anxiety disorders in children and adolescents (those aged 13–17 years) does not match the pattern for adults, in that both genders in this group have similar prevalences for depressive and anxiety-related disorders. However, males have a higher prevalence of attention deficit hyperactivity disorder and conduct disorder than females in all age groups (Sawyer et al 2000). This tends to lead to problems associated with the legal system and a higher use of mental health facilities for male children and adolescents. The above figures are not restricted to the Australian population; similar results have been found in studies conducted in many other countries.
The discussion of gender differences in mental health cannot be limited to the statistics alone; there are many factors involved, such as the acceptance of treatment and the amount of disability suffered by individuals. As already discussed, females are more likely to report recent episodes of depression and anxiety disorders, and to seek treatment for mental health problems, whereas men tend to be more reluctant to seek professional help. Women make up the majority of service users at most health services. They are more than twice as likely as males to seek help from a counsellor at some point in their life. This difference is not necessarily an indication that women have a greater need for such services but is more likely to reflect gender differences in help-seeking behaviours (Clarke et al 2007).
This delay in seeking assistance may be attributed to a number of things, such as the stigma associated with mental health services, or the belief that seeking help is a sign of weakness and therefore a threat to an individual’s manhood; or, if a person is in full-time work, it may be difficult to attend clinics. This delay results in poor access to early intervention and prevention services, which may lead to increased disability caused by the disorder. In general, men have a stronger tendency to turn to alcohol and other drugs as a means of dealing with their emotional problems, which does little more than exacerbate the problem in the long term (Nielsen, Katrakis & Raphael 2001).
Although women access services, they may have concerns about taking medication for their illness if they are pregnant, likely to become pregnant or are breastfeeding, for fear of the effects the medication may have on the baby. A pregnant woman or nursing mother may well be limited in the medications she is able to take, leaving her susceptible to relapse due to inadequate treatment. Women are more likely than men to discontinue successful treatment because of medication-related weight gain and adverse side effects. Women with severe mental illnesses such as bipolar disorder and major depression are at increased risk for an episode after childbirth, with some women experiencing their first episode at this time (Fullagar & Gattuso 2002; Meadows & Singh 2001).
Because of the later onset of some severe mental illnesses, many women may already be married/partnered and be mothers before the initial onset of their illness. This may indicate that although the woman has support and security, ongoing severe mental illness may have a detrimental effect on her relationships with her husband/partner and children, leading to family breakdown and long-term hardship (National Institute of Mental Health, http://www.nimh.nih.gov/wmhc/research.cfm).
Men with severe mental illness such as schizophrenia generally have worse outcomes than females, as measured by early onset, cognitive disabilities and social impairments. The earlier onset usually prevents males from developing personal relationships, which leads to most remaining single, childless and with reduced employment prospects. Women with schizophrenia seem to have an increased risk of relapse at times of rapid changes in their levels of oestrogen, such as at menopause or before the onset of menstruation (Fontaine 2003; Fullagar & Gattuso 2002).
Marital status
Statistics from the Australian Bureau of Statistics (ABS 2006) indicate that in 2004/05 mental or behavioural problems were most commonly reported by those who were separated (20% of females and 20% of males) or divorced (17% of males and 19% of females). Married/de facto partnered people reported lower rates of mental or behavioural problems (9% of males and 11% of females). High to very high levels of psychological distress were reported more frequently by adults who were separated (22%) and divorced (18%) than by adults who were married (9%).
Females aged 18 years or older who were separated had a high prevalence of a high to very high level of psychological distress (25%), while the lowest rates of psychological distress were among married men (9.4%) (ABS 2006).
The cost of mental disorders
The direct monetary cost of mental illness is high. In 2003 the Australian Commonwealth Government spent $650 million on mental health; the states and territories spent $1267 million; and $156 million was spent in private hospitals (Meadows, Singh & Grigg 2007). The New Zealand Government increased its budget for both secondary and tertiary mental health services to $687 million in 2001 (Powell 2002).
These figures have not taken the hidden (indirect) cost of mental health into consideration—that is, the health costs and loss of earnings for families and carers, the community and welfare costs, charity agencies and the coronial work in the case of suicide. In addition, it has been estimated that only 38% of adult Australians with a mental disorder actually receive help for their problem (McLennan 1998) and only 29% of children and adolescents with a mental health problem had been in contact with a professional service (Sawyer et al 2000). These findings are consistent with studies conducted in other countries. The actual cost of mental health problems is unknown and potentially underestimated.
Disability and mental health
Disability in mental health refers to an individual’s impairment in one or more important areas of functioning. Mental health disorders are a leading cause of disability and account for 11% of all disease burden worldwide (Murray & Lopez 1996). In 1990, five of the ten leading causes of disability worldwide were mental disorders: unipolar depression, alcohol abuse, bipolar affective disorder, schizophrenia and obsessive-compulsive disorder (Ministry of Health 1997). Among these disorders, depression was ranked fourth, but the World Health Organization (WHO) has predicted that depression will be the second leading cause of disability in the world by 2020 (WHO 2001). In 2003, Australian statistics revealed that mental illnesses were among the ten leading causes of disease burden, accounting for 13% of the total burden of disease (Australian Institute of Health and Welfare 2006). According to Te Rau Hinengaro, mood disorders are reported to be more disabling than either anxiety disorders or substance use disorders. The experience of multiple mental disorders is associated with greater role impairment than are single disorders. Mental disorders and chronic physical conditions are, on average, associated with similar degrees of disability, and the combination of the two is more disabling than either alone (Ministry of Health 2006).
Although mortality rates from mental disorders are not considered high, the impact of chronic disability on an individual’s life can be measured in days out of their normal role. The severity of an individual’s disorder can be measured using the Disability Adjusted Life Year (DALY) tool developed by the WHO Harvard School of Public Health and the World Bank (Meadows & Singh 2001; Murray & Lopez 1996). This tool measures lost productivity associated with disability due to an individual’s altered health status and is based on the years of life lost through living with disease, impairment and disability (Meadows & Singh 2001). The results from the Australian National Survey of Mental Health and Wellbeing indicate that chronic disability from a mental disorder accounts for 27% of years lost to disability (Andrews et al 1999).
The type and length of illness (as measured by DALY) is a major factor when determining the effects of a particular illness on an individual’s life. For example, people with a psychotic disorder may be socially isolated, unemployed and suffer considerable psychological and physical distress. Likewise, anxiety disorders have a profound effect on a person’s work, social and family life. The Anxiety Disorders Foundation of Australia NSW Branch Inc. (1998) states that one in twelve Australians (1,360,000 people) suffer from an anxiety disorder and that people suffering from an anxiety disorder have a higher risk of suicide, drug and alcohol abuse, causing considerable disability to sufferers.
People with some mental disorders such as psychotic disorders or severe depression, may well be unable to attend adequately to their hygiene needs, or shop and/or prepare meals, or to make sure their environment is clean and safe, thereby placing their physical wellbeing in jeopardy. Poor physical health places a huge burden on the sufferer, their family, the community and the healthcare system. A significant number of people with mental health problems are living below the poverty line, requiring assistance from welfare groups (government and non-government). Even with assistance, a number of people may not have the means to provide adequate nutritious food, heating, clothing, housing, electricity, telephone or furniture for themselves and their families. Some housing and accommodation is available through a number of agencies, but the demand is greater than the resources available (Pinches 2002). A relatively small number have turbulent illnesses and often find that they are turned out of accommodation because of disruptive behaviour (Robinson 2003). Many welfare agencies run homeless shelters but have limited resources to deal with the complex needs of those with mental disorders.
Misconceptions about mental health
Misconceptions regarding mental health disorders have a negative impact on the perception of mental health issues. Some commonly held misconceptions are as follows:
Unfortunately, misconceptions have influenced the general perception and treatment of mental health problems for centuries. In line with recent studies undertaken in conjunction with the Australian National Mental Health Strategy, research was conducted in 1993 to determine the community’s attitudes, knowledge and beliefs regarding mental health issues at the time. The results confirmed that extensive ignorance and fear remain prevalent in the community, reinforcing the need for extensive education as a means of increasing public awareness of mental health issues (Commonwealth Department of Health and Aged Care, HSD 2000).
People who develop mental health disorders may have had their own preconceived ideas and prejudices in regard to mental health issues before becoming ill. Many people believe it is the end of their life and will grieve for the life they had and for the aspirations they held for their future. While people are unwell, work or study can be interrupted. Unemployment often leads to financial hardship, forcing people to live below the poverty line, thereby exacerbating the feelings of frustration, low self-esteem and entrapment. The potential for suicidal thoughts and behaviour is particularly high in this group of people (Fryer 1995; Mathers & Schofield 1998).
Parents and siblings will also have their own misconceptions and prejudices against the mentally ill. Parents may blame themselves for their child’s illness, or may be ashamed or embarrassed and try to hide the illness from extended family members, neighbours, and friends and work colleagues. Siblings may also feel embarrassed and stop bringing friends home. They may be fearful that they too will develop a mental illness and may become afraid of their brother or sister. The acute phase of many mental health disorders, especially psychotic disorders, will cause major disruption to family life (Fontaine 2003). Parents may need to take time out from work, which will have financial implications for the family, and siblings may find it difficult to function at school or in the workforce. Both parents and siblings may well go through the grieving process as a result of the changes in their lives. Children who grow up with a parent who
Even working in the ‘general’ medical/surgical arena, the skills learned as a mental health nurse are used every day. I teach mental health to undergraduate nurses, and with the assistance of my colleagues, strive to demystify all aspects of mental illness and provide students with a positive and fulfilling experience.
has a mental disorder are at higher risk of developing a mental illness, such as depression, through either genetic susceptibility or gaps in parenting (CDHAC & AIHW 1999; Davies 2002; Dean & Macmillan 2002).
Critical thinking challenge 6.2
The media and misconceptions about mental illness
73% of people with a mental illness were depicted as violent, while 23% of people were portrayed as homicidal maniacs. When the same study analysed media reports about mental illness on television and in newspapers, it found that nearly 90% of stories depicted people with mental illness as violent and usually homicidal. This is grossly inaccurate (SANE Australia 2000).
Research into the reporting and portrayal of mental ill ness in the Australian and New Zealand media reveals similar attitudes and sensationalism. Newspaper reporting has a tendency to sensationalise issues related to mental disorders at times, thereby perpetuating negative stereotypes and unnecessary fears in the community (Blood 2002; Lindberg 2001; Mitchell 2003).
Just as the media can have a negative impact, it can also be used as a tool to educate and change public opinion by ensuring that accurate information is reported in a rational and sensitive manner. In order to achieve this, scriptwriters, journalists and newspaper editors need to be educated on mental health issues (Martin 1998). As a result of work done with the Australian National Mental Health Strategy, the Mindframe National Media Strategy (http://www.mindframe-media.info) was developed to provide educational resources to media professionals, to recognise good practice in the reporting of mental health issues and to watch for stigmatisation in the media. The New Zealand national plan to counteract stigma also examines the impact of media on perceptions of mental health issues.
Numerous organisations, both government and private, monitor and provide information to the general public, consumers, teachers, nurses, universities, general practitioners and journalists in relation to mental health issues (three are listed in Box 6.1).
Cultural diversity in Australia and New Zealand
Australia and New Zealand have a history of British colonisation and settlement. Both countries are officially English speaking, both have minority Indigenous populations, and since the Second World War both have increasingly relied on immigration to supplement their populations as reproduction rates decline. With improving life expectancy, both have ageing populations. This section focuses on diversity in ethnicity; however, mental health nurses can encounter diversity in their clients’ age, gender, religion, sexual preference, disability and so on. Ethnically diverse clients can include Indigenous people, migrants, refugees, asylum seekers and people from long-term settled communities.
Migration patterns in both countries have been influenced mainly by economic conditions and shifts in gov ern ment policy. Australia’s migrant stream expanded in the post-war period to include displaced persons from eastern and southern Europe. Since the 1970s, increasing proportions of migrants have come to Australia and New Zealand from Asia, and to New Zealand from the Pacific Islands. Between 1996 and 2000 the largest group of permanent and long-term arrivals in Australia was from New Zealand (15%), while Australia’s contribution to New Zealand immigration was 10%. The 2006 New Zealand Census found that European New Zealanders made up 67.6% of the population of people, Māori made up 14.6 %, Pacific peoples 6.9%, Asians 9.2% and Middle Eastern, Latin American and African people 0.9% (Statistics New Zealand 2006).3
The life expectancies of Indigenous people in both countries are considerably lower than those of the total population, and ill health is endemic (Reser 1991). Life expectancy for Aboriginal men in Australia ranges from 53 to 58 years, and for Aboriginal women from 58 to 63 years (ABS 2000). In New Zealand, life expectancy for Māori men is estimated at 67.2 years and for Māori women at 71.6 years (SNZ 2000). Life expectancy for the non-Indigenous population in both countries is estimated at 75 years for men and 81 years for women (ABS 2000; SNZ 2000). Suicides make a significant contribution to mortality statistics for both Australian Aboriginal and Māori peoples (Tatz 2001).
Critical thinking challenge 6.3
Consider current cross-Tasman migration trends.
Find out which population groups are migrating between Australia and New Zealand, using published statistics.
Cultural diversity and mental health nursing
Māori are the Indigenous people of Aotearoa/New Zealand, whose relationship with Pakeha (non-Māori) is defined in Te Tiriti o Waitangi/The Treaty of Waitangi, a document signed in 1840 by the British Crown and Māori Chiefs. Te Tiriti forms the basis for biculturalism, which Sullivan (1994) defined as equal partnership between two groups, in which Māori are acknowledged as tangata whenua (‘people of the land’), and the Māori translation of Te Tiriti o Waitangi is acknowledged as the founding document of Aotearoa/New Zealand.
Biculturalism is concerned with addressing past injustices and returning self-determination to Māori. The nursing profession has a responsibility to respond to Māori health issues by improving care to Māori through understanding the socio-political issues and historical processes that affect the status of Māori. From a nursing point of view it means incorporating ‘principles of partnership, participation, protection and equity’ (Cooney 1994, p 9) in the care that is delivered. More recently there has been a policy and strategic shift away from a deficit model and towards a model of potential that emphasises the recognition of Māori potential, strengths and opportunities, and investing in Māori as an integrated, but culturally distinct, Indigenous community (De Souza 2007).
In New Zealand, all nurses are expected to practise cultural safety and it is their actions that are under scrutiny, rather than the diversity of clients; therefore, the client defines whether the care they have received is safe. Put simply, ‘unsafe practitioners diminish, demean and disempower those of other cultures, whilst safe practitioners recognize, respect and acknowledge the rights of others’ (Cooney 1994, p 6).
Cultural safety encompasses both a conceptual framework for understanding the power inequalities that structure the relationships between tangata whenua and health professionals and practical strategies that can be utilised. Cultural safety education has been a compulsory part of nursing education in New Zealand since 1992 (Jeffs 2001), but it is not known whether it has had an impact on negative Māori health outcomes. Cultural safety has been broadened to apply to any person or group of people who may differ from the nurse/midwife because of socioeconomic status, age, gender, sexual orientation, ethnic origin, migrant/refugee status, religious belief or disability (Ramsden 1997).
Mental health nursing practice in Australia and New Zealand is also guided by national standards in relation to culture and ethnicity. These include the Australian College of Mental Health Nurses Standards of Practice for Mental Health Nurses in Australia (ACMHN 1995), currently under review, and the New Zealand College of Mental Health Nurses Standards of Practice for Mental Health Nurses in New Zealand, 2nd edition (Te Ao Maramatanga 2004). Both countries also publish National Mental Health Standards. The Australian Standards were published in 1997, and have since been expanded by the publication of National Practice Standards for the Mental Health Workforce (AHMAC 2002). The New Zealand National Mental Health Standards were first developed in 1997 and provide clear guidance to service providers, services users, family and whanau on what they can expect from mental health services in New Zealand. They have since been revised and renamed the National Mental Health Sector Standards and are currently undergoing review. There are 18 standards, relating to particular areas of service delivery. These are commonly identified by number, so for example, standards relating to culture and ethnicity include: 1. Tangata Whenua; 2. Pacific People; and 3. Cultural Safety (Mental Health Commission n.d.).
Where New Zealand is a bicultural society with a multi-ethnic population, Australia expects a practice of ‘multiculturalism’, offering respect to the cultural background of all Australians, including, but not singling out, the diverse Aboriginal cultures that enrich Australia’s heritage. Many Indigenous people (and other Australians) believe that a treaty between the Aboriginal peoples of Australia and the Commonwealth Government would improve the political status of Aboriginal Australians (Ring & Firman 1998). In New Zealand, opponents of multiculturalism worry that such an ideology is problematic because it removes the primacy of Māori. Calling Māori ‘the first immigrants’ negates their rights as First Nation people and counters their claim for special status as tangata whenua (Walker 1995). Many argue that Māori are the Indigenous people of New Zealand, with a language and culture that exists nowhere else, while migrants (and refugees) have other places that maintain and preserve their culture. It is thought that because the treaty has not been honoured, other ethnic groups have had no other option but to relate only to the Crown. Increasingly, resources are being developed that enhance migrants’ understanding of Māori (Maclachlan & DeSouza 2006).
Cultural diversity within Aboriginal societies is also recognised. The Aboriginal Mental Health Consultative Group, workshopping policy development guidelines for the Northern Territory Government, asked that non-Aboriginal mental health staff recognise the diversity, beliefs and values within Aboriginal societies. They wanted mental health staff to learn, ‘without becoming so-called experts’, to understand, recognise, respect and respond to the diversity of Aboriginal cultures, and to work within a two-way model of healing. The two-way model recognises and uses the strengths of biomedical models and traditional practices (Northern Territory Government 1998). Chapter 7 provides specific information and practical approaches for mental health nurses to work with Māori, Aboriginal and Torres Strait Islander people.
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