Schizophrenia Spectrum disorders (F20-F29 DSM)

Schizophrenia typically begins in late adolescence/early adulthood (though onset tends to be later in women). Behaviour can be seriously disturbed during some phases, leading to adverse social consequences. (WHO, 2001) The most important psychopathological phenomena include thought echo; thought insertion or withdrawal; thought broadcasting; delusional perception and delusions of control; influence or passivity; hallucinatory voices commenting or discussion the patient in the third person; thought disorders and negative symptoms.

Schizophrenia spectrum disorders can be continuous, or episodic, or there can be one or more episodes with complete or incomplete remission. Complete symptomatic and social recovery occurs in about half of all cases with drug therapy and psychosocial care. (WHO, 2001)

Mood Affective Disorders (F30-F39 DSM)

Mood disorders affect 6.2% of Australians (7.1% of women and 5.3% of men). (ABS, 2009) They include: bipolar disorder and depressive disorders (major depressive disorder, persistent mood affective, or depressive, disorders).

Anxiety disorders (F40-F49, F90-98 DSM)

Anxiety disorders generally have symptoms which include pounding heart, sweating, trembling, shaking and having difficulty breathing. In Australia, anxiety disorders are the most common mental disorder, affecting 14% of all people, though not always at a severe and persistent level. (ABS, 2009) Anxiety disorders include: phobic anxiety disorder, agoraphobia, panic disorder, generalized anxiety disorder, obsessive compulsive disorder.

Trauma and stressor-related disorders (F40-F49 DSM)

Trauma and stressor-related disorders are thought to arise as a direct consequence of acute severe stress or continued trauma. They interfere with successful coping mechanisms and therefore lead to problems of social functioning, for example, post-traumatic stress disorder, and adjustment disorders.

Somatoform Disorders (F40-F49 DSM)

Presentation of physical symptoms which produce distress, discomfort and pain, despite no evidence of organic disturbance or dysfunction. The symptoms are real and not under the control of the client but are representative of unconscious conflict. The course of the disorder is chronic and fluctuating and is often associated with disruption of social, interpersonal, and family behaviour.

Conduct Disorders (F60-F69, F90-98 DSM)

Disorders characterized by a repetitive and persistent pattern of dissocial, aggressive, or defiant conduct, in which the rights of others or major age-appropriate societal norms or rules are violated. Examples include: aggression to people and animals; destruction of property; deceitfulness or theft; serious violations of rules.

Personality Disorders (F60-F69, F20-29 DSM)

A variety of conditions and behaviour patterns of clinical significance which tend to be persistent and appear to be the expression of the individual’s characteristic lifestyle. They represent extreme or significant deviations from the way in which the average individual in a given culture perceives, thinks, feels and, particularly, relates to others. Examples include; paranoid personality disorder, schizoid personality disorder and schizotypal (personality) disorder, and borderline personality disorder (the most common of personality disorders).

Definitions

Disability (mental illness), in relation to a person, means:

• total or partial loss of the person’s bodily or mental functions; or
• a disorder or malfunction that results in the person learning differently from a person without the disorder or malfunction; or
• a disorder, illness or disease that affects a person’ thought processes, perception of reality, emotions or judgment or that results in disturbed behaviour;

and includes a disability that:

• presently exists; or
• previously existed but no longer exists: or
• may exist in the future; or
• is imputed to a person.

To avoid doubt, a disability that is otherwise covered by this definition includes behaviour that is a symptom or manifestation of the disability. (CTH, 1992)

Mental Health: a state of emotional and social wellbeing. It influences how individual’s cope with normal stresses of life, and whether they can achieve their potential. (ABS, 2008)

Mental health problem: Diminished cognitive, emotional or social abilities but not to the extent that the criteria for a mental illness are met. (CTH, 2009)

Mental Illness: a clinically diagnosable disorder that significantly interferes with an individual’s cognitive, emotional or social abilities. It includes short and long term conditions. (ABS, 2008)

Mental illness: A clinically diagnosable disorder that significantly interferes with an individual’s cognitive, emotional or social abilities. The diagnosis of mental illness is generally made according to the classification systems of the Diagnostic and Statistical Manual of Mental Disorders (DSM) or the International Classification of Diseases (ICD). (CTH, 2009)

Personal Recovery: Being able to create and live a meaningful and contributing life in a community of choice with or without the presence of mental health issues. (CTH, 2013)

Psychosocial Disability: relates to the ‘social consequences of disability’ – the effects on someone’s ability to participate fully in life as a result of mental ill-health. Those affected are prevented from engaging in opportunities such as education, training, cultural activities, and achieving their goals and aspirations. Not everyone with a mental illness will have a level of impairment that will result in a psychosocial disability. (MHCA, 2014)

Psychotic disorders: (A) diverse group of illnesses that have their origins in abnormal brain function and are characterised by fundamental distortions of thinking, perception and emotional response… The two main symptoms are delusions and hallucinations. (CTH, 2011)

Recovery: A personal process of changing one’s attitudes, values, feelings, goals, skills and/or roles. It involves the development of new meaning and purpose and a satisfying, hopeful and contributing life as the person grows beyond the effects of psychiatric disability. The process of recovery must be supported by individually-identified essential services and resources. (CTH, 2009)

Recovery-oriented mental health practice: the application of sets of capabilities that support people to recognise and take responsibility for their own recovery and wellbeing and to define their goals, wishes and aspirations. (CTH, 2013)

Recovery-oriented practice encapsulates mental health care that:

• Recognises and embraces the possibilities for recovery and wellbeing created by the inherent strength and capacity of all people experiencing mental health issues;
• Maximises self-determination and self-management of mental health and wellbeing;
• Assists families to understand the challenges and opportunities arising from their family member’s experiences. (CTH, 2013)

Social and emotional well-being: an holistic Aboriginal definition of health that includes: mental health; emotional, psychological and spiritual well-being; and issues impacting specifically on well-being in Aboriginal and Torres Strait Islander communities such as grief, suicide and self-harm, loss and trauma. (CTH, 2009)

Scope for Action

There are similarities and boundaries between the concepts of mental health promotion and mental illness prevention. They are distinct, yet interrelated. (WHO, 2004) (Davis, 2014)

Mental Health Promotion

Mental health promotion usually refers to the promotion of positive mental health in people who are not at risk, people who are at an increased risk, and people who are currently experiencing mental health problems. It focuses on the individual, social and environmental conditions that enable optimal psychological performance.

Mental Illness Prevention

Mental illness prevention focuses on mental health disorders of either a temporary or a permanent nature. Interventions work to reduce risk factors and to enhance protective factors in order to reduce the incidence, prevalence, or recurrence of mental illness symptoms and to decrease the impact of that illness on the affected person, their families and their communities. (WHO, 2004)

Strategic and Legislative Context

International Policy

United Nations Convention on the Rights of Persons with Disabilities

The purpose of the UN Convention on the Rights of Persons with Disabilities is to ‘promote, protect and ensure the full and equal enjoyment of all human rights and fundamental freedoms by all persons with disabilities, and to promote respect for their inherent dignity.’

A person with a disability is defined to include people who have long-term physical, mental, intellectual or sensory impairments which in interaction with various barriers may hinder their full and effective participation in society on an equal basis with others.’ (UN, 2006)

See also World Health Organization Mental Health Action Plan 2013-2020.

National Policy

The Roadmap for National Mental Health Reform 2012-2022

The Roadmap underpins the National and State government mental health strategies, policies, plans and frameworks. It confirms a national commitment to ongoing mental health reform.

There are six priorities recognized:

• Promoting person-centred approaches
• Improving the mental health and social and emotional wellbeing of all Australians
• Preventing mental illness
• Focusing on early detection and intervention
• Improving access to high quality services and supports
• Improving the social and economic participation of people with mental illness. (COAG , 2012)

National Mental Health Strategy

The Strategy is the framework which guides mental health reform in Australia. It aims to:

• Promote the mental health of the Australian community
• Prevent the development of mental disorder where possible
• Reduce the impact of mental disorder on individuals, families and communities
• Assure the rights of people with mental illness. (DH, 2014)

Recovery-oriented Framework

The Strategy outlines the recovery-oriented framework for practice, culture and service delivery in mental health service provision. Recovery oriented approaches focus on the needs of the people who use services and challenges traditional notions of professional power and expertise. It reflects a respect for the experience, expertise and strength that all people, including service users, can contribute to the treatment of mental health issues. Central to the concept of recovery are hope, self-determination, self-management, empowerment, advocacy, inclusion and freedom from stigma and discrimination. (CTH, 2013)

Terminology

The language of recovery is essential to the National Mental Health Strategy to combat discrimination and disempowerment. The following descriptors are used throughout the Strategy:

• ‘person’, ‘people with lived experience’, ‘lived expertise’ and ‘experts by experience’ rather than ‘clients’, ‘service users’ or ‘patients’.
• ‘family and support people’ includes family members, partners, friends or anyone whose primary relationship with the person concerned is a personal, supportive and caring one.
• ‘mental health issues’, ‘challenges’ and ‘emotional distress’ are used in place of, and at times alongside, the term ‘mental illness’. (CTH, 2013)

The Strategy incorporates a National Mental Health Policy 2008, and a National Mental Health Plan (2009-2014).

National Mental Health Policy 2008

The National Mental Health Policy sets the broad agenda for efforts in mental health reform and is implemented via national plans and other developments in individual jurisdictions. (CTH, 2009)

The aims of the policy are to:

• Promote mental health and well-being and, where possible, prevent the development of mental health problems and illness
• Reduce the impact of mental health problems and illness
• Promote recovery
• Assure the rights of people with mental health problems and illness, and enable them to participate meaningfully in society. (CTH, 2009)

Fourth National Mental Health Plan (2009-2014)

The Fourth National Mental Health Plan priority areas and planned outcomes are:

• Social Inclusion and Recovery (community understanding, improved social outcomes, coordinated care)
• Prevention and Early Intervention (improved understanding and support, improved help seeking, recognition of co-morbidities)
• Service Access, Coordination and Continuity of Care (improved access to care, effective and efficient use of services)
• Quality Improvement and Innovation
• Accountability. (CTH, 2009)

E-Mental Health Strategy for Australia

Three key areas for action are:

1. Improving Access and Services (establishment of an E-mental health portal, the Virtual Clinic, and other online mental health support services)
2. E-Mental Health Support Service (an E-mental health support service for clinician support)
3. Promotion and Evaluation of the new E-Mental Health Service Environment. (DHA, 2012)

National Carer Strategy

The National Carer Strategy gives effect to the principles of the Carer Recognition Act 2010. The vision of the policy is that ‘carers in Australia are valued and respected by society. They have rights, choices, opportunities and capabilities to participate in economic, social and community life’.

A carer includes family members, friends, relatives, siblings, foster carers, grandparents or neighbours, regardless of the amount of care, support and assistance they provide. (CTH, 2011)

National Disability Strategy 2010-2020

The National Disability Strategy (NDS) adopts the principles of the rights of people with a disability set out in the UN Convention on the Rights of People with a Disability.

There are six policy areas covered by the NDS:

1. Inclusive and Accessible Communities (people with disability live in accessible and well designed communities with opportunity for full inclusion in social, economic, sporting and cultural life.)
2. Rights Protection, Justice and Legislation (people with disability have their rights promoted, upheld and protected.)
3. Economic Security (people with disability, their families and carers have economic security, enabling them to plan for the future and exercise choice and control over their lives.)
4. Personal and Community Support (people with disability, their families and carers have access to a range of supports to assist them to live independently and actively engage in their communities.)
5. Learning and Skills (people with disability achieve their full potential through their participation in an inclusive high quality education system that is responsive to their needs. People with disability have opportunities to continue learning throughout their lives.)
6. Health and Wellbeing (people with disability attain highest possible health and wellbeing outcomes throughout their lives). (CTH, 2011)

Other Policies

• National Aboriginal and Torres Strait Islander Suicide Prevention Strategy 2013
• National Standards for Mental Health Services
• Disability and carers policy and research publications from the Department of Social Services
• National Aboriginal and Torres Strait Islander Health Plan 2013-2023

National Legislation

National Disability Insurance Scheme Act 2013 (CTH, 2013)

Under the NDIS, any person under the age of 65 who acquires a permanent (or likely to be permanent) disability that substantially reduces their functional capacity, will be eligible for funding of support services based on their individual needs. People with a significant and enduring psychiatric disability are included in the NDIS. To meet the access criteria for the NDIS under the Act, the prospective participant must meet certain disability and early intervention requirements.

The NDIS is a three tiered system:

• Tier 3 provides the highest level of support for participants who are eligible under the NDIS criteria. Tier 2 support provides for Local Area Coordinators who will link people who need some support to mainstream services and community supports.
• Tier 2 is called ‘Information, Linkages and Capacity Building’. Tier 2 will be developed to build the capacity of the community, people with disability, their families and carers, and greater community inclusion in order to reduce demand for and level of support required from individually funded responses. (CTH, 2015)
• Tier 1 is to build community awareness of disability issues.

Disability Requirements for the NDIS

A person will meet the disability requirements under the Act if:

• The person has a disability that is attributable to one or more intellectual, cognitive, neurological, sensory or physical impairments or to one or more impairments attributable to a psychiatric condition; and
• The impairment or impairments are, or are likely to be, permanent; and
• The impairment or impairments result in substantially reduced functional capacity to undertake, or psychosocial functioning in undertaking, one or more of the following activities:
  • Communication;
  • Social interaction;
  • Learning;
  • Mobility;
  • Self-care;
  • Self-management; and
• The impairment or impairments affect the person’s capacity for social and economic participation; and
• The person is likely to require support under the National Disability Insurance Scheme for the person’s lifetime.

Early Intervention Requirements for the NDIS

A person will meet the early intervention requirements under the Act if:

The person

• Has one or more identified intellectual, cognitive, neurological, sensory or physical impairments that are, or are likely to be, permanent: or
• Has one or more identified impairments that are attributable to a psychiatric condition and are, or are likely to be, permanent; or
• Is a child who has developmental delay; and

The CEO is satisfied that provision of early intervention supports for the person is likely to benefit the person by reducing the person’s future needs for supports in relation to disability; and

The CEO is satisfied that provision of early intervention supports for the person is likely to benefit the person by:

• Mitigating or alleviating the impact of the person’s impairment upon the functional capacity of the person to undertake communication, social interaction, learning, mobility, self-care or self-management; or
• Preventing the deterioration of such functional capacity; or
• Improving such functional capacity; or
• Strengthening the sustainability of informal supports available to the person, including through building the capacity of the person’s carer.

The NDIS and Mental Illness

Participants in the NDIS with a psychiatric condition who have significant and permanent functional impairment will have support needs from both the NDIS and the health and mental health system. The NDIS is designed to address the functional impact of the psychiatric condition, not to provide activities designed to alleviate psychiatric conditions. (CTH, 2014) A person living with mental illness may be eligible for the NDIS if that permanent impairment substantially reduces their ability to undertake one or more of the following:

• Communication
• Social interaction
• Learning
• Mobility
• Self-care
• Self-management
• Social and economic participation. (MIFV, 2011)

People who are deemed ineligible to receive Tier 3 support under the NDIS, but who are showing signs of having a psychiatric condition will be assisted under Tier 2 to be referred to mainstream health and mental health services responsible for diagnosis and treatment. The Scheme will not cover any out of pocket costs resulting from access to these services.

Tension between the NDIS and mental health services

Many concerns have been expressed regarding the tension between the NDIS and mental health service and support, including:

• The NDIS has been shaped by the specialist disability sector and does not fully serve the needs of the mental health sector. The definitions of impairment and permanence under the Act are problematic when applied to mental health and recovery.
• The requirement for ‘permanent’ impairment is juxtaposed with the recovery model proposed by Australian mental health policy and the Victorian Mental Health Act.
• Many people with persistent and severe mental health problems do not view themselves as ‘disabled’.
• The Australian Federal and State governments have agreed that funding from their existing mental health programs will be included in the NDIS funding pool.
• NDIS may not be flexible enough to respond to the fluctuating support needs of people who have a mental illness of an episodic nature. People who experience mental illness may not meet the criteria for support under the NDIS because they are not deemed to have a permanent impairment.
• There are many challenges in predicting permanent impairment for mental illness, so early intervention support may be difficult to access.
• Tier 2 supports need to be developed immediately and mapping of current programs and services for people with psychosocial disability need to be mapped in each State and Territory.
• NDIS supports are predominantly compensatory and do not involve the psychosocial rehabilitative approaches designed to remediate impairment and build capacity.
• Support for carers appears to be limited to training in parenting skills or managing behaviours of concern. Carer support programs will be limited, with only a proportion of carer support funding remaining outside of the NDIS. (Williams & G, 2014) (Meldrum, n.d.) (MHCA, 2014) (MHCA, 2014)

Key Definitions in the NDIS Act

Permanent Impairment

An impairment that varies in intensity (such as an impairment of chronic episodic nature) may be considered permanent.

An impairment is, or is likely to be, permanent only if there are no known, available and appropriate evidence-based clinical, medical or other treatments that would be likely to remedy the impairment.

An impairment may be permanent even if the severity of its impact on the functional capacity of the person may fluctuate or there are prospects that the severity of the impact of the impairment on the person’s functional capacity, including their psychosocial functioning, may improve. (CTH, 2013)

Substantially Reduced Functional Capacity

An impairment results in substantially reduced functional capacity of a person to undertake one or more of the relevant activities if its result is that:

• The person is unable to participate effectively or completely in the activity, or to perform tasks or actions required to undertake or participate effectively or completely in the activity, without assistive technology, equipment (other than commonly used items such as glasses) or home modifications; or
• The person usually requires assistance (including physical assistance, guidance, supervision or prompting) from other people to participate in the activity or to perform tasks or actions required to undertake or participate in the activity; or
• The person is unable to participate in the activity or to perform tasks or actions required to undertake or participate in the activity, even with assistive technology, equipment, home modifications or assistance from another person. (CTH, 2013)

Early Intervention Benefit to the Participant

The evidence for benefit that must be considered is:

• The likely trajectory and impact of the person’s impairment over time; and
• The potential benefits of early intervention on the impact of the impairment on the person’s functional capacity and in reducing their future needs for supports; and
• Evidence from a range of sources, such as information provided by the person with disability or their family members or carers. The CEO may also in some cases seek expert opinion. (CTH, 2013)

Reasonable and Necessary Supports

In relation to mental health, the NDIS will fund the following reasonable and necessary supports:

• Assistance to coordinate supports and assistance with daily personal activities (community reintegration and day to day living including assistance with planning, decision-making, personal hygiene, household tasks, social relationships and financial management);
• Development of daily living and life skills (to increase the participant’s ability to live as autonomously as possible including skills in daily life activities, communication and social skills, problem solving and managing funding of supports);
• Assistance with accommodation and tenancy obligations (to guide, prompt, or undertake activities to ensure the participant obtains/retains appropriate accommodation, including specialist tenancy support services where no other tenancy support option is available);
• Assistance with daily life tasks in a group or shared living arrangement (non-clinical) – where residential accommodation is provided as an integral part of non-clinical care);
• Assistance with transport (specialist transport to and from health appointments required as a result of a participant’s disability (where no other transport option is appropriate and not substituting for parental responsibility). (CTH, 2013)

The NDIS will generally not fund:

• Diagnosis of psychiatric conditions;
• Clinical treatment;
• Early interventions related to mental health;
• Residential care (clinical) where the primary purpose is for inpatient treatment or clinical rehabilitation;
• Mental health crisis services. (CTH, 2014)

Carers and the NDIS

One of the general guiding principles of the NDIS Act is that ‘the role of families, carers and other significant persons in the lives of people with disability is to be acknowledged and respected’. (CTH, 2013)

Under the guidelines to the Act, while the participant is the central focus of the plan, the consideration of ‘informal supports’ must take account the carer’s circumstances, capacity and future plans. (CTH, 2014)

The following matters will be considered in determining what it is reasonable to expect families, carers, informal networks and the community to provide:

• The extent of any risks to the wellbeing of the participant arising from the participant’s reliance on the support of family members, carers, informal networks and the community; and
• The suitability of family members, carers, informal networks and the community to provide the supports that the participant requires, including such factors as:
  • The age and capacity of the participant’s family members and carers, including the extent to which family and community supports are available to sustain them in their caring role; and
  • The intensity and type of support that is required and whether it is age and gender appropriate for a particular family member or carer to be providing that care; and
  • The extent of any risks to the long term wellbeing of any of the family members or carers (eg a child should not be expected to provide care for their parents, siblings or other relatives or be required to limit their educational opportunities); and
• The extent to which informal supports contribute to or reduce a participant’s level of independence and other outcomes.

Other considerations come into play if the person with the disability is a child. (CTH, 2013)

Carer Recognition Act 2010 (Cth)

The object of the Carer Recognition Act is to ‘increase recognition and awareness of carers and to acknowledge the valuable contribution they make to society’. (CTH, 2010)

A carer is someone who provides ‘personal care, support and assistance to another individual who needs it because that other individual:

• Has a disability; or
• Has a medical condition (including a terminal or chronic illness); or
• Has a mental illness; or
• Is frail and aged.’

Under this Act, ‘carer’ does not mean those caring for people under a contract for services, while doing voluntary work for an organisation, or as part of a training course. Nor is an individual a ‘carer’ simply because they are a partner, parent, child, relative or guardian, or lives with an individual who requires care. (CTH, 2010)

The Act includes a Statement for Australia’s Carers.

Victorian Policy

Victorian Mental Health Reform Strategy 2009-2019 Because Health Matters

Reforms are based on the elements of prevention, early intervention, recovery and social inclusion.

There are eight reform areas:

1. Promoting mental health and wellbeing – preventing mental health problems by addressing risk and protective factors.
2. Early in life – helping children, adolescents, and young people (0-25 years) and their families
3. Pathways to care – streamlining service access and emergency responses
4. Specialist care – meeting the needs of adults and older people with moderate to severe mental illness
5. Support in the community – building the foundations for recovery and participation in community life
6. Reducing inequalities – responding better to vulnerable people
7. Workforce and innovation – improving capacity, skills, leadership and knowledge
8. Partnership and accountability – strengthening planning, governance and shared responsibility for outcomes. (DHS, 2009)

Victorian Public Health and Wellbeing Plan 2015-2019

The plan includes promoting mental health. (VIC, 2015)

Other Policies

• The Melbourne Charter for Promoting Mental Health and Preventing Mental and Behavioural Disorders
• Koolin Balit: Victorian Government strategic directions for Aboriginal health 2012-2022
• Koolin Balit State-wide Action Plan: 2013-2015
• Victoria’s Priorities for Mental Health Reform 2013-2015
• VicHealth Action Agenda for Health Promotion
• VicHealth: Improving Aboriginal health and wellbeing local government action guide no. 2
• The Victorian Refugee and Asylum Seeker Health Action Plan 2014-2018

Victorian Legislation

Mental Health Act 2014 (Vic)

Mental health legislation provides for the assessment, detention and compulsory treatment of people with severe mental illness. (DoH, 2014) In Victoria the Mental Health Act 2014 (Vic) replaced the Mental Health Act 1986 and represents a major reform of mental health legislation by putting people with a mental illness at the centre of decision-making about their treatment, care and recovery. It also recognises the family and carers of those people. (DoH, 2014)

Mental health service providers must have regard for the twelve ‘mental health principles’ included in Section 11 of the Act. (Vic, 2014) They are in resources:

Recovery-oriented Framework and Supported Decision Making

The major reforms under the legislation in this regard include:

• A presumption of capacity – all people are presumed to be able to make treatment decisions. They should be provided with information and support to make these decisions. The Act includes a capacity test and principles to assist determination of whether they can or cannot give informed consent to treatment, and where they are deemed to be unable to consent, they must be supported to be involved in the decision-making process to the greatest extent possible.
• A right for patients to seek a second psychiatric opinion at any time about their treatment and whether the treatment criteria still apply to the patient. The intention is to empower patients to make decisions or participate in decision making regarding their treatment. A patient is entitled to apply to the Chief Psychiatrist for a review of their treatment in the event that recommendations of the second psychiatrist are not adopted by the authorised psychiatrist.
• An advance statement may be made to record a person’s treatment preferences in the event that they become too unwell to communicate their treatment preferences.
• A patient can nominate a person to receive information and to support the patient during a compulsory treatment order. This person will represent the patient’s views and preferences, but cannot make treatment decisions on behalf of the patient. (Department of Health, 2014)

Compulsory Treatment Orders

The legislation promotes voluntary treatment in preference to compulsory treatment wherever possible by introducing three different types of compulsory treatment orders:

• Assessment Order (AO): a medical or mental health practitioner can make an assessment order if their patient appears to have a mental illness and needs treatment to prevent serious harm to themselves, serious deterioration in their mental or physical health, or serious harm to another person. The AO allows an authorised psychiatrist to assess the person to determine whether they have a mental illness and require compulsory treatment. The AO will last up to a maximum of 72 hours.
• Temporary Treatment Order (TTO): At the assessment the authorised psychiatrist can make a Temporary Treatment Order if the criteria for compulsory treatment applies. This order has a maximum duration of 28 days. The person’s treatment must be regularly reviewed and the TTO must be revoked immediately if the criteria no longer apply.
• Treatment Order (TO): If a patient remains under a TTO at the end of the period of the order, the Mental Health Tribunal will conduct a hearing to decide whether the criteria for a TO apply. TOs have a maximum duration of six months for an Inpatient TO or twelve months for a Community TO. For young people the maximum duration of any TO is three months. A patient can make an application to the Mental Health Tribunal to have the order revoked at any time. Any decision made by the Mental Health Tribunal can be reviewed by application to the Victorian Civil and Administrative Tribunal. (Department of Health, 2014)

Safeguards to Protect the Rights and Dignity of People with Mental Illness

Extra mechanisms which protect the rights of people with a mental illness under the legislation are:

• Mental Health Tribunal: The Tribunal is to take a holistic approach in making decisions which encompasses a patient’s recovery goals, treatment preferences and the views of the nominated person, carer, guardian or parent of a young person, and to take into account any second psychiatric report.
• Electroconvulsive Treatment (ECT): ECT may only be performed with the approval of the Mental Health Tribunal on a patient who does not have capacity to give informed consent or a person under 18 years of age. Also, ECT will not be compulsorily performed on any patient with capacity to give informed consent who has refused ECT.
• Restrictive Interventions: Restrictive interventions (bodily restraint and seclusion) now includes physical restraint as well as mechanical restraint and seclusion. They must only be used after all reasonable and less restrictive options have been tried or considered.
• A Statement of Rights is included in the legislation. Patients must be informed of their rights which includes the right to make or participate in decisions about treatment and care, even where a patient does not have the capacity to provide informed consent. (Department of Health, 2014)

Oversight and Service Improvement

The legislation establishes an independent Mental Health Complaints Commissioner (MHCC). The role of the Chief Psychiatrist has been redefined to focus on supporting mental health service providers to deliver quality mental health services. Community Visitors will continue to monitor the adequacy and appropriateness of public mental health services.

Carers Recognition Act 2012 (Vic)

Enacted to recognise, promote and value the role of people in care relationships, to recognise their different needs, to support and recognise the benefits to the community that care relationships bring, and to promote the understanding of the significance of care relationships.

Under the Act a care relationship is defined as a person providing another person, or receiving from another person, care because one of the persons in the relationship:

• Has a disability
• Is older
• Has a mental illness
• Has an ongoing medical condition.

The Act sets out three Care Relationship Principles, and the obligations of care support organisations. (Vic, 2012)

Impacts and Outcomes

Mental illness can have severe effects on both the individual and the families and carers of that individual. The more persistent the illness, the more disabling it is – particularly when it coexists with another mental or physical health condition. (OECD, 2012) Many of the issues people with a severe and enduring illness face, such as unemployment, social isolation and discrimination, are both a contributor to, and a by-product of, mental illness.

For people living with psychosis, the most common challenges they face are financial problems, loneliness and isolation and a lack of employment. The other challenges are: physical health issues; uncontrolled symptoms; lack of suitable housing; stigma and discrimination; no family/carer; and inability to access specialised services or appointments. (CTH, 2011)

Statistics relating to the impact of psychotic illnesses can be found in the National Survey of People Living with Psychotic Illness 2010.

Burden of Disease and Injury

The Australian Institute of Health and Welfare, Burden of Disease and Injury in Australia reports are a good source of statistical information regarding the impact of mental illness on Australians. The report measures the burden of disease and injury using the disability-adjusted life year (DALY). This describes time lost due to fatal and non-fatal events (ie years of life lost because of premature death plus years of healthy life lost because of disability).

Mental disorders are one of the top three leading contributors to the burden of disease and injury in Australia. Mental disorders are also the leading cause of non-fatal disability burden in Australia. Anxiety and depression, alcohol abuse, and personality disorders dominate the burden of mental disorders.

The ABS Survey of Disability, Ageing and Carers covers Psychological Disability. In Australia nearly 20% of people with any type of disability have a psychological disability. The majority of those people who report a psychological disability also report having one or more other disabling conditions. The prevalence of psychological disability has increased over time, with the most striking increases amongst people in the 15-24 year age group. One of the main drivers behind this increase is an increase in anxiety related disorders.

Most people with psychological disability report needing assistance or experiencing difficulty in at least one of the broad activity areas of everyday life. Those people experiencing psychological disability also show lower participation in education and employment than people with no disability. (ABS, 2015)

Physical Impact

Mental disorders have a variety of symptoms. For individuals living with psychotic illness, the most common symptoms are delusions, hallucinations, depressed mood, loss of pleasure, poor concentration, irritability and elevated mood.

Side effects from medication and other associated impairments are other factors which are recognised as having a physical impact. Most people living with psychotic illnesses take prescribed medication such as antipsychotics. Side effects include: daytime drowsiness, drier or more watery mouth, weight gain, inner restlessness, trembling or shaking of limbs, and an inability to relax. (CTH, 2011)

Co-morbidity

Mental health is strongly linked to physical health outcomes. Mental illness is associated with increased exposure to health risk factors, poorer physical health, and higher rates of death. The cardiovascular and immune systems are affected by stress and anxiety and creates vulnerability to other conditions such as infection, diabetes, high blood pressure, stroke and coronary heart disease. (VicHealth, 2007)

The National Survey of Psychotic Illness 2010 found that respondents were at much greater risk of experiencing many chronic conditions than the general population, including: chronic pain, asthma, heart or circulatory conditions, headaches/migraines, arthritis, and diabetes. (CTH, 2011)

Other research has found that:

• People who have had a mental health disorder at any point in their lives were twice as likely to have experienced heart disease or stroke, or had a higher risk of developing CVD; and
• People who used psychiatric medication were twice as likely to have heart disease, and three times as likely to have had a stroke than people who do not take this medication. (HSF, 2014)

The reasons for this comorbidity are varied, and include:

• The symptoms of mental illness (for example, low motivation);
• Other co-occurring mental health diagnoses (for example, substance-use disorders);
• Comorbid physical illness (for example, asthma, arthritis and cancer are all linked with depressive symptomology); (Chapman, 2005)
• Suboptimal lifestyle factors (for example, poor diet, reduced ability to cease smoking);
• Low socio-economic status and unemployment (known to be associated with CVD risk);
• Deficits in CVD health monitoring and response by health workers;
• The adverse metabolic effects of antipsychotic and mood-stabilizing agents used to treat severe mental illness. (Gladigau, 2013)

Cardiovascular Disease

The mortality rate of people with severe mental illness is two or three times that of the unaffected population, which corresponds to a reduction in life expectancy by 10-25 years – a comparable health gap to that experienced by the Aboriginal and Torres Strait Islander population. The major contributor to this increased mortality in people living with severe mental illness is cardiovascular disease. In those people there is an increased prevalence of modifiable risk factors: they are more likely to smoke, to be overweight or obese, to have high blood pressure and/or cholesterol, insulin resistance or diabetes, and to have metabolic syndrome. (Gladigau, 2013)

Obesity

While it is important to note that most overweight or obese people do not suffer from serious mental illness, The National Survey of Psychotic Illness 2010 found that almost half of their respondents were classified as obese, and that 96.4% were classified as either sedentary or undertaking low levels of exercise (compared with 72% for the general population). (CTH, 2011) (Chapman, 2005)

Diabetes

Diabetes has been consistently associated with elevated rates of depression and some other serious mental illnesses. Research has shown that depression is twice as prevalent among people with diabetes as among people without diabetes. (Chapman, 2005) (Roberts A. e., 2015)

Other Mental Disorders

Individuals living with schizophrenia have a higher risk of suffering from other mental disorders, particularly depression and substance abuse (alcohol, illicit drugs and tobacco). Depression during a remission period (when an individual may have increased insight into their condition) is strongly associated with a high risk of suicide. Substance abuse reduces the effect of treatment, worsens psychotic symptoms, increases social disability, and increases the likelihood of violence. (Barbato, 1996)

Depression has also been linked with non-adherence to medical treatment (depressed patients were found to be three times more likely not to comply than non-depressed patients). (WHO, 2001)

Substance Misuse

The relationship between substance abuse and mental health is very complex. Dependence on, or abuse of, drugs is often accompanied by high rates of mental disorder, while at the same time the existence of a mental disorder may exacerbate the misuse of drugs. (ABS, 2008)

Around half of all those living with a severe mental illness will develop a substance use disorder at some point. Individuals with co-occurring mental illness and substance use disorder are more likely to have sub-optimal health, will respond poorly to treatment, be less likely to comply with treatment, use health services more often, are at risk of contact with the criminal justice system, and are more likely to commit violent offences (see Contact with the Prison System). (Butler, 2011)

The ABS National Survey of Mental Health and Wellbeing has statistics covering mental disorders and misuse of drugs. See also the National Survey of People Living with Psychotic Illness 2010.

A high percentage of respondents to that survey reported failure to fulfil their normal role over the past year as a result of their substance use, and social or legal problems related to substance use. A quarter reported engaging in risk-taking behaviour over the past year as a result of their substance use.

Smoking

The relationship between mental illness and smoking is complex. People living with mental disorders are nearly twice as likely to smoke as others, with rates much higher for those with schizophrenia. The reasons for this are unknown, but it has been suggested that nicotine is a highly psychoactive chemical that has a variety of effects on the brain. It leads to dopamine release in parts of the brain that are strongly related to mental disorders. It may also be consumed to mitigate the effects of mental illness, not only for symptom reduction, but also in response to the social environment of isolation and boredom. (WHO, 2001)

Alcohol Consumption

The relationship between mental illness and alcohol consumption is also a complex one. For instance, people with alcohol dependence are more likely to suffer from other mental health problems, and people with mental health problems are more likely to experience problems relating to alcohol. (ABS, 2008) People who are living with psychotic illnesses are far more likely to abuse alcohol than the general population. (CTH, 2011)

Disability

The ABS National Survey of Mental Health and Wellbeing has some data showing the relationships between mental disorder and disability. In mental illness, disability can affect social functioning across a number of areas, in particular:

• Self-care (personal hygiene, dressing and feeding);
• Occupational performance (work, study, housework);
• Family functioning
• Social functioning. (Barbato, 1996)

Schizophrenia is particularly associated with lower levels of social functioning than other severe and persistent mental disorders. (Schretlen, 2000) (Barbato, 1996) When considering the definition of ‘recovery’ it must be noted that a positive clinical outcome is not always accompanied by social recovery and functional outcomes. (Pope, Dudley, & Scott, 2007)

The Personal Helpers and Mentors (PHaMs) service aims to increase recovery opportunities for people whose lives are severely affected by mental illness. The Australian Institute of Health and Welfare collects information about PHaMs participants and the program which is available on the website. Here you can find data around the functional limitations reported by participants which indicates a measure of disability. Limitations reported include: social and community activities; learning; interpersonal relationships; employment; self-care and domestic activities, and mobility.

Suicide and self-harm

Suicide is the main cause of premature death for people with a mental illness. It has been strongly linked to depressive illnesses and schizophrenia, and also to substance use. (WHO, 2001) The lifetime risk of suicide for schizophrenia spectrum disorders is believed to be 10% (about 12 times that of the general population). (Barbato, 1996) The burden of suicidality is generally underestimated due to data collection issues. (CTH, 2011) (ABS, 2012)

Availability of the means to complete suicide has a strong impact on suicide rates. Internationally, alcohol consumption and access to toxic substances and firearms have been positively related to suicide rates. It is the leading cause of death for young adults and in the top three causes of death in the 15-34 year age group. International data on suicide attempts indicate that it may be up to 20 times higher than the rate of completed suicides. (WHO, 2001)

In Australia, the ABS National Survey of Mental Health and Wellbeing reports on rates of suicide ideation and the ABS Suicide and ABS Causes of Death data reports on death rates.

The National Survey of People Living with Psychotic Illness 2010 reports on suicide ideation and attempted suicide.

When interpreting this data, it must be remembered that ‘intentional self-harm’ does not always involve suicidal intent. The national suicide rate has remained stable since 2003 at around 11 per 100 000, or 0.011%. Suicide is the 10^th leading cause of death for males and the 14^th leading cause of death overall. (ABS, 2012) (DHA, 2013)

While many more women than men have serious thoughts or attempt suicide, the number of women who die as a result of suicide is far less than that of men. The reasons for this may be due to the mechanism used – women tend to use less fatal methods such as poison, while men tend to use more extreme methods such as firearms.

Hospital separation data can be used as an indicator of the potential size of suicide problems in Australia. The majority of people who attempt suicide have had a previous diagnosis of a mental illness. (Simon-Davies, 2011)

The AIHW Injury publications show trends in hospitalised injury in Australia including data on cases of intentional self-harm. Almost half of all cases of intentional self-harm occur in the 25-44 year age group.

Social Impact

The negative impact of mental illness is both substantial and sustained, even after recovery. This is considered to be a result of social factors. (WHO, 2001)

Education and Employment

Young people with a mental disorder often perform poorly in the education system, which leads to earlier school leaving and negative consequences for future working lives. (OECD, 2012)

People with mental disorders are more likely to be unemployed than people without mental disorders, and the employment gap increases sharply with the severity of mental illness. Worldwide, the Organisation for Economic Cooperation and Development (OECD) has found that the employment rate for people with a severe mental disorder is between 45 and 55% (60-70% for people with a common mental disorder). People with a severe mental disorder are 6 or 7 times more likely to be unemployed than people with no such disorder. (OECD, 2012)

The more chronic a mental disorder is, the greater impact it has on labour market inclusion. Equally, unemployment itself is detrimental to mental health. People with mental disorders who find employment can enjoy improvements in mental health (though the opposite is true if that employment is of poor quality). (OECD, 2012)

Work in community settings (rather than a setting specifically designed for the employment of individuals with psychiatric disability) has been shown to generally predict an increase in levels of social functioning over time for people experiencing severe and persistent mental illness. (Weinberg, 2009)

What may be more important than employment could be having an element of choice: employment as only one element available to enhance social inclusion. People may gain equal advantage from being involved in activities that are meaningful for them, so that a sense of personal fulfilment and connection to others can be achieved. (Tew, 2012) (see Social Isolation)

Australia has one of the lowest rates of employment participation by people with mental illness. Of the six major health conditions (cancer, CVD, major injury, mental illness, diabetes and arthritis), mental illness is associated with the lowest likelihood of being employed. (CTH, 2009)

Data for employment and mental illness are available from the National Mental Health Report.

The National Survey of Psychotic Illness which found that only one third of respondents living with a psychotic illness were in paid employment (CTH, 2011). The OECD has developed some policy principles to inform government about the issues and interventions necessary to help reduce unemployment of people with a psychological disability.

Poverty

People with a severe mental disorder have lower incomes, and a much larger risk of poverty. People experiencing a mental illness earn almost 5% less than a person with no illness. This income effect is stronger for more severe mental illness. (Inder, 2012)

The National Survey of Psychotic Illness 2010 found that three quarters of people with psychosis had earned less than half the national estimated average disposable income, and that the main source of income for 85% of their respondents was the Disability Support Pension. (CTH, 2011)

Homelessness

Mental health and substance use disorders both increase the risk of, and are exacerbated by, homelessness. (Fazel, 2014) Safe and stable housing is critical for the recovery of people living with mental illness. (DHA, 2013) Homeless people face enormous challenges, including the absence of a stable home; unemployment; economic insecurity; poor health and wellbeing; and a lack of safety. (Riley, 2014)

The ABS National Survey of Mental Health and Wellbeing found that more than half the people who reported ever being homeless had a 12 month mental disorder. This was three times the prevalence of people who reported never experiencing homelessness. (ABS, 2008)

Up to 75% of homeless adults in Australia have a mental illness, and about a third of these are affected by severe disorders. (CTH, 2009)

The National Survey of Psychotic Illness 2010 found that half of the respondents living with psychotic illness were living in rented accommodation, and that 5% were homeless at the time of the survey. Overall, 12.8% of respondents had experienced periods of homelessness over the previous year. (CTH, 2011)

AIHW Specialist Homelessness Services (SHS) reports measure clients with a current mental health issue. This represents about a quarter of all SHS clients.

Clients with a current mental health issue are the fastest growing client group for SHS, growing at an average annual rate of 12% a year. The top three reasons for clients with and without a mental health issue seeking assistance from SHS were: Housing crisis; domestic and family violence, inadequate or inappropriate dwelling conditions and financial difficulties. (AIHW, 2015)

Research findings from The Trauma and Homelessness Initiative in 2014 showed that exposure to trauma, mental health difficulties, social disadvantage and homelessness have a profound and cyclical relationship.

Model of the relationship between trauma, homelessness, mental health and social disadvantage

They found that between 91 and 100% of people experiencing homelessness had experienced at least one major trauma in their lives, particularly during childhood and adolescence, and were at increased risk for experiencing traumatic events during the time that they spent homeless. Mood disorders, psychotic disorders, and trauma-related disorders were all found to be over-represented amongst adults experiencing homelessness. (O'Donnell, 2014)

Stigma, prejudice and discrimination

The World Health Organisation define stigma as: ‘a mark of shame, disgrace or disapproval which results in an individual being rejected, discriminated against, and excluded from participating in a number of different areas of society’. (WHO, 2001)

People with mental illness may experience stigma, which can lead to isolation and discrimination. Stigma is deeply rooted in culture and society and may even be found at the level of the affected individual as an internal negative perception. (Barbato, 1996) Stigma has a strongly negative impact on affected individuals. The effects include: psychological stress and depression, fear, participation restrictions, increased risk of disability, delays in diagnosis and treatment, and non-adherence or default from treatment. (Van Brakel, 2006) Stigma acts as a barrier to treatment due to the fear of being labelled mentally ill. (Barbato, 1996)

Stigmatising attitudes have a complex and multifaceted interaction with the help-seeking behaviour of young people. Young people who perceive a mental disorder as more of a personal weakness and less dangerous or unpredictable are more likely to seek help from informal sources rather than professionals. Young people who desire to distance themselves from peers with a mental disorder are less likely to seek help at all. (Yap, 2011)

Stigma is multifaceted. It can manifest as:

• Attitudes towards the people affected
• Discriminatory and stigmatizing practices, services, legislation and materials, such as media representations, discrimination in the workplace
• Experience of actual discrimination and/or participation restrictions
• Perceived or felt stigma
• Internalized stigma (feelings of loss of self-esteem and dignity, shame and guilt). (Van Brakel, 2006)

The 2011 National Survey of Mental Health Literacy and Stigma found that one relatively common belief in the community is that personal weakness is a cause of mental disorders. The respondents believed that more common illnesses, such as social phobia, were not real medical illnesses. Young people in particular highly endorsed the belief that a person could snap out of the problem. This reflects the stigmatising attitude towards mental illness. (Reavley, 2012)

Attitudes and stigma vary across different types of mental illness. (Reavley, 2011) Social distance involves the desire to avoid contact with people who live with mental illness. It is a core component of stigma. Community attitudes showing desire for social distance is most pronounced for chronic schizophrenia, followed by early schizophrenia, depression and depression with suicidal thoughts. Some improvement in Australian attitudes has been shown for depressive illnesses, which is largely believed to be due to the social awareness campaigns of organisations such as Beyondblue. (DHA, 2013) Although much work has been done in the community towards the reduction of public stigma towards mental illness, it is not always translated into acceptance. (Mak, 2014)

A comprehensive literature review in 2009 made the following conclusions from the literature regarding stigma:

• That measuring social distance is a reliable measure of stigma;
• Desire for social distance is higher in older people than in younger people;
• Desire for social distance declines during adolescence;
• Weaker desire for social distance is found in people who have had contact with people living with mental illness, and in people who have had experience with mental illness;
• Stronger desire for social distance is found after exposure to negative events in the media, such as violent crime committed by people experiencing a mental disorder;
• Greater social distance is desired from people who: have substance use disorders; have schizophrenia; have depression/anxiety disorders; and from male individuals more than from female individuals with mental disorders;
• Social distance can be reduced by planned interventions. (Jorm, 2009)

The National Survey of Psychotic Illness 2010 found that nearly 40% of respondents said they had experienced stigma or discrimination in the past year as a result of their mental illness (47%F/32%M). Fear of stigma or discrimination had stopped nearly a quarter of respondents from doing some of the things they had wanted to do, and actual discrimination had stopped a fifth of respondents from doing some of the things they had wanted to do. Twelve percent of respondents said that stigma and discrimination was one of their top three challenges for the coming year. (CTH, 2011)

Stigma does not only affect those with a mental illness, but also affects the family members of that individual as a form of associative stigma. Research shows that this is partly due to a perceived likelihood that a child will develop the same disorder as their parents. (Koschade & Synd-Stevenson, 2011)

Victimisation

Stigma and discrimination can result in high levels of victimisation for people living with a severe and persistent mental illness. The National Survey of Psychotic Illness 2010 found that 39% of their respondents reported victimisation over the past year. Twenty-five percent reported being a victim of an assault (4.8% in the general population). Only 29% of those who had been assaulted reported the most recent incident to police. (CTH, 2011)

Recent research in the US into homeless women found that 97% of their cohort of 291 women screened positive for one or more psychiatric conditions. The odds of violence towards these women (including physical and emotional violence, from partners and non-partners) increased with each additional psychiatric diagnosis. Interestingly, in that cohort of impoverished, homeless women with significant mental disorder, social isolation was protective for levels of violence and victimisation, contrary to studies within other populations. It was concluded that in this particularly unsafe environment, social isolation can be an effective means for some women to remove themselves from a potentially dangerous environment in the absence of other options. (Riley, 2014)

Social Isolation

Social isolation has been defined in the context of mental illness as ‘a state of being unintentionally alone, with a lack of fulfilling social connection, resulting in the subjective experience of loneliness and distress’. Stigma seriously affects the acceptance of people with serious mental illness in society. Isolation is also caused by some of the negative symptoms of mental illness such as social withdrawal, and by some of the positive symptoms, such as delusions. (Linz, 2013)

Social relationships act as protective factors for the onset or recurrence of mental illness, and support recovery. The National Survey of Psychotic Illness 2010 found that 22% of their respondents reported feeling socially isolated and lonely. 69% reported that their illness made it difficult to maintain close relationships. Nearly a third of respondents lived alone, but of these over 40% reported they would prefer to be living with someone else, and almost half reported that they needed and would like more friends. (CTH, 2011) A SANE Australia research study found that a high percentage of their respondents who were living with mental illness reported frequently feeling lonely. (Elisha, 2006)

Connectedness and the rebuilding of positive identity within a context of stigma and discrimination have been identified as two central components of recovery within the experience of mental illness. Relationships are important. Having one or more personal relationships that provide hope and encouragement may be critical for the achievement of recovery. People who live alone are at greater risk of social isolation and poorer outcomes. (Tew, 2012) Social isolation also increases the risk of suicide. (Elisha, 2006)

Contact with the prison system

The ABS National Survey of Mental Health and Wellbeing found that people reporting a period of incarceration had twice the prevalence of a 12 month mental disorder as people who report that they have never been incarcerated. (ABS, 2008) 10-20% of those who report a period of incarceration are affected by severe disorders. (CTH, 2009) The National Mental Health Report also reports on mental illness and those people in contact with the prison system.

The National Survey of People Living with Psychotic Illness 2010 found that the proportion of their respondents charged with an offence over the past year was nearly 11%. About 3% had spent time in a prison or lock up over the past year. (CTH, 2011)

A 2009 Australian study in a sample of prisoners found that within this population the overall prevalence of any mental disorder was 42.7%. The prevalence of any substance use disorder was 55.3%. The prevalence of a co-occurring mental illness and substance use disorder was 29% (46%F/25%M). This comorbidity rate of 46% for incarcerated women compares with a rate of 4.8% for women in the general community. For men it is 25% in prison, and 2.8% in the community. (Butler, 2011)

However, despite the strong link between mental illness and incarceration, there is no fundamental causality between mental illness and crime. A weak association between mental illness and violent behaviour has been demonstrated, but it is limited to people who are not receiving treatment, or who have a history of violence and/or a history of alcohol or substance abuse. (Henderson, 2007) In the few studies which have investigated this association, attributable risk was shown to be between 3% and 5%.

Other factors which might explain the over-representation are:

De-institutionalisation:

• The shifting of resources from the hospital sector to the community with inadequate support provided at the community level. There may be a direct relationship between prison bed use and hospital bed use – as one is reduced the other may be utilized. (Chaimowitz, 2011)

Co-morbidity between mental illness and substance abuse:

• Comorbidity leads to poor psychosocial functioning, poor compliance with treatment, and higher acute care service utilisation;
• Comorbidity enhances the risk of violence beyond that for either condition alone;
• Comorbidity reduces access to treatment services; (Butler, Indig, Allnutt, & Mamoon, 2011)
• For young people in correctional centres, the relationship between substance abuse and mental illness are linked with child sexual abuse and violence, and homelessness; (Henderson, 2007)

Homelessness:

• Increases the likelihood of treatment non-adherence; (Henderson, 2007)

Parenting

Many people with severe and enduring mental illness are parents. There is a demonstrated need for services to ensure that those parents and their children are well supported. The symptoms of mental illness, along with the effects of medication, directly affect the quality of a parent’s interaction with their child. For instance, some of the symptoms of borderline personality disorder such as impulsivity, interpersonal difficulty, suicidal ideation and self-harm are challenging for children and may increase the likelihood that they will also experience behavioural and emotional problems. Childcare routines, recreational and social outings, and school attendance are just some of the areas in which children can be affected. (COPMI, 2009) The National Survey of Psychotic Illness 2010 found that just over half the women and a quarter of the men with psychosis were parents with children. The Survey found that almost a quarter of those parents with dependent children at home were rated as having obvious or severe dysfunction in their provision of care for their children. (CTH, 2011)

Economic Impact

The economic burden of mental illness is large and complex. It includes the direct costs to the health care system, as well as the indirect costs such as that carried by the social security system and the labour market, such as reduced productivity and loss of income - both from those with the mental illness and their carers. There is a widespread lack of knowledge regarding these hidden costs. (OECD, 2012) (VicHealth, 2007)

Psychotic illnesses account for the majority of specialist mental health care resources in Australia. (DHA, 2013) In the United States studies into the economic impact of schizophrenia show that the direct and indirect costs associated with that mental disorder are close to that of diabetes. Those studies concluded that there were greater prospects for potential economic gains through treatment of schizophrenia than there were for diabetes. (Barbato, 1996)

Direct Costs

The AIHW estimates costs associated with mental health related services in Australia in the Mental Health Services – in brief annual publications. The AIHW Burden of Disease and Injury in Australia 2003 study indicated that mental disorders constitute the leading cause of non-fatal disability burden in Australia, accounting for an estimated 24 per cent of the total years lost due to disability. (NCA, 2014)

The States provide hospital-based, specialised, clinical and community-based mental health services that target people with severe and persistent mental illness. People with severe mental illness are also supported by the Commonwealth through the primary health care system and psychiatrist services, as well as some community and social support services. (NCA, 2014)

People affected by severe and persistent mental illness, and their carers, families and friends, have a variety of medical and other needs. Illness management may require hospitals, GPs, psychiatry, psychology, community mental health, private mental health, allied health and emergency department resources. In recovery they may require PHaMs, supported accommodation, carer education and support, therapeutic groups, activity programs, education, employment, Centrelink, and housing and home support resources. (Meldrum, n.d.)

People affected by the less common mental illnesses also need many services over a long period of time and account for about 80% of Australia’s mental health care expenses. (CTH, 2009) Economic analysis has suggested the following real financial costs in Australia:

• Schizophrenia and associated suicide: $1.85 billion per annum
• Bipolar disorder and associated suicide: $1.59 billion per annum
• Depression and mental disorders in the workplace: $3.3 billion per annum (not including compensation claims). (VicHealth, 2007)

A comprehensive Australian report by Inspire and Ernst & Young on the impact of young men’s mental health on the economy found that mental illness in young men aged 12-25 costs the Australian economy $3.27 billion per annum (or $387 000 per hour across a year) in lost productivity. The Federal government bears 31% of this cost as direct health costs, disability welfare, unemployment benefits, and the direct costs of imprisonment.

That report also concluded that Australia loses over 9 million working days per annum to young men with mental illness. (Degney, 2012)

Indirect Costs

Because mental illness is often associated with disability, government assistance extends beyond specialist health treatment to include community services such as housing, community care, income support, and employment and training opportunities the costs of which substantially exceed specialist health care costs. (CTH, 2009)

In addition to government expenditure, mental illness has an impact on the broader economy. The OECD found that workers with mental illness are absent from work for health reasons more often, and for longer periods, than other workers. Productivity losses caused by underperformance at work are also an issue, with four out of five workers with a severe mental disorder reporting reduced productivity. (OECD, 2012) However, recent research has shown that undergoing treatment for severe disorders results in productivity gains to levels above those of people who experience more moderate forms of mental illness who do not have treatment. (Dewar, 2011)

The Inspire and Ernst & Young report on the impact of young men’s mental health found that young men with mental illness have much lower rates of education, which limits their skills development and reduces their earning potential by $559 million per year over the long term. (Degney, 2012)

The National Mental Health Commission report The Mentally Healthy Workplace Alliance (2014) by PwC shows that by intervening in organisations to create a mentally healthy workplace, those organisations can expect a positive return on investment of 2.3 (that is, for every dollar spent there is on average $2.30 in benefits to be gained). Those returns take the form of improved productivity and lower numbers of compensation claims. (PwC, 2014)

Impact on Carers

The work that carers in the community do is of enormous social and economic value. However, it comes at a high cost to themselves. For instance, it has been estimated that the reduction in hours worked for a mental illness caregiver is greater than the reduction in hours worked for a person experiencing the mental illness. (Inder, Meadows, & Cornwell, 2012)

It has been estimated that 15% of the Australian adult population (which equates to about 2.4 million individuals) act as carers (including individuals who provide emotional support). Around two thirds of carers were female, and half fall into the 16 – 44 age bracket, notably a time during which people are at their most productive. Carers are significantly more likely to have experienced a mental disorder at some point in their lives, the main disorders being depression, anxiety, and substance abuse problems. (Pirkis, 2010)

The National Survey of People Living with Psychotic Illness 2010 found that one quarter of the respondents to that survey had a carer. For 40.8% it was their mother, for 25.7% it was a partner, and for 5.4% it was their child. (CTH, 2011)

The Experience of Caregiving

While caring for a family member or relative with severe and persistent mental illness is most often perceived as a burden with negative consequences, there are occasionally times when caregiving can be a positive and self-satisfying experience. For this reason it may be better to use the expression ‘the experience of caregiving’ instead of the negatively-framed term ‘the burden of care’. (Awad, 2008)

Most commonly, carers provide emotional support, help with practical things such as housework, medication and transport, and in severe cases with washing, dressing and other personal activity. Carers also have associated financial costs, either in terms of money spend, or earnings forfeited. (Pirkis, 2010)

The strain on carers can be immense. Over the course of the experience of caring for someone with a mental illness, the burden on the families and carers of someone living with a mental illness will include:

• Financial difficulties (need to support the patient plus the loss of productivity of the carer),
• Provision of emotional and physical support,
• Emotional reaction to mental illness, such as guilt and fear,
• Bearing of the negative impact of stigma and discrimination,
• Coping with disturbed behaviours,
• Coping with behaviours in a social setting,
• Disruption of households,
• Family relationship breakdown,
• Increase in behaviours such as alcohol use by family members,
• Restriction of social activities, and
• Impact on other family members, such as depression, shame, loss of confidence and self-esteem, decline in work or school performance.

As well as these direct burdens, lost opportunities in work, social relationships and leisure also need to be taken into account. (WHO, 2001) (Barbato, 1996) (Awad, 2008)

Patterns of exclusion experienced by carers for people living with mental illness identified four main types:

1. Personal exclusions: stigma, desire to keep mental health problems a secret, taboos surrounding mental health care;
2. Social exclusions: isolation, narrowing of social networks, restrictions due to time commitments;
3. Work life exclusions: involving education, training, employment and leisure;
4. Financial exclusions: resulting from a reduction in employment opportunity and lack of access to government benefits. (Gray, 2010)

When the Carer is a Child

The children of parents living with a mental illness are at risk of higher rates of mental illness, and poorer behavioural, social and academic development. (Fraser, 2009) In Australia it has been estimated that 21.73% of Australian children live with either one or two parents with mental illness. (COPMI, 2009) For many of these child carers, the onset of their caring role began between the ages of 8 and 10 years. More than half of them live in a single-parent family situation, which means that often the burden of responsibility for other family members rests with that young person as well. (McAndrew, 2012)

In many cases, the children of a parent experiencing mental illness are also cared for by their grandparents. Grandparents may moderate the effect of parental psychiatric illness on children, but again, at a cost to themselves both financial and physical. (COPMI, 2010)

The levels of care provided by children are influenced by a number of factors:

• Socio-economic status
• Social environment
• Lack of outside support
• Parental marital status
• Socialization into caring roles (McAndrew, 2012)

It has been estimated that up to 60% of children caring for a parent who has severe mental illness will experience mental health difficulties themselves. (McAndrew, 2012)

Some of the negative repercussions of caring for parents are believed to be heightened for children caring for parents with a severe mental illness. These include:

• Stigma
• Isolation
• Difficulties in accessing schooling (poor attendance, bullying)
• Less time for leisure activity
• Lack of recognition for their contribution (McAndrew, 2012)
• Disruptions to the parent/child relationship (sometimes due to the parent being hospitalised, or the child being involved in the parent’s delusions)
• Misconceptions regarding their parent’s illness, such as self-blame for their parents illness, and worries about their parent’s illness being passed on to them
• Associative stigma
• Maladaptive coping strategies, such as becoming hyper-vigilant, anger, depression, overeating, withdrawal, and acting out (Reupert, 2012)
• Disruption of family roles and functioning
• Detriments in attachment security, particularly in children less than 10 years old (Ireland, 2010)
• Low self esteem
• Anxiety regarding parental health affects concentration and attendance at school as well as socialising (COPMI, 2008) (Gray, 2010)

When parents have a dual diagnosis of a mental health disorder plus a substance abuse disorder, further issues arise with:

• Added vulnerability to poverty, family dysfunction, violence and homelessness
• Added fear of family separation and being reported to authorities by professionals
• Greater potential for isolation (Dawson, 2013)
• The struggle between intense loyalty to the parent, and the shame and dislike of the parent’s drug-taking behaviour
• Breakdown in family relationships and conflict (to the point of violence and abuse) (Reupert, 2012)

Some of the positive aspects of caring for parents include:

• Increased self esteem
• Early, and higher levels of maturity
• Close relationships between parent and child (McAndrew, 2012)
• Increased tolerance, independence, and helpfulness
• Greater practical skill development (Ireland, 2010)

Prevalence

Prevalence of common mental health conditions

Worldwide, surveys have shown that over their entire life span, more than 25% of individuals develop one or more mental or behavioural disorders (WHO, 2001). This means that potentially one in four families has at least one member currently living with a mental disorder.

Surveys

The ABS Australian Health Survey

This survey reports on levels of psychological distress and mental and behavioural conditions. The last survey was conducted in 2011-12. It found that about one in ten adults (10.8% or 1.8 million people) experienced high or very high levels of psychological distress, and that the most common conditions were mood (affective) disorders such as depression and anxiety (ABS, 2012).

The ABS National Survey of Mental Health and Wellbeing

The last survey was conducted in 2007. It provides much of the information we have about prevalence in Australia of the most common types of mental health conditions. The survey collects information on:

1. Anxiety disorders;
2. Affective disorders; and
3. Substance Use disorders

The 2007 Survey found that 45% of Australians aged 16-85 years had a mental disorder at some point in their life (ABS, 2008).

The ABS Survey of Disability, Ageing and Carers

The last survey conducted in 2012 found that almost one in five people with disability (19% or 813 900 people) reported a mental or behavioural disorder as the long term health condition causing them the most problems.

General Practitioner Mental Health-related Services

The Australian Institute of Health and Welfare estimates that just over 12% of GP encounters in 2012-2013 were mental health-related (nearly 15 million GP encounters). There is an annual average increase of nearly 5% in mental health-related GP encounters since 2008-2009. Depression was the most common presentation.

The ten most frequent mental health problems managed by GPs are: Depression, anxiety, sleep disturbance, acute stress reaction, tobacco abuse, dementia, schizophrenia, drug abuse, alcohol abuse, and affective psychosis.

Other Victorian Statistics

Approximately one in five (20%) of Victorians live with mental illness. Anxiety and depression are the most common disorders. (VIC, 2015)

The Australian Institute for Health and Welfare publishes data for Medicare subsidised mental health-related GP services for Victoria.

The Victorian government publishes information from a number of health surveys, including the Victorian Population Health Survey, which shows prevalence for regional Victorian areas.

Most people seek help from their general practitioner for mental health problems in Victoria. (VIC, 2015)

Prevalence of less common mental health conditions

Statistic vary, but it is estimated that people living with lower prevalence mental disorders such as schizophrenia and other psychoses affect another 1-2% of the adult population. Although they are relatively uncommon, these conditions account for about 80% of Australia’s spending on mental health care. (CTH, 2009)

It is also estimated that 2-3% of Australian adults have severe disorders based on an analysis of diagnosis, intensity of symptoms, duration of illness, and the degree of disability caused. About half of these have a psychotic illness (usually schizophrenia or bipolar affective disorder), and others have severe and disabling depression or anxiety disorders. (CTH, 2009)

12-month prevalence estimates of mental illness in the Australian population (DHA, 2013)

The National Survey of People Living with Psychotic Illness 2010 found in its survey of public and non-government mental health services that an estimated 0.31% of the population aged between 18 and 64 years had a psychotic illness and were in contact with public specialised mental health services at a given time. Over a 12 month period, it was estimated that 0.45% of the population have a psychotic illness. This equates to nearly 64 000 people between the ages of 18-64. (CTH, 2011)

This survey found that the most common psychotic disorder experienced by the survey respondents was schizophrenia.

When the 2010 survey is compared with results from the 1997-98 National Survey of Psychotic Illness some improvements can be noted: more people experienced periods of good recovery in between multiple episodes of psychotic illness, and the proportion of people experiencing deterioration due to chronic psychotic illness has halved. (CTH, 2011)

Admitted Patient Mental Health-Related Care

Hospital separation event data can be accessed through the Australian Institute of Health and Welfare Admitted Patient Mental Health-Related Care statistics. Patients are either hospitalised in a psychiatric hospital or unit and received specialised psychiatric care, or are hospitalised in a general ward without specialised psychiatric care. (AIHW, 2012) Data is available by States and Territories as well as nationally.

Community Mental Health Care Contacts

The Australian Institute of Health and Welfare regularly measure the numbers of community mental health care contacts. People aged 25-34 usually comprise the highest proportion of community mental health care contacts.

Of all community mental health care service contacts, schizophrenia is usually the most frequently recorded principal diagnosis, followed by depressive episode, and bipolar affective disorders.

Emergency Department Mental Health Related Presentations

Emergency Departments are often used as an initial point of care for people needing mental health services for the first time, and as an alternative point of care for people needing after-hours mental health services. (AIHW, 2012)

Data from emergency departments will not capture all mental health-related presentations, therefore these statistics represent an under-reporting of the actual number of mental health-related contacts. For example, in 2012 the Australian Institute of Health and Welfare noted that although there were a total of 177 400 Australian public hospital emergency department occasions of service with a mental health-related principal diagnosis, the AIHW estimated that it was more likely to be 243 444 mental health-related occasions of service. (AIHW, 2012)

Victoria has the lowest rates of emergency department mental health-related presentations of all the states and territories. The differences between the States and Territories are explained in a variety of ways. In particular, higher rates in the Northern Territory may indicate a greater reliance on this type of care in NT. Other variances may be explained by differences in population characteristics, health-care systems, and service delivery practices.

Residential Mental Health Care Services

The Australian Institute of Health and Welfare collects data from government-funded specialised mental health care services based in a domestic-like environment (but not those funded under the Aged Care Act 1997). Their services may include rehabilitation, treatment or extended care. People aged 35-44 usually comprise the highest proportion of residential care episodes, and have the highest number of episodes per 10 000 population.

When population size is accounted for, Aboriginal and Torres Strait Islander Australians access residential services at more than double the rate of non-Indigenous Australians. The rate of episodes for Australian-born residents is also much higher than the rate for those born overseas.

The most common principal diagnosis recorded for residents who have a mental health-related residential care episode is schizophrenia. Residential Mental Health Care Service statistics are also available by state and territory.

Psychiatric Disability Support Services

The Australian Institute of Health and Welfare also collects data concerning the use of psychiatric disability support services. Other AIHW information can be found on their Mental Health Services in Australia portal.

Victorian Statistics

• AIHW Community Mental Health Care Service Contacts - Victorian statistics for mental health care service contacts.
• AIHW Victorian Emergency Department Presentations - Emergency Department presentations with mental-health related principal diagnosis for Victoria.
• AIHW Hospital Separation Data - Reports hospital separation data with specialised psychiatric care for Victoria.
• AIHW Residential Mental Health Care Episodes - Residential mental health care episodes for States and Territories by principal diagnosis, Indigenous status, age and sex and other variables.

Comorbidity

Two or more mental disorders commonly occur together in the one individual. The ABS National Survey of Mental Health and Wellbeing 2007 found that 3.2% of respondents reported comorbidity of two or more mental disorders in the previous 12 months. (ABS, 2008) Anxiety and depressive disorders commonly occur together, as do mental disorder and substance use and dependence. (WHO, 2001)

The ABS National Survey of Mental Health and Wellbeing 2007 found that 11.7% of respondents reported comorbidity of mental health disorder and physical condition in the previous 12 months. Around one third of those had two or more disorders – either a physical and mental disorder, or more than one mental disorder. (ABS, 2008) Physical health problems coexist with mental disorders such as depression, and can also predict the onset and persistence of depression. (WHO, 2001)

The presence of comorbidity has implications for the identification, treatment and rehabilitation of affected individuals, as well as for the impact and burden on the individual and their carers and families. (WHO, 2001)

Prevalence in population groups

Women

Women experience higher rates of mental disorders than men, except for substance use disorders. (ABS, 2008)

Men

While women are at higher risk of most mental disorders, prevalence of the less common psychotic disorders is higher for men than for women. 59.6% of people with psychosis are male. Men aged 25-34 years have the highest rates of psychotic illness (0.52% total population). (CTH, 2011)

Men also have almost three times the fatal burden for mental illness and behavioural disorders than women. (AIHW, 2010)

Children and Young People

An estimated fourteen percent of Australian children score in the clinical range for mental health problems. (DH, 2015) Findings from the child and adolescent component of the National Survey of Mental Health and Wellbeing are published by the Department of Health.

The AIHW report Young Australians: Their health and wellbeing found that one of the gaps in our knowledge is prevalence rates of mental health disorders among 12-15 year olds. (AIHW, 2011)

The National Survey of People Living with Psychotic Illness 2010 showed that over half the women affected by psychosis have children of any age, and around a quarter of males with psychosis have children of any age. (CTH, 2011)

Adolescence and young adulthood is a critical period of mental and physical development and transition. Vulnerability is heightened at this time – 76% of people who experience mental disorder during their lifetime will first develop a disorder before the age of 25. (ABS, 2010)

Adolescents with mental health problems report a high rate of suicidal ideation and other health-risk behaviours such as smoking, drinking and drug use. (Arney, 2000)

The prevalence of mental disorders in the 16-24 year age group is 26% - that is, one in four young people have experienced at least one mental disorder (AIHW, 2011). The most commonly reported disorders are anxiety disorders, substance use disorders and affective disorders. Of the anxiety disorders, the most prevalent types reported are post-traumatic stress disorder and social phobia. Harmful use of alcohol was the most common substance use disorder. (AIHW, 2011)

Mission Australia report on the Annual Youth Survey. In 2014 they reported specifically on youth mental health and found:

• Over one fifth of young people met the criteria for have a probable serious mental illness
• Females were twice as likely as males to be classified as having a probably serious mental illness
• Respondents who identified as Aboriginal or Torres Strait Islander have much higher rates of probable serious mental illness
• Respondents who reported a disability had much higher rates of probable serious mental illness. (Mission Australia, 2015)

The ABS Mental Health of Young People survey shows that young people also have a relatively low use of mental health services, with GPs being the most frequently used health professional. Those with a severe level of impairment were more likely to use mental health services. (ABS, 2010)

AIHW Hospital separation data shows the percentage of all separations for young people for a principal diagnosis of mental and behavioural disorders. The leading causes of hospital separation for mental and behavioural disorders are mood disorders, disorders due to psychoactive substance use, and neurotic, stress-related and somatoform disorders. (AIHW, 2011)

People with a Disability

The ABS National Survey of Mental Health and Wellbeing found that 43% of people with a profound or severe core-activity limitation had experienced a mental disorder in the previous 12 months. (ABS, 2008)

Aboriginal Australians

Information sourced from mental health services are likely to underestimate the actual rates of mental illness within Aboriginal communities for reasons of both identification practices, and because many Aboriginal people do not access mainstream services. Even so, Aboriginal people are over-represented in mental health care throughout Australia. (Garvey, 2008)

Australia-wide Indigenous Australian’s are hospitalised for psychiatric disorders at a much higher rate than non-Indigenous Australians. (Hunter, et al., 2012) They are 2-3 times more likely than non-Indigenous Australians to be admitted to hospital for intentional self-harm. (Cunningham, 2012)

The National Aboriginal and Torres Strait Islander Health Survey, the National Health Survey and the National Aboriginal and Torres Strait Islander Social Survey record high or very high levels of psychological distress in the Indigenous population. (AIHW, 2011)

The statistics for Victoria show that Aboriginal Victorians are about three times more likely to experience high/very high levels of psychological distress than non-Indigenous people, particularly those living in remote areas. (VIC, 2013)

The higher levels of psychological distress reported by Aboriginal people are consistent with the relative frequencies with which they experienced family stressors. The most commonly reported family stressors are:

• Death of a family member or friend
• A serious illness
• Inability to get a job
• Mental illness
• Trouble with the police
• Alcohol-related problems
• Involuntary loss of a job
• Pregnancy
• Drug-related problems.

Aboriginal and Torres Strait Islander people aged 15 years and over are 1.4 times more likely than non-Indigenous people to have experienced one or more of these specific stressors. (ABS, 2013) Aboriginal Australians have higher rates of suicide, disability and chronic disease, and are exposed to high levels of racism, trauma and grief. (Cunningham, 2012)

The Australian Institute of Family Studies longitudinal study Footprints in Time reports on the frequency with which parents have been feeling depressed, anxious, angry or impulsive, and their experience of significant stressful life events. The study found that around half the parents reported experiencing three to six major life events in the past 12 months. The three most frequently experienced life events parents had experienced were a pregnancy or the birth of a child, the death of a close family member or friend, and that they had felt crowded where they lived, moved house, or had housing problems. (DFHCSIA, 2009)

The Western Australian Aboriginal Child Health Survey (2005) used carer reports to assess the risk of emotional and behavioural difficulties for Aboriginal children aged 4-17 years. The study found that

• nearly a quarter of Aboriginal children in that age group were at a high risk of clinically significant emotional or behavioural difficulties (compared with 15% in non-Indigenous children).
• 16% of young people aged 12-17 had seriously thought about ending their own life in the 12 months prior to the survey (females 20%/males 12%)
• Of those young people who had thought about suicide, 39% had also attempted suicide in the previous 12 months
• A much larger proportion of young people at high risk of clinically significant emotional or behavioural difficulties had thought about suicide (37%) or had attempted suicide (21%) in the previous 12 months. (AT, 2005)

The Victorian Governments Aboriginal Affairs Report reports on Aboriginal presentations at emergency departments with injuries die to self-harm in Victoria, which are much higher than for non-Indigenous people. (VIC, 2013)

Carers

This ABS Disability, Ageing and Carers survey found that we are likely to underestimate the number of carers in the community as many people do not identify as carers despite the assistance they provide to family members and friends with disability. Women make up the majority of carers (70% of primary carers, 56% of carers overall). 37% of primary carers have a disability themselves. (ABS, 2012) (CTH, 2011)

When are they at risk?

Mental illness usually has its onset in childhood or adolescence (CTH, 2009). Two thirds of people with a psychotic illness experience their first episode before the age of 25 years. The mean age of onset is 23 years for men, and 24 years for women. (CTH, 2011)

Determinants

The determinants of severe and persistent mental illness can be understood using a biopsychosocial framework. This helps us to understand the complex interplay of biological, psychological, and social factors that determine a diagnosis of mental illness.

World Health Organisation: Interaction of the biopsychosocial model (WHO, 2001)

Genes create the framework for early responses to the world, but the continuous interaction over a lifetime with personal and social environments may lead to the specific psychological and behavioural responses we recognise as mental illness. These factors interact throughout the life span to increase or decrease the likelihood of the onset of a disorder, and determine its clinical form and outcome. Factors which create vulnerability appear to have a multiplying rather than an additive effect: the risks associated with having at least two determinants or risks are significantly greater than the sum of those individual risks.

Recovery

Most significantly, these environmental factors not only influence the path from health to illness, but also from illness to recovery. Some individuals become severely disabled by their condition, while others are more able to work towards recovery. (Ellis, 2001) In the context of mental illness, ‘recovery’ means ‘the challenge of maintaining or rebuilding a meaningful and satisfying life…whether or not the symptoms can be eliminated’. (Fossey, 2012)

In a public health context, these determinants not only affect the development and onset of severe and persistent mental illness, but also have a determinant effect on rates of hospitalisation, levels of disability, rates of help-seeking, rates of relapse, and adherence to treatment.

Biological determinants

Genes

Genes are an important factor for determining risk of both psychotic and non-psychotic illnesses. Most illnesses are caused by a number of genes with varying contributions.

• For bipolar disorder, for example, the risk for children of an affected person is 20% (1-2% for children of non-affected parents). Fifty percent of people with bipolar disorder have a parent with a mood disorder. (MHRI, 2003) Australian research on adolescents with a genetic risk of bipolar disorder (with either a parent or sibling with bipolar disorder) found that those adolescents had reduced brain activity in a specific part of the brain known to regulate emotional responses. (Roberts G, 2012)
• Risk of schizophrenia is also heightened in the children of an affected person (10%, compared with 1% for people without an affected family member). Genetic contribution to schizophrenia is estimated to be around 60%. (Barbato, 1996) (Ellis & Hickie, 2001)
• Genetic predisposition for PTSD is calculated to be 60%. It may be caused by multiple genes. (Ellis & Hickie, 2001)

However, clinical presentation is not entirely determined by genetics.

Physiology and the brain

Some mental illnesses are linked to disruption of neural communications. If the nerve cells in the brain are unable to facilitate communication along neurotransmitters (either through brain damage, drug use, or some life experience/event) long-term changes to the way an individual thinks, expresses emotion, and behaves can occur. (HealthInfoNet, 2013)

Some severe and persistent mental illnesses may be neurodevelopmental in origin, though in many instances it is unknown whether the changes in brain function associated with these illnesses are a causal factor or a consequence of mental illness. There is now a body of evidence that suggests that variations in the quality of early life environments may alter the epigenetic regulation of genes and affect future disease risk. (Sweeny, 2014)

• In schizophrenia exposure in utero or in early life to factors affecting brain development may lead to changes in the brain which increase the risk of schizophrenia. Low-birth weight, exposure to influenza during the second trimester of pregnancy, and obstetric complications at birth are linked to risk. This may be due to the impact these have on the structural development of the brain. (Ellis & Hickie, 2001)
• Abnormal cell metabolism may play a role in bipolar disorder. Imaging of brain cells can detect differences in metabolism in the cerebral white matter and cerebellar regions of people affected by bipolar disorder but not in the brains of people who do not have bipolar disorder. (Johnson, 2015)
• Psychosis is characterised by rapid and pronounced cerebral grey matter loss – a tissue loss which occurs before exposure to antipsychotic drugs. The brain changes appear to be part of the natural course of psychotic disorders.
• Personality disorders may be associated with impaired regulation of the brain circuits that control emotion. (PHAC, 2006)
• Babies born with extremely low birthweight whose mothers received a full course of steroids prior to giving birth are at greater risk for psychiatric disorders such as depression, anxiety disorders or ADHD. (Lieshout, 2015)
• Exposure to stressors during early childhood has been associated with persistent brain hyper-reactivity, and also to the increased likelihood of adult depression. Affectionate and stable relationships of care during childhood is of crucial importance for children to develop normally. When children are not nurtured they are more likely to develop mental and behavioural disorders. (WHO, 2001)
• Alcohol and other substance use have psychiatric implications. Substance, or experience-driven alterations in synaptic connections may produce long term changes in thinking and behaviour. (WHO, 2001)
• Some medical disorders can lead to psychiatric illness; for example, multiple sclerosis, endocrine disorders, infections like glandular fever and HIV, as well as injuries to the brain. Several chronic illnesses are associated with an increased prevalence of major depression. They include stroke and heart disease, obesity, arthritis, cancer and dementia. (PHAC, 2006) Some clinically prescribed medications will also have psychiatric side-effects. (Ellis & Hickie, 2001)

Determinants which influence and interact with genetic and physiological factors include both the psychological and social determinants of mental illness.

Psychological determinants

Personality can be defined as the way in which people relate to others, react to interpersonal stimuli, and evaluate themselves over time. Some people have a wide range of responses which help them to cope with different circumstances. Others have a more limited range which creates a vulnerability when circumstances become challenging.

Some personality styles are associated with different severe and persistent mental illness. For example, a hypomanic personality style is associated with risk of bipolar disorder. (Lancaster, 2015)

Social determinants

The action of social determinants on mental illness will interact to reduce or enhance underlying genetic vulnerability. Adverse social conditions may affect mental health by creating chronic stress, triggering the arousal of neural and somatic stress response. The degree of vulnerability of any individual will be influenced by their genetic make-up, psychological resources, and accumulation of negative life events. (Fisher, 2010) For instance, twin studies have found that the risk of developing depression or anxiety in adult life is comprised of: 30% genetic factors, 10% childhood factors, and 60% current environmental factors. (Ellis & Hickie, 2001)

Some genetic risk factors may be exacerbated by environmental factors such as; substance use or poor nutrition during pregnancy; childhood neglect; and trauma. These may have a negative effect on mental health outcomes of the child. (WHO, 2001) (HealthInfoNet, 2013)

Some genetic risk factors may be mitigated through environmental intervention. For example, early intervention for people with a history of depression in both parents may reduce both the incidence and the severity of the illness. Factors such as social participation and quality caring relationships will also have a positive effect on mental health outcomes. (Ellis & Hickie, 2001)

Socio-economic status

Most traditional indicators of socio-economic status – education, employment, income, home ownership, geographic disadvantage – have all been associated with prevalence of very high psychological distress, as well as substance use disorders. (Cunningham, 2012) (WHO, 2001)

There are three main models of life course which explain the influence of socio-economic status on health generally:

1. The timing model: SES-related factors have the greatest influence on adult health if experienced during specific developmental periods;
2. The accumulation model: the risk for poor adult health increases with increasing intensity of socioeconomic disadvantage and increasing duration of exposure;
3. The change model: change in SES levels may affect health either positively or negatively, depending on the direction of change between lower and higher levels of SES. (Sweeny, 2014)

There is strong evidence showing that poverty increases the risk for, course of, and recovery from, mental illness. The effects of poverty accumulate over time. (WHO, 2001)

Children living in poverty are more likely to be exposed environmental risk factors such as illness, family stress, poor social support, parental mental illness, chaotic home environments, alcohol and drug use, family violence, child abuse, unsafe neighbourhoods, community crime and violence. The risks affect the pre-natal environment, as well as childhood and adolescence. (Robinson, 2013) (Webb, 2013)

Intergenerational persistence of poor mental health is transmitted from parent to child not only via a genetic pathway, but also as a consequence of the low socioeconomic status and social functioning associated with parental mental illness. (Johnston, 2013)

Unemployment also has links to mental illness, particularly when the overall rate of unemployment is low. (Ellis & Hickie, 2001)

Age and gender

Mental illness affects women and men of different ages differently. Anxiety and depressive disorders are more common among women, and substance use disorders and antisocial personality disorders are more common among men. There are gender differences in self-care and prevention behaviours, and in responses to a variety of stressors, but it is unclear to what extent gender itself is a determinant. Patterns of risk, psychological, and social factors, such as rates of family violence against women, may account for much of the gender difference. (WHO, 2001)

Social networks and social capital

Having caring intimate relationships protects against most forms of mental illness. In times of crisis, supportive social networks are particularly crucial. These networks include religious and cultural groups, as well as family and friends. (Ellis & Hickie, 2001) The social and emotional environment of the family is strongly linked to the course of, and recovery from, severe and persistent mental illness. (WHO, 2001)

Social capital refers to the strength of personal support networks and the ability to access this support. It encompasses levels of trust, collaboration and mutual responsibility. High levels of social capital have a protective effect against mental illness.

Life events

Life events tend to affect individuals rather than populations. The impact of any event on an individual will depend on both its severity and duration, as well as on the availability of social support and other personal factors. They are particularly harmful when experienced at a young age. (WHO, 2013) For example, a diagnosis of borderline personality disorder has been particularly associated with experiences of early childhood physical and sexual abuse. (PHAC, 2006)

Life events can include: chronic health conditions, exposure to maltreatment and neglect, substance use, exposure to discrimination and human rights violations, and exposure to natural disaster. (WHO, 2013) Australian studies have found that the impact of drought on rural communities has an impact on mental health, and the greater the severity of drought, the greater the impact on mental health. (Edwards, 2014)

Conflict and disaster affect population groups and have repercussions for mental health. The most frequent diagnosis is post-traumatic stress disorder, along with depressive or anxiety disorders (WHO, 2001). These social factors which influence the risk of onset and severity of mental illness are discussed in greater depth below in Risk and Protective Factors.

A framework for understanding determinants

A common framework showing the links between determinants and risk factors, with examples, is as follows: (Selzer, 2014)

Risk and Protective Factors

Exposure to risk factors will increase the likelihood of onset, the severity of symptoms, and the duration of mental illness. Some risk factors, such as the pre-natal environment, may have an effect a long time before the emergence of a mental illness. Other risk factors, such as the death of a parent, may have a more immediate effect. It is often the cumulative effect of many risk factors, combined with a lack of protective factors, which will precipitate the onset of mental illness (WHO, 2004).

This resource is focused on risk factors to which exposure can be modified by public health and health promotion intervention.

Protective Factors

Protective factors can reduce the likelihood of, or ameliorate responses to, environmental hazards. The presence of protective factors has been shown to reduce risk regardless of the number of risk factors. The Commonwealth government published the following list of protective factors which potentially influence the development of mental health problems and mental disorders in individuals (particularly children).

Protective Factors for Mental Health Problems and Mental Disorders (McCanlies, Mnatsakanova, Andrew, Burchfiel, & Violanti, 2014)

Recent research into post-traumatic stress disorder with police officers found that personality traits such as resilience, satisfaction with life and a grateful disposition are protective factors (McCanlies, Mnatsakanova, Andrew, Burchfiel, & Violanti, 2014).

VicHealth also recognises that social support and social networks have a beneficial effect on mental health and are associated with reduced experience of psychological distress (VicHealth, 2005).

Risk Factors

The Commonwealth government published the following list of risk factors which potentially influence the development of mental health problems and mental disorders in individuals (particularly children).

Risk Factors for Mental Health Problems and Mental Disorders (Commonwealth Department of Health and Aged Care, 2000)

Some risk factors are common to many mental disorders, and other risk factors are disease specific (WHO, 2004).

Pre-Natal Risk Factors

Intrauterine exposure to risk factors may have consequences for the child’s long-term behavioural and emotional well-being. The research in this field has been inspired by the developmental origins of health and disease model (DOHaD), which sees a link between foetal development and the non-communicable diseases which emerge in adulthood. Theoretically, it is understood that responses to in utero experiences lead to biological changes in the foetal brain. Brain development, in the form of epigenetic programming, cell distribution, and establishment of endocrine systems and metabolic activity, is believed to vary depending on the timing, type, dosage and duration of a number of environmental exposures (Robinson, 2013) (Lewis A, 2014).

It can be argued that some of the findings regarding pre-natal influence on mental illness may also be explained by the post-natal environment, and research is yet to determine the degree of association. A note of caution: there is the potential for ‘mother blaming’ in the interpretation of this research.

Those risk factors for which we now have some evidence include:

Physical Health Factors

Lifestyle factors are potentially modifiable risk factors and a good target for prevention intervention.

• Famine: children who experience famine in utero have higher rates of mental illness, including schizophrenia.
• Smoking: maternal smoking during pregnancy increases the child’s risk for both externalising (for example, ADHD, conduct disorder, antisocial behaviour) and internalising (for example, depression, anxiety) behaviours. One study found that mothers who cease smoking early in pregnancy will alleviate the risk. However, the results of these studies could be interpreted to suggest that psychosocial processes may be a factor: that is, that quitting smoking shows higher self-efficacy and positive parenting practices which will impact mental health outcomes.
• Alcohol: Extreme levels of exposure to alcohol is highly damaging to the unborn child. However, studies of pregnant women who consume low levels of alcohol show that this is not associated with developmental risk. As with the example of smoking cessation above, low to moderate alcohol intake may also imply that exerting self-control is characteristic of better parenting practices.
• Obesity: a 2013 study found that the children of women who were overweight or obese before pregnancy were more likely to have significant problems, including major depression, during childhood and adolescence. Once again, this may imply that the later influence of an obesogenic environment (such as poor quality diet and sedentary behaviour) also has an impact on mental health.
• Vitamin D Status: there may be a relationship between low vitamin D in pregnant women and serious mental illness in children. Further research is required (Robinson, 2013).

Maternal Mental Health

• Stress: children of women who experience stressful events during pregnancy are at increased risk, with that risk increasing with each additional stressful event experienced. One study found that for women who experienced six or more stressful life events, their children had about four times the risk of developing a mental health problem during childhood. There appears to be no difference in risk if the stress occurs earlier or later in the pregnancy (Robinson, 2013). Mild stress exposure may not always be a risk factor. Some studies have shown that mild stress exposure in late pregnancy may well be advantageous for the child. (Lewis A, 2014)
• Unwanted pregnancy: Risk of psychosis in adulthood has also been found if the mother reported that a baby was unwanted during pregnancy (Bentall & Fernyhough, 2008).
• Depression: perinatal exposure to maternal depression is associated with some dysregulation of the child’s response to stress and may be a foetal programming pathway for the transmission of depression to the child. Research in this area is limited and associations between pre- and post-natal depression have not been clearly differentiated. (Lewis A, 2014)

Teratogenic and Neurotoxic Exposures

Teratogens are agents which alter foetal development. For instance, chemicals with endocrine-disrupting properties are related to adverse neurodevelopmental outcomes.

• Prenatal exposure to alcohol, cigarettes, cocaine, marijuana, benzodiazepines, methamphetamine, and some prescribed medications have been associated with increased risk of emotional, behavioural and cognitive problems. The association appears to be independent of the social factors which may be associated with their use.
• Psychotropic medications such as antidepressants, antipsychotics and mood stabilizers are now the focus of research due to the increasing rates of exposure in the community. Risks of exposure must be balanced against the harms of withholding treatment in these cases. (Lewis A, 2014)

Environmental toxins are beyond the control of the individual, yet are still important modifiable risk factors.

• Lead persists in the environment though exposure has been markedly reduced. Pre-natal, lifetime and current exposure are all important and results in adverse outcomes across a broad ranging neurodevelopmental spectrum.
• Other historic environmental toxins include methyl mercury and PCBs (polychlorinated biphenyls)
• Modern chemicals are now the subject of research, including manganese, cadmium, and other endocrine-disruptors such as BPAs (bisphenol A), organochloride pesticides and organophosphate pesticides.

Early Life Trauma

It has been estimated that childhood trauma affects five million Australian adults. Traumatic experience takes many forms, but is characterised by the powerlessness of the child to prevent or minimise it (Kezelman, Hossack, Stavropoulos, & Burley, 2015).

Experiencing trauma early in childhood has a significant impact on brain development (McAloon, 2014). The first two years of life see strong growth and development of the brain. The direction and pattern of this development is partly genetically, and partly environmentally, driven. The science of epigenetics suggests that gene expression is moderated by the environment. Alterations to genetic expression may be part of the explanation of how maltreatment affects the developing brain (Webb, 2013).

Many adverse childhood experiences can co-occur – exposure to one experience increases the likelihood of exposure to others (Putnam, Harris, & Putnam, 2013). Childhood exposure to even non-interpersonal trauma (such as parental depression or anxiety, parental alcohol and drug abuse) is associated with severe and persistent mental illness (Putnam, Harris, & Putnam, 2013) (Westphal, et al., 2013). The association between childhood trauma and psychosis is strong and significant, even after controlling for genetic risk (Van Winkel, Van Nierop, Myin-Germeys, & Van Os, 2013) (Bentall, Wickham, Shevlin, & Varese, 2012). A rigorous meta-analysis of studies into the associations between trauma and psychosis found that sexual abuse, physical abuse, emotional abuse, bullying, parental death and neglect were all individually related to an increased risk of psychosis (Varese, et al., 2012).

Childhood trauma and adversity have an intergenerational effect, as parents who suffer in childhood struggle to provide a positive environment for their own children (Read & Bentall, 2012). In a recent study of the family history of people experiencing comorbid mental illness and substance abuse, those with two or more first-degree relatives with alcohol, drug or psychiatric problem histories were more likely to report histories of physical, sexual and/or emotional abuse than the other respondents (Wilson, Bennet, & Bellack, 2013).

People experiencing psychotic illnesses with a history of early life trauma may experience persistent interpersonal difficulties which prevent them from engaging effectively with services and obtaining treatment (Bentall & Fernyhough, Social Predictors of Psychotic Experiences: Specificity and psychological mechanisms, 2008).

The strongest evidence for risk is found in the following categories of trauma:

Inter-parental violence

Children in homes where inter-parent violence is present are at increased risk for psychosocial difficulties and mental illness. A 2014 study found that in that environment, the variables most strongly associated with child psychosocial impairment were the father’s antisocial personality traits, and the interpersonal hostility within the home (Febres, et al., 2014).

Child abuse

Physical, sexual, and emotional abuse are associated with all mental conditions. Child abuse has a dose-response relationship with both onset and symptom severity of severe mental illness (Bentall, Wickham, Shevlin, & Varese, 2012).

Sexual abuse, particularly for women, results in the most potent childhood trauma (Putnam, Harris, & Putnam, 2013) (Perrin, et al., 2014). In a 2013 study on a large number of people experiencing severe mental illness found that childhood sexual abuse was the most commonly experienced trauma (Lu, 2013).

Investigation of an extensive UK survey of psychiatric morbidity found a specific and significant association between childhood sexual abuse (rape – not sexual touching or talk) and auditory-verbal hallucinations. Experiences of other types of physical abuse predicted paranoia and auditory-verbal hallucinations (Bentall, Wickham, Shevlin, & Varese, 2012).

People exposed to childhood physical or sexual abuse are more likely to: be admitted to a psychiatric hospital; have earlier, longer and more frequent admissions; take more psychiatric medication; self-harm and attempt suicide; and have greater global symptom severity (Read & Bentall, 2012).

Various studies have found: that 40% of people experiencing chronic depression had experienced sexual abuse during childhood; that survivors of child sexual abuse account for 34% of all presentations across the mental health sector; that adults who had been abused as children were 2.5 times more likely to have major depression and 6 times more likely to have PTSD; that 81% of adults diagnosed with Borderline Personality Disorder, and 90% of adults diagnosed with Dissociative Identity Disorder, were sexually and/or physically abused as children, and that 35-70% of female mental health patients self-report a childhood history of abuse (Kezelman, Hossack, Stavropoulos, & Burley, 2015).

Neglect

Trauma may be experienced in the form of neglect. A child’s developmental needs may not be met causing neurodevelopmental change (McAloon, 2014). The UK survey psychiatric morbidity survey found a significant relationship between being brought up in institutional care and the experience of paranoia. That study also found that quality foster care can repair disturbed attachment styles in children who have experienced adversity and is a protective factor for mental illness (Bentall, Wickham, Shevlin, & Varese, 2012).

Other Trauma

Other childhood traumas found to have an association with mental ill health include: dysfunctional parenting (particularly ‘affectionless overcontrol’), separation from parents in early life, parental substance misuse, criminal behaviour and mental illness, childhood medical illness, and war trauma (Read & Bentall, 2012).

Life Events

Life events may also trigger, or have a cumulative effect, on relapse for people with a diagnosed mental illness. Identifying relapse risk factors has clinical implications for treatment and recovery. Understanding the importance of severity of the threat a life even presents can inform clinical intervention aimed at preventing or reducing the impact (Fallon, 2009).

References