Mental Health Review Paper 2018 Part B

Impacts & 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)

Paper continues in Part C