information sheet Mental

information sheet Mental Health Issues Over the past 20 years one of the most critical issues government and the community sectors have been required to respond to is the mental health of young Australians. Mental health is a significant concern for millions of Australians young and old, either living with a mental health problem themselves or caring for another person. Mental health is a major issue for populations living in the most developed countries of the world and is the second main reason (after abuse and violence) for children and young people contacting child helplines from countries ranked in the top nine of the Human Development Index (HDI) 1. What is mental health? Mental health and mental illnesses are determined by multiple and interacting social, psychological, and biological factors 2. Being mentally healthy involves much more than just not having a mental illness. Being mentally healthy indicates a mind that embraces positive attitudes rather than negativity a state of wellbeing in which a person can manage the normal stresses of life, be productive and contribute to their communities and form meaningful relationships. Children and young people who are not nurtured effectively nor given the opportunities they need to successfully develop their emotional as well as physical and social lives, will find it difficult to get the most out of life. Research demonstrates that people who are mentally healthy are more productive, more socially connected and more likely to achieve their goals in life 3. Australian data on mental health According to figures released in 2007 by the Australian Bureau of Statistics (ABS) following a national survey of the Australian population s mental health and wellbeing, one-in-five (3.2 million) Australians aged 16 85 years reported having a mental health disorder within the previous 12 months. More than four million people had previously experienced a mental health disorder but had not had any symptoms for 12 months prior to the survey. Of 16 million Australians aged 16-85 years, 45% (or 7.3 million) were found to have had a mental health disorder at some point in their life 4. Young people are said to carry the greatest burden of mental illness 3. This is because more than 75% of all severe mental illnesses occur prior to the age of 25. Just over a quarter (26%) of people surveyed in 2007 aged 16 26 had a mental health disorder compared to only 6% of people aged 75 85 4. In a 2000 study that specifically targeted the mental health issues of children and adolescents aged 4 17 years, it was estimated that 14% experience mental health problems 5. Impact of mental health problems The challenges of living life affected by a mental health disorder cannot be overstated. Many factors can combine to compound the negative life experiences of those with poor mental health. Children and adolescents with emotional and behavioural problems have lower self-esteem 1

and are less likely to achieve in school and engage productively with their peers than children with fewer problems 5. Feeling socially excluded due to the stigma attached to having a mental health disorder, experiencing obstacles in obtaining everyday educational and social opportunities and gaining access to housing, goods and services can multiply the impacts of poor mental health. Suicide and self-injury Adolescents with mental health problems report higher rates of suicidal ideation and other risky behaviours including self injury 6 and the use of alcohol, tobacco, and other drugs 5. The results of a community-based study suggested that up to 30% of young people experience severe suicidal ideation by 18 years of age. Young people with persistent and severe suicidal ideation are more likely to attempt suicide, and those who have attempted suicide are at increased risk of later completing suicide 7. Suicide is the main cause of premature death among people with a mental illness. More than 10% of people with a mental illness die by suicide within the first 10 years of diagnosis 8. An attempt of suicide may also be a sign that a mental illness is developing. Further information on the topics of suicide and self-injury can be found at: Kids Helpline Suicide 2012 Information Sheet: www.kidshelp.com.au/upload/22913.pdf Kids Helpline Self-Injury 2011 Information Sheet: www.kidshelp.com.au/upload/22902.pdf Risk factors Specific indicators have been noted as risk factors for the development of mental health disorders. Studies have shown that people of lower socioeconomic status have higher rates of mental health disorders, particularly depression and certain anxiety disorders 9. Economically disadvantaged young people, such as those who are unemployed, are more vulnerable to mental health disorders as they are more likely to experience insecurity, hopelessness, rapid social change and risks to their physical health 2. Family factors such as conflict, violence, separation, step/blended families, single parenting and poor parenting are some of the other most commonly identified risk factors for mental health problems among children and young people. Physical, sexual and emotional abuse, neglect and witnessing domestic violence are particularly viewed as contributors. Other risk factors associated with the development of mental health problems include bullying and poor school attachment 10. Self-injury is the deliberate damage of a person s own body in a way that is not intended to be fatally harmful, often through cutting the skin or ingesting substances believed to be non-lethal. Emotional regulation and self-punishment are common motivations for this behaviour and it tends to be exacerbated during difficult times. Australian data on self-injurious behaviour suggests that 2.6% of Australians engage in self-injury within a 12 month period and it is more common among adolescents and young adults 6. In the same study, it was found that self-injurers were more likely to have a mental health condition as well as a range of other issues including substance use and suicidal ideation. While suicide and self-injury are two separate phenomena there is a degree of relatedness between the two as selfinjury was a strong predictor of attempted suicide in the previous 12 months 6. 2

A strong correlation has also been reported between homelessness and mental illness. A 2007 ABS study revealed 484,400 people reported ever being homeless 4. Of those, more than half (54%) had a 12-month mental health disorder. This was almost three times the rate of 12-month mental health disorders in people reporting they had never been homeless (19%). Protective factors A number of protective factors can help to reduce the likelihood of lower-level psychological difficulties developing into more severe mental health problems. These protective factors can also assist in the recovery process for those who have already developed a mental health issue. If the experience of abuse or neglect is considered a risk factor for developing a mental health problem then conversely, growing up in a safe and nurturing environment tends to lead to better health outcomes and less mental health problems 3. Social relationships and networks can act as a protective factor against the onset or recurrence of mental illness and improve recovery from mental health disorders 2. Developing resilience in children and young people can help to overcome existing risk factors as well as enhancing their ability to cope with adverse life events. Many approaches to resilience building highlight the development of social and emotional skills. reluctant to access mental health services due to fear of government authorities becoming involved and children being removed from their families 11. Furthermore, rural children and young people also have lower rates of help-seeking for mental health issues due to a number of issues relating to the cost and accessibility of health services 12. In rural and remote areas, males are particularly less likely to seek assistance compared with males generally 13, who also have lower rates of help seeking behaviour compared with females 14. The Kids Helpline experience Kids Helpline is an important service for children and young people seeking information and support relating to mental health issues. The ability to contact confidential support 24/7 via telephone or online is a valuable resource for young people wary of asking for help from traditional sources such as a family doctor or school teacher. For clinical and accountability purposes Kids Helpline counsellors collect demographic data and create case notes related to the nature and outcome of each counselling session held. De-identified data can be used at an advocacy level to highlight the issues of children and young people and to give voice to their concerns to relevant policy and decision-makers. Help-seeking behaviour While a significant proportion of young people experience mental health problems, only some seek help for their issues. Rates of help-seeking for those who self-injure have been found to be particularly low in spite of high levels of distress including suicidal ideation and gestures 6. It has been reported that only one-in-four young people with a mental health problem receives professional help. Even among young people with the most severe mental health problems, only 50% indicated they had received professional help 5. Certain groups are particularly less likely to engage in effective help-seeking strategies in spite of being over-represented in statistics of mental health problems. Many Indigenous youth and their families are 3

Contacts about mental health During 2011, there were 8,506 contacts from young people aged 25 years or less where mental health concerns were the primary reason for their contact. At 13.2% of all counselling contacts, it was the third most frequent reason young people contacted the service in comparison to other types of concerns. The rate of contacts to the service where young people directly seek help about their mental health has been increasing every year since 2006 when there were 5,226 contacts reported by counsellors (9.2% of all direct help-seeking by young people under 26 years of age). Kids Helpline is aware of the significant barriers young people can experience when seeking formal psychiatric assessment, diagnosis and treatment. Therefore, all contacts to the service are informally assessed for signs of mental health problems regardless of the issue the young person is contacting about or whether they yet have a formal medical diagnosis. The result of this assessment activity is that in 2011, Kids Helpline counsellors recorded another 17,930 contacts (in addition to the 8,506 specific contacts requesting assistance for mental health related concerns) that included information leading a Kids Helpline counsellor to assess that mental health issues were a complicating factor in a young person s life. Age, gender and cultural background In 2011, the 8,506 counselling sessions specifically about mental health issues tended to be held with older clients. Forty-six percent of mental health related counselling was with young people aged 19-25 years compared with all types of problems where only 31% of clients were in this age group. Adolescence and young adulthood is a critical time for the social and emotional development of young people and most mental health conditions, including depression, substance abuse, anxiety disorders and psychoses, have their peak onset during this stage. Receiving assistance at this age is crucial as the long-term consequences of not responding to first episodes of mental illness can lead to social, emotional, physical and cognitive difficulties throughout adulthood 10,15. Males generally make less contact with Kids Helpline for counselling for all problem types (18% in 2011). However, they are consistently under-represented in help-seeking for mental health concerns, making only 12% of those contacts in 2011. Twenty-five percent of young people contacting Kids Helpline for counselling for any type of problem are from culturally and linguistically diverse (CALD) backgrounds (not including Indigenous Australians). However, young people from CALD backgrounds are comparatively less likely to contact for assistance specifically with mental health problems (20%). Rates of contacts for mental health problems from Indigenous young people are consistent with their rates of contact for all kinds of problems (2%). This data is shown in Figure 2. Figure 1 Proportion of counselling contact specifically about mental health. % Counselling Sessions 14 12 10 8 6 4 2 0 10.0% 10.7% 13.0% 13.2% 11.5% 9.2% 2006 2007 2008 2009 2010 2011 Year Figure 2 Cultural background % Counselling Sessions 80 70 60 50 40 30 20 10 0 73.0% 78.0% Does not identify as Indigenous or CALD 25.0% 20.0% Other CALD ALL PROBLEM TYPES MENTAL HEALTH CONCERNS 2.0% 2.0% Indigenous Cultural Background 4

Medium of contact and location In 2011, almost one third of counselling sessions were delivered through online media compared with telephone (32% vs 68%). However, those who sought counselling specifically for mental health issues used online media slightly more frequently (38%). Figure 3 Mental health contacts by modality 12.2% 61.9% 25.9% More than one quarter of mental health related contacts were from rural and remote communities. This is consistent with the average rate of contacts for all types of problems from regional areas. Frequency of contact Phone Web Counselling Email Children and young people seeking counselling from Kids Helpline may only require once-off or occasional support from a counsellor. Others may require ongoing support or even a case management plan that provides for more holistic support in the form of wrap around care, particularly for complex issues where the client is at risk of harm. Children and young people who sought support related to mental health in 2011, were more likely to be supported in an ongoing way or with a case management plan compared with the average for all types of problems. This data is shown in the graph below. Related concerns During counselling, children and young people frequently raise multiple issues of concern. Generally, these additional issues will be linked to the primary reason for the contact and bring a deeper understanding of the issues impacting on, and being impacted by, the mental health of young Australians. In 2011, 35% of contacts regarding mental health had an additional concern recorded. The most common factors compounding young people s mental health problems were relationships with family members (13%) and the difficulties they experienced in trying to manage their own emotions and behaviours (26%). Significantly, almost 13% were contemplating suicide and/or had previously attempted suicide. Eight percent were struggling with eating behaviours, while relationships with partners and child abuse were compounding the mental health problems of young people in another 6% and 5% respectively. The rate at which self-injury was reported in mental health related counselling sessions was 41%, much higher than the average rate across all counselling issues (21%). In addition, 1,612 mental health related counselling sessions led to young people revealing they were experiencing thoughts of suicide. This proportion of suicidal thinking is also much higher than the average for all types of counselling issues (19% vs. 13%). Figure 5 Issues associated with mental health concerns Emotional Behavioural Managment Family Relationships Suicide Behaviours and Issues Eating Behaviours or Weight Issues 8.0% 13.0% 13.0% 26.0% Figure 4 Types of support % Counselling Sessions 40% 35% 30% 32.0% 25% 23.0% 20% 21.0% 15% 17.0% 10% 5% 0% 0 First Time Occasional 36.0% 31.0% Ongoing MENTAL HEALTH ALL PROBLEM TYPES 26.0% 14.0% Case Managed Related concerns Partner Relationships Child Abuse Relationships with Peers Self-Image Study and Education Issues 6.0% 5.0% 4.0% 4.0% 4.0% Grief and Loss 3.0% 0 5 10 15 20 25 30 % Counselling Contacts 35 5

Suicidality and self-injury In addition to the recording of the primary reason for the young person s contact, Kids Helpline counsellors also conduct assessments, where appropriate, of whether the client is struggling with self-injuring behaviours or thoughts of suicide at the time of the contact. Of the 64,442 counselling sessions with children and young people for all types of problems in 2011, 13,508 sessions involved the client reporting they were engaging in deliberate self-injury. In 8,383 counselling sessions the young person reported they were experiencing thoughts of suicide at the time of the contact. These reports of serious risk have been increasing with a rise of 204% for reports of thoughts of suicide, and 59% for reports of self injuring behaviour since 2006. Figure 6 Self-injury and suicidality trends Number of Contacts 16,000 14,000 12,000 10,000 8,000 6,000 4,000 2,000 0 8,472 8,498 2,750 Self Injury Current Thoughts Suicide 3,289 7,710 8,166 3,991 4,564 11,072 6,829 2006 2007 2008 2009 2010 Although suicidality and deliberate self-injury are two separate issues, they are somewhat related as shown by the degree of overlap between those reporting current thoughts of suicide and those reporting engaging in self-injury. For those reporting current thoughts of suicide in 2009, 56% also reported engaging in self-injury. Similarly, 35% of those engaging in self-injury were also reporting thoughts of suicide. This data reflects the findings of other research 6. Further information sheets on contacts to Kids Helpline regarding suicide and self-injury can be found at www.kidshelp.com.au/ grownups. Nature of concerns about mental health 13,508 8,383 A review of 610 case notes recorded by Kids Helpline counsellors regarding mental health counselling sessions, provided details on the specific mental health disorders presented. Additionally, risk 2011 factors, impacts of having a mental health disorder, associated management issues and information on how Kids Helpline responds to young people s needs were highlighted. Three main groups of young people were identified as motivated to pick up the phone or write to Kids Helpline for help with mental health concerns. Some young people were starting to experience worrying signs and symptoms and were looking for answers about what might be causing them. Counsellors trained to recognise potential mental health problems talked with the young people about broad indicators of mental health disorders. They were generally encouraged to see a doctor or specialist mental health service to receive a full mental health assessment. A second group may have received a formal clinical diagnosis at some point prior to their contact with Kids Helpline, but were not in current treatment. These clients may have been re-experiencing symptoms that were having a major effect on their life. Counsellors would talk with them about their anxieties or distress relating to their diagnosis or medication, educate them about the benefits of re-engaging with the formal mental health system if required, and frequently provide actively managed referrals back to their treatment team. A third group of clients were seeking additional support to complement the therapy and treatment being currently received in face-to-face services. As these services were often accessible during business hours only, Kids Helpline was able to provide support (including crisis response) and encouragement with the clients therapy and case plans after hours. Consultations might be held with the treating doctor, psychiatrist or therapist to ensure that information and communications with shared clients was as consistent as possible across all agencies involved. Kids Helpline refers to this model of service delivery as wrap-around-care. Of those who specified having a particular mental disorder diagnosis, the range of disorders reported in order of frequency was: Depression Anxiety (including phobias) Psychotic disorders Obsessive-compulsive disorder Personality disorders Post-traumatic stress disorder Eating disorders Bipolar disorder 6

A number of risk factors relating to both the development as well as the maintenance of a suspected or diagnosed mental health disorder were reported and support the findings of the research noted above. Child abuse was the most common reported risk factor. Sexual abuse was the most common form of child abuse along with physical and emotional abuse and emotional neglect. This particular finding relating to the impact of sexual abuse on the development of mental health disorders is also in line with other research 16. Other risk factors reported included familial mental illness and substance use, homelessness and living in supported accommodation, substance use by the young person, bullying and low socio-economic status. Relationship breakdown and family conflict were other risk factors cited by young people asking for help. Michelle* (16 years) called concerned she might be developing a mental health disorder. Michelle had been noticing she was tuning out regularly and finding it hard to concentrate. She felt she had lost interest and motivation in everything, including school. She regularly drank large amounts of alcohol and had been smoking marijuana weekly since her parents divorce. Her mother was also drinking regularly, staying in the house all the time and Michelle thought she most probably had depression. The counsellor talked with Michelle about getting a mental health assessment through a doctor and about possible ongoing therapy with a psychologist or drug and alcohol counsellor. The counsellor offered ongoing support to Michelle and asked her to call back after her visit to her doctor. *Name changed for privacy reasons Referrals and emergency responses While Kids Helpline is able to refer contacts to a face-to-face service if needed, many young people are unable or unwilling to seek assistance from a support service other than Kids Helpline. Where the young person is not assessed to be at risk of harm, counsellors might spend many weeks developing an ongoing trusting relationship with the client while continuing to educate them about the benefits of face-to-face support and/or medication. In some cases, a young person contacts in crisis showing signs of severe mental illness, having already harmed themself or having a serious plan to do so. In these situations, Kids Helpline, under its Duty of Care policy, works in tandem with emergency services such as police, ambulance, hospital emergency departments or after hours mental health assessment teams to ensure their safety. In 2011, there were 684 presentations linked to mental health concerns including suicide and self-harm that required a response under the organisation s Duty of Care procedures. In these cases the service took responsibility for either passing relevant information to emergency services able to find and transport the young person to a place of safety or negotiated with mental health services and hospital emergency departments on their behalf to have them assessed for admission. 7

BoysTown s response to mental health issues While Kids Helpline telephone and online services support young people struggling with mental health issues, BoysTown also provides face-to-face services assisting young people and their families with concerns impacting on their mental health. These services include parenting programs and support, drug and alcohol counselling, employment and training services, family refuges and life skills workshops. In addition, BoysTown advocates for the needs of children and young people affected by mental health concerns to be considered in public policy decision-making. Since 2009, BoysTown has made submissions to state and federal government on a number of mental health related issues including suicide, drugs, bullying, body image, Indigenous issues and the National Mental Health Plan. BoysTown has also created a number of online resources related to mental health, which can be accessed by young people and those who care for them. Additional collaborative mental health related projects in which BoysTown participates include: The Inspire Foundation s Technology and Wellbeing Roundtable, exploring how technology can enable young people s wellbeing and identifying possible issues to then develop and promote best practice Young and Well Cooperative Research Centre, exploring the role of technologies in young people s lives and the opportunities to leverage these technologies to improve their mental health and wellbeing The New South Wales Health development of Guidelines for Discussing Suicide and Attempted Suicide. The aim of the guidelines will provide support for schools, workplaces, families and communities to strengthen their capacity to participate in suicide prevention action Research studies with Griffith University and Queensland University of Technology, exploring the use of technology to support young people s mental health during job-seeking and understanding the barriers to help-seeking for young people with a range of issues including self injury and thoughts of suicide. 8

Seventeen year-old Peter* called worried his mental illness had returned because he was hearing voices again telling him to kill himself or his father. Peter told the counsellor that his father had always picked on him and in the past he had seen a psychiatrist and taken medication for a while after he first started hearing voices. The counsellor reassured Peter he was doing the right thing to tell someone about hearing the voices again and checked out what Peter could do tonight so everyone could stay safe until he could contact the psychiatrist tomorrow. Peter said he was interested in receiving wrap-around care from Kids Helpline and agreed to ask his psychiatrist to talk with the counsellor about his treatment plan. *Name changed for privacy reasons 5. Sawyer et al, Mental Health and Special ProgramsBranch, Commonwealth Department of Health and Aged Care, 2000: The Mental Health of Young People in Australia; The child and adolescent component of the national survey of mental health and well-being 6. Martin, G., Swannell, S., Harrison, J., Hazell, P., & Taylor, A. (2010). The Australian National Epidemiological Study of Self-Injury (ANESSI). Centre for Suicide Prevention Studies: Brisbane, Australia 7. Hider, P. (1998). Youth suicide prevention by primary healthcare professionals: A critical appraisal of the literature. NZHTA Report 4. 8. SANE Australia. (2008). Factsheet: Suicidal behaviour and self-harm. [Accessed 17/09/2010 at http://www.sane.org]. 9. Fryers, T., Melzer, D., Jenkins, R., & Brugha, T. (2005). The distribution of the common mental disorders: Social inequalities in Europe, Clinical Practice and Epidemiology in Mental Health, 1(14), 1-12. 10. CDHAC (2000) Promotion, Prevention and Early Intervention for Mental Health- A Monograph: Canberra; Mental Health and Special Programs Branch, Commonwealth Department of Health and Aged Care 11. Williamson, A.B., Raphael, B., Redman, S., Daniels, J., Eades, S.J. & Mayers, N. (2010). Emerging themes in Aboriginal child and adolescent mental health: findings from a qualitative study in Sydney, New South Wales. Medical Journal of Australia, 192, 603-605 12. Beer, A. and Keane, R. (2000). Population decline and service provision in regional Australia: A South Australian case study. People and Place, 8(2), 69-76 Caldwell, T.M., Jorm, A.F. & Dear, K.B.G. (2004). Suicide and mental health in rural, remote and metropolitan areas in Australia. Medical Journal of Australia, 181, S10-S14 References 1. Child Helpline International; (2011), Briefing Paper 1/2011: Children in high HDI countries suffer from boredom, higher suicidal tendencies and the urge to harm themselves. [Accessed on 19/3/2012 http:// www. childhelplineinternational.org/assets/cms/file/ Briefing%20Paper%201%20-%20CHI%20-%20 High%20HDI%20High%20PSMH.pdf ] 2. World Health Organization. (2005). Promoting mental health: Concepts, emerging evidence, practice. A report of the WHO, Department of Mental Health and Substance Abuse. [Accessed 17/09/2010 at http://www.who.int/] 3. National Advisory Council on Mental Health. (2009). A Mentally Healthy Future For All Australians 4. ABS: The 2007 National Survey of Mental Health and Wellbeing (SMHWB) 13. Caldwell, T.M., Jorm, A.F. & Dear, K.B.G. (2004). Suicide and mental health in rural, remote and metropolitan areas in Australia. Medical Journal of Australia, 181, S10-S14. 14. Quine, S., Bernard, D., Booth, M., Kang, M., Usherwood, T., Alperstein, G. & Bennett, D. (2003). Health and access issues among Australian adolescents: A rural-urban comparison. Rural and Remote Health 3:245. [Accessed on 18/08/10 at http://www.rrh.org. au/publishedarticles/article_print_383.pdf] 15. COAG National Action Plan on Mental Health 2006-11 [Accessed 20/3/2012 http://www.coag.gov.au/coag_meeting_ outcomes/2006-07-14/docs/nap_mental_ health.pdf ] 16. Paolucci, E.O., Genuis,.M.L. & Violato, C. (2001). A meta-analysis of the published research on the effects of child sexual abuse. Journal of Psychology, 135(1), 17 36 24.07.12 9