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Please, some perspective on recent alarming headlines about youth mental health

The recent spate of alarming headlines about youth mental health needs to be put into perspective, says Melissa Raven, an adjunct lecturer in public health from Flinders University. Things may not be quite as bad as the headlines suggest.

It’s another reason to be wary of headlines-based policy, perhaps. Interestingly, one of her conclusions is that: “Tackling poverty and social disadvantage has greater potential to improve the wellbeing of young people than a specific focus on reducing diagnosable mental disorders.”

She writes:

“Monday’s release of the ABS report on youth mental health has generated predictable reactions of shock and outrage. Drawing on data from the 2007 National Survey of Mental Health and Wellbeing, the ‘Mental Health of Young People, 2007’ report highlighted the fact that one in four Australians aged 16–24 years had a mental disorder in 2007, but only a quarter of them accessed mental health services (including GP treatment of mental disorders).

In The Australian, headspace CEO Chris Tanti, declared this ‘a shocking state of affairs’. On Crikey, Richard Farmer described the ABS report as ‘depressing and distressing’.

However, although we certainly should be concerned about mental disorders in young people, these prevalence rates and treatment access rates need to be seen in perspective.

Firstly, the prevalence figures are significantly boosted by relatively high rates of substance use disorders, particularly harmful use of alcohol. A superbly-timed paper by Nicola Reavley and colleagues from Orygen Youth Health has just been published in the Australian and New Zealand Journal of Psychiatry. It emphasises that the gulf between prevalence and help-seeking in young people is largely due to higher rates of substance use disorders and low rates of help-seeking for these disorders, particularly by young men. In most cases, the substance involved is alcohol, and the disorder is harmful use, not dependence.

It does not take much to qualify for an ICD-10 diagnosis of harmful alcohol use, which is defined as a pattern of alcohol use that is causing damage to health. The damage can be physical or mental, and it does not have to be severe. Reavley et al. noted that just over half of the cases of substance use disorders were mild. So essentially binge drinking with a relatively low level of physical or mental harm is the main problem.

This is not to say that binge drinking is a trivial issue. It is a significant factor in suicide and self-harm (and injuries more broadly, including those caused by car crashes and assaults). It increases the risk of sexually transmitted diseases and unplanned pregnancies. It contributes to interpersonal conflict and crime and absenteeism from work and education. It is very important to try to reduce binge drinking.

However, conceptualising it as a psychiatric disorder is not helpful for the large proportion of young people who sometimes drink too much. Binge drinking does not have to be habitual to be harmful – one drinking session can have catastrophic consequences. So focusing on identification and treatment of everyone who qualifies for an alcohol use disorder is not the solution (besides, how many young male binge-drinkers would be receptive to treatment?).

Instead, we need to continue with population-based strategies such as restricting the availability of alcohol and challenging marketing practices that target young people and encourage excessive consumption. Unfortunately, binge drinking is normative in some demographic groups, and it needs to be tackled at a cultural and subcultural level (among other levels). Fortunately, binge drinking often dissipates as young people mature and settle more firmly into employment and long-term relationships. Even diagnosable cases of harmful alcohol use have high rates of so-called spontaneous remission – which is the main reason prevalence rates are so much lower in older age groups, as shown in graph 1.2, ‘Prevalence of selected mental disorders’, in the ABS report.

The other key issue in relation to prevalence and treatment rates of mental disorders in young people is the fact that diagnosis is not the same as treatment need, contrary to the usual interpretation. According to Professor Scott Henderson (one of the architects of the original NSMHW) and colleagues, having a disorder as assessed in the NSMHW does not automatically mean needing treatment:

Our view is that having symptoms, even at case level, is necessary but not sufficient to justify treatment…. it is irrational to suggest that one in five adults need treatment for a case-level mental disorder.

Elsewhere, more emphatically, he declared: ‘SYMPTOMS ≠ NEED’.

Leading US psychiatric epidemiologists have similarly argued that prevalence rates in surveys do not directly represent treatment need. Robert Spitzer, a key player in the development of the DSM (Diagnostic and Statistical Manual of Mental Disorders) published a paper with the title: ‘Diagnosis and need for treatment are not the same’. According to Regier and colleagues: ‘most episodes of mental illness are neither severe nor long-lasting’.

Similarly Professor Gavin Andrews has emphasised that many cases of mental disorders are transient, and Henderson and colleagues have documented the fact that a significant proportion are non-disabling. Furthermore, people with serious problems are more likely to seek treatment than those with mild problems: the NSMHW revealed a clear dose-response between severity of disorders and rates of treatment, with people with severe disorders being much more likely to access treatment. There would also be a gradient of treatment-seeking based on duration and disability. So there is a strong bias towards treatment of the cases that most need treatment.

An important issue related to duration is that the one-in-four figure refers to 12-month period prevalence (how many people have had a disorder at some point in the last 12 months) not point prevalence (how many people have the disorder at one specific time). Unfortunately, the prevalence rates reported by the ABS will inevitably be misrepresented as point prevalence rates in statements like: ‘At any one time, one quarter of all young Australians have a mental illness’. The actual point prevalence rates would be significantly lower.

In the longitudinal component of the landmark US Epidemiologic Catchment Area (ECA) study, although 28% of the adult population have a mental or addictive disorder during the course of a year, only 16% have a disorder at any point in time. Unfortunately, prevalence studies like the NSMHW and the ECA lend themselves to misinterpretation.

Finally, one finding in the ABS report that is likely to be largely ignored is that young people living in the most disadvantaged areas are more likely to have a mental disorder (22%, compared with 16% in the least disadvantaged areas). Disadvantage also contributes to hazardous and harmful use of alcohol and other drugs (including, of course, tobacco, the drug that causes most harm in Australia), and many other health and social problems.

Tackling poverty and social disadvantage has greater potential to improve the wellbeing of young people than a specific focus on reducing diagnosable mental disorders.”

Correction, 22 Feb, 2011
Melissa Raven writes:

The ABS corrected its report on 15 October 2010, reporting that there was no significant difference in mental disorder rates between the most and least disadvantaged areas compared (22% and 26% respectively). However, there is considerable evidence from Australia [<http://www.vichealth.vic.gov.au/en/Publications/Economic-participation/Access-to-Economic-Resources-as-a-determinant-of-mental-health-and-wellbeing.aspx> ] and elsewhere [http://jama.ama-assn.org/content/290/15/2023.full] that socioeconomic status is an important determinant of mental health.

Comments 4

  1. Malcolm Gillies` says:

    Many thanks to Melissa Raven for shedding some light on this murky area.

    I would love to see a further analysis of the figures, putting some figures on the specific treatment gaps, and comparing them to gaps in other population segments.

    Promulgating the idea that 1 in 4 young people need professional psychological care implies a disturbing level of medicalisation. But perhaps more disturbing, crying wolf in this way risks provoking even greater public apathy towards real gaps in youth mental health services.

  2. Eile says:

    Previous (1999/2000) statistics published by both Commonwealth and NSW Governments placed the prevalence of adolescent mental health issues at between 12 and 14 percent depending on age grouping and sex demographics. This prevalence rate is considered closer to the ‘point prevalence’ Melissa mentions. I base this estimate on the work I have done working with adolescents in NSW over the last 14 or so years.
    I also agree with Melissa’s comment that many adolescent mental health issues are transient. Recent initiatives within Australia in general and NSW (in particular to my work) include the advent of ‘Resilience Programs’ through the Education Department and various adolescent programs. I also note that often young people recover when supported by family and peers, particularly when they have been exposed to a Resilience Program and where there is ‘linking’ between the providers of the resilience training and the young persons’ parents/carers through a care program.
    As Melissa notes many (?) adolescent mental health issues, as defined within the frameworks of the ICD-10 and the DSM-IV probably do not need psychiatric intervention/treatment because of a lower level of severity. An analogy to physical health explains the issue. A mild cold is definitely a physical health issue but is probably not one that needs immediate professional medical intervention. Usually some ‘over the counter’ symptom ease and some home care does the trick. Should the cold begin to show symptoms indicating a more serious respiratory tract infection then medical intervention should be enlisted. Hospitalisation is only considered once such an infection becomes acute and possibly life threatening. A situational depression following the death of a family member can usually be dissipated in reasonable time with care from family and friends and with the young person’s involvement in the funeral rites. Should the depression begin to become chronic and/or acute then some psychological counselling might be in order, but psychiatric care only if the psychological intervention is not effective.
    In his introduction to Positive Psychology (American Psychologist, Jan 2000, p.5) Martin Seligman was somewhat critical that psychology was persuaded to intervention on psychological pathology and away from the other two goals of psychology; making ‘all peoples’ lives better and nurturing intelligence’ (p.6). As I see it accepting the statistics presented in the National Survey of Mental Health and Wellbeing, 2007 as a call to arms for psychologists is to further immesh our discipline within the medical model of care to the detriment of our focus on the wellness of all persons through the sound principles of ‘prevention rather than cure’ and, when it is required, ‘early intervention’. Positive Psychology initiatives such as the Resilience Programs already in place focus on those principles and promise to address many of the issues that are considered precursor to the 2007 Survey statistics, eg., Socio-economic status, AOD use/abuse.

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Equally Well
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Pregnancy and childbirth
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Acknowledgement
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PIJ Commissions 2021
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#PreventiveHealthStrategy
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air pollution
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Health in All Policies
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Media Doctor Australia
media-related issues
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National Preventive Health Agency
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Testing Croakey News category 1
The Croakey Archives
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Croakey Conference News Service 2013 – 2019
2013 conferences
Australian Centre for Health Services Innovation Forum 2013
Australian Health Promotion Association Conference 2013
Closing the Credibility Gap 2013
CRANAplus Conference 2013
FASD Conference 2013
Health Workforce Australia 2013
International Health Literacy Network Conference 2013
NACCHO Summit 2013
National Rural Health Conference 2013
Oceania EcoHealth Symposium 2013
PHAA conference 2013
2014 conferences
#IPCHIV14
AIDA Conference 2014
Congress Lowitja 2014
CRANAplus conference 2014
Cultural Solutions - Healing Foundation forum 2014
Lowitja Institute Continuous Quality Improvement conference 2014
National Suicide Prevention Conference 2014
Racism and children/youth health symposium 2014
Rural & Remote Health Scientific Symposium 2014
2015 conferences
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#HSR15
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#OTCC15
Population Health Congress 2015
2016 conferences
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#cphce2016
#CPHCEforum16
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#IAMRA2016
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2017 conferences