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Figure 1. Years of life lost through disability (YLD),
Australia, 1996. From Mathers and others (14)
Figure 2. Contribution to total burden of disease and injury in Australia, 1996. From Mathers and others (14)
Well-Being in Australia
During the Survey’s planning, consumer and caregiver spokespersons urged
that well-being be measured to complement measures of morbidity. This proved
to be a valuable addition (15). Well-being was measured by the single-item
Life Satisfaction Scale, expressed as a percentage, with 0% indicating
“terrible” and 100% repesenting “delighted.” The mean score for the Australian
adult population was 70.4%, which matches the proposed universal norm.
Men and women had very similar mean scores. Well-being was higher in persons
with tertiary education and in those owning or purchasing their homes.
It was lower in persons with physical or mental disorders, particularly
depression. A U-shaped relation was found for alcohol use, whereby well-being
was lower in both abstainers and heavy users. Multiple regression analysis
showed that, when adjustment is made for confounders, women had higher
life satisfaction than men and that, with age, high life satisfaction became
less common in men but even more common in women. Life satisfaction was
impaired for respondents with high psychological distress, especially among
the unemployed, the divorced, and those with tertiary education, whether
their symptoms led to a CIDI-A diagnosis of depression, or not. Of particular
interest is the existence of a few persons with current anxiety or depressive
disorders who reported having high life satisfaction.
The Survey of Persons With Psychoses
Jablensky and his team provide an account of this survey elsewhere (16–18).
Cases known to public and private services, including GPs, were identified
across 4 sites: Perth, Melbourne, Canberra, and Brisbane. The point prevalence
of psychotic disorders in the urban Australian population aged 18 to 64
years has a weighted mean of 4.7 per 1000. No fewer than 60% of this population
were found to be severely disabled in daily life. Only 30% were in self-care.
Most lived in marked social isolation. Despite this, 60% reported satisfaction
with their independence, and 44% felt satisfied with their life as a whole.
Ten percent had been arrested in the last year, and 18% had been victims
of violence. There was very high use of tobacco, alcohol, and illegal drugs.
Some 50% had an admission in the previous year, mainly to a general hospital
psychiatry unit. A remarkable finding was that 81% had been to their GP
in the previous year. Predictably, 86% were taking medication; 75% said
they were impaired by the side effects. Three-quarters of the patients
had no regular job, and 85% were receiving a government pension. Only 20%
had participated in any rehabilitation program in the past year, a finding
with a considerable impact on service planning.
The Survey of Children and Young Persons
Sawyer and colleagues (19,20) used the parent version of the Diagnostic
Interview Schedule for Children (DISC-P) and the Child Behaviour Checklist
(CBCL) to interview the parents of 4509 children aged 4 to 17 years. Adolescent
respondents completed the Youth Behaviour Questionnaire. The findings identified
14% with mental health problems. Many had problems in other areas of their
lives, including suicidal behaviour. Only 25% had reached any professional
service in the previous 6 months.
The point prevalence of attention-deficit hyperactivity disorder (ADHD)
as defined by the DSM-IV was 7.5%, with the inattentive subtype being more
common than the hyperactive-impulsive and combined subtype (21). ADHD was
more prevalent among young male subjects and was linked to social adversity.
The findings support the DSM-IV view of ADHD subtypes as distinct clinical
entities with impairments in multiple domains.
One-quarter of the adolescents in the sample had used cannabis (22). There
were no sex differences. Use increased rapidly with age. The association
with depression, conduct problems, excessive drinking, and use of other
drugs shows a prognostically malignant pattern of comorbidity.
The Impact and Consequences of the National Survey
Are these prevalence rates believable? The overall pattern of morbidity
in adults is very similar to that reported for the UK by Jenkins and others
(23). Our view is that having symptoms, even at case level, is necessary
but not sufficient to justify treatment. In this regard, Andrews and Henderson
offer a careful analysis of the need for treatment, including the reality
of unmet need (24). It is irrational to suggest that 1 in 5 adults need
treatment for a case-level mental disorder, and there are 3 possible interpretations
for these statistics: first, the case-finding instrument may have too low
a threshold, especially when used by nonclinicians. Second, some people’s
symptoms may be manageable by self and others; this is a group we need
to know more about. Third, the relation between symptoms and disablement
may be nonlinear.
Whatever the validity of the estimates, the National Survey has yielded
many benefits. Both training opportunities and expertise in epidemiology
and health services research have advanced. Collaborations that did not
previously exist have been forged between investigators or between them
and administrators and policy-makers. Australia now has better estimates
of the degree to which mental disorders contribute to the overall disease
burden (14). Health inequalities have been shown to exist, particularly
in relation to the availability of specialist mental health services—the
aptly-named “inverse care law,” whereby those in most need often get the
least treatment. Population groups with conspicuously unmet needs have
been identified, such as youth with alcohol-related problems. Also identified
is the low rate of help seeking (62%) for treatable and common mental disorders.
There have been some surprises. Anxiety, depression, and substance abuse
are all less frequent in the elderly. No statistically significant differences
could be found between metropolitan and rural populations. Foreign-born
persons have somewhat lower rates than those born in Australia. (The reasons
for this can only be speculative.) The disability associated with mental
disorders is far greater than has been recognized. It accounts for 15%
of the total burden of disability and is the third cause of disability
after heart disease and cancer.
For persons with psychoses, the findings are powerful. A debt is owed to
Professor Assen Jablensky and his collaborators across 4 sites for the
high quality of their methods and the administrative significance of the
data they generated (16). People with psychotic disorders experience high
rates of functional impairments and disability, decreased quality of life,
persistent symptoms, substance use comorbidity, and frequent medication
side effects. Although these individuals make high use of hospital-based
and community mental health services, as well as of public and nongovernmental
helping agencies, most live in extreme social isolation and adverse socioeconomic
circumstances. Among many unmet needs, the limited availability of community-based
rehabilitation, supported accommodation, and employment opportunities are
particularly prominent. The so-called low-prevalence psychotic disorders
represent a major and complex public health problem. They are associated
with heavy personal and social costs. A broad programmatic approach to
the recovery and rehabilitation of such persons is needed. It must involve
various sectors of the community to tackle the multiple dimensions of clinical
disorder, personal functioning, and socioeconomic environment that influence
the course and outcome of psychosis and ultimately determine the effectiveness
of service-based intervention.
These data provide invaluable evidence for advocacy, to be used in policy
decisions and in planning resource allocation. They also can be used to
good effect by NGOs, by the general public, by consumers and caregivers,
and by health care professionals. The findings are believed already to
have influenced allocation of funds for mental health services, although
the causal effect obviously cannot be proved. The National Survey has also
contributed inter alia to greater resource allocation for mental health
research. Some major banks, foundations, and the Australian Rotary Health
Research Fund have now contributed considerable sums to mental health research.
There have now been some 94 publications from the National Survey (Note
1).
Within federal and state governments, the need to improve mental health
literacy has become accepted (25), and intervention programs are now active.
Their aim is to raise the level of knowledge about mental disorders, to
inform people how and where they can seek help, and to reduce stigma not
only among the public but also among health professionals. Parallel with
this is a nationwide move to improve the contribution of family physicians
to mental health care—a continuing and demanding exercise. It will be part
of the continuing National Mental Health Strategy in which a more effective
deployment of limited resources will be pursued.
Funding Support
The National Survey was funded by the Commonwealth Department of Health
and Ageing, Canberra.
Note
1. This Publication List may be accessed on the Web site of the Mental
Health and Special Programs Branch, Commonwealth Department of Health and
Ageing, Canberra, at http://www.mentalhealth.gov.au.
References
1. Whiteford H. Introduction: the Australian mental health survey. Aust
N Z J Psychiatry 2000;34:193–6.
2. Peters L, Andrews G. Procedural validity of the computerized version
of the Composite International Diagnostic Interview CIDI-auto in the anxiety
disorders. Psychol Med 1995;25:1269–80.
3. World Health Organization. The ICD-10 Classification of Mental and Behavioural
Disorders. Diagnostic Criteria for Research. Geneva: WHO; 1993.
4. American Psychiatric Association. Diagnostic and statistical manual
of mental disorders. 4th ed. Washington (DC): APA; 1994.
5. Henderson S, Andrews G, Hall W. Australia’s mental health: an overview
of the general population survey. Aust N Z J Psychiatry 2000;342:197–205.
6. Andrews G, Henderson S, Hall W. Prevalence, comorbidity, disability
and service utilisation: overview of the Australian National Mental Health
Survey. Br J Psychiatry 2001;178:145–53.
7. Hall W, Teesson M, Lynskey M, Degenhardt L. The 12-month prevalence
of substance use and ICD-10 substance use disorders in Australian adults:
findings from the National Survey of Mental Health and Well-Being. Addiction
1999;9410:1541–50.
8. Henderson AS, Jorm AF, Korten AE, Jacomb P, Christensen H, Rodgers B.
Symptoms of depression and anxiety during adult life: evidence for a decline
in prevalence with age. Psychol Med 1998;28:1321–8.
9. Jorm A. Does old age reduce the risk of anxiety and depression? A review
of epidemiological studies across the adult life span. Psychol Med 2000;30:11–22.
10. Hickie I, Davenport T, Issakidis C, Andrews G. Neurasthenia: prevalence,
disability and health care characteristics in the Australian community.
Br J Psychiatry 2002;181:56–61.
11. Jackson HJ, Burgess PM. Personality disorders in the community: a report
from the Australian National Survey of Mental Health and Wellbeing. Soc
Psychiatry Psychiatr Epidemiol 2000;3512:531–8.
12. Jorm AF. Association between smoking and mental disorders: results
from an Australian National Prevalence Survey. Aust N Z J Public Health
1999;233:245–8.
13. Sanderson K, Andrews G, Jelsma W. Disability measurement in the anxiety
disorders: comparison of three brief measures. J Anxety Disord 2001;15:333–44.
14. Mathers C, Vos T, Stevenson C. The burden of disease and injury in
Australia. Canberra: Australian Institute of Health and Welfare; 1999.
15. Dear K, Henderson S,Korten A. Well-being in Australia: findings from
the National Survey of Mental Health and Well-being. Soc Psychiatry Psychiatr
Epidemiol. Forthcoming.
16. Jablensky A, McGrath J, Herrman H, Castle D, Gureje O, Evans M, and
others. Psychotic disorders in urban areas: an overview of the Study on
Low Prevalence Disorders. Aust N Z J Psychiatr, 2000;342:221–36.
17. Gureje O, Herrman H, Harvey C, Morgan V, Jablensky A. The Australian
National Survey of Psychotic Disorders: profile of psychosocial disability
and its risk factors. Psychol Med 2002;32:639–47.
18. Castle D, Morgan V, Jablensky A. Antipsychotic use in Australia: the
patients’ perspective. Results from the National Survey of Mental Health
and Well-being. Aust NZ J Psychiatry. Forthcoming.
19. Sawyer MG, Arney FM, Baghurst PA, Clark JJ, Graetz BW, Kosky RJ, and
others. The mental health of young people in Australia: key findings from
the child and adolescent component of the national survey of mental health
and well-being. Aust N Z J Psychiatry. 2001;356:806–14.
20. Rey JM, Sawyer MG, Clark JJ, Baghurst PA.. Depression among Australian
adolescents. Med J Aust 2001;1751:19–23.
21. Graetz BW, Sawyer MG, Hazell P, Arney F, Baghurst P. Validity of DSM-IV
ADHD subtypes in a nationally representative sample of Australian children
and adolescents. J Am Acad Child Adolesc Psychiatry 2001;40:1410–7.
22. Rey J, Sawyer MG, Raphael B, Patton G, Lynskey M. The mental heath
of teenagers who use marijuana. Results of an Australian survey. Br J Psychiatry
2002;180:216–21.
23. Jenkins R., Lewis G, Bebbington P, Brugha T, Farrell M, Gill B, Meltzer
H. The National Psychiatric Morbidity Surveys of Great Britain initial
findings from the household survey. Psychol Med 1997;27:775–89.
24. Andrews G, Henderson S, editors. Unmet need in psychiatry: problems,
resources, responses. Cambridge: Cambridge University Press; 2000. p 444.
25. Jorm AF, Korten AE, Jacomb PA, Christensen H, Rodgers B, Pollitt P.
“Mental health literacy”: a survey of the public’s ability to recognise
mental disorders and their beliefs about the effectiveness of treatment.”
Med J Aust 1997;166:182–6.
Authors
Manuscript received and accepted September 2002.
1. Emeritus Professor and Visiting Fellow, Centre for Mental Health Research,
The Australian National University, Canberra, ACT 0200, Australia.
Address for correspondence: Dr S Henderson, 9 Timbarra Crescent, O’Malley,
ACT 2606, Australia e-mail: as.henderson@bigpond.com
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