In Review
The National Survey of Mental Health and Well-Being in Australia:
Impact on Policy
Scott Henderson, MD, Hon MD (UNSW), DSc, FRACP, FRANZCP, FRCP, FRCPsych1
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Objective: To provide a synopsis of the 3-part National Survey of Mental Health and Well-Being in Australia and to examine the yield in terms of policy and other changes in mental and general health services.
Method: Published data are examined, and a commentary is provided on service-delivery issues that the data have revealed.
Results: One-year prevalence estimates for the common mental disorders, defined according to ICD-10 criteria and assessed using the automated version of the Composite International Diagnostic Interview (CIDI-A), have indicated rates similar to those of other countries (17.7%). Alarmingly high rates were found for alcohol and substance abuse in young persons, especially among young men. The number of years of life lost owing to disability attributable to mental disorders exceeds the number lost owing to cardiovascular disease and cancer. Only 35% of persons with 1 or more of the common mental disorders had sought help in the 12 months prior to interview. The point prevalence for mental health problems was 14% for persons aged 4 to 17 years. The point prevalence for psychotic disorders was 4.7 per 1000. An encouraging finding is that 81% of affected individuals had been to their general practitioner (GP) in the last year. However, only 20% had participated in any rehabilitation program in the past year.
Conclusions: The Survey results are based on a national population sample, not on individuals reaching services. They have therefore proved to be of great value in influencing policy at federal and state levels and may have contributed to increased funding for both services and research.
(Can J Psychiatry 2002;47:819–824)
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Clinical Implications
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The profile of morbidity revealed by a general population survey differs importantly from that of the population reaching clinicians.
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Psychiatrists can more effectively contribute to mental health by spending some time in consultative work instead of engaging exclusively in 1-to-1 encounters.
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Much greater effort needs to be put into rehabilitation and recovery, particularly for persons with psychoses.
Limitations
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Some important groups in the Australian population could not be adequately studied, either for financial or for administrative reasons.
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The validity of the prevalence estimates needs to be critically assessed.
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No information could be obtained on the performance of general practitioners (GPs), who were by far the most frequently used source of professional help.
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Key Words: psychiatric epidemiology, unmet need, prevalence estimates, children,
psychoses, health policy
Résumé : L’enquête nationale de santé mentale et de bien-être en Australie : répercussions sur les politiques
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In the mid-1990s, a National Survey of Mental Health and Well-Being
was carried out in Australia. The purposes were mainly administrative:
to inform policy at the federal and state levels and to provide information
for advocacy at a time of major changes for mental health services (1).
The success of the undertaking is probably largely attributable to the
consortium of expertise that was assembled. This included senior administrators,
consumer and caregiver spokespersons, psychiatric epidemiologists, and
survey experts from the Australian Bureau of Statistics. Three aims were
agreed upon: 1) to estimate the 1-month and 1-year prevalence of mental
disorders and of significant psychological symptoms in the Australian population,
2) to estimate the amount of disability associated with such morbidity,
and 3) to estimate the use of health and other services by affected persons.
To achieve these aims, the National Survey needed 3 complementary parts:
1) a survey of adults in the general population, 2) a survey of people
with low-prevalence disorders and psychoses, and 3) a survey of children
and young people. This paper provides a synopsis of the main findings and
retrospectively considers the utility of the National Survey for improving
both mental and general health services.
The Survey of Adults
Some 10 600 persons aged 18 years to late life completed an interview with
the automated version of the Composite International Diagnostic Interview
(CIDI-A), developed in Sydney by Peters and Andrews (2). This represents
a response rate of 78% of the target sample. The CIDI-A algorithms give
both ICD-10 (3) and DSM-IV (4) diagnoses, the former being used in this
analysis. The sample was unable to generate stable estimates of the following
groups: people living in rural and remote areas of Australia; the indigenous
population; people not fluent in English; those in prison, colleges, and
other institutions; those in the armed forces; and the very elderly. With
this caveat, the National Survey showed that just under 1 in 5 Australian
adults (17.7%) had an anxiety, affective, or substance use disorder in
the 12 months prior to interview (5–7).
Anxiety Disorders
These are the most common disorders. They affect just under 1 in 10 adults
(9.7%). Contrary to expectation, it was found that anxiety disorders are
unrelated to education in Australia, that they cause much more disablement
in people’s lives than was realized, and that three-quarters of all affected
individuals had not sought help from health services. Comorbidity is present
in almost one-half of all cases.
Depressive Disorders
According to ICD-10, this refers to both depressive episodes and dysthymia.
In the 12 months before the interview, 5.8% of the adult population had
1 or more depressive disorders. They were more frequent in women (7.4%)
than in men (4.2%). For men, depression is a little more common in mid-life.
In women, the highest rates occur in those aged 18 to 24 years, where 1
in 10 respondents had experienced depression in the previous year. Thereafter,
depression gradually decreases with age. Comorbidity was again conspicuous:
over one-half of the women and two-thirds of the men with a depressive
disorder had at least 1 other mental disorder.
Disablement was much higher than expected, leading to the conclusion that
the depressive disorders cause considerable disruption to sufferers and
to those around them. Regarding service use, 40% of persons with a depressive
disorder had consulted their general practitioner (GP) for mental health
problems in the previous 12 months, compared with 3% of people with no
mental or physical disorders. The National Survey does not indicate whether
GPs recognized that these subjects suffered from clinical depression. Contrary
to the belief of many members of the general public and many health professionals,
there is some evidence that, in the general population, the prevalence
of depressive disorders is lower in persons aged 65 years and over than
in younger adults (8,9). This finding applies to the elderly living in
the community, not to those in nursing homes or other special accommodation.
There, the prevalence of depression is known to be high. Again contrary
to popular belief, depression is no higher in the capital cities than in
the rest of each state and territory.
Substance Use Disorders
One in 13 Australian adults aged 18 years and older (7.7%) had a substance
use disorder in the past 12 months. Cannabis use accounted for more drug
use disorders than did any other illicit drug: 1.7% of Australian adults
had a cannabis use disorder in the past 12 months. The prevalence of substance
use disorders declined steeply with age for both men and women. One in
6 Australians aged 18 to 24 years had a substance use disorder, but only
1 in 90 Australians aged 65 years and over had such a disorder. As expected,
comorbidity with anxiety or depression was high. Only about 1 in 7 individiuals
with a substance use disorder had sought assistance from a health professional
in the previous 12 months. This is one-half the rate at which people with
an anxiety disorder sought treatment. Almost twice as many women as men
sought such assistance. Most often, treatment was provided by a GP rather
than by a psychiatrist, psychologist, or other mental health professional.
Neurasthenia
Formerly a common diagnosis throughout the world, this diagnosis was reintroduced
to ICD-10 because of its utility and the need to reassess its status. Neurasthenia
(F48.0) is characterized by persistent and distressing physical or mental
fatigue, together with muscular aches, dizziness, tension headaches, insomnia,
inability to relax, or irritability. Because of its significance in primary
care, the investigating team decided to include neurasthenia in the National
Survey. Prolonged and excessive fatigue was reported by 13% of the sample
(10). Of these, only 1 in 9 people met the ICD-10 criteria for neurasthenia.
Comorbidity was associated with affective, anxiety, and physical disorders.
Fatigue is frequent in the Australian community and is common in people
attending general practice. Neurasthenia is disabling and places pressure
on health services, largely because of its comorbidity with other mental
and physical disorders.
Personality Disorders
Personality disorders are rarely included in general population surveys,
but were included on this occasion. It was estimated that approximately
6.5% of the adult population of Australia have a lifetime prevalence of
1 or more personality disorders (11). They are more likely to be younger,
male, and not married. They are also more likely to have an anxiety disorder,
an affective disorder, a substance use disorder, or a physical condition.
They are more likely to have greater disability.
Smoking and Mental Disorders
A strong relation was found between mental disorders and smoking (12).
This association is age-specific, being much stronger in younger adults
than in the elderly. It could be caused by a cohort difference in motivation
to take up smoking. Public health efforts to reduce the prevalence of smoking
need to take into account the strong relation between smoking and mental
disorders.
Disability and Service Use
The disablement caused by the common mental disorders is considerable:
on average, 3 days of disablement were experienced by affected individuals
in the 4 weeks prior to interview, compared with 1 day for the general
population (13). The National Survey made it possible for Mathers and his
colleagues (14) to estimate the contribution of mental disorders to overall
disability, expressed as years of life lost through disability (YLD) (Figure 1): YLD arising from mental disorders exceed all the other major categories.
These researchers also found that mental disorders came third in terms
of disability adjusted life years (DALYs), surpassed only by cardiovascular
disease and cancer (Figure 2).
Of those individuals with 1 or more of the common mental disorders, 65%
had not used any form of health service in the 12 months prior to interview.
Most who did use a service visited a GP.
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