Chapter 7 - Promotion, prevention and early intervention
There is indisputable evidence that the bulk of mental
health care resources are allocated to acute care and the treatment of mental
illness through hospital-based services.
Whilst the importance of treating mental illnesses and their symptoms should
not be understated, the question remains as to how much pain – experienced by
the consumer, the health care system and the community – could be avoided if preventative
measures had been taken to reduce the
potential for developing a mental illness, or there had been early intervention?
Mass media campaigns over the years have targeted community-wide
issues, such as the prevention of AIDS, skin cancer and damage caused by
smoking. Yet given the social impact and often devastating consequences of
mental illness, there has been relatively little effort to raise awareness of a
range of mental health issues on a national scale, and to break down the
damaging stereotypes and misconceptions surrounding mental illness that create
strong barriers to the seeking of help.
A number of community organisations are implementing
valuable prevention, promotion and early intervention programs. However, the
short term funding outlook of governments at the federal, state and territory levels
in supporting the future development and continued delivery of such programs
was criticised, as was the lack of back-up mental health care services to
handle referrals and provide continuity of care, and the absence of a national
effort to coordinate successful local programs or support their roll-out on a broader
This chapter reviews: the stigma associated with mental
illness and the need to realign the public's perception of mental illness; the
prevention of mental illness by targeting the young and other high risk groups;
the role of early intervention programs; and examines a number of community
programs that are delivering positive results.
Setting the context of prevention, promotion and early intervention in
mental health care
What are prevention, promotion and early intervention?
Promotion, prevention, and early intervention
approaches are relevant across the entire spectrum of mental health problems
and disorders, from behavioural disorders and depressive and anxiety disorders,
through to psychotic disorders. Anxiety disorders in children, for example, can
be prevented through school-based programs designed to promote resilience. Research also shows the positive
effects of early intervention in reducing the impact of psychotic illness.
Mental health promotion
is any action taken to maximise mental health
and wellbeing among populations and individuals. An example is programs that
support and strengthen family functioning.
is defined as 'interventions that occur before the initial onset of a disorder'
to prevent the development of disorder. Prevention relies on reducing the risk
factors for mental disorder, as well as enhancing the protective factors that
promote mental health. Selective prevention interventions
target at-risk populations: an example is school-based programs specifically
targeting young people at risk of depression. Universal prevention interventions are aimed at improving the
overall mental health of a population: an example would be programs aimed at
building connectedness and a sense of belonging in school students.
intervention refers to interventions targeting people displaying the early
signs and symptoms of a mental health problem or disorder, and people
developing or experiencing a first episode of mental disorder. Early
intervention aims to prevent progression into a diagnosable disorder, and for
those experiencing a first episode of mental disorder, it aims to reduce the
impact of the disorder.
The national approach
The National Mental Health
Strategy of 1992 and subsequent National Mental Health
Plans recognised the importance of promotion, prevention, and early
intervention. The Second National Mental Health
Plan 1998-2003 identified promotion and prevention as one of three priorities
for future activity. The current (third) National Mental Health
Plan 2003-2008 identifies 'promoting mental health and preventing mental health
problems' as one of four priority themes.
The need for national direction in promotion and
prevention was identified in a 1997 evaluation of the National Mental
Health Strategy. A Mental Health
Promotion and Prevention Working Party was set up to develop a plan of action
to provide this national direction.
Subsequently, a National Action Plan for
Promotion, Prevention, and Early Intervention for Mental Health 2000 (PPEI Action Plan) was published. PPEI Action Plan is a joint
initiative of federal and state governments. It is accompanied by a second
document – a monograph providing the theoretical and conceptual framework and
background (Monograph 2000).
Working in parallel with PPEI Action Plan is the
Australian Network for Promotion, Prevention, and Early Intervention (Auseinet),
funded by the federal Department of Health and Ageing, which collects and
disseminates information, and works collaboratively with government and
Why are prevention, promotion and early intervention important?
There is strong support for a prevention and early
intervention approach, as it has the significant potential to reduce future
adverse outcomes and:
It is widely recognised and understood that treatment
interventions alone cannot significantly reduce the burden of mental disorder
and that there is compelling evidence that implementation of promotion,
prevention and early intervention approaches will significantly reduce the
burden of mental illness and mental disorder. Given the current limitations in
effectiveness of treatment interventions for decreasing disability due to
mental disorders, the only sustainable method for reducing the burden caused by
these disorders is prevention.
The NSW Children's Commissioner similarly argued:
The Commission supports the establishment and maintenance of
prevention and early intervention programs rather than a single focus on the
tertiary treatment of people with mental health issues. International research
suggests that mental health outcomes are improved by effective prevention
programs and that early identification and treatment of problems is a priority
for reducing the potentially disruptive influence of mental health problems on
social engagement and functioning.
The proportion of people with a mental disorder who
access care is half that of comparable physical disorders. Almost all those
with schizophrenia receive services but only 60 percent with depression, 35
percent with anxiety disorders and 11 percent with substance use disorders
consult for their disorder.
Savings can be made through prevention and early
The emphasis on treatment is extremely costly. Planned and
systematic prevention could save costs, time, suffering and much community and
for prevention is not disputed by governments. The PPEI Action Plan states:
interventions alone cannot significantly reduce the enormous... burdens
associated with mental health problems and...disorders...
There is a compelling need to make promotion, prevention and
early intervention priorities in global, national and regional policy, and to
develop a clear plan for progressing activities in these areas.
Promoting a healthier attitude to mental illness in the community
Stigma as a barrier to health care and services
Ignorance of and fear about mental illness exists in
the general community, in organisations, and even in some cases amongst health
care professionals. Stigma leads to discrimination, which compounds the
disadvantage experienced by people already battling with difficult diseases. It
results in low self-referral, under-reporting of illness and under-use of
The stigma attached to mental illness is evident in
many ways. It can be seen in the terminology often used relating to mental
...we are not "the Mentally Ill", we are "people
with mental illness", we are not "beds", we are not
"schizophrenics" we are people with Schizophrenia. Imagine what it
would be like if a patient who had cancer was called "a cancer", what
would that do to their self image and illness, to the attitudes of others to
the patient called "the cancer".
The language used in mental health legislation, which
conventionally refers to detainment and control, may underpin or promote the
association of mental illness with criminality:
The [NSW Mental Health] Act
promotes social stigma. The words in the Act alone promote stigma: ‘Control’,
‘detention’, ‘to apprehend’, ‘the court’, ‘the magistrate’, ‘police’, ‘forensic
patients’, the association of the Act with the Mental Health
(Criminal Procedure) Act (NSW) 1990 that leads to a perception that people with
mental illness are criminals or likely to be criminals. And if the Act were
better known by the community (I am glad that it is not), it would promote the
association with criminality by a community always sensitive to aberrant
behaviour and ready to lay blame on that disadvantaged group.
Lumping all mental illnesses together does not help
people understand them, or help them understand that there are different issues
associated with different illnesses:
The current practice of using the generic term ‘mental illness’
rather than specifically addressing the issues contributing to stigma for
different mental illnesses is a major barrier to destigmatisation of ANY mental
illness. As such, current education programs are totally inappropriate and
inadequate in de-stigmatising mental illness and disorders.
The term ‘mental health’ should only be applied in the same
situations that the term ‘physical health’ would also be used and deemed
essential to differentiate from ‘mental health’ or ‘spiritual health’ etc. In
fact if we use common practices in physical health as a guide when
communicating about all health and specifically when referring to mental
health, significant steps forward will be made.
I have often been on the podium with Barbara
Hocking from SANE. Usually I go first, which
is one of the things about being a consumer—they ask you to speak first. We
need to reclaim this language. We need to call ourselves ‘batty’; Cath has a
wonderful T-shirt about ‘batty’ and ‘nut case’. We need to reclaim that
language and make it not scary. Then Barbara
gets on to speak and from a non-consumer perspective says, ‘We need to get rid
of all these horrible words like ‘nut case’. Both of us are trying to do the
same thing in totally opposite ways. That is where the consumer perspective is
so vital. If we just rely on people who read it from a non-consumer
perspective, I think that we will not make inroads into discrimination as
quickly as we will if consumers start to challenge it in unorthodox ways
through such things as cartoons and language.
Stigma associated with mental illness is also
inhibiting people from seeking much-needed treatment. Submitters suggested that
stigma is a major reason people attempt to 'self manage' their illnesses, with
a consequent delay in treatment:
My personal experience agrees with that, as my son took about 3
years to agree to assessment and treatment, despite support from university
football colleagues and administrators including a doctor associated, and other
friends. His fear was about future relationships, jobs etc., which was
realistic. Alas lack of family unity due to ignorance did not help, and has taken
some years to overcome, as we all learned how best to cope.
If people are afraid to speak about their illness in
their workplace, it can prevent them making use of support services that
employers may have available. The committee was contacted by people who wanted
to make submissions to its inquiry, but were not prepared to be identified in
case their employers found out their identity. Employers are often ill informed
about the nature of mental illnesses, and unsure how to make the best of
employees affected. One consumer reported:
I haven’t disclosed
anything about my illness to my employer, though I’m sure they know there is
something going on. Initially, I had a shared office, which was really hard—I
avoided going in to the office whenever I could (I work part time and have a
fair bit of flexibility). We just didn’t get on very well—but my employer was
accommodating and found me another place where I could be by myself. But they
have gone to the extreme—I have a whole level to myself and there is no one
else around. I don’t get to see anyone—it’s weird but I get a sense that I’m
there because they think I’m weird. Work is now very lonely.
However, many consumers have no access to
employment. The Catholic Welfare Australia Member Organisations reported that
the negative perception attached to mental health problems and disorders is a significant
factor inhibiting people's access to employment and other services within the
Our Member Organisations report that owing to negative community
attitudes, people with a mental health problem face difficulty finding private
accommodation, achieving employment through accessing generic employment
services, and other education and training programs. And it is often the case,
that until these basic needs are met, further assistance for the client is
Damaging misconceptions of mental illness in the media
Negative stereotypes of people with mental illness are
reinforced through representations of mental illness in the media:
As a society, we are bombarded with negative images of people
with mental illnesses. The media and entertainment industries overwhelmingly
present people with mental illnesses as dangerous, violent and unpredictable
individuals. These inaccurate and unfair portrayals shape the public’s
perception of people with mental illness as people to be feared and avoided.
Sensational reportage of the most appalling outcomes,
such as the recent case of child murder and sexual assault by a 23 year old
with acute psychosis and substance abuse disorder, draws attention to serious flaws in
the health care system but also engenders the highest degree of
misunderstanding and fear:
stories of 'psycho killers' and 'feral psychotics' which are
splashed in the tabloid press harm all people with mental illness and hamper
the rehabilitation of offenders with mental illness.
The Brotherhood of St Laurence commented:
At a public level, the
association of violence and aggression with mental illness must be challenged
whenever it appears. The public must be made aware that such violence is an
exception, and that people who do have a psychiatric illness are much more
likely to be on the receiving end of it rather than to be the perpetrators. All
people with a mental illness suffer at some level by them is the conception
that is created by sensationalist media reporting.
Consumers asked that, instead of the stigmatising
portrayal of the mentally ill as 'crazy', the media should focus on educating
the community about the experiences of people with mental illness.
A number of submitters commented on the 'silencing' of the real impacts
of neglected mental health needs, especially in relation to the high number of
suicides that are consequent to untreated depression:
Anecdotal information given to NCOSS shows that not reporting on
suicide marginalises and stigmatises mental illness even further, as it suggests
that suicide is shameful and should not be publicly discussed – yet it is an
issue that the whole of the community needs to consider.
Damaging misconceptions of mental
illness in the health care system
Experiences of discrimination and ignorance within
health care services appear widespread, with potentially serious consequences. Some
of this is specific to particular illnesses, a topic referred to again in Chapter
5. A common complaint was that
people with mental illness felt dehumanised by a system which took little
account of their individuality. Consumers felt as they were seen through the
lens of their illness, so that outside of their diagnosis they ceased to exist.
A young consumer reported:
I have been lucky I have not experienced stigma in the broader
community. Everyone that I know and have met since my first episode has
accepted and embraced my openness about it. Where I have felt like less of a
person is within the adult mental health system...One thing that drives me to
maintain my health is that I refuse to be part of a service that can't see me
as a person, and believes that I am only a schizophrenic that speaks
“schizophrenise”. There are services out there that adopt a caring and
responsive philosophy, if these places do it, why can't they all?
A number of submitters maintained that mental
health reform has exacerbated stigma by placing pressure on the mainstream
health system to absorb care responsibilities for people with mental health
problems when it is ill-prepared, and not sufficiently funded, to do so. The
Public Advocate, South Australia,
identified the following
systemic features as drivers of this response:
non-mental health personnel still appear to be reluctant participants in
service responses for the mentally ill and their families;
occupational health and safety issues and responses to protect staff seem to
drive considerations of service responses (at times appropriately) which may
serve to further traumatise and alienate already severely disturbed people (eg
the use of security guards to guard detained patients in general hospitals);
are conflicting beliefs from site to site about the nature, scope and service
responsibilities and ethos that mental health services should be providing.
Promoting better mental health at the national level
The stigma described above creates a barrier to mental
health promotion. Many submissions argued for a sustained national education
campaign to inform Australians about the true nature and extent of mental
illness. However, it was equally strenuously argued that such a campaign must
be grounded in community-based education programs that promote good mental
health and attack stigma in schools and in the workplace at the local level:
AICAFMHA believes that the concept of mental health literacy
should not be confined to a sole focus on mental health problems and disorders
but should include knowledge and awareness of what constitutes positive mental
health and strategies that promote good mental health. Multiple education and
community awareness strategies that promote knowledge and skill development are
required to improve mental health literacy and need to be specifically designed
within a developmental framework for target populations and settings.
A focus on reform of media commentary was just one
aspect of this agenda:
Currently there appears
to be no standard to address the inaccurate statements that occur in many of
the media reporting of mental health incidents. The complexity of the problems
experienced by the mentally ill and the staff who provide support to them
appear to exceed the capacity of the media to present a balanced report. This
has implications if one is to encourage people to seek treatment. It is also a
disincentive in recruiting people to the area. Considered, resourced
educational programs for the press, for emergency services such as the police
and the ambulance, and the public generally, are priorities. Resource
allocation to the non-government sector and professional organisations could
facilitate the development of de-stigmatising programs, which would then be
able to offer education through effective targeted professional development
A number of individual projects have been undertaken by
non-government organisations to raise awareness of mental illnesses (discussed
later in this chapter). However, Mr
Chairman of beyondblue, stated the importance of addressing mental health in
the context of a government campaign on well being:
...every day in the media we hear, see or read about deaths on our
roads around the country. We do not hear about the injuries, only the deaths.
But every day about eight or nine Australians take their life—suicide—as a
result of depressive illnesses. The number of those who die by their own hand
is almost more than double those who die in a motor vehicle accident, yet we
hear nothing on our radio or see on our television screen or in the press
nothing to try to prevent that. In other words, we get this media concentration
on deaths and then we have governments responding to deaths, but in the area of
mental illness we do not have the same concentration on promoting good health
and wellbeing as an ongoing program.
However, for any such promotional activity or campaign to
be truly effective, it must capture the authentic and diverse voices of consumers,
and their images. The effect of
this empowerment would be profoundly remedial for both consumers and for the
community in general. Insane australia
The consumer-survivor movement is as culturally diverse as any,
again, with parallels to the feminist and gay movements. insane welcomes,
endorses and encourages this diversity of voices. One of the primary aims of insane
is to promote the awareness of Mad Culture as a community with a culture
and a unique voice of its own. We seek to promote this both among consumers and
survivors as well as in the general community. With this awareness, we seek to
encourage consumer-survivors to speak of their experience, in their own language,
with pride rather than shame and for the general community to hear our voices
with open minds and open hearts rather than with fear and judgement. We believe
this will promote a much healthier dialogue and understanding of the many
complex issues around mental health than is currently the situation in Australia.
An enormous amount of evidence to the inquiry outlined
how mental illness and the community in general suffer through an inadequate
understanding of mental illness. It is the opinion of the committee that
effective media campaigns are needed o raise community awareness. This will provide an important step in better
managing mental health care in Australia,
particularly given the community-based care focus that resulted from
Minimising the impact of mental illness through prevention and early
The importance of prevention and early intervention was
a particularly strong theme in evidence to the inquiry. The significance of
applying prevention and early intervention approaches from an early age, and
throughout childhood and youth are recognised to be of vital importance, while people
of any age that are exposed to adverse environmental conditions (such as
poverty or unemployment) also benefit from early intervention and prevention.
Early influences on the young
The literature on mental health refers to risk and
protective factors as influences in the development of mental health problems. Experiences
in infancy, childhood and youth have an influence on the development of future
mental health problems, and also there is a continuity of disorders between
childhood, adolescence and into the adult years.
Risk factors that increase the likelihood that a mental
disorder will develop include insecure attachment in infancy, family
disharmony, and harsh discipline style by a parent. Protective factors include
a secure and stable family, a sense of belonging at school and adequate
A number of submissions argued that many risk and
protective factors came into play even before birth, and that prevention and
early intervention strategies need to begin in the antenatal and infancy
periods. Parental mental disorder
has been identified as a risk factor for the development of mental health
Association for Infant Mental
NIFTeY referred to research indicating that infants as young as 3 months old
can detect depression in their mothers.
According to the Post and Antenatal Depression
[PND] can interfere with the behavioural and emotional
interactions that are now recognised as being necessary for a successful
mother-infant relationship. Mothers with
depression tend to be less sensitive to the needs of their babies and can be
less responsive to their communications
Many women and their partners are not aware that mood changes
are common after childbirth and can vary from mild to severe. In fact in the year after childbirth a woman
is more likely to need psychiatric help than at any time in her life'.
Studies show that 17 per cent of women giving birth in
any year are likely to have postnatal depression, 10 per cent antenatal
depression and 0.2 per cent postnatal psychosis and that 10 per cent of male
partners of women giving birth may also have postnatal depression. Children whose parents have
untreated perinatal mental illness will demonstrate learning and developmental
difficulties, hyperactivity disorders, mental illness and adult criminal
three mood disorders in the postnatal period:
The 'baby blues', which affect most mothers
between the third and tenth days after birth
Postnatal depression (PND), affecting around 15
to 20 percent of mothers, and
Postpartum psychosis, which affects about 1 in
500 mothers, usually in the first 3 to 4 weeks after delivery.
PND is not always well understood or diagnosed. One
mother recounted attempts to get help:
I finally decided to tell my GP how I felt. He would help me, I
thought. I tried to tell him how I felt, but it was too hard. Instead I
complained that my baby was not feeding and sleeping well. I went back every
week worried about my baby’s health. Each week he reassured me that my baby was
fine. Maybe, if he had asked about me, I would have told him that something was
wrong and that I was scared, but he never did. I kept trying to tell him how I
felt but the words just wouldn’t come out. Each week I left his office and
cried all the way home.
Risk factors for PND include poor support from partner,
family and or staff during labour, unplanned pregnancy, previous stillbirth,
childhood sexual abuse, high trait anxiety, perceptions of not being in
control, inadequate pain relief and fear for the wellbeing of the baby.
Helpful in dealing with childbirth disorders were:
early identification of the symptoms of PND; provision of accurate information
and interventions; emotional support from family, friends and services;
practical help with housework and childcare; psychological help with
counselling and cognitive therapy; support groups; medical assessment and
monitoring by GPs or psychiatrists; antidepressant medication; hospitalisation,
ideally in a mother-baby unit and lifestyle changes – diet, exercise, rest.
Beyondblue says there has been a lack of national focus
and insufficient attention paid to improving women’s mental health before they
Left untreated, the impact on the mother and her child can be
If women at risk of postnatal depression are identified during
pregnancy and effective psychological and social interventions are provided,
then it is possible that postnatal depression may be reduced in severity or
a four year National Postnatal Depression Program of research across six states
to determine the scope for prevention through screening, information packages
and psychological and social interventions.
The findings show that new mothers were unlikely to identify their own depression
and unlikely to seek treatment. Their
beliefs about PND were often at odds with those of GPs over pharmacological
treatment for depression. New mothers
were also reluctant to use psychological or psychiatric therapies favoured by
maternal and child health nurses.
PANDA conducts a helpline in Victoria
for PND but its limited state government funds allow it to operate only 4 days
a week. The only two other states with
PND help lines are WA and the ACT, neither of which receives public funds.
The organisation reported that many women calling their
helpline admit to supplying deliberately false positive answers to a
self-report scale used by health professionals working with mothers in the
first postnatal year, for fear of being seen as bad mothers, insane, or that
their child/ren will be placed in protective care. This highlights both the stigma that
can attach to mental illness and the need to ensure effective support is
provided to women who feel they are experiencing, or at risk of, PND.
PANDA made a range of recommendations regarding
perinatal mental health, including that there be a national strategy to support
perinatal health services for 'the early identification, intervention,
prevention and education of perinatal mental illness for men and women having
children', arguing that it would be highly cost effective.
The Australian Infant, Child, Adolescent and Family Mental
Health Association (AICAFMHA) pointed to the negative effects
of domestic violence:
Of particular significance relating to infant mental health is
the presence and effect of domestic violence - "a stressful life
event" - experienced by women ante-natally and post-natally and her risk
of developing post-natal depression. A mother's emotional availability and
ability to respond sensitively to her infant are severely compromised and are
influential in limiting the infant's secure attachment leading to early
development of poor mental health.
supported the use of information campaigns as part of a prevention and early
intervention strategy, and suggested parenting was an area in which education
for parents could be valuable:
there is a lot of research showing that, if children grow up in
an environment where there is a lot of conflict in the home from the parents,
they are at greater risk of developing anxiety disorders and depressive disorders
when they grow up. The critical thing seems to be that the children are
involved in or witness the conflict. If all parents knew not to involve the
children in arguments, not to argue in front of the children and not to involve
them—it is a very simple thing—they could then take the personal action that is
going to reduce risk. That is a preventive action.
AICAFMHA also pointed to the consequences for a child
when the parent has a mental illness, and the need for health professionals to
recognise that families needed support. AICAFMHA advised the committee of its
successful collaboration with psychiatrists:
AICAFMHA, through its Children of Parents with a Mental Illness
(COPMI) Project, has been successful in working with the Royal Australian and
New Zealand College of Psychiatrists (RANZCP) in developing a Position
Statement (Position Statement #56) which acknowledges the effects of parental
mental illness on family and also recommends that any assessment of an adult
psychiatric patient must take into account the impact of the parental mental
illness on any children within the family and ensure that appropriate supports
are available for the family.
Suggested early intervention strategies for children
included a specific Medicare item number for GPs for health checks for children
and adolescents. The ADGP submitted a recommendation to:
Develop, fund and implement an infant and early childhood
promotion, prevention and early intervention program for primary care under the
National Agenda for Early Childhood that includes... a child and adolescent
health check item number into the Medicare Benefits Schedule.
Strategies to identify children at risk were not well
received by all. The Australian Mental Health
Consumer Network recognised the benefits of a diagnosis for a young person in
distress, but expressed concern at the negative consequences of the ensuing
The AMHCN is anxious about the attempts that have been made to
intervene early in people’s lives. We are not convinced that giving people medical
diagnoses (labels) when they are young does anything to help their self esteem
and generate the strengths that are necessary to deal with the ...real life
The identification of potentially unstable parents
prior to birth of a child also was met with criticism. The Mental Health Legal
Centre in Melbourne
submitted that such identification was not backed up by practical initiatives
such as support for those parents identified:
A range of negative and discriminatory consequences can flow
from labelling by government agencies which is not matched by appropriate
service provision. In Victoria we have a push for antenatal notifications
against parents the Department of Human Services perceive may have trouble
parenting, there is nothing more offered, no parenting support or guidance,
these parents continue with a pregnancy under surveillance, knowing that the
child may be whipped away upon delivery.
These circumstances seem likely to place additional
stress in the parents, and this could potentially exacerbate the mental health
risk factors for the child. There is an
obvious need for antenatal identifications to be matched with support programs.
Adolescents and Young Adults
Mental disorders are most prevalent during adolescence
and young adulthood, and account for 55 per cent of the total disease burden of
those aged 15 to 24 years.
According to ORYGEN Research Centre, over 75 per cent
of all serious mental health and related substance use disorders commence
before age 25 years and approximately 14 per cent of 12-17 year olds and 27 per
cent of 18-27 year olds experience such problems in any given year. Effective, early intervention is necessary to
reduce the burden of disease in this age group.
Yet young people are particularly reluctant to get
help. The ADGP advised on major barriers to young people:
...14 percent of adolescents reported being worried about what
other people would think of them if they sought help. 38 percent report that
they preferred to manage their own problems, and other major barriers include
thinking nothing would help (18 percent) and not knowing where to get help (17
Young males suffer the additional barrier conferred by
the Australian stereotype of masculinity. Evidence suggested that rural males
are even more affected, as the 'tougher than John
Wayne' image supported the high incidence of
suicide in the bush. A submission stated:
Unless they have lost a limb it is hard to get any young
Australian male to a doctor. It is viewed as a sign of weakness to seek help
and the fact that there are few physical symptoms with mental illness, the
adage of ‘It’s all in your head’, couldn’t be any more relevant.
The Victorian Task Force report on Suicide Prevention
...young people living in family environments that display
disharmony, inconsistent discipline, violence, neglect and abuse are at
significantly increased risk of suicide and require particular support. Some young people living in such
circumstances subsequently become homeless, and their risk of engaging in
self-harming behaviours then may escalate.
youth population through school-based programs
A number of submissions acknowledged the importance of GPs
as a primary point of contact for families but many also acknowledged that
young people do not necessarily seek help from GPs. This was especially so for young
people who are marginalised and disconnected from family and school. A child and adolescent mental health
service in Perth indicated that 35
percent of referrals came from schools.
The Australian Guidance and Counselling Association
(AGCA) representing school counsellors and school psychologists argued that
schools are an obvious location in the community for mental health promotion,
prevention and early intervention.
The AGCA pointed out that as young people were at school anyway, there was less
of a problem associated with the stigma of seeking help, and less of a problem
accessing transport when services were not locally available.
Schools currently conduct a number of programs aimed at
building students' healthy development and resilience. MindMatters is a mental
health promotion initiative in secondary schools, funded by the Federal
Department of Health and Ageing and discussed later in this chapter. The AGCA
argued that although schools already conducted such programs, there was
considerable room for improvement, and for mental health promotion and
prevention to be built into the ongoing curriculum in the same way as subjects
such as literacy and numeracy:
Mental health promotion and illness prevention needs to be
clearly built into the curriculum for teachers to afford it the same consistent
attention they give to literacy and numeracy skills. Literacy and numeracy
skills are reinforced year after year in school. All students need to develop
resilience, social competence and coping skills. These abilities also need to
be reinforced year after year in school.
AGCA pointed to the importance of linkages between
schools, health professionals, and community agencies to ensure effective early
intervention. The ADGP argued that GP groups played an important role in
bringing together schools, health professionals and family/community support
groups for improved collaboration and referral pathways.
Minimising the impact of adverse conditions or disadvantage
A number of submissions emphasised the importance of
social connectedness as a protective factor against the development of mental
health problems, and also stressed the importance of minimising risk factors,
such as poverty, unemployment, and poor education. The AGCA indicated that
children from impoverished backgrounds and disadvantaged population groups are
at greater risk of adult mental health concerns. The ADGP submitted that:
Social connectedness, stable accommodation, employment and
relationships are well documented factors that protect against the development
of mental health problems and disorders.
ACOSS argued that there was a strong link between
poverty and disadvantage, and poor mental health:
While there is a clear and strong association between poverty
and mental illness, the causal links are more complex. Nevertheless, it is at
least as likely that the stresses relating to poverty and disadvantage are as
significant in contributing to mental illness as the presence of mental illness
is to the likelihood of a person living in poverty. What is indisputable is
that poverty and mental illness can combine in a vicious cycle in which the
fact of poverty contributes to the manifestation of mental illness, which in
turn contributes to the risk of poverty.
ACOSS argued for greater investment in supports and
social services to not only reduce the poverty of people with mental illness,
but to ensure that poverty did not contribute to the incidence of mental
illness in the first place, or to its severity or persistence.
In a similar vein, the AMHCN supported a focus on
addressing social inequities that are risk factors in the development of mental
health problems. Representing people living with mental illness, AMHCN
Many of our members believe very strongly that their experiences
of mental distress are closely linked to life experiences. Poverty, physical
illness, immigration detention, racism, family violence, breakdown of adult
relationships, losing substantial amounts of money, gambling etc. etc. lead to
Over the past decade it has been fashionable to attempt to
understand mental illness as some sort of a biochemical abnormality acting in
isolation from the rest of people’s lives. This has meant that the focus has
come off searching for ways of preventing the social and cultural inequities
and traumas that many consumers believe precedes the development of signs of
Social disadvantage may also be vertically transmitted
from one generation to the next in deprived communities, thus perpetuating
emotional and behavioural and psychological problems.
Delivering promotion, prevention and early intervention programs to the
A variety of community-based services are working to
reduce the stigma of mental illness and raise awareness in the community. There
is also a number of programs that are assisting to recognise the onset of
mental illness and prevent the escalation of harm. Some concentrate on
particular modes of service delivery; others concentrate on addressing specific
issues. The following provides an overview of some of the services available in
the areas of telephone counselling, online services, child and youth-focussed services,
and other national initiatives.
A number of telephone counselling services exist that
have an important place in the spectrum of prevention and early intervention
strategies in Australia,
providing a cost-effective and practical way of responding to the immediate
needs of consumers.
runs the longstanding free 24-hour telephone counselling service from 42
centres throughout Australia
in around 59 different locations, half of which are in rural and remote areas.
In addition, Lifeline provides information and referral services and has
recently developed Just Ask, a mental health information telephone service with
a particular focus on rural and regional areas and Just Look, a one-stop
national service directory available through a web-based portal or CD-ROM.
Lifeline answered 489,406 calls in 2004-05, which gives
an indication of the scope of assistance provided to the community. The vast majority of Lifeline's
workforce is volunteers (estimated at 10,000), providing telephone counselling
and administrative support.
Telstra has committed around $1 million per annum for
the next three years to Lifeline. Other sources of funding include corporate
sponsors, partners and donors and contributions from community members.
Funding from the Australian Government (Department of Health and Ageing
and Department of Family and Community Services) over the past year has enabled
Lifeline to develop a range of new initiatives for improving access to care in
the community. However, Lifeline has stated that it does not
receive recurrent state government funding to manage the ever increasing demand
for telephone counselling services, despite Commonwealth and State Government
services advising clients to contact Lifeline for assistance.
Kids Help Line
Kids Help Line is a free 24-hour national telephone and
on-line counselling service for children and young people aged 5 to 18. The service is run by Boystown and adopts a
child-centred early intervention approach towards the mental health issues of young
people, employing 100 professionally trained, paid counsellors, and as well as
24-hour telephone counselling, provides crisis response, after-hours services,
and ongoing support. Many young
people who contact Kids Help Line have experienced adverse life events and/or
display early warning signs of mental health problems. In 2004, Kids Help Line
answered 447,367 calls and more than half of these calls were from rural and
Kids Help Line is well-recognised by young people. A
study conducted by the NSW Commissioner for Children found that it was the only
formal service that most children and young people could identify.
The key sources of revenue for Kids Help Line are
Boystown lotteries and special community fund-raising activities, while funding
from the Australian Government supports specific programs relating to suicide
prevention, supported accommodation and employment assistance. Revenue is also provided through
donations from the public and corporate sponsors, with Optus being the major
sponsor of Kids Help Line.
Kids Help Line has also developed the Parentline
telephone counselling service, which assists parents and carers with
behavioural management, parenting skills, and interpersonal relationships.
Parentline is a Queensland and Northern
Territory service, funded by the respective state
The Internet has been used effectively in recent times
for various online counselling and therapy initiatives. These services deliver
treatment in the form of computer-based therapy, facilitating care that may be
otherwise unaffordable to the consumer or very difficult to access based on
location. This mode of delivery is also more cost
effective than visiting a healthcare professional, yet effectiveness of
treatment is reported to be on par.
MoodGYM is a free-of-charge interactive software
program delivering therapy for depression.
It leads the user through a number of modules that explore varying areas
of their life, such as learned behaviours, coping skills and relationships, and
how to better manage some of the difficulties of everyday life. The site
currently attracts around 18,000 visits per month, has 80,000 registered users
and is accessed in 62 countries.  The site is fully funded through the
Research by the
Centre for Mental Health Research has shown that MoodGYM is effective in
reducing depression and anxiety symptoms, with the degree of improvement
equivalent to that achievable through face-to-face psychotherapy.
Kids Help Line online email and counselling
Boystown (through Kids Help Line) was funded by the
Australian Government to establish real-time web counselling and email services. Boystown reported these services as
becoming increasingly popular, and the number of online contacts about mental
health issues being 'three times higher than the rate of contacts to Kids Help
Line via telephone counselling'. 
This is encouraging support for the further development of on-line
Reach Out! is a web-based mental health service
targeting late adolescent and early adults (18-24 year old age group). The
service provides self-help information, illustrated by personal stories from
people facing challenges, and is focussed on empowering individuals to work
through difficulties themselves wherever possible, whilst also providing
details of referral services for additional support. Reach Out! is funded by the Inspire
DepressioNet is an on-line service providing
information and resources on depression, including 24-hour peer based
support. The service emphasises that it
is operated by people who live with depression, providing encouragement and
support that is tailored to the unique needs of people with depression, their
families and carers. DepressioNet
is funded through grants, donations and corporate partnerships.
Child and youth-focussed services
MindMatters supports the development of
sound emotional and social development of pupils in Australian secondary
schools through delivering education and resources for promotion of mental
health, and prevention of and early intervention in mental illness. An evaluation of the project by the
Australian Principals Associations Professional Development Council reported
very positive results, and this view is supported across other parts of the
community. A number of side
projects have been created under the MindMatters
banner, including MindMatters Plus
(supporting students deemed to be at risk) and MindMatters Plus GP (establishing referral pathways between MindMatters Plus schools and primary
mental health care practitioners).
was funded from 2000-2005 through the National Mental Health Strategy, and the committee
was informed that future funding requirements were to be sought through the
Department of Health and Ageing. The
Australian Divisions of General Practice stated its support for federal
Government funding to ensure the longevity of the project, as well as to expand
MindMatters Plus GP initiative nation-wide. Mr Don Zoellner,
Chair of the MindMatters National
Reference Committee, also informed the committee that the MindMatters program has not been taken up by all schools, possibly
because they already have programs in place.
The Mental Health Council of Australia was supportive of MindMatters, but also stated that MindMatters is currently 'limited
in its scope and application', and cannot be fully effective unless supported
by broader community strategies.
ORYGEN is a youth-focussed (12-25 years old) mental
health care and research organisation servicing the western and north-western
regions of Melbourne, Victoria.
Key services provided by the organisation include operating a youth clinical
program, the ORYGEN Research Centre and managing the support and training
service for early psychosis in Australia.
ORYGEN is the 'only specialist youth mental health service of its type in Australia',
and has received international recognition.
The philosophy of ORYGEN is to acknowledge the special
needs of youth and develop promotion, prevention and treatment strategies
tailored to their specific requirements. ORYGEN advises:
Treatments have never been better – if treated appropriately and
early, a young person has excellent prospects for a happy and healthy
life. Early case identification and
intensive treatment of the emerging disorder has been shown to reduce the need
for inpatient treatment and is associated with better outcomes and subsequent
cost reductions for the health care system.
Like many community-based organisations, ORYGEN has
stated that it is unable to deliver services to all those in need due to a lack
of resources. This results in a situation where 'a substantial number of very
unwell young people have to be turned away' with longer-term impacts of
untreated mental illness felt by both the consumer and society as a whole.
In December 2005, the Prime Minister announced that a
consortium, led by the ORYGEN Research Centre, will establish a Youth Mental
Health Foundation. The Foundation will have access to $54
million funding over four years from the Australian Government, and will bring
together a number of organisations to improve coordination of mental health
services for young people. This model of
service delivery could be adopted across other areas of mental health care in Australia.
ORYGEN recommended the creation:
of youth-specific specialist mental health services for young
people aged 12-25, which would complement existing state funded child and adolescent,
adult and aged persons’ services, and would provide access to integrated mental
health, substance use, and vocational recovery supports and services.
Such services would have a special focus on first episode and
early stage psychotic disorders and major mood disorders — illnesses which
eventually make up the clientele of the State public mental health system. It is estimated that the roll-out of
youth-specific, specialist mental health services across Australia
would require a recurrent budget of $525M per annum, although a proportion of
this cost may be offset by re-allocation of resources from existing CAMHS and
adult public mental health services.
Under this model, there would be at least three age
brackets to which mental health care would be delivered: children; adolescents
and/or youth; and adult. There is strong evidence that the onset of many mental
health problems occurs during the teenage and early adult years, and that the
special needs of this group deserve a targeted response. Mental health amongst young people
is also discussed further in Chapter 15.
Other Child and Youth Services
The committee heard about examples of other child and
youth services, in addition to those above, and those discussed earlier such as
PANDA. Mental Health Child Safety Support
Teams, established by the Queensland Government, provide specialist identification,
treatment and long-term therapy for children with severe psychological and
behavioural problems. These teams are linked with primary health care providers,
as well as non-government organisations to facilitate the continuity of care as
the child matures.
The Intensive Community Youth Service is under
development by the Western Australian Government. It aims to strengthen the opportunities for
early intervention in young people by linking a spectrum of both
community-based and specific mental health services to young people to support
them in life.
The Perinatal and Infant Mental Health
In the Community project, funded by
the South Australian Government, is working to improve the diagnosis and
management of perinatal and maternal health problems by primary health
providers and community organisations.
Beyondblue is a
national organisation for raising awareness about depression, anxiety disorders
and related substance abuse in Australia.
It is a bipartisan project of the Commonwealth, State and Territory
Governments, and the overwhelming focus to date has been raising awareness of
mental illness as a health problem in Australia
and reducing the associated stigma.
The organisation has conducted extensive research into people affected by
depression, their carers and families, and is working to develop new
initiatives for early intervention and prevention, destigmatisation of mental
illness, and to improve access to training and support services for both the
community and health care providers.
An example of recent work is beyondblue working with a
range of health care bodies to ensure those with mental illness receive the
same rights when dealing with insurance companies as are those with physical
disabilities. This is in response to
concerns from consumers that they are less able to access insurance products as
compared to people with a physical disability, so are being discriminated
Many important projects – at both the national and
local level – have been funded through the 'Living is for Everyone' (LIFE) framework
of the National Suicide Prevention Strategy.
The suicide rate is higher for mentally ill people than
the general population, particularly for people with disorders such as
depression, yet there is strong evidence that many individuals with this
illness are not recognised or do not receive adequate treatment. The indigenous population also has a
much higher rate of suicide, compared with the general population.
A key outcome of the LIFE framework is to reduce known risk factors for
suicide and self-harm.
Suicide Prevention Australia stated that for the 150
local projects funded through the LIFE framework, project areas include: 
Aboriginal and Torres Strait Islander
communities, ensuring that programs are culturally appropriate;
suicide prevention in males, as they are more
likely to commit suicide than females;
families, carers and friends bereaved by an act
alcohol and substance abuse associated with
self-harm and the increased risk of suicide;
suicide prevention in older people, as
international studies demonstrate that people over the age of 65 years have the
highest rate of suicide;
reduction in the impact of adverse social
conditions associated with an increased suicide risk, such as a death in the
family or domestic violence;
support to people involved with, or that may
potentially become involved with, the criminal justice or juvenile justice
enhancement of community acceptance and support
for marginalised groups, people with risk factors for suicide and those
affected by suicide; and
promotion of increased acceptability of
help-seeking to respond to mental health problems.
However, the ORYGEN Research Centre argues that the
LIFE suicide prevention strategy takes a public health oriented approach that
is too broad to be effective:
While such a broad population based approach is important if we
are to reduce suicide at a population level, it is very hard to measure and
implement. To make a measurable
difference it is important to tackle populations we know to be at high-risk –
the mentally ill (depression is present in 88 per cent of suicides), those in
early stages of a mental illness or recently discharged from a mental health
service and those with both mental health and substance abuse problems.
The challenges of delivering promotion, prevention and early intervention
A number of key challenges is restricting the long term
delivery of programs, or they are not available across the wider community. Challenges
examined in this section are: resourcing, short-term funding approach and a
lack of back-up services, and the need to embed a prevention approach within
health bureaucracies. There is also a
need to ensure that programs producing positive outcomes are recognised, funded
appropriately, and strategies developed to roll them out on a national scale.
The effectiveness – and difficulties – of using on-line
services as an alternative approach to reaching out to people in need is also
examined in this section.
Despite consensus on the need to give priority to
promotion, prevention and early intervention, a number of submissions argued
that insufficient resources generally for mental health had the effect of tying
up available resources in the treatment end:
... despite the policy directions and the evidence, the mental
health service system appears to reflect a sense of competing priorities
between treatment and promotion and prevention activities. Mental health
expenditure needs to reflect commitment across the spectrum of services, not a
focus on treatment services only.
Whilst expressing praise for PPEI Action Plan, the Australian
Health Promotion Association also lamented the competing resources that limited
the implementation of the Plan:
A significant barrier to progress in implementing [PPEI Action
Plan] in jurisdictions is created by the need for ‘prevention end’ interventions
to constantly compete with established clinical services for priority in
Submissions giving the perspective of medical and
allied health professionals painted a picture of this competition for resources
as it was felt at the coalface in hospitals and community mental health teams.
Frustration was expressed at the lack of opportunity to provide prevention and
early intervention services, because of the pressing need to deal with acute
cases of mental disorder. Auseinet
argued strongly for increased expenditure on prevention and early intervention
It is very clear that if we are going to stem the tide of
increasing prevalence of mental disorders such as depression, anxiety and mood
disorders, a greater proportion of the mental health budget needs to be
expended on [promotion, prevention and early intervention] initiatives which
intervene at a much earlier stage.
Short-term funding approach and a lack of back-up services
Concerns were raised that many initiatives were funded
on only a short-term basis, and did not result in lasting changes to the mental
health system. The Mental Health Council of
Australia commented that prevention and early intervention services were
restricted to demonstration funding rather than ongoing funding. The Australian Divisions of General
Practice supported federal government initiatives to build capacity of general
practitioners in the area of early intervention for children, but expressed
concern at what was seen as 'ad hoc, uncoordinated funding of a series of
projects by various levels of government'.
These comments reflect similar concerns expressed
throughout the inquiry regarding the drawbacks of short-term funding and pilot
project funding for many mental health initiatives, not just those associated
with prevention and early intervention. These concerns are discussed in Chapter
Suicide Prevention Australia argued that short-term
funding of prevention and early intervention projects runs the risk of
increasing demand for mental health services, without increasing services to
meet that demand:
The prevention ‘push’ often has encouraged the funding of
short-term projects that risk increasing expectations without interventions
being sustainable. Such funding enhancements generally have not generated
ongoing new mental health services.
The problem of creating demand without providing
services to meet the demand can also apply to well-supported programs such as
beyondblue, the depression awareness initiative, discussed earlier in this
chapter. One medical practitioner (from regional NSW) told the committee of her
concern that whilst the beyondblue initiative raised awareness of depression
and encouraged people to seek help, it could result in frustration when
services were not available:
... I would articulate the concern that, if we create more need,
unless we have more services we can deliver to support these people we are
going to have even more disappointed people. There is the difficulty of
beyondblue coming to town and identifying and raising awareness but then the
system does not have the capacity, or feels like it does not have the capacity,
to respond to those needs being generated.
Parham of Auseinet echoed these concerns,
telling the committee that a major problem in progressing the promotion and
prevention agenda was under-funding of the treatment end of services that
resulted in long waiting lists to access specialist mental health services. Ms
Parham told the committee:
... if we are serious about wanting to identify mental illness
early and get early intervention on the agenda, we really have to do something
about the service system that supports it.
Need to embed a prevention approach within health bureaucracies
A variable level of commitment to prevention and early
intervention strategies across jurisdictions was raised as a concern with the committee.
In particular, it was argued that there was a need within health bureaucracies
to get past a short-term, project-funding outlook, and move towards firmly
embedding a long-term prevention approach. Auseinet described its efforts in
assisting jurisdictions to develop infrastructure to support work in the
prevention and early intervention area, and indicated that all jurisdictions
now have some level of infrastructure in place to advance implementation.  Auseinet argued, however, that 'there
is still a way to go in embedding [prevention and early intervention
approaches] in sustainable systems and structures'. Ms
of Auseinet told the committee:
Unless you have things actually bedded down in what I would call
bureaucratic capacity, then really they are not sustainable and we are just
going to be back to square one. 
Auseinet also indicated that the level of
prevention/early intervention infrastructure developed was in some cases
determined by the energy and commitment of 'champions' or 'advocates', who made
progress through developing collaborative relationships. Unfortunately, as Professor
told the committee, the collaborative relationships can break down when these
key people move on, because the system supports are not there.
At a more general level, the Australian Divisions of
General Practice expressed concern at what it saw as a national lack of effort
and commitment to prevention and early intervention:
The problem is not a lack of evidence, availability of programs,
or that these programs lack merit. The issue is quite the opposite. On a
national scale, there has been insufficient effort and funding to promote
awareness, and coordinated access and uptake of these vital mental health
promotion, prevention and early intervention programs.
To monitor progress of jurisdictions in implementing
prevention and early intervention strategies, Auseinet suggested the
development of a promotion and prevention scorecard.
On-line services – a new way of targeting mental health problems?
A number of submissions pointed to the benefits of
online resources for mental health. The anonymity of online services was seen
as important in encouraging help-seeking by those who would otherwise not wish
to reveal their concerns. As the Australian Health Promotion Association
pointed out, ‘the advantage of anonymity in accessing online help is likely to
prove life-saving in many cases'.
The Australian Guidance and Counselling Association
reported anonymity as being particularly important for young males who are more
likely to seek anonymity and avoid closeness.
However, preliminary monitoring of gender and web counselling usage by Boystown
revealed that males were not accessing this service at a higher rate than
females, which was not the expected result.
Online services also were seen as very positive for
increasing access to services for people in rural and remote areas, especially
in locations where professional help was not available locally.
Inspire Foundation, sponsor of the Reach Out! website,
argued that online services were more appropriate than telephone services for
the late adolescence and early adult group, which generally does not access
Lifeline and Kids Help Line.
Inspire also argued that online services were much cheaper to provide than
Although many submissions were very positive about the
potential of online services in prevention and early intervention, some
drawbacks were raised. The Australian Health Promotion Association (AHPA) put
forward that online service provisions had further potential, and deserved
continued support, but pointed to the problems of access for people on limited
incomes. One submitter, a parent
of a person with a mental illness, echoed this concern, and suggested that
mental health care using e-technology was primarily for benefit to people on
middle and upper incomes. The
submitter argued that people with mental illness would make more use of such
online services if they were more accessible and affordable:
While people on low incomes and those below the poverty line may
be able to obtain some access to the internet through social and other support
services ... this access is not regular enough to be of any real help. Although
my younger son rejects almost all support services, I believe he would access
mental health care over the internet if he had free access to the internet in
his home. He is very computer literate, very concerned about his privacy and
would like to manage his life by himself (although he is not able to do so).
Accessing mental health care by himself in the privacy of his own home would
suit him very well.
This parent suggested that 'people with a mental
illness who are interested in accessing mental health care over the internet
should be provided with a cheap second-hand computer and a certain amount of
free internet access in their own home'.
AICAFMA raised a further concern with online services
provided to young people, suggesting that consideration needed to be given to
the ethics of providing counselling to children without the consent of their
approach is taken to the labelling of mental
illness, greater community awareness is widely regarded as an important part in
the process of healing and acceptance. Raising community awareness will reduce
fear and ignorance. This will allow people with mental illnesses to live and
work more successfully in their communities.
But it is also a key part of enhancing mental health promotion, prevention and
Prevention and early intervention clearly have a
critical role in alleviating the impact of mental illness in the longer term,
particularly when targeted at developing members of the community, such as the
children, adolescents and young adults. The future benefits of proactive
management of mental illness at an early stage and in minimising the social
factors that may lead to the onset of mental illness are overwhelming. This includes a reduction in the social
burden associated with supporting people left untreated for so long that they
are in very poor health and unable to function independently, lower clinical
care costs, reducing the incidence of suicide, and a better quality of life for
people with, or at risk of developing, a mental illness.
However, this is only part of the work that is needed.
Much more still needs to be done at the national level to raise community
awareness of other disorders with devastating effects, and in promoting the much-needed
services that are available across communities, in every state and territory
to deliver health care. Awareness raising is largely ineffective if the back-up
services are not available. This also
extends to ensuring a steady and reliable funding stream to evolve promotion,
prevention and early intervention initiatives and ensure their longer term
Navigation: Previous Page | Contents | Next Page