The mental health survey will be run in 2020, with new data on how common mental illness is due the year after. This is a welcome announcement for the mental health sector, because information gathered in a survey like this can be used to shape policy reform.
But eating disorders, a major category of mental illnesses, have been neglected by all previous important data collection initiatives in Australia so far. Notably, they were missing from the last national mental health surveys in 1997 and 2007.
Eating disorders are not yet an official part of this new survey, but we understand they are being considered.
If people with eating disorders are not counted, they don’t count. In other words, we need to know who has these severe and debilitating conditions, and then work towards improving the treatment and supports available for them.
National surveys ask the public if they have experienced symptoms of various mental illnesses, either in their lifetime or during the past 12 months.
People who answer “yes” to particular clusters of symptoms are “diagnosed”, or assumed to have had the illness.
Asking the public about their symptoms is the best way to understand how common mental illnesses are. This is because most people with a mental illness don’t seek treatment and may never have had a diagnosis. So collecting data from health services or based on reported diagnoses doesn’t provide a full picture.
Also, for some mental illnesses, such as anorexia nervosa or psychosis, people might not realise they have a diagnosable illness. But they are likely to respond “yes” to direct questions about their experiences with body dissatisfaction or thinking difficulties.
Eating disorders are more than just anorexia
A person with anorexia nervosa engages in dangerous behaviours to maintain a very low body weight, or to lose more weight. Although most people have heard of it, anorexia is not common. We know this from other countries who have previously studied the prevalence of anorexia in community surveys.
That being said, it’s very serious and can be fatal. It has the highest mortality of all non-substance use mental disorders, and one in five of those deaths is by suicide.
People with eating disorders often have a negative body image, and a strong perception their self-worth is tied to their appearance or body weight.
Burden of disease
Every year in Australia, millions of years of healthy life are lost because of injury, illness or premature deaths in the population. This is known as “burden of disease”.
Like national surveys, burden of disease studies are extremely important for planning and funding health services. They use prevalence statistics, or how many people per 100,000 Australians are assumed to have a particular illness. Given we don’t have good data on how prevalent eating disorders are, we likely underestimate their burden of disease.
The recently released Australian Burden of Disease Study 2015 lists eating disorders among the most burdensome illnesses for Australian females, being the tenth leading cause of total burden of disease for females aged 5-14 and women aged 25-44.
Eating disorders were estimated to cost the health system A$99.9 million in the year 2012 alone.
Better treatment and prevention of eating disorders would reduce the cost and the burden of disease. But we need the data to show where the treatment gaps are and how to fund better services.
There are many promising elements of the proposed Intergenerational Health and Mental Health Study. These include surveying multiple people in a family, gathering physical and mental health data, and a target of more than 60,000 Australians. But it’s time eating disorders were included.
Unfortunately, we cannot use this type of evidence to promote eating chocolate as a safeguard against depression, a serious, common and sometimes debilitating mental health condition.
This is because this study looked at an association between diet and depression in the general population. It did not gauge causation. In other words, it was not designed to say whether eating dark chocolate caused a reduction in depressive symptoms.
People in the study reported what they had eaten in the previous 24 hours in two ways. First, they recalled in person, to a trained dietary interviewer using a standard questionnaire. The second time they recalled what they had eaten over the phone, several days after the first recall.
The researchers then calculated how much chocolate participants had eaten using the average of these two recalls.
Dark chocolate needed to contain at least 45% cocoa solids for it to count as “dark”.
The researchers excluded from their analysis people who ate an implausibly large amount of chocolate, people who were underweight and/or had diabetes.
The remaining data (from 13,626 people) was then divided in two ways. One was by categories of chocolate consumption (no chocolate, chocolate but no dark chocolate, and any dark chocolate). The other way was by the amount of chocolate (no chocolate, and then in groups, from the lowest to highest chocolate consumption).
The researchers assessed people’s depressive symptoms by having participants complete a short questionnaire asking about the frequency of these symptoms over the past two weeks.
The researchers controlled for other factors that might influence any relationship between chocolate and depression, such as weight, gender, socioeconomic factors, smoking, sugar intake and exercise.
What did the researchers find?
Of the entire sample, 1,332 (11%) of people said they had eaten chocolate in their two 24 hour dietary recalls, with only 148 (1.1%) reporting eating dark chocolate.
A total of 1,009 (7.4%) people reported depressive symptoms. But after adjusting for other factors, the researchers found no association between any chocolate consumption and depressive symptoms.
However, people who ate dark chocolate had a 70% lower chance of reporting clinically relevant depressive symptoms than those who did not report eating chocolate.
When investigating the amount of chocolate consumed, people who ate the most chocolate were more likely to have fewer depressive symptoms.
What are the study’s limitations?
While the size of the dataset is impressive, there are major limitations to the investigation and its conclusions.
First, assessing chocolate intake is challenging. People may eat different amounts (and types) depending on the day. And asking what people ate over the past 24 hours (twice) is not the most accurate way of telling what people usually eat.
Then there’s whether people report what they actually eat. For instance, if you ate a whole block of chocolate yesterday, would you tell an interviewer? What about if you were also depressed?
This could be why so few people reported eating chocolate in this study, compared with what retail figures tell us people eat.
Finally, the authors’ results are mathematically accurate, but misleading.
Only 1.1% of people in the analysis ate dark chocolate. And when they did, the amount was very small (about 12g a day). And only two people reported clinical symptoms of depression and ate any dark chocolate.
The authors conclude the small numbers and low consumption “attests to the strength of this finding”. I would suggest the opposite.
Finally, people who ate the most chocolate (104-454g a day) had an almost 60% lower chance of having depressive symptoms. But those who ate 100g a day had about a 30% chance. Who’d have thought four or so more grams of chocolate could be so important?
This study and the media coverage that followed are perfect examples of the pitfalls of translating population-based nutrition research to public recommendations for health.
My general advice is, if you enjoy chocolate, go for darker varieties, with fruit or nuts added, and eat it mindfully. — Ben Desbrow
Blind peer review
Chocolate manufacturers have been a good source of funding for much of the research into chocolate products.
While the authors of this new study declare no conflict of interest, any whisper of good news about chocolate attracts publicity. I agree with the author’s scepticism of the study.
Just 1.1% of people in the study ate dark chocolate (at least 45% cocoa solids) at an average 11.7g a day. There was a wide variation in reported clinically relevant depressive symptoms in this group. So, it is not valid to draw any real conclusion from the data collected.
For total chocolate consumption, the authors accurately report no statistically significant association with clinically relevant depressive symptoms.
However, they then claim eating more chocolate is of benefit, based on fewer symptoms among those who ate the most.
In fact, depressive symptoms were most common in the third-highest quartile (who ate 100g chocolate a day), followed by the first (4-35g a day), then the second (37-95g a day) and finally the lowest level (104-454g a day). Risks in sub-sets of data such as quartiles are only valid if they lie on the same slope.
The basic problems come from measurements and the many confounding factors. This study can’t validly be used to justify eating more chocolate of any kind. — Rosemary Stanton
Research Checks interrogate newly published studies and how they’re reported in the media. The analysis is undertaken by one or more academics not involved with the study, and reviewed by another, to make sure it’s accurate.
HILDA surveys collate data on the “reported diagnosis” of depression and anxiety disorders. Many people with these conditions have remained undiagnosed by a health practitioner, so it could simply be a matter of more people seeking professional help and getting diagnosed.
To find out whether there is a real increase, we need to survey a sample of the public about their symptoms rather than ask about whether they have been diagnosed. This has been done for almost two decades in the National Health Survey.
This graph shows the percentage of the population reporting very high levels of depression and anxiety symptoms over the previous month, from 2001 to 2017-18.
Rather than worsening, the nation’s mental health has been steady over this period.
Shouldn’t our mental health be improving?
So it seems while our mental health is not getting worse, we are more likely to get diagnosed. With increased diagnosis, it’s no surprise Australians have been rapidly embracing treatments for mental-health problems.
Psychological treatment has also skyrocketed, particularly after the Australian government introduced Medicare coverage for psychology services in 2006. There are now around 20 psychology services per year for every 100 Australians.
The real concern is why we’re not seeing any benefit from these large increases in diagnosis and treatment. In theory, our mental health should be improving.
There are two likely reasons for the lack of progress: the treatments are often not up to standard and we have neglected prevention.
Antidepressants, for example, are most appropriate for severe depression, but are often used to treat people with mild symptoms that reflect difficult life circumstances.
Psychological treatments can be effective, but require many sessions. Around 16 to 20 sessions are recommended to treat depression. Getting a couple of sessions with a psychologist is too often the norm and unlikely to produce much improvement.
The big area of neglect in mental health is prevention. Australia achieved enormous gains in physical health during the 20th century, with big drops in premature death. Prevention of disease and injury played a major role in these gains.
We might expect a similar approach to work for mental-health problems, which are the next frontier for improving the nation’s health. However, while we have been putting increasing resources into treatment, prevention has been neglected.
Parents who are in conflict with each other and fight a lot, for example, may increase their children’s risk for depression and anxiety disorders, while parents who show warmth and affection towards their children decrease their risk. Parents can be trained to reduce these risk factors and increase protective factors.
Yet successive Australian governments have lacked the political will to invest in prevention.
Where to next?
There is an important opportunity to consider whether Australia should be heading in a very different direction in its approach to mental health. The Australian government has asked the Productivity Commission to investigate mental health.
While we’ve had many previous inquiries, this one is different because it’s looking at the social and economic benefits of mental health to the nation. This broader perspective is important because action on prevention is a whole-of-government concern with resource implications and benefits that extend well beyond the health sector.
The reduction in life span [for people experiencing loneliness] is similar to that caused by smoking 15 cigarettes a day, and it’s greater than the impact on life span of obesity … Look even deeper, and you’ll find loneliness is associated with a greater risk of heart disease, depression, anxiety and dementia.
Research suggests low-income individuals are more likely to experience loneliness. So, too, are people who have a serious mental or physical health condition or have had a serious disruptive event (financial or job loss, illness or injury, or relationship breakdown) in the last couple of years.
The impact of housing tenure on loneliness has received little attention. While recognising that there are no definite associations, we interviewed about 80 older (65-plus) private renters and social housing tenants who depended on the Age Pension for their income. These in-depth interviews indicated that their housing tenure was a critical factor in their risk of experiencing loneliness.
Many older private renters have little disposal income, because the cost of housing uses up much of their income. They also live with the constant possibility that they may be asked to vacate their accommodation. Their limited budgets mean they often end up living in a poorly located property. These features, individually or in combination, create fertile ground for anxiety and loneliness.
Their dire financial situation was often an obstacle to social activities. One interviewee told of how she had to choose between food or breaking her isolation by using public transport.
Well, you sort of think what you can do with $2.50. That’s a loaf of bread type of thing. – Beverley *
A 72-year-old woman living by herself said she could not afford the outings organised by her church.
There’s quite an active social club at the church for over-55s but I can’t go to any of those … Sometimes I think it would be nice to go on something that appeals to me, yes. And they might have an afternoon at somebody’s home and you’re asked to bring a plate [of food]. You see, I couldn’t afford to do that.
Peter, 67 and divorced, had left the workforce prematurely due to ill-health.
I’ve become very isolated. I used to, before I had the hip operation, I used to play tennis and I loved to play tennis … but I really can’t afford it. I’ve found a few clubs that I could go and play in. I’d like to get back to it, but they say, ‘Ah, the fees are this and you pay it annually,’ and I can’t come up with $150 or $200 or whatever.
Lack of money and insecure tenure were sources of enormous distress and anxiety, which further discouraged social contact. Brigette (67) was brutally honest:
You do get depressed and I believe that’s why people suicide … And there have been times when I’ve thought, what is the point to life? I really have thought this can’t go on, you know … I feel sorry for people because it is hard, and once you stay in it’s like crawling out of a slime pit … I have to say, ‘Get up and go out, go up the shops … Pretend you need potatoes or something.’
Not all of the private renters interviewed experienced loneliness. These interviewees usually had strong family ties or had managed to find affordable and secure accommodation.
In sharp contrast, only a small proportion of the social housing tenants interviewed said they were lonely. Almost all were adamant they did not experience loneliness and felt they had strong social ties. Their affordable rent, security of tenure, long-term residence and having neighbours in a similar position meant they could socialise and were not beset by anxiety.
An 85-year-old long-established social housing tenant’s response to the question about loneliness and isolation was typical:
I do like it around here. I know where everything is and I know all the people, especially around these units you know. I know everyone and they know me. I like it around here. This is my home, you know. This is a community, I think. Like I know all the people and we’ve become really good friends. I couldn’t think of being anywhere else. – Kay
Pam, who had been a private renter before being allocated social housing, reflected on how her life had changed:
Well, it is changed because I’m happier and I think I’m healthier and I have a lot of new friends. I also have a lot more people around me for support if anything does happen. If I get sick and if they don’t see me for a few days someone will come and say, ‘Pam, are you OK?’ In private housing there was nobody.
The residualisation of social housing meant some tenants were living in what they perceived to be unbearable conditions. However, they generally were able to deal with their situation. Patricia coped with her very challenging neighbours by going to the local community centre.
No, I hate it [public housing]. I live here [at the community centre] every day. Yes, I’m on the committee here and I do things every day. This is my home, my family. Everybody is friendly with everybody. We have outings and things.
What the interviews indicate is that the housing tenure of age pensioners often plays a fundamental role in whether they are able to escape the experience of loneliness. Older private renters are far more likely to experience loneliness than their counterparts in social housing and that loneliness can be acute.
This year’s budget includes $448.5 to modernise Australia’s Medicare system, by encouraging people with diabetes to sign up to a GP clinic for their care. The clinic will receive a lump sum payment to care for the person over time, rather than a fee each time they see their GP.
The indexation freeze on all GP services on the Medicare Benefits Schedule (MBS) will lift from July 1, 2019, at a cost of $187.2 million. The freeze will be lifted on various X-ray and ultrasound MBS rebates from July 1, 2020.
The budget announces $461 million for youth mental health, including 30 new headspace centres, some of which will be in regional areas. But it does little to address the underlying structural reforms that make it difficult for Australians to access quality and timely mental health care.
In aged care, the government will fund 10,000 home care packages, which have been previously announced, at a cost of $282 million over five years, and will allocate $84 million for carer respite. But long wait times for home care packages remain.
Other announcements include:
$62.2 million over five years to train new rural GPs
$309 million for diagnostic imaging services, including 23 new MRI licences
$331 million over five years for new pharmaceuticals, including high-cost cancer treatments
$107.8 million over seven years for hospitals and facilities including Redland Hospital, Bowen Hospital, Bass Coast Health and Ronald McDonald House
$70.8 million over seven years for regional cancer diagnosis, treatment and therapy centres
$114.5 million from 2020-21 to trial eight mental health facilities for adults
$43.9 million for mental health services for expectant and new parents
$35.7 million over five years for increased dementia and veterans’ home care supplements
$320 million this year as a one-off increase to the basic subsidy for residential aged-care recipients.
Here’s what our health policy experts thought of tonight’s budget announcements.
A hesitant step forward for Medicare
Stephen Duckett, Director, Health Program, Grattan Institute
Medicare funding is slowly creeping into the 21st century. The 19th-century model of individual fees for individual services – suitable for an era when medicine was essentially dealing with episodic conditions – is being supplemented with a new fee to better manage the care of people with diabetes.
The precise details of the new fee – including the annual amount and any descriptors – have not yet been released. But it should encourage practices to move towards a more prevention-oriented approach to chronic disease management, including using practice nurses to call patients to check up on their condition, and using remote monitoring technology.
The budget announcement contained no evaluation strategy for the initiative. The government should produce such a strategy soon.
Support for aged and disability care
Hal Swerissen, Emeritus Professor, La Trobe University, and Fellow, Health Program, Grattan Institute
The budget has short-term measures to address major issues in aged care and disability while we wait for the royal commissions to fix the long-term problems.
The National Disability Insurance Agency (NDIA) is struggling with the huge task of putting the National Disability Insurance Scheme (NDIS) in place.
There has been a major under-spend on the on the scheme. Price caps for services such as therapy and personal care are too low and nearly one-third of services are operating at a loss. The under-spend would have been more if there hadn’t been a last-minute budget decision to significantly increase service caps, at a cost of $850 million.
$528 million dollars has also been announced for a royal commission to look at violence, neglect and abuse of people with disabilities – the most expensive royal commission to date.
There is more funding for aged care. Currently, 130,000 older people are waiting for home care packages – often for a year or more. Nearly half of residential care services are losing money and there are major concerns about quality of care.
The short-term fix is to give residential care $320 million to try to prevent services going under. The budget includes 10,000 previously announced home care packages, at a cost of $282 million, but that still leaves more than 100,000 people waiting.
Little for prevention, Indigenous health and to address disparities
Lesley Russell, Adjunct Associate Professor, Menzies Centre for Health Policy, University of Sydney
Preventable diseases and conditions are a key factor in health inequalities and rising health-care costs. The two issues looming large are obesity and its consequences, and the health impacts of climate change.
There is $5.5 million for 2018-19 and 2019-20 for mental health services in areas affected by natural disasters, and $1.1 million over two years for the Health Star rating system – otherwise nothing for primary prevention.
The Treasurer did not mention Closing the Gap in his budget speech, and there is little in the budget for Indigenous health.
Just $5 million over four years is provided in the budget for suicide-prevention initiatives. And the Lowitja Institute receives $10 million for health and medical research.
$6.3 million to continue the development of the Health Data Portal for services funded under the Indigenous Australians Health Program.
Inequalities and disparities
Disadvantaged rural and remote communities will (ultimately) benefit from efforts to boost National Rural Generalist Training Pathway, with $62.2 million provided over four years. This was a 2016 election commitment.
Peter Sivey, Associate Professor, School of Economics, Finance and Marketing, RMIT University
There are no major changes to public hospital funding arrangements in this year’s budget.
Funding for public hospitals is predicted to increase at between 3.7% and 5.6% over the forward estimates. However, these figures are contingent on the new COAG agreement on health funding between the Commonwealth and states, which is due to be finalised before the end of 2019.
The states will be hoping to wring some more dollars from the federal government given their soaring public hospital admissions and pressure on waiting times.
Government spending on the private health insurance rebate is projected to increase more slowly than premiums at between 1.8% and 3.2% because of indexation arrangements which are gradually reducing the rebate over time.
Smaller targets for mental health
Ian Hickie, Co-Director, Brain and Mind Institute, University of Sydney
Numerous reports and accounts from within the community have noted the flaws in Australia’s mental health system: poor access to quality services, the uneven roll-out of the NDIS, and the lack of accountability for reforming the system.
The next federal government faces major structural challenges in mental health and suicide prevention.
Not surprisingly, this pre-election budget does not directly address these issues. Instead, it focuses on less challenging but worthy targets such as:
continued support for expansion of headspace services for young people ($263m over the next seven years) and additional support for early psychosis services ($110m over four years)
support for workplace-based mental health programs ($15m)
support for new residential care centres for eating disorders ($63m).
A more challenging experiment is the $114.5 committed to eight new walk-in community mental health centres, recognising that access to coordinated, high-quality care that delivers better outcomes remains a national challenge.
Despite the commitment of health minister Greg Hunt to enhanced mental health investments, the total increased spend on these initiatives ($736.6m) is dwarfed by the big new expenditures in Medicare ($6b), improved access to medicines ($40b), public hospitals ($5b) and aged care ($7b).
It will be interesting to see whether mental health reform now receives greater attention during the election campaign. At this stage, neither of the major parties has made it clear that it is ready to deal directly with the complex challenges in mental health and suicide prevention that are unresolved.
New funding for research, but who decides the priorities?
Philip Clarke, Professor of Health Economics, University of Melbourne
The budget contains several funding announcements for research.
The government will establish a Health and Medical Research Office, to help allocate money from the Medical Research Future Fund (MRFF). This will be needed, as the budget papers commit to a further $931 million from the MRFF for:
Clinical trials for rare cancers and rare diseases
Emerging priorities and consumer-driven research
Global health research to tackle antimicrobial resistance and drug-resistant tuberculosis.
In addition, the budget includes:
$70 million for research into type 1 diabetes
a large investment for genomics (although that is a re-announcement of $500 million promised in last year’s budget)
a series of infrastructure grants to individual universities and institutions, such as $10 million to establish the Curtin University Dementia Centre of Excellence.
The government appears to be moving away from allocating medical research funding through existing funding bodies, such as the National Health and Medical Research Council (NHMRC), towards allocating research funds to specific disease areas, and even to individual institutions.
This is a much more direct approach to research funding, but it raises a few important questions. On what basis are these funding decisions being made? And why are some diseases considered priorities to receive funding? There is very little detail to answer these questions.
Australia’s allocation of research funding through the MRFF is diverging from long-held traditions in other countries, such as the United Kingdom, which apply the “Haldane principle”. This involves researchers deciding where research funding is spent, rather than politicians.
* This article has been updated since publication to clarify the 10,000 home care packages have been previously announced.
Depression has long been treated with medication and talking therapies – and they’re not going anywhere just yet. But we’re beginning to understand that increasing how much exercise we get and switching to a healthy diet can also play an important role in treating – and even preventing – depression.
So what should you eat more of, and avoid, for the sake of your mood?
Ditch junk food
Research suggests that while healthy diets can reduce the risk or severity of depression, unhealthy diets may increase the risk.
Of course, we all indulge from time to time but unhealthy diets are those that contain lots of foods that are high in energy (kilojoules) and low on nutrition. This means too much of the foods we should limit:
processed and takeaway foods
refined grains, such as those in white bread, pasta, cakes and pastries
This way of eating is common in Mediterranean countries, where people have been identified as having lower rates of cognitive decline, depression and dementia.
In Japan, a diet low in processed foods and high in fresh fruit, vegetables, green tea and soy products is recognised for its protective role in mental health.
How does healthy food help?
A healthy diet is naturally high in five food types that boost our mental health in different ways:
Complex carbohydrates found in fruits, vegetables and wholegrains help fuel our brain cells. Complex carbohydrates release glucose slowly into our system, unlike simple carbohydrates (found in sugary snacks and drinks), which create energy highs and lows throughout the day. These peaks and troughs decrease feelings of happiness and negatively affect our psychological well-being.
Antioxidants in brightly coloured fruit and vegetables scavenge free radicals, eliminate oxidative stress and decrease inflammation in the brain. This in turn increases the feelgood chemicals in the brain that elevate our mood.
Omega 3 found in oily fish and B vitamins found in some vegetables increase the production of the brain’s happiness chemicals and have been known to protect against both dementia and depression.
Pro and prebiotics found in yoghurt, cheese and fermented products boost the millions of bacteria living in our gut. These bacteria produce chemical messengers from the gut to the brain that influence our emotions and reactions to stressful situations.
Over a 12-week period, 31 participants were given nutritional consulting sessions and asked to change from their unhealthy diets to a healthy diet. The other 25 attended social support sessions and continued their usual eating patterns.
The participants continued their existing antidepressant and talking therapies during the trial.
At the end of the trial, the depressive symptoms of the group that maintained a healthier diet significantly improved. Some 32% of participants had scores so low they no longer met the criteria for depression, compared with 8% of the control group.
The trial was replicated by another research team, which found similar results, and supported by a recent review of all studies on dietary patterns and depression. The review found that across 41 studies, people who stuck to a healthy diet had a 24-35% lower risk of depressive symptoms than those who ate more unhealthy foods.
We found nearly 55% of the population feel they lack companionship at least sometime. Perhaps unsurprisingly, Australians who are married or in a de facto relationship are the least lonely, compared to those who are single, separated or divorced.
While Australians are reasonably connected to their friends and families, they don’t have the same relationships with their neighbours. Almost half of Australians (47%) reported not having neighbours to call on for help, which suggests many of us feel disengaged in our neighbourhoods.
Impact on mental and physical health
Lonely Australians, when compared with their less lonely counterparts, reported higher social anxiety and depression, poorer psychological health and quality of life, and fewer meaningful relationships and social interactions.
Loneliness increases a person’s likelihood of experiencing depression by 15.2% and the likelihood of social anxiety increases by 13.1%. Those who are lonelier also report being more socially anxious during social interactions.
This fits with previous research, including a study of more than 1,000 Americans which found lonelier people reported more severe social anxiety, depression, and paranoia when followed up after three months.
Interestingly, Australians over 65 were less lonely, less socially anxious, and less depressed than younger Australians.
Researchers are just beginning to understand the detrimental effects of loneliness on our health, social lives and communities but many people – including service providers – are unaware. There are no guidelines or training for service providers.
So, even caring and highly trained staff at emergency departments may trivialise the needs of lonely people presenting repeatedly and direct them to resources that aren’t right.
Increasing awareness, formalised training, and policies are all steps in the right direction to reduce this poor care.
For some people, simple solutions such as joining shared interest groups (such as book clubs) or shared experienced groups (such as bereavement or carers groups) may help alleviate their loneliness.
But for others, there are more barriers to overcome, such as stigma, discrimination, and poverty.
Many community programs and social services focus on improving well-being and quality of life for lonely people. By tackling loneliness, they may also improve the health of Australians. But without rigorous evaluation of these health outcomes, it’s difficult to determine their impact.
But we need to better measure and understand these different predictors and how they influence each other over time. Only with Australian data can we predict who is at risk and develop effective solutions.
We need a campaign to end loneliness for all Australians. Campaigns can raise awareness, reduce stigma, and empower not just the lonely person but also those around them.
Loneliness campaigns have been successfully piloted in the United Kingdom and Denmark. These campaigns don’t just raise awareness of loneliness; they also empower lonely and un-lonely people to change their social behaviours.
A great example of action arising from increased awareness comes from the Royal College of General Practitioners, which developed action plans to assist lonely patients presenting in primary care. The college encouraged GPs to tackle loneliness with more than just medicine; it prompted them to ask what matters to the lonely person rather than what is the matter with the lonely person.
Australia lags behind other countries but loneliness is on the agenda. Multiple Australian organisations have come together after identifying a need to generate Australian-specific data, increase advocacy, and develop an awareness campaign. But only significant, sustained government investment and bipartisan support will ensure this promising work results in better outcomes for lonely Australians.
With each new version of the widely-used manual of mental disorders, the number of mental health conditions increases. The latest version (DSM-5) lists around 300 disorders. To complicate things, many share common features, such as depression and anxiety.
The manual is a useful guide for doctors and researchers, but making a diagnosis is not a precise science. So if the “experts” are still debating what’s what when it comes to categorising disorders, it’s not surprising misconceptions abound in the community about certain mental health conditions.
We learn about mental health conditions in a number of ways. Either we know someone who has experienced it, we’ve experienced it ourselves, read about it or seen something on TV. Movies and TV series commonly portray people with mental illness as dangerous, scary and unpredictable. The most popular (mis)representations are of characters with multiple personalities, personality disorders, schizophrenia and bipolar disorder.
While the media is an important source of information about mental illness, it can misinform the public if reported inaccurately, promoting stigma and perpetuating myths. And research shows negative images of mental illness in the media (fictional and non-fictional) results in negative and inaccurate beliefs about mental illness.
Dissociative identity disorder
“Multiple personality disorder” or “split personality disorder” are colloquial terms for dissociative identity disorder. Despite being colloquially named a personality disorder, it’s actually a dissociative disorder.
A personality disorder is a long-term way of thinking, feeling and behaving that deviates from the expectations of culture. Whereas in dissociative identity disorder, at least two alternate personalities (alters) routinely take control of the individual’s behaviour. The individual is usually unable to remember what happened when an alter takes over: there are noticeble gaps in their memory, which can be extremely distressing.
The popular TV series “The United States of Tara” actually does a pretty good job of portraying dissociative identity disorder. The main character has a series of alters and experiences recurrent gaps in her memory.
While it used to be considered rare, dissociative identity disorder is estimated to affect 1% of the general population, and is typically related to early trauma (such as childhood abuse). People commonly confuse dissociative identity disorder with schizophrenia. Unlike schizophrenia, the individual is not imagining external voices or experiencing visual hallucinations: one personality literally “checks out” and another appears in their place.
Borderline personality disorder
Borderline personality disorder is often misconstrued. People with this condition are often portrayed as manipulative, destructive and violent. In reality, these behaviours are driven by emotional pain: the person has never learned to ask effectively for what they need or want.
It is also often assumed “borderline” means the person almost has a personality disorder. The term “borderline” here creates some confusion. First introduced in the United States in 1938, the term was used by psychiatrists to describe patients who were thought to be on the “border” between diagnoses (mostly psychosis and neurosis). The term “borderline” has stuck in the diagnosis, but there is now a much better understanding of the causes, symptoms and treatment.
Those with borderline personality disorder have difficulties regulating their emotions. This contributes to angry outbursts, anxiety and depression, and relationships fraught with difficulties. It’s also commonly associated with trauma (such as childhood abuse or neglect).
Many actions of a person with borderline personality disorder (such as self-harm and overdose) are done out of desperation in an attempt to manage difficult and intense emotions.
While borderline personality disorder and bipolar disorder can look similar (mood problems, impulsive behaviour and suicidal thinking), there are several key differences.
Bipolar disorder is characterised by extreme mood swings – from severe lows (depression) to periods of high activity, energy and euphoria. The different mood states can seem like a personality change, but a return to the “usual self” occurs once mood stabilises.
While depression is part of borderline personality disorder and bipolar disorder, those with bipolar disorder experience significant “up” mood swings. This is known as mania in bipolar I disorder and hypomania (less intense mania) in bipolar II disorder.
Bipolar mood episodes last longer (four days or longer for “ups” and two weeks or longer for “downs”), with periods of wellness in between, and are less likely to be triggered by external events. And bipolar disorder is more likely to run in families, disrupt sleep patterns, and psychotic symptoms (delusions, hallucinations) can occur during mood episodes.
We all have ups and downs, but bipolar disorder is much more than that with extreme, recurrent mood episodes that are not only distressing, but have a significant long-term impact on key areas of a persons’s life. Positively, with the right treatment, good quality of life is entirely possible despite ongoing symptoms.
Schizophrenia, meaning “split mind” in Greek, is often confused with dissociative identity disorder. However, the “split” refers not to multiple personalities, but to a “split” from reality. People with schizophrenia may find it difficult to discern whether their perceptions, thoughts, and emotions are based in reality or not.
Hearing voices (auditory hallucinations) is a common symptom, along with seeing, smelling, feeling, or tasting things others can’t. Unusual beliefs (delusions), including some that cannot possibly be true (such as a belief that one has special powers) are also common. So too is disordered thinking, where the person jumps from one topic to another at random, or makes strange associations to things that don’t make sense. They may also exhibit bizarre behaviour including socially inappropriate outbursts or wearing odd clothing that is inappropriate to the circumstances.
Other symptoms of schizophrenia look a lot like depression, such as an inability to experience pleasure, social withdrawal and low motivation. Depressive symptoms are also present in schizophrenia, but are slightly different in that emotion is diminished altogether, rather than a depressed mood per se.
Mental health conditions don’t come in neat packages
Unlike physical conditions, we don’t have a biological test that can magically tell us what mental condition we’re dealing with. Mental health practitioners are carefully trained to observe symptom patterns: the right diagnosis guides the appropriate treatment.
For example, first-line treatment of schizophrenia and bipolar disorder often focuses on medication. While dissociative identity disorder and borderline personality disorders are treated primarily with psychological therapy.
Mental health conditions are serious – whether disorders of personality, mood or somewhere in between. Improved understanding and balanced representation of these conditions is needed to shift stigmas and misconceptions in the community.