challenges and opportunities for mental health research in australia
TRANSCRIPT
COMMENTARY
Challenges and opportunities for mental health research inAustralia
SIMON L. COLLINSON & DAVID L. COPOLOV
Mental Health Research Institute of Victoria, Parkville, Victoria, Australia
AbstractAustralia is a diverse country comprising people from many different backgrounds, races and ethnicgroups including immigrant and indigenous cultures. The mental health needs of Australian societyreflect the composition of the Australian population and the particular issues faced by the varioussectors of the society. In conjunction with greater understanding of the significant burdens that illnessessuch as dementia, depression, schizophrenia, suicide and anxiety disorders place on all levels ofAustralian society, there is a changing view of the priorities for mental health research. In this article wesummarize current, emerging and future mental health challenges confronting Australia and review theefforts that Australian researchers are making to meet these challenges.Declaration of interest: The first author (S.L.C.) is a consultant for Cogtest Ltd, London and the secondauthor (D.L.C.) has received Research funding from Eli Lilly and is a consultant for Novartis andBristol-Myers Squibb.
Keywords: Australia, mental health, multicultural, aboriginal, schizophrenia, depression, Alzheimer’s.
Introduction
In population terms, Australia is a relatively small country of 20 million people. Its ethnic
diversity includes a majority population descended from early European settlers, a growing
immigrant community originating in over 180 countries and a disparate indigenous
population. Australia is also a very large country, approximate in size to continental Europe
or the USA, with highly urbanized population centres separated by vast distances. Providing
for the mental health of Australians is a challenge that requires coordination at every level
from government to service providers. A key component in meeting this challenge is
ensuring that mental health research is appropriate to the prevalence, burden, and cost of the
mental illnesses that affect Australia.
Large-scale epidemiological studies have shown that Australia faces many of the same
mental health issues of other western industrialized nations. In 1997 the Australian
government embarked upon a major epidemiological survey of the nation’s mental health—
the National Survey of Mental Health and Wellbeing of Adults (Australian Bureau of
Statistics, 1997). This study confirmed the high level of morbidity associated with mental
Correspondence: David L. Copolov, Mental Health Research Institute of Victoria, Locked Bag 11, Parkville 3052, Victoria,
Australia. Tel: + 61 3 9388 1633. Fax: + 61 3 9387 5061. E-mail: [email protected]
Journal of Mental Health, February 2004; 13(1): 29 – 36
ISSN 0963-8237 print/ISSN 1360-0567 online # Shadowfax Publishing and Taylor & Francis Ltd
DOI: 10.1080/0963823041000654512
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illness including dementia, depression, schizophrenia, suicide and anxiety disorders and the
significant burden that such disorders impose on the community at large.
Presently, mental illness contributes approximately 19% to Australia’s total disease
burden, placing it ahead of cardiovascular disease and cancer; and yet it is comparatively
under-researched—receiving less than 9% of national medical research funding (Jorm,
Griffiths, Christensen, & Medway, 2002). This shortfall reflects a general lack of investment
in health research and development in Australia (0.25% of GDP), which is low compared
with other OECD countries (0.15 – 1.1%); and a decline in public sector funding in the
1990s of about 8% (Australian Society for Medical Research, 2003). One consequence of
the shortfall is an increasing awareness of the need to establish priorities for mental health
research that reflect the differing prevalence, burden and cost of the various mental
disorders that affect Australians (Jorm et al., 2002). Presently, no explicit set of priorities or
system of assigning priorities is in place to meet this need, a problem that has been
compounded by lack of agreement about key areas for mental health research and
disproportionate allocation of available funds to particular disorders at the expense of others
(Jorm et al., 2002).
Despite these problems, research efforts in university departments, specialist research
institutes and hospital research facilities are making significant progress in tackling the major
neurobiological, psychosocial and service-related issues. Academic societies such as the
Australasian Society for Psychiatric Research (ASPR) and the Australasian Society of
Biological Psychiatry (ASBP) provide a vibrant forum for dissemination, collaboration and
discussion. In the tradition of Aubrey Lewis and John Cade, Australia continues to make a
significant international contribution to mental health knowledge, but in recent years the
shift towards domestic mental health concerns has begun to forge a new agenda for mental
health research in Australia.
Enduring challenges
The significant distances between Australian cities and individual commonwealth, state and
territory priorities in education, research and healthcare have led to the establishment of
specialized research and mental health care facilities and new approaches to the study of
serious mental illnesses. For example, in the case of psychosis, several research units are
developing new ways of understanding the cognitive and neurobiological substrates of
specific psychotic symptoms such as auditory hallucinations (McKay, Hedlam, & Copolov,
2000) or delusions (Coltheart & Davies, 2000) rather than focus on psychosis as a unitary
phenomenon. One example is the work of researchers at the Macquarie Centre for Cognitive
Science in Sydney led by the eminent neuropsychologist Max Coltheart. In studies
developed from a range of delusional disorders, researchers are attempting to develop a
comprehensive cognitive model of the system used to generate, accept or reject beliefs.
From this foundation, an understanding of how delusional beliefs arise from damage to this
system could provide an explanation for delusional systems observed in schizophrenia and
other delusional disorders.
One benefit of the wide distribution of population centres is the opportunity to investigate
large psychiatric cohorts that otherwise would be difficult to acquire and follow-up or that in
other countries might be shared between competing research groups. Studies in Melbourne
are elucidating the time course of developmental changes in the brains of people with
psychosis. Pantelis et al. (2003) recently examined MRI scans of people at ultra high-risk of
development of psychosis from a specialized clinic that manages young people at risk of this
disorder. Follow up of patients who went on to develop psychosis revealed that certain grey-
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matter abnormalities predated the onset of frank symptoms, whereas others appeared with
their first expression. The implications of such advances may be seen in earlier detection and
intervention in psychosis from the prodromal and early stages of illness (Schaffner &
McGorry, 2001), in the psychological and pharmacological management of schizophrenia
and the provision of collaborative mental health services for ongoing treatment (Gilbert,
Miller, Berk, Ho, & Castle, 2003).
Current challenges
Australia is one of the most ethnically diverse countries in the world. Twenty-three per cent
of Australians were born overseas (Organization for Economic Co-operation and
Development, 2001), the highest proportion of any Western country, and 40% are either
immigrants or the children of immigrants (Federal Race Discrimination Commissioner,
1997). Providing mental health services in a multilingual nation, with large numbers of new
immigrants and refugees, presents special challenges (Kirmayer & Minas, 2000). In general,
immigrants have variable but higher rates of mental illness and suicide compared with
people born in Australia, are less likely to access mental health services, and will stay in
hospital for substantially longer periods once admitted. In response, there has been
continued development of Australian transcultural mental health research. Notably, the
Victorian Transcultural Psychiatry Unit, in conjunction with collaborating partners
including the WHO centre for International Mental Health, is one of a number of centres
that provides leadership in the development of mental health services for multicultural, low-
income and post-conflict societies around the world (Minas, Lambert, Kostov, & Borgana,
1996; Minas, 2000; Klimidis, McKenzie, Lewis, & Minas, 2000).
The psychiatric issues associated with indigenous Australia continue to present one of the
greatest challenges to Australian society. Endemic problems including suicide, depression
and substance abuse persist in many indigenous communities particularly in remote regions
of northern and central Australia and demand the greatest cultural sensitivity (Swan &
Raphael, 1995; Hunter, Reser, Baird, & Reser, 2000). In 2001, ATSIC, the peak body of
Aboriginal and Torres Strait Islander representation, commissioned an evaluation of the
emotional and social wellbeing of indigenous Australians as part of a national initiative to
enhance the effectiveness of mental health organizations and services for indigenous people
(Office for Aboriginal and Torres Strait Islander Health, 2001). The goal of this process is
the establishment of a community driven, culturally appropriate approach to promoting
emotional wellbeing in indigenous people and the prevention of mental illness. The success
of such initiatives relies upon appropriate research and education. One example, the
Menzies School of Health Research in Darwin, has been engaged in a research and
education programme aimed at understanding and reducing the impact of abuse of harmful
substances in indigenous communities, including alcohol, tobacco, kava, and petrol sniffing
(Cairney, Maruff, Burns, & Currie, 2001; Cairney, Maruff, & Clough, 2002; Clough,
Burns, Guyula, & Yunubingu, 2002).
Another key area in indigenous mental health relates to parenting. There is an
overrepresentation of child abuse and neglect (Australian Institute of Health & Welfare,
2001), conduct disorder and delinquency (Aboriginal Justice Council, 1999) in indigenous
families in Australia. Researchers under the direction of Professor Matt Sanders at the
Parenting and Family Support Centre at The University of Queensland are engaged in
research programmes designed to assist parents with the demands of raising children. The
Positive Parenting Program, or triple P, is a parenting and family support strategy that aims
to prevent severe behavioural, emotional and developmental problems in children by
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enhancing parents’ capacities and confidence. The programme is receiving widespread
recognition and has cross-cultural applications. Triple P is currently being adapted and
evaluated for indigenous parents in remote communities in North Queensland.
The provision of mental health services in an ethnically diverse nation such as Australia
requires a sophisticated understanding of the epidemiology of the major mental illnesses
occurring within the population. One notable contributor to both world and Australian
epidemiological research is Professor Assen Jablensky of the Centre for Clinical Research in
Neuropsychiatry at the University of Western Australia. As part of the National Survey of
Mental Health and Wellbeing, Jablensky et al. (1999) detailed the prevalence of psychoses in
urban areas in Australia in a large representative sample. In addition to characterizing
symptomatology, impairments, disabilities and quality of life issues, the study collected
information on services needed and received by patients and carers.
Jablensky et al.’s findings have confirmed the expected high rates of impairment and
disability, substance use and medication side effects associated with psychosis. Furthermore,
the study revealed that while utilization of public and private hospitals, services and agencies
is high, the majority of sufferers live in extreme isolation and adverse socio-economic
conditions. Among the many needs, the limited availability of community-based
rehabilitation services, supported accommodation and employment opportunities are
particularly pressing. The conclusion from this work is that a broad approach, involving
the important stakeholders of the community, is needed to tackle the multiple clinical issues
associated with psychosis as well as issues of social functioning and the socio-economic
environment that determine the effectiveness of intervention and ultimately the course and
outcome of psychosis (Gilbert et al., 2003).
Emerging challenges
Though multicultural, Australia is predominantly a Western society. Depression and anxiety
disorders are a major threat to the health and wellbeing of people in industrialized nations. It
is estimated that about 800,000 Australians suffer from depression each year making it the
fourth leading cause of disability (National Survey of Mental Health and Wellbeing of
Adults, 1997). In terms of treatment, there has been growing recognition that ‘‘mental
health literacy’’, community knowledge of mental disorders, is one of the main determinants
of the effectiveness of intervention strategies for problems such as depression and suicide
(Jorm, 2000). The development of this concept has been assisted by the Government’s
adoption of ‘‘beyondblue’’—a national initiative arising from the National Action Plan for
Depression (2000) that is designed to address the causes, treatment and stigma of
depression. Over a number of years, research centered at Sydney’s Black Dog Institute has
made significant progress in modelling depressive conditions, generating new models for
discriminating depressive sub-types, developing measures of disability, and refining services
for those with chronic depression and other psychiatric conditions (Parker, 2000).
Anxiety disorders affect a large and increasing proportion of Australians but often go
untreated. Evidence from the National Survey of Mental Health and Wellbeing of Adults
(1997) showed that 9.7% of adults in Australia reported symptoms in that year which met
criteria for one of the six main anxiety disorders. Sydney’s Clinical Research Unit for
Anxiety Disorders at the University of New South Wales, in conjunction with the World
Health Organization, has worked towards effective treatment for anxiety disorders for over
20 years. Under the leadership of Professor Gavin Andrews, ongoing research seeks to find
better ways to treat a range of anxiety disorders including panic disorder, agoraphobia, social
phobia, avoidant personality disorder, obsessive-compulsive disorder and generalized
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anxiety disorders (Andrews, Creamer, Crino, Hunt, Lampe, & Page, 2002). Amongst the
prevention and treatment programmes developed at this centre, school based and computer-
administered cognitive behaviour therapy based approaches are presently under trial and are
being met with considerable success.
In addition to depressive and anxiety disorders, suicide is a major problem affecting
hundreds of thousands of Australians every year. In world terms, the overall suicide rate for
Australia remains in the mid to upper range, ranking 15th highest out of 26 Western
countries in 1993 (World Health Organization, 1993). More recently, trends show that
suicide is particularly marked in the young where suicide is now the second leading cause of
death among 15 – 24 year olds, the fourth highest rate amongst western countries
(Australian Bureau of Statistics, 1999, 2000). Among pertinent risk factors in the young
are changing family structures, unemployment and domestic violence.
It is increasingly recognized that suicide is not the same issue in all age groups and
ethnicities. The elderly (over 75) have become a particularly at risk group for suicide in the
last 10 – 15 years (Hassan, 1995). Suicide rates in indigenous Australians are substantially
higher than for non-indigenous Australians (Hunter, Baird, & Reser, 2000) and vary for
ethnic minorities (Hassan, 1995). A common element in all of these groups is their
increased levels of dependency within society and the stigma that is associated with poverty
and unemployment, lack of education, disability and language or cultural barriers. For these
reasons, the problem of suicide in Australia has led to a change in research strategy reflecting
the different needs of the various ages and ethnic groups most at risk of suicide. To this end,
the National Advisory Council for Suicide Prevention (NACSP) has been formed and a
National Suicide Prevention Strategy launched with the aim of reducing suicide, suicidal
thinking and self-harming behaviours across all age groups in the population. A three stream
approach focussing on community initiatives, strategic initiatives and initiatives in
indigenous communities has been developed in order to direct cooperative efforts across
all levels of government, the community and those directly involved in research and
prevention.
There is now a wider understanding of prevalence and cost of posttraumatic stress
disorder (PTSD) within the community. It is estimated that as many as 65% of males and
50% of females in the Australian population have been exposed to some form of trauma in
their lifetime stemming from experiences such as combat, assault, sexual assault, natural
disaster and accidents (Creamer, Burgess, & McFarlane, 2001). Researchers at Adelaide
University continue to make progress in determining the aetiology, course and
phenomenology of PTSD through the co-application of epidemiological, phenomenological
and neurobiological methodologies. The Australian Centre for Post Traumatic Mental
Health in Melbourne also conducts research in PTSD and facilitates collaboration by
providing advice and consultancy to researchers in the area. This centre has close links with
military organizations and maintains a database regarding the psychosocial status of veterans
at the commencement of treatment and at various follow-up points. Such information is
used to evaluate the efficacy of treatment programmes, make changes to treatment and
rehabilitation programmes and improve the selection of suitable veterans for research.
Future challenges
One of the greatest mental health issues to face Australia in the next 50 years is related to the
rapidly ageing population. The impact of ageing of the post-war generation ‘‘the baby-
boomers’’ and downward trends in birth rates coupled with increased longevity will lead to
increasing incidence of psychogeriatric illnesses, foremost being dementia. Between 1995
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and 2041 the number of people in Australia with dementia will increase by 254%. It is
projected that over 580,000 Australians (2.3% of the population) will have dementia by
2051 (Henderson & Jorm, 1998).
Researchers in many parts of Australia are already meeting the challenge of dementia. At
the Centre for Mental Health Research at the Australian National University in Canberra
Professor Tony Jorm and colleagues have developed a strong reputation in the epidemiology
of dementia, with particular emphasis on studies of relevance for public health. The
Canberra Longitudinal Study, based at this centre, is a 12-year study into the health and
memory of older people that began in 1990 and has continued to provide invaluable insights
into the nature and progression of dementia within the Australian community.
Rapid developments both internationally and in Australia are beginning to shed light on
the underlying neurobiology of Alzheimer’s disease (AD). Recent findings in the
biochemistry of AD have revealed that the hallmark amyloid plaques long believed to be
the cause of neurodegeneration in AD represent an attempt by the body to sequester and
neutralize soluble forms of A-beta protein that have undergone a toxic gain of function. It is
these modified forms of soluble A-beta that are the focus of new therapeutic strategies. The
development of the first animal models of AD in mice have been made possible due to
discoveries that abnormal genes in families with early onset AD result in abnormal
metabolism of A-beta. Current drug treatments for AD, the cholinesterase inhibitors, and
other drugs which boost neurotransmission, in conjunction with effective early detection
have shown some benefits in the treatment of Alzheimer’s, but the real advances will derive
from the ability to test in animal models new compounds derived from advances in the
biochemistry of A-beta that can potentially lead to prevention or cure. Researchers at the
Mental Health Research Institute in Melbourne are leading efforts to unravel the biology
and metabolism of APP, factors that influence aggregation, deposition, toxicity and
clearance of A-beta proteins and developing new treatments that target A-beta (Bush,
Masters, & Tanzi, 2003).
Promising new areas of research in the neurobiology and treatment of chronic
schizophrenia are opening up in Australia. Recent data from work in post-mortem
CNS, also at the Mental Health Research Institute of Victoria has shown a down
regulation of muscarinic M1 receptors in the dorsolateral prefrontal cortex from
subjects with schizophrenia (Dean, Bymaster, & Scarr, 2003). This would seem to
confirm a recent US study that has shown decreases in the binding of a non-selective
muscarinic receptor antagonist in a number of CNS regions in drug-free schizophrenia
subjects (Raedler et al., 2003). Data from Alzheimer’s disease suggests that stimulating
cortical muscarinic M1 receptors improves cognition. Preliminary data, using
cholinesterase inhibitors, suggests that a similar approach would improve cognition in
schizophrenia. Moreover, animal data suggest that M4 receptor agonism could have
marked antipsychotic effects in humans. The implications of these findings for future
therapeutic approaches, leading to better treating the symptoms of schizophrenia, are
potentially great. It would be exciting to envisage new approaches to treating treatment-
resistant psychoses from this basis.
Conclusions
After many years in the background of Australian government policy and planning, mental
health is now recognized as a major public health problem. A coordinated approach is now
required if the mental health issues facing Australia are to be addressed in a manner that has
long lasting benefits to its citizens. Increasingly, governments and researchers are realizing
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the need for strategy and prioritization of research goals and developments such as the
National Depression Initiative and National Suicide Prevention Strategy are welcome.
Future initiatives in the areas of Alzheimer’s disease and schizophrenia are overdue.
In general, the research programmes and facilities in Australia are world class and the
calibre of mental health research is high. Australian researchers are well placed to deal with
the major current and future mental health challenges, but in recent years have faced a
critical lack of funding from both the public and private sector brought about by lack of
prioritization and disproportionate allocation of research funds. The benefits of successful
early detection, treatment or successful remediation are potentially immense in terms of
both the financial and human costs of mental illness. One estimate suggests that a 25%
reduction in schizophrenia would save the Australian government $0.5 billion per annum,
whereas curing Alzheimer’s disease would save the nation as much as $6 billion (PMSEIC,
2003). Greater emphasis on ensuring a world-class environment for high quality research is
necessary if Australia is to continue to meet the mental health challenges of the 21st century.
Acknowledgements
The authors would like to thank Dr Robert Cherny and Professors Andrew Mackinnon and
David Castle for their comments.
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