challenges and opportunities for mental health research in australia

8
COMMENTARY Challenges and opportunities for mental health research in Australia SIMON L. COLLINSON & DAVID L. COPOLOV Mental Health Research Institute of Victoria, Parkville, Victoria, Australia Abstract Australia is a diverse country comprising people from many different backgrounds, races and ethnic groups including immigrant and indigenous cultures. The mental health needs of Australian society reflect the composition of the Australian population and the particular issues faced by the various sectors of the society. In conjunction with greater understanding of the significant burdens that illnesses such as dementia, depression, schizophrenia, suicide and anxiety disorders place on all levels of Australian society, there is a changing view of the priorities for mental health research. In this article we summarize current, emerging and future mental health challenges confronting Australia and review the efforts 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 second author (D.L.C.) has received Research funding from Eli Lilly and is a consultant for Novartis and Bristol-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 J Ment Health Downloaded from informahealthcare.com by University of California Irvine on 11/02/14 For personal use only.

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Page 1: Challenges and opportunities for mental health research in Australia

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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Page 2: Challenges and opportunities for mental health research in Australia

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-

30 S. L. Collinson & D. L. Copolov

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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

Mental health research in Australia 31

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Page 4: Challenges and opportunities for mental health research in Australia

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

32 S. L. Collinson & D. L. Copolov

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Page 5: Challenges and opportunities for mental health research in Australia

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

Mental health research in Australia 33

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Page 6: Challenges and opportunities for mental health research in Australia

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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