SWSLHN and Bowral's Health - 1

Challenging accepted wisdoms about young peoples’ health and wellbeing

April 22, 2011 – 1:19 am, by Melissa Sweet

Mental health is in the political limelight in the lead-up to the federal budget, with the Government and Opposition both promising support for mental health services.

The researcher and writer Richard Eckersley argues that we need to develop a much broader understanding of mental health and wellbeing in young people. In particular, he challenges the conventional narrative around the social determinants of health.

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Challenging the accepted wisdom about young peoples’ health

Richard Eckersley writes:

The widely accepted story of young people’s health in developed nations is that it is continuing to improve in line with historic trends and the progress of nations. Death rates are low and falling, and most young people say they are healthy, happy and enjoying life. For most, social conditions and opportunities have improved. Health efforts need to focus on the minorities whose wellbeing is lagging behind, especially the disadvantaged and marginalised.

There is another, very different story. It suggests young people’s health may be declining – in contrast to historic trends. Mortality rates understate the importance of non-fatal, chronic ill-health, and self-reported health and happiness do not give an accurate picture of wellbeing. Mental illness and obesity-related health problems and risks have increased. The trends are not confined to the disadvantaged. The causes stem from fundamental social and cultural changes of the past several decades.

The contrast between the old and new stories is graphically illustrated by these Australian statistics: about 40 per 100,000 young people (aged 12-24) die each year and the rate is falling; 26,000 per 100,000 (26%) (aged 16-24) suffer a mental disorder each year and the rate has probably risen, perhaps steeply. Which statistic says more about young people’s wellbeing?

Stories inform and define how governments and society as a whole address youth health issues, so which story is the more accurate matters. The usual narrative says interventions should target the minorities at risk. The new narrative argues that broader efforts to improve social conditions are also needed. The old story may still generally hold true in developing nations, but the issues raised in the new story are also of increasing importance to these countries as modernisation and globalisation impact more on the lives of their young people.

A central dimension of the changed trajectory in health over recent decades, and which underpins the new story, concerns the declining significance of material and structural determinants of health and the growing importance of existential and relational factors to do with identity, belonging, certainty and purpose in life. There is a shift in emphasis from socio-economic causes of ill-health to cultural; from material and economic deprivation to psychosocial deprivation; from a problem of material scarcity to one of excess. With this has come a shift in significance from physical health to mental health.

This argument is not to suggest sharp, categorical distinctions and clear breaks from the past. Physical and mental health are closely interwoven and interdependent. Physical illness, including infectious diseases, still matter. Disadvantage and inequality still matter. Indeed, the cultural changes of past decades may well have exacerbated their effects by making material wealth and status more important to how people see and judge themselves. Environmental problems such as climate change have serious implications, including the risk of possible catastrophic effects on human health.

The contrast between the old and new stories of young people’s health and wellbeing is part of a larger contest between the dominant narrative of material progress and a new narrative, sustainable development. Material progress sees economic growth and a rising standard of living as the foundation for a better life; sustainable development seeks a better balance and integration of economic, social and environmental goals to produce a high, equitable and enduring quality of life.

Material progress represents an outdated, industrial model of progress: pump more wealth into one end of the pipeline of progress and more welfare flows out the other. Sustainable development reflects (appropriately) an ecological model, where the components of human society interact in complex, multiple, non-linear ways. Not only does sustainable development better fit the new story of youth health, it is likely to achieve better outcomes in relation to the old story’s focus on socio-economic disadvantage and inequality because it less intent than material progress on economic growth and efficiency.

The health of young people should be a focal point in the larger contest of social narratives. They should, by definition, be the main beneficiaries of progress; conversely, they will pay the greatest price of any long-term economic, social, cultural or environmental decline and degradation.

If young people’s health and wellbeing are not improving, it is hard to argue that life is getting better.

• This is an edited extract from: Eckersley, R. 2011. A new narrative of young people’s health and wellbeing. Journal of Youth Studies. First published 13 April 2011 (iFirst) (http://dx.doi.org/10.1080/13676261.2011.565043). An author version is available at www.richardeckersley.com.au

• Richard Eckersley is a director of Australia21 Ltd, an independent, non-profit research company and a visiting fellow at the Australian National University.

SSWAHS = SWSLHN and mental health in the Southern Highlands - 12

Mental health: a continuing history of neglect

April 12, 2011 – 11:01 pm, by Melissa Sweet

Chronic disease prevention is gathering increasing steam, at a national and international level. So why is mental health not part of this agenda? Richard Eckersley argues that the importance of mental health continues to be neglected, and not only in Australia.

Richard Eckersley writes:

Physical and mental health are closely interwoven and deeply interdependent, the result of a complex interaction of biological, psychological and social factors. Medicine, however, continues to focus on the biological and neglect the psychosocial, despite the growing recognition of its importance to population health.

This artificial separation has been a formidable obstacle to understanding mental health; as a consequence, its importance to the wellbeing of individuals, communities and societies has been underestimated. Both developing and developed countries show this bias towards physical health, and especially mortality.

Developing countries tend to give priority in health to infectious disease and reproductive and child health; developed countries prioritise non-communicable diseases that cause early death (such as cancer and heart disease) over those that cause years lived with disability (such as mental disorders).

The relative neglect of mental health is seen in the growing efforts in disease prevention and health promotion, both internationally and nationally. These include: the WHO global strategy for the prevention and control of non-communicable diseases; the Oxford Health Alliance; the Trust for America’s Health (in a report, ‘Prevention for a healthier America’); and the Australian National Preventative Health Taskforce (in its strategy paper, ‘Australia: the healthiest country by 2020’).

All imply a wide health perspective, but focus on the physical diseases that contribute most to premature mortality, notably cardiovascular diseases, cancer, chronic respiratory diseases and diabetes. These diseases account for about 60% of all deaths globally.

The efforts will culminate in the United Nations’ first high-level meeting of the General Assembly on chronic non-communicable diseases in September 2011, billed in Lancet as ‘a once in a generation opportunity to put chronic diseases on the global and national agendas’. These diseases have been ‘surprisingly neglected elements of the global-health agenda’. Mental illnesses, while also chronic, non-communicable diseases, are not part of this agenda, but are acknowledged to be ‘similarly ignored’.

About 450 million people worldwide are suffering mental illness; only a small minority receives treatment. Worldwide, community-based studies have estimated the lifetime prevalence of mental disorders at 12%-49%, and 12-month prevalence at 8%-29%. In 2004, neuropsychiatric conditions as a group accounted globally for 13.1% of the total burden of disease, measured as both death and disability (disability-adjusted life years or DALYs), the second largest contributor after infectious and parasitic diseases. They account for about a third of the burden of disability, making them the most important source. Depressive disorders are the third largest specific cause of death and disability (and the largest in high- and middle-income countries), and are projected to become the leading cause by 2030. Yet the median allocation of the total health budget of nations to mental health is only 3.8%.

The ‘global burden of disease’ study has played a seminal part in exposing the importance of mental health to overall population health. However, its estimates of the burden of mental illness may still understate its significance for several reasons:

• mental disorders might affect many more people than the burden of disease estimates suggest, especially in middle- and low-income countries.
• the estimates do not include the growing burden of suicide and self-inflicted injuries, which is counted under injuries.
• the burden of mental disorders (in sharp contrast to chronic, physical diseases) falls mostly on those under 60, so increasing the personal, social and economic costs.
• mental disorders increase the risk of physical diseases and injuries, with one estimate that depressive disorders raise the risk of all-cause mortality by about 70%, and affect adherence to treatment for other diseases.

Aspects of this picture of mental health have been contested. For example, it has been argued that the high prevalence of mental disorders reflects changed DSM diagnostic criteria and the medicalisation of normal human emotions. This is part of a wider concern about the medicalising of life itself, and ‘disease mongering’: the selling of sickness that widens the boundaries of illness and grows the markets for those who sell and deliver treatments, including the medicalisation of health problems previously regarded as ‘troublesome inconveniences’.

While medicalisation is undoubtedly occurring in the sense that new treatments are being developed for new conditions, this does not negate the core argument here that mental illness has been neglected relative to physical illness. The charge of ‘disease mongering’ applies to both physical and mental health, and is directed particularly at treatment provision. Indeed, it has been specifically associated with a policy priority of market-based economic development at the expense of more equitable social policies, such as public-health strategies. (Ironically, the medicalisation of mental health has contributed to greater awareness of its importance.)

Questions of definition, diagnosis and treatment aside, the disability associated with mental health problems is generally higher than for other chronic conditions. Even mild cases cause levels of impairment equivalent to those associated with clinically significant, chronic physical disorders.

People attribute higher disability to mental disorders than to commonly occurring physical disorders, especially with respect to their ‘social and personal role functioning’ (with ‘productive role functioning’, the disability of mental and physical disorders is comparable). A comparison of the disability of 15 disease stages found severe depression ranked third behind quadriplegia and being in the final year of a terminal illness, and ahead of stroke and acute myocardial infarction.

• This is an edited extract from:
Eckersley R. 2011. The science and politics of population health: giving health a greater role in public policy. WebmedCentral PUBLIC HEALTH 2011; 2(3):WMC001697.

• Richard Eckersley is a director of Australia21 Ltd, an independent, non-profit research company and a visiting fellow at the Australian National University.

One Comment

1. carolinestorm@iinet.net.au
   Posted April 13, 2011 at 11:33 pm

   “… focus is on the physical diseases that contribute most to premature mortality.”
   So, are the seriously mentally ill to be allowed slowly to become more deprived of treatment and hospital care? Already only a third receive these when in crisis, according to the MHCA. Are they still to be deprived of psychotherapy, essential to to their well-being; are they further to be deprived of social therapies, and more and more descend into homelessnness and complete social exclusion? Why does focussing on the diseases which contribute most to premature mortality exclude the seriously mentally who, in Australia, have a life expectancy of some 55 years.
   More and more suicides will occur as the seriously mentally ill realise, finally, the greatest stigma of all: this is too hard; we’ll just leave it and see what happens.
   What can be done? How can we help? Many people care, but how do we become a force for change?
   But even hope lessens as Richard Eckersley cites the WHO as excluding mental illness from its global strategy of prevention and control of non-communicable diseases.
   The Australian Budget, 2011, is to be made public tomorrow…and little hope there.