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STIGMA: THE GREATEST BARRIER IN THE PREVENTION OF BETTER MENTAL HEALTH
Written by: Alfredo Zotti
December 2004

COMMUNITY PROFILE

The Central Coast of New South Wales lies north of Sydney and south of Newcastle. It has an area of 1,855 square kilometers and incorporates two local Government namely Wyong Shire and Gosford City Council. It is a holiday destination for people who love white-sandy beaches, natural waterways, rainforests and mountainous terrain. It is bound by the beautiful Great Divide Range in the West; the Hawkesbury River in the South; and Lake Macquarie in the North.

In recent years many visitors have chosen to become permanent residents. The Central Coast, that for long has been the playground of Sydney-siders, is today one of the fastest growing regions in NSW. The figures of the ABS 1991 Census reported a total population of 229.382; the 1996 Census figures reported a population of 260.382 showing a growth of 13.7% in just five years; the ABS 2001 Census showed that this figure had grown to over 290.000. Gosford City Council has a population of 154,654 while Wyong has a population of 135,856. It is estimated that the growth is going to continue at a rate of 3.7% per year (Gosford Demographic Profile 1999:6). Despite this growth and popularity the Central Coast is an area with substantial social problems. The population of the Central Coast is quite different from that of the rest of NSW. In 2001 18% of the population was aged 65 years or older compared with a NSW average of 12%. The mean age for the region had grown from 36 years in 1996 to 38 years in 2001 and continues to rise indicating that the population is getting older. A high proportion of the population, or 22%, are young people aged 14 years or younger. The Coast has a higher birth rate (15.6%) than the rest of NSW (14.9) (ABS 2001 Census).

There is a high level of unemployment on the Central Coast particularly youth unemployment. Wyong Shire has an unemployment rate of 8.8% compared with 5.2% for the Sydney Region and 6.5% for Australia as a whole (ABS, 2001). These are the highest unemployment figures higher than both the National State national figures. The proportion of people who are currently employed part time but would rather be full time is not known but there is evidence that it is also significant. Over one third of the population were, back in 1996, health card holders (Gosford Demographic Profile 1999) and this has not changed according to the figures of the 2001 Census. This comprises people on old age pension, on sickness benefit, on disability pension and their carers, on single parent pensions, and unemployment.

The 1996 Census found that 31.6% of the workforce of 40.000 commuted to work outside of the Central Coast on a daily bases. In 2001 the labor force had grown to 53.000 but it is not clear how many people travel to Sydney or Newcastle to work. The ABS 2001 Census give an estimate of 16.000 people who supposedly travel to Sydney or Newcastle every day. Given the distance between the Central Coast and Sydney this travel time adds an extra four hours to the normal working hours. The working day becomes extremely long and this situation leaves little or no time for family life, recreation and relaxation. (ABS 2001).

Wyong has a high number of criminal incidents compared to the rest of NSW. The number of assaults in 1999 was 823.5 in Wyong while it was 697.8 in Gosford and 846.6 in the whole of NSW. Malicious damage to property was also the highest in Wyong (1305) compared to 1261 in NSW and 1159 in Gosford..

The proportion of residents who have post-school qualifications is approximately 10% below that of Gosford and NSW. In 2001 only 4.5% of the Wyong Shire was enrolled in tertiary studies compared with 7.0% for NSW. The future outlook is not good. It is estimated that the gap between the population of Wyong and NSW residents with post-school qualifications, will widen (Gosford Demographics Profile 1999:24).

The Chart below shows the impact of depression and the Disability-adjusted life year (DALY) that is a measure of healthy life lost due to a particular illness.

DALY

Ischaemic heart disease ______________________________________12.4%

Stroke ____________________________________________________ 5.4%

Chronic Obstructive pulmonary disease __________________________3.7%

Depression________________________________________________3.7%

Lung cancer ________________________________________________3.6%

Dementia __________________________________________________ 3.5%

Diabetes mellitus ____________________________________________3.0%

Colorectal cancer ____________________________________________ 2.7%

Asthma ____________________________________________________2.6%

Osteoarthritis_______________________________________________2.2%

Disability-adjusted life year (DALY) is a measure of the years of healthy life lost due to illness or injury (one Daly is one lost year of “healthy” life). Camberra AIHW 1999.

HEALTH PROBLEM

Approximately one third of young people with a diagnosed depressive disorder attempt Suicide (National Health and Research Council, 1997, p.15). On the Central Coast alone in 1997, there were 48 completed suicides. This was a substantial increase from 25 in 1995 (ABS 1996; 2001). This increase was enough to spark a general moral panic amongst health professionals, academics and the population in general . As a consequence much local research has been done in the area (Vulkelich & Howe 1998: 4). Between 1997 and 2002 there has been a decrease in deaths related to depression from 17 deaths per 100,000 to 15.6 deaths in 2002. The decrease was solely due to a decline in male deaths from these disorders, down from 19.1 deaths per 100,000 males in 1997 to 16.1 per 100,000 in 2002. The rate for females remained stable with 14.4 deaths per 100,000 in 1997 and 14.8 per 100,000 in 2002 (AIHW National Mortality Database).

Suicide remains a major concern. According to the ABS (2001) figures when compared with world trends Australia has one of the highest suicide rates in the world. Everyday we have an average of 7 completed suicides and approximately 210 attempted suicides. A total 2,454 people complete suicide in 2001 Australia wide. Not all suicides are recognized as such and many suicides go unaccounted for due to a variety of reasons. According to the ABS (1998c) …”When there is a doubt about the intention of death, suicides could be misclassified into other causes of death categories”.

If it is taken into consideration that approximately 1 in 5 people develops depression both at a national level and in the Gosford/Wyong region then it can be estimated that out of 300.000 people that make up the Central Coast population about 58.000 will suffer from depression at one stage in their lives.

AVAILABLE SERVICES TO THE COMMUNITY

The World Health Organization (WHO), at the conference on primary health care in Alma- Ata (1978), defined health as a state of physical, mental and social well-being and not just the absence of disease, disorder or disability. The WHO also declared that provision of adequate education, health care, housing, employment and leisure is correlated to the physical and mental health of the population. The Central Coast Health Area (2002) follows the WHO advice and services are both preventative, and in this sense the focus is on the improvement of the social environment and the infrastructure, as well as medical.

On The central Coast there are currently three hospitals which are Wyong hospital, Gosford hospital and Woy Woy hospital. In addition, there are also nine community health care centers throughtout the Central Coast. In total there are 789 hospital beds to meet the needs of a population of around 300,000 people. Recently both the local and federal governments have allocated $212 million for the purpose to redevelop both Gosford and Wyong hospitals. (Opening Celebration, Central CoastHealth Area , 2003: 1-2).

This redevelopment means that there will be more beds for people with mental disorders. For example, a new section at Wyong Hospital has open its doors this year and currently provides an extra 10 older persons mental health beds within a new and dedicated older persons unit. When it will become fully operational the mental health facility will offer 25 acute mental health beds, 15 older persons mental health beds and 10 high level observation beds. The number of beds will triple the number of mental health beds (Opening Celebration, Central Coast Health Area, 2004, 1-2).

Doctors have been given the task and funds to aid people who suffer from depression and mental disorders more generally. In recognition of the fact that GPs are the potential first point of contact for help with mental health issues the Government allocated $120.4 million to assist GPs develop skills in mental health diagnosis, care planning, and treatment (Wooldridge, budget 2001-2002). It was also stated that this strategy would significantly improve the mental health care available in Australia and provide a comprehensive range of care options (Wooldridge, budget 2001-2002). To complement this, Commonwealth funds ($17.5 millions) were also used to create a website, today named beyondblue, which is a good source of information about mental health where most information about available mental health services and contact numbers can be found.

Since 1993 there have been a number of reports written on mental health and related issues. In total there have been nineteen studies: 13 from the Central Coast Area Health Services, (eight from Mental health division and five from other services); four from the Central Coast Community; two from state an national sources (Vukelich & Howe 1998:4).

Some major issue that highlight important strategies areas for the provision of better services have risen. An important report on mental health, compiled from the Central Coast, was titled “Mental health Strategic Plan” which was published in December 1997. The report was a Strategic Plan developed to provide strategic direction for mental health services provision and service development up to the year 2001. This was designed following the direction of the NSW Department of health and the NSW Department of Health’s Center for Mental Health (Mental Health Strategic Plan 1997: preface).

From the Mental Health Strategic Report four major themes have risen. These are:
1) A shift in focus from providing services to the seriously mentally ill to improving the mental health of the whole community.
2) A focus on outcome of services rather than outputs, with an emphasis on cost effectiveness.
3) A shift in focus in resources from impatient services to community services which are responsive to the community and its needs.
4) The need for community involvement in service provision.

The four themes derived from the Mental Health Strategic Report (1997) clearly demonstrate that governments and academics do have a real concern for the problem of depression. However, there are great barriers to the realization of these directions and visions.

BARRIERS TO ADEQUATE PROVISSIONS FOR MENTAL HEALTH.
GPs AND MENTAL HEALTH

Hickie (Hickie, Davenport, Scott, 2000,10) who is one of beyondblue consultant psychiatrist, writes that a survey carried out by his office revealed that the response to the question: “if you thought you might be suffering from depression, who would you be most likely to turn to?” indicates that young people are reluctant to speak to their doctor about depression. Yong people are more inclined to disclose this to their family and friends. This is the case for young people aged between 18 up to 44 years of age. Older people, on the other hand, are more likely to talk to the GP first.

Only one in six people, as the statistics revealed, will reveal that they are experiencing depression and will attempt to access an effective medical or psychological treatment. Hickey recognizes some major problems that contribute to this phenomena such as the stigma associated with the illness. In other words people are afraid to disclose the fact that they suffer from depression (2002:25).

Dr Sculling who is the General Practitioner Chairman of the Central Coast argued that the figures for the year 2004 from the Central Coast Health indicate that there was one GP for every 2000 residents in the Wyong area while that for Gosford is one for every 1535 residents. This is far higher than the national figures that are one for every 1400 residents. He further argued that there is evidence that some doctors’ books have between 2000 and 3000 patients (Pillans, 2004: 4). While there seems to be a general call for more doctors it would seem that a better alternative would be to promote better health through education so as to reduce need for visits to GPs and therefore high demand for medical attention. This is because the professions tend to create more demand for services and this is a danger. For example a good indication of this is the creation of a vast assortment of anti-depressants. In this respect there seems to be a great effort from pharmaceutical companies to create need for drugs through doctors. To what extent are doctors aware of this and what they do about it is certainly an area of much needed research.. For example what influence do pharmaceutical companies exercise on doctors for the promotion of drug use such as anti-depressants?

ANTIDEPRESSANTS

There is much evidence that depression, as all forms of mental disorders, is mostly treated by medications. For example in Australia, 8.2 million prescriptions for anti-depressants were written in 1998. In 1998-99. Prescription were mostly written by doctors (85% of the total medications) while only 11.2% by psychiatrists. This indicates that most treatment is based on the aid of medication (McManus et al, 2000). There is a growing concern that overworked general practitioners are becoming over-reliant on medication to treat people with mental disorders. Professor Hickey argues that the Australian system has strongly favored the prescription of medication and a real shift is needed. (Sexton, 2001: 3).

Currently the cost of prescription anti-depressants, to the Government, is roughly $155 million dollars per year (Tickle, 2004: 1). While the prescription of anti- depressants seems to be the most used intervention to aid depression there are real dangers because anti-depressants can be harmful in many individuals particularly younger sufferers as various studies have indicated. It makes good sense, therefore, to try to reduce medication and to use it as a last resort.

STIGMA

SANE Australia (2004) defines stigma as the act of labeling a group of people as less worthy of respect than others. Stigma hurts, and reducing stigma in the media is the number one factor that would improve the lives of people with mental disorders.

What makes the provision of mental health care particularly difficult is the widespread stigma and discrimination against people who are mentally ill, poor community awareness of the nature and determinants of mental health and mental illness, lack of mental health legislation and policy, and a failure to value mental health as a community resource. (WHO 2001).

The media often portraits those who suffer from a mental disability as dangerous individuals who can harm the public for no reason. These people, therefore, are to be avoided and kept at a distance according to this logic (Mitchell, 2003: 1)

These are erroneous beliefs. Research and statistics show that there is a weak association between mental illness and violence. Violence is more likely to be a greater problem among people who do not have a mental disability but who abuse alcohol; and among young males aged between 15 and 25 (Better Health, 2003).

The weak association between mental illness and violence appears to be limited to certain subgroups such as people with mental illness who are not receiving medication or treatment; those who have a history of violence and those who abuse drugs and alcohol (ibid).

Unfortunately stigma is found amongst the most learned people in society and this perhaps shows the power of the ideology that is at the heart of stigma against those who suffer from a mental disorder. Bathurst and Grove write that there is a kind of fear about disclosing any form of mental disability. A research carried out throughout Universities and TAFE colleges showed that the majority of students who suffer a form of mental disability do not disclose their disorders for fear of prejudice. To combat stigma there is need of a wide spread education that reaches the majority of the population particularly the less educated.

THE INTERNET AGAINST STIGMA

While the exact statistics of 2004 are not yet known about the percentage of households with access to the internet it can be safely speculated by averaging ABS statistics of the previous two years, that about 40% of all households have no access to the internet. Moreover, this portion of the population is constituted by disadvantaged people. People who are most likely to access the internet as an educational source are those with a diploma (69%of internet users) and those with a bachelor degree (81% of internet users). Many people on unemployment benefit and those who are classified as poor have no access to the internet claiming that the internet is too expensive or that they simply have not enough skills to go online (Auststats, 2004).

DE-INSTITUTIONALIZATION

There is evidence that since the policies of de-institutionalization have been introduced and implemented the situation for many sufferers has worsen. The problem seems to be that there is not enough community support and provision of services for an adequate de-institutionalization.

The justification for this process was that our institutions had become outdated, and improper places for the mentally ill. The sad irony is that our jails have become our mental health hospitals – the most inappropriate and inhospitable institutions we can imagine are now crowded with patients suffering mental disorders, and jail suicides by young people are the highest in the world (Mental Health Care Australia (MHCA), 2002).

The failure by governments to adequately care for people who suffer from mental disorders was highlighted by the Mental Health Council of Australia that claimed services had deteriorated across the nation in the past 12 months. In NSW, the situation for sufferers has become so bad that there are now claims the best care for the mentally ill is in this State is at Long Bay Jail. According to the Mental Health Council of Australia up to one third of people in jail suffer from serious mental disorders, the question is being asked – are our jails the new asylums? (MHCA, 2002).

According to Barbara Hatten (2000) [Online] when Greiner former NSW premier came into power NSW had 8,200 beds for people with a mental disorder in this state and 2,500 people in jail. Today NSW has only 750 people in care and 8,000 in jail.

While these are real problems it can be said that it is not desirable to go back to the days where people with mental health disorders were locked away. This leads to a lot of problems such as possible abuse of inpatients and the subjection of interventions without the patient’s consent. The problem is a complex one.

SUGGESTIONS FOR IMPROVEMENTS

A possible strategy would be to educate the people about ways to prevent illness, disease and mental disorders through an adequate education driven by adequate policies. While the focus here is on depression this is true for health in general. At an holistic level, this is true for all social problems.

It would seem that the ideal move is to work towards the realization of a community owned television station that screens mental health issues 24 hours a day and seven days a week. A joint effort of communities, government organizations, Universities and TAFE colleges could be directed towards an education that combats stigma, promotes good health, and educates people with mental disorders about were to seek help.

More importantly, given that academics, health practitioners and governments do not know what interventions to implement given that the problems are enormous and require continuous enquiry and information, it is of the outmost importance to keep an open dialogue between consumers and various government and non government agencies. There is need to listen to the voice of consumers; to get to know people with mental disabilities and realize that “we” are intelligent, caring and loving people who can contribute to our society.

While the exact causes of depression remain unknown there is good evidence in support of the fact that cognition has a lot do with it (Back, 1976). This is why Stigma, which is a conceptual and intellectual problem, has much impact of mental health. Speaking from a personal experience, I believe that, generally speaking, consumers can cope with many problems that they may face with the exception of Stigma. This seems to be the problems of all problems that needs to be eradicated.

CONCLUSION

Both governments, academics and health professionals have put a good effort to tackle the problem of depression and mental health more generally However, there is much evidence that despite these great efforts the problem of depression is worsening. Perhaps we need less effort towards these professional attempts, such as more report or more medical provisions, and towards different strategies. Education and Stigma seem to be the key word from the arguments presented in this report.

Stigma generates barriers that, like a cancer, affect the lives of sufferers. Stigma prevents transparency in dialogue, creates suspicion, misperception and fear. This is an environment that cannot be fruitful for a better mental health in society. Given that television can be used to influence people as it is clearly the case for advertising it would make good sense to use this strategy in order to eradicate stigma. Television can reach the majority of the population. Today every person in Australia has access to a television and this, according to the ABS has been so for a few years.

A national television community program dedicated to mental health seems the appropriate intervention. If people were to be brain washed in order to learn to dislike Stigma and all that it stands for this would be acceptable it would seem. Propaganda used for our own good. A revolutionary strategy at a good price. Another strategy could be to train normal citizens to volunteer as cognitive therapists. This could be possibly consumers of mental health themselves. This would reduce the cost of cognitive therapy offered by expensive psychiatrist and psychologist who’s books are already full

References

Australian Bureau of Statistics (2001) 2001 Census Data. 105 Sydney Statistical Division. Australia New South Wales. Retrieved from www.abs.gov.au/austats/abs@census.nsf/4079a1bbd2a04b80ca256b9d00208f92/82a516450d832eefca256bbe008371f7!OpenDocument.htm. On November 7, 2004.

Australian Bureau of Statistics (2001). 2001 Census Data. 1 New South Wales. Retrieved from http://www.abs.gov.au/Austats/abscensus2/ABSpopulation/Austats 1 New South Wales.htm on November 11, 2004.

Australian Bureau of Statistics (1998a). Mental health and wellbeing profile of adults. Australia 1997. Camberra, Commonwealth of Australia, 1-61.

Australian Bureau of Statistics (2004). Measures of a knowledge-based economy and society, Australia: information and Communications Technology Indicators. Proportion of individuals (adults aged 18 years or over) accessing the internet by age, sex, occupation, level of education and broad region. Retrieved from http://www.abs.gov.au/Auststats/abs@.nsf/Lookup/560A5E4843EBCA94CA256D97002C8644 on November 11, 2004.

Back, A.T. (1967). Depression: Clinical, experimental and theoretical aspects. New York: Harper & ROW.

Back, A.T. 1976.) Cognitive therapy and emotional disorders. New York: International University Press.

Back, A.T. 1987). Cognitive models of depression. Journal of Cognitive Psychotherapy: An International Quaterly, 1, 5-37.

Bathurst, L. & Grove, J. Damned if you do. Damned if you don’t. Students’ experiences of disclosing a mental health disorder. Retrieved from www.camberra.edu.au/pathways/papers/grove.pdf. on November 7, 2004.

Community Statistics (Australian Bureau of Statistics) [online] 14/ 10/ 2004 – 1996-2001.Available: www.abs.gov.au.

Central Coast Health Area www.rcna.org.au/content/clinical_practice_dev.pdf

Central Coast Health (2004) Health Access Plan News: Mental Health Centre Open Celebration. Retrieved from www.ccah.org.au/fs02234au/987-bc.htm on November 28, 2004

Gosford City Council (1999) Gosford Demographic Profile, Gosford local Government area, NSW.

Hickie, I., Davenport, T., Scott, E. (2000) Depression: out of the shadows. The Australian women’s weekly health series.

Howe, D. & Vukelich, K. (1998). Mental Health Needs Report for Young People. Central Coast Area Health Services Mental Health Division.

Hatten, B. (2000) The hell of a prisoner’s cell. The Australian Centre for Independent Journalism’s web magazine. October 2002 pp 1- 3. Retrieved from htpp://www.aus%20Documents\Reportage%20The%20Australian%20Centre%20for%20Independent%20Journalism’s%20web%20magazine%20.

McManus et al (2000) Recent trends in the use of anti depressant drugs in Australia, 1990-1998. MJA 2000; 173: 458-461.

Mental Health Strategic Plan website. Available: http://www.mental.health.wa.gov.au/one/aboutus- smhp-asp. Retrieved on 23-11-2004.

MHCA mortality database. Available: http://www.mhca.mortdatbas.com.au. Retrieved on 20-11-2004.

MCHA (2003) Jails as mental institutions.Retrieved from www.Sunday.ninemsn.com.au/Sunday/cover-stories/article_1609.asp on 5,November, 2004.

Mitchell, N. (2003) Media Interrupt: Mental Health and the Media. Retrieved from http://www.abc.net.au/rn/science/mind/s788631.htm. On November 14, 2004.

NCCH (2001-2). Depression classification Mental Health Services in Australia. Retrieved from www.aihw.gov.au/publications/hse/mhsa01-02/mhsa on October 11, 2004.

Pillans, H. (2004) ‘Exhausted GP Had to get away. Express Advocate. Friday, November 19 p 4.

SANE (2004) Fight Stigma. Retrieved from http://www.sane.org/index.php?option=displaypage&Itemid=266&op=page on October 11, 2004

Sexton, J. (2001) Concern over mental illness medication. Retrieved from Australian Broacasting News [Online] http://www.abc.net.au/pm/s351582,htm on November 2, 2004.

Tickle, M (2004) The Sports Factor. ABC Radio National [Online]. Retrieved from http://www.abc.net.au/cgi/bin/common/printfriendly.pl?http://www.abc/net/au/rn/talks/8.30/htmon November 14, 2004.

World Health Organization. International Conference of Primary Health Care, Alma Ata, USSR 6-12 September 1978. Retrieved from www.who.int/hpr/NPH/docs/ declaration_almaata.pdf. on November 12, 2004.

Wooldridge, M. (2001) Better outcomes in mental health. Retrieved from www.health.gov.au/budget2001/fact/hfact2.htm on November 23, 2004.

Our thanks to Alfredo Zotti for sending this in


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