Young minds, the highs and lows

Lynne Malcolm:  You’re with All in the Mind on ABC RN, I’m Lynne Malcolm and today young minds, where do you turn when it all gets too much.

Eric Barker:  I guess every young person sees their friends and they have a perception of what normal is, what they’re supposed to be doing but I guess the realisation was that there were certain things about my personal experience that didn’t fit the normal.  I was going to school; sometimes I would skip school because there was just no point that I could perceive of getting up and going to school.  There was just a feeling that there was no point to it.

Lynne Malcolm:  What were your parents doing when you were struggling?

Eric Barker:  Well as any parents would be feeling, they didn’t know how to cope, they didn’t know what to do because my mother is from a more traditional background, I’m half Cambodian and half Australian and in that sort of background there isn’t a very strong awareness about mental health in the Cambodian community so they weren’t too well equipped to deal with that.  And then I got referred to the school councillor, obviously I needed something more so I went to Headspace, I was referred from the school to Headspace, southern  Melbourne.

Lynne Malcolm:  Eric Barker, he now runs the Youth Advisory Committee for the Headspace centre.

Markey:  Hi, I’m Markey I’m 28 years old. It started for me at a very young age with some sort of standard depression and anxiety symptoms.  I began to feel isolated, I  began to have panic attacks, being so young I  didn’t understand what was going on with me.  I would hear voices in my mind telling me very, very horrible things that I didn’t want to hear but I had no control over what I was hearing which led to self harm.  It was a very long journey to where I am now to discover what was going on and how to treat it.

Lynne Malcolm:  And at this time did your parents know anything, how were they involved in it?

Markey:  My parents knew as much as I would tell them as did friends.  For me it was something that I could only talk small amounts about because I didn’t think anyone would understand and even still to this day I sometimes think that some people just don’t understand – it makes me feel sad.

Lynne Malcolm:  The transition from childhood to adulthood for most young people is a bit of a roller coaster; sometimes thrilling and exciting and the next minute confusing and devastating.  Pressures from family and friends and school not to mention self expectations can all build to a point where it’s very difficult to deal with it alone.  Not surprisingly with adolescence and teenage-hood also comes a greater risk of developing mental health problems than at any other time of life.

Today we’ll look at how we are supporting young people at this potentially fragile time.  Christopher Davey is a psychiatrist at Orygen Youth Health; he has a specialist interest in young people and depression.

Christopher Davey:  I think we’ve become well aware in the last 20 years of brain research that brain maturation really doesn’t finish until people are in their mid 20s, till probably about 30, more recent research would show and I guess when we think of the sort of changes that go on in adolescence, the fact that young people have such a complex sort of social world to navigate that the sort of brain changes that occur you know allow people to navigate that, but at the same time there’s a lot that can go wrong.  Especially as the brain is still kind of developing and there are vulnerabilities there is a lot that can go wrong both in their social world and their capacity to really cope with the emotions that accompany that.  So I think given the sort of systems that mature I guess last are the sort of systems that regulate emotions and allow you to sort of encompass sort of judgement and those sorts of things, given those sorts of systems are probably the last to really kind of mature I guess it does leave people pretty vulnerable to coping with often complex and difficult emotions during those kind of years.

Lynne Malcolm:  It’s known that 1 in 4 young people will develop a mental health problem and considerably more than that will experience some form of psychological or emotional distress.

Patrick McGorry is Professor Youth Mental Health at the University of Melbourne and Director of Orygen Youth Health and he was also Australian of the Year in 2010 for his tireless work in this area.  What’s his assessment of the state of young people’s mental well being today.

Patrick McGorry: Well mental health or mental and substance use disorder are the major health problems that young people in transition from childhood to adulthood have to confront.  It’s more than 50% of the health burden, or the burden of disease in this age group because young people these days are healthier in a physical sense than they’ve ever been in human history yet it’s a paradox that it’s the major part of a lifespan that mental disorders actually emerge for the first time.  And there are some indications in the last few decades that the mental health for young people in this age group is getting worse.

Lynne Malcolm:  Why do you think that is?

Patrick McGorry: Well it hasn’t been properly pinned down I’ve got to say the actual drivers and causes of it but at face value it’s got to be due to changes in the social world and the experience of transition to adulthood in this sort of early 21^st century and leading up to that.  Because obviously the genetic basis of risk has not changed and so it’s got to be the environmental risk factors, the gene environment interaction that’s actually making this problem worse.  And some candidates that have been suggested include the increased rate of family breakdown, the increased availability of drugs and alcohol, the economic forces that keep young people perhaps more dependent on the scaffolding of their families until perhaps the mid to late 20s.  Changes in the first age of marriage probably due to birth control being available and more freedom in that sense so all these things have been looked at and there are indicative findings but nothing conclusive really.

Lynne Malcolm:  So what’s your assessment of Australia’s past approach to young people’s mental health issues and what new models do we need to look towards?

Patrick McGorry:  Well I think it’s important to take the historical perspective here because it’s only 20 years or so ago when we were grappling with the task of dismantling the old 19^th century models of care and the thinking associated with them.  So there has been a lot of freeing up but I think what’s happened in the last few years is we’ve got re-institutionalised in a complacent sort of mainstream modelling of mental health care and we’ve made the mistake of structuring our mental health services exactly the same as physical health services in the sense in that we have a paediatric adult divide.  That makes sense with physical illnesses because a system that focuses on older adults and young children is probably sensible in the main for most, but not all physical illnesses.  But in mental health care it’s the mirror image, the big surge of need is in the transition to adulthood from 12 to 25 and we haven’t had a stream of care either based on that pattern of onset of disorder, nor on the cultural group that is actually young people, which is really teenagers and young adults, emerging adults.

And they are a distinct cultural group, they are not going to engage in services that are focussed on younger children, they feel very alienated and uncomfortable in services geared to older adults.  So we haven’t designed the structure of mental health care in a broad mental health system in a very sensible way and we’re starting to do that.  Australia is one of the countries in the world that has actually quite inspirationally invested in Headspace, this very rapidly scaling up model of primary youth mental health care and beginning now to back that up with specialist youth mental health models of care.  And other countries are looking very closely with great enthusiasm for what we are doing here.

Lynne Malcolm:  Patrick McGorry was one of the pioneers of Headspace the early intervention mental health services operating across Australia.  They provide expert support for everyone between the ages of 12 and 25. 

Lynne Malcolm :So describe what happened when you first came to Headspace?  How did you feel about having to come in the first place?

Eric Barker: In fact it’s quite intimidating to go into a place and be expected to talk about your problems to someone you’ve never met before.  And the counsellors know they’re nervous, they don’t want to talk to anyone, so they make it a key point to reduce that anxiety, reduce that intimidation and then it all just comes after that and it becomes quite productive.  And I came for about a period of two months, at first it’s what you want to talk about but it becomes more of an all facts laid on the table, everything laid bare type of thing, when you feel comfortable enough, when the individual feels comfortable enough with the particular counsellor.  And yet it was very helpful, we did things like goal setting, working with my personal hobbies, I’m a musician, it’s easier to write a song about something than talk about it for me personally, the music becomes a voice rather than having to articulate emotions and we played on that as a constructive tool to climb the proverbial staircase out of the dark.

Lynne Malcolm:  Eric Barker.  Here’s Chris Tanti the CEO of Headspace.

Chris Tanti:  Headspace is a program that is accepting of all people 12 to 25 regardless of their presentation.  So a young person for example may be experiencing difficulties around study and anxiety around study or they may be in the middle of a relationship breakup or there may be family conflict.  And these people are all eligible for Headspace services but they probably wouldn’t be eligible for a public mental health service because they wouldn’t meet the threshold for that particular program.  And we know if we capture young people in the middle of those situations where there’s a relationship breakup or a family problem that they are less likely to go on to develop other problems like homelessness for example in the middle of a family conflict where they are kicked out of home.  You can equip people to have the skills to negotiate their way through that rather than end up being kicked out of the family home and then having to deal with a whole range of services who can support them. And I guess the argument that we’ve put forward successfully is that if you get in at the earliest point in that crisis then you’re less likely to have to deal with a myriad of other problems that result in not getting attention.

Lynne Malcolm:  That’s probably easier said than done though young people wouldn’t necessarily first think of going and seeking support from an organisation if they are having problems – it may be the last thing on their minds.

Chris Tanti: It’s absolutely the last thing on their minds and so in lots of ways what we need to do with the community is raise awareness of these issues.  And it’s pretty hard for young people, and their family and teachers to disentangle what is a sort of normal developmental issue and then when someone needs help and we hear this all the time.  And young people might experience psychological or emotional distress one day and the next be getting on with their lives.  So somehow we need to equip the community with the language around mental health which, because of the stigma associated with mental health, the community hasn’t necessarily developed that language.  So we work very hard in our community awareness campaigns to assist people to understand better the issues around mental health and then obviously to have a solution which is Headspace which is a very simple solution.  And I think if we’re going to encourage young people to get help we need to create a very simple solution that takes into consideration the whole range of other community services that bolts those into Headspace in order to make sure that once the young person makes the decision to get help help’s available.

Lynne Malcolm: Eric Barker’s sessions at Headspace when he was at high school really helped him with the difficulties he’d been having.  He then decided to continue his participation in Headspace and this is why.

Eric Barker: It does a lot of good things for young people at little to no cost and I guess I sort of felt it was my place to give back.

Lynne Malcolm:  Tell me what you do?

Eric Barker:  I run the youth supervisory committee for Headspace southern Melbourne.  We do public appearances, we raise awareness in the community, we do stuff like the Big Day Outs, the St. Kilda Fest, the Melbourne marathon all around the placed.  But when we started pretty much no one that we talked to had heard of Headspace before but since then when we’ve gone out in public there’s been an increased recognition in Headspace.  People come up to us at the stalls and say hey, you’re doing a great job and that makes us feel good.

Lynne Malcolm:  Chris Tanti says that what sets Headspace apart from other services is this youth participation element.  Their youth groups provide them with advice on how to engage and work with young people.

Chris Tanti:  The key thing for me with the youth participation model is the enthusiasm that young people bring and the optimism that they bring and the sense of what is wrong with the system.  And so young people will convey that in a way that I didn’t realise it could be conveyed in lots of ways without having set this group up.  I keep reading you know about the criticism of this particular generation and this stuff I read doesn’t at all fit with my experience of running youth participation Headspace.  What I see is a whole group of young people who are very committed to each other, very committed to the society and the community in which they live and are optimistic about their futures.  And so the enthusiasm they bring to Headspace and the optimism enables us to continue to develop a system that reflects that.

And often in mental health we get bogged down in what can’t be done rather than what can be done so it allows us to move forward on that basis.

Lynne Malcolm:  You’re with All in the Mind on ABC RN, Radio Australia and online, I’m Lynne Malcolm.  We’re looking at the mental wellbeing of young people and some new approaches to supporting them at a time when they are often at their most vulnerable.

The idea of the Headspace centres is to try and intervene soon after a difficulty emerges, to prevent mental health problems escalating.  But some young people need more specialist care.

Orygen Youth Health is a world leading clinical service and research centre based in      Melbourne and that’s where Markey eventually found support after a long painful struggle.

Markey:  When I arrived at Orygen I was, I had hit rock bottom in every sense of the word, I was losing everything, I couldn’t leave the house, I was a complete mess.  The staff were really good and were able to sort of emotionally hold my hand through everything, I was traumatised, I just couldn’t go on any further.  And then I was appointed a case manager and started weekly appointments, I was appointed a psychiatrist and for the first time as opposed to the past I actually made use of my time with these people, told them everything and found it very important not to hold anything back.  So the more I told them the more information I got and when I was diagnosed I was able to look further into my illness, learn what was going on and begin to understand and manage it.

Lynne Malcolm:  So what was the diagnosis?

Markey:  I was diagnosed with borderline personality disorder and panic disorder.  Once the diagnosis had been put in place I would have weekly appointments with my case manager, sometimes it would have to be two, maybe three times a week depending if I was going through a really bad patch or not and weekly appointments with my psychiatrist who I still currently see and learn and still constantly grow and learn new things every day and then able to manage my life better.

Lynne Malcolm:  And were you put on medication at any stage?

Markey:  Yes, I’ve been on medication most of my life, it was just a matter of the appropriate doctors and psychiatrists getting the right medications and the right dosage so that I could handle things better.  So that was a very, very important part too.

Lynne Malcolm:  Christopher Davey is a Psychiatrist at Orygen Youth Health, he specialises in treating young people with depression which he says is without a doubt the most common chronic illness of youth.  Orygen tend to see the more severe cases and their research is focussed on improving treatments.

Christopher Davey:  The main treatments we offer for depression principally is therapy and cognitive behavioural therapy, a time limited, so usually over three to six months weekly therapy that really tries to target the sort of thinking patterns that young people who are depressed get into, that really try to get them active again because I guess one of the main consequences of depression in young people is this social withdrawal.  So really just kind of stop participating in their social life often stopped participating in their education or their work and trying to get them to participate in that again is a really important part of the therapy.

And for the young people that we see at Orygen most of them have fairly severe depressions and a good portion of them who come to Orygen will also be offered anti-depressant medication as well as therapy and they would be the sort of mainstays of treatment and the most effective treatments we have for youth depression.  Albeit but both of them in the sort of people we’re seeing with more severe depression probably only modestly effective.  I think everybody should be offered psychotherapy but when you’re offered a good quality psychotherapy whether there is advantage to adding medication to that or not is really a question and I don’t think we have clear answers to yet.

Lynne Malcolm:  So it’s a little bit up in the air about whether a combination of the two really works?

Christopher Davey:  Yes that’s right.  I mean the best evidence we have would suggest that a combination of treatments is better than either treatment alone but I wouldn’t say it’s really strong evidence and there’s you know many people would suggest that medications aren’t that useful in young people.  So it’s an open clinical question and as a psychiatrist working in the field I’d say is probably the number one clinical question we need to answer.  You know well what sort of role does medication have in these young people and that’s a study we’re going to get underway towards the end of the year.  So we’re going to be comparing young people treated with CBT and taking a placebo pill be compared to young people being treated with CBT and taking fluoxitine.  Fluoxitine is the medication that seems most effective in young people.  And really to answer that question does medication add anything to good quality CBT and both fluoxitine and CBT have been around now for at least 30 years and you would have imagined that this question would have  been well and truly answered  by now; but it really hasn’t and from my own point of view I think I could say I would be genuinely uncertain about the outcome if we can show for example that medication doesn’t really add anything to good CBT and I think that gives us the impetus to focus on providing good quality therapy to young people.

On the other hand you know if medication does add something to the therapy and it does allow young people to get better more quickly and more often I think equally we shouldn’t be withholding medication if that’s the case.

Patrick McGorry:  You know we really have to develop a much stronger evidence base for all of the things that we’re actually using.  And that’s something these new platforms of care combined with practical research strategies we can actually build a lot more expertise and capacity within the field.

Lynne Malcolm:  Patrick McGorry and he’s currently leading research into more innovative and effective ways to manage youth mental health.  So what are the most promising approaches?

Patrick McGorry:  First of all to involve young people, youth participation, peer support, youth engagement to programs to create culture of care and then in terms of specific therapies we need to develop practical approaches to common problems that young people are presenting with and that means obviously substance misuse, it means deliberate self harm, it means persistent depression and these sorts of features.  And there’s also a need for I would say on the biological side of treatment a need for safer forms of drug therapies as well which have got less side effects, less harms associated with them and also work in perhaps more neuro-protective ways.  So in other words to actually protect or optimise the developing brain because the bodies are developing rapidly through this stage of life but some of their brains and its subtle disturbances in brain development that might be associated with some of these symptoms.  So treatments like Omega 3 fatty acids, we’ve been finding some positive results with that in reducing risks for psychosis.  Some people have talked about doing studies with anti-inflammatory drugs for example which are pretty safe types of medication and they may actually also have a role in terms of reducing risks for more severe disorders. So these are sorts of more research orientated pathways that we are exploring.

Lynne Malcolm:  An aspect of psychiatry which has been under scrutiny lately is the way people are diagnosed.  The Diagnostic and Statistical manual which mental health professionals use to categorise and assist with diagnosis and treatment is to be revised.  The new DSM V will be published in May next year.

And suggestions to include various new categories of mental illness have been surrounded by heated debate.  So do we need to rethink diagnosis when it comes to treating young people?  Patrick McGorry.

Patrick McGorry:  Well that’s an area of very hot controversy at the moment as you’re probably aware that the DSM V is being formulated and I think the controversy highlights the inadequacy of the existing diagnostic system but also highlights the need for more practical and simple concepts that allow us to intervene early without actually having negative effects of labelling and also preventing over treatment because like in America for example, the tendency is for everyone to be medicated.  Now obviously drug therapy is vitally important at a certain point but we need to have an array of therapies and diagnosis is only useful to the extent that it guides treatment, that’s the whole purpose of it.  So we have to find a balance between the unique personal qualities of the individual but we also have to be able to recognise patterns when a certain type of treatment is more likely to work than another type.

And that’s all diagnosis really is.  In psychiatry of course we’ve had some very stigmatising diagnoses like borderline personality disorder and schizophrenia which really had very therapeutic and realistic connotations and we’ve got to present a much more optimistic recovery orientated ethos with whatever terms we are actually using.  So I do think we need to have diagnostic reform and it needs to have this clinical staging sort of approach built into it so that we can balance risks and benefits at each stage.

Lynne Malcolm:  In the recent Federal budget over $400 million was allocated to early intervention mental health services for young people. Patrick McGorry says this is a positive move but there’s still room for improvement.

Patrick McGorry:  The trouble is implementation as usual particularly when it involves Federal/State partnerships.  What we’re looking for and what young people and their families are looking for is a national standard, a national system of care.  I think with Headspace we’ve seen work very well with the scaling up we will have 90 of these centres by 2015 and we want to see that happen at the more specialist end as well but it does mean that we’ve got to move beyond the traditional structure at the state level and there’s obviously resistance from vested interests and status quo in doing that.

So the money that was committed in the last federal budget is a challenge to actually get it onto the ground and we really need everyone pushing for that particularly members of the general public because I think both state and federal are very well intentioned people trying to make this work but they need a bit of a push from the community I think.

Lynne Malcolm:  So what difference will it make to our society if we can effectively improve the level of support and treatment offered to our young people?

Patrick McGorry:  Well the world economic forum in September last year issued a report showing that by 2030 mental disorders will equal cardio vascular disorders as the major threat to GDP in developed and developing countries among the non-communicable diseases.  And the reason for that is not just the level of mental ill health in the community but the timing of it.  Because it strikes on the threshold of productive life it sort of robs the emerging generation of their potential and their capacity to produce and contribute to society.  If we can actually impact on that by restructuring and re-engineering our services to be more effective and more cost effective then I think the benefits to society are not just going to be in human terms, in terms of you know fulfilling lives and realised potential but also very much in the hardnosed economic end as well.  Which is why the world banks said the most valuable person in society is the 22 year old and they are talking in human perhaps terms but also in economic terms.  So I think if we do this, and Australia could really show the rest of the world exactly how to do this if we get over our jurisdictional and implementation problems then we will actually be setting the pattern for I think mental health care to come of age really.  And we’ve got the capacity to do it but there has to be the investment and I think on the research front as well as the reform front.  And if we really embrace the 21^st century we can really I think transform lives across the whole world.

Lynne Malcolm:  Patrick McGorry, Professor of Youth Mental Health at the University of Melbourne and Director of Orygen Youth Health.

Eric Barker:  I still play music, I think personally I’ve grown a lot since then.  Last year I went to Cambodia and I taught English and that aside from Headspace and the counselling that opened up a whole new mindset for me.  Over there people don’t complain as much as here and I think when you can see other people battling things that are far more confronting than you will ever have to go through it sort of gives you a perception, an insight into how you should be dealing with things and things really aren’t that bad.

Markey:  At the moment I am unable to work due to my illness but I volunteer advice and support to other people going through the same thing as a support role, just to talk to people and see if I can even make someone laugh, or smile – for me that’s a very rewarding feeling

Lynne Malcolm:  Thanks to Markey and to Eric Barker for sharing their stories with us and Eric Barker wrote and performed the music in the show today too.

Go to our website for further information and links about youth mental health and leave a comment on the page too abc.net.au/radionational and select All in the Mind in the program list.  Join All in the Mind on Face book and Twitter as well.

Ann Marie de Bettencor is our sound engineer, I’m Lynne Malcolm, thanks for joining me – by for now.

.