Land of the Long Black Cloud

Land of the Long Black Cloud

Sarah Robson, Matthew Backhouse and Nina Fowler,

We all have crappy days, even crappy weeks. Somewhere down the line, a persistent crappy mood morphs into that monster we call clinical depression. The key symptoms are a consistently low mood, low energy, and a loss of interest and pleasure. Following close behind are the associated symptoms of disturbed sleep, poor concentration, low self-confidence, poor or increased appetite, agitation or lethargy, feelings of guilt, or suicidal thoughts.

If that sounds like you, then you probably feel like shit. The relatively good news is that you’re not alone. An Otago University clinical study estimated 20 percent of the general population in New Zealand suffers from depression during any given year. Patch that statistic onto Victoria University of Wellington, and that’s a total of 4 000 students who will suffer some kind of depressive episode this year.

Government has tried to tackle the issue of youth depression, but so far the initiatives have not necessarily been successful in engaging with youth. Students, one of the groups most likely to be affected by depression, cannot always get adequate help and treatment for depression in the public mental health system. Despite efforts by Victoria University student support services to pick up the slack, males in particular are still reluctant to seek help.

Cause and Effect

Depression has no single cause. Family history can play a part, although a strong genetic influence has not been proven. A depressive episode can be triggered by a specific event, ongoing stress, certain medications and recreational drugs, or lifestyle factors. Some people report feeling depressed for no reason at all.

While the expression of depression is equally varied, a few broad trends have been observed. Women are more likely to become tearful or despondent, and men are more prone to aggression and heavy drinking. According to the Ministry of Health, an irritable rather than stereotypically ‘sad’ mood change is particularly common for men from Maori and Pacific ethnic groups.

Dr Garry Brown, Medical Director of Victoria University Student Health Services, says cultural factors can influence the way people with depression seek help. “I don’t profess to be an expert, but I know sometimes Pacific Island communities find it harder to address issues of mental health because of cultural barriers, and I think that’s true at Victoria to a certain extent. We also see international students, some Korean and Japanese students, who have a background where mental health problems are highly stigmatised. We repeatedly see instances where families send their children away to university as far away as possible to lower the shame to their family and they end up in all sorts of far flung places, including Wellington. It’s very traumatic for them, and it’s very difficult for everyone to deal with.”

Gerard Hoffman, Head of the Counselling Service at Victoria, has also observed differences in the way students use mental health services.

“Pacific students are more likely to seek help through one of the Pacific services available on campus, not that there’s a lot of them, but the Manaaki Pihipihinga mentoring programme has a Pacific Support Coordinator who deals with a lot of pretty unwell students who would otherwise never get to us. We work pretty closely together, but Pacific students generally don’t just rock on up to see us. Maori use our services directly, to some degree, but we employ a Maori Services Counsellor specifically to break down that barrier. Again, that’ll suit some students and not others.”

Hoffman picks gender barriers as a bigger issue than cultural factors. “We see two-thirds women and one-third men in counselling, year after year, and while there are more women than men at university these days, it’s not by much. It’s the stereotype of the great Kiwi bloke. We drink and get agro rather than tearful, until it gets really bad.”

For all students, overcoming the social stigma associated with depression is the first step towards treatment and recovery. As Dr Brown points out, “the more you can normalise the truth about depression, the less perceived barriers people will have.”

What’s the Government doing about it?

A 1996 inquiry into mental health services recommended that the government fund a public education campaign to reduce discrimination associated with mental illness. A campaign was needed, the inquiry concluded, to improve the status and well-being of people who have experienced, or are suffering from, mental illness.

In 1997, the Ministry of Health launched a five-year $12.6 million public health project to tackle mental health issues at national and community levels. The ‘Like Minds, Like Mine’ public education programme was launched in 2001 and a second programme, the National Depression Initiative (NDI) was introduced in October 2006. Like Minds receives $1 million of government funding each year, and the NDI has an annual advertising budget of about $1.5 million.

According to Candace Bagnall, a Ministry of Health senior analyst in Mental Health Promotion, ‘Like Minds, Like Mine’ is acknowledged internationally as a leading education programme. The primary societal outcome of the programme is to ensure New Zealand is a nation that “values and includes all people with experience of mental illness.” For individuals who have experienced mental illness, the programme seeks to ensure they “have the same opportunities as everyone else to participate in society and the everyday life of their communities and whanau.”

The NDI, famously fronted by John Kirwan, is one of the most visible depression awareness campaigns. The campaign’s vision is to create a society with an effective response to depression. Understanding more about depression, says the NDI’s website, will help those experiencing depression “find a way through”. The NDI includes a series of television advertisements, the promotion of a freephone depression helpline and website, and a youth-oriented interactive website dubbed the ‘Lowdown’.

The Ministry of Health response to mental health is built around advertising campaigns and media work, but have ‘Like Minds’ and NDI been successful? Bagnall says “Both campaigns have demonstrated significant success in meeting their objectives.” Along with all other health services, both campaigns are being audited in the government’s ‘line by line review’. The future of the campaigns “will depend on the outcome of this review,” Bagnall says. She adds that the results of this review have not yet been finalised, and that “it would be premature to consider potential campaigns since the review of existing campaigns is still underway.”

Last year, the NDI received an award for advertising effectiveness in the social marketing and public service category for the Lowdown website. The website also grabbed international attention when it was presented at a US conference on mental health. However, international attention and advertising awards do not necessarily mean that the NDI—and particularly its youth component—are effective public health campaigns.

Lowdown on the Lowdown

“Living in the shadow of fear” is how Roberta Woodgate has described young peoples’ experiences of living and dealing with depression. Earlier this year the Ministry of Health commissioned a literature review of how to communicate effectively with young people about depression. This included a review of the Lowdown website. The review cited the work of Woodgate, who elaborated on the ‘shadow of fear’ metaphor. “The shadow of fear is associated not only with fear of a return of the ‘bad’ feelings related to their depression, but also fear of not getting help, not surviving the ‘bad’ feelings, and fear of having to do all the ‘hard work’ in overcoming the ‘bad’ feelings.”

Destigmatising depression and reinforcing a sense of normalcy, the review says, should be the main focus of the youth component of the NDI. “This would reinforce to young people the sense that they are mentally well, acceptable and included, even though they are going through a rough patch, and that this will pass,” the review says. “Implicit in this is an emphasis on recovery, support and hope.”

Furthermore, the review recommends that communications to young people emphasise that depression is not a fixed state. “Talking about ‘feeling depressed’ or ‘down’, or ‘experiencing depression’ suggests a more temporal experience that is within their agency, than does ‘having depression’.”

While it is important to alert young people to the symptoms of depression, the review questions whether “alerting youth to risk factors would activate them to avoid these factors, or depress them further.” It was recommended that knowledge of risk factors must be accompanied by practical solutions about where to get help, how to open up and talk to people and what can be done to avoid the risk factors of depression. “Without the skills or resources to avoid these factors, perhaps the knowledge on its own would be dismaying.”

Lowdown seeks to address the complex issues surrounding youth depression, but is it really achieving its worthy goals? The review cites a 2003 study which concluded there were no mental health campaigns aimed at youth, and the existing campaigns were not reaching out to youth audiences. The study also questioned the effectiveness of the internet in reaching out to youth audiences: “They do not particularly see the internet as a source of help or support; rather they see it primarily as a socialising tool.” Communication technologies were recognised as useful in providing constant access to peer support, but television was still the most effective means of reaching at-risk youth. Effectively, Lowdown can only be as useful as the audience it is able to attract.

So how big is Lowdown’s audience? The latest NDI figures show that the website received 95,000 unique visits in the last year, but the number of return visits was not reported. Return visits have been identified as an area of concern by the Ministry of Health review, which recommends that youth should be actively encouraged to revisit the site. It also suggests that youth need to feel that visiting the site is “completely acceptable”.

The NDI’s latest figures also show that 3000 support sessions have been provided by counsellors via text and email, with a total of 90,000 texts and 5000 emails being sent and received by the Lowdown team. It is significant to note that about three quarters of service users have been diagnosed as suffering from depression. However, the Ministry of Health review suggests that contact with site users could be improved, particularly by ensuring users are re-contacted over an extended period of time.

Overall, the Ministry of Health review concludes that Lowdown is already implementing measures consistent with the most recent academic recommendations. Nevertheless, several areas of the service need to be addressed. The site must take into account the importance of individual autonomy while making it easier for people to get information on helping out friends and family in need. It should affirm that seeking help is not only normal, but astute. It should explain what the experience of a counselling session is like. The website also needs a search function to make information easier to find.

Most significantly, the review found that simply having a well-tailored website is not enough to serve its audience. Traditional advertising campaigns and engagement with schools are still vital in promoting the service. Lowdown is already advertised on youth-friendly websites, but the review found that successful social marketing campaigns—which are most likely to be effective to youth—are non-existent.

What’s Vic got to offer?

Victoria University’s Student Health and Counselling Services are dealing with students seeking help for depression on a day-to-day basis. Dr Brown says that Student Health takes a cross-service approach to depression.

“They can come in the health door or the counselling door and get a reasonably consistent approach to the way their problems are picked up and managed,” he says.

“If people have more severe problems then we have a series of programmes which … are more particular and careful and [we] put more resources into helping them.”

A stepped care approach is taken to dealing with mental health issues. “Essentially [it] says you provide a level of service in accordance to the severity of the issue,” Hoffman explains. This approach is now fairly well-defined around the world, and the Ministry of Health have put out direct guidelines to GPs and mental health professionals for dealing with issues like depression, he says.

“There’s a role for self-help strategies for people who are suffering from periods of mild depression, things like exercise, activation approaches—just to get moving and get going,” Hoffman says.

Self-help approaches like staying in contact with social supports, talking to family and friends, and keeping involved in activities and pastimes are some important ways that people can deal with depression. “That’s going to work for a lot of people,” Hoffman says.

However, some people will need more help to overcome depression. “The next level beyond that is to engage in a focused course and talk things through, on a relatively short term.”

Health professionals will consider prescribing antidepressants to people with more moderate symptoms of depression. Hoffman says that the general view is to not put young people on antidepressants too quickly. “Antidepressants can be pretty effective but so can a lot of these other approaches,” he says.

“If students have got longstanding depression or things aren’t shifting within a few weeks or a month, then we could consider a referral to a doctor and start questioning whether antidepressants might be useful. Even then, we still encourage people to keep using us [the Counselling Service] so they get a joint approach.”

Vic is one of only two universities in New Zealand—the other being Otago—to employ a psychiatrist. Dr John Gregson works two days a week in his University-funded position. While two days of work may not seem like enough, he says “Victoria is pretty proactive in employing a psychiatrist.”

When people have much more serious symptoms, or are not responding to antidepressants or therapy, the Counselling Service will consider referral to the psychartrist, Hoffman says. “They have to be pretty unwell for us to do that.”

Dr Gregson’s position does not act as a replacement for services offered by the Capital and Coast District Health Board (DHB). “There are naturally a lot of students here with quite complex problems who’ve got great strengths to keep on going through it all,” he says. Many of these students don’t meet the requirements for mental health treatment under the DHB. “They’re some of the people who come to us.”

Victoria’s Medical Director, Dr Gary Brown, says the mental health services funded by the DHB deal with only the three percent of the population who have the most severe mental health problems. “If you accept as more or less truth the study that found 20 percent of the general population are suffering, then that’s 17 percent of the population who are not going to get help when they need it from hospital services,” he says.

“The strength of the university is that we have immediate access to healthcare services, a free counselling service and John [Gregson]’s service, which strengthens the ability of both services to deal with those people.” Access to services is a problem across the health sector, Dr Brown says. “Like lots of things in health, it’s probably fair to say that the ability to access appropriate services depends on education and income.

“Supposing you have severe depression, you’ll be seen by the DHB mental health service. If you’ve got mild to moderate depression, you won’t make the criteria. “There is some recognition there is that gap which needs to be met. The reality for a lot of people is that their best chance of getting that [help] might be to pay for it privately with a private clinical psychologist.”

We’re pretty lucky here at Vic to have easy access to top quality services to help deal with depression. Student Health and Conselling services take depression seriously, Hoffman says. “Depression is the most common health issue that we as a people face. It’s so closely linked to negative outcomes in people’s lives, including suicide. It’s the biggest risk factor for suicide, and the vast majority of people who attempt suicide or actually succeed are depressed.”

“Our population at Victoria is a really high risk population, if you look at the age range of the students that come to Vic. That’s one of the reasons we take it so seriously.”

http://www.salient.org.nz/columns/land-of-the-long-black-cloud

This story was syndicated by the Aotearoa Student Press Association via Salient www.salient.org.nz

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