Updates and insights
Here we provide expert commentary on mental health topics, including lay summaries of research projects and publications, news from international journals, expert commentary from Black Dog Institute researchers and interesting articles from reputable sources.
Prepared for the Australian Government | Department of Health - February 2020
Insomnia is closely associated with many mental illnesses, both as a symptom and a potential trigger.
It co-occurs most commonly in major depression with around 80% of people diagnosed with depression experiencing insomnia. Interestingly, around 40% of those suffering insomnia may also have undiagnosed yet clinically significant depressive symptoms.
We know that people are far more likely to seek help for insomnia over depression - probably due to the perceived stigma associated with mental illness. Research shows that Cognitive Behaviour Therapy (CBT) can be used to effectively treat and prevent both conditions.
Black Dog Institute researchers, in partnership with the Australian National University, University of Sydney, and the University of Virginia, have trialled an online CBT-based insomnia intervention to see if it can reduce depression symptoms and prevent escalation into major depression.
Called SHUTi, the intervention was delivered online to over 500 trial participants. A further 500 participants were allocated to another online program containing information about general health.
Results, published today in the prestigious journal Lancet Psychiatry, showed that the SHUTi treatment group experienced significantly reduced insomnia, anxiety and depression, with these improvements persisting for at least 6months.
Chief Investigator Professor Helen Christensen says there are two important conclusions to take from these results.
"This is the first trial in the world to demonstrate that CBT-based insomnia treatment can also have a significant impact on the development of depression."
"Since insomnia treatment is rarely stigmatised, this will remove a significant hurdle for those people who feel uncomfortable seeking help."
"Just as we have sun cream to prevent the development of skin cancer, use of an insomnia treatment like SHUTi before depression symptoms escalate will essentially prevent transition into major depression, saving costs and lives."
"It is also of significant importance for young people, who may not be able to specifically identify depression symptoms but are aware of their insomnia."
"Secondly, the success of the SHUTi program has significant implications for the clinical delivery of mental health interventions."
"This program had the same level of effects expected of face to face treatment but was delivered by automated software, giving us a cost-effective way for us to quickly distribute quality treatment and prevention programs across large geographic areas and to a wide range of users."
Christensen et al (2016) Effectiveness of an online insomnia program (SHUTi) forprevention of depressive episodes (the GoodNight Study): a randomised controlled trial. The Lancet Psychiatry , Volume 3 , Issue 4 , 333 - 341
Many major medical and scientific advances occur in association with technology and there is no argument that computers, and indeed the Internet, are the greatest technological inventions of this era. Web 2.0 has quite literally ‘created’ a global village where anyone with an internet connection can access specialised medical information.
The Internet has certainly made possible things that were nearly impossible before. Historically, it has taken a median of 24 years to take new research discoveries from the lab to the clinic. The Internet enables this translation to occur much more quickly, provides broader dissemination and allows cost-effective tailoring to the individual.
While new technologies are useful across the medical spectrum, there are a number of features that make them especially impactful for mental health.
Unlike the more physiological conditions like cancer or diabetes, many people experiencing poor mental health will not need a physical intervention. Gold standard psychological therapy such as CBT can be delivered via the internet, and research shows you don't need any further human interaction for it to be effective. This means people who may not be able to attend face-to-face therapy, or those may not want to due to perceived stigma, can still access quality treatment programs.
Mental health tools can actually work better when they are mobile and accessible 24/7. You can now use your smartphone to test yourself for mental illness, engage with an online treatment program or obtain real-time crisis counselling. Sophisticated bio-sensing technologies and Bluetooth can collect data, information and geographical location to provide a real-time view of behaviour and mood. These capabilities facilitate identification of at-risk individuals and assist in referral and access to treatment. This is of particular use when preventing suicide.
Technology lets us create interactive treatment programs in a wide range of formats. Need to deliver a program to high school kids? The latest research shows us that programs presented as online games are both attractive and effective. A specially created app called iBobbly is uses artwork, stories and music to deliver quality mental health care to young indigenous people.
Big data and social media can give us real time insights into how the human mind works. We can now measure the emotional content of the global twitter stream using a program called "We Feel" giving us unprecedented vision of how major world events can impact the collective mental health of communities.
Finally, the growth of self-help and the empowered patient movement has meant people are more likely to investigate their symptoms online. Whilst we don't advise people to use "Dr Google" when experiencing poor mental health, having access to a range of specialised medical knowledge and treatments, as well as the many personal stories available on blogs and social media, does increase mental health literacy, reduce stigma and encourage help-seeking.
The most exciting thing for researchers and clinicians is that the impact of technological developments will become clear over a very short time. In the meantime, we will continue to see exciting new technologies that have the potential to extend, make more efficient and add value to mental health care. Learn more about how digital technology is transforming mental health care at Digital Dog
Prof Helen Christensen
Here we are again, with yet more reports reminding us that suicide is the leading cause of death of Australians in the 15-44 years age bracket. That suicide impacts more than 85% of us. That 1 in 7 of us will experience suicidal thoughts in our lifetime. These statistics are not anomalous, this is a brutal ongoing fact that we need to deal with.
Over the past month, as happens every September, we’ve all been called on to reach out and connect, to recognize suicidal behavior and provide support to our loved ones who are struggling. We’re having the conversations, we’re checking on our mates. Yet we’re not seeing any immediate impact in these awful statistics.
Why is this? Put simply, because conversations and awareness are only the first steps to saving a life.
By trawling through the available scientific literature it is possible identify what strategies can have demonstrable impacts on the suicide rate. Not surprisingly, the most powerful way to reduce suicide is to improve access to quality mental health care. The second most effective strategy is supporting GPs to address depression and suicidality in their clinics. Awareness campaigns ranked number seven on that list.
If we really want to address the suicide rate, we need to rethink how we tackle mental health issues in our society. More specifically, we need to be able to better identify people at risk of suicide and give them the care and support they need before they reach crisis point.
There are plans afoot to address this. The Federal Government has announced their plan to have 12 suicide prevention trial sites around the country, although information is sparse as to what strategies are actually being implemented in these sites. Black Dog Institute, in partnership with the NSW Government, is trialing a large-scale suicide prevention program called Lifespan that includes all of the nine strategies researchers identified as being important. Both of these programs are community-focused and aim to address local need.
We’re also seeing a groundswell of support for the integration of technology into suicide prevention activities. Evidenced-based online programs in combination with awareness campaigns could have a real, lasting impact. We tend to be frightened of technology, and particularly in the case of mental health and suicide, but it can provide immense support when an individual is not willing, or not able, to attend face-to-face therapy.
Importantly, we need to be able to measure and evaluate the success of suicide prevention activities. From the perspective of the researcher, this goes way beyond counting likes and retweets. We want to see a reduction in suicide and suicide attempts. We want to see an improvement in the overall mental health of a community and we want to be able to quickly translate anything we learn into better services. Lifespan has this evaluation framework built in and we’re hoping to be able to extend this framework to the twelve other suicide prevention sites around the country.
So when we hear these terrible statistics over and over again, we take heart in the fact that the wheels of progress are turning, albeit slowly. Rigorous, evidence-based suicide prevention activities in partnership with the 'in-your-face' impact of national awareness campaigns will help us to reduce the suicide rate and save lives.
An interesting review published in the Medical Journal of Australia has questioned the benefit of antidepressant medication as a front line treatment for depression.
Why was this review done?
Antidepressants are one of the most commonly prescribed medications in Australia. Around 10% of all Australian adults are taking antidepressants and the rate of prescription is rising. Yet we are not seeing a corresponding improvement in mental health outcomes with depression rates remaining static. This paper explores why this may be the case.
What was the result?
There is no argument that antidepressants are an important frontline treatment for people experiencing severe depression.
How effective they are on a population level is more contentious. Some research has shown that antidepressants are no better than placebo in people with mild depression. Other research has shown that antidepressants are considerably more effective when combined with other forms of treatment such as psychological therapy and lifestyle management.
The authors of this paper conclude that more work needs to be done to understand the biological basis of depression and thus develop more targeted treatments. They also strongly recommend that antidepressants be prescribed within a strict framework that includes other treatment options.
What does this mean for me?
Whilst this article gives us some interesting things to ponder, it does not mean that antidepressants won’t work for you. People respond in different ways, and for many, antidepressant therapy is a lifesaver. It is important to note the benefits of non-pharmaceutical therapies for mild to moderate depression, and you may like to visit your GP or mental health care provider to discuss additional treatment options.
A hospital admission for self-harm represents an important opportunity for clinicians to provide formal mental health assessment and treatment as well as linking patients into ongoing mental health care.
Researchers from the University of Melbourne and the Black Dog Institute conducted a study to measure how many people admitted to hospital were referred to community health care and who was most likely to be referred. Results have been published in Australian and New Zealand Journal of Psychiatry
Using data from the NSW health system, researchers identified that nearly 43,000 people were admitted to hospital for self-harm in NSW between January 2005 and Dec 2011.
Results showed that only 41% of people admitted for self-harm received follow-up care from a community mental health service within 30 days of being discharged from hospital.
This result was significantly lower for people who had not been connected with community health care previously, with only 27% of this group receiving care.The odds of receiving community mental health care declined with age, with older men being particularly less likely.
Whilst there were some limitations to the study, overall the results are contrary to international clinical practice guidelines for treatment of self-harm. These typically recommend a management plan including community care be developed for patients while they are still in hospital, and are based on evidence that shows fostering strong relationships between hospital staff and community mental health teams can reduce subsequent incidents of self-harm
Strategy 1 of the Lifespan program is focussed on the coordination of health services following a suicide attempt, with research showing that this strategy could reduce suicide attempts by almost 20%. Find out more about the Lifespan strategies her
Spittal et al. (2016) Community mental health care after self-harm: A retrospective cohort study. Aust N Z J Psychiatry, published online November 7
A global research analysis conducted by the Black Dog Institute shows that national delivery of school-based prevention programs will reduce incidence of depression and anxiety.
Depression is the leading cause of disease burden in Australia and predicted to be the leading cause of disease burden across the world by 2030.
In Australia, around 3 million people will experience depression or anxiety every year, and up to 20% of Australians will experience anxiety or depression before turning 18. Early onset of mental illness is associated with poorer health and social outcomes including increased risk of drug and alcohol abuse, unemployment and suicide.
According to research conducted by Black Dog Institute, and published this week in Clinical Psychological Review, delivery of quality prevention programs via the school system will significantly reduce the community burden of depression and anxiety by preventing or delaying onset, and reducing severity.
“Our meta-analysis of research studies from across the world clearly showed that school-based prevention programs do reduce the impact of depression and anxiety,” says lead author Dr Aliza Werner-Seidler.
“This is a significant finding, as schools are the ideal location to deliver mental health interventions.”
“Not only do they enable us to reach all young Australians, the integration of programs into the school curricula alleviates the barriers to treatment that we know young people are currently experiencing – stigma, time, access and cost.”
The analysis of 81 research trials from across the world showed that the anxiety and depression prevention programs were still having an effect more than 12 months after delivery, suggesting that the benefit is sustained.
Interestingly, for depression prevention programs, effects were greater when programs were delivered to students aged 14 years or younger.
“These findings highlight the enormous potential of school-based prevention,” says Dr Werner-Seidler, “but also demonstrate just how much more we need to understand before we can optimise program delivery.”
“Important factors such as the best time to deliver programs, how they should be delivered and who should deliver have not been clearly established.”
“We strongly believe that the delivery of prevention programs via primary and high schools should be further investigated as a matter of priority as the benefits could be life-saving.”
A.Werner-Seidler et al. (2016) School-based depression and anxiety prevention programs for young people: A systematic review and meta-analysis. Clinical Psychological Review 51 : 30–47