Foxes, Hedgehogs and Mental Health

My AFR column today is on mental health, arguing that while there are some good youth programs, we shouldn't ignore the potential for mental health interventions before age 12 and after age 25.


Narrow Mental Health Focus, Australian Financial Review, 12 April 2011

An essential characteristic of great innovators is their single-minded focus. Imagine how much poorer the world would be if the Wright Brothers had been part-time trainspotters, if Bill Gates had spent half his childhood studying archaeology, or if Howard Florey had split his time equally between economics and medical research.

The great Oxford philosopher Isaiah Berlin once divided thinkers into hedgehogs, who know one big thing – and foxes, who know many little things. Using this metaphor, most scientific breakthroughs are performed by hedgehogs, whose unwavering focus on a single goal is what cracks the nut. By contrast, policymakers often need to be foxes, recognising that the world’s problems are complex, and that most challenges cannot be boiled down into a single idea.

In mental health policy today, considerable attention has been given to a pair of youth-focused approaches: headspace (for moderate mental ill-health) and EPPIC (for serious mental illness). Both strategies have shown promising results, with evaluations using matched treatment groups suggesting that headspace and EPPIC are effective.

While these results are impressive – and the work has been noted internationally – it is critical to keep the success of youth-based programs in perspective. The age range of 12 to 25 is undoubtedly an important one, but it is far from clear that this is the only point at which policymakers can intervene.

In lifecycle terms, most measures of mental illness peak are highest in the age range 35-44. According to the Australian Bureau of Statistics’ most recent National Survey of Mental Health and Wellbeing, this is the peak age range for affective disorders (such as depressive episodes) and anxiety disorders (such as post-traumatic stress disorder). The suicide rate also peaks in the age range 35-44. The average age of a suicide victim in Australia is 44, well above the eligibility age for headspace and EPPIC.

Like many physical health problems, mental disorders often have a long history – sometimes stretching back to adolescence. But it does not automatically follow that youth services will prevent problems from arising later in life. The Royal Australian and New Zealand College of Psychiatrists has noted that intervening prematurely could lead to patients being inappropriately labelled and medicated. As an analogy, we know that obesity and smoking can have their roots in the teenage years – yet it would be a mistake to think that either could be solved by a youth-only approach.

A whole-of-life approach to mental health requires a primary health care system that is better integrated, and in which doctors and nurses are trained to deal with mental disorders. It also involves investing in perinatal depression, direct suicide prevention, and crisis intervention (such as after the Victorian bushfires or the Queensland floods).

The other feature of the youth model is that it misses the potential for interventions before age 12. In one study, expert observations of toddlers correlated with suicide attempts in adulthood. Improving mental wellbeing at young ages requires high quality childcare, skilled teachers, and a system in which educators and medical workers are adept at managing minor problems and referring more serious issues.

Yet despite the evidence, Tony Abbott’s current mental health policy has just one approach: boost youth services. This is like having an education policy that focuses only on high schools, and dismisses the potential to improve skills through early childhood programs, apprenticeships or on-the-job training. And because Mr Abbott’s policy cuts back on other aspects of health care (such as electronic patient records), there is a risk that his plan would make the primary health care system even less adept at dealing with mental illness.

The good news in mental health is that the Australian suicide rate has steadily fallen over the past decade, and is now lower than at any time since the end of World War II. Funding has also increased, with federal mental health spending in 2010-14 nearly triple what it was in 2004-08.

But the bad news is that mental health still imposes a major burden on sufferers and their families. Australians with mental illnesses are overrepresented in our jail cells and on our park benches. Anyone who is passionate about reducing disadvantage – as I am – must be serious about addressing mental illness. And as any fox knows, you don’t solve a complex problem with simple solutions.

Andrew Leigh is the federal member for Fraser.

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