Family relationships and mental illness: Impacts and service responses

AFRC Issues No. 4 – June 2008

Section 1: Overview of mental health problems in the general population

The scale of mental health problems in Australia

Recent years have seen a growing public awareness of the nature and scale of mental health problems as they impact on the general population. One contributory influence in this country has been the information gathered by the first Australian National Survey of Mental Health and Wellbeing, conducted by the Australian Bureau of Statistics (ABS) in 1997. The published results of this survey remain the primary source of quantitative data on Australia's mental health.1 The 1997 study found that around one in five adults in the population had experienced a depressive, anxiety or substance use disorder in the past 12 months meeting the conventional diagnostic criteria used in psychiatry (Andrews, Hall, Teeson, & Henderson, 1999). The prevalence of affective (i.e. depressive) disorders was 7.2%, anxiety disorders 9.5%, and substance use disorders 7.7%, and the more specific diagnoses within these broader categories are shown in Table 1.

Table 1: Prevalence of psychiatric disorders in the past 12 months by ICD-10 diagnostic criteria
Diagnosis %
Any affective disorder 7.2
      Major depression 6.7
      Dysthymia 1.3
Any anxiety disorder 9.5
      Panic disorder 1.1
      Agoraphobia without panic disorder 1.1
      Social phobia 2.7
      Generalised anxiety disorder 3.0
      Obsessive-compulsive disorder 0.3
      Post-traumatic stress disorder 3.3
Any substance use disorder 7.7
      Alcohol harmful use or abuse 3.0
      Alcohol dependence 3.5
      Drug harmful use or abuse 0.2
      Drug dependence 2.0
Any of the above disorders 18.6

Source: 1997 National Survey of Mental Health and Wellbeing as reported by Andrews, Henderson and Hall (2001)

In addition to these common mental disorders, we know that around two to three percent of adults will experience more serious disorders during their lifetime, such as schizophrenia and bipolar disorder (i.e. manic depression). Although these overall figures of the prevalence of mental disorders appear very high (and are sometimes referred to as being of "epidemic proportions") they could well be underestimates. Some other disorders, including personality disorders, eating disorders and pathological gambling are not included in the national survey figures. Furthermore, many individuals experience mental health problems that impact on the quality of their lives or on the lives of other family members, even though these do not meet the criteria for psychiatric diagnoses.

It is notable that the sum of the prevalence figures for specific disorders in Table 1 exceeds the percentage for having any disorder (18.6%) by a considerable margin. This reflects the fact that many people meet criteria for more than one diagnosis, and further, that having any one disorder increases the likelihood of receiving an additional diagnosis. Over a third of individuals with any diagnosis met the criteria for two or more disorders (Andrews et al., 2001).

One reaction to the high prevalence estimates of mental disorders has been to suggest that diagnostic criteria identify problems of a trivial and self-limiting nature. However, additional information on the burden of mental disorders (covering economic costs and disability) serves to emphasise their seriousness. From the same national survey it has been estimated that, in Australia, around 680,000 work days per month are lost due to sickness absence for mental health reasons (Lim, Sanderson, & Andrews, 2000). Of these, about 351,000 were attributed to depressive disorders. An additional 1.9 million "work cutback days"2 per month were attributed to mental disorders, 900,000 of these to depression. These figures focus exclusively on temporary absences from work and do not include lost productivity from unemployment due to mental disorders.

At the population level, mental disorders are the leading cause of non-fatal disease burden in Australia (Mathers, Vos, & Stevenson, 1999) and depression is estimated to become the second leading cause of disease burden and the major cause of disability worldwide by 2020 (Murray & Lopez, 1997). Although rare, the fatal consequences of mental illness are also significant in Australia. Suicide accounts for only about two percent of all adult deaths in recent years, but was responsible for 10.6 percent of years of life lost through premature death when estimated for 1998. This estimate was based on a notional "full" life of 75 years (ABS, 2003) and the figure of 10.6 percent is therefore a reflection of the comparatively young age of many people who died from suicide. Fortunately, youth suicide rates have fallen in recent years, especially for young men where the rate is now about half of the peak reached in 1997 (Australian Insitute of Health and Welfare [AIHW], 2007). However, suicide is still the second highest contributor to deaths in the 12-24 year old age group, accounting for 19% of deaths in 2004.

The youth suicide rate in particular highlights the need to consider mental health problems in childhood and adolescence, as does the evidence that adolescence is the period in which many mental disorders begin (Patel, Flisher, Hetrick, & McGorry, 2007). According to the child and adolescent component of the 1997 National Survey of Mental Health and Wellbeing, about 14% of children aged 4-17 years had mental health problems (Sawyer et al., 2000; Rey, 2001). Internalising disorders (where psychological distress is expressed or directed internally, e.g., depression) and externalising disorders (where the distress is directed outwards, e.g., ADHD, conduct disorder) were equally common (AIHW, 2005). For young people aged 18-24 years, the 1997 National Survey of Mental Health and Wellbeing showed that around 27% had experienced a mental disorder in the past year, a higher proportion than for adults generally. The most common category of disorder in this age group was substance use problems, affecting 21% of young men and 11% of young women. This raises the question of the use of substances either as a precursor to mental illness or for the purposes of self-medication to deal with mental illness. Whilst a discussion of dual diagnosis of mental illness and substance abuse is outside the scope of this paper, its frequency is worthy of note.

These figures highlight the importance of early identification in order to increase the chances of early diagnosis and treatment. Barriers to help-seeking at this age, however, include stigma and negative attitudes towards help-seeking from professionals, believing that services won't be useful and a tendency to think that problems should be handled personally. Young men and young people from an Aboriginal or Torres Strait Islander or other culturally and linguistically diverse (CALD) minority groups may be particularly reluctant to seek help (Rickwood, Dean, & Wilson, 2007). If help is sought by young people it is more likely to be from friends or family, or in the case of professionals, family doctors or school counsellors (Rickwood et al., 2007). The Internet may also be a source of information and support, particularly for more stigmatised or extremely personal problems (Nicholas, Oliver, Lee, & O'Brien, 2004). As a result, many young people who are dealing with mental health problems may not come to the attention of professionals who can assist with appropriate early interventions or treatments.

Mental illness and families

The extremely high population burden of mental disorders assumes special significance for family relationship services for several reasons. These include:

  1. Mental disorders impact not just on the individuals affected but also on those around them - including immediate family and other relatives - and may be both a cause and a consequence of family/relationship difficulties.
  2. Although most common mental disorders are amenable to treatment, the majority go undiagnosed and untreated.
  3. Many disorders are chronic or recurrent and they often call for long-term management, not just acute care.
  4. Much of the care provided for people with mental disorders (even very serious disorders) is informal care provided by family members.
  5. Many of the "vulnerable" family groups that represent the clientele of family relationships services have a greater risk of mental health problems than the population average.

1. The interpersonal nature of mental health problems

Mental health problems are often of a deeply personal nature in that:

  • they are often not visible to others;
  • most are characterised and identified by emotional and other subjective symptoms; and
  • many individuals experiencing problems attempt to conceal or downplay their difficulties.

At the same time, mental health problems have features that are fundamentally interpersonal. The clinical diagnosis of almost all mental disorders includes the criterion that "symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning." Although the onset of disorders may not be identified as such by family members, it is still usually the case that relatives and close friends recognise that "something is wrong" with the person affected and they can be influential in decisions to seek professional help. Impaired functioning in occupational roles has already been described, but similar impairment is also likely in an individual's parenting role or their engagement in a couple relationship. Postnatal depression is an obvious example where a mental health problem is seen to affect functioning in a parental role, including development of attachment and other parent-child interaction. Other common mental disorders are also found to be linked with a range of adverse social outcomes, including marital dissatisfaction (Whisman, 1999) and the likelihood of marital breakdown (Mendlowicz & Stein, 2000; World Health Organization, 2001; Kessler, Walters, & Forthofer, 1998).

An additional interpersonal feature of mental health problems is the importance of perceived stigma (when public endorsement of prejudice related to a stigmatised group occurs), and self-stigma (what stigmatised people may do to themselves, if the public stigma is internalised) (Corrigan, 2004). Both types of stigma are associated with help-seeking for mental health issues, and both impact on the likelihood of receiving help. Individuals may be particularly sensitive to the views or presumed views of relatives and friends about mental health problems and this can be a factor in their willingness to disclose their own problems or to seek professional help.

2. Untreated disorders

Most people in Australia who experience common mental disorders do not receive adequate services. In the 1997 national survey, 28% of people with an anxiety disorder, 14% of those with a substance use disorder, and 55% of those with a depressive disorder in the past year had received some form of professional help (Andrews et al., 1999). Although professional help for depression was comparatively high, only 32% of the people receiving help were provided with treatments that are known to be efficacious (Andrews, Sanderson, Corry, & Lapsley, 2000), so the proportion obtaining effective help was only about one in six. It will be interesting to see if these figures improve for the second survey (due for release in late-2008), as a result of a possible increase in public knowledge and greater willingness to seek care since 1997 and the recent availability of time-limited treatment by psychologists under Medicare arrangements, on referral by a medical practitioner.

The lack of professional care for mental health problems has implications for family relationship service providers for the following combination of reasons:

  • Untreated problems are likely to last longer and may worsen in terms of severity.
  • Inappropriate forms of self-help, such as substance use, can lead to secondary problems (i.e. comorbidity).
  • Clients with untreated disorders will be less likely to benefit from interventions provided by family relationship services, either because their problems (e.g., depression) reduce engagement with the intervention or because problems work directly against the intervention (e.g., substance use or gambling problems could undermine financial counselling).

3. Managing chronic and recurrent disorders

Whilst treatment can often be effective for common mental disorders, particularly if help is received before difficulties become too entrenched, there will be many instances where problems continue to be chronic or recurrent. The management of diabetes has been suggested as analogous to management of chronic depressive and anxiety disorders (Andrews, 2001). Such management should cover not just personal care but also ways of dealing with the broader context of interpersonal relationships and family responsibilities. For some therapies (e.g., behaviour marital therapy or family therapy) the importance of family relationships is an integral part of treatment, but this is not always so for other therapies, such as individual cognitive behaviour therapy. This presents a challenge for both mental health services and for family relationship services to accommodate issues arising from mental health problems that can impact on families (just as chronic physical disease or disability affect families as a whole). Services will often have expertise in one or other area, mental health or family relationships, but typically not in both.

4. Informal caregiving

A significant part of the caregiving burden falls on family members, especially for more serious mental disorders. This role is often undertaken by parents when a young person or child is affected, by spouses, siblings or ageing parents when an adult is affected, and by adult children of the elderly. However, less typical instances represent important exceptions, for example, children and young people under 18 years caring for their parents. Notable issues for carers of people with severe mental disorders include access to specialist services, availability of ancillary services such as respite care, eligibility for financial assistance (e.g., carers' payments), and therapeutic support for themselves (Edwards, Higgins, Gray, Zmijewski, & Kingston 2008). Caregiving for family members is dealt with in more detail in a later section. However, it should be noted here that there is no clear-cut separation between caregiving (with a defined carer and receiver) and the more common circumstance of providing emotional and practical support for a relative with mental health problems. This is best viewed as a continuum of care, often involving reciprocal support, which merges into the issues mentioned in the previous section on managing chronic and recurrent disorders.

5. Vulnerable families

For some family relationship service providers, their whole target client group can be seen as potentially vulnerable to mental health problems. Domestic violence services need no reminding of the possible mental health consequences for victims, particularly if this has been a repeated event. The research literature on risk and protective factors for adult mental disorders provides the evidence base for the characteristics of individuals and families that increase the likelihood of being affected by mental health problems. Unlike the vast majority of physical disorders, mental disorders are more common in young and middle-aged adults, compared with older adults. Depression and anxiety disorders are more common in women than men, whereas substance use disorders are more prevalent in men. Family history of mental health problems, especially of parents or other first-degree relatives, is another important risk factor.

The demographic and socio-economic factors that have the strongest association with depression and anxiety are lone parenthood and unemployment (especially when long term) (Butterworth, 2003; Crosier, Butterworth, & Rodgers, 2007). An underlying feature in both instances is financial hardship, which is indicated by lack of material resources and inability to afford essentials rather than by income alone. Adults with dependent children, especially mothers, are at increased risk for depression and anxiety, with the mothers of younger (pre-school) children having the highest risk. Past (own) relationship breakdown is also related to an increased risk of depression and anxiety (as seen in stepfamilies as well as lone parent families), as is parental separation in the family of origin even after many years (Rodgers, Power, & Hope, 1997).

Occupational skill level as such is not strongly related to risk of mental health problems. Rather, work characteristics such as insecurity, high demands and low control are more pertinent, and having a combination of these poor characteristics may be worse than having no job at all (Broom et al., 2006). Some occupations place people at particular risk of mental health problems, most notably, the possibility of post-traumatic stress disorder (PTSD) for those in the defence forces and for workers employed in emergency services. PTSD often occurs in conjunction with other anxiety disorders and/or depression.

The risk of mental health problems in children and young adults also varies substantially across groups in the population. The child and adolescent component of the national survey showed that problems were more common in children whose families had low incomes or whose parents were unemployed. Both internalising and externalising childhood disorders were roughly twice as common in lone parent families and in step/blended families as in original parent families (AIHW, 2005). In young adults, those who had not completed a secondary education had higher rates of mental disorders; and, as in older adults, the unemployed and those not in the labour force, were also at greater risk (AIHW, 2007).

Stressful life events and transitions, whether expected or unexpected, or forms of longer-term disadvantage can influence the mental health status of one or more family members. Such life events and disadvantages include violence, death or serious illness of a family member, other relative or close friend, redundancy, financial crises, homelessness, incarceration, natural and other large-scale disasters, family breakdown, criminality in parents, and parental substance abuse (Department of Health and Aged Care, 2000). The impact on family and individual wellbeing and functioning will vary according to the intensity and duration of the issue, and the capacity of family members to react in adaptive ways. Some serious life events, such as family separation, may have a substantial impact on personal wellbeing for two years or longer (Hope, Rodgers, & Power, 1999).

The causal relationship between life events, long-term disadvantage and mental health is not always clear-cut. Studies of unexpected events (e.g., sudden bereavement) or of major disasters that affect large numbers of people show that acute stressors can have a direct impact on mental health, although not everyone exposed to such events does develop problems. It is also the case that experiencing mental health problems can place people at greater risk of future adversity, such as financial hardship or homelessness. A third connection is that past circumstances and events may place people at greater risk of both stressful circumstances and mental health problems. This indicates the complex and reciprocal processes underlying interactions between mental health and aspects of family functioning or family events. The significance of mental health problems as both a cause and a consequence of relationship difficulties and instability means that such problems are likely to be of high prevalence in the clients of family relationship services.

Protective factors

Social support and particularly the emotional support from a close relationship is one important protective factor for mental health problems. Often, but not always, this close relationship is with a spouse/partner or parent. People lacking such a close supportive relationship are at greater risk of anxiety and depression, and whilst this demonstrates one of the special strengths of family support it also identifies a possible weakness. When life events or other disadvantages affect several family members simultaneously, this can sometimes undermine the capacity of individuals to support one another. Some families may "pull together" in the face of mutual difficulties while others lose their collective strength. Family separation is a special example where support systems that have been in place for a long time may no longer be sustained or cease to be effective for a family. In these circumstances, family members (including children) may need to seek support from elsewhere.

Additional protective factors are self-help strategies that aid recovery from mental health problems and may prevent difficulties progressing to diagnosable disorders. These include psychological strategies (e.g. increasing coping skills and cognitive approaches), behavioural strategies (e.g., exercise and relaxation techniques) and use of complementary therapies (e.g., St John's Wort) (Jorm, Christensen, Griffiths, & Rodgers, 2002; Jorm et al., 2004).

This section has addressed a number of ways in which mental health problems are particularly relevant for families. Clients of family relationship services may present with issues linked to mental health in many ways. One key feature that may impact on family functioning is a changed or changing relationship arising from a family member's mental health problems. The issues for those who live with or care for a person with mental health problems are examined further in the following section.

Endnotes

1. Findings from the second National Survey of Mental Health and Wellbeing are due for release in late-2008.

2. Work cutback days are defined here as days where people worked but reported that their productivity was reduced, in quantity or quality, by their problems.