Young people suffer from mental health disorders in disproportionate numbers and New Zealand has the second highest suicide rate in the developed world. What is being done to help those people get well?
This piece includes frank discussion of suicide. If you, or someone you know is struggling, help is available.
A few days before Christmas last year, after a number of her friends died by suicide within a couple of weeks, Grace*, 28, found herself at Wellington Hospital, hysterical, waiting in the emergency room for eight hours. “I was basically told that there was no room, that there was no one available to see me. It was just before Christmas so everything was shutting down.
“For that month between December and January, and a bit of February I was quite often in hospital, in the emergency room, and the nurses got to know me quite well,” she says. “Because it was the place I could go where I knew that I wouldn't necessarily get help, but I wouldn't be able to kill myself. So I know those waiting room chairs all too well.”
Grace first tried to kill herself when she was 14. Since then, she has spent half her life in and out of mental health care, with varying success. She suffers from a combination of mental illnesses, including bi-polar disorder and serious depression.
“Usually what trips me off that I am about to have a major breakdown is that I go through a manic period, where I am extremely excited,” she says. “This usually happens about three months after I've stopped taking meds.
“I can do everything and I book one way tickets to the other side of the world, and indulge in some incredibly risky behaviour. And then, sort of a month, or a couple of months after that is when I can't get out of bed, I just cannot function, and then I just spiral into this sort of chaos.”
Grace says it shouldn’t be so hard for her to get help – more help than a 15 minute appointment with a psychiatrist, or counselling she has to pay for herself, which she can’t afford.
A 2011 report [pdf] by the then Mental Health Commission says an estimated 29 per cent of youth (aged 16-24) have a mental disorder in a 12 month period. Maori have higher 12-month prevalence than other ethnic groups.
The report says people aged 16–24 have a higher prevalence of suicide ideation (thinking about taking their own life), making suicide plans and suicide attempts than those over 25. “The youth suicide rate remained relatively unchanged between 1999 and 2008. Suicide is still a leading cause of death for young people.” Again, Māori youth had twice the suicide rate of non-Māori youth in 2008. (The table above is data from the Ministry of Health’s 2011 statistics.)
It found that there are ongoing issues around access to primary and secondary mental health and addiction services. In particular, access is low for Māori and Pacific young people. It says collaboration and coordination between services and sectors is working well in some regions, but further work is required to ensure access and continuity of services.
Kirsten Smith, the manager of Evolve, a youth health service in central Wellington, says there are plenty of services available, but they can be hard for people to get to. “Especially if they haven't got an advocate, kind of pushing for and with them,” she says.
Kirsten says people often don’t know where to find the support they need. “If you've got a young person out in the community who is suicidal ... if they don't know how to work that system and say the right words to trigger, it's very likely that because those services are so stretched themselves, that they may not get that support that they need, which is heart-breaking, sometimes.
The need for mental health services to be accessible is incredibly important, she says, especially for vulnerable groups, like queer - gay, lesbian, bisexual, and trans* - young people. She points to a rainbow flag in Evolve’s reception, saying they try to make getting help as easy as possible.
“So we make it free, and we make sure that no one is going to judge them when they walk in the door, and we'll have the music going, and we'll let them make themselves a cuppa, and whatever it is they do.”
Kirsten says Evolve tries to make sure every young person knows where and how to access support when they need it. “And that it's OK and that it doesn't mean they're weak if they ask for help.” She says while she’d never turn down more money (Evolve is mostly funded by the Capital and Coast District Health Board), health professionals need to look at different ways to make people feel more comfortable and secure asking for help.
One attempt at that is Lifehack, a collaboration between the Enspiral Network, and the Ministry of Social Development, which is looking at different ways of using technology to assist with mental health and wellbeing. The idea is to look at projects, devised by young people, who will then have the opportunity to work with other collaborators, including clinicians, to build them.
The group’s Sam Rye says despite all the concerns about bullying on social media, the technology is “agnostic”. “The technology itself is not the cause of these problems, technology is an enabler for good and bad. So, it’s really about the content that we’re putting into it. And that speaks to the role of the conversation around mental health and wellbeing in New Zealand and understanding how we’re using technology and what we’re using it for.”
He says a lot of young people are indicating that they want to connect through technology, and they’re unable to. He cites a statistic brought up at a conference in Australia that 60 per cent of young men aren’t accessing services, even though they are in distress. “That to me is part of that disconnect with the services provided.”
But that disconnect isn’t just technological. Anna*, 28, has post traumatic stress disorder (PTSD), which in her case comes with anxiety and depression. “I carefully plan my schedule to avoid combining too many situations that may exacerbate my anxiety in a single day or week. My PTSD is triggered by things that many people view as day-to-day activities - children’s music, large social gatherings where people bump into me, places in my home town and more.”
The smallest thing might set off a chain reaction that results in a severe panic attack, and at the same time she’s fending off depression. “My depression goes in waves; sometimes I’ll be fine for weeks, or even months, before slipping back into it.” A depressive episode feels like she’ll never be happy again. “I feel like I am failing at everything I do. Tiny tasks that, at normal times, are so insignificant that you don’t even notice them, become barriers that are virtually impenetrable. Getting out of bed. Showering. Eating. Talking. Let alone making a phone call to a doctor, getting to an appointment and explaining this.”
But at the end of last year, Anna slid into a particularly bad depressive episode. She had been falling into it for months, following a week in May during which she had four panic attacks. “I couldn’t sleep. I was lucky to get more than 30 minutes sleep per night and at one point I didn’t sleep for five days.” Her work suffered, and she thought constantly about suicide. “I spent hours looking at the razor sitting on my bathroom sink, fighting with my brain. The only thing that stopped me was the thought that I was so worthless that I had no right to burden my flatmate with discovering my body.”
Eventually, I couldn’t cope with searching any more, and I gave up, which resulted in the meltdown at the end of last year.
Eventually a friend helped her make an appointment with her GP. Anna was referred to the Crisis Mental Health Team, and prescribed anti-depressants. “It was the week before Christmas,” she says, “which is a pretty inconvenient time to fall apart. My GP was going away on holiday the next day for three weeks. My friends were leaving town.”
After daily check-in phone calls and appointments with several different psychologists, in January she finally met with a caseworker and now has a regular psychiatrist, treatment and medication.
“I was only able to be referred into the crisis team and access free assistance because I was suicidal,” Anna says. She had previously been referred to a partially subsidised service, with which she could access 5 sessions with a psychologist at $50 a session. “I couldn’t afford to continue the sessions without the subsidy, and as I wasn’t suicidal at the time, despite my depression, I wasn’t eligible for referral to the public system.”
“After those sessions finished, my GP helped me to send a referral to ACC’s Sensitive Claims team, but the process to find help is incredibly arduous. You are presented with a list of several dozen service providers, most of whom have no website and no information readily available about their ACC surcharges. I called several trying to find a suitable provider, whilst slipping further and further into my depression. Most providers I called had an $80-$100+ surcharge per session. Eventually, I couldn’t cope with searching any more, and I gave up, which resulted in the meltdown at the end of last year.”
John Crawshaw, the Ministry of Health’s director of mental health, says there has been tremendous growth in mental health services. He points out that access rates for the specialist mental health service have improved from 1.8 per cent of young people in 2002/3 to 3.3 per cent & in 2012/13. (The Ministry’s target is 3 per cent.)
Dr Crawshaw says part of the work that is being done includes trying to increase “youth friendly” approaches in primary care, and supporting one stop shops like Evolve. “It's about a number of small initiatives, each trying to reduce some of those barriers to access.”
Getting people the right help at the right time – and making it easy to figure out where to get that help – seems to be the problem. Dr Crawshaw says there’s always challenges in getting the initial contact right, and in trying to get to people before they develop significant challenges.
And he points out that there’s only so much the government can do. “The community has to be involved. It has to be everyone’s business.” Dr Crawshaw is encouraged by new initiatives to address the suicide rates in the Māori and Pacific communities.
The Ministry’s 2011 suicide statistics [pdf] show that the Māori youth suicide rate for 2011 was 36.4 per 100,000 Māori youth population – 2.4 times higher than that of non-Māori youth (15.1 per 100,000 non-Māori population).
Dr Te Kani Kingi, a health researcher at Massey University, says there has been a huge growth in Maori mental health services in the past 20 years. “Huge gains have been made recently in terms of developing approaches that are more suited to our diverse population. But access has aleays been an issue.” He says Māori tend to access help late, so they enter the health care system in crisis.
It’s just really dark stuff…‘no one would want to help me. If I told them my story they’d be scared, they’d never talk to me again’.”
“Often through the police, which is not a good way to access the mental health service for the first time,” he says. “Often times, people may not recognise symptoms or signs. They think, or are told, they should just harden up.”
“You can create as many mental health services as you like, but that won’t help prevalence,” he says, adding that many of the causes of mental ill-health come from outside the health sector – like employment, education and housing.
Te Rangatahi Taniora, 27, grew up in the Bay of Plenty, with a father who was a gang member. His mother sent him to Australia when he was 16, to get him away from the gang he idolised, and from drugs and alcohol. “For some reason I loved it, but I hated it. Sometimes I’d be up about two in the morning, and they’re still banging and fighting and doing whatever, out the front of my window. I might have been five or six.”
But when he arrived in Sydney, it wasn’t much better, He spent several years homeless and using. “It was a culture shock coming over here to a new country, feeling displaced. I had a lot of opportunities but I wasn’t exposed to that back home, so I don’t know what to do with them, so I f...ed them all up.
Depression overwhelmed every sense, emotionally and physically. “And that’s when you turn to drugs,” he says. “I had a lot of support around me, but I honestly was thinking that they were only doing it because that was their job. Or ‘this person doesn’t love me’. It’s just really dark stuff…’no one would want to help me. If I told them my story they’d be scared, they’d never talk to me again’.”
Reaching out was the hardest thing. “Our country is built on hunters and gatherers ... the All Blacks, the most feared team in the world ... For a person to come from New Zealand, reaching out was considered weak. I think a lot of our young fullas over there may have that perspective as well.”
For us as Māori, when we say things that are what we call ‘kino’, that don’t make for a happy relationship, then when you’re putting that out onto Facebook, it’s going to have a whole lot of reactions.
Dr Kahu McClintock, a senior researcher for Te Rau Matatini, a Māori mental health workforce organisation, says the degeneration of connections with land, whanau, culture and customs has an impact on a population’s mental health.
Te Rau Matatini is part of a scheme announced earlier this year to develop community programmes for Māori and Pacific suicide prevention called Waka Hourua. The aim is to make mental health a priority in the community – before people need specialist help. The leader of that project, Mapihi Raharuhi, says part of it is re-connecting young people to what’s been lost: their whakapapa or marae. “But not only that, re-connecting them with their new groups.”
“How we ensure [in social media] that it’s done safely, that they know what they’re doing?” she asks. “For us as Māori, when we say things that are what we call ‘kino’, that don’t make for a happy relationship, then when you’re putting that out onto Facebook, it’s going to have a whole lot of reactions.” She says part of the work is to have those conversations within communities.
Mental Health Foundation chief executive Judi Clements says the high suicide rate for young is shameful. She says more needs to go into the country’s mental health thinking, so the conversation isn’t all about people in crisis. “Thinking about ending your life isn't that really all that uncommon. Actually doing it is. Support groups people make for each other can be really helpful.”
“It’s a great thing that the government has invested a lot more money into programmes for Māori and Pacific suicide prevention. So they’re just at the beginning of their work, but I’m sure they are beginning to work in a different way, because it has to be about working with those communities, working with whanau, with community, and seeing what they know will make a difference rather than professional people that work in the system saying ‘we think we’re doing that because evidence from overseas shows this’.”
Clements says the more that mental health care can be small-scale and local, the better. She thinks the notion of mental health services are moving away from an idea of a scary psychiatric ward with locked doors and straightjackets, but they’re not there yet. “I don't even think we're halfway through,” she says. “Let's work faster. We’ve still got people going into emergency departments in a state of distress getting not a great reception, or not getting much help…We haven't got it right. We're moving, but we need to move faster.”
But the co-founder of the suicide prevention organisation Casper, Maria Bradshaw, thinks the reason suicide rates aren’t going down is because the policy-makers are addressing the wrong thing. ““It’s an absolute no brainer that the numbers are not going down, because if you keep doing the same old thing, you’re going to get the same old result ... [It’s] a whole raft of policies based on an erroneous belief that suicide is called by mental illness.”
She says there’s research that shows that people need two things to want to end their own life: a sense they are a burden, or that they don’t belong, and overcoming the natural self-preservation instinct – through repeated painful experiences or the use of drugs, for example.
“There are groups in society who never turn on the TV or listen to the radio or open the newspaper and hear anything positive about themselves,” she says. “Single parents, prisoners, young people, tend to hear about what a drain and a burden they are on the community.”
But Bradshaw says that people can survive the most horrific events and circumstances. “The key to suicide prevention is creating protective environments rather than waiting until people are in crisis. And so I think we need to focus on that. It would be naive to suggest though that there aren’t a huge number of people in New Zealand already in crisis, and already feeling they are coming to the end of their ability to cope.”
“For too long, we have handed vulnerable people over to a system that is unable to cope, doesn’t actually know what it’s doing…It’s not easy to solve the problems of unemployment, and poverty and isolation and loneliness, and imprisonment. But if we’re actually serious about reducing suicide we have to stop saying we’ll chuck a few million dollars into the mental health system and our responsibility ends there.”
When you’re depressed, climbing the hurdles to seek treatment is almost impossible. We need to lower the barriers.
“I think one of the trickiest things about mental health is that you have to want to help yourself before you get better,” says Grace. “You have to decide that lying in bed isn't making this any better. You can leave the house, you can brush your hair. And you know, sometimes that's the most insurmountable thing in the world.
She isn’t sure about the idea of digital services. “I know that Youthline has a service where you can do counselling by email, which I think is really great. I think part of the problem is that people don't really know what those services are.”
Anna thinks many people have lost sight of the relationship they should have with their GP. “Rather than seeing them regularly, enabling them to spot issues early, we see them only when something goes wrong. When we do see them, we’re acclimated to expect a magic pill to fix everything.”
But the cost of seeing a GP is prohibitive for many people. And fixing the “GP problem” is only part of it, Anna says. “Rather than expecting GPs to prescribe anti-depressants in isolation and send the patient out the door, hoping they don’t get worse, offer the treatment that’s right for that patient. That might be medication. It might be therapy. It might be both. When you’re depressed, climbing the hurdles to seek treatment is almost impossible. We need to lower the barriers.”
Plenty of people are trying to lower those barriers. Money is being spent, policies are being made, and appointments are being set. But everyone seems to agree on one thing: not much will get better while people feel uncomfortable asking for help.
Some names in this story have been changed.
If you need to talk to someone about your own mental health, try these helplines. If it is an emergency, call 111.
Lifeline - 0800 543 354 or (09) 5222 999 within Auckland
Depression Helpline - 0800 111 757
Healthline - 0800 611 116
Samaritans - 0800 726 666 (for callers from the Lower North Island, Christchurch and West Coast) or 0800 211 211 / (04) 473 9739 (for callers from all other regions)
Suicide Crisis Helpline (aimed at those in distress, or those who are concerned about the wellbeing of someone else) - 0508 828 865 (0508 TAUTOKO)
Youthline - 0800 376 633, free text 234 or email firstname.lastname@example.org