Male Why Current Mental Health Literacy Suicide ...malesuicidepreventionaustralia.com.au/wp-content/... · mental health and the difficulties of human experience, or will it simply

This narrative also has implications for suicide mortality, because it conflates mental illness with suicide, and has blindsided many suicide prevention initiatives by diverting attention away from situational distress, circumstantial distress, and powerlessness, which are commonly associated with suicide (especially male suicide) and onto mental illness – principally depression, without a basis of evidence to do so.

A significant irony of mental health literacy is its fundamental claim that it diminishes the stigma of mental illness, a stigma that it has not only actively contributed to creating, but one that it continuously reinforces, and is contrary to the best interests and mental health of the general public.

Our system of mental health appears unable to escape its present deadlock, and is strongly resistant to change, despite numerous government reform documents and much reform posturing over many years. Many reform initiatives have begun with fanfare and promise, only to mutate once ‘implemented’ through sub-systems of delivery (such as NGO preferred service providers), until they are almost unrecognisable, except for the rhetoric with which they were originally framed.

In all the debates of recent decades, one thing that is conspicuous by its absence, and again a symptom of the present institutionalised and medicalised mental health/mental illness paradigm, is the role that families and communities could play in promotion, prevention, and early intervention for mental health and suicide prevention. A major shift in how we conceptualise and respond to mental health difficulties could also open the way for the huge capacity of families and communities to be utilised in preventative and supportive activities.

Change must and will come; the critical question is, will this reflect a creative and evidence-based approach to mental health and the difficulties of human experience, or will it simply take the form of new austerities and strategies of intended but false economy in responding to public mental health, while ignoring the fundamental flaws and undeniably negative outcomes of the present approach?

Definition of Terms

Mental Health Literacy

Mental health literacy has been defined as: Knowledge and beliefs about mental disorders which aid their recognition, management, or prevention. Mental health literacy includes the ability to recognise specific disorders; knowing how to seek mental health information; knowledge of risk factors and causes, of self-treatments, and of professional help available; and attitudes that promote recognition and appropriate help-seeking.1 This concept is derivative of health literacy, the purpose of which is to increase patient knowledge about physical health, illnesses, and treatments.2

Mental health literacy generally consists of several major components: recognition (symptom or illness recognition), knowledge (about sources of information, risk factors, causes, self-help and professional help), and attitudes (about mental illness, sufferers, and help-seeking).1,3,4

Mental Health System

For the purpose of the following discussion in which this term is used, it should be taken to mean both government and government-funded NGO services and agencies, engaged in any form of mental health promotion, mental health literacy training, institutional or community based clinical mental health service delivery.

Mental Health

This can be defined as: an agreeable and functional quality of everyday experience involving one’s mental activity, emotions, physiology, reflexive and behavioural responses, and capacities. An undesirable disruption of this experience – a disruption of mental health could simply be called a mental health difficulty, encompassing the broad spectrum of emotional and mental functioning psychiatrists refer to as ‘mental disorder’ and ‘mental illness’. The severity of this difficulty could be registered as either a low intensity mental health difficulty or a high intensity mental health difficulty, thus avoiding the words disorder and illness altogether.5

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The dominant national initiatives of mental health literacy in Australia, have powerfully promoted a mental illness narrative that is arguably not only contradictory but also, in effect, potentially clinically

iatrogenic, and wasteful of countless millions of dollars that might otherwise be spent on effective preventative mental health. This narrative serves well certain interest groups and key players with a vested interest in its perpetuation, yet does a profound disservice to the public it purports to help. In needlessly medicalising and pathologising prevalent and common human experience, it has far-reaching negative consequences for individuals, society, and our economic capacity to sustain the

ever-increasing demand for mental health and psychological services.

MaleSuicide PreventionA U S T R A L I A

Why Current Mental Health Literacy Initiatives Should be Abandoned

© Dr John Ashfield 2016

Situational Distress

Situational distress encompasses a significantly challenging or troubling mixed experience of mind, thoughts, emotions, bodily sensations, or behaviours, associated with an apparent decompensating event, such as bereavement, a change in health status, relationship breakdown, financial, or occupational difficulties. This distress may significantly overlap with many of the symptoms usually taken to suggest mental ‘disorder’ (such as those associated with depression and anxiety). However, it needs to be said that sometimes distress is inexplicable, and though being equally important as a potential signal that support is needed, is not necessarily an illness or disorder.

Circumstantial Distress

Circumstantial distress, in common with situational distress, encompasses a significantly challenging or troubling mixed experience of mind, thoughts, emotions, bodily sensations, or behaviours, yet is associated with apparent decompensating circumstances arising from a wider context than is usually the case with situational distress (such as the failure of a local employing industry, natural disaster, or community tragedy). As with situational distress, circumstantial distress may significantly overlap with many of the symptoms usually taken to suggest mental ‘disorder’ (such as those associated with depression and anxiety). Circumstantial distress is often associated with wider social determinants, which affect not just an individual, but a whole cohort of individuals. How an individual is affected may constitute their situation, but circumstantial distress arises from wider influences than those evident in an individual’s situation.6

Clinical Iatrogenesis

Iatrogenesis (derived from the Greek term iatros, meaning physician) describes harm done or caused to patients by doctors or other health professionals. Clinical iatrogenesis has most commonly described the harmful effects of medical errors, such as mistakes made in surgery, wrong diagnoses resulting in unnecessary or irreversible illness progression, prescribing an inappropriate drug, poor handwriting resulting in a pharmacist dispensing an incorrect drug or a nurse being delegated to conduct a procedure on a patient without appropriate supervision by a doctor. This term equally applies to other actions taken by doctors and other health professionals that result in harm to patients. Arguably, there are features of clinical activity being conducted by many such professionals that are iatrogenic, due to their unquestioning complicity with the current dominant mental illness paradigm.7

Mental Health Literacy is Fundamentally FlawedMental health literacy in Australia has been promoted in several major ways: through whole of community campaigns (mainly focussing on depression), school based mental illness education and interventions, and individual training programs, such as mental health first aid.8,9,10

The narrative of mental illness which is the basis of current mental health literacy initiatives is one that has been very successfully developed and promoted by corporate and community interest groups, resulting in an almost uncritically accepted orthodoxy within the mental health system, and in training programs for mental health professionals. Marketing of this narrative by the mass media in recent years has also seen it firmly embedded in the language and mindset of popular culture. Adding to this pervasiveness has been the profitable marketing of mental health literacy programs by training organisations, who have targeted the mandatory staff training budgets of employers, as well as communities, wanting to promote mental health and wellbeing.

Far from being benign, current mental health literacy (aiding and abetting the mental illness orthodoxy), has far-reaching implications and consequences affecting individuals, society, and the Australian economy. Its cascade effect will be briefly identified under a number of topic headings following.

How Language Does HarmWords are not merely descriptive, as one might imagine, they are causative. Or, as the philosopher Heidegger put it: Words, like the chisel of the carver, can create what never existed before, rather than simply describe what already exists.

Medicalising and pathologising common human experience (situational and circumstantial distress) as ‘illness’ and ‘disorder’ is a central and conspicuous feature of current mental health literacy messaging, and of our mental health system.

Take the example of individuals who experience situational distress, and who seek professional support and help to work though it and manage it; for most, their GP will likely be their first port of call. Many may quickly find themselves (often not more than 15 minutes later) with a diagnosis of depression, anxiety disorder, or some other ‘mental disorder’ or ‘mental illness’, as well as a script for medication. Even if their GP is careful not to use the term disorder or illness, with so much broad scale

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mental health literacy campaigning, once a significantly difficult psychosocial experience is disclosed to a doctor, a diagnosis and treatment almost inevitably follows; within the framework of medical practice, naming a disorder or illness, followed by a drug prescription, is after all expected.

On receiving a diagnosis, patients are inducted into the category of ‘mentally disordered’ or ‘mentally ill’, and have medication to confirm and reinforce this status. Patients generally believe the public narrative, they believe their GP and, accordingly, tend to redefine their perception of their experience and themselves (reinforced by a daily reminder of drugs) as mentally ill or disordered. Once a patient’s ‘condition’ becomes known, the response by others to their changed status may further reinforce their revised self-definition and consequent stigma. This can be a classic case of self-fulfilling prophecy: I am told I am ill, my daily medication confirms I am ill, I internalise what I’m told, the responses of others reinforce my illness status, and this influences my experiential trajectory to the extent of me fulfilling what was prophesied. It is easy to understand how this medicalising and pathologising of often common (albeit difficult) human experience, can result in harm – clinical iatrogenesis. This process of internalised language and modified perceptions has not only individual, but society-wide implications. This is a phenomenon nonchalantly ignored by our present mental health system and, unfortunately, many of the professionals who work in it.5

What About the Role of Counselling and Psychological Support?For people who resist the idea of being diagnosed with a disorder or illness, and being prescribed medication (although their doctor may still insert a diagnosis in their clinical record), obtaining support may still draw them back into the illness domain. Many people simply need some skilled support and help to make sense of and manage an issue like bereavement, a change in health status, relationship breakdown, financial, or occupational difficulties. However, in order to access subsidised psychological or mental health services, they must first have a referral and Mental Health Treatment Plan from their GP, which states the nature of their illness or disorder. This diagnosis remains in their medical file and is permanent, transferrable, and defines how they are subsequently viewed and treated by their doctor and subsequent doctors, and may have implications when it comes to insurance.

People can of course seek out a private full fee-for-service counsellor, psychotherapist, or psychologist, without a doctor’s referral or Mental Health Treatment Plan, but this is not an option that is usually suggested, because the most common clinical pathway of referral for doctors is into mostly free or highly subsidised services provided by the State or Federal governments. It is also the case that, often, the kind of early support that people need which could be provided by counsellors, for example, is unavailable, because counselling receives no subsidy, and counsellors in private practice struggle to survive. So, despite many people recognising they could probably work through and manage their situational distress with some skilled support, such support is not readily available, at least in a subsidised way, and is thus much less likely to be recommended by their GP.

The Rise and Rise of Depression and Anti-depressants

Perhaps the most prominent and publicised duo of the mental illness narrative is depression and anti-depressants. In recent decades, mental health literacy messaging has popularised depression in a way that is arguably not only exaggerated and misleading, but also hugely harmful and economically costly.

Once an obscure psychiatric diagnosis (originally termed melancholia), depression is now deemed to be an ‘epidemic’ and a ‘serious social issue’. There is of course a mental health difficulty termed ‘depression’ that can be profoundly debilitating. The problem is, depression is now a diagnostic explanation that is applied to a broad range of human distress (significantly challenging or troubling mixed experience of mind, thoughts, emotions, bodily sensations, or behaviours, associated with an apparent decompensating event) to which it should not be applied. Such distress does not warrant an illness diagnosis or medication in most cases, even though it might be sufficiently intense to warrant referral for counselling or psychological support. Nevertheless, ‘depression’ has been popularised by a variety of interest groups in such a way as to dominate contemporary thinking about the experience of distress, unhappiness, and dissatisfaction.11

Depression is diagnosed with much greater frequency now than throughout most of the twentieth century, and is the main condition for which antidepressant medication is prescribed.12, 13 The prescribing of antidepressants has hugely escalated with increases in depression diagnosis.14 In Australia, antidepressant utilisation nearly trebled between 1990 and 1998, and has continued to increase.15,

16 Vastly more people are now being diagnosed with

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depression, and prescribed antidepressants, than several decades ago. These developments have profound social, economic, and public health implications.

Prevalence estimates of depression have been found to be exaggerated and flawed. Clinical assessments based on problematic diagnostic criteria, and powerful marketing biases favouring biological explanations of depression (such as those emphasising the role of serotonin) have aggressively popularised the use of drugs as a solution to depression, the efficacy of which is overstated, and the safety and adverse effects understated.11

An Increasingly Expensive and Overwhelmed Mental Health SystemThe inappropriate and unnecessary medicalisation of human distress has had profound consequences, not only for individuals, but also for the functionality and economy of the mental health system. Mental health literacy messaging, and the narrative it reinforces, permits the present mental health system to unrelentingly grind on with an inexorable and unquestioned ‘logic’ of its own, despite costing an estimated 28.6 billion dollars each year.17 These factors have also resulted in the system becoming overwhelmed, and more and more ineffectual. In many regional and rural communities in particular, it is almost impossible to gain access to support without being in abject crisis. For people seeking psychosocial support with low intensity mental health difficulties, there can be a very long wait for appropriate therapeutic support.

By pathologising and medicalising common situational and circumstantial difficulties of human experience, and consequently being overwhelmed by demand, the mental health system’s reflex is to shift its service delivery emphasis to acute, high intensity presentations of mental health difficulties, while neglecting people needing more basic support or early intervention. This is also highly problematic for suicide prevention, which needs to account for many suicides that are associated with acute psychological distress, but not with mental ‘illness’ or ‘disorder’. This is a system that works poorly for everyone, whether in the low or high acuity range of mental health difficulties, or suicide prevention.

A Stop-gap and Cheap Substitute for Reform

Following the UK trend in using the Improving Access to Psychological Therapies (IAPT) model, some Australian NGOs are rolling out an adaptation that is intended to address low intensity mental ‘disorder’, and act as a first

port of call triaging process for those seeking psychological therapy. This approach uses a strictly manualised CBT (cognitive behavioural therapy) model, conducted by people with often minimal training. However, though this may cut costs (because the ‘therapists’ are poorly paid), and may get people off conventional mental health and psychological service waiting lists, it is still operating largely within the current dominant mental illness paradigm. Nevertheless, the education and training component of this program is becoming another cottage industry for pre-tertiary education providers who, understandably, have a vested interest in singing its praises.

The irony of this approach is that it is a cost saving ‘dumbing down solution’ to a problem that is largely of the mental health system’s own making. It is also a model that fails to take account of emerging evidence that mono-modality CBT has been found to be diminishing in effectiveness. One reason advanced as an explanation for this is the placebo advantage of its wide endorsement by government agencies that have adopted it. The effects of CBT have apparently declined linearly and steadily since its introduction, as measured by patients’ self-reports, clinicians’ ratings, and rates of remission. Not a good report card, given its place in the newly introduced Australian version of IAPT.18 The IAPT CBT-centric model is also problematic because it ignores the voluminous trans-theoretical research data suggesting that CBT is little better than placebo in effectiveness, compared to a robustly effective common factors approach based on the value of developing simple therapeutic rapport, rather than trying to adjust people’s thinking and behaviour through a regimented therapy method.19, 20

Mental Illness Conflated with Suicide: A Dangerous Diversion

The mental illness and disorder narrative that has erroneously encircled, medicalised, and redefined as pathological, much common human experience, also has implications for suicide prevention and suicide mortality.

Despite the now discredited ‘research’ suggesting a high prevalence of mental ‘disorder’ associated with suicide, much of the current approach to suicide prevention is still erroneously premised on a presumption of mental disorder.21 Whilst conditions like major depression may sometimes be implicated in cases of suicidal ideation and death by suicide, and are an important consideration in the design of appropriate preventive measures, this should not be considered license to assume an association with suicide to a degree that is unsupported by evidence. Limiting

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preventive strategies to those built upon the unfounded presumption of mental disorder will simply not help many, perhaps the majority, of those at risk of suicide.5

Suicide prevention initiatives that are preoccupied with detection of disorders like depression may well be putting people’s lives at risk, by not attending to forms of distress that don’t constitute illness or disorder, and yet which can result in suicidal ideation and suicide. A term best able to capture and communicate this reality is situational distress. However, it needs to be said that sometimes distress

is inexplicable and, though being equally important as a potential signal that support is needed, is still not necessarily an illness or disorder.

There needs to be an immediate and incisive review of current suicide prevention initiatives and expenditure, given the fact that there has been a 42.9 percent increase in suicide in the last decade, with suicide and attempted suicide in Australia costing an estimated 17.5 billion dollars annually.22, 23

Serious Concerns about Antidepressants and Suicide

For some years now we have been aware that antidepressant medications are contraindicated for use with young adults. In the USA, the Food and Drug Administration (FDA) proposed that manufacturers update the existing warnings on their products’ labels to include the warning that anti-depressant medications can increase the risk of suicidality in 18 to 24 year olds during initial treatment.24

Studies are now showing that we should also be concerned about the correlation between antidepressants and increased risk of suicide in adults. For example, a study published in Social Psychiatry and Psychiatric Epidemiology, in 2014, found that such drugs could make people nearly six times more susceptible to suicide.25 In a study conducted by the US federal government, it was shown that in a pooled-analysis of short-term, placebo controlled trials of nine antidepressant medications, patients taking an antidepressant had twice the risk of suicidality in the first few months of treatment than

those taking placebo.26 In an issue of the British Medical Journal, research showed that antidepressants were estimated to cause 10 to 44 deaths in 1000 people over the period of a year, depending on the type of antidepressant. Interestingly, it only took 7 in 1000 cardiac events with patients prescribed the painkiller Vioxx, for the drug to be taken off the market.27 Australia is now second in the world for its prescribing of antidepressants.28

Alternatives to the Present Approach to Mental Health and Mental Health Literacy

In the year 2000 the Commonwealth Government published a new model of Promotion, Prevention, and Early Intervention for Mental Health. Once made to run the political and bureaucratic gauntlet, this suffered the same fate as many other now dust-gathering initiatives that were not properly funded or executed, and disappeared into the mists of time. However, this approach did at least demonstrate that creative and alternative ideas are available, and that there is good evidence for supporting initiatives at the opposite end of the current mental health promotion spectrum.29

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SituationalDistressRisk

Factors

• Sickness• Financial difficulties• Relationship or family breakdown• Bereavement• Conflict• Unemployment• Alcohol/drugs• Trauma

Focus needsto be onrisk factors

and onExperientialand behaviourale�ects

Impact uponMajor

Depression“Melancholia”

in oldterminology

• Mental performance• Mood• Energy levels• Sleep• Appetite• Anxiety levels• Behaviour (such as social withdrawal, projected anger, uncommunicativeness)

Many suicides are about situational distress, the signs of which may be missed or overlooked if we are too intent on identifying depression or other so called “mental disorders”




Perhaps the gathering dark cloud of dysfunction and cost will force much needed reform of the current mental illness narrative and mental health system? What is promising is that increasingly the corporate sector is taking an interest in the issues of mental health and suicide prevention, and may just manage to drive some authentic outcomes-based initiatives in a way that governments have not seemed able to do. It would also appear that corporate philanthropy and social entrepreneurship are emerging as major drivers of social and health initiatives across the world, and are a good deal more insistent on long range thinking and real outcomes than publicly funded government endeavours tend to be.

A key component in the whole equation of a much-needed change of narrative for mental health, and a shift towards promotion, prevention, and early intervention for mental health, must be the utilisation of the good will and immense resourcefulness of communities and ordinary citizens.

Despite mental health literacy campaigns purporting to conscript the public to help with the ‘problem’ (and the use of slogans like, ‘mental health is everybody’s business’), ordinary citizens are actively discouraged from all but superficial engagement, because the current emphasis on mental ‘illness’ and ‘disorder’ understandably persuades them to leave it to the professionals. Illness and disorder suggest that a professional medical response and medication are needed or, at the very least, intervention by allied health professionals. Initiating a radical shift in how we frame and respond to human distress and mental health difficulties, would open up a whole new potential for meaningful community engagement, central to a grounded endeavour of promotion, prevention, and early intervention for mental health. Such a grounded endeavour has already proven to be beyond the scope and capacity of the present mental health system alone.

Practicable promotion, prevention, and early intervention initiatives and reforms might include:

• Radically altering how we conceptualise various manifestations of human distress, and the language and responses we apply to them. This will include promoting a strictly evidence-based approach to the way depression is conceptualised, diagnosed, and treated, and breaking the conflation of depression and mental illness with suicide and suicide prevention initiatives.

• Remodelling service design and delivery requirements for all government and non-government providers and mental health promotion organisations.

• Reviewing all current mental health literacy initiatives and engaging with communities, employers, and organisations (including human service organisations) in providing practical, gender specific, and self-help oriented psycho-education. Such education needs to be much broader than a merely individual problem oriented approach, and will include consideration of social context and social determinants.

• Initiating preventative mental health peer support and suicide prevention education programs in communities and organisations, in order to embed trained individuals to be the ‘eyes and ears on the ground’, able to detect and provide timely support to people in distress and, if needed, referral to an appropriate professional service provider.

• In-service training for GPs in a new model of responding to low and high intensity mental health difficulties, and the broad range of mental health presentations that do not require diagnostic categorisation or medication. Training for GPs in suicide prevention, and risk factors, with a focus on people most at risk, and how to effectively engage them.

• Abolishing the use of Mental Health Treatment Plans by GPs, and replacing them with reimbursement for providing proper referrals to allied health professionals, with auditing of this practice. GPs would need to be educated in the use of counsellors and psychotherapists, in addition to current mental health and psychological service providers. Differential years of tertiary qualifications of allied professionals could be reflected in MBS scheduling.

• Therapy and counselling approaches need to be broadened beyond CBT to include other evidence-based approaches, with a realistic number of allowable sessions.

• Videoconferencing technology using closed system and user friendly options (including fixed unit, and point to point capacities) should be available under the present Better Access to Mental Health funding provisions for private practitioners, including counsellors and psychotherapists.

• Including counsellors and psychotherapists in the repertoire of subsidised service providers, financially offset by all non-health care card holders being required to make part payment for any psycho-social allied health service. Counselling and psychotherapy are much less prone to reflecting a pathologising view, and yet are presently the least valued approaches to mental health difficulties in the way current government policy is

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framed. Part user-pay services could allow a significant expansion, without cost, of new options for consumers.

• Professional development for allied health mental health practitioners, counsellors, psychotherapists, psychologists, and social workers, in a situational distress oriented model for understanding and responding to mental health difficulties, and a gender specific approach to suicide prevention.

• Production and dissemination of self-help literature which avoids medicalised and pathologising concepts and language, and is tailored and targeted. Much current literature reinforces an illness narrative, is too complex or generic, and sometimes lacks much needed informed and evidence-based gender specificity.

• The requirement that all Primary Health Network service commissioning organisations apply these reform criteria in the process of funding preferred service providers, and that proper auditing and evaluative processes occur to ensure integrity of compliance.

References1. Jorm, A.F., Korten, A.E., Jacomb, P.A., Christensen, H., Rodgers, B.

& Pollitt, P. (1997). Mental health literacy: a survey of the public’s ability to recognise mental disorders and their beliefs about the effectiveness of treatment. Medical Journal of Australia, 166, 182-186.

2. Roundtable on Health Literacy; Board on Population Health and Public Health Practice; Institute of Medicine (10 February 2012). Facilitating state health exchange communication through the use of health literate practices: workshop summary. Washington, D.C.: National Academies Press. p. 1

3. Jorm, Anthony F. (2000). Mental health literacy: Public knowledge and beliefs about mental disorders (PDF). British Journal of Psychiatry, 177, 396-401.

4. O’Connor, M., Casey, L., & Clough, B. (2014). Measuring mental health literacy – a review of scale-based measures. Journal of Mental Health, 23(4), 197-204, from http://dx.doi.org/10.3109/09638237.2014.910646

5. Ashfield, J. (2016). ‘First, Do No Harm’: Challenging the Status Quo of ‘Mental Health’ & Suicide Prevention. Adelaide: Australian Institute of Male Health and Studies.

6. Ashfield, J., Smith, A., & Macdonald, J. (2017). Clarification of some key terms and definitions in suicide prevention. National Guidelines – Suicide prevention for males. Australian Institute of Male Health and Studies, and, Western Sydney University, Men’s Health Information and Resource Centre.

7. Illich, I. (2000). Limits to Medicine: medical nemesis, the expropriation of health. London: Marion Boyars publishers.

8. Jorm, A.F., Christensen, H. & Griffiths, K.M. (2005). The impact of beyondblue: the national depression initiative on the Australian public’s recognition of depression and beliefs about treatments. Australian and New Zealand Journal of Psychiatry, 39, 248-254.

9. MindMatters Evaluation Consortium (2000). Report of the MindMatters (National Mental Health in Schools Project) Evaluation Project, vols 1-4. Newcastle: Hunter Institute of Mental Health.

10. Kitchener, B.A. & Jorm, A.F. (2006). Mental Health First Aid training: review of evaluation studies. Australian and New Zealand Journal of Psychiatry, 40, 6-8.

11. Raven, M. (2012). Depression and antidepressants in Australia and beyond: A critical public health analysis. (Doctoral thesis) (pp. 13-14) University of Wollongong, Faculty of Arts.

12. Norman, Trevor R. (May 2006). Prospects for the treatment of depression. Australian and New Zealand Journal of Psychiatry, 40(5), 394-401.

13. Eccles, Martin, Freemantle, Nick, & Mason, James, for the North of England Antidepressant Guideline Development Group. (1 April 1999). North of England evidence-based guideline development project: summary version of guidelines for the choice of antidepressants for depression in primary care. Family Practice, 16(2), 103-111. Retrieved 8 September 2008 from http://fampra.oxfordjournals.org/cgi/content/full/16/2/103

14. McManus, P., Mant, A., Mitchell, P.B., Montgomery, W.S., Marley, J., & Auland, M.E. (2000). Recent trends in the use of antidepressant drugs in Australia, 1990-1998. Medical Journal of Australia, 173(9), 458-462.

15. Department of Health and Ageing. (2005). Australian Statistics on Medicines 2003. Canberra: [Australian] Department of Health and Ageing. Retrieved 12 March 2006, from http://www.health.gov.au/internet/wcms/Publishing.nsf/Content/pbs-pubs-asm2003

16. Department of Health and Ageing. (2008). Australian Statistics on Medicines 2006. Canberra: [Australian] Department of Health and Ageing. Retrieved 21 August 2008, from www.health.gov.au/internet/main/publishing.nsf/content/pbs-pubs-asm2006

17. Medibank & Nous Group (2013) The case for mental health reform in Australia: a review of expenditure and system design, from https://www.medibankhealth.com.au/files/editor_upload/File/Mental%20Health%20Full%20Report.pdf

18. Johnsen, T. & Friborg, O. (2015). The effects of cognitive behavioral therapy as an anti-depressive treatment is falling: a meta-analysis. Psychological Bulletin, 141(4), 747-768, from http://dx.doi.org/10.1037/bul0000015

19. Hubble, M., Duncan, B., & Miller, S. (2006). The heart and soul of change (1st ed.). Washington. D.C.: American Psychological Association.

20. Duncan, Barry L., Miller, Scott D., Wampold, Bruce E. & Hubble, Mark A. (eds.) (2010) The heart and soul of change: Delivering what works in therapy (2nd ed.). Washington, D.C.: American Psychological Association, from http://dx.doi.org/10.1037/12075-000

21. Hjelmeland, H., Dieserud, G., Dyregrov, K., Knizek, B., & Leenaars, A. (2012). Psychological autopsy studies as diagnostic tools: are they methodologically flawed? Death Studies, 36(7), 605-626, from http:// dx.doi.org/10.1080/07481187.2011.584015

22. Australian Bureau of Statistics. (2016). Causes of Death, Australia, 2015. Catalogue No. 3303.0. Belconnen, ACT: Commonwealth of Australia. Accessed 28 September 2016, from http://www.abs.gov.au/AUSSTATS/[email protected]/allprimarymainfeatures/47E19CA15036B-04BCA2577570014668B?opendocument

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23. Rosenburg, Sebastian & Mendoza, John. (2010). Suicide and suicide prevention in Australia: breaking the silence. Lifeline Australia, and, Suicide Prevention Australia.

24. U.S. Food and Drug Administration. (2007). Antidepressant use in children, adolescents, and adults, from http://www.fda.gov/Drugs/DrugSafety/InformationbyDrugClass/UCM096273

25. Large, M. & Ryan, C. (2014). Disturbing findings about the risk of suicide and psychiatric hospitals. Social Psychiatry and Psychiatric Epidemiology, 49(9), 1353-1355, from http://dx.doi.org/10.1007/s00127- 014-0912-2

26. Atypical antipsychotic medications: use in adults. (2013). Retrieved 20 January 2017, from http://www.cms.gov/ Medicare-Medicaid-Coor-dination/Fraud-Prevention/MedicaidIntegrity-Education/Pharma-cy-Education-Materials/Downloads/ atyp-antipsych-adult-factsheet.

27. Andrews, P. (2017). Negative Effects of Antidepressants. Mad In America. Retrieved 20 January 2017, from http:// www.madinamer-ica.com/2012/09/things-your-doctor-should-tellyou-about-antide-pressants/

28. ABC News. (2017). Australia second in world in anti-depressant prescriptions. Retrieved 20 January 2017, from http://www.abc.net.au/ news/2013-11-22/australia-second-in-world-in-anti-depressant-prescriptions/5110084

29. Commonwealth Department of Health and Aged Care. (2000). Pro-motion, prevention and early intervention for mental health: a mono-graph. Canberra.




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