428017

2012
ANP46410.1177/0004867411428017Jorm and ReavleyANZJP Articles

Research

Australian & New Zealand Journal of Psychiatry

Changes in psychological distress 46(4) 352­–356

DOI: 10.1177/0004867411428017

in Australian adults between 1995 © The Royal Australian and

New Zealand College of Psychiatrists 2012

and 2011 Reprints and permission:

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Anthony F Jorm and Nicola J Reavley

Abstract
Objective: To monitor changes in psychological distress in Australia over a 16-year period during which the availability
of mental health services was increasing.
Method: Data on psychological distress using the 4-NS scale were analysed from national surveys of adults carried out
in 1995, 2003–04 and 2011.
Results: No change in psychological distress was found.
Conclusions: The data show no improvement in adult mental health during a period when the availability of pharmaco-
logical, psychological and population interventions increased. Regular population monitoring of mental health is needed
in the future in order to identify emerging needs and to evaluate the impact of service improvements and preventive
programmes.

Keywords
Anxiety, depression, psychological distress, age, gender, historical changes, mental health services

Introduction
For diseases that are major causes of mortality, there is
routine monitoring of changes at a national level using
death certificate data (Australian Institute of Health and
Welfare, 2011). This monitoring can be used to evaluate
the impact of public health efforts and to monitor for
emerging diseases. However for mental disorders, which
are primarily causes of disability rather than mortality,
national monitoring is more difficult. While suicide data
are available (Australian Government Department of
Health and Ageing, 2008), these reflect only the tip of the
iceberg of the national impact of mental disorders.
Repeated national surveys of mental disorders could in
principle provide relevant data, but changes in diagnostic
criteria and survey instruments over time, as happened with
the 1997 and 2007 Australian National Surveys of Mental
Health and Wellbeing (Slade et al., 2009), make time series
comparisons difficult. A more feasible alternative is to
use short screening instruments for national monitoring
(Mackinnon et al., 2004). These are much less time con-
suming and expensive to administer than diagnostic instru-
ments, and are less likely to change in content or scoring
over time. Such instruments include the K10, K6, the
Patient Health Questionnaire and the 4-NS (Furukawa
et al., 2003; Henderson et al., 1981; Kroenke et al., 2010).
In Australia, a national approach to monitoring changes
in mental health in this way has yet to emerge. Nevertheless,
a number of relevant national and state datasets have been
analysed in recent years to examine historical changes. The
first study used data from national surveys of mental health
literacy carried out in 1995 and 2003–04 to examine
changes in psychological distress in adults aged 20–74
(Jorm and Butterworth, 2006). Using the 4-NS as a meas-
ure of distress, it found an increase in males aged 20–29
years, but no change in females or other male age groups.
Orygen Youth Health Research Centre, Centre for Youth Mental
Health, University of Melbourne, Melbourne, Australia
Corresponding author:
Anthony F Jorm, Orygen Youth Health Research Centre, Centre for
Youth Mental Health, University of Melbourne, Locked Bag 10, Parkville,
VIC 3052, Australia.
Email: ajorm@unimelb.edu.au

Australian & New Zealand Journal of Psychiatry, 46(4)

Jorm and Reavley 353
The second study compared the prevalence of major depres-
sion, as measured by the Patient Health Questionnaire, in
people aged 15 or over in South Australia in 1998, 2004
and 2008 (Goldney et al., 2010). This study found an
increase in prevalence of depression in males aged 15–29
and females aged 30–49, but no change in other age groups.
The third study used K10 screening test data from the 1997
and 2007 National Surveys of Mental Health and Wellbeing,
and from the 2001 and 2004/5 National Health Surveys
(Reavley et al., 2011). Results showed a significant increase
in anxiety symptoms for females aged 30–49 between 1997
and 2007, but no difference for males or for females in
other age groups. Depression symptoms did not change
over this period. Despite the differences in methodology
and time periods studied, these three studies are consistent
in finding no overall improvement in mental health in
Australia, but rather deterioration in some sub-groups of
the population.
The purpose of this paper is to report data from a 2011
national survey of mental health literacy which extends
observations previously reported for 1995 and 2003–04
(Jorm and Butterworth, 2006). The 16 years from 1995 to
2011 cover a period of considerable change in Australian
mental health care, with increases in the provision of psy-
chological, pharmacological and population interventions.
There were major increases in the provision of psychologi-
cal therapies through the Better Outcomes in Mental Health
Care scheme introduced in 2001, and the Better Access to
Psychiatrists, Psychologists and General Practitioners
scheme introduced in 2006 (Bassilios et al., 2010; Jorm,
2011; Pirkis et al., 2011a, 2011b, 2011c), and the introduc-
tion of freely available self-help therapy via the internet
(Bennett et al., 2010). There were also continuing increases
in the use of antidepressant medication over this period
(Hollingworth et al., 2010). The public mental health sys-
tem underwent significant reform, with a shift towards
community-based care and a reduction in in-patient care
(Short et al., 2010). Population interventions received a
boost with the start of the National Suicide Prevention
Strategy in 1999 and beyondblue: the national depression
initiative in 2000. It might be expected that these changes
would improve the mental health of the population.
Methods
Survey methods
The methods of the 1995 and 2003–04 household surveys
have been described in detail previously (Jorm et al., 1997,
2005). Briefly, the 1995 survey involved a national sample
of 2031 people aged 18–74 years, while the 2003–04 sur-
vey involved 3998 people aged 18 years or over. The 2011
survey differed from the early ones in that it covered ages
15 and over, and interviews were carried out with 6019
people by telephone based on random digit dialling of both
landlines and mobile phones (Reavley and Jorm, in press).
To allow direct comparison of 5-year age groups, we used
the data from 20–24 years to 70–74 years from each survey.
This selection gave 1964, 3507 and 5131 participants,
respectively. All three surveys were primarily concerned
with mental health literacy. The second survey contained
the same questions as the first, but with some additional
ones added. Similarly, the third survey contained the same
questions as both the first and the second, but with some
additional ones.
Measure of psychological distress
Toward the end of the surveys, the participants were given
the 4-NS (Henderson et al., 1981) as a measure of psycho-
logical distress. This questionnaire asks: “In the past month
have you suffered from any of the following: colds, sore
throats, headaches, dizziness, palpitations, breathlessness,
backache, flu, anxiety, depression, tiredness, irritability,
nervousness”, with response options of “yes”, “no” or
“don’t know”. The 4-NS score is the sum of “yes” responses
to the four symptoms of anxiety, depression, irritability and
nervousness. The 4-NS was developed in Australia, but is
not widely used. It has not been validated against clinical
diagnosis, but has a correlation of 0.62 with the total score
of the clinician-administered Present State Examination
(Henderson et al., 1981). The 2011 survey included the
more widely used K6 (Furukawa et al., 2003) as an addi-
tional measure of psychological distress, allowing an
examination of the correlation between the two measures.
Statistical analysis
The reliability of the 4-NS was assessed at each time point
using Cronbach’s alpha. Pearson’s r was used to examine
the correlation of the 4-NS with the K6 in 2011. For descrip-
tive analysis of changes over time, means on the 4-NS were
graphed for each age and gender group in the three surveys.
The data were also analysed using negative binomial regres-
sion for men and women separately. The negative binomial
model was used because of the negative skew. In these anal-
yses, age, survey occasion, and age-by-occasion were used
as predictors of 4-NS score. Age group was dummy coded
using the median age group (45–49 years) as the reference
category. Survey occasion was also dummy coded using
1995 as the reference year. Data were weighted using survey
weights to give better population estimates and to control
for possible differences across surveys in response rates and
representativeness. Geographical clustering in the 1995 and
2003–04 samples was ignored in view of evidence that area
clustering effects are minor with mental health measures
(Butterworth et al., 2006; Weich et al., 2003).
To check whether there were any differences across sur-
veys in the prevalence of high scores, the analysis was also
carried out using binary logistic regression with a cut-point
Australian & New Zealand Journal of Psychiatry, 46(4)
354 ANZJP Articles
Figure 1.  Mean 4-NS score by gender and age group for three survey time points
Males
1.4
1.2
Mean 4-NS score
1 1
0.8
0.6
0.4
0.2
0 0
20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74
Age group
1995 2003-04
2/3 on the 4-NS. The prevalence of high distress with this
cut-point was approximately 15%.
The 0.05 alpha level was used in the regression analyses.
Analysis was carried out using SPSS Statistics 19 for
Cronbach’s alpha and Intercooled Stata 10 for regressions.
Results
Cronbach’s alpha for the 4-NS was 0.64 in 1995, 0.70 in
2003–04 and 0.63 in 2011. The correlation between the
4-NS and the K6 in 2011 was 0.49.
Figure 1 shows mean 4-NS scores by gender and age
groups across the three surveys. Regression analyses showed
no significant overall difference between years. In the nega-
tive binomial regression analysis, there was an age-by-year
interaction effect for 20–24-year-old males in 2003–04
which approached statistical significance (p = 0.053). This
interaction effect reached statistical significance in the logis-
tic regression analysis (p = 0.011). This effect can be seen in
Figure 1, where 20–24-year-old males showed a higher mean
score in 2003–04 compared to 1995. However, the 2011
mean for males in this age group did not differ from 1995.
Discussion
The data show no overall change in psychological distress
between 1995, 2003–04 and 2011. As previously noted,
there was an increase in distress in young men between
1995 and 2003–04 (Jorm and Butterworth, 2006), but this
had reduced by 2011. The results are consistent with previ-
ous studies which cover part of the same time period in
showing no improvement in mental health (Goldney et al.,
2010; Reavley et al., 2011).
By contrast, the Australian national suicide rate has
shown changes, at least for males. The male suicide rate
peaked in 1998 and then declined by 44% from 1999 to
Australian & New Zealand Journal of Psychiatry, 46(4)
Females
1.4
1.2
Mean 4-NS score
0.8
0.6
0.4
0.2
20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74
Age group
2011 1995 2003-04 2011
2005 (Australian Government Department of Health and
Ageing, 2008). Although it has been suggested that this
decline could be an artefact of misclassification of suicides,
changes have still been found after making allowance for
misclassification (Page et al., 2010). More recent suicide
statistics are consistent with this improvement (Australian
Bureau of Statistics, 2011), but may be subject to future
revision to allow for misclassification.
The lack of improvement in mental health is surprising
given the increase in services and population interventions
that has occurred over the period and the reduction in per-
ceived unmet need for services that has been found between
the 1997 and 2007 National Surveys of Mental Health
and Wellbeing (Meadows and Bobevski, 2011). There are a
number of possible reasons for a lack of improvement. One
possibility is that real changes have occurred, but are too
small to detect in community surveys using short screening
measures. To investigate this possibility, a power analysis
was carried out for the current data. Assuming a population
prevalence of 15% for high psychological distress in 1995,
the study had 61% power of detecting a 2% drop and 93%
power of detecting a 3% drop by 2011. The power to detect
changes between 2003–04 and 2011 was somewhat better
due to the larger sample sizes, with 81% power to detect a
2% drop and 99% power to detect a 3% drop. However, if
the drop in prevalence was only 1%, which still represents
an important population impact, the study would not be
likely to detect it, with power of only 20% between 1995
and 2011, and 29% between 2003–04 and 2011. The moder-
ate reliability of the 4-NS is also a factor here, with error of
measurement possibly reducing any real effects that existed.
There are other possible explanations for the lack of
change over time. It is possible that the increase in services
has had a positive impact, but was counteracted by other fac-
tors that increased prevalence. Prevalence of psychological
distress is known to be associated with socioeconomic
Jorm and Reavley 355
factors (Mackinnon et al., 2004) and may also be affected by
environmental change (Albrecht et al., 2007). It is notable
that major flooding was occurring in some parts of Australia
at the time the 2011 survey was carried out. Another possible
counteracting effect is changing response to screening tests
over time. With increasing mental health literacy (Jorm et al.,
2006), the population may have become more aware of
symptoms and more willing to report them than previously,
which could counterbalance any true reduction in symptom
prevalence.
Another possibility is that while the number of services
has improved, the quality has not. A number of pieces of
evidence support this possibility. An analysis of perceived
unmet need in the 1997 and 2007 National Surveys of
Mental Health and Wellbeing found that while unmet need
declined, fully met need did not improve, indicating that
the number, but not the quality, of services had increased
(Meadows and Bobevski, 2011). Similarly, while antide-
pressant use has increased substantially in Australia, many
users do not appear to have a mental disorder (Harris et al.,
2011a) and the peak age of use (90–94 years) does not cor-
respond to the peak age of prevalence of depression and
anxiety disorders (under 50 years), indicating that these
medications are being used for non-approved purposes
(Hollingworth et al., 2010). Psychological therapies have
also increased substantially, with 1 in every 19 Australians
receiving at least one Better Access service in 2009 (Pirkis
et al., 2011a). However, there is some evidence that users of
these services are often receiving psychoeducation and
non-specific counselling rather than the more evidence-
based cognitive-behaviour therapy (Harris et al., 2011b).
Finally, it is possible that reducing prevalence requires
greater emphasis on the social determinants of mental
health (Fisher and Baum, 2010) and taking preventive
action (Brugha et al., 2004). Prevalence is a function of
incidence and duration of disorders. Whereas services
mainly reduce duration of episodes, prevention is aimed at
reducing incidence. While preventive programmes have
become more available in Australia, mainly in school set-
tings, these have received far fewer resources than treat-
ment services, particularly for adults.
While these findings apply specifically to Australia, the
data available from other countries are consistent in show-
ing no detectable population effect of increases in services.
In the USA, analysis of data from National Comorbidity
Surveys showed no change in prevalence of mental disorders
between 1990 and 2003 in the population aged 18–54 years,
despite an increase in the rate of treatment from 12.2% to
20.1% (Kessler et al., 2005). Other US survey data have
shown that the prevalence of major depression increased
over the period 1991–92 to 2001–02 (Compton et al., 2006).
Similarly, in Great Britain, comparison of national survey
data in 1993, 2000 and 2007 showed no change in the preva-
lence of depressive episodes, mixed anxiety and depression
states and suicidal ideations in 16–64-year-olds, despite an
increase in the prevalence of antidepressant treatment from
1.1% to 4.9% and an increase in psychotherapy/counselling
from 1.6% to 3.0% (Brugha et al., 2004; Compton et al.,
2006; Kessler et al., 2005; Mojtabai et al., 2011). In addition,
studies from a number of countries have investigated whether
increases in antidepressant use have affected national suicide
rates (Baldessarini et al., 2007). However, the findings from
these studies have been inconsistent.
In conclusion, the present data and those from other
similar studies present a challenge in that they show no evi-
dence of improvement in mental health in Australia in
recent years. There is a need for governments to support
regular population monitoring of mental health, just as they
support the collection of mortality data, in order to identify
emerging needs and to evaluate the impact of service
improvements and preventive programmes.
Acknowledgements
Marie Yap provided helpful comments on the paper.
Funding
The study was funded by the Australian Government Department
of Health and Ageing. The authors receive salary support from the
National Health and Medical Research Council. Orygen Youth
Health Research Centre is supported by the Colonial Foundation.
Declaration of Interest
The authors report no conflicts of interest. The authors alone are
responsible for the content and writing of the paper.
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