About one in five people will suffer, over the course of their lifetime, a meaningful destabilising mental condition. While the human costs of mental illness are horrendous, the financial burden on society is also significant. One estimate is that suicide alone, which is the fourthmost- common stated cause of death, costs the life insurance industry about $100 million a year.
About one in 10 death claims on industry funds is from suicide, although the figure for some funds may be significantly higher. According to CommInsure, the average figure for its policies is one in 13 deaths from suicide. The highest-risk members tend to be young, male and, often, from a rural or regional area. Insurance through super funds generally has a long tail. The payouts for younger members on death will be significantly higher than for older members, given the same number of units of cover. So, when younger members die, they have higher payouts and have had less time to make contributions via premiums.
Super funds, particularly not-for-profit funds, have been looking to address the problem through a program called Super Friend, which is an initiative from a special trust set up by Industry Funds Forum, the Mental Health Foundation.
Last December CommInsure, which is the largest sponsor of Super Friend, sponsored a special roundtable of medical practitioners and superannuation industry representatives to discuss the issues surrounding mental health. It was organised by Conexus Financial, publisher of Investment & Technology.
This is the first in a series of mental health roundtables sponsored by CommInsure. Participants at the roundtable were:
• Professor Gordon Parker, director of psychiatry, Prince of Wales Hospital, and an expert on mood disorders
• Dr Alex Wodak, director of alcohol and drug service at St Vincent’s Hospital and activist for the needle exchange program and non-law-enforcement programs for addressing the drug problem
• Graham Long, pastor, Wayside Chapel in Sydney’s King’s Cross
• Simon Swanson, managing director, CommInsure
• Michael Back, head of wholesale risk, CommInsure
• Helen Hewett, executive officer, Industry Funds Forum
• Greg Staunton, director, group risk, IFS Insurance Broking
• Damian Hill, chief executive, REST, and chair of the Industry Funds Forum Mental Health Foundation
• Paul Watson, deputy chief executive, ARIA, former deputy chief executive, MTAA Super
• Ian Morante, fund secretary, Nationwide Super
• Bernard O’Conner, assistant chief executive, Non-Government Schools Superannuation Fund
• Greg Bright, Colin Tate and Stephen Shore, from Conexus Financial. (Colin Tate is also a director of Wayside Chapel.)
This is an edited version of presentations and discussion at the roundtable. For a full transcript, go to www. investmenttechnology.com.au Source: IFS Insurance Broking (figures based on real industry funds) Professor Gordon Parker: There was a famous document that the World Bank, World Health Organisation and Harvard produced where they actually quantified burden and disability for all disorders. And within the top 10, four were psychiatric disorders.
Most people misinterpret the figures, saying that in 1990 depression was the second most disabling, expected to rise to number one in 2020. But, in fact, the disability data showed depression to be number one already by then… Schizophrenia was also in there. Bi-polar was number six. But the (estimated) prevalence of bipolar in those calculations was almost certainly way way down. So, the total morbidity in the general population, which might be over a lifetime, is in the order of 20 per cent.
One in five people over their lifetime will have a meaningful severe disabling mental condition. We can break that down to probably 1 per cent of the general community again having schizophrenia. And about 10 per cent having a mood disorder. And then the residual would be made up of a whole residue category comprising anxiety disorders and so on and so forth. So, depression and bi-polar disorder are the key conditions in terms of disability. They are the most disabling because they tend to come on at a young age. They are recurrent. And the episodes are lengthy and that’s why they top the pops in terms of disability.
Depression is highly correlated with suicide data. Of those who killed themselves, 90 per cent were depressed. So the correlation is immensely strong. With bi-polar, in the old days we talked about ‘manic depressive’ disorder. ‘Psychosis’ we now call ‘bi-polar 1’. That probably has a lifetime rate of 0.5 to 1 per cent in the general community. ‘Bi-polar 2’ disorder is often regarded as a milder version. Stephen Fry, the BBC comedian who has it, described it as bi-polar lite. In fact it is not a trivial condition. And it is increasing for reasons we may care to go into.
But it is at least 10 times more common, up to 20 times more common than bi-polar 1. There’s a lot of it around. It is not bipolar lite in the sense that good studies have shown that the suicide rate is at least as high as bi-polar 1, and in some studies slightly higher. Basically, what you have with bipolar 1 is people having episodes lasting months, getting better, and then another episode. Bi-polar 2 people are oscillating most of the time. So, if you look at a hare-and-tortoise sort-of analogy, every time someone on a high goes into a low, they go back into that black space again – that suicidal, terrible world.
They have lives that are really very much like snakes and ladders. They may go into a firm – creativity is over represented in bi-polar people – and they get promoted. And they go higher and higher. Then one day they go into a depression and eventually they get sacked. They can’t get out of bed. They lose their job. In addition to the direct impact and disability of these mood disorders, is huge collateral damage.
Alcoholism and drugs are over represented. Failed marriages. All sorts of things. However, bi-polar is still more a stigmatising diagnosis than depression. It is over-represented in creative people. It is over-represented in people who are successful. But what they’ll say to me is, “I’m prepared to say I’m depressed but I’m not prepared to say I’m bi-polar because I think I’ll lose responsibility for finances”. And we think it’s increasing.
And the big tragedy for bi-polar is that it’s a condition that comes on in adolescence, and usually in years eight to ten at school. And the average duration in Australia, if it gets diagnosed at all, is 15 to 20 years. And during that time people lose their careers. Alcohol becomes a big problem and so on.
Damian Hill: Why is it increasing?
Gordon Parker: . If I could just back up a little bit. Is depression increasing? Probably not. It’s much more that depression is being diagnosed. Fifty years ago when the first antidepressant was discovered, pharmaceutical companies thought there was not enough money in making any antidepressants and now they dominate the market. And that’s partly a reflection of depression being moved away from what we used to call melancholia – describing the biological depression – to bring in a whole range of other conditions where people get depressed because of stress or because of personality or both…
Depression has been destigmatised and redefined and that has caused this suggestion of an increase. But it probably hasn’t increased. In terms of bi-polar, there’s a very interesting correlation with diet. And basically as we change our diet and Omega 3 has gone down and Omega 6 has gone up we’ve seen an increase in certain disorders. Cardiac disorders and bi-polar 2 in particular. And so there’s a very rich story there…
That’s one explanation and probably the most powerful. Other ones are: there are more illicit drugs being used that might predispose people; pace of life including high energy drinks and so on… I actually think 5-6 per cent as a lifetime risk of bi-polar disorder is very true. And this group is even more likely to kill themselves than those with unipolar depression.
Greg Bright: Where are we with the treatment?
Gordon Parker: There are different types of depression … there are some that are purely biological and deserve medication as a priority. Some are a consequence of stress and would benefit from counselling and problem solving. And some are a reflection of personalities. So, we argue a ‘horses for courses’ model.
In regard to the medical approach, it hasn’t improved very much in the last 20 years, despite what the pharmaceutical companies would say. The newer antidepressants are not much more effective. And in fact for the melancholic depressants, they’re actually less affective… There’s been recent studies in America showing basically the atypical antipsychotic drugs, which are expensive, are actually not much more affective than the old ones.
We’ve done a lot better in destigmatising depression and mood disorders. We’ve done a lot better in getting people coming forward. We’ve got some richer approaches. Some drug combinations a bit better. Psychologists are a bit better trained. But it hasn’t improved anything like the rest of medicine.
Simon Swanson: We would say internally at CommInsure that early intervention has been an extraordinary success in the managing of some medical illness claims and income protection claims. So we’d say the awareness that Black Dog and Beyond Blue [programs] have brought to society are assisting the early intervention process.
Gordon Parker: Yes it’s wonderful when we get somebody who comes through at the age of 18. When I was working the specialist field, people would go to 50 or 60, coming through as ‘treatment resist’. If they come through at 18 and we can get the right treatment, you can actually change lives. That’s the advantage of destigmatisation. People are coming further earlier, comfortably.
And at Black Dog 60 per cent of young people coming through bring a partner or a parent. And I think that’s absolutely fantastic that they’re comfortable. Helen Hewett: Is there any behaviour that can be identified in people before the psychosis is there? Are there any trends?
Gordon Parker: Nothing really. You get some atypical presentation. Sometimes before a girl develops bi-polar disorder she’ll have anorexia nervosa. And sometimes before people develop depression they’ll be describing anxiety. But it’s not pristine. It’s not clear-cut.
Frequently what you do as a clinician is you try and find out what’s in the family. So if there’s schizophrenia in the family or there’s depression, then you’re thinking ‘well maybe’ and try to crystallise it. But the answer in broad terms is a negative.
Colin Tate: What is the general claims experience?
Simon Swanson: One in 13 claims is suicide… But we have a 13 month exclusion… So, the insured population is not the same as the general population… We don’t do experience investigations any more but we’re about to bring them back because we believe the insured population is going to have quite a different signature, so to speak, from the general population in this area.
Helen Hewett: We have to remember that not all suicide deaths are likely to be called suicide… I see lots of certificates where it says whether or not it’s suicide, and it will say ‘unknown’, even though it was a gun-shot wound to the head. I don’t think it would take Einstein to work out what it was.
But some of those claims, depending on the coroner, do not say suicide. The other important thing is, and I know this from a friend’s personal experience, that where it is most likely that the child took a deliberate overdose of drugs for example, but it’s not absolutely conclusive, for of the parents or the family they do not write suicide. So the claims are understated.
Greg Bright: How do drugs, alcohol and mental health relate? Are there causal relationships and, if so, in which direction?
Dr Alex Wodak: I think most people working in the alcohol and drug field and even psychiatry would conclude that there are obviously cases where both theories can be demonstrated. That is where a primary alcohol and drug problem causes the secondary mental health problem. And where a primary mental health problem causes a secondary alcohol and drug problem.
In other words someone has a drinking problem and then gets depressed. Or alternatively someone’s depressed and then starts drinking out of control. So both exist. But I think most people would argue that what is much more common is for alcohol and drug problems to be the primary event and mental health problems to be the secondary event.
I’ll just deal with suicide and alcohol and drugs problems quickly… There’s a very high correlation between alcohol consumption and suicide. And it’s particularly high in young males, in rural areas. Alcohol is often present at the time of suicide. And often contributes to the suicide.
In terms of illicit drugs though, just the broad parameters for elicit drugs and death, in the late 1990s (drugs) were causing up to 10 per cent of deaths in certain young age groups, particularly in males in their late 20s to early 30s. So it was a substantial public health problem. This was when heroin availability was very high. There was a glut of heroin. And deaths from heroin reached over 1,000 in 1999 (in Australia). They’re now down to about 350 because of the shortage of heroin.
NSW accounted for 50 per cent of all drug related deaths in the country. And 10 per cent of all drug related deaths in the country occurred within a twokilometre radius of Springfield Mall in King’s Cross. The market has switched from predominately a heroin market to a predominantly amphetamine market. And last year for the first time the number of people who, at their most recent episode of injecting, injected amphetamines was greater than the percentage injecting heroin. This causes fewer deaths but it’s causing more psychosis.
So the incidence – the number of psychotic episodes related to amphetamines – increased 60 per cent from 2000 to 2004. We don’t have more recent figures yet… So, there’s a big correlation between alcohol and suicide, but a poor correlation between illicit drugs and suicide. There’s a big correlation between (illicit drug related) deaths but suicide’s a small proportion, perhaps only 5 per cent of illicit drug related deaths.
People who inject drugs die at a rate that is much less than many people would expect. It’s about 1.5 per cent per annum. Most people think the percentage dying each year would be much higher than that, although that’s still 20 times higher than you would expect of people of that age and sex, who don’t inject drugs… But I guess you people in the insurance industry would know these sorts of things.
Simon Swanson: I’m not sure. A lot of this happens below the insured line, outside the insurance industry.
Damian Hill: The disconnect we generally have is that we’re providing insurance cover which is sometimes the primary source within an employment relationship. And that employment relationship automatically skews figures.
Alex Wodak: Now the other big correlation in this area, in the insurance industry, is the high number of fires started in Australia which are related to smoking. But that’s a very close correlation. So, a lot of property fires and bush fires are started by cigarettes – just carelessness. Sometimes there’s a high correlation between heavy smoking and heavy drinking. And people who smoke and drink a lot, the risks are not often additive: they don’t add, they multiply.
For example, risks of cancer of the upper airways and the oesophagus, the gullet, are about 40 times greater for people who both smoke and drink. People who just drink heavily or just smoke heavily might have a 10 fold increase in risk of death from upper airways cancer. But if they do both it’s not 20 times greater it’s 40 times. So that interaction between drinking and tobacco is very important.
Overall though what gets repeatedly over-emphasised is illicit drugs as a heath problem, as a social problem and as an economic problem. And what gets under-emphasised is the enormous contribution that alcohol and tobacco, the legal drugs, make to health problems in the country and to economic problems. Tobacco’s annual cost to the economy is $21 billion. Alcohol’s is $7 billion. Illicit drugs’ is about $6.5 billion.
But the one you hear about in the newspapers every day and from the politicians is illicit drugs. And without putting too fine a point on it, the tobacco industry’s been a generous donor to both major political parties in this country.
Graham Long: In some ways what we deal with at the Wayside isn’t that vastly different to the world you know. And it’s for this reason: a mental illness makes the drop from ordinary life to the street a small step. It is not a big leap at all. If you don’t have family and you get a mental illness – and I’ve known people who have had a very ordinary life, ordinary jobs and everything, and doing quite well and then they get hit by a mental illness in the same way you get hit by a truck – and in no time at all you hit the street if you don’t have backup somehow.
So the street isn’t that far away. And there are doctors. There are lawyers. There are journalists. There are all kinds of people. Everyone except fund managers are on the street. To back up something that Alex said as well. The drug we hate the most is alcohol because alcohol is a drug that makes people want to hurt each other. If all of these pubs and all of these bottle shops were flogging off heroin, the biggest social problem you’d have would be stepping over the bodies on the way out.
They’d all be asleep which from a management point of view is easy. But with alcohol, you take any crowd and add alcohol and you will have a fight. People want to hurt each other. So from what it’s worth from the trenches, alcohol is by far a nastier drug. In fact, when we have child abuse, which happens a lot, or very nasty assaults, which happen pretty much every day, I would say alcohol is involved close enough to 100 per cent of the time.
The Super Friend Program
Colin Tate: Helen, can you tell us what industry funds have done about mental health?
Helen Hewett: Industry funds – the people managing them – are well aware from looking at the claims history that comes through all the time, and individual claims, that mental health is a significant issue and has been for a long while. The funds looked at how they might be able to do something collectively through the Industry Funds Forum to develop some services to members…
We held some focus groups which included mental health professionals… It was just amazing how many people have been personally affected at some point in their lives by mental health, that were sitting around at those focus groups. The people there felt that if our industry funds offered access to services they would go for it. The other thing we realised from the mental health professionals was that the biggest challenge was not the people so much that had already come to terms with or identified that they were dealing with a mental health problem, but the people who didn’t yet recognise that’s what they were dealing with.
And the parents of children who didn’t recognise that’s what they were dealing with. We realised we could get to those people with education material and help increase the awareness about mental health issues, and about services. So, what the funds decided to do was set up a foundation, a trust. We asked our insurers to contribute voluntary levies if you like, which is a portion of premium income to that fund. All of the work that’s done is pro bono. The lawyers and everybody do it pro bono.
We applied and were successful in getting tax deductibility status so people can make donations and get a tax deduction. The program is called Super Friend. We came up with that name after some research because people said they would look at that and they would be inquisitive to find out what it was all about. It was a way of subtly leading people into being educated about mental illness.
So the first two programs are: we’re developing a web site, which will help guide people to services that are available. The intention is to have two primary objectives – to encourage early help and to give people a guided access to services available. And the other program is to do some work in the area of prevention. That would probably include researching, helping researchers to actually help cure mental illness. With the web site we will have a number of mental health partners who will provide information on things like bi-polar, schizophrenia, depression, and they will maintain that area of data on their own web sites…
Essentially the way it will work for members is, you might go into that link, curious to see what it was all about, and there will be a lot of educational material in there. You might then scroll down and after then you’ll be asked if you would like to speak to an online counsellor. And if you say ‘yes’ then you will be told that you’re now being transferred to our project partner Beyond Blue or Lifeline.
And if you don’t want to go, you hang up… The other important part of it is that we’re developing a tool kit that will go with it. The funds participating will have a pin number. They’ll be able to access all of the resources, and they’ll be able to download the template, put their logo on, print them, distribute them. It will be like a fact sheet for members. And all the information will be provided by and maintained by mental health professionals. So we’re developing, if you like, the point of access and the distribution of the educational material and helping people to access the right service.
Michael Back: I think this is the first time insurers have ever worked together on a project like this. I mean, we have a competitive environment. But we’ve all talked together through the Super Friends program. And I think it’s been a fantastic effort.
Greg Staunton: I’d add to that. The attitude of insurers has been fantastic and they’re all supportive of each other and definitely committed to the goals. We’ve got 13 fully committed insurers now and one partially committed insurer. So I think beyond that there are only two other major insurers in Australia. So really we’ve got the whole market.
‘Read the Signs ’: MTAA Super ’s program
Paul Watson: : During my time at MTAA Super I signed off and considered death claims that came through the fund (as deputy chief executive until last year……..)… Going back several years, we didn’t think that we had a very good handle on the statistics. The single-car accident on a sunny day – that sort of thing. And MTAA had compulsory insurance. Often we were the only thing between the family getting some insurance or not.
The board thought about what we should do. They thought about something we haven’t spoken about today, which is the Sole Purpose Test… We thought about how MTAA could both make a difference for its members and their families and also it had to be with a business context around it too, so we could demonstrate to ourselves, members and the regulators that there was some benefit to this that would meet that prescriptive test.
MTAA Super set about gathering its own statistics. We were shocked to learn – or have it confirmed – that when you compare it to the national statistics its members were highly over-represented in certain categories. Most certainly there were hot spots: young males, rural. The membership, like a lot of national industry superannuation funds, is a bit of a cross-section of the Australian community. But we were overly represented in these categories.
We decided we had to do something about that. MTAA Super are not experts in the field so we talked to some experts. Lifeline was one through an association we had in the ACT that we talked to a bit, and their educational working programs interested us. And that led to the running of a pilot where Lifeline and MTAA Super went out and talked to some employers and others where a suicide had occurred in the work place. Everywhere we went with this pilot a recurring theme emerged that with 20/20 hindsight the signs were always there.
There were signs for the employers, the work mates, the family. They saw it in hindsight but at the time hadn’t put two and two together. So MTAA Super set about this pilot program called ‘Read the Signs,’ which it then launched and I’m pleased to say is still running today and very successfully. The Fund developed a whole heap of things like cards with dots points, and the phone number about reading the signs. The presenters would leave them in a tearoom. Everyone sort-of said jokingly, ‘not for me thanks’. But they were all gone by the end of the session. So we tried to discover ways that we could get to people, without their having to lose face if they take the card ‘for a friend.’
The ‘Read the Signs’ program has been excellent most worthwhile. MTAA Super diverted some of its discretionary funds within its marketing budget towards the program in the initial stages. To put that in context, If the program succeeded in intervening in one life, say someone in their early 20s, MTAA would have, through the insurer, probably not had to pay out something around $125,000. Two lives, if we’ve intervened, paid for that entire program… I am pleased to say, MTAA has done some follow-up research into its own statistics and the death-bysuicide rate within the fund has come down in the time that the program’s been running.
The next part of course is to do some cause-and-effect analysis and see how much can be attributed to that. This has all steamrolled – MTAA Super’s experience is but one fund’s example. Cbus and other funds have had their examples too. Similar conversations were happening in every super fund boardroom.
Greg Staunton: Cbus is another fund which has started to do a fair bit of work through group training with apprentices, and now roll out workplace programs. Likewise, we are seeing a downward trend in their suicide rate. Again it’s early days and we might see that deteriorate when we get the full claims through, but I think the initial indications suggest there might be positive impact from these programs.