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3.2.1 We can do more to help each other

New Zealand is experiencing a rising tide of mental distress and addiction. Our experience is mirrored in other countries, including Australia, Canada, England and the United States.34 The fact we are not alone in this is hardly reassuring, but it suggests some of the shared problems reflect common features of life in contemporary Western countries:35

If our treatments work shouldn’t we have fewer people presenting in crisis, [fewer] people on a disability benefit due to mental illness, a reduction in community measures of psychological distress and a decrease in the suicide rate? …

… despite access to costly biomedical treatment, something central to recovery appears to be missing in the social fabric of developed countries.

The cost of poor mental wellbeing and addiction is high. It is a high cost to individuals, families and whānau, businesses and organisations, communities, government and the country as a whole.

Clear links exist between social deprivation, trauma, exclusion and increasing levels of mental distress. Our wellbeing is being further undermined by aspects of modern life, such as loss of community, isolation and loneliness.

Part of the answer must lie in addressing inequity in our society – income inequality, child poverty, homelessness, unemployment, family violence and abuse. Māori disadvantage on all those measures is incompatible with the promises in the Treaty of Waitangi. Government has a crucial role to play in fixing these long-term, widely acknowledged problems. We highlight areas for action later in this report (see Part 2, chapters 4–12). Similarly, in the face of enormous harm to our communities from alcohol and other drug abuse, we need to act on international evidence and our own experience of previous epidemics (notably HIV in the 1980s) and respond with effective public health and legislative interventions.

However, New Zealand’s mental health and alcohol and other drug problems cannot be fixed by government alone, nor solely by the health system. Many of the solutions lie with families, whānau and communities and with social services. Some of the answers lie in new ways of thinking about the problems besetting us.

The epidemic of mental distress and addiction is affecting all layers of our society. When heart disease was very high 30 or 40 years ago, we didn’t bring in more heart surgeons, we changed our lifestyles – and significantly reduced the prevalence of cardiovascular problems. We think we’re at that point with mental health and addictions in New Zealand.

We agree with the view that we can’t medicate or treat our way out of the current crisis.36 We need to ensure practical help and support in the community are available when people need it, and government has a key role to play here. But some solutions lie in our own hands. We can do more to help each other.

The pressures of modern life are clearly impacting on people’s mental health and contributing to unhealthy behaviour and addictions. Social media is an important connector of people, but children and parents are spending hours on their devices, isolated from their immediate surroundings and from the outdoors.37

We know there is increasing evidence of the importance of strong early bonding for growing a healthy brain and talking to babies and young people is critical to this. While scientists investigate whether excessive device use may be affecting brain development and sleep patterns, we think it would be sensible to encourage some time out from social media and devices – as well as taking steps to keep people safe from bullying and limit exposure to violent and pornographic material.

Although lots of vibrant community hubs exist throughout New Zealand – around schools, sports clubs, arts centres, marae and churches – many people are isolated from their neighbours and local communities. We have much to learn from cultures that value collectivism and emphasise family, spirituality and connection to each other and the natural environment.

We also need to rethink our approach to urban growth in response to population pressures. Our planning and development processes should enable community and connections, with provision for communal facilities and parks, and access to public transport in new housing developments.

We observe that consumerism and strongly materialistic and competitive values do not lead to improved mental health. Many people are buying more, but according to surveys we’re less happy. Young children and elderly people remind us of the old truth that the simple things in life give the greatest pleasure.

We also think modern society places too much emphasis on the unrealistic idea that we can constantly be happy. We need to remind ourselves that life consists of peaks and valleys. Many people who experience deep lows or serious mental illness report that the slow process of healing their heart and spirit brought them great strength and enriched their life.38

Everyone agrees that we should pay more attention to the wellbeing of our children. Some children experience great inequity through poverty, neglect, parental alcohol and other drug use and addiction, and parental mental distress. The wellbeing of these children is especially at risk. But parents and teachers report that all children and young people need to learn skills in regulating emotions, mindfulness, and coping with adversity – to be resilient.

Wellbeing has been a theme during this Inquiry and in national conversation in recent years. It can be especially hard for people who are struggling with poverty, abuse and deprivation or dealing with mental health and addiction challenges to take steps to become well – yet, every day, people recover from distress, overcome addictions and find strength in their lives. The people we heard from talked about the simple but powerful things they did to climb out of a dark hole.

Sleep, nutrition, exercise and time outdoors are important for recovery. So too is regaining one’s cultural identity and participating in cultural activities. Many people begin to regain their own wellbeing by helping others:39

The best way to increase our own wellbeing is to have more concern for the wellbeing of others. There’s a saying I try to take on board – don’t think less of yourself, just think of yourself less.

Work, including voluntary and part-time work, is vital to recovery – a reason to get out of bed in the morning. Healing can come from helping others facing similar challenges, and the social connections provided by work can form a natural bridge to fuller employment and moving off income support. During 2018, an OECD team undertook a review of how New Zealand addresses mental health and work policy challenges. Many of the challenges the OECD team has identified in its draft report, provided to us as we finalised our own report, are similar to those expressed by people we heard from.40

Our views above do not detract from the importance of continuing to respond to the needs of people with more severe distress and prolonged episodes of mental illness. The special duty of care owed to this group was the focus of the Mason Inquiry, and the Government’s response to that Inquiry, in the late 1990s, has given New Zealand a solid foundation to build on.

3.2.2 We have a solid foundation to build on

On the back of the closure of large institutions and the changes driven by the Mason Inquiry, the 1990s and early 2000s were times of excitement and energy within the mental health and addiction sector. The Blueprint developed by the Mental Health Commission, with extensive engagement from the sector, provided a clear pathway forward. New models and relationships emerged, often on the back of new investment and expanded innovative programmes, services and supports including Kaupapa Māori services. This was supported by a clear and explicit incremental funding pathway, ‘the Blueprint funding’.

That surge of development created a sound base we can build from. We consider New Zealand’s mental health and addiction system has valuable strengths, including:

  • the availability of publicly funded services and support for those with the highest needs, including a significant network of experienced non-governmental organisations (NGOs) providing services and supports in the community
  • a comprehensive range of services that support people within a forensic environment
  • some services delivered in ways that meet the needs of particular groups, often in ways unique to Aotearoa, such as tikanga and Kaupapa Māori services and services designed around the needs and preferences of Pacific peoples, as well as approaches and models for other high-need groups such as young people
  • a history of successful promotion, prevention and anti-stigma initiatives and strong advocacy
  • laws and processes to promote quality improvement, human rights and consumers’ rights
  • an enviable infrastructure of mental health and addiction workforce development centres
  • a small, but valued, peer workforce
  • a wider workforce providing support in community settings
  • a rapidly growing Māori health workforce within health-related professions and community agencies
  • some primary and community support for people with mild to moderate needs
  • pockets of innovation, the most promising of which are often designed and delivered by people wanting to change the way things are done, including people with lived experience and people focused on, and based in, communities
  • an extensive data and evidence base.

We also identified another vital strength within our system and society: a shared, widespread and strong desire to change our way of thinking about, and our collective approach to dealing with, mental health and addiction. Many people want to apply a wider perspective to prevention, and to respond more effectively and comprehensively when people experience mental health and addiction challenges.

3.2.3 But the system is under pressure

Some people told us that the mental health and addiction system had been responsive to their needs. This is backed up by data that shows:

  • most adults have relatively timely access to specialist services
  • higher needs groups tend to be higher users of specialist services
  • most people’s wellbeing improves when they are using services 41
  • most people are satisfied with the services they receive.42

However, our existing approach to mental health and addiction challenges is under considerable pressure. Markers of this are:

  • continually escalating demand for specialist services, across all age groups, especially in infant, child and adolescent services
  • specialist services operating at capacity, applying restrictive criteria and being able to accept only the most distressed or unwell people
  • limited or unavailable advice or support at times of crisis
  • lack of forensic services to meet the needs of a growing number of prisoners with serious mental illness
  • waiting times for young people (0–19 years) that are longer than for all other age groups and do not meet government targets or community expectations
  • persistently high numbers of people presenting with suicidal thoughts and behaviours
  • health and social service providers reporting increasingly complex individual and family situations
  • New Zealand’s extremely high rates of compulsion, including community treatment orders and seclusion, compared with rates in other countries
  • limited access to funded mental health and addiction services for those with mild to moderate and moderate to severe needs
  • increasing numbers of complaints about access.

International data shows that in countries comparable to New Zealand, 35% to 50% of people with a mental illness receive no treatment. 43 Comprehensive and robust information to identify unmet need in New Zealand is lacking, but it is clear that many people are struggling to get access to appropriate, or even any, support, other than medication. Moreover, for many people, taking mental health problems to a general practitioner is not seen to be an appropriate or affordable response.

It is also clear that workers are often stressed and unable to work in the way that they want to and that would most benefit their clients. Recruiting staff to mental health and addiction roles and retaining existing staff are major problems. Workforce shortages, working conditions, increasing assaults on staff in inpatient units, negative perceptions about mental health, and a risk-averse culture are all contributing to a workforce crisis. These problems are putting pressure on existing staff. We are not preparing adequately for the workforce needed now and into the future.

Cumulative pressures are building at the intensive end of the system, where most services are located. Overall, the system is under severe pressure and is unsustainable in its current form.

3.2.4 We’re not getting the outcomes we want for our people

Despite our current level of investment in mental health and addiction services, we don’t appear to be achieving good outcomes, and the outcomes for specific populations are poor. The results highlight the complexity of the relationships between socioeconomic factors, housing, social exclusion, and mental wellbeing and addiction.

The poor outcomes for particular population groups (for example, Māori, Pacific peoples and Rainbow communities), the inequities in physical health of people with more serious mental health challenges, and our persistently high suicide rates are of particular concern. Mental health problems in schools and for children in state care, and the connections between employment, income and mental health, are also highlighted in the next sections.


Māori experience significantly higher rates of mental illness, higher rates of suicide and greater prevalence of addictions.

While the prevalence of mental distress among Māori is almost 50% higher than among non-Māori, Māori are 30% more likely than other ethnic groups to have their mental illness undiagnosed.44 The outcomes for Māori who access mental health services are poorer across a variety of measures and diagnoses.45

In primary care, there is evidence that Māori present more often with mental health problems but their problems are underdiagnosed. In secondary care, Māori are more likely to be admitted to hospital, to be readmitted after discharge, to be secluded during admission, and to be compulsorily treated under the Mental Health (Compulsory Assessment and Treatment) Act 1992 (the Mental Health Act) and in forensic services.46

Pacific peoples

Pacific peoples (including Samoan, Cook Islands Māori, Tongan, Niuean, Fijian, Tokelauan, Tuvaluan and a small number of other Pacific groups) make up 7% of the New Zealand population. A consistent pattern of high mental health need and low service use has persisted for Pacific peoples over time. While Pacific peoples are more likely to experience mental distress than the total population, they are much less likely to have received treatment.47

Overall, Pacific peoples’ suicide rates are lower than Māori and non-Māori rates, but suicide rates among Pacific youth (particularly young men) are high. Alcohol abuse and problem gambling are also significant challenges in Pacific communities, but the rates of addiction behaviours among Pacific youth appear to have reduced over time.48

Refugees and migrants

Refugees and migrants form a significant and growing proportion of New Zealand’s population and come from diverse backgrounds. According to the 2013 New Zealand Census of Population and Dwellings, the number of people living in New Zealand who were born overseas accounted for more than 1 million people, a quarter of the population.49

Both refugees and migrants from different ethnicities report challenges accessing mental health and addiction services. In the case of refugees, many will have experienced trauma before coming to New Zealand to live, are more likely to be isolated from their family and their community, have experienced significant loss and grief, and may have pre-existing mental health and addiction challenges that require help. Barriers to access, over and above those that may be experienced by the general population, include language barriers, a lack of access to qualified interpreters, poverty, a lack of knowledge about entitlements and the healthcare system, and cultural beliefs about mental health that influence whether people seek help.50

Rainbow communities

Rainbow communities are estimated to account for 6% to 15% of the total New Zealand population. A strong body of evidence shows that Rainbow communities have significantly poorer mental health and are at a much higher risk of distress, addiction and suicide. Poor mental wellbeing and substance use among Rainbow communities are often attributed to the cumulative effects of discrimination, bullying, prejudice and exclusion. Very limited access to gender reassignment services also has a negative effect on the mental health and wellbeing of people seeking to access them. Population-level data on the mental health of Rainbow communities in New Zealand, except for youth, is lacking. The Youth 2012 survey found that, compared with heterosexual youth, Rainbow youth were more than twice as likely to have deliberately self-harmed, and nearly one in five had attempted suicide during the previous year.51 Despite these high risks, few services specifically support the mental health of Rainbow communities. Many of the services available are in the NGO sector and are provided by minimally funded or volunteer organisations.52

Rural communities

While the prevalence of mental health conditions is similar in urban and rural settings, people in rural settings are less likely to access mental health care.53 In addition, while numbers are relatively small, data suggests that suicide rates are slightly higher for people in rural areas than in urban areas.54 Young farm labourers are at highest risk of suicide among the rural population, with isolation, alcohol use and availability of firearms considered to be contributing factors.55

Sparsely populated regions present challenges geographically as people may have to travel long distances to receive or deliver mental health and addiction services. Slow or no internet connection, limited cell phone coverage and poor roads can also make it difficult to access services and support. Recruiting staff to work in rural areas is also challenging. Often only crisis services are provided, with limited opportunity to undertake preventative work.

Disabled people

‘Disability’ is an umbrella term for a range of impairments. One-quarter of the New Zealand population reported a disability in the 2013 census. Disability is more common at older ages, with 59% of people aged over 65 reporting a disability, and more common among Māori and Pacific peoples.56 The prevalence of different types of disabilities differs among the population. For example, autism spectrum disorder, which describes a range of conditions that includes autism and Asperger syndrome, is thought to affect one in 100 New Zealanders. For children, a learning difficulty is the most common type of impairment.

The boundary between mental health and disability can be blurred, and mental health challenges can be both causes and consequences of disability. There is also some evidence of diagnostic overshadowing, whereby symptoms are attributed to a person’s disability rather than to mental health needs (particularly for those with learning disabilities or autism spectrum disorders).57 According to the 2013 Disability Survey, an estimated 242,000 people (or 5% of New Zealanders) are living with a disability caused by psychological and/or psychiatric conditions.58 However, information is very limited about the mental health and wellbeing of disabled people, and disability support services and mental health and addiction services have remained relatively siloed.59


No information is routinely collected about the mental health of New Zealand veterans. However, the incidence of mental health issues and substance misuse among New Zealand veterans appears to be high. Nearly 36% of impairment compensation claims made by veterans since the Vietnam War have been for mental health and addiction challenges. Australian data suggests veterans are significantly more likely to experience post-traumatic stress disorder and affective disorder (especially depression) than the wider population.60

The nature of contemporary conflict has shown a shift away from the post-traumatic stress injuries of earlier conventional conflicts to adjustment disorders and moral injuries.61 Many veterans with mental health and addiction needs require specialised care over an extended period, which is frequently not available in New Zealand.


New Zealand’s prison population has increased markedly over the past 30 years. In 2016, the prison population exceeded 10,000 for the first time, and it has continued to grow.62

The vast majority of prisoners experience significant challenges related to mental health and addiction, often in combination, and at rates much higher than in the general population. A study published in 2016 found that 91% of prisoners had a lifetime diagnosis of a mental health or substance use disorder and 62% had this diagnosis in the past 12 months.63 As the Office of the Ombudsman has noted, prisoners (and people detained in other settings) often lack appropriate mental health support.64

Experiences of abuse and trauma can also contribute to an increased risk of mental distress and substance use. An overwhelming majority of prisoners have been victims of violence, with almost half of those in prison reporting experiences of family violence as a child, and 53% of women and 15% of men reporting experiences of sexual abuse.65

Young people

New Zealand young people are more likely than older people to report symptoms of depression, anxiety and psychological distress, and New Zealand has one of the highest rates of adolescent suicide in the OECD.66 The Youth2000 survey series has identified that suicidal ideation and attempts, self-harm and bullying are common experiences for secondary school students.67 The Youth Wellbeing Survey estimates that up to half of young research participants (16- to 18-year-olds) have deliberately hurt themselves at least once.68

While a range of targeted mental health services is available for young people, barriers to access include internal factors, such as privacy concerns, lack of knowledge about where to go and concerns about the attitudes of clinicians, and external factors, such as the cost and geographical location of services. Some groups are particularly at risk (including Māori, Pacific, and Rainbow young people and disabled young people) but are not seeking help or accessing services at the same rates as their peers. There are also reports of young people being inappropriately treated in adult services due to access problems.69

Older people

Older people (65 years and over) are an important and growing segment of the New Zealand population. It is expected that by 2036 around two out of every nine New Zealanders, or 1,258,500 people, will be aged 65 and older, representing a 77% increase since 2016. This increasing proportion of older people in the population is expected to continue in the long term.70

Mental distress in older people may arise from cognitive decline, grief and loss, role changes and loss of function, loneliness, isolation and stigma. They may be living with chronic anxiety, depression and dementia or may develop schizophrenia, psychosis or addictions late in life. These issues may be compounded by complexities relating to co-existing addiction, long-term disability and physical health issues. Data indicates that older people are less likely than people aged 25–64 to use primary mental health care services and are especially unlikely to use psychologist services.71

Children experiencing adverse childhood events

Children who have experienced adverse childhood events (ACEs) have higher rates of mental illness and addiction and worse health outcomes overall than others. To have multiple ACEs is a major risk factor for many health conditions. Research shows that the children of parents with multiple ACEs are also more likely to experience high levels of adverse outcomes due to the violence, mental illness and substance use they experience. Studies show that the greater the number of ACEs experienced as a child, the higher the risk of poor health outcomes. There is a moderate association for people with two or three ACEs for increased likelihood of smoking, heavy alcohol use, poor self-rated health, cancer, heart disease and respiratory disease and a strong link for sexual risk taking, mental ill health and problematic alcohol use. ACE links are strongest for problematic drug use and interpersonal and self-directed violence. The research provides support for a strong public health approach to preventing childhood exposure to adverse events, to building resilience in children to cope when they do occur and to ensuring all health and social services provide ACE-informed responses.72

Children in state care

The incidence of mental health and addiction challenges is considerably higher among children in state care than among the overall population, reflecting the impact of wider social determinants and adverse childhood events. The mental wellbeing of parents is also associated with having children in state care. One review of children who came into Oranga Tamariki care before their second birthday showed 71% of their mothers had alcohol or other drug problems and 43% of their mothers had mental health problems.73

Physical health

People with severe mental health or addiction challenges have higher rates of many health conditions and shorter life expectancy, and this gap has increased over time. New Zealanders accessing specialist mental health services have double the risk of premature mortality compared with the overall population and their life expectancy is shorter by up to 25 years.74 The risk is greater for women and Māori.

High mortality from physical health conditions is due to a higher risk of developing a disease, late diagnosis and poorer intervention levels as well as worse outcomes once a disease develops. While the risk of suicide is higher in this population, most premature deaths are due to cardiovascular disease, cancer and other chronic disease.75 The estimated annual cost of premature deaths of people who have both physical and long-term mental health conditions, when the impact of addiction is factored in, is $6.2 billion.76

Equally Well – a collective initiative to reduce disparity

Equally Well is a sector-wide movement that has raised awareness of the poor health outcomes for people with mental challenges and engaged all parts of the sector in addressing this issue.

More than 100 organisations support Equally Well and are doing their part to work together for change. These supporters are cross-sectoral and include community organisations, mental health and addiction non-governmental organisations, primary care services including general practitioners, district health boards, medical colleges, and education providers. Mental health and addiction service users are important partners in all of Equally Well’s work.

Hundreds of activities supporting Equally Well’s goal are under way across the country, making promising steps towards improving the physical health of people facing mental health and addiction challenges. Change is occurring for individuals through increased awareness, improved service integration, and policy change. As a result of seeing the impact in New Zealand, there are now Equally Well collaboratives in Australia and the United Kingdom.


Rates of suicide were relatively stable in the decade to 2015 and down from a high in the mid-1990s. Rates of suicide are higher for males, Māori and people living in high-deprivation areas. Although New Zealand’s suicide rates are highest for adults, especially middle-aged men, our youth suicide rates are among the highest in the OECD. Recent data from Coronial Services of New Zealand shows a concerning upward trend in suicides in recent years, signalling a need for a rethink of our current approach to suicide prevention and to the support available to suicide bereaved families, friends, whānau and communities. We discuss suicide prevention in chapter 10.


Mental wellbeing affects the ability of young people to engage successfully in their academic learning and acquisition of social skills and as a contributing member of their school community. Young people with mental health challenges are less likely to complete their schooling.77

The Ministry of Education advises that the education sector as a whole is seeing increased violent and uncontrolled behaviour at younger ages, high rates of youth suicide and deliberate self-harm among teenagers and young adults, and increased anxiety among young people about their educational performance and academic testing.

The Ministry of Education also advises that Māori and Pacific students and disabled students all report poorer wellbeing in student surveys compared with the overall student population, correlating with disparities in educational engagement and achievement and contributing to inequities in life outcomes. While intensive work is under way to address exposure to bullying, New Zealand has the second highest rate of bullying in the OECD.78

Employment and income

Unemployment (and job loss) is associated with a greater risk of developing a mental illness. Jobseekers with mental health challenges have particularly poor outcomes. For over 40% of all recipients of health and disability income support, mental illness is the primary barrier to being able to work. This group has almost doubled since 2000, and is likely an underestimate of income support recipients with mental illness.79

While work can have positive impacts on mental health, work environments can also have negative impacts through overwork, bullying and other stressors. Data from WorkSafe New Zealand indicates that the experience of work-related stress or mental illness is increasing year on year (7% in 2014 to 11% in 2016).80 The OECD has identified that many New Zealanders with mental health challenges are living in low-income households.81

3.2.5 Quality of services and facilities is variable

People reported, and we visited, facilities and service environments that are not conducive to recovery and wellbeing and are inappropriate for some groups, such as young people. We regulary fail to provide a system response or experience that meets people’s needs. Some tāngata whaiora are not treated well or with kindness or given adequate time for their needs to be understood or met.

New Zealand does not have a mental health and addiction system that consistently works with people, wrapping around them to meet their needs. Although survey feedback suggests many people have positive experiences of accessing services and support, this is not always the case.82 Too many people are treated with a lack of dignity and respect and in a way that demeans their mana and their human rights. Frequently, tāngata whaiora are on the receiving end of poor communication and processes and services that do not meet their needs. Limited options are offered to people seeking help.

Our mental health system is set up to respond to people with a diagnosed mental illness. It does not respond well to other people who are seriously distressed. Even when it responds to people with a mental illness, it does so through a lens that is too narrow. For example, early intervention for psychosis works best when people are supported in their whānau or community, have access to talk therapies, education and training, and are helped to connect to others. This sort of comprehensive approach is uncommon.

At the moment, too many services are provider-oriented or have a solely individual focus, rather than considering people in the context of their family and whānau and the other things that are important in their life.

There are few suitable services for, and poor responses to, people with complex or multiple needs (for example, people with an intellectual disability and/or autism as well as a mental health need). Age and life stage transitions are not well supported. The lack of integration between and within the health and social sectors and for high-need population groups is a barrier to improving people’s experience and outcomes.

Current laws and practice result in unacceptable levels of compulsion and restrictive practices. Too often, lacking a full range of connected services that wrap around and care for people earlier (such as talk therapies and group support), we fall back on the use of compulsion and restriction.

3.2.6 Key components of the system are missing

Sector development has stalled and, in some areas, regressed. Important models, principles and directions are talked and written about, but are not implemented and followed. As a result, we have not made the system shift that has been signalled for several decades. This stall has resulted in an underdeveloped mental health and addiction system. Some services and supports do not exist in the system or are not provided in suitable and culturally appropriate ways. This is leading to lost opportunities and a lack of choice.

We do not have a continuum of care – few options are available to people who do not meet the threshold to access specialist mental health and addiction services. Of particular concern is the limited progress in developing services for people with mild to moderate and moderate to severe needs. Also, few initiatives aim to respond to serious distress and prevent people from ‘tipping over’ into crisis situations.

People experiencing psychological distress may be offered medication, but not appropriate support and therapies to manage and recover from their distress. We do not address people’s wider social needs, including housing, employment, isolation and income, which impact on people’s lives; nor do we provide the full range of evidence-informed interventions that we know are important in supporting recovery. While evidence exists that trauma is a major factor in the lives of many people with more serious mental distress or addictions, we do not provide comprehensive trauma-informed responses, nor do we offer appropriate psychological and talk therapies.

The initial expansion of culturally appropriate and population group–oriented models and services has not been maintained. In recent years, services that focus on high-need populations have received insufficient investment. Funding and contracting changes have negatively affected Kaupapa Māori and Pacific mental health and addiction services in particular.

Ample evidence exists that better respite and crisis support options, more forensic step-down services in the community, and earlier access to a broader range of peer, cultural and talk therapies would relieve pressure on inpatient and forensic units, yet growth in these areas has been limited, with little new investment. Pilot initiatives and partially constructed service models have not been properly evaluated, refined and rolled out.

Community forensic step-down services

Emerge Aotearoa provides four regional forensic mental health step-down services in Auckland (11 beds in two locations), Palmerston North (4 beds) and Wellington (4 beds).

Services provide a structured environment with 24-hour intensive support and a programme oriented towards recovery and rehabilitation of tāngata whaiora. People are supported to attain life skills, improve their quality of life and achieve independence in the community with reduced support. The services cater for people with a range of sophisticated needs who are moving from a forensic inpatient setting back into the community.

Intensive support is provided by a combination of onsite support staff and mental health professionals, with additional support from Forensic Community Mental Health teams to meet the unique needs of tāngata whaiora.

Services have seen many success stories and great outcomes, including tāngata whaiora:

  • securing and maintaining employment
  • gaining academic qualifications
  • achieving pre-vocational goals
  • reconnecting with their children and whānau
  • moving towards independent living
  • moving from Special Patient status.

We lack a strong, organised and long-term focus on promotion, prevention and early intervention – although it is questionable whether New Zealand is getting the maximum benefit from the many promotion, prevention and early intervention programmes and activities currently in place.

Despite a lot of consensus about the need for reform, we are yet to take a bold, health-oriented approach to the widely recognised problems of misuse of alcohol and other drugs in our community and to provide a wider range of community-based services to help people recover from addiction. Our approach to suicide prevention and the support available to people after a suicide is patchy and under-resourced. Raising awareness of suicide by itself is not enough; prevention initiatives should be monitored and evaluated for effectiveness, and there must be avenues for people to access early support for their distress.

As well as the big gaps in our mental health and addiction system, we lack a coordinated, integrated approach from social services to tackling the social and economic determinants of mental health and wellbeing. We need to target these underlying determinants to intervene early in the life course and at critical transition points in the lives of children and young people.

Leadership and oversight are important, given the impact of government agencies and policies on mental health and wellbeing and on all the factors that affect broader wellbeing in society. Key players will be a new commission – the Mental Health and Wellbeing Commission (discussed in Part 2) – and a reinvigorated Ministry of Health. A central locus of responsibility within government is needed for the wide range of wellbeing activities under way in the state sector to ensure coordination and integration and maximise impact.

But leadership from Wellington will not be enough to transform mental health and wellbeing in New Zealand. Everyone can help create an environment where mental health is promoted and distress responded to more effectively. Everyone includes individuals, families and whānau, Iwi, district health boards (DHBs), organisations and communities. We need to build our collective capability and capacity to prevent and respond to mental health and addiction challenges.

3.2.7 It’s time to build a new system on the existing foundations

The foundations are in place for supporting those people with the highest mental health and addiction needs. We will always have a special responsibility to those most in need. We must continue to provide appropriate treatment and support and improve the quality of care. While some growth has occurred in community-based services over the years, it has been insufficient to respond to the needs of this group. Inpatient and DHB-provided services have remained at the centre of specialist services. More intensive community support options and pathways are required to support people so they don’t need an inpatient admission or are helped to return to the community earlier.

Crucially, we need to build a continuum of care and support. We must expand the options available for people below the current eligibility threshold for specialist services. Many people with common, disabling problems such as stress, depression, anxiety, trauma and substance abuse have few options available through the public system. Often, they do not require medical interventions, but do need support to deal with the adverse events they may be experiencing and their distress. Within the health sector, the limited investment and lack of development in primary and community care has negatively affected the options available. This is despite strong evidence for focusing on primary and community care and early intervention and support, and the policy intent, expressed many times over the years, to target this area for growth. By failing to provide support early to people under the current threshold for specialist services, we’re losing opportunities to improve outcomes for individuals, communities and the country.

We think New Zealand’s future mental health and addiction system should build on the foundations in place, but should look and be very different. At its heart should be a vision of mental health and wellbeing for all.

34  AF Jorm, SB Patten, TS Brugha and R Mojtabai. 2017. Has increased provision of treatment reduced the prevalence of common mental disorders? Review of the evidence from four countries. World Psychiatry 16(1): 90–99. DOI: 10.1002/wps.20388(external link).

35  R Mulder, J Rucklidge and S Wilkinson. 2017. Why has increased provision of psychiatric treatment not reduced the prevalence of mental disorder? Australian and New Zealand Journal of Psychiatry 51(12): 1,176–1,177. DOI: 10.1177/0004867417727356(external link).

36Analysis of prescribing data for New Zealand adults for 2008–2015 shows that antidepressant prescribing rates continue to increase in New Zealand. The authors note, “Simply giving more people more antidepressants does not seem to be working”: S Wilkinson and R Mulder. 2018. Antidepressant prescribing in New Zealand between 2008 and 2015. New Zealand Medical Journal 131(1485).

37  The OECD found that tamariki and rangatahi use of the internet increased outside of school in Aotearoa from just under 100 minutes per day in 2012 to just over 150 minutes in 2015. OECD. 2018. Children and Young People’s Mental Health in the Digital Age: Shaping the future. Paris: OECD. www.oecd.org/health/health-systems/Children-and-Young-People-Mental-Health-in-the-Digital-Age.pdf(external link)

38 M O’Hagan. 2014. Madness Made Me: A memoir. OpenBox.

39  D Chisholm. 2014. The survivor gene. North & South (January): 32–39, p 38, quoting Hugh Norriss.

40  OECD. 2018. Mental Health and Work: New Zealand. Paris: OECD Publishing.

41  Ministry of Health. 2017. Office of the Director of Mental Health Annual Report 2016. Wellington: Ministry of Health. www.health.govt.nz/publication/office-director-mental-health-annual-report-2016(external link); HDC. 2018. New Zealand’s Mental Health and Addiction Services: The monitoring and advocacy report of the Mental Health Commissioner. Auckland: Health and Disability Commissioner. www.hdc.org.nz/resources-publications/search-resources/mental-health/mental-health-commissioners-monitoring-and-advocacy-report-2018(external link); S Gibb and R Cunningham. 2018. Mental Health and Addiction in Aotearoa New Zealand: Recent trends in service use, unmet need, and information gaps. Wellington: University of Otago.

42  Ministry of Health. 2017. Office of the Director of Mental Health Annual Report 2016. Wellington: Ministry of Health. www.health.govt.nz/publication/office-director-mental-health-annual-report-2016(external link)

43 World Health Organization. 2011. Global Burden of Mental Disorders and the Need for a Comprehensive, Coordinated Response from Health and Social Sectors at the Country Level (EB130/9). Geneva: World Health Organization. http://apps.who.int/gb/ebwha/pdf_files/eb130/b130_9-en.pdf(external link).

44  Based on results from the New Zealand Health Survey between 2006/07 and 2016/17, cited in R Cunningham, A Kvalsvig, D Peterson, S Kuehl, S Gibb, S McKenzie, L Thornley and S Every-Palmer. 2018. Stocktake Report for the Mental Health and Addiction Inquiry. Wellington: University of Otago.

45  Based on results from the New Zealand Health Survey between 2006/07 and 2016/17, cited in R Cunningham, A Kvalsvig, D Peterson, S Kuehl, S Gibb, S McKenzie, L Thornley and S Every-Palmer. 2018. Stocktake Report for the Mental Health and Addiction Inquiry. Wellington: University of Otago.

46  R Cunningham, A Kvalsvig, D Peterson, S Kuehl, S Gibb, S McKenzie, L Thornley and S Every-Palmer. 2018. Stocktake Report for the Mental Health and Addiction Inquiry. Wellington: University of Otago.

47  MA Oakley Browne, JE Wells and KM Scott (eds). 2006. Te Rau Hinengaro: The New Zealand Mental Health Survey. Wellington: Ministry of Health. www.health.govt.nz/publication/te-rau-hinengaro-new-zealand-mental-health-survey(external link). Only 25% of Pacific people with severe mental health or addiction needs had received treatment from mental health services compared with 58% of the total population.

48  Based on results from the Youth Health Surveys between 2001 and 2012, cited in R Cunningham, A Kvalsvig, D Peterson, S Kuehl, S Gibb, S McKenzie, L Thornley and S Every-Palmer. 2018. Stocktake Report for the Mental Health and Addiction Inquiry. Wellington: University of Otago.

49  Statistics New Zealand. 2014. 2013 Census QuickStats about culture and identity. http://archive.stats.govt.nz/Census/2013-census/profile-and-summary-reports/quickstats-culture-identity/ethnic-groups-NZ.aspx(external link) (accessed 25 October 2018).

50  R Cunningham, A Kvalsvig, D Peterson, S Kuehl, S Gibb, S McKenzie, L Thornley and S Every-Palmer. 2018. Stocktake Report for the Mental Health and Addiction Inquiry. Wellington: University of Otago.

51  MFG Lucassen, TC Clark, E Moselen, EM Robinson and The Adolescent Health Research Group. 2014. Youth’12 The Health and Wellbeing of Secondary School Students in New Zealand: Results for young people attracted to the same sex or both sexes. University of Auckland. http://oro.open.ac.uk/43995/.

52  R Cunningham, A Kvalsvig, D Peterson, S Kuehl, S Gibb, S McKenzie, L Thornley and S Every-Palmer. 2018. Stocktake Report for the Mental Health and Addiction Inquiry. Wellington: University of Otago.

53  S Gibb and R Cunningham. 2018. Mental Health and Addiction in Aotearoa New Zealand: Recent trends in service use, unmet need, and information gaps. Wellington: University of Otago.

54  S Gibb and R Cunningham. 2018. Mental Health and Addiction in Aotearoa New Zealand: Recent trends in service use, unmet need, and information gaps. Wellington: University of Otago.

55  A Beautrais. 2018. Farm-related suicides in New Zealand, 2007–2015: A review of coroners’ records. Australian and New Zealand Journal of Psychiatry 52(1): 78–86.

56  Office for Disability Issues. No date. Key facts about disability in New Zealand (web page). www.odi.govt.nz/home/about-disability/key-facts-about-disability-in-new-zealand/(external link) (accessed 23 October 2018).

57  Ministry of Health. 2013. Innovative Methods of Providing Health Services for People with Intellectual Disability: A review of the literature. Wellington: Ministry of Health. www.health.govt.nz/publication/providing-health-services-people-intellectual-disability-new-zealand-literature-review-and-case.(external link)

58  Based on results from the 2013 Disability Survey, cited in R Cunningham, A Kvalsvig, D Peterson, S Kuehl, S Gibb, S McKenzie, L Thornley and S Every-Palmer. 2018. Stocktake Report for the Mental Health and Addiction Inquiry. Wellington: University of Otago.

59  J Cumming. 2011. Integrated care in New Zealand. International Journal of Integrated Care 11(special 10th anniversary edition), e138. www.ncbi.nlm.nih.gov/pmc/articles/PMC3226018(external link)/.

60  AC McFarlane, SE Hodson, M Van Hooff and C Davies. 2011. Mental Health in the Australian Defence Force: 2010 ADF Mental Health and Wellbeing Study. Canberra: Department of Defence. www.defence.gov.au/Health/DMH/Docs/MHPWSReport-FullReport.pdf(external link).

61  ‘Moral injury’ refers to an injury to an individual’s moral conscience resulting from an act of perceived moral transgression that produces profound emotional shame – for example, witnessing an act in combat or peace-keeping that transgresses beliefs about what is right or wrong.

62  R Cunningham, A Kvalsvig, D Peterson, S Kuehl, S Gibb, S McKenzie, L Thornley and S Every-Palmer. 2018. Stocktake Report for the Mental Health and Addiction Inquiry. Wellington: University of Otago.

63  D Indig, C Gear and K Wilhelm. 2016. Comorbid Substance Use Disorders and Mental Health Disorders among New Zealand Prisoners. Wellington: Department of Corrections. www.corrections.govt.nz/resources/research_and_statistics/comorbid_substance_use_disorders_and_mental_health_disorders_among_new_zealand_prisoners.html(external link)

64  Office of the Ombudsman. 2018. Ombudsman Quarterly Review (Issue 24). Wellington: Office of the Ombudsman. www.ombudsman.parliament.nz/ckeditor_assets/attachments/668/OQR_-_Sep18_-_Published.pdf.(external link)

65  R Cunningham, A Kvalsvig, D Peterson, S Kuehl, S Gibb, S McKenzie, L Thornley and S Every-Palmer. 2018. Stocktake Report for the Mental Health and Addiction Inquiry. Wellington: University of Otago.

66  For the age group 15–19, the OECD reports that in 2015 the highest suicide rates among OECD countries were observed in Canada, Estonia, Latvia, Iceland and New Zealand, with New Zealand having the highest rate overall. OECD. 2017. CO4.4: Teenage suicides (15–19 years old). OECD Family Database. www.oecd.org/els/family/CO_4_4_Teenage-Suicide.pdf.(external link)

67  TC Clark, T Fleming, P Bullen, S Denny, S Crengle, B Dyson, S Fortune, M Lucassen, R Peiris-John, E Robinson, F Rossen, J Sheridan, T Teevale and J Utter. 2013. Youth’12 Overview: The health and wellbeing of New Zealand secondary school students in 2012. University of Auckland.

68  M Wilson, J Garisch, R Langlands, A O’Connell, L Russell, L, E Brown, T Kingi, K Robinson, M Brocklesby and M Judge. 2015. Adolescent non-suicidal self-injury in Aotearoa New Zealand. Psychology Aotearoa 7(2): 130-133.

69  B Keogh. 2017. Children admitted to adult mental health wards. NZ Herald, 18 November. www.nzherald.co.nz/health/news/article.cfm?c_id=204&objectid=11944708,(external link) based on 18 requests to the Ministry of Health under the Official Information Act 1982 (accessed 29 October 2018).

70  Office of Seniors. No date. Key statistics (web page). www.superseniors.msd.govt.nz/about-superseniors/media/key-statistics.html(external link) (accessed 25 October 2018).

71  S Gibb and R Cunningham. 2018. Mental Health and Addiction in Aotearoa New Zealand: Recent trends in service use, unmet need, and information gaps. Wellington: University of Otago.

72  K Hughes, MA Bellis, KA Hardcastle, D Sethi, A Butchart, C Mikton, L Jones and MP Dunne. 2017. The effect of multiple adverse childhood experiences on health: a systematic review and meta-analysis. The Lancet Public Health 2(8): e356–e366.

73  D Rankin. 2011. Upfront: Meeting the needs of children and young people in New Zealand who have been abused and neglected. Best Practice Journal (issue 37). https://bpac.org.nz/BPJ/2011/August/upfront.aspx.(external link)

74  Te Pou o Te Whakaaro Nui. 2014. The Physical Health of People with a Serious Mental Illness and/or Addiction: An evidence review. Auckland: Te Pou o Te Whakaaro Nui. www.tepou.co.nz/resources/the-physical-health-of-people-with-a-serious-mental-illness-andor-addiction-an-evidence-review/515(external link)

75  R Cunningham, A Kvalsvig, D Peterson, S Kuehl, S Gibb, S McKenzie, L Thornley and S Every-Palmer. 2018. Stocktake Report for the Mental Health and Addiction Inquiry. Wellington: University of Otago.

76  Victoria Institute of Strategic Economic Studies. 2016. The Economic Cost of Serious Mental Illness and Comorbidities in Australia and New Zealand. Melbourne: Royal Australian and New Zealand College of Psychiatrists. www.ranzcp.org/Files/Publications/RANZCP-Serious-Mental-Illness.aspx.(external link)

77  OECD. 2015. Fit Mind, Fit Job: From evidence to practice in mental health and work. Paris: Mental Health and Work, OECD Publishing.http://dx.doi.org/10.1787/97(external link) 89264228283-en.(external link)

78  Based on students’ reports of bullying across countries who took part in PISA 2015: Ministry of Education. 2017. PISA 2015: New Zealand Students’ Wellbeing Report. Wellington: Ministry of Education. www.educationcounts.govt.nz/publications/schooling/pisa-2015-new-zealand-students-wellbeing-report.(external link)

79  Ministry of Health. 2018. Appendix 1: Cross-government mental health strategy development. In Submission to the Inquiry into Mental Health and Addiction. Wellington: Ministry of Health. www.health.govt.nz/our-work/mental-health-and-addictions/mental-health/mental-health-work-ministry/submission-government-inquiry-mental-health-and-addiction(external link)

80  Nielsen Co. 2017. Health and Safety Attitudes and Behaviours in the New Zealand Workforce: A survey of workers and employers. 2016 cross-sector report. Wellington: WorkSafe New Zealand. https://worksafe.govt.nz/data-and-research/research/attitudes-and-behaviours-survey-2016/.(external link)

81  OECD. 2015. Fit Mind, Fit Job: From evidence to practice in mental health and work. Paris: Mental Health and Work, OECD Publishing. http://dx.doi.org/10.1787/9789264228283-en.(external link)

82  The Health and Disability Commissioner collects the voices of consumers and their families through Mārama (real-time feedback from consumers of mental health and addiction services and their families). Of more than 14,000 consumers and family and whānau in three years to 30 June 2017, 81% reported being happy with the communication with the people they see. Of the 247 mental health and addiction complaints to the Health and Disability Commissioner in 2016/17, 13% were about the coordination of care: HDC. 2018. New Zealand’s Mental Health and Addiction Services: The monitoring and advocacy report of the Mental Health Commissioner. Auckland: Health and Disability Commissioner, p 71. www.hdc.org.nz/resources-publications/search-resources/mental-health/mental-health-commissioners-monitoring-and-advocacy-report-2018. (external link)

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