Source document: https://docs-lawep.s3.us-east-2.amazonaws.com/1697645249704.pdf (Australia)
Royal Commission into Victoria’s Mental Health System Submission prepared by ReachOut Australia July 2019 REACHOUT KEY INSIGHTS 2018 Contacts from young people 5 most common reasons that young people visited ReachOut Young people supported through online peer support Duty of care interventions Contacts from parents 5 most common reasons that parents visited ReachOut Parents to support their teenager Parents supported through peer support Number of parent coaching sessions Schools supported through ReachOut Schools * 6 months, period July to December 2018 National 2,474,684 1.
Drugs and alcohol 2.

Bullying and cyberbullying 3.

Friendship issues 4.

Relationship issues 5.

Depression 68,881 318* majority related to suicide ideation or suicide attempt 313,523 1.

Depression 2.

Anxiety 3.

Parenting support for the drought 4.

Self-esteem issues 5.

Education and study stress 30,150 930 1,698 Victoria 650,842 1.

Drugs and alcohol 2.

Bullying and cyberbullying 3.

Friendship issues 4.

Depression 5.

Stress 17,756 N/A 72,424 1.

Depression 2.

Anxiety 3.


Education and study stress 4.

Self-esteem issues 5.

Bullying and cyberbullying 7,860 246 367 Helping all young people be happy and well.
Mental Health and Suicide PreventionSubmission 168 - Attachment 6 Royal Commission into Victoria’s Mental Health System: ReachOut Submission EXECUTIVE SUMMARY Every year, one in five Victorians experiences some form of mental illness or disorder, and almost half will directly experience a mental health condition in their lifetime.1 Timely and appropriate help-seeking, especially during adolescence, can reduce the long-term health, social and economic impact of many of these mental health problems,2 yet studies continue to show that the majority of people experiencing a mental illness don’t get the help they need.3 This problem is especially pronounced among young people, with 70 per cent of young people who experience a mental illness receiving no help.4 There is no question that continued investment in mental health treatment services is required.
However, what is also required is new investment in prevention, shifting ‘upstream’ to increase people’s capacity to manage their mental health and similar to investments in healthy eating and physical activity education to prevent obesity or sun safety to prevent skin cancer.

With a focus on prevention, what is also required is investment in the fundamentals of wellbeing such as housing, financial stability and connection to friends, family and community.
The Royal Commission has been tasked with considering issues important to Victoria’s mental health system.
This submission is focused on what can be done better to prevent mental illness and to support people to get early treatment and support, with specific reference to young people, including: responding early to signs of distress   enhancing support for parents to help young people experiencing mental health difficulties resourcing programs that build young people’s ability to cope with stress and adversity.
 RECOMMENDATIONS Shift funding priorities from treatment and crisis, to prevention and early intervention supported by digital technologies, including peer support.

Provide parents and carers with opportunities, both digital and in community settings, to develop their recognition and understanding of mental health difficulties, knowledge of appropriate mental health first aid responses and awareness of available support services so that they are better able to provide support to young people.
Invest in social and emotional learning programs that are integrated into the school curriculum and promoted across whole-of-school life.

Provide training and support to schools and teachers to implement social and emotional learning programs, and to provide up-to-date help and support to students.

ABOUT REACHOUT ReachOut is Australia’s leading online mental health organisation for young people.
ReachOut co-designs programs and products with young people, ensuring that the evidence-based digital tools, and information and support a young person accesses on ReachOut are relevant and delivered in a way that makes sense to them.

1 health.vic, 2018, The Royal Commission in Victoria’s Mental Health System, available at: https://www2.health.vic.gov.au/mental- health/priorities-and-transformation/royal-commission 2 Rickwood D., Deane F.P.
and Wilson C., 2007, When and how do young people seek professional help for mental health problems?, Medical Journal of Australia, 187:S35-S39.

3 McLennan W., (1998), Mental Health and Wellbeing: Profile of Adults, Australia 1997, Canberra, Australian Bureau of Statistics.

4 Australian Bureau of Statistics, 2008, National Survey of Mental Health and Wellbeing: Summary of results, 2007, Cat no 4326.0.
2 Mental Health and Suicide PreventionSubmission 168 - Attachment 6 Royal Commission into Victoria’s Mental Health System: ReachOut Submission ReachOut supports young people in the way they’ve told us they want it – an online one-stop-shop that doesn’t feel like a mental health service – and using the digital channels they rely on for information and interaction.
Available 24/7 and accessible from just about anywhere, Reachout provides on-demand, self- serve support that includes information, apps and tools, and Australia’s largest digital peer support community for young people exploring mental health.

In 2018, ReachOut’s service was visited by more than 650,000 young people in Victoria; and 17,756 accessed digital peer support.
ReachOut’s digital-first approach overcomes many of the traditional barriers to help-seeking: stigma, cost, waiting times, transport, a fear of breach of confidentiality and a preference for self-reliance.

ReachOut has developed a range of innovative programs and tools that extend its reach and impact, including:  ReachOut Peer Support Communities: established in 2007, it is one of the most active and best established online youth mental health forums in Australia and globally.
ReachOut Forums offers peer support by both formally trained moderators and peer moderators, and informally between members.

 ReachOut Next Step: a tool that recommends customised support options based on a young person’s symptoms and how significantly the symptoms are affecting them.

Support options include articles, apps, forums, and online, face-to-face or phone counselling.

Referral issues include mental health, alcohol, drugs, bullying and much more.
 Apps and Tools: recommends mental health and wellbeing apps, and digital resources, that have been endorsed by both professionals and young people.

This online resource includes three apps that have been developed by ReachOut: Recharge (managing sleep), WorryTime (managing worry/anxiety) and Breathe (managing stress and anxiety).
 ReachOut Parents: provides information, tools and resources to help parents and carers support 12–18 year-olds in their family environment; and includes an added option of coaching, delivered through a partnership with The Benevolent Society, to give parents concerned about their relationship with their teenager additional one-on-one online support.
 ReachOut Schools: provides free educational resources, digital tools and practical tips for educators in secondary school settings to encourage the development of positive mental health and wellbeing.
THE IMPACT OF MENTAL ILL-HEALTH Half of all mental health disorders emerge by the mid-teens, while 75 per cent have their onset prior to age 25.5 Just under one in four adolescents aged 15 to 19 years live with a probable serious mental health illness, and there has been a significant increase in the proportion of young people meeting this criteria over the past five years, rising from 18.7 per cent in 2012 to 22.8 per cent in 2016.6 Mental health disorders, such as depression and anxiety, experienced by this age cohort can cause a range of negative effects to wellbeing, functioning and development, both in the short and long term.7,8 These disorders also put young people at greater risk of suicide.
The number of deaths by suicide of young 5 Kessler R.C., Amminger G.P., Aguilar-Gaxiolas X., Alonso J., Lee S and Ustun T.B., 2007, “Age on onset of mental disorders: A review of the recent literature”, Current Opinion Psychiatry, 20(4):359-364.

6 Mission Australia, 2017, Youth mental health report: Youth survey 2012–16.
7 Scott J., Fowler D., McGorry P., Birchwood M., Killackey E., Christensen H. and Hickie I., 2013, Adolescents and young adults who are not in employment, education, or training, BMJ, 347.
8 McGorry P.D., Goldstone S.D., Parker A.G., Rickwood D.J., and Hickie I.B., 2014, Cultures for mental health care of young people: an Australian blueprint for reform, The Lancet Psychiatry, 1 (7), 559-568 3 Mental Health and Suicide PreventionSubmission 168 - Attachment 6 Royal Commission into Victoria’s Mental Health System: ReachOut Submission Australians is the highest it has been in ten years.9 Of great concern is that in 2017, suicide accounted for over one-third of deaths among 15 to 24 year-olds.10 Without appropriate support, mental health problems often increase in severity and can lead to social withdrawal, the breakdown of relationships and poor education and employment outcomes.11,12 In addition to these significant personal costs, economic analysis estimates the cost to the economy is almost $70 billion per year, which is approximately 4 per cent of GDP or about $4,000 for every taxpayer.13 Between $6.29 billion14 and $10.6 billion15 of this cost could be attributed to young people aged 12 to 25.
RESPONDING EARLY TO SIGNS OF DISTRESS The 2014 National Mental Health Commission report Contributing lives, thriving communities: Review of Mental Health Services and Programmes16 noted that Australian Government investment in mental health is currently reactive and tipped towards acute mental illness and people experiencing crisis.

This focus on people already in need, and already experiencing the social and economic impacts of mental ill-health, is inefficient.
The National Mental Health Commission argued there was a need for a change in mental health service provision in Australia to shift groups of people towards upstream services (such as population health, prevention, early intervention, recovery and participation) to reduce pressure on downstream and more costly services (such as emergency department presentations, acute admissions, avoidable readmissions and income support payments).
Further, a range of studies have found that, even under ideal conditions, only half of the burden of all mental health disorders could be averted with treatment (both psychological and pharmaceutical)17.

Australian research estimates that existing treatment averts only 13–16% of the disease burden from mental health disorders and even if all cases of depression were treated using evidence-based treatments, only 24–52 per cent of the total disease burden would be averted18.
On the basis of this research the prevention of mental disorders in the first instance is critical.

Young people and digital technologies Young people face considerable barriers to accessing support for mental health issues, whether practical such as lack of time or money, transport issues and lack of local services; or attitudinal such as embarrassment, fear of what could happen, a desire for autonomy and a preference for self reliance.
A key way to make inroads into minimising the impact of these barriers is to design services that young people want, that embody the characteristics that are important to them and that are accessible and meet their needs.

9 Beyond Blue, 2018, Stats and facts, Youth Beyond Blue.

10 Australian Bureau of Statistics, 2018, 3303.0 Causes of death, Australia, 2017.
11 Cornaglia F., Crivellaro E. and McNally S.,Mental Health and Education Disorders, 2012, London: Centre for the Economics of Education, London School of Economics.

12 Olesen S.C., Butterworth P., Leach L.S., Kelaher M. and Pirkis J., 2013, Mental health affects future employment as job loss affects mental health: Findings from a longitudinal population study, BMC Psychiatry, 13:144.

13 National Mental Health Commission, 2016, The Impact of Poor Mental Health – An Economic Issue, NHMC: Sydney.
14 Hosie A., Vogal G., Carden J., Hoddinott J. and Lim S.,A way forward: Equipping Australia’s mental health system for the next generation, 2015, EY and ReachOut Australia.

15 Access Economics, 2009, The economic impact of youth mental illness and the cost effectiveness of early intervention.

16 National Mental Health Commission, 2014, Contributing lives, thriving communities: Review of Mental Health Services and Programmes.
17 Cujipers P., Van Straten A. and Smit F., 2005, Preventing the incidence of new cases of mental disorders: A meta-analytic review, Journal of Nervous and Mental Disease, 193:2.

18 Mihalopoulos C., Vos T., Pirkis J and Carter R., 2012, The population cost-effectiveness of interventions designed to prevent childhood depression, Pediatrics, 129:1-8.

Doi: 10.1542/peds.2011-1823.


4 Mental Health and Suicide PreventionSubmission 168 - Attachment 6 Royal Commission into Victoria’s Mental Health System: ReachOut Submission In 2018, Mission Australia and ReachOut brought together qualitative and quantitative data19 on the experiences of young people living in rural and regional Australia.

While the research focused on rural and regional young people the findings have broader application, including for young people located in metropolitan areas.
The most popular types of services nominated by young people were face-to-face (53.4 per cent) followed by online (44.3 per cent).

For online services the appeal was anonymity and accessibility; that they are available 24/7 from virtually any location; and allow for self-guided help-seeking, placing the young person firmly in control of their help-seeking experience.

Digital mental health services are playing a progressively larger role in the delivery of services and in supporting young people.
In 2018 the Mission Australia Youth Survey asked young people for the first time if they had used the internet for help with important issues in their lives.

Nearly one third of young people used the internet to source information about specific issues (31 per cent).
Close to one in five young people used the internet to access an online quiz or assessment tool (19 per cent) or for personal stories or testimonies (19 per cent), while one in six had used the internet to chat one-on-one with someone who has had a similar experience (16.5 per cent) and for information about available services (16.5 per cent).20 There is a strong case for increased investment in digital technologies to improve mental health and wellbeing and reduce the broader social and economic costs associated with mental ill-health.
In the short term this investment should focus on prevention and early intervention, increasing access and adding capacity to the mental health system so that more people get help; and in the long term, developing a framework and undertaking reforms that build a new, scalable, effective and integrated 21st century mental health care model.

Peer support Peer support is an impactful component of Australia’s mental health support system.
Peer support amongst young people has been shown to help to validate their concerns, increase a sense of hope and aspiration for the future, and increase access to formal supports.21 It has also been shown to reduce hospital re- admissions when incorporated as part of a discharge and recovery plan.
There is increasing evidence that digital peer support, when supported by robust risk management, can play a valuable role in supporting young people experiencing the early stages of mental health difficulties as well as those experiencing more acute risk.22 The scale, access and cost-effectiveness of digital peer support make it a vital component in the future system of mental health support.
Recommendation: Shift funding priorities from treatment and crisis, to prevention and early intervention supported by digital technologies, including peer support.

Supporting young people in distress: ReachOut.com In 2015-16 ReachOut conducted a cohort study which tracked 1,953 consenting ReachOut users aged 16– 25 across three months.

ReachOut’s self-help information and tools, and peer support aim to assist young people with mild to moderate mental health problems.
The cohort data showed that a range of young people access the service at different points in the help-seeking journey.
The study found that ReachOut reaches young people in high distress who have no previous formal help-seeking experience, with 56.3 per cent of those with no prior visit 19 Ivancic L., Cairns K., Shuttleworth L., Welland L., Fieldes J. and Nicholas M., 2018, Lifting the Weight: Understanding young people’s mental health and service needs in regional and remote Australia, Sydney: ReachOut Australia and Mission Australia.
20 Mission Australia, 2018, Youth Survey Report 2018 21 Cairns K., Welland L., Tayeb R., Shuttleworth L., Boadle A., and Greenwood N., 2018, Evaluation of the ReachOut Youth Forums: Stage One Monitoring and Process Evaluation, ReachOut Australia: Sydney.

22 Ibid.
22 Ibid.

5 Mental Health and Suicide PreventionSubmission 168 - Attachment 6 Royal Commission into Victoria’s Mental Health System: ReachOut Submission to a mental health professional and no prior hospitalisation for a mental health issue scoring ‘severe’ on the Depression Anxiety and Stress Scale (DASS) and 18.2 per cent at ‘high risk’ of suicide based on their Suicide Ideation Questionnaire (SIQ) score.
Of the ReachOut users who participated in the study, around 50 per cent (or 1 in 2) experienced an improvement in symptoms (based on change in DASS scores) over the three month time period, and those who were classified as severe or extremely severe showed the most improvement.

Digital peer support: ReachOut Forums ReachOut has facilitated digital peer support via an online community for over 10 years.

When ReachOut Forums launched in 2007, it was the first of its kind.
Since then, ReachOut has advised mental health organisations, in Australia and in other countries, on delivering effective and safe peer communities that put young people at the centre of their support and are underpinned by robust risk management procedures.
As the peer support community has evolved, ReachOut has worked alongside academics and engineers at the University of Sydney and the University of Technology, Sydney to develop Moderator Assist, a tool that uses natural language processing and AI, to assist with risk identification and management.
A recent evaluation of the peer support community demonstrated the benefits of the program for young people including: – – – – reduced isolation (particularly for young people who have limited social connections) improved self-confidence improved emotional and mental health literacy increased confidence and skills to access professional mental health support.
Importantly, there were positive impacts for active members that joined in the discussions as well as young people who simply read the comments of others, demonstrating that peer support is effective even for those that don’t actively contribute, but get value from reading the experiences and stories of others.
ENHANCING SUPPORT FOR PARENTS TO SUPPORT YOUNG PEOPLE EXPERIENCING MENTAL HEALTH DIFFICULTIES Parents and carers are an important source of informal support for young people and in helping them to navigate mental health difficulties and facilitating timely and appropriate support.

The Mission Australia Youth Survey Report 2018 asked young people to indicate where they would go for help with important issues in their lives.
The top three sources of help for young people were friend/s, parent/s or guardian/s and relative/family friend (84.5 per cent, 76.1 per cent and 60.1 per cent respectively).23 Anecdotally, we know that parenting today is a lot more complex.

This generation of parents of teenagers is the first to have to deal with issues such as their children’s social media use, cyberbullying and when their child should get their first mobile phone.
They are also very time-poor, and are increasingly turning to the internet for information and advice.

As part of the content and design research conducted by ReachOut to develop the ReachOut Parents service24, parents identified their top concerns about their teenagers as: communicating with their teenager, peer pressure, education and study stress, anxiety, drugs, alcohol and smoking, bullying and social media and technology use.
Parents also identified the major barriers to accessing help including:  a lack of resources – financial and transport.
23 Mission Australia, 2018, Youth Survey Report 2018 24 ReachOut Australia, 2016, ReachOut Parents: Informing a new digital service for parents of teenagers in Australia, available at: https://about.au.reachout.com/wp-content/uploads/2016/05/ReachOut-Parents_Research-Summary.pdf 6 Mental Health and Suicide PreventionSubmission 168 - Attachment 6 Royal Commission into Victoria’s Mental Health System: ReachOut Submission  not knowing where to get help   stigma changing world and feeling ill equipped to deal with it, particularly in relation to technology, bullying, and school and university pressures  past experiences with services  racism and discrimination  young person not wanting to be helped, or not believing that their parents are able to help them.
Parents need to be equipped with the skills, knowledge and confidence to provide information, support and, where appropriate, referrals to professional support.

Acknowledging that parents and carers live busy lives, the provision of information and support should be flexible and integrated into settings where they spend time e.g.

online and schools.
online and schools.

Recommendation: Provide parents and carers with opportunities, both online and in community settings, to develop their recognition and understanding of mental health difficulties, knowledge of appropriate mental health first aid responses and awareness of available support services so that they are better able to provide support to young people.
Helping parents and carers support teens: ReachOut Parents ReachOut Parents is an online service for parents and carers of teenagers aged 12-18 that helps to support them with issues that affect their mental health and wellbeing.

In 2018, ReachOut Parents was visited by more than 72,000 parents in Victoria; and 7,860 parents accessed digital peer support.
The service is free and accessible 24/7 and comprises: – Information and tools: self-help resources, tips and information for parents on a range of topics.

– Parent Peer Support Communities: peer support by both formally trained moderators and peer moderators, and informally between members.
– One-on-one coaching: free one-on-one support delivered by telephone and online through a partnership with The Benevolent Society, to give parents concerned about their relationship with their teenager additional one-on-one online support.
The service is designed to increase parent’s mental health literacy and their confidence to deal with emerging mental health issues, and to support them in strengthening their relationship with their teenager so that they can better support them through everyday issues and tough times.
RESOURCING PROGRAMS THAT BUILD YOUNG PEOPLE’S ABILITY TO COPE WITH STRESS AND ADVERSITY Social and emotional learning to build student resilience and mental wellbeing In order for young people to be able to cope with stress it is critical that they are equipped with the skills and behaviours to be able to bounce back from adversity, an ability that is referred to as social and emotional learning (SEL).
Building these skills early allows young people to better respond to rapidly changing and new environments, to reduce or avoid the negative impacts of stress and, ultimately, to prevent the onset of mental health issues.
SEL develops young people’s emotional literacy, stress management and emotional regulation skills, as well as positive coping strategies, and encourages help-seeking and peer support, while also building decision- 7 Mental Health and Suicide PreventionSubmission 168 - Attachment 6 Royal Commission into Victoria’s Mental Health System: ReachOut Submission making and problem-solving skills.25 These skills all help to provide resilience to stressors and prevent emotional and behavioural issues from developing.
There is mounting international evidence supporting the benefits of SEL, however it is not holistically provided in Australian schools.

There has been increasing uptake in recent years as more programs and initiatives are made available, for example the ‘Be You’ initiative led by Beyond Blue.

Additionally, digital solutions can be incorporated into schools to support SEL.

A report by the World Economic Forum26 stated that the number of SEL products in the education technology market is insufficient.
The report identified several opportunity areas, such as digital role-play and strategy games, and leading- edge technologies such as wearable devices, apps and virtual reality, as platforms for further developing social and emotional skills for young people.
Supporting schools to improve the mental health and wellbeing of young people Schools play a central role in the lives of young people and offer an opportunity to implement a range of mental health promotion, education and intervention initiatives during the early and later stages of development.
Evidence suggests that successful approaches to teaching wellbeing are achieved when schools adopt a holistic approach, which involves coordinating strategies across the whole school community: parents, students, staff and the wider community.
School staff are often the first to identify the symptoms of mental health difficulties in students.27 Yet, many teachers feel they don’t have the time or the confidence to give students the mental health care they need.28 It is important to equip school staff with the skills and training required to confidently and effectively identify the early symptoms of mental health issues and to intervene successfully.
Recommendations: Invest in social and emotional learning programs that are integrated into the school curriculum and promoted across whole-of-school life.

Provide training and support to schools and teachers to implement social and emotional learning programs, and to provide up-to-date help and support to students.
Digital solutions that teach social and emotional learning: ReachOut Orb ReachOut Orb is an innovative and engaging ‘serious’ game designed for use in year 9 and 10 classrooms – mapped to the Australian Health and Physical Education and NSW Personal Development, Health and Physical Education Curriculums and General Capabilities – to improve students’ understanding of key factors and skills that contribute to improved mental fitness and wellbeing.
Students enter a virtual world where a negative force known as The Glitch has drained colour from the world, causing people and machines to behave oddly.

Students interact with a range of characters in an attempt to return colour and positivity to the world.
ReachOut Orb uses positive psychology principles to increase 25 R. Midford, H. Cahill, G. Geng, B. Leckning, G. Robinson and A. T. Ava, ‘Social and emotional education with Australian Year 7 and 8 middle school students: A pilot study’, Health Education Journal, 76(3), 2017, 362–72.
https://doi.org/10.1177/0017896916678024 26 World Economic Forum, New Vision for Education: Fostering Social and Emotional Learning through Technology, 2016, available at: www3.weforum.org/docs/WEF_New_Vision_for_Education.pdf 27 D. Lawrence, J. Johnson, K. Hafekost, H. Boterhoven, M. Sawyer, J. Ainley and S. R. Zubrick, The Mental Health of Children and Adolescents: Report on the Second Australian Child and Adolescent Survey of Mental Health and Wellbeing, Department of Health, Canberra, 2016.
28 Beyond Blue, ‘Beyond Blue launches new MindMatters initiative to improve mental health in Australian secondary schools’, Media Release, Beyond Blue, 2017.

8 Mental Health and Suicide PreventionSubmission 168 - Attachment 6 Royal Commission into Victoria’s Mental Health System: ReachOut Submission students’ knowledge and understanding of the evidence-based actions they can take to enhance their mental fitness and provide a buffer against mental illness.
improve their mental fitness and wellbeing The game helps students to:   understand a positivity mindset  identify and use their strengths  develop and sustain positive relationships  build resilience.

ReachOut Orb is supported by a comprehensive teacher resource, to help teachers plan lessons to reinforce the wellbeing messages.
Equipping teachers to build wellbeing and resilience: ReachOut Schools Funded through corporate and private philanthropy ReachOut Schools provides high school educators with resources and tools to educate students about mental health, wellbeing and resilience, as well as build safe and supportive learning environments.

It also links educators with support services that can help them to better support students experiencing mental health difficulties.
ReachOut’s research has shown that educators are overwhelmed by an explosion of new and existing mental health initiatives targeted at schools, ranging from meditation and mindfulness apps, peer and lived experience speakers and other wellbeing and mental health promotion programs.

ReachOut Schools provides simple, flexible resources that align with the curriculum and clearly fit within other mandated mental health and wellbeing strategies.
367 schools in Victoria are subscribed to the ReachOut Schools program.

CONCLUSION This submission has taken a particular focus on what can be done to prevent mental illness, with a focus on young people and their support networks, including parents and schools.

There is an opportunity to focus investment on building resilient young people and to take action before the first onset of the symptoms of mental ill-health.
There is no question that continued investment in mental health treatment services is required.

However, what can be done better, and that has been overlooked in implementing the recommendations of previous reviews and inquiries, is prevention and shifting investment ‘upstream’ to increase people’s capacity to manage their mental health, and to prevent mental health issues.

9 Mental Health and Suicide PreventionSubmission 168 - Attachment 6