Lynne Malcolm: Hello, welcome to All in the Mind on RN, I'm Lynne Malcolm. Today, the elephant in the room; men and their mental health.

Max Birchwood: The language of emotion and of communicating emotion…it's a bit of a social cliché but it's true, that men do not feel comfortable in rehearsing and discussing, particularly my generation and I think probably younger ones it is changing a little bit I think, I think that ability to feel articulate and comfortable with the language of emotion and well-being is a problem because people don't develop the concepts very well in their minds, they don't communicate it, it's not part of everyday discourse, and in particular as mental health difficulties begin to rise in adolescence, there's one thing we know for absolutely sure, young people, particularly young males, do not seek help. And that is one of the biggest barriers to these important gender differences that are becoming more and more evident now.

Lynne Malcolm: Max Birchwood, Professor of Youth Mental Health at the University of Warwick in the United Kingdom.

Mental health problems affect more than 1.3 million men in Australia every year. Suicide rates, particularly in rural and remote regions are high, and related drug and alcohol problems cause damage and pain to individuals and their loved ones.

Professor Richie Poulton:

Richie Poulton: Men are meant to be reasonably stoical and grow a couple of inches when adversity strikes, and of course that's not the truth. Men suffer from mental health problems and illness at very similar rates to women. For example, depression is very high and significant, and suicidality associated with depression is a real problem. Men also are overrepresented in the group of people who act out under stress. And so they are naughty and they hit the turps too much and they take drugs to the point where it's harmful for them. So mental health among men is a real issue. It's a bit of a stigma to own up to the fact that you're suffering and you feel lousy or you feel anxious. As a man you are meant to be able to tough it out. That's a nonsense of course. And so men are needlessly suffering, in silence often.

Lynne Malcolm: More from Richie Poulton later.

One young man who's very familiar with this feeling of being alone with his suffering is Sebastien Robertson. He'd had a stable and happy upbringing and became a highly motivated and entrepreneurial young man. While studying commerce and economics at university, he became president of his residential college, fulfilling his leadership aspirations. But then, privately, things started to go awry.

You talk about being divided, there were two faces of Sebastien. Just tell me about what that was and how that developed.

Sebastian Robertson: Yes, so I developed two Sebs. One was around other people and family and friends, and that was the person that I loved, I loved being that person, it was bubbly, it was social, sporty, and I really enjoyed the interactions with other people. But when I was by myself, mainly in my college room, which is quite a small little room, it was extremely challenging, it was isolation, it was fear, constantly berating myself mentally around what was happening and that I should be better, challenges that I guess just spiralled and built on each other, and the more it built up and the more I didn't deal with it, the worse it became.

And of course when you are dealing with this, the two personalities separate further and further apart, and the further apart they are the more you blame yourself that they are further apart and so the less likely you are to reach out for support because…well, for me I flagged it that I should be able to deal with these issues, that if I could help other people with their issues and be a 'leader', that I really should be able to manage my own challenges. And I think that that expectation, that stigma around that issue, around mental health issues…and for me it was going through severe depression…was it stopped me from seeking help.

Lynne Malcolm: You really reached a trigger point. Just tell me about what happened there.

Sebastian Robertson: Yes, I had a…I call it my trigger night I guess. It was the first night that anyone in the public sphere would have known that I was facing some challenges. There was a social event on campus, it was a big event about 1,000-odd students were there, and there was an incident that occurred and I was called back to the scene, and by then the police and ambulance had been called on by protocol from ANU Security. I got called back just to help out with my friend, and I was there, and then we got her up into the ambulance and she was taken to hospital, and she was okay in the long term.

But as soon as those ambulance doors shut I emotionally lost it, just completely lost control, I became very aggressive and violent, I guess under the influence of a bit of alcohol, started to express my emotions in ways that I probably hadn't done publicly. And so that ended with me approaching a group of police officers and making some certain demands about how things should be treated differently, and that ended not in the best ways, I ended up being tackled to the ground and handcuffed and put in the back of a police paddy wagon and driven to the holding cell where I spent the night there.

And the challenge there I guess…it was my first light-bulb moment of where I wanted to be at the hospital to help my friend but I couldn't be there because I hadn't helped myself and addressed my own issues. And so that was kind of the first time that I went I need to go do something about this so that I can do the thing that I love to do which is help other people.

Lynne Malcolm: And in that period leading up to this trigger point, you'd also had episodes of self-harm and…

Sebastian Robertson: This is kind of the best way to describe it, when I got back to my room I was approached by a gentleman who I didn't expect to turn up on my door but he literally turned up five minutes afterwards and he knocked on my door and he asked me, 'Are you okay?' And the first thing I said was, 'I'm fine.' And then he said, 'You're not, you've got to start talking.' And that was the point that I realised that I had an opportunity to actually just talk. And I kind of embraced it and just started speaking, and one of the things that he asked me was, 'How bad is this? Have you ever been suicidal?' And that was the first time that I'd openly admitted to somebody that I had tried to take my life on three occasions during the year. And even after those episodes and experiences, even in my mind I still punished myself for not seeking help, for not doing it and addressing it, and even then going, like, I'm not that bad, there are people worse off than me, the services aren't designed for somebody like me, they are for people more in need. And I think that that mentality really put a huge barrier in me ever going and seeking help.

But that first conversation with this guy turned my mindset around and he said, 'You've got to see someone, you've got to go,' and that's when I started to go yes, I'll actually go and address it. So I went to the counselling service at ANU, which was located above the Sport and Rec Centre which would be fine except that I had a constant fear that I was going to be judged by my peers about using that service. So every time I walked there I thought I was going to be judged, and when I was in there with the counsellor there was no way they could have helped because the entire time I sat there I was trying to judge them whether or not I wanted to share my story, and secondly I thought 'who's going to see me coming out of this service?' And so they never really were in a position to provide the support I needed because I don't think the community environment created a safe place for me to seek help.

That was a real turning point for me again around the challenges in the mental health space more broadly for Australia and for young people. So I stopped seeking help. And then the guy followed up with me and I started…he said, 'You've got to go back, you've got to start seeing someone again.' And I saw someone off-campus that no one else knew about, and that put me through cognitive behavioural therapy, and that gave me the ground work of assessing my thought patterns and what I could do to change my behaviours and the way I addressed certain issues and challenges that arose. That was hugely beneficial for me.

I got to the end of the year and everyone was, like, 'You've done such a great job of being president of the college,' and for me the greatest achievement was the fact that I was alive and that I could stand there. But nobody knew that, and I didn't really want to tell anyone because that's not really what you want to be judged on.

Lynne Malcolm: Sebastian Robertson. And we'll hear later how he's drawn on his own experience to address this stigma to help other young men with their mental health challenges.

Man: I was totally paranoid. I mean, I thought the government was spying on me, stuff like that. I thought I was being followed by the police, I thought my phone was being tapped. That's the thing about delusions, they seem so totally real.

Lynne Malcolm: A young man's experience of psychosis which appears on the Headspace Australia website.

You're with All in the Mind on RN, Radio Australia and on your ABC radio app. I'm Lynne Malcolm, and we are considering the mental health issues particularly relevant to men.

Max Birchwood: I think the first thing to understand is that different disorders have different vulnerabilities by gender, and most notably for severe mental health problems we are talking about psychosis is probably the greatest vulnerability that males have.

Lynne Malcolm: Max Birchwood is Professor of Youth Mental Health in the United Kingdom.

Max Birchwood: So if you look at the spectrum of psychoses, about three-quarters are male, and these would be onsets that are occurring in late adolescence, early adulthood. But these onsets stretch down back into early adolescence. What is also now known at the first severe mental health problems there is a variety of related disorders that are kind of linked phenomenologically and in some cases genetically to psychosis; so bipolar disorder and the psychoses, the latest thinking suggests they lie in a bit of a continuum. So that males have a particular vulnerability to these severe mental health problems.

Lynne Malcolm: Max Birchwood from the University of Warwick in the UK has researched psychosis extensively and says that 70% of the cases he sees are young males. They are younger when their first symptoms appear and they have poorer outcomes than females with the disorder. And now they're realising that social factors play a major role.

Max Birchwood: One of the greatest changes and innovations in our thinking in the psychoses over the last 10 years has been this understanding that there are major social risk factors for psychosis. We've known about the genetic ones for a long time. There is some tendency for it to run in families, but not as strong as some people think. And it's kind of akin to the way in which in the '50s and '40s we thought that lung cancer, which was very common then, was entirely a genetic disorder. And then we found that this major social risk factor, smoking, was staring us right in the face, and suddenly our understanding of the onset of cancer and so on, the risk factors of cancer, were completely transformed.

I think a similar revolution in thinking is occurring in psychosis, because we know now…some very powerful studies have been done in the UK…that there are major social risk factors in operation in the development of psychosis. For example, in Birmingham where I work in the UK, two-thirds of the psychoses are concentrated in an area of population that's roughly a quarter of the population of Birmingham. So in other words, these are major social risk factors to do with social marginalisation, deprivation and social defeats, as it's often called.

Lynne Malcolm: These are young men who don't have work, they are not being educated, they've got nothing much to do?

Max Birchwood: Exactly. So these are, if you like, generic social risk factors, socially adverse experiences that particularly young males, and in the UK and in Birmingham particularly young black males are particularly at risk of. So if you look at the young black males, for example, in Birmingham who get psychosis, you'll find that they do tend to be what we call NEETs, not in education, employment or training, by the age of 25, and that sets them up for some longer-term disadvantages over their lifetime. These social risk factors are now known to operate in psychosis. And there are other…at a more micro level, for example, family fragmentation, even neighbourhood fragmentation where people are not feeling part of a cohesive community, those sorts of micro factors, we now know that those are in operation in the genesis of psychosis, they are kind of the early changes that can increase the risk of developing psychosis.

Lynne Malcolm: Max Birchwood, who has pioneered the strategy of intervening at the earliest signs of psychosis, to ensure the best possible future for these young people.

Max Birchwood: The most important thing is to give these kids important social opportunities. For example, there is this approach called Individual Placement and Support, this is actually an intervention that's been shown to be very effective. And what it does is to engage these young people in developing the confidence and the ability to work. It might be a training opportunity, placement, it could be paid work, and support them while they are doing that. That's the best way of building confidence, is to get people into the workforce at some level, and the important thing is that services need to be either to help people through the inevitable hoops and problems that they are going to face over time.

So in many ways I guess this sounds common sense, and I make no apology for that because it is. And in many respects in the psychoses and schizophrenia we haven't applied the thinking that you would apply to the situation that young males might find themselves in. This approach has been shown to be very effective indeed, it's been a very good study that has been done on individual placement and support over in Melbourne by Eóin Killackey and Pat McGorry and so on. And in the UK it's our leading recommended intervention for social recovery in psychosis.

Lynne Malcolm: I guess the key is to help these people at the very early stage, and it's not always easy to identify, is it, that people are vulnerable, in those early stages.

Max Birchwood: I think that's right. If you were able to go back in time, someone who develops a psychosis at 21, or it's formally declared, and you go back to what they were like at 14, you'd see someone who is not doing so well at school, finding it difficult to make friends, really on a pathway to social disengagement. The important thing here is that…and this again I think is one of the new findings from this new epidemiology of psychosis that has emerged over the past few years, you could look at that social withdrawal, that social disability as simply the early signs of a psychosis developing.

The other way of looking at it, however, is that these very powerful social experiences that these young people have at 14, rather than being early signs of disorder they are actually risk factors for the later development of disorder. So the exciting idea that's now coming into the fore is a true public mental health and understanding that these wider social forces, as well as being potentially disadvantage in in themselves, are actually social major risk factors for in this case psychoses, but we've known this for years, they are also risk factors for other adverse mental health outcomes. And the other thing that we now know is very clear, all the mental health problems we see in adulthood, they don't start in adulthood, they all start in adolescence.

So these are some of the exciting…would 'revolutionary' be too extreme a word? No, I don't think it would be. If I had said this 30 years ago to colleagues they would have thought this is probably a bit fanciful, but now everyone accepts it. This is why the concept of early intervention in mental health has attracted so much credibility now because of the impact of the exposure to these social risk factors and to the developing brain. This is where the future understanding of mental health problems in males in my area certainly lies.

Lynne Malcolm: Max Birchwood. He's worked with Australia's Professor of Youth Mental Health Patrick McGorry and colleagues on the Headspace Youth Early Psychosis Program, which is being rolled out across the country throughout this year.

You're listening to All in the Mind on RN, Radio Australia, and on your ABC radio app, with a spotlight today on men and their mental health.

Professor Richie Poulton is director of a New Zealand based unit which runs one of the most detailed studies on human development ever undertaken. The Dunedin longitudinal study has tracked and measured the health of 1,000 people from early childhood into their adult lives. It shows that mental illness is far more common than you might expect, and that symptoms commonly emerge very early in life. And when it comes to men, they've made some interesting preliminary observations about the relationship between their mental health and ageing.

Richie Poulton: We have identified that having a mental health problem, in particular the types of problems associated with feeling low and depressed and sad or anxious, actually accelerates the ageing process in men, not women it seems, at least up to the age of 38, and that's the period in which we've studied our people to date. So men are more likely to react to those types of disorders or problems in a way that basically biologically drives their clock towards the end point faster than those men that don't experience those problems. And this is very interesting. I mean, it's novel, this sort of research is cutting-edge and has to be replicated by others to know if this is real, but it certainly points to a potentially important risk factor for accelerated ageing and ageing poorly in the mental health area. So not only should you intervene to stop mental health problems because they in themselves are very damaging and debilitating to the individual and to the family, but also because they are associated with rapid ageing and people will end up dying earlier as a result.

Lynne Malcolm: So your observation of this association came about by looking at the telomeres. Can you explain what they are and what you found in relation to the telomeres in men?

Richie Poulton: Telomeres are the caps on chromosomes, the protective cap at the end of a chromosome, that every time your cells divide, and we are constantly as human beings or any mammal having cells divide and replicate themselves, every time they divide they get slightly shorter, and there's a point at which they get so short that they essentially senesce, which is they die. And so we measured that biological clock as reflected in terms of telomere length.

So we assayed people's blood, we took their blood and we measured in their genes the length of their telomeres, these caps on the end of chromosomes, and we found that people who had shorter telomeres were far more likely to have problems to do with stress, to do with anxiety and also depression, for men but not for women. I guess you might say that men are more physiologically vulnerable to the effects of these types of problems and they age more rapidly.

Lynne Malcolm: Do you know anything about what comes first though, what causes what?

Richie Poulton: We don't yet, and that's a good question. So all we've done is establish that there seems to be a pretty robust association. So not only do we show that association, we controlled for alternative explanations that might explain away why those things are correlated. What we found was that this looks pretty solid, there is an association. But we don't know exactly which way it runs; is it the mental health problems that are driving faster ageing, or it could be a reverse situation where telomeres as they shorten lead to certain vulnerabilities that are manifested, among other things, as mental health problems.

If of course you find that these problems are driving accelerated ageing, then it allows you to justify investing a lot more money and resource and effort in trying to mitigate or ameliorate these mental health problems, because not only do they lead to unpleasant psychosocial outcomes but they also accelerate ageing, which is a problem right now because we've got so many people who are growing old and we don't want them to end up having extra disability and handicap their older age.

Lynne Malcolm: Can you speculate about why there would be a difference between men and women and what the mechanism might be?

Richie Poulton: It's probably something to do with inflammatory processes. There is some evidence that men, in the context of high levels of stress, have a more dysfunctional immune response. It may be, on the other hand, that women are protected to some degree by oestrogen. So oestrogen may be protective, or it may be that men's immune systems are more susceptible or sensitive to these types of stresses.

Lynne Malcolm: Richie Poulton, director of the Dunedin Multidisciplinary Health and Research Unit in New Zealand.

After finally getting help with his own mental health problems, Sebastien Robertson, who we heard from earlier, felt he had something to offer other young people facing difficulties. He started a social enterprise called Batyr.

Sebastian Robertson: Yes, so the name Batyr was from an elephant in Kazakhstan that used to say 20 human phrases in Russian. So the idea of the organisation is to give a voice to the elephant in the room.

Lynne Malcolm: It's playing on that thing of people not asking for help, it's a secret.

Sebastian Robertson: Exactly. I guess when you look at the statistics around mental illness and mental ill health within the community, and in particular for us we look a lot at young people. This is a huge issue and we're not doing enough about it, and help-seeking rates of young people sit in between 20% and 30%. I think that we have to do a lot to address getting people to a service.

So there are few challenges within the space, but I think one of the hardest ones that we haven't yet worked out a way to really combat is this idea of how do we break down that stigma and actively look at people changing their behaviours rather than just their increasing awareness. And central to that is the idea of sharing lived experiences from peers. So that's what Batyr essentially does, we train young people with a lived experience of any form of mental ill health, about how to share their story and focus on messages of hope, of how they got through, their recovery methods, and really focusing on trying to break down that barrier and that stigma that young people face in those core environments in school and also university settings.

We have this one young guy who had this social anxiety, and it was triggered by public speaking. So we are here going, all right, we are going to train you how to tell your story of a fear of public speaking which triggers your social anxiety. And I was there going, oh God, this might not end too well. And he was so determined to use his experience to help someone else. So he came through our Being Heard program, which is where we trained him how to share his story with another group of young people. And we got him to a point and then we did some one-on-one coaching with him, and he ended up going and speaking at the Sydney Town Hall during Youth Week in front of 200 young people and shared his story, all year 10 students.

And he said straight out, upfront, 'The last time I public spoke it brought on a panic attack, and I'm just embracing that this might not end too well,' and I think by him acknowledging that space it drew everyone in but it also gave him the confidence to be like, it's okay if something doesn't happen too much, and we supported him through it. And the response that he got from those young people, it's like a pin drops, everyone listens in. It's a young man standing up there, he would have been about 21, talking about experience from when he was 15, 16 in school, and he is sharing his vulnerability about that challenge of who he was at that time and how much pain it caused him, but then also spoke about how he got into a place where he could stand up in front of 200 young people in Youth Week and share his story.

And he just got bombarded…it was like he became a mini celebrity afterwards, he just got bombarded by students talking about the connection that they had with his story and how they recognise challenges both within themselves and with others and about what they can go and do about it. I think that's incredibly powerful for the young man sharing his story but also for those in the audience listening and hearing those stories.

Lynne Malcolm: So how is Sebastian Robertson himself doing now?

Sebastian Robertson: The truth is I'm great. You know, I have bad days like everyone does. I love the challenge of Batyr, and being able to set up an organisation that focuses in this area has made me a lot more aware of my own journey and has forced me to acknowledge what do I actually do for myself. So I love to exercise and I play a lot of sport in different sports, and that has been really important, but I also value family time a lot more than I did previously. I think the other thing for me is you have to be able to stop and allow yourself time to sit back and acknowledge where you've been and where you've come from.

I can give you a specific example. On the weekend I didn't take my computer home. I can't remember the last time I did that. It was just me going I don't need to do it, I don't need to be looking at my computer 24/7, I don't have to respond to my emails every day, it's not that urgent and it's okay for me to have an actual weekend. And I think that those little things just make me in a lot better place to be able to keep doing the work I'm doing as well, which I love.

Lynne Malcolm: Sebastian Robertson, founder of Batyr, giving voice to the elephant in the room.

If today's program has raised difficulties for you, call for support on Lifeline on 13 11 14. And you'll find more useful links on the All in the Mind website. Go to abc.net.au/rn and choose All in the Mind from the program list. We always love to hear your thoughts so leave a comment on the site while you're there, and you can sign up for our podcast if you haven't already done that.

Thanks to producer Diane Dean and sound engineer Andrei Shabunov. I'm Lynne Malcolm, great to have your company. Join me again next week.