13 Reasons Why

Here are 13 compelling reasons to care about the mental wellbeing of every patient that walks through your door

Chances are you’ve heard of the controversial Netflix series 13 Reasons Why in the news, online… or perhaps you’ve binge-watched it already, maybe even with your kids.

For those who don’t know, 13 Reasons Why is a television series that follows the story of 17-year-old Hannah Baker.

Hannah’s parents own a local pharmacy in the show 13 Reasons Why.

After bearing the brunt of bullying and sexual abuse from her schoolmates, Hannah experiences a downward spiral of mental health, ending in her decision to end her own life.

Narrated through a series of tapes that Hannah recorded before her death, the show explores the lead up to her death as well as the aftermath for her parents – who own a local pharmacy – and the community.

Some have argued in favour of the show’s unabashed look into the complex social world of teenagers, while others have been more critical—labelling the show “dangerous” and a potential driver of suicide contagion.

Whatever your view on the topic, the show has certainly brought the issue of mental illness and suicide into the public forum.

There is a dire need to break down the stigma associated with mental illness, as well as providing those struggling the opportunity to be heard and helped.

Pharmacists as accessible healthcare professionals are particularly well-positioned to reach out to those in need.

In a positive spin on this sad tale, we look at 13 reasons why you should care about the mental health care of every person who walks through the door of your pharmacy or place of practice.

1. It’s a huge issue

Mental illness has most likely affected you or someone close to you – a friend, family member or colleague.

It is estimated almost half of Australians will experience a common mental disorder in their lifetime.

In just one year (2014-15), there were four million Australians (17.5%) who reported having a mental or behavioural condition.

Women experience higher prevalence of mental disorders than men.

2. Some are especially prevalent

Anxiety disorders are the most commonly reported mental health disorder, at 2.6 million Australians or 11.2% of the population.

Mood (affective) disorder including depression are the second most common (9.3%), followed by substance-use disorders.

Around one in 20 Australians (5.1%) report having both an anxiety-related and a mood (affective) disorder.

“We see a large variety of mental health presentations, but the most common would be anxiety and depression,” says Elise Apolloni, Managing Partner of Capital Chemist Wanniassa in the ACT.

Locum pharmacist Luke Vrankovich has seen a similar trend.

“In the pharmacy I am faced everyday with young people who have either one, or a mixture of, anxiety and depression. Anxiety, seems more prevalent in the young population, perhaps due to heightened social and educational pressures and self-expectation,” he says.

“However, suicidal ideations are more common than one would think.”

3. Doorway to other health issues

Depression is often comorbid with other chronic diseases and can worsen their associated health outcomes. Conversely, chronic disease exacerbates symptoms of depression.

A 2015 review found people with schizophrenia are 2.5 times more likely to have diabetes compared with the general population. Similarly, high rates of and risk for metabolic syndrome have been documented in bipolar disorder, depression and other mental disorders such as post-traumatic stress disorder.

There is also a well-established relationship between depression and cardiovascular disease: major depression is associated with an increased risk of coronary artery disease, myocardial infarction, congestive heart failure, and isolated systolic hypertension.

Mental illnesses can also lead to substance abuse. Individuals with overt, mild, or even subclinical mental disorders may abuse drugs as a form of self-medication.

4. Autonomy impacted

People with mental health disorders are more likely to be unemployed than those who do not have them.

Research shows that people aged 15-64 years with a mental or behavioural condition are more than twice as likely to be unemployed than people without a mental or behavioural condition.

Unemployment affects a person’s ability to meet bills, save for retirement, or care for dependent family members. It affects a person’s self-esteem and increases stress levels, leading them into a cycle of poor mental health and unemployment.

5. Suicide is a real risk and it is devastating

Just as Hannah’s parents in 13 Reasons Why are heartbroken and stunned by their daughter’s unexpected passing, so suicide in real life is an experience that changes people forever.

“Not a day goes by that I don’t miss him and ask ‘Why?’” says one Aussie woman who lost her husband to suicide.

“Sometimes I miss him so much it’s hard to bear,” says another, who lost her young adult son to suicide.

“With suicide being the leading cause of death in people aged 15-44, there is no doubt this is the most difficult issue surrounding mental health in Australia,” says Vrankovich.

“This is for many reasons including stigma, patient withdrawal, lack of recognition of warning signs, and lack of relationship with an appropriate healthcare professional.”

6. Kids and teens are vulnerable

Depressive disorders tend to first appear in adolescence or early adulthood. Overall, about 25% of people who develop a depressive disorder will do so before the age of 20 years.

Almost one in seven young people (aged 4-17) have experienced a mental health disorder in the previous 12 months.

Children who experience bullying—either traditional bullying or cyberbullying—have more suicidal thoughts and are more likely to attempt suicide than those who have not experienced such forms of peer aggression.

Bullying can be devastating to kids and teenagers who are still learning how to navigate the world around them.

7. Rural residents, LGBTQI+ community and veterans are at risk

Australians living in rural and remote areas are vulnerable to mental health difficulties, with suicide rates in these regions rising over the past three decides—especially among men.

Common issues faced by people living in the country include:

  • Social isolation
  • Financial hardship
  • Stress caused by natural disasters
  • Easier access to means of suicide
  • Being less likely to want to seek help
  • Problems with alcohol and drug abuse
  • Reduced access to support and healthcare services

Veterans are also at higher risk of suicide and self-harm than the general population. The act of leaving the defence force itself can for some be a significant risk factor for suicide and self-harm, with the attendant loss of identity, purpose and social connections. They may also have difficulty adjusting to civilian life; higher risk of exposure to trauma (i.e. physical injury and emotional distress); difficulty dealing with defence life; and survivor guilt.

Within the LGBTQI+ community, 55% of young women, and 40% of young men are likely to experience psychological distress, compared with 18% and 7% in the general population respectively.

The LGBTQI+ community are almost twice (31%) as likely to experience anxiety disorders, and more than three times (19%) as likely to experience affective disorders.

8. Services are stretched

While the government is working towards implement stronger mental health care across the country—with a Fifth National Mental Health Plan currently in the pipeline—the system is struggling with the sheer number of people needing help.

Red tape, a lack of hospital beds and overloaded staff mean people fall through the cracks.

People such as Bec* and her husband, who recently attempted suicide.

9. Lack of access

Through Medicare’s Better Access initiative, people who receive a referral are eligible for rebates for psychological services.

Unfortunately these rebates usually do not cover the entire cost of the appointment, which can require hundreds of dollars up front to attend.

In addition, a patient is restricted to 10 services per calendar year – less than one consultation a month (barring exceptional circumstances).

10. Society struggles with stigma

Many don’t feel they can share what they are feeling or going through with those closest to them.

Dr Rona Hu, Director of the Acute Psychiatric Inpatient Unit at Stanford Hospital and a psychiatric consultant for 13 Reasons Why, says Hannah’s difficulty in sharing her struggles reflects the experiences of young people she has seen in her clinical work.

“There’s so much stigma and shame in talking about mental health issues. There was a real desire to raise awareness, let suffering teens know they’re not alone, and help start honest conversations.”

One of the priority areas for the Federal Government’s upcoming National Mental Health Plan is to reduce stigma and discrimination against people living with mental health issues.

11. Training is available

Pharmacists can pursue further education in mental health to better support patients.

For example, Apolloni is currently studying a graduate diploma in Mental Health Counselling. And how does she prepare her staff?

“Training, training, training, practice, practice, practice,” says Apolloni.

“Our team members are mental health first aid officers, and we pride ourselves on practising conversations with our team members to build their confidence and ability when helping people with their mental health.”

NAPSA National President Shefali Parekh argues that mental health first aid should be compulsory for pharmacists.

“NAPSA believes that mental health first aid education should be a requirement of the Pharmacy Board, for registration of a pharmacist—much like physical first aid is,” says Parekh.

“The importance of mental health first aid is substantial and only growing exponentially. The integration of this kind of education in university curriculums to prepare pharmacy students with the knowledge and skills to provide an appropriate level of assistance is a necessity.”

Mental health first aid workshops are offered throughout the year as CPD activities by the PSA and the Pharmacy Guild—see psa.org.au and guild.org.au for further details.

12. A need for compassion and a listening ear

The importance of listening skills and empathy is of utmost importance in mental health care, says Vrankovich.

“Pharmacists have, through our training, been ingrained with the amazing ability to show empathy and listen non-judgmentally. These qualities are of utmost importance when helping a patient with a mental health concern,” he says.

“You must be willing to listen attentively and empathise with their situation. If you can do this, then it will open the door to have ‘real’ and meaningful conversations—although this might not happen straight away.”

Unfortunately, empathy and a listening ear can sometimes be in short supply, particularly in the busy healthcare environment with myriad patients waiting to be seen.

13. You can make a difference

Pharmacists are well-placed to use their skills and experience in a safe and appropriate way to help people experiencing mental illness.

While diagnosing is not part of a pharmacists’ scope of practice, they “have the opportunity to recognise potential psychological distress and there is a good opportunity for the pharmacist to have a conversation and discuss what they have noticed”, says the PSA in its Mental Health Care Project framework.

“Pharmacists who notice early signs that a person may be at risk of developing or exacerbating a mental illness can refer or encourage people to seek further assessment from their GP or other available mental health services,” it says.

Apolloni and her team are an example of pharmacists actively making a difference in the mental health space.

She tells the story of a patient who exhibited signs of paranoia while waiting in line at the pharmacy.

“When we sat down to have a chat, it was clear the person was experiencing extreme anxiety. After some time, we came to realise the person had not been taking their medicines recently and were experiencing psychosis. They were talking about taking their life…

“We were able to support that person to seek crisis help from the mental health unit in the hospital, and continue now, several years down the track to support that person to get the most from their medicines,” says Apolloni.

“The patient often comments that they enjoy being able to ‘check-in’ with our pharmacists to share how they are travelling in terms of their mental health.”

Locum pharmacist Liam Murphy, who works at Perisher Ski Resort in Australian Snowy Mountains, also relates the story of a male patient in his 20s who recently presented with a foot injury.

“Rather than simply counselling him on the use of Panadeine Forte, which was prescribed for the pain, we discussed the impact the injury could have on his ability to work and enjoy the winter and strategies for coping with this,” says Murphy.

“I recommended some simple lifestyle measures such as colouring in, simple breathing techniques and meditation as some first-line, easy to access non-pharmacological measures for dealing with stress.

“Considering he was a young male living in a lively ski resort, we also discussed how he should be mindful of his alcohol consumption, not only because it could slow healing and increase the risk of worsening the injury, but also because it is an ineffective and unsafe crutch to rely on for coping with the injury.

“Though the injury was slower to heal than first anticipated, the patient acknowledged that the holistic counselling approach helped with his frame of mind throughout the recovery process.”

*names have been changed

This article was first published in the June 2017 issue of the Australian Journal of Pharmacy.

References/Further reading:

Australian Bureau of Statistics (ABS) 2015. National Health Survey: First Results, 2014-15. Canberra: ABS.

Australian Institute of Health and Welfare (AIHW) 2016. Mental health services—in brief 2016. Canberra: AIHW.

Chapman, P, Perry, G & Strine, T 2005. ‘The Vital Link Between Chronic Disease and Depressive Disorders’. Preventing Chronic Disease. Vol 2, no. 1.

Federal Department of Health 2016. Fifth National Mental Health Plan: Draft for consultation. Canberra: Dept of Health.

Federal Department of Health 2007. Suicide in rural and remote communities: Fact sheet 18. Canberra: Dept of Health.

Headspace. Understanding depression – for health professionals (Online). Accessed 1 May 2017.

Hinduja, S & Patchin, J 2010. ‘Bullying, Cyberbullying, and Suicide’. Archives of Suicide Research. Vol 14, no. 3, pp. 2016-221.

Mental Health Commission of NSW (2016). Physical health and mental wellbeing: evidence guide. Sydney: Mental Health Commission of NSW

MindHealthConnect 2015, Rural or remote health (Online). Accessed 1 May 2017.

National Institute on Drug Abuse 2010.’Why do drug use disorders often co-occur with other mental illnesses?’.  Comorbidity: Addiction and Other Mental Illnesses (Online). Accessed 1 May 2017.

National Mental Health Commission 2017. Review into the Suicide and Self-Harm Prevention Services Available to current and former serving ADF members and their families – Final report: Findings and Recommendations. Sydney: National Mental Health Commission.

Nemeroff, C & Goldschmidt-Clermont, P 2012. ‘Heartache and heartbreak-the link between depression and cardiovascular disease’. Nature Reviews Cardiology, no. 9, pp. 526-539.

Pharmaceutical Society of Australia (PSA) 2013. Mental Health Care Project: A framework for pharmacists as partners in mental health care. Canberra: PSA.

Support After Suicide. Other People’s Stories (Online). Access 1 May 2017.

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  1. HaroldAMaio

    —There is a dire need to break down the stigma associated with mental
    There is a dire need to stop those associating a stigma with mental illnesses.

  2. (Mary) Kay Dunkley

    An excellent article Shestyn on a very important topic. As Harold says below there is a dire need to break down the stigma. Pharmacists (and interns and pharmacy students too) also experience this stigma and we need to be looking out for our colleagues. Often pharmacists can put on a “brave face” at work and seem to be coping while really struggling underneath. The Pharmacists’ Support Service is available to support pharmacists, pharmacy interns and pharmacy students. Although we are not a treating service we can offer a listening ear to our colleagues over the phone and help each person to work out what to do next. The services is provided by pharmacists for pharmacists and all the volunteers are trained in providing crisis support. You can call 1300244910 every day of the year between 8.00am and 11.00pm EST.

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