1. Department of Psychology University of Otago Dunedin, New Zealand Professor Richie Poulton, FRSNZ Director, Dunedin Multidisciplinary Health and Development Research Unit; Co-Director, National Centre for Lifecourse Research Men and mental health: What has longitudinal research taught us?

2. Retention in the Dunedin Study Age Year Number Percent* Birth1972-73 31975-761037100% 51977-78 991 96% 71979-80 954 92% 91981-82 955 92% 111983-84 925 90% 131985-86 850 82% 151987-88 976 95% 181990-91 993 97% 211993-94 992 97% 261998-99 980 96% 322004-05 972 96% 382010-12 961 95% * Percentage seen of those who were eligible (i.e. alive) at each age

3. Location of Study Members seen at age 38

4. Current research activities include studies of: SES inequalities - selection v causation SES inequalities - selection v causation Pathways to employment Pathways to employment Personality continuities across the life-course Personality continuities across the life-course Antisocial behaviour and criminality Antisocial behaviour and criminality Long-term consequences of childhood adversity Long-term consequences of childhood adversity Maori health/cultural identity Maori health/cultural identity Cognition and neuropsychology Cognition and neuropsychology Family health history study Family health history study Mental health (including substance abuse) Intimate relationships and domestic violence Oral health Sexual & reproductive health Cardiovascular risk factors Retinal imaging and endothelial function Respiratory health Next generation studies (age 3 and age 15 years)

5. Current research activities (contd) Blood based studies Blood based studies – Chlamydia trachomatis – Herpes immunity – Cardiovascular disease risk factors – Inflammatory biomarkers Genetic studies –Mental health phenotypes –Asthma/allergy –Cardiovascular risk factors –Periodontal disease Methodological studies Methodological studies – Comparison of Dunedin sample with national data – Attrition analyses

6. Conventional wisdom Kim-Cohen, Caspi, Moffitt, Harrington, Milne and Poulton. Prior juvenile diagnoses in adults with mental disorder: Developmental follow-back of a prospective-longitudinal cohort. Archives of General Psychiatry, 2003, 60: 709-719.

8. Antisocial behaviour We have identified: early-onset individuals whose behaviour persists throughout their lives (i.e. lifecourse persistent); early-onset individuals whose behaviour persists throughout their lives (i.e. lifecourse persistent); as well as another larger group comprising about one-fifth of the population, who begin to engage in antisocial behaviour in adolescence. as well as another larger group comprising about one-fifth of the population, who begin to engage in antisocial behaviour in adolescence. The Dunedin study has arguably one of the most detailed research programmes on antisocial behaviour in the world.

9. The implications for intervention Early onset life-course persistent group: you need to intervene with both child and their family as early as possible Early onset life-course persistent group: you need to intervene with both child and their family as early as possible Adolescent-onset group: the worst thing you can do is use a group intervention approach, given that their behaviour is partly driven by peer influence – individual interventions are required Adolescent-onset group: the worst thing you can do is use a group intervention approach, given that their behaviour is partly driven by peer influence – individual interventions are required NB: Prison is a group intervention which tends to expand rather than diminish the antisocial repertoire.

10. Bad behaviour = bad health Antisocial behaviour that emerges early in life and persists over time is not only associated with –poor mental health; –bad relationships; and –criminal behaviour in adulthood but also increased risk for a range of physical health problems: –Heart disease and stroke (x 3) –Symptoms of chronic bronchitis (x 3) –Gum disease (x 4) –Herpes (x 2) –Smoking (x 10) –Injuries (x 4) –High rates of hospitalisation (x3) Odgers, Caspi, Broadbent, Dickson, Hancox, Harrington, Poulton, Sears, Thomson, Moffitt. Archives of General Psychiatry, 2007, 64: 476-484

11. Take away messages Serious conduct problems have a long reach Serious conduct problems have a long reach Their impact is pervasive Their impact is pervasive Previous ‘cost’ calculations are likely to be underestimates Previous ‘cost’ calculations are likely to be underestimates Should be a top public health priority Should be a top public health priority ‘Earlier the better’ for intervention efforts ‘Earlier the better’ for intervention efforts

12. Aging, men and mental health Life expectancy increasing but want extra ‘life’ in those extra years! Life expectancy increasing but want extra ‘life’ in those extra years! Aging begins early – an accumulation of wear and tear in multiple organ systems Aging begins early – an accumulation of wear and tear in multiple organ systems A lifecourse perspective asks: are there modifiable interventon targets that might slow or even reverse disease-causing processes when people are still young? A lifecourse perspective asks: are there modifiable interventon targets that might slow or even reverse disease-causing processes when people are still young?

13. Psychiatric diagnoses as novel targets? Compared to the general population, those with diagnoses have higher mortality rates, but die of same causes (e.g., CVD, cancer) Compared to the general population, those with diagnoses have higher mortality rates, but die of same causes (e.g., CVD, cancer) Internalising disorders (depression, GAD, PTSD) are sufficiently common to be a public health intervention target Internalising disorders (depression, GAD, PTSD) are sufficiently common to be a public health intervention target Timing is right: internalising disorders onset in first ½ of lifecourse, age-related diseases in the 2 nd half of the lifecourse Timing is right: internalising disorders onset in first ½ of lifecourse, age-related diseases in the 2 nd half of the lifecourse Internalising disorders are treatable Internalising disorders are treatable

14. Shalev, Moffitt, Braithwaite, Danese, Fleming, Goldman-Mellor, Harrington, Houts, Israel, Poulton, Robertson, Sugden, Williams and Caspi. Molecular Psychiatry, 2014, 19(11): 1163-1170.

15. Analysis – 2 parts Number of assessments at which individuals met criteria for an internalsing disorder (depression, GAD and PTSD), from age 11 to 38 and telomere length at age 38 years Number of assessments at which individuals met criteria for an internalsing disorder (depression, GAD and PTSD), from age 11 to 38 and telomere length at age 38 years Focus not on telomere length at age 38, but on the amount of telomere erosion between age 26 and age 38 and internalising disorders experienced between the same ages Focus not on telomere length at age 38, but on the amount of telomere erosion between age 26 and age 38 and internalising disorders experienced between the same ages

16. Telomere length. Association between internalizing disorder from age 11 to 38 years, and leukocyte telomere length (LTL) at 38 years for men (a) and women (b). Molecular Psychiatry (2014) 19, 1163-1170; doi:10.1038/mp.2013.183

17. Pearson correlations and multivariate linear regression analyses of internalizing disorder from 11–38 years, predicting LTL at 38 years, controlling for alternative explanatory variables Molecular Psychiatry (2014) 19, 1163-1170; doi:10.1038/mp.2013.183

18. Telomere erosion. Association between generalized anxiety disorder (GAD), depression and post-traumatic stress disorder (PTSD) between ages 26–38 years, and leukocyte telomere length (LTL) at age 38 years (after controlling for baseline LTL at age 26 years) for men (a) and women (b). Molecular Psychiatry (2014) 19, 1163-1170; doi:10.1038/mp.2013.183

19. Some strengths of the study Improvement over single point-in-time assessment of internalising disorder Improvement over single point-in-time assessment of internalising disorder Able to also examine erosion (change) in relation to disorder Able to also examine erosion (change) in relation to disorder Could rule out multiple alternative explanations for the association Could rule out multiple alternative explanations for the association Examined multiple internalising disorders (i.e not just depression) Examined multiple internalising disorders (i.e not just depression)

20. Possible mechanisms Some studies show that physiological and/or biochemical processes involved in internalising disorder affect men more than women Some studies show that physiological and/or biochemical processes involved in internalising disorder affect men more than women Dysregulation of the HPA axis, elvated proinflammatory cytokines and elevated oxidative stress markers Dysregulation of the HPA axis, elvated proinflammatory cytokines and elevated oxidative stress markers Protective role of estrogens against mitochondrial damage from oxidation processes (i.e., the women were still in reproductive years) Protective role of estrogens against mitochondrial damage from oxidation processes (i.e., the women were still in reproductive years)

21. Take home messages Male Mental Health “Is there such a thing?” Male Mental Health “Is there such a thing?” (still) High prevalence (internalising disorders) AND/OR high impact (externalising) (still) High prevalence (internalising disorders) AND/OR high impact (externalising) Men may be physiologically more vulnerable to aging effects of mental health problems? Men may be physiologically more vulnerable to aging effects of mental health problems? Policy implications are to intervene much earlier than current practice Policy implications are to intervene much earlier than current practice Multiple benefits are likely to accrue – a healthier future indeed! Multiple benefits are likely to accrue – a healthier future indeed!

22. Acknowledgements This on-going research would not have been possible without the co-operation and commitment of the Study members, their families and friends over a long period of time. This on-going research would not have been possible without the co-operation and commitment of the Study members, their families and friends over a long period of time. Core funding for the Dunedin Multidisciplinary Health and Development Research Unit comes from the Health Research Council of New Zealand. Core funding for the Dunedin Multidisciplinary Health and Development Research Unit comes from the Health Research Council of New Zealand. For copies of research articles referred to in this presentation or other information on the Study, contact Michelle McCann:  +64 3 479-8507  email: dmhdru@otago.ac.nz  +64 3 479-8507  email: dmhdru@otago.ac.nz http://www.otago.ac.nz/dunedin study