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Australian Indigenous HealthBulletin
 
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Social and emotional wellbeing (including mental health)

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Social and emotional wellbeing (including mental health)

Good mental health is essential to the health and wellbeing of individuals, families, and communities [1]. Mental health remains, however, a complex domain due to the multiplicity of contributing internal and external factors, and the diverse views, and subsequent varying terminology, which exists within the field [2].

National policies provide some clarity by defining terms such as mental health, mental health problems, and mental illness. These policies accept the World Health Organization (WHO) definition for mental health, describing it as a state of social and emotional wellbeing in which individuals can cope with the normal stresses of life and realise their potential [2][3]. Mental health is influenced by a complex interplay of biological, psychological, social, environmental, and economic factors [1][2][4]. People with good mental health are able to contribute to community life, participate in the workforce, and foster meaningful and positive relationships with others [2][3][5].

Some individuals experience compromised mental health due to mental health problems or mental illness. The distinction between mental health problems and mental illness is not well defined [2], but it is important to delineate the meaning of these concepts to ensure all aspects of mental health/illness are adequately addressed within the Indigenous and wider populations. Mental health problems are characterised by reduced cognitive, emotional, or social functioning, but not to the extent that the criteria for a mental illness are met [1][2]. Conversely, a mental illness is a clinically diagnosable disorder that significantly interferes with an individual’s cognitive, emotional, or social abilities, and is generally determined according to the classification system of the Diagnostic and Statistical Manual of Mental Disorders (DSM) or the ICD.

Mental health, mental health problems, and mental illness are not discrete entities, rather they occur on a continuum, and it is expected that people will fluctuate between periods of good mental health, and periods of not-so-good mental health during their lifetime [1][2][5]. This broader conceptualisation of mental health has been recognised in Australia and is fundamental to the aims of current mental health policy. This conceptualisation also closely aligns with the Indigenous view of mental health and wellbeing, which is termed social and emotional wellbeing.

Social and emotional wellbeing refers to the social, emotional, spiritual, and cultural wellbeing of an individual [5]. It goes beyond traditional mental health concepts to encapsulate the importance of connection to land, culture, spirituality, ancestry, family and community, and how these impact on an individual while also recognising the influence of political and historical factors on mental health and wellbeing [5][6]. It is the preferred terminology by many Indigenous people because of its more positive and holistic connotations.

Box 3: Sources of information about mental illness and mental health problems

Historically, the extent of mental illness and mental health problems in the Indigenous population have been poorly documented [7]. It was not until the 2004-05 National Aboriginal and Torres Strait Islander Health Survey (NATSIHS) that information on the social and emotional wellbeing of Indigenous people was systematically collected at a national level [8][9]. More comprehensive information has since been provided by the 2008 NATSISS [10]. More recently, the 2012-13 AATSIHS sought to provide a broad understanding of the social and emotional wellbeing of Indigenous people aged 18 years and over by collecting information on psychological distress, personal stressors, positive wellbeing, discrimination, social support, cultural identification, and personal control beliefs [11][12].

As well as the valuable information collected by these major national surveys, useful information about mental illness and mental health problems can be derived from health services utilisation and death data.

Extent of mental illness and mental health problems among Indigenous people
Prevalence

The 2012-2013 AATSIHS found that the social and emotional wellbeing of many Indigenous people was compromised: 30% of respondents aged 18 years or over reported high or very high levels of psychological distress in the four weeks prior to the interview, an increase of more 10% since the 2004-2005 NATSIHS [13][7].12 After age-adjustment, the proportion of Indigenous people reporting high or very high distress levels in 2012-2013 was more than 2.7 times that of non-Indigenous people [7]. There were variations in psychological distress levels within the Indigenous population in terms of sex and remoteness. More than one-third (36%) of Indigenous females and one-quarter (24%) of Indigenous males reported high or very high levels of psychological distress in the four weeks prior to the survey; the proportion of Indigenous people reporting high or very high distress levels was higher for people living in non-remote areas than for those living in remote areas (32% and 24% respectively).

The higher overall levels of psychological distress reported by Indigenous people than by non-Indigenous people are consistent with the relative frequencies with which the two populations experienced specific stressors in the previous 12 months. According to the 2012-2013 AATSIHS, 69% of Indigenous people aged 15 years and over experienced one or more specific stressors in the 12 months prior to the survey [14]. After age-adjustment, this was almost 1.4 times the proportion of non-Indigenous people reporting experiencing one or more specific stressors. The most prevalent stressors for Indigenous people included: death of a family member or close friend; serious illness; unable to get a job; alcohol or drug related problems; and mental illness (Table 20). These specific stressors were also the most commonly reported stressors in the non-Indigenous population, but at lower levels. The greatest disparities in the frequency of the reported stressors were for ‘trouble with the police’ and ‘gambling problems’; after age-adjustment, Indigenous people were five times and almost six times more likely, respectively, than non-Indigenous people to report these stressors.

Among Indigenous people, a greater proportion of females than males reported experiencing one or more specific stressors (72% and 65% respectively) [14]. The most commonly reported stressors were fairly consistent for both females and males, and for each of the age cohorts. Across the age-groups, a steady increase was observed in the proportion of Indigenous people reporting one or more specific stressor, with the exception of the 55 years and over age-group where the proportion of people reporting one or more specific stressor was at its lowest (62%).
Table 20: Proportion (%) of stressors reported by Indigenous people in the previous 12 months and Indigenous:non-Indigenous ratios, by stressor type, Australia, 2012-2013
Type of stressorProportionRatio
Source: ABS, 2013 [14]
Notes:
  1. Proportions are expressed as percentages
  2. Ratios are based on age-adjusted prevalences from the 2012-2013 AATSIHS and the 2011-2013 Australian Health Survey
Death of a family member or close friend 37 1.9
Serious illness 23 1.4
Not able to get a job 23 2.5
Alcohol or drug related problems 18 3.6
Mental illness 16 1.7
Trouble with the police 13 5.0
Involuntary loss of job 9 2.4
Divorce or separation 8 1.0
Gambling problems 8 5.8
Witness to violence 8 3.9
Abuse or violent crime 7 3.4
Serious accident 7 1.8
Serious disability 6 2.3
Total reporting specific stressor(s) 69 1.4

Psychological distress and the contributing life stressors are just one aspect of social and emotional wellbeing. Also providing an indication of a person’s state of social and emotional wellbeing is the degree to which they experience positive feelings. In the 2008 NATSISS, survey respondents reported on feelings of calmness and peacefulness, happiness, fullness of life, and energy [13].13 Nine-tenths (90%) of Indigenous people reported feeling happy either some, most, or all of the time, but considerable proportions responded ‘a little/none of the time’ to questions relating to having ‘lots of energy’ (21%), a sense of calmness and peacefulness (16%), and fullness of life (17%). The absence of comparable data precludes definitive statements about the relative positive wellbeing of Indigenous and non-Indigenous people, but the greater frequency of psychological distress in the Indigenous population, together with the types and numbers of stressors reported, suggests Indigenous people experience lower levels of social and emotional wellbeing than do non-Indigenous people.

Social and emotional wellbeing are influenced by the support a person receives from their social networks [10]. Information collected in the 2008 NATSISS showed that 89% of Indigenous people aged 15 years and over were able to obtain emotional, physical, or financial help from someone else during a time of crisis. Non-Indigenous people experience similar levels of social support: the 2010 General social survey (GSS) found that 93% of non-Indigenous people were able to access support at a time of crisis [15].

Removal from one’s natural family also has significant implications for a person’s social and emotional wellbeing [16]. The 2008 NATSISS revealed that Indigenous people who had been removed, or had had a relative removed, from their natural family were more inclined to experience high or very high levels of psychological distress compared with those who had not been removed from their natural family. About 39% of Indigenous people experiencing high or very high levels of psychological distress reported having been removed, or having had a relative removed, from their natural family. Almost one-third (30%) of Indigenous people with high or very high levels of distress hadn’t been removed from their natural family.

In terms of the social and emotional wellbeing of Indigenous children, the WAACHS, undertaken in 2001 and 2002, remains the most recent and detailed source of information. The WAACHS reported that 24% of Indigenous children and young people aged 4-17 years were rated by their carers (parent or guardian) as being at high risk of clinically significant emotional or behavioural difficulties (compared with 15% of their counterparts in the general WA population) [17]. Children of Indigenous carers who had been forcibly separated from their families were more than twice as likely to be at high risk of incurring clinically significant emotional and behavioural difficulties, and had twice the rates of alcohol and other drug use than children of Indigenous carers who had not been forcibly separated from their families. Around 71% of Indigenous children were living in families that had experienced three or more major life stress events (such as death in the family, serious illness, family breakdown, financial problems or arrest) in the 12 months prior to the survey, and 23% had experienced seven or more such events.

Hospitalisation

Reflecting the high levels of distress experienced by many Indigenous people, 15,009 of the hospital separations in 2011-12 with a principal diagnosis of ICD ‘Mental and behavioural disorders’ were identified as Indigenous (7.4% of Indigenous separations, excluding those for dialysis) [18]. After age-adjustment, the hospitalisation rate for Indigenous people was 2.1 times the rate for non-Indigenous people.14

Information about hospitalisation for the specific sub-categories within the ICD chapter ‘Mental and behavioural disorders’ are not available for 2011-12, but data from 2008-10 show hospitalisation rates for each sub-category were generally higher for Indigenous people than for other Australians [19]. For this period, the age-adjusted separation rates for mental and behavioural disorders due to ICD ‘Psychoactive substance use disorders’ were 3.7 times higher for Indigenous people living in NSW, Vic, Qld, WA, SA and the NT than those for their non-Indigenous counterparts. Similarly, the rate for Indigenous people for ICD ‘Schizophrenia, schizotypal, and delusional disorders’ was 3.0 times higher than the rate for other people.

Intentional self-harm, categorised separately to the ‘Mental and behavioural disorders’ principal diagnosis chapter within the ICD, was responsible for 1.1% of all hospital admissions for Indigenous people in 2011-12, excluding care involving dialysis [20][18]. Indigenous people living in NSW, Vic, Qld, WA, SA and the NT in 2008-10 were more likely to be admitted for intentional self-harm than were their non-Indigenous counterparts [19]. After age-adjustment, separation rates were 2.9 times higher for Indigenous males and 2.1 times higher for Indigenous females than those for their non-Indigenous counterparts. Indigenous people living in remote areas had a particularly high separation rate for intentional self-harm – more than 3.7 times the rate reported for their non-Indigenous counterparts.

Mortality

The most recent detailed information about Indigenous mortality as a result of mental health related conditions is for Indigenous people living in NSW, Qld, WA, SA, and the NT in 2006-2010: there were 312 deaths of Indigenous people (147 males and 165 females) (Table 21) [19].15 After age-adjustment, the death rates were 1.7 times higher for Indigenous males and 1.3 times higher for Indigenous females than those for their non-Indigenous counterparts.
Table 21: Numbers and rates of deaths from mental health related conditions, excluding intentional self-harm, and Indigenous:non-Indigenous rate ratios, by sex and condition, NSW, Qld, WA, SA, and the NT, 2006-2010
Cause of deathMalesFemales
NumberRateRatioNumberRateRatio
Source: AIHW (2013) [19]
Notes:
  1. Details of death from intentional self-harm are not included in this table, see Tables 22 and 23.
  2. ‘Mental disorders due to substance use’ comprises ICD codes F10-F19, ‘Organic mental disorders’ ICD codes F00-F09, and ‘Other mental disorders’ ICD codes F20–F99, G30, G47.0, G47.1, G47.2, G47.8, G47.9, O99.3, R44, R45.0, R45.1, R45.4, R48.
  3. Rates are deaths per 100,000 standardised using the Australian 2001 ERP
Mental disorders due to substance use 79 14 5.7 36 5 6.7
Organic mental disorders 55 30 1.6 104 38 1.4
Other mental disorders 13 6 0.7 25 9 0.7
All mental disorders 147 49 1.7 165 52 1.3

More recent data are available for deaths due to ICD ‘Intentional self-harm’ (suicide) (not included among the deaths for mental health related conditions shown in Table 22). In 2012, the death rate for ICD ‘Intentional self-harm’ for Indigenous people living in NSW, Qld, WA, SA, and the NT was 2.0 times the rate reported for non-Indigenous people [21]. It was the fifth leading specific cause of death among Indigenous people.

For the period 2008-2012, deaths from intentional self-harm were much higher for Indigenous people living in NSW, Qld, WA, SA, and the NT than those for their non-Indigenous counterparts, with age-standardised death rates ranging from 14 per 100,000 (NSW) to 39 per 100,000 (WA) [21]. Death rates were higher for Indigenous males than for Indigenous females (in those jurisdictions for which details for females were available).
Table 22: Age-standardised death rates for intentional self-harm, Indigenous people by sex and jurisdiction, and Indigenous:non-Indigenous rate ratios, NSW, Qld, WA, SA and the NT, 2008-2012
JurisdictionIndigenousRate ratios
PersonsMalesFemalesPersonsMalesFemales
Source: ABS, 2014 [21]
Notes:
  1. Rate per 100,000 population, standardised to the Australian 2011 ERP
  2. Rate ratio is the Indigenous rate divided by the non-Indigenous rate
  3. n.p.: not published
  4. Due to the incomplete identification of Indigenous status, these figures probably under-estimate the true differences between Indigenous and non-Indigenous people
NSW 14 24 n.p. 1.6 1.8 n.p.
Qld 22 30 14 1.8 1.6 2.6
WA 39 55 22 3.3 3.1 4.1
SA 25 35 n.p. 2.2 2.0 n.p.
NT 29 47 n.p. 2.4 2.3 n.p.

These overall death rates conceal the very high rates of suicide among young Indigenous people: Indigenous people die from suicide at much younger ages than do non-Indigenous people. Combined data for NSW, Qld, WA, SA and the NT in 2008-2012 show the highest death rates for intentional self-harm were among Indigenous people aged 15-24 and 25-34 years (43 and 45 deaths per 100,000, respectively) (Table 23) [21]. The burden of suicide is highest among Indigenous males aged 15-24 and 25-34 years (rates of 62 and 66 per 100,000, respectively), but is also very high among young Indigenous females. The suicide rates for Indigenous females in the 1-14 years to 35-44 years age-groups ranged from more than two to around 16 times the rates for their non-Indigenous female counterparts. Even more striking is the fact that suicide rates for Indigenous females in the 1-14 years to 35-44 years age-groups were all higher than the rates for non-Indigenous males in those age-groups.
Table 23: Age-standardised death rates for intentional self-harm, Indigenous people by sex and age-group, and Indigenous:non-Indigenous rate ratios, NSW, Qld, WA, SA and the NT, 2008-2012
Age-group (years)IndigenousRate ratios
PersonsMalesFemalesPersonsMalesFemales
Source: ABS, 2014 [21]
Notes:
  1. Rate per 100,000 population, standardised to the Australian 2011 ERP
  2. Rate ratio is the Indigenous rate divided by the non-Indigenous rate
  3. n.p.: not published
  4. Due to the incomplete identification of Indigenous status, these figures probably under-estimate the true differences between Indigenous and non-Indigenous people
1-14 2 1 2.2 10.3 6.3 16.2
15-24 43 62 23 5.2 5.2 5.2
25-34 45 66 23 3.5 3.3 4.4
35-44 32 49 17 2.0 1.9 2.4
45+ n.p. n.p. n.p. n.p. n.p. n.p.
All ages 22 33 n.p. 2.1 2.0 n.p.

Research in NSW, Qld, the ACT, and the NT has highlighted the increasing impact of suicide among young Indigenous people [22][23][24]. It has been suggested that suicide and attempted suicide among Indigenous youth (at least in NSW and the ACT) are not the result of mental illness ‘in the strict pathological sense’ ([25], p.88), but it is certainly a manifestation of mental health problems. The level of intentional self-harm has been recognised as a key indicator of Indigenous disadvantage [13].

References

  1. Department of Health and Ageing (2009) National mental health policy 2008. Canberra: Commonwealth of Australia
  2. Australian Health Ministers (2003) National Mental Health Plan 2003-2008. Canberra: Australian Government
  3. World Health Organization (2009) Mental health: strengthening mental health promotion. Retrieved September 2007 from http://www.who.int/mediacentre/factsheets/fs220/en/index.html
  4. Fourth National Mental Health Plan Working Group (2009) Fourth National Mental Health Plan: an agenda for collaborative government action in mental health 2009-2014. Canberra: Australian Government Department of Health and Ageing
  5. Garvey D (2008) Review of the social and emotional wellbeing of Indigenous Australian peoples. Retrieved 2008 from http://www.healthinfonet.ecu.edu.au/other-health-conditions/mental-health/reviews/our-review
  6. Vicary D, Westerman TG (2004) 'That's just the way he is': some implications of Aboriginal mental health beliefs. Australian e-Journal for the Advancement of Mental Health; 3(3) Retrieved 2004 from http://www.atypon-link.com/EMP/doi/pdf/10.5172/jamh.3.3.103
  7. Australian Bureau of Statistics (2013) Australian Aboriginal and Torres Strait Islander health survey: first results, Australia, 2012-13: Table 7 [data cube]. Canberra: Australian Bureau of Statistics
  8. Australian Bureau of Statistics (2006) National Aboriginal and Torres Strait Islander Health Survey: Australia, 2004-05: user's guide. Canberra: Australian Bureau of Statistics
  9. Australian Bureau of Statistics (2006) National Aboriginal and Torres Strait Islander Health Survey: Australia, 2004-05. Canberra: Australian Bureau of Statistics
  10. Australian Bureau of Statistics (2009) National Aboriginal and Torres Strait Islander social survey, 2008. Retrieved 11 April 2011 from http://www.abs.gov.au/ausstats/abs@.nsf/mf/4714.0?OpenDocument
  11. Australian Bureau of Statistics (2013) Australian Aboriginal and Torres Strait Islander health survey: first results, Australia, 2012-13. Canberra: Australian Bureau of Statistics
  12. Australian Bureau of Statistics (2010) National Aboriginal and Torres Strait Islander social survey: users' guide, 2008. Retrieved from http://www.abs.gov.au/ausstats/abs@.nsf/mf/4720.0?OpenDocument
  13. Steering Committee for the Review of Government Service Provision (2011) Overcoming Indigenous disadvantage: key indicators 2011. Canberra: Productivity Commission, Australia
  14. Australian Bureau of Statistics (2013) Australian Aboriginal and Torres Strait Islander health survey: first results, Australia, 2012-13: table 19 [data cube]. Canberra: Australian Bureau of Statistics
  15. Australian Bureau of Statistics (2011) General social survey: summary results: 2010. Canberra: Australian Bureau of Statistics
  16. Australian Bureau of Statistics (2010) The health and welfare of Australia's Aboriginal and Torres Strait Islander peoples, Oct 2010: Social and emotional wellbeing [data cube]. Retrieved 29 October 2010 from http://www.abs.gov.au/AUSSTATS/subscriber.nsf/log?openagent&social%20and%20emotional%20wellbeing%20data%20cube.xls&4704.0&Data%20Cubes&F0C653AD3494AB79CA2577CA00138F43&0&Oct%202010&29.10.2010&Previous
  17. Zubrick SR, Silburn SR, Lawrence DM, Mitrou FG, Dalby RB, Blair EM, Griffin J, Milroy H, De Maio JA, Cox A, Li J (2005) The social and emotional wellbeing of Aboriginal children and young people: vol 2. Perth: Telethon Institute for Child Health Research and Curtin University of Technology
  18. Australian Institute of Health and Welfare (2013) National tables for principal diagnoses (part 1). Canberra: Australian Institute of Health and Welfare
  19. Australian Institute of Health and Welfare (2013) Aboriginal and Torres Strait Islander health performance framework 2012: detailed analyses. Canberra: Australian Institute of Health and Welfare
  20. Australian Institute of Health and Welfare (2013) Australian hospital statistics 2011–12. Canberra: Australian Institute of Health and Welfare
  21. Australian Bureau of Statistics (2014) Causes of death, Australia, 2012: Deaths of Aboriginal and Torres Strait Islander Australians [data cube]. Retrieved 25 March 2014 from http://www.abs.gov.au/ausstats/subscriber.nsf/log?openagent&3303_12%20deaths%20of%20aboriginal%20and%20torres%20strait%20islander%20australians.xls&3303.0&Data%20Cubes&0585A7BA09CCB81DCA257CA5000C9072&0&2012&25.03.2014&Latest
  22. Hunter E, Reser J, Baird M, Reser P (2001) An analysis of suicide in Indigenous communities of North Queensland: the historical, cultural and symbolic landscape. Cairns: University of Queensland, Department of Social and Preventive Medicine, Gurriny Yealamucka Health Service & the Yarrabah Community Council, James Cook University of North Queensland, School of Psychology and Sociology
  23. Tatz C (2001) Aboriginal suicide is different: a portrait of life and self-destruction [1st ed.]. Canberra: Aboriginal Studies Press
  24. Measey ML, Li SQ, Parker R, Wang Z (2006) Suicide in the Northern Territory, 1981-2002. Medical Journal of Australia; 185(6): 315-319
  25. Tatz C (2005) Aboriginal suicide is different: a portrait of life and self-destruction [2nd ed.]. 2nd ed. Canberra: Aboriginal Studies Press

Endnotes

  1. The percentage increase in psychological distress levels is based on age-standardised data as the actual prevalence was not available for 2004-2005
  2. The 2012-2013 AATSIHS collected data on positive wellbeing, but information was not available at the time this report was prepared.
  3. The ICD chapter ‘Mental and behavioural disorders’, used for the classification of both hospitalisation and mortality, is very broad. As well as mental illness and mental health problems, it includes mental retardation and a broad sub-category for disorders relating to the use of psychoactive substances (including alcohol, tobacco, other drugs and volatile substances). The chapter doesn’t include, however, the results of intentional self-harm, which are classified within the ICD chapter ‘External causes of morbidity and mortality’.
  4. Under the ICD, intentional self-harm is classified under ‘External causes of morbidity and mortality’ (codes X60-X84): details are provided separately.
 

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