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Australian Indigenous HealthBulletin
 

Social and emotional wellbeing (including mental health)

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Social and emotional wellbeing (including mental health)

Social and emotional wellbeing (SEWB) is a complex and multifaceted concept that has particular resonance and meaning for Aboriginal and Torres Strait Islander people [1][2]. While the term SEWB has been used interchangeably with ‘mental health’ and ‘mental illness’, Gee et al. argue that these latter terms should be positioned ‘within’ a broader understanding of SEWB rather than ‘equated with SEWB’ [2]. SEWB for Aboriginal and Torres Strait Islander people then, may be defined as ‘a multidimensional concept of health that includes mental health, but which also encompasses domains of health and wellbeing such as connection to land or ‘country’, culture, spirituality, ancestry, family and community’ [2]. Understanding SEWB and mental health as cultural constructions enhances the capacity for culturally appropriate, strengths based approaches to managing emerging issues for individuals and communities. Colonisation has had a systematically profound impact on Aboriginal and Torres Strait Islander peoples’ traditional cultural practices and by implication on their SEWB [3][4]. A number of factors have been linked to SEWB concerns for Aboriginal and Torres Strait Islander people such as discrimination and racism, grief and loss, child removals and unresolved trauma, life stress, social exclusion, economic and social disadvantage, incarceration, child removal by care and protection orders, violence, family violence, substance use and physical health problems [3]. They also identify a number of important factors that enhance SEWB such as connection to country, spirituality and ancestry; kinship; and self-determination, community governance and cultural continuity.

The World Health Organization (WHO) defines mental health as a state of social and emotional wellbeing in which individuals can cope with the normal stresses of life and realise their potential [5][6]. Like SEWB, mental health is influenced by a complex interplay of biological, psychological, social, environmental, and economic factors [7][8]. Some individuals experience compromised mental health due to mental health problems or mental illness. 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 [5][7]. Mental illness is a psychological 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. Severe mental illness, while evident in the anthropological or ethnographic records, was relatively rare in traditional Aboriginal societies [9].

For Aboriginal people broadly speaking, the structure and cultural practices of traditional society buffered the impacts experienced since colonisation. Similarly, for Torres Strait Islander people, traditional cultural practices enhanced the likelihood of better health outcomes, including SEWB.

Extent of social and emotional wellbeing, mental illness and mental health problems among Aboriginal and Torres Strait Islander people
Prevalence

The 2012-2013 AATSIHS found that the SEWB of many Aboriginal and Torres Strait Islander people was compromised: 30% of respondents aged 18 years and over reported high or very high levels of psychological distress in the four weeks prior to the interview [10]. After age-adjustment, the proportion of Aboriginal and Torres Strait Islander people reporting high or very high distress levels in 2012-2013 was more than 2.7 times that of non-Indigenous people in 2011-2012 [10]. There were variations in psychological distress levels within the Aboriginal and Torres Strait Islander population in terms of sex and remoteness. Around one-third (36%) of Aboriginal and Torres Strait Islander females and one-quarter (24%) of males reported high or very high levels of psychological distress in the four weeks prior to the survey; the proportion of Aboriginal and Torres Strait Islander 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) [11]. Additionally, remoteness affected the level of mental illness among Aboriginal and Torres Strait Islander people 15 years and over, with 18% of those in non-remote areas reporting mental illness, compared with 8% in remote areas [12].

The 2012-13 AATSIHS found a relationship between education level and employment status, and the level of psychological distress for Aboriginal and Torres Strait Islander people [13]. Thirty-four percent of Aboriginal and Torres Strait Islander people who were educated to year 9 level experienced high/very high levels of psychological distress, whereas for those who were educated to year 12, the figure was 26%. Similarly, 42% of unemployed Aboriginal and Torres Strait Islander people experienced high/very high levels of psychological distress, compared with 22% of employed Aboriginal and Torres Strait Islander people. The higher overall levels of psychological distress reported by Aboriginal and Torres Strait Islander 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 Aboriginal and Torres Strait Islander people aged 15 years and over experienced one or more specific stressors in the 12 months prior to the survey: after age-adjustment, this was almost 1.4 times the proportion of non-Indigenous people [14]. The most prevalent stressors for Aboriginal and Torres Strait Islander people were death of a family member or close friend (37% of people surveyed), followed by; serious illness (23%); inability to get a job (23%); alcohol or drug related problems (18%); and mental illness (16%). 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, Aboriginal and Torres Strait Islander people were 5.0 times and 5.8 times more likely, respectively, than non-Indigenous people to report these stressors. Among Aboriginal and Torres Strait Islander people, commonly reported specific stressors were fairly consistent for males and females, however a greater proportion of females than males reported experiencing one or more specific stressors (72% and 65% respectively).

Psychological distress and the contributing life stressors are just one aspect of SEWB. Also providing an indication of a person’s state of SEWB is the degree to which they experience positive feelings. In the AATSIHS 2012-13, survey respondents reported on feelings of calmness and peacefulness, happiness, fullness of life, and energy and 91% of Aboriginal and Torres Strait Islander people reported feeling happy either some, most, or all of the time [11]. However, considerable proportions responded ‘a little/none of the time’ to questions relating to having ‘lots of energy’ (21%), a sense of calmness and peacefulness (18%) and fullness of life (19%). The absence of comparable data precludes definitive statements about the relative positive wellbeing of Aboriginal and Torres Strait Islander and non-Indigenous people, but the greater frequency of psychological distress in the Aboriginal and Torres Strait Islander population, together with the types and numbers of stressors reported, suggests Aboriginal and Torres Strait Islander people experience lower levels of SEWB than non-Indigenous people. The 2008 Household income and labour dynamics in Australia survey (HILDA) offers mixed support for this suggestion: it found that holding a wide range of other factors constant, overall life satisfaction was significantly higher for Aboriginal and Torres Strait Islander people, compared with non-Indigenous Australians [15].

SEWB are influenced by the support a person receives from their social networks [16]. Information collected in the 2008 National Aboriginal and Torres Strait Islander social survey (NATSISS) showed that 89% of Aboriginal and Torres Strait Islander 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 94% of non-Indigenous people were able to access support at a time of crisis [17]. Removal from one’s natural family also has significant implications for a person’s SEWB [18]. The 2008 NATSISS revealed that Aboriginal and Torres Strait Islander 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 Aboriginal and Torres Strait Islander 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 Aboriginal and Torres Strait Islander people with high or very high levels of distress had not been removed from their natural family [18].

In terms of the SEWB of Aboriginal children, the Western Australian Aboriginal child health survey (WAACHS), 2001-2002, remains the most recent and detailed source of information. It reported that 24% of Aboriginal 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 [19]. Children of Aboriginal 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 Aboriginal carers who had not been forcibly separated from their families. Around 71% of Aboriginal children were living in families that had experienced three or more major life stress events (such as death of a close family member, illness, family break-up, financial difficulties or arrest) in the 12 months prior to the survey, and 23% had experienced seven or more such events (Derived from [19]). The Footprints in time: longitudinal study of Indigenous children found that Indigenous boys had higher average behavioural and emotional difficulties scores than Indigenous girls, (scores of 13 and 11 respectively). Differences between boys and girls were significant on the hyperactivity, prosocial and total difficulties scales.

Hospitalisation

Reflecting the continuing high levels of distress experienced by many Aboriginal and Torres Strait Islander people, 16,070 of the hospital separations in 2013-14 with a principal diagnosis of ICD ‘Mental and behavioural disorders’ were identified as Aboriginal and Torres Strait Islander [20].8

Information about hospitalisation for the specific sub-categories within the ICD chapter ‘Mental and behavioural disorders’ are not available for 2013-14, but data from 2008-10 show hospitalisation rates for each sub-category were generally higher for Indigenous people than for other Australians [21]. 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 non-Indigenous people.

Intentional self-harm categorised as a principal diagnosis chapter within the ICD, was responsible for 2,619 (0.6%) of all hospital admissions for Indigenous people in 2013-14 (Derived from [20]). 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 their non-Indigenous counterparts [21]. 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 [21].

Mortality

The most recent detailed information about Aboriginal and Torres Strait Islander mortality as a result of mental health related conditions is for those 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 20) [21]9. After age-adjustment death rates were 1.7 times higher for Indigenous males and 1.3 times higher for Indigenous females than for their non-Indigenous counterparts.

Table 20. Numbers and rates of deaths from mental health related conditions, excluding intentional self-harm, and Aboriginal and Torres Strait Islander:non-Indigenous rate ratios, by sex and condition, NSW, Qld, WA, SA, and the NT, 2006-2010

Cause of death

 

Males

Females

Number

Rate

Rate ratio

Number

Rate

Rate ratio

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

Notes:

  1. Details of death from intentional self-harm are not included in this table; see Tables 21 and 22
  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, rounded to the nearest whole number, standardised using the Australian 2001 ERP

Source: AIHW, 2013 [21]

In 2013, the death rate for ICD ‘Intentional self-harm’ for Aboriginal and Torres Strait Islander people living in NSW, Qld, WA, SA, and the NT was 2.2 times the rate reported for non-Indigenous people [22]. It was the fourteenth leading specific cause of death among Aboriginal and Torres Strait Islander people.

For the period 2009-2013, deaths from intentional self-harm were much higher for Aboriginal and Torres Strait Islander people living in NSW, Qld, WA, SA, and the NT than those for their non-Indigenous counterparts, with age-standardised death rates ranging from 12 per 100,000 (NSW) to 36 per 100,000 (WA) [22]. Death rates were higher for Aboriginal and Torres Strait Islander males than females (in those jurisdictions for which details for females were available) (Table 21).

Table 21. Age-standardised death rates for intentional self-harm, Aboriginal and Torres Strait Islander people by sex and jurisdiction, and Aboriginal and Torres Strait Islander:non-Indigenous rate ratios, NSW, Qld, WA, SA and the NT, 2009-2013

Jurisdiction

 

Aboriginal and Torres Strait Islander people

Rate ratios

Persons

Males

Females

Persons

Males

Females

NSW

12

20

n.p.

1.4

1.5

n.p.

Qld

21

32

12

1.7

1.6

2.1

WA

36

52

20

3.0

2.9

3.7

SA

21

29

n.p.

1.8

1.7

n.p.

NT

29

44

15

2.5

2.2

n.p.

Notes:

  1. Rate per 100,000 population, rounded to the nearest whole number, standardised to the Australian 2011 ERP
  2. Rate ratio is the Aboriginal and Torres Strait Islander rate divided by the non-Indigenous rate
  3. n.p.: not published
  4. These figures probably under-estimate the differences between Aboriginal and Torres Strait Islander and non-Indigenous people due to the incomplete identification of Indigenous status

Source: ABS, 2015 [22]

These overall death rates conceal the very high rates of suicide among young Aboriginal and Torres Strait Islander people who die from suicide at much younger ages than non-Indigenous people. Combined data for NSW, Qld, WA, SA and the NT in 2009-2013 show the highest death rates for intentional self-harm were among Aboriginal and Torres Strait Islander people aged 15-24 and 25-34 years (39 and 40 deaths per 100,000 respectively) (Table 22) [22]. The burden of death by intentional self-harm is highest among Aboriginal and Torres Strait Islander males aged 15-24 and 25-34 years (rates of 54 and 59 per 100,000 respectively), but is also very high among young Aboriginal and Torres Strait Islander females. The suicide rates for females in the 1-14 years to 25-34 years age-groups ranged from more than two to around 23 times the rates for their non-Indigenous female counterparts. Even more striking is the fact that suicide rates for Aboriginal and Torres Strait Islander females in the 1-14 years to 25-34 years age-groups were all higher than the rates for non-Indigenous males in those age-groups.

Table 22. Age-standardised death rates for intentional self-harm, Aboriginal and Torres Strait Islander people by sex and age-group, and Aboriginal and Torres Strait Islander:non-Indigenous rate ratios, NSW, Qld, WA, SA and the NT, 2009-2013

Age-group (years)

 

Aboriginal and Torres Strait Islander people

Rate ratios

Persons

Males

Females

Persons

Males

Females

1-14

2

2

2.1

7.8

6.7

9.5

15-24

39

54

23

4.3

4.2

4.5

25-34

40

59

21

3.1

2.9

3.8

35-44

31

48

16

1.9

1.9

2.2

45+

n.p.

28

n.p.

n.p.

1.2

n.p.

All ages

20

29

n.p.

1.9

1.8

n.p.

Notes:

  1. Rate per 100,000 population, rounded to the nearest whole number, standardised to the Australian 2011 ERP
  2. Rate ratio is the Aboriginal and Torres Strait Islander rate divided by the non-Indigenous rate
  3. n.p.: not published
  4. Due to the incomplete identification of Aboriginal and Torres Strait Islander status, these figures probably under-estimate the true differences between Aboriginal and Torres Strait Islander and non-Indigenous people

Source: ABS, 2015 [22]

Research in NSW, Qld, WA, SA, the ACT and the NT has highlighted the increasing impact of suicide among young Indigenous people [11][23][24][25]. 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’ ([26], 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 [11].

References

  1. Dudgeon P, Walker R, Scrine C, Shepherd C, Calma T, Ring I (2014) Effective strategies to strengthen the mental health and wellbeing of Aboriginal and Torres Strait Islander people. Canberra: Closing the Gap Clearinghouse
  2. Gee G, Dudgeon P, Schultz C, Hart A, Kelly K (2014) Aboriginal and Torres Strait Islander social and emotional wellbeing. In: Dudgeon P, Milroy H, Walker R, eds. Working together: Aboriginal and Torres Strait Islander mental health and wellbeing principles and practice. 2nd ed. Canberra: Department of The Prime Minister and Cabinet: 55-68
  3. Zubrick SR, Shepherd CCJ, Dudgeon P, Gee G, Paradies Y, Scrine C, Walker R (2014) Social determinants of social and emotional wellbeing. In: Dudgeon P, Milroy H, Walker R, eds. Working together: Aboriginal and Torres Strait Islander mental health and wellbeing principles and practice. 2nd edition ed. Canberra: Department of The Prime Minister and Cabinet: 93-112 (chapter 6)
  4. Sherwood J (2013) Colonisation - it's bad for your health: the context of Aboriginal health. Contemporary Nurse; 46(1): 28-40
  5. Australian Health Ministers (2003) National Mental Health Plan 2003-2008. Canberra: Australian Government
  6. World Health Organization (2009) Mental health: strengthening mental health promotion. Retrieved September 2007 from http://www.who.int/mediacentre/factsheets/fs220/en/index.html
  7. Department of Health and Ageing (2009) National mental health policy 2008. Canberra: Commonwealth of Australia
  8. 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
  9. Parker R, Milroy H (2014) Aboriginal and Torres Strait Islander mental health: an overview. In: Dudgeon P, Milroy H, Walker R, eds. Working together: Aboriginal and Torres Strait Islander mental health and wellbeing principles and practice. 2nd ed. Canberra: Department of The Prime Minister and Cabinet: 25-38
  10. 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
  11. Steering Committee for the Review of Government Service Provision (2014) Overcoming Indigenous disadvantage: key indicators 2014. Canberra: Productivity Commission
  12. Australian Bureau of Statistics (2014) Australian Aboriginal and Torres Strait Islander health survey: biomedical results, 2012-13 - Australia: table 18 [data cube]. Retrieved 10 September 2014 from http://www.abs.gov.au/AUSSTATS/subscriber.nsf/log?openagent&table%2018%20family%20stressors%20by%20age,%20remoteness%20and%20sex,%202012-13%20-%20australia.xls&4727.0.55.001&Data%20Cubes&5319AD44A7925E65CA257CA6000E35AF&0&2012-13&26.03.2014&Latest
  13. Australian Health Ministers' Advisory Council (2015) Aboriginal and Torres Strait Islander health performance framework 2014 report. Canberra: Department of the Prime Minister and Cabinet
  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. Shields MA, Price SM, Wooden M (2009) Life satisfaction and the economic and social characteristics of neighbourhoods. Journal of Population Economics; 22(2): 421-443
  16. 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
  17. Australian Bureau of Statistics (2011) General social survey: summary results: 2010. Canberra: Australian Bureau of Statistics
  18. 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
  19. 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
  20. Australian Institute of Health and Welfare (2015) Admitted patient care 2013–14: Australian hospital statistics. Canberra: Australian Institute of Health and Welfare
  21. 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
  22. Australian Bureau of Statistics (2015) Causes of death, Australia, 2013: Deaths of Aboriginal and Torres Strait Islander Australians [data cube]. Retrieved 31 March 2015 from http://www.abs.gov.au/ausstats/subscriber.nsf/log?openagent&3303_12%20%20deaths%20of%20aboriginal%20and%20torres%20strait%20islander%20australians.xls&3303.0&Data%20Cubes&4D9A9ADDB3C2F0ACCA257E18000F913C&0&2013&31.03.2015&Latest
  23. 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
  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 (2001) Aboriginal suicide is different: a portrait of life and self-destruction [1st ed.]. Canberra: Aboriginal Studies Press
  26. Tatz C (2005) Aboriginal suicide is different: a portrait of life and self-destruction [2nd ed.]. 2nd ed. Canberra: Aboriginal Studies Press
  27. Australian Bureau of Statistics (2014) Australian Aboriginal and Torres Strait Islander health survey: updated results, 2012-13 - Australia: table 6.3 [data cube]. Retrieved 6 June 2014 from http://www.abs.gov.au/AUSSTATS/subscriber.nsf/log?openagent&472705500606.xls&4727.0.55.006&Data%20Cubes&7F2DBD07A515E7A2CA257CEE0010D7BF&0&2012%9613&06.06.2014&Latest
  28. Australian Institute of Health and Welfare (2010) Diabetes in pregnancy: its impact on Australian women and their babies. Canberra: Australian Institute of Health and Welfare
  29. Australian Institute of Health and Welfare (2014) Type 2 diabetes in Australia’s children and young people: a working paper. Canberra: Australian Institute of Health and Welfare
  30. Australian Institute of Health and Welfare (2009) Insulin-treated diabetes in Australia 2000–2007. Canberra: Australian Institute of Health and Welfare
  31. International Diabetes Federation (2013) IDF diabetes atlas. 6th ed. Brussels, Belgium: International Diabetes Federation

Endnotes

  1. For further details see ’Limitations of the sources of Aboriginal and Torres Strait Islander information’.
  2. The prevalence for Indigenous people in the 2-14 years and 15-24 years age-groups were also reported (0.5% and 1.4% respectively), but data for non-Indigenous people in these age groups was not provided [27].
  3. Data from the NT are for public hospitals only [28].
  4. Based on combined data from the National diabetes services scheme (NDSS) and the Australasian Paediatric Endocrine Group (APEG) [29].
  5. Data are for public and private hospitals in all jurisdictions [11].
  6. Based on the ICD-10-AM sixth edition codes E10-E14 (this excludes GDM) [22].
  7. It should be noted that death data on diabetes are probably an underestimate as the condition tends to be under-reported on death certificates or is not recorded as the underlying cause of death [30][31].
  8. 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’.
  9. 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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