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 that exists within the field [2].

National government 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]. It 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 lifetimes [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 discourse 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.

Extent of mental illness and mental health problems among Indigenous people

Prevalence

The extent of mental illness and mental health problems has been recognised as ‘a major difficulty for most [Indigenous] communities’ ([7], p.7), but the precise details have been poorly documented up until the 2004-2005 NATSIHS [8], and, particularly, the 2008 National Aboriginal and Torres Strait Islander Social Survey (NATSISS). The NATSISS sought to provide a broad understanding of Indigenous social and emotional wellbeing by collecting information on psychological distress, stressors, positive wellbeing, social networks and social support, and removal from family [9].

After adjusting for differences in age structures of the Indigenous and total Australian populations, the 2008 NATSISS found that Indigenous people aged 18 years or older were more than two-and-a-half times as likely as their non-Indigenous counterparts to feel high or very high levels of psychological distress [10]. A significantly greater proportion of Indigenous people reported feeling sad and without hope than did their non-Indigenous counterparts.

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 2008 NATSISS, 79% of Indigenous people aged 18 years and over experienced at least one significant stressor in the previous 12 months (Table 17) [11]. During this time, Indigenous people reported experiencing an average of 4.5 stressors; the most commonly reported stressor being death of a family member or close friend. A pattern was observed between psychological distress levels and stressors: high or very high levels of distress were associated with high numbers of reported stressors among Indigenous people.

In comparison, 62% of the total population reported in the 2010 General Social Survey (GSS) that they experienced at least one or more significant stressors in the previous 12 months [12]. The proportions reporting specific stressors were generally higher for Indigenous people than for the total population, particularly for ‘death of a family member or close friend’ and ‘trouble with the police’ [11][12]. Several stressors, including ‘pregnancy’, ‘time in jail’, ‘overcrowding at home’, and ‘treated badly/discrimination’, were reported only for the Indigenous population.

Table 17: Proportions of stressors reported in the previous 12 months, by Indigenous status, year and stressor type, Australia, 2008 and 2010

	Indigenous status/year
	indigenous	Total population
Type of stressor	2008	2010
Source: AIHW, 2011 [11] ABS, 2011 [12]
Notes: Proportions are expressed as percentages The content of this table is restricted to the more frequently reported stressors Data have not been age-standardised The total population proportion for ‘serious illness or disability’ data has been estimated by adding proportions for the two sub-components together, so may slightly overstate the true proportion The 2010 GSS combined alcohol and drug related problems within the one sub-category
Death of a family member or friend	40	23
Serious illness or disability	33	30
Not able to get a job	23	15
Alcohol-related problems	21	8
Mental illness	17	13
Pregnancy	17	--
Drug-related problems	15	--
Trouble with the police	15	4
You, a family member or friend spent time in jail	13	4
Overcrowding at home	13	-
Treated badly/discrimination	10	-
Total reporting stressor(s)	79	62

The 2008 NATSISS sought to broaden the scope of social and emotional wellbeing information captured by going beyond the deficit focus of the 2002 survey and including of measures of positive wellbeing [9]. Indigenous people reported on feelings of calmness and peacefulness, happiness, fullness of life, and energy. Nine-tenths (90%) of Indigenous people reported feeling happy either some, most, or all of the time, approximately 21% reported feeling energetic a little or none of the time, and around 16% reported feeling full of life, and calm and peaceful, a little or none of the time [10]. The lack of comparable data precludes definitive statements about the positive wellbeing of Indigenous people compared with that of non-Indigenous people. However, the greater frequency of psychological distress in the Indigenous population, together with the type and number of stressors reported, suggests Indigenous people experience lower levels of social and emotional wellbeing than do non-Indigenous people.

Social and emotional wellbeing is influenced by the support a person receives from their social networks [13]. Data from 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 2006 GSS found that 93% of non-Indigenous people were able to access support at a time of crisis.

Removal from one’s natural family also has significant implications for a person’s social and emotional wellbeing [14]. The 2008 NATSISS revealed that Indigenous people who had been removed, or 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. Almost two-fifths (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. Three-tenths (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 remains the most recent and detailed source of information. The WAACHS, undertaken in 2001 and 2002, reported that 24% of Indigenous children and young people aged 4-17 years were rated by their parents as being at high risk of clinically significant emotional or behavioural difficulties (compared with 15% in the general WA population) [15]. 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. Around 72% 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 22% had experienced seven or more such events.

Hospitalisation

Reflecting the high levels of distress experienced by Indigenous people, 12,099 of the hospital separations with a principal diagnosis of ICD ‘mental and behavioural disorders’ were identified as Indigenous in NSW, Vic, Qld, WA, SA and the NT in 2009-10 (7.6% of separations excluding those for dialysis) [16]. Information about hospitalisation rates are not available for 2009-10, but the hospitalisation rate of Indigenous males for ‘mental and behavioural disorders’ in 2008-09 in was 28 per 1,000, 2.2 times the rate for non-Indigenous males [10]. For the same period, the hospital rate for ‘mental and behavioural disorders’ among Indigenous females was 23 per 1,000, 1.4 times the rate for non-Indigenous females. ⁶

Hospitalisation for the specific sub-categories within the ICD chapter ‘mental and behavioural disorders‘ was generally higher for Indigenous people than for the total population [10]. In 2008-09, the separation rates of mental and behavioural disorders due to ICD ‘schizophrenia, schizotypal, and delusional disorders’ were 4.1 times higher for Indigenous people than for their non-Indigenous counterparts in NSW, Vic, Qld, WA, SA and the NT. Similarly, the rate for Indigenous people for ICD ‘substance use disorder’ was 3.8 times higher than the rate for non-Indigenous people.

Hospital admissions for intentional self-harm were also more common for Indigenous people than for non-Indigenous people living in NSW, Vic, Qld, WA, SA and the NT in 2008-09 [10]. Separation rates were 2.7 times higher for Indigenous males and 2.2 times higher for Indigenous females than for their non-Indigenous counterparts. Indigenous people living in remote areas had a particularly high rate of separations for intentional self-harm – more than 3 times the rate reported for non-Indigenous people.

Mortality

In 2005-2009, 268 Indigenous people living in NSW, Qld, WA, SA, and the NT died as a result of ICD ‘mental and behavioural disorders’ ⁷, accounting for 2% of all deaths among Indigenous people [10]. Based on indirect standardisation, it has been estimated that the death rate for Indigenous males due to ‘mental and behavioural disorders’ in 2005-2009 was 2.5 times the rate for non-Indigenous males. For the same period, the death rate for Indigenous females due to ‘mental and behavioural disorders’ was 1.6 times the rate for non-Indigenous females.

The reported number of deaths for ICD ‘mental and behavioural disorders’ do not include deaths due to ICD ‘intentional self-harm’ ⁸(suicide), which accounted for a further 453 deaths in 2005-2009 [10]. Deaths from intentional self-harm were much higher for Indigenous people than for non-Indigenous people, particularly for males (Table 18). Age-standardised death rates ranged from 17 per 100,000 (NSW) to 65 per 100,000 (NT) for Indigenous males, and from 12 per 100,000 (Qld) to 15 per 100,000 (WA) for Indigenous females. Rates for Indigenous people were higher than those for non-Indigenous people in all jurisdictions, with the rate ratios highest for SA for males (3.4) and WA for females (3.3).

Table 18: Age-standardised death rates for intentional self-harm, by Indigenous status and sex, and Indigenous:non-Indigenous rate ratios, NSW, Qld, WA, SA and the NT, 2005-2009

Jurisdiction	Indigenous	Non-Indigenous	Rate Ratio
Males	Females	Males	Females	Males	Females
Source: Steering Committee for the Review of Government Service Provision, 2011 [10]
Notes: Indirect standardisation rates per 100,000 population; rate is not available for Indigenous females for NSW, SA, and NT Rate ratio is the Indigenous rate divided by the non-Indigenous rate Due to the incomplete identification of Indigenous status, these figures probably under-estimate the true differences between Indigenous and non-Indigenous people n.p. indicates data not published
NSW	17	n.p.	12	4	1.4	n.p.
Qld	39	12	17	4	2.3	2.6
WA	51	15	17	5	3.4	n.p.
SA	60	n.p.	18	5	3.4	n.p.
NT	65	n.p.	20	n.p.	3.2	n.p.
All jurisdictions	39	10	15	4	2.6	2.4

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 non-Indigenous people, particularly those aged less than 25 years and 25-34 years (Table 19) [10].

Table 19: Death rates for intentional self-harm, by Indigenous status and age-group, and Indigenous:non-Indigenous rate ratios, NSW, Qld, WA, SA and the NT, 2005-2009

Age group (years)	Indigenous	Non-Indigenous	Rate Ratio
Source: Steering Committee for the Review of Government Service Provision, 2011 [10]
Notes: Crude rates per 100,000 population Rate ratio is the Indigenous rate divided by the non-Indigenous rate The ‘All ages’ death rates for the Indigenous and non-Indigenous populations are indirect standardised death rates Due to the incomplete identification of Indigenous status, these figures under-estimate the true differences between Indigenous and non-Indigenous people
Under 25	14	4	4.1
25-34	41	13	3.3
35-44	30	14	2.1
45 and over	10	12	0.8
All ages	24	10	2.5

Research in NSW and the ACT, Qld, and the NT has highlighted the increasing impact of suicide among young Indigenous people [17][18][19]. 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’ ([20], p.88), but it is certainly a manifestation of mental health problems. The level of intentional self-harm has certainly been recognised as a key indicator of Indigenous disadvantage [10].

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. Swan P, Raphael B (1995) "Ways forward": national Aboriginal and Torres Strait Islander mental health policy national consultancy report. Canberra: Department of Health and Ageing, Australia
8. Australian Bureau of Statistics (2006) National Aboriginal and Torres Strait Islander Health Survey: Australia, 2004-05. Canberra: Australian Bureau of Statistics
9. 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
10. Steering Committee for the Review of Government Service Provision (2011) Overcoming Indigenous disadvantage: key indicators 2011. Canberra: Productivity Commission, Australia
11. Australian Institute of Health and Welfare (2011) Aboriginal and Torres Strait Islander health performance framework 2010: detailed analyses. Canberra: Australian Institute of Health and Welfare
12. Australian Bureau of Statistics (2011) General social survey: summary results, Australia, 2010 : Personal stressors [data cube]. Retrieved 30 September 2011 from http://www.abs.gov.au/AUSSTATS/subscriber.nsf/log?openagent&4159do011_gss2010.xls&4159.0&Data%20Cubes&0EEA50189835C2CCCA25791A00146784&0&2010&30.09.2011&Latest
13. 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
14. 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
15. 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
16. Australian Institute of Health and Welfare (2011) Australian hospital statistics 2009-10. Canberra: Australian Institute of Health and Welfare
17. 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
18. Tatz C (2001) Aboriginal suicide is different: a portrait of life and self-destruction [1st ed.]. Canberra: Aboriginal Studies Press
19. Measey ML, Li SQ, Parker R, Wang Z (2006) Suicide in the Northern Territory, 1981-2002. Medical Journal of Australia; 185(6): 315-319
20. Tatz C (2005) Aboriginal suicide is different: a portrait of life and self-destruction [2nd ed.]. 2nd ed. Canberra: Aboriginal Studies Press

Endnotes

6. 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’.

7. Mental and behavioural disorders include ICD-10 codes F00-F99.

8. Under the ICD, intentional self-harm is classified under ‘External causes of morbidity and mortality’ (codes X60-X84, Y87.0).

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