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Good mental health is essential to the health and wellbeing of individuals, families, and communities . 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 .
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 . It is influenced by a complex interplay of biological, psychological, social, environmental, and economic factors . People with good mental health are able to contribute to community life, participate in the workforce, and foster meaningful and positive relationships with others .
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 , 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 . 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 . 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 . It goes beyond traditional mental health 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 . It is the preferred terminology by many Indigenous people because of its more positive and holistic connotations.
The extent of mental illness and mental health problems has been recognised as ‘a major difficulty for most [Indigenous] communities’ (, p.7), but the precise details have been poorly documented up until the 2004-2005 NATSIHS , 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 .
After age-adjustment, the 2008 NATSISS found that Indigenous people aged 18 years or older were more than 2.6 times as likely as their non-Indigenous counterparts to feel high or very high levels of psychological distress . 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) . 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. An association 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 . 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’ . Several stressors, including ‘pregnancy’, ‘time in jail’, ‘overcrowding at home’, and ‘treated badly/discrimination’, were reported only for the Indigenous population.
|Type of stressor||Indigenous status / year|
|Proportion of Indigenous people (%)||Proportion of total population (%)|
|Source: AIHW, 2011 , ABS, 2011 |
|Death of a family member or close friend||40||23|
|Serious illness or disability||33||30|
|Not able to get a job||23||15|
|Trouble with the police||15||--|
|You, a family member or friend spent time in jail||13||--|
|Overcrowding at home||13||--|
|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 through the inclusion of measures of positive wellbeing . 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 . The lack of comparable data precludes definitive statements about the positive wellbeing of Indigenous people compared with that of non-Indigenous people, but 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 are influenced by the support a person receives from their social networks . 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 GSS found that 94% 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 . 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, 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) . 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.
Reflecting the high levels of distress experienced by many Indigenous people, 13,824 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 2010-11 (7.5% of Indigenous separations, excluding those for dialysis) . After age-adjustment, the hospitalisation rate for Indigenous people was 2.1 times the rate for non-Indigenous people.10
Information about hospitalisation for the specific sub-categories within the ICD chapter ‘Mental and behavioural disorders’ are not available for 2010-11, but data from 2008-09 show hospitalisation rates for each sub-category were generally higher for Indigenous people than for other Australians . For this period, the age-adjusted separation rates for mental and behavioural disorders due to ICD ‘Substance use disorder’ were 3.8 times higher for Indigenous people living in NSW, Vic, Qld, WA, SA and the NT than for their non-Indigenous counterparts. Similarly, the rate for Indigenous people for ICD ‘Schizophrenia, schizotypal, and delusional disorders’ was 2.9 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 living in NSW, Vic, Qld, WA, SA and the NT in 2010-11 . The most recent information available for hospital admission rates for intentional self-harm shows Indigenous people living in NSW, Vic, Qld, WA, SA and the NT were more likely to be admitted for intentional self-harm than were non-Indigenous people in 2008-09 . After age-adjustment, 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 separation rate for intentional self-harm – more than three times the rate reported for non-Indigenous people.
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’11, accounting for 2% of all deaths among Indigenous people . After age-adjustment, the death rate for Indigenous males for ‘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.
More recent data are available for deaths due to ICD ‘Intentional self-harm’12 (suicide), which is not included among the deaths for ICD ‘Mental and behavioural disorders’. In 2010, the death rate for ‘Intentional self-harm’ for Indigenous people living in NSW, Qld, WA, SA, and the NT was 2.4 times the rate reported for non-Indigenous people . For the period 2006-2010, deaths from intentional self-harm were much higher for Indigenous people living in NSW, Qld, WA, SA, and the NT than for non-Indigenous people, particularly for males. Age-standardised death rates in these jurisdictions ranged from 18 per 100,000 (NSW) to 59 per 100,000 (WA) for Indigenous males; rates for non-Indigenous males ranged from 13 per 100,000 (NSW) to 24 per 100,000 (NT). Rates were highest for Indigenous people living in WA (36 per 100,000) and the NT (28 per 100,000) (Table 18).
|Source: ABS, 2012 |
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. Data for NSW, Qld, WA, SA and the NT in 2006-2010 show the highest death rates for intentional self-harm were among Indigenous people aged 15-24 and 25-34 years (40 and 44 per 100,000 respectively) . The burden of suicide is highest among Indigenous males aged 15-24 and 25-34 years (rates of 55 and 72 per 100,000 respectively), but is also very high among young Indigenous females (Table 19). The suicide rates for Indigenous females aged 15-24, 25-34, and 35-44 years were more than six times higher than the rates for their non-Indigenous female counterparts. The suicide rate for Indigenous females aged 15-24 years was higher than the rates for non-Indigenous males in this age-group.
|Age-group (years)||Indigenous||Non-Indigenous||Rate ratio|
|Source: ABS, 2012 |
Research in NSW, Qld, the ACT, and the NT has highlighted the increasing impact of suicide among young Indigenous people . 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’ (, 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. 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’.