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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, which 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 . Mental health 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 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 . It is the preferred terminology by many Indigenous people because of its more positive and holistic connotations.
Historically, the extent of mental illness and mental health problems in the Indigenous population have been poorly documented . 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 . More comprehensive information has since been provided by the 2008 NATSISS . 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 .
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.
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 .1 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 . 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 . 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 1). 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) . 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%).
|Type of stressor||Proportion||Ratio|
|Source: ABS, 2013 |
|Death of a family member or close friend||37||1.9|
|Not able to get a job||23||2.5|
|Alcohol or drug related problems||18||3.6|
|Trouble with the police||13||5.0|
|Involuntary loss of job||9||2.4|
|Divorce or separation||8||1.0|
|Witness to violence||8||3.9|
|Abuse or violent crime||7||3.4|
|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 .2 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 . 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 .
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 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) . 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.
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) . After age-adjustment, the hospitalisation rate for Indigenous people was 2.1 times the rate for non-Indigenous people.3
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 . 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 . 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 . 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.
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 2) .4 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.
|Cause of death||Males||Females|
|Source: AIHW (2013) |
|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 3). 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 . 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) . Death rates were higher for Indigenous males than for Indigenous females (in those jurisdictions for which details for females were available).
|Source: ABS, 2014 |
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 4) . 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.
|Age-group (years)||Indigenous||Rate ratios|
|Source: ABS, 2014 |
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 been recognised as a key indicator of Indigenous disadvantage .