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Tier 3 - Health system performance

3.10 Access to mental health services

Key facts

Why is it important?

Aboriginal and Torres Strait Islander people experience a higher rate of mental health issues than non-Indigenous Australians with deaths from suicide almost twice as high; hospitalisation rates for intentional self-harm 2.7 times as high and a rate of high/very high psychological distress 2.4 times as high as for non-Indigenous Australians (see measure 1.18 Social and emotional wellbeing). While Indigenous Australians use some mental health services at higher rates than non-Indigenous Australians, it is difficult to assess whether this use is as high as the underlying need. Leading Indigenous mental health researchers and advocates maintain that mental health care for Indigenous Australians remains inadequate and inequitable (Dudgeon et al. 2020).

Social, historical and economic disadvantage contribute to the high rates of physical and mental health problems, adult mortality, suicide, child removals and incarceration, which in turn lead to higher rates of grief, loss and trauma (see measure 1.18 Social and emotional wellbeing). Most mental health services address mental health conditions once they have emerged rather than addressing the underlying causes of distress, using a clinical approach that treats rather than prevents. Even so, early access to effective services can help diminish the effects of these problems and help restore people’s emotional and social wellbeing.

Mental health care may be provided by specialised mental health care services (for example private psychiatrists, and specialised hospital, residential or community services), or by general health care services that supply mental health related care (for example general practitioners (GPs) and Indigenous primary health care organisations).

The social determinants of health are the conditions in which people are born, grow, live, work and age, and are mostly responsible for health inequalities (WHO 2020). The causes of inequality have been identified as unequal access to health care, schools and education, conditions of work and leisure, housing, and the associated chances of leading a healthy life (Australian Psychological Society 2018). The causes of this inequality are due to the structural disadvantage brought about by social policy, economic systems and the distribution of power and resources. Social determinants of health also have substantial effects on mental health and social and emotional wellbeing, and people with a mental health illness are more likely to have experienced disadvantage and be on a low income, with many living in poverty. In these circumstances, people are not only more likely to experience mental illness but are also less likely to be able to access mental health support services due to their situation.

Findings

What does the data tell us?

In the 2018–19 National Aboriginal and Torres Strait Islander Health Survey (Health Survey), 31% (45,800) of Indigenous Australian adults with high/very high levels of psychological distress had visited a health professional about their distress in the previous four weeks.

The rate was higher for Indigenous females (33%; 29,025) compared with Indigenous males (28%; 16,865), and for those living in Non-remote areas (31%; 38,565) compared with Remote areas (27%; 6,933) (Table D3.10.1).

In 2017–18, 10.6% (82,847) of Indigenous Australians accessed Medicare Benefits Schedule (MBS) subsidised clinical mental health-care services (that is, consultant psychiatrists, clinical psychologists, GPs and allied health professionals), as did 10.5% of non-Indigenous Australians (SCRGSP 2020).

In 2018–19, the proportion of Indigenous and non-Indigenous Australians aged under 25 years who accessed MBS-subsidised primary mental health-care services (that is, clinical psychologists, GPs and allied health professionals) was roughly the same (8.5% and 8.6%, respectively)­­­. In Victoria, Indigenous Australians aged under 25 were 1.4 times as likely as non-Indigenous Australians to have contact with these services (13.5% compared with 9.5%). In comparison, in the Northern Territory, they were half as likely to do so (1.9% compared with 4.1%) (SCRGSP 2020).

Based on the Bettering the Evaluation and Care of Health (April 2010–March 2015) survey data, 11% of all problems managed by GPs among Indigenous patients were related to mental health. Depression (47 per 1,000 encounters) and anxiety (23 per 1,000 encounters) were the main mental health related problems managed. After adjusting for differences in the age structure between the two populations, GPs managed mental health problems for Indigenous Australians at 1.2 times the rate as for Other Australians (173 and 139 per 1,000 encounters, respectively) (Table D1.18.21, Figure 3.10.1). (Other Australians includes non‑Indigenous Australians and those whose Indigenous status is unknown.)

Figure 3.10.1: Age-standardised rate of mental health related problems managed by general practitioners, by Indigenous status of the patient, April 2010–March 2015

This bar chart shows that the rate for Indigenous Australians was 173 per 1,000 GP encounters, compared with 139 per 1,000 encounters for Other Australians. Other Australians includes non-Indigenous Australians and those with unknown Indigenous status.

Source: Table D1.18.21. Analysis of BEACH data by the Family Medicine Research Centre.

Indigenous primary health-care organisations

In 2017–18, 55% (108) of the 198 Australian Government funded Indigenous primary health-care organisations provided mental health promotion activities (Table D3.03.9). Of the 198 organisations, 89% (177) provided clients access (onsite, offsite, or both) to a psychiatrist, while 94% (187) provided access to a psychologist (AIHW 2019a).

As at 30 June 2018, these organisations employed 534 full time equivalent social and emotional wellbeing staff (Table D3.22.11). In 2017–18, these staff provided over 217,100 client contacts for social and emotional wellbeing, the majority of which were for Indigenous clients (86% or 186,500) (AIHW 2019a).

More detailed data for social and emotional wellbeing services offered through Indigenous primary health-care organisations was available for 2016–17. In this period, the most common issues related to social and emotional wellbeing managed in terms of staff time and organisational resources were depression (77%), anxiety and stress (76%), grief and loss issues (64%), family and community violence (60%) and family and relationship issues (57%) (AIHW 2018a).

In 2016–17, there were 88 organisations funded by the Commonwealth to provide care on social and emotional wellbeing or Link Up counselling services to Indigenous Australians (72 of these were also funded for primary health care and are included above). Eight of these organisations provided Link Up services that assist clients with family tracing and provides reunion support. Within these organisations, 189 counsellors provided 77,068 client contacts to 16,324 clients (an average of 4–5 contacts for each client) (AIHW 2018a).

Community and residential mental health services

In 2017–18, state and territory-based specialised community mental health services reported approximately 902,900 service contacts for Indigenous clients (10% of service contacts). The rate for Indigenous Australians was 3.3 times the rate of non-Indigenous Australians and was higher across all age groups, particularly those aged 25–44 (Table D3.10.3, Figure 3.10.2).

Figure 3.10.2: Community mental health care service contacts, by Indigenous status and age group, 2017–18

This bar chart shows that Indigenous Australians were more likely than non-Indigenous Australians in all age groups to have a mental health care service contact, the overall age-standardised rates were 1,151 per 1,000 compared with 348 per 1,000, respectively. Indigenous Australians aged 35–44 were most likely to have a service contact (2,074 per 1,000), followed by those aged 25–34 (1,778 per 1,000) and 15–24 (1,550 per 1,000).

Note: Totals are age-standardised.

Source: Table D3.10.3. AIHW analysis of National Community Mental Health Care Database.

The community mental health care contact rate for Indigenous Australians was highest in the Australian Capital Territory (2,688 per 1,000) and lowest in Tasmania (360 per 1,000). In New South Wales, the rate of Indigenous Australians was 3.9 times the rate of non-Indigenous Australians (1,385 and 358 per 1,000 respectively) (Table D3.10.4). By remoteness, the rate for Indigenous Australians was highest in Major cities (1,312 per 1,000), and lowest in Very remote areas (523 per 1,000). In Major cities, the rate of Indigenous Australians was 3.9 times the rate of non-Indigenous Australians (333 per 1,000) (Table D3.10.11).

The rate of residential mental health care episodes in the same period was 6.4 per 10,000 for Indigenous Australians—2.1 times the rate for non-Indigenous Australians (3.0 per 10,000) (Table D3.10.5).

In 2017, for clinical psychologists, there were 32 full-time equivalent staff per 100,000 people in Remote/Very remote areas compared with 105 per 100,000 in Major cities (Table D3.22.19).

In 2017–18, after adjusting for differences in the age structure between the two populations, Indigenous Australians were 67% as likely as non-Indigenous Australians to have claimed through Medicare for psychologist care (144 per 1,000 compared with 215 per 1,000). The same was for psychiatric care (58% as likely, 56 per 1,000 compared with 96 per 1,000) (Table D3.10.2).

In 2015–16, after adjusting for differences in the age structure between the two populations, Indigenous Australians were 4.3 times as likely to have utilised the Access to Allied Psychological Services program than non-Indigenous Australians (826 per 1,000 compared with 193 per 1,000) (AIHW 2020).

Hospitalisation

From July 2015 to June 2017, there were 42,185 hospitalisations for Indigenous Australians with a principal diagnosis of mental health related conditions. After adjusting for differences in the age structure between the two populations, the hospitalisation rate for mental health issues for Indigenous Australians was 1.8 times the rate for non-Indigenous Australians (31 per 1,000 compared with 18 per 1,000). The rate of Indigenous males was 2.1 times the rate of non-Indigenous males, and for Indigenous females, it was 1.5 times that of non-Indigenous females. The hospitalisation rate for Indigenous Australians was highest for those aged 35–44 (56 per 1,000), which was 2.3 times the rate of non-Indigenous Australians for the same age group (25 per 1,000) (Table D1.18.14).

Between 2004–05 and 2016–17, there was a 65% increase in the hospitalisation rate for Indigenous Australians due to mental health related conditions (from 20 to 32 per 1,000), in the six jurisdictions with Indigenous identification data of adequate quality (New South Wales, Victoria, Queensland, Western Australia, South Australia and the Northern Territory). This compared with an increase of 17% for non-Indigenous Australians (from 15 to 18 per 1,000) over the period. Trends for Indigenous Australians differed by sex: there was a 76% increase for females in this period, compared with a 55% increase for males (Table D1.18.20, Figure 3.10.3).

Figure 3.10.3: Age-standardised hospitalisation rates for mental health related conditions, by Indigenous status, NSW, Vic, Qld, WA, SA and NT, 2004–04 to 2016–17

This line chart shows that the hospitalisation rate for Indigenous Australians increased from 20 to 32 per 1,000 over the period for mental health related conditions. The Indigenous rate remained higher than the non-Indigenous rate for the entire period, but the gap increased from 5 to 15 per 1,000.

Source: Table D1.18.20. AIHW analysis of National Hospital Morbidity Database.

From July 2015 to June 2017, after adjusting for differences in the age structure between the two populations, the largest difference in the hospitalisation rate for mental health related conditions between Indigenous and non-Indigenous Australians was in South Australia (a difference of 34 per 1,000), followed by the Northern Territory (a difference of 23 per 1,000). The rate in Tasmania was lower for Indigenous Australians compared with non-Indigenous Australians (18 per 1,000 and 24 per 1,000) (Table D1.18.15, Figure 3.10.4).

Figure 3.10.4: Age-standardised hospitalisation rates for mental health related conditions, by Indigenous status and jurisdiction, July 2015 to June 2017

This bar chart shows that the hospitalisation rate for Indigenous Australians was highest in South Australia, at 47 per 1,000, and lowest in Tasmania, at 18 per 1,000. For all other jurisdictions the Indigenous rate ranged from 25 to 33 per 1,000. The Indigenous rate was higher than for non-Indigenous Australians in all jurisdictions, except for in Tasmania, where the non-Indigenous rate was 24 per 1,000.

Source: Table D1.18.15. AIHW analysis of National Hospital Morbidity Database.

Hospitalisations for mental health care can be divided into two main categories: ambulatory-equivalent (comparable to care provided by community mental health-care services) and admitted patient care.

From July 2015 to June 2017, Indigenous Australians were less likely (0.3 times) than non-Indigenous Australians to receive ambulatory-equivalent care that involved specialised psychiatric care (1.6 compared with 5.1 per 1,000), yet for ambulatory-equivalent care that did not involve specialised psychiatric care, Indigenous Australians received care at a rate 2.6 times that of non-Indigenous Australians (4.0 compared with 1.5 per 1,000). For admitted patient mental health care, the hospitalisation rate for Indigenous patients were about twice the rate of non-Indigenous patients where there was specialised psychiatric care (12.6 and 6.6 per 1,000), and 3.1 times the rate where there was no specialised psychiatric care (13 and 4.2 per 1,000) (Table D3.10.7).

In 2017–18, the rate of available psychiatric beds in public psychiatric hospitals ranged from 8.2 per 100,000 in Major cities to 3.2 per 100,000 in Inner regional areas and 1.3 per 100,000 in Outer regional areas (Table D3.10.10).

For mental health care provided in hospitals, the average length of stay was 13 days for Indigenous patients and 14 days for non-Indigenous patients (Table D3.10.8).

From 2017–18, 5.7% (30,630) of all emergency department presentations for Indigenous patients were mental health-related, compared with 3.4% for non-Indigenous Australians (AIHW 2020).

Homelessness service clients

In 2017–18, 23% (14,700) of Indigenous clients seeking specialist homelessness service assistance had presented with a current mental health issue—an increase from 14% (6,200) in 2011–12 (AIHW 2019b).

What do research and evaluations tell us?

Colonisation disrupted sources of social and emotional wellbeing within cultures, communities and families, with resulting intergenerational impacts (Calma et al. 2017). These effects are exacerbated by the negative impact of social determinants today, including the forced removal of children from families, racism and broader forms of social exclusion. A demographic assessment of life outcomes facing Stolen Generations survivors and their descendants used data from the Health Survey and National Aboriginal and Torres Strait Islander Social Survey to identify individuals who were born before 1972 and who reported being removed from their families (AIHW 2018b). In 2014–15, compared with other older Indigenous Australians who did not report having been removed, the Stolen Generations aged 50 years and over were found to be 1.5 times as likely to have poor mental health. The descendants, who were not removed themselves, but who have elder relatives who were removed, were 1.3 times as likely to have poor mental health, compared with those who did not experience any type of removal.

An analysis of over 400 Indigenous suicide deaths in Queensland from 1994 to 2007 found that only 23% had received treatment from a mental health professional in their lifetime, compared with 42% of non-Indigenous cases (De Leo et al. 2011). Only 10% of Indigenous cases were seen by a mental health professional in the three months prior to suicide, compared with 26% of non-Indigenous cases.

The Aboriginal and Torres Strait Islander Suicide Prevention Evaluation Project identified success factors for suicide prevention and developed a suite of community tools (Dudgeon et al. 2016b). This evaluation recommended that all mental health service provider staff working with Indigenous Australians at risk of suicide, and in Indigenous communities be required to achieve key performance indicators in cultural competence and the delivery of trauma informed care.

Guidelines have recently been developed containing specific recommendations for the effective and appropriate psychosocial assessment of Indigenous Australians presenting to hospital with self-harm and suicidal thoughts (Leckning et al. 2019). The guidelines are intended to enhance existing practices with aims including developing the cultural competency of hospital staff in providing more culturally responsive and culturally safe mental health services, improving patient satisfaction with hospital services and encouraging help-seeking behaviours.

Barriers to accessing mental health services include perceived potential for unwarranted intervention from government organisations, long wait times (more than one year), lack of inter-sectoral collaboration and the need for culturally competent and culturally safe approaches, including in diagnosis (McGough et al. 2017; Williamson et al. 2010).

Two primary mental health care initiatives were introduced through Australia’s national Access to Allied Psychological Services (ATAPS) program—Aboriginal and Torres Strait Islander Mental Health Services (from July 2010) and the Aboriginal and Torres Strait Islander Suicide Prevention Services (from July 2011). These initiatives were intended to improve access to, and the cultural appropriateness and cultural safety of, ATAPS services for Indigenous Australians (Reifels et al. 2018). The introduction of these enhanced services increased the uptake of Indigenous ATAPS services between 2010 and 2013 (Reifels et al. 2015). Data from 2015–16 show that, after adjusting for differences in the age structure between the two populations, Indigenous Australians were 4.3 times as likely as non-Indigenous Australians to use ATAPS (AIHW 2020; DoHA 2012). An evaluation of these services conducted interviews with 31 service providers, but it was limited by a lack of data on the perspectives of Indigenous stakeholders and service users (Reifels et al. 2018). Implementation strategies included: local service needs assessments; Indigenous stakeholder consultation and partnership development; establishment of clinical governance frameworks; workforce recruitment, clinical/cultural training and supervision; stakeholder and referrer education; and service co-location at Indigenous health organisations. The findings from the evaluation highlighted that national primary mental health care initiatives need to be complemented with local agency-level and provider-level efforts in partnership with Indigenous stakeholders to optimise their integration and use within local Indigenous community and health-care service contexts.

Research into the extent to which primary health care services undertake social and emotional wellbeing (SEWB) screening analysed 3,407 Indigenous client records between 2012 and 2014 from a sample of 100 government and community controlled Indigenous primary health care (PHC) services in the Northern Territory, Queensland, South Australia and Western Australia (Langham et al. 2017). Screening involved the use of standard SEWB tools, such as the Kessler 5, Kessler 6, Kessler 10, Patient Health Questionnaire 2, Patient Health Questionnaire 9, and Edinburgh Postnatal Depression screen. Other standard tools could also be used. There was wide variation in the screening rate at the state/territory level, and variation was also related to PHC service characteristics. Overall, around one-quarter (26.6%) of clients were screened for SEWB in the two years prior to the audit, and no further action was taken for 25.4% of clients for whom a SEWB concern was identified. Langham and others (2017) suggested the lack of national guidelines for SEWB screening and management means there is no guidance for best practice when providing these services, which may contribute to the wide variation in SEWB service provision. The data set used for this study was not a representative sample of Indigenous PHC services, and only captured those that were part of the Audit and Best Practice for Chronic Disease research project, a national research-based Continuous Quality Improvement initiative focused on improving Indigenous primary health care.

The nine-item Patient Health Questionnaire (PHQ-9) has been used for nearly two decades as a screening tool for depression and for assessing symptom severity in a wide range of cultural settings, but had not been formally validated for use in Indigenous Australian communities (Getting it Right Collaborative Group et al. 2019). The PHQ-9 text was re-worded in “Aboriginal English” and found to be internally consistent in a study with Indigenous Australians from central Australia. The Getting it Right study assessed the validity of the culturally adapted nine-item Patient Health Questionnaire (aPHQ-9) as a screening tool for depression among Indigenous Australians attending PHC services. This was a prospective, observational diagnostic accuracy study with 500 participants, undertaken in 10 Indigenous PHC services in New South Wales, Queensland, Western Australia, South Australian, the Australian Capital Territory and the Northern Territory and. The study found that the aPHQ-9 was an effective screening tool for depression in Indigenous Australians, and was regarded as acceptable by 86% of participants, while 13% felt that some or all questions were too personal. While adapting the aPHQ-9 for use with people from five Indigenous language groups, seven key features of depression in Indigenous Australian men not covered by the aPHQ-9 were identified. These were: anger, weakened spirit, homesickness, irritability, excessive worry, rumination, and drug or alcohol use. Additional questions were developed for assessing these features.

The Royal Commission into Victoria’s Mental Health System Interim Report (2019) recommended expansion of social and emotional wellbeing teams throughout Victoria, and that these teams be supported by a new Aboriginal Social and Emotional Wellbeing Centre (Armytage et al. 2019). The Final Report is due in early 2021. The Royal Commission heard significant concerns from Indigenous organisations and experts about the intersections between the mental health and justice systems for Indigenous Australians. Systemic racism and intergenerational trauma contribute to the over-representation of Indigenous Australians in the Victorian justice system. The Commission heard that when Indigenous Australians enter the justice system, mental health supports were often inaccessible or inappropriate.

Research into the effects of stigma and discrimination related to problematic alcohol and other drug use in Queensland found that most participants felt they could not obtain support for mental health and problematic alcohol and other drug use when they needed it (QMHC 2020). Participants felt judged by mainstream service providers, and noted the services lacked an understanding of the experiences of Indigenous Australians. They hesitated to seek support from service providers because of ‘personal shame and fear that they will be judged by staff or recognised by other Indigenous patients’, and tended to access mainstream services only in a crisis. Participants suggested that mainstream services could help overcome this barrier of shame associated with mental health issues, for example by enabling discreet access to the building.

Aboriginal Community Controlled Health Services (ACCHS) have partnered with government service providers to establish new mental health programs, and increased Indigenous Australians’ access to mental health services (Campbell et al. 2018). The Maga Barndi Mental Health Service, run through the Geraldton Regional Aboriginal Medical Service, was introduced to provide a culturally safe service to Indigenous Australians in Geraldton and Midwest Western Australia (Laugharne et al. 2002). Following the commencement of this service, there was a marked increase in use of mental health services by Indigenous Australians in the area, and psychiatric admissions for Indigenous patients at the local hospital were reduced by 58%.

Most mental health and wellbeing services are delivered by non-Indigenous practitioners (Mullins & Khawaja 2017). A qualitative research project conducted semi-structured individual interviews with twelve non-Indigenous psychologists experienced in working with Indigenous Australians and based in Queensland, the Northern Territory, Western Australia, New South Wales and Victoria (in Major cities, Regional and Remote locations). Participants saw flexibility, adaptability and willingness to step beyond traditional psychology as essential. Ongoing attention and effort must be paid to relationships. Trust, respect, honesty, collaboration and safety were fundamental to good relationships with Indigenous clients, their family, community, local Elders, and colleagues. Trauma-informed and client-specific approaches were important, and approaching cultural competence development as a journey rather than a destination.

Qualitative research conducted with Aboriginal mental health workers (AMHW) working in community mental health (CMS) services in rural and remote New South Wales found that most of the research participants reported an attitude from other staff that anything ‘Aboriginal’ was their responsibility, and assumed that Indigenous clients would always want to see an Indigenous worker (Cosgrave et al. 2018). One participant reported that they were trying to instil greater cultural understanding among staff, to teach staff that they shouldn’t assume Indigenous clients would want to see an Indigenous worker, and that they should ask the client.

While the prevalence of mental illness is similar across Australia, evidence suggests that people living in Outer regional and Remote areas access mental health services at much lower rates than people living in Major cities and Inner regional areas (DoH 2018). Almost one-fifth (18.6%) of Indigenous Australians live in Remote or Very remote areas (6.7 % in Remote and 11.9% per cent in Very remote), compared to only 2% of non-Indigenous Australians (ABS 2018). There are low numbers of mental health professionals such as psychiatrists, mental health nurses and psychologists in regional and remote areas (DoH 2018). A ‘unique combination of factors’ are believed to contribute to low rates of access to mental health services and high rates of suicide in rural and remote communities. These include poor access to primary and acute health care, social and geographical isolation, limited mental health services, funding restrictions, stigma around mental illness and the cost of travelling to and accessing mental health services (DoH 2018). In addition to these factors, Indigenous Australians also face cultural barriers and a lack of culturally appropriate mental health services. Fly-in, fly-out (FIFO) and outreach services are often provided for communities in these areas. Communities are often not receptive to FIFO workers as they visit for short periods, lack local knowledge and do not build relationships with the community (SCAC Secretariat 2018). Telehealth has increasingly played an important role in mental health service provision in rural and remote Australia, but evidence suggests that access to the internet for telehealth varies widely across these areas (SCAC Secretariat 2018).

Recent studies have shown that remote culturally appropriate health care may be enhanced by the use of telehealth because it allows care to be provided in the supportive environment of an Aboriginal Community Controlled Health facility. It allows for the advocacy and assistance of an Indigenous health worker and reduces the burden of travel and dislocation from community and family (Caffery et al. 2018). With increasing evidence on the effectiveness of e-mental health interventions for enhancing mental health and wellbeing of remote Indigenous populations, a growing challenge is how to translate promising research findings into service delivery contexts (Bennett-Levy et al. 2017). A recent review of digital health solutions found there was limited evidence for digital solutions in Indigenous contexts beyond specific examples and pilot projects (Hensel et al. 2019). Digital solutions fell into three categories: remote access to specialists; building and supporting local capability; and patient-directed interventions. Further to telehealth services, some digital Apps treatments have also been found to be effective in treating anxiety and depression in Indigenous Australians, some outcomes being similar to those of non-Indigenous patients. Mental health digital App treatment options if further developed and promoted could help in overcoming barriers to access to mental health care for Indigenous Australians (Titov et al. 2018).

Implications

Mental health and substance use disorders were the leading cause of the total burden of disease for Indigenous Australians (19%) and were also responsible for 14% of the gap with non-Indigenous Australians (AIHW 2016). While the rate of several types of mental health care and services use may be similar or higher for Indigenous Australians compared with non-Indigenous Australians, there remains unmet need particularly for specialist services, such as clinical psychologists in Remote and Very remote areas.

ACCHS have an important role in delivering culturally safe mental health services to Indigenous communities, as the community-based model of care can be empowering for Indigenous Australians with mental illness (SCAC Secretariat 2018). Aboriginal community controlled substance use treatment and support services also play an important role. Indigenous community-led innovations are developing local, culturally based SEWB programs and new ways of working with mainstream systems (Calma et al. 2017). There is also a need to support growth in the Indigenous mental health workforce, and build the cultural competence of the mainstream mental health workforce.

To support access to mental health services for Indigenous Australians, all mental health services need to offer a culturally safe environment. Culturally valid understandings must shape the provision of services and guide assessment, care and management of Indigenous Australians’ health (DoH 2017). There are a range of tools and strategies practitioners can use to help them develop key competencies to be culturally respectful and effective in their practice in Indigenous mental health. Telehealth has great potential to deliver care in culturally appropriate settings such as ACCHS and reduces the burden of travel on patients, allowing them to remain with their family and community.

A lack of understanding regarding Indigenous Australians’ life experiences, stressors, and concept of SEWB and its relationship with mental health, has ‘posed problems for policy-makers and to mental health service delivery in the past two decades’ (Dudgeon et al. 2016a). The solutions for addressing mental health issues for Indigenous Australians requires a ‘best of both worlds’ approach, including clinical and specialised, culturally informed areas of practice’ (Calma et al. 2017).

The Gayaa Dhuwi (Proud Spirit) Declaration proposes that change is needed across all levels of the mental health system, and that an approach guided by self-determination is needed (Dudgeon et al. 2016a). In particular, Indigenous leadership is needed to ensure that culturally informed practices are available in addition to clinical responses, and that there is an appropriate balance of clinical and culturally informed mental health system responses to mental health problems among Indigenous Australians (Calma et al. 2017). New approaches are needed that acknowledge disempowerment, cultural losses, racism, and how the cumulative, stressful effect of entrenched poverty and disadvantage adversely affect Indigenous mental health. Key responses needed are the healing of trauma in a culturally appropriate context in a way that includes families and communities as well as individuals, and those that are aimed at strengthening SEWB, which is a protective factor.

The effects of the COVID-19 pandemic have heightened the urgency of the need for accessible and affordable internet access and culturally safe and trauma-informed digital and telehealth services for Indigenous communities (Dudgeon et al. 2020).

The National Strategic Framework for Aboriginal and Torres Strait Islander Peoples’ Mental Health and Social and Emotional Wellbeing 2017–2023 provides a dedicated focus on Indigenous Australian social and emotional wellbeing and mental health and sets out a comprehensive and culturally appropriate stepped care model that applies to both Indigenous specific and mainstream health services (PM&C 2017). The framework is designed to complement the Fifth National Mental Health and Suicide Prevention Plan (the Fifth Plan), endorsed in 2017. The Fifth Plan seeks to establish a national approach for collaborative government effort from 2017–2022 across eight targeted priority areas, including improving Indigenous Australian mental health and suicide prevention.

Reform of the Australian mental health system is a focus of the Australian Government’s Long Term National Health Plan, including the Vision 2030 for Mental Health and Suicide Prevention blueprint and implementation roadmap for which consultations occurred in late 2020.

More information on the framework, the Fifth Plan and the Implementation Plan for the Fifth Plan is in Policies and strategies.

The policy context is at Policies and strategies.

References

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