National Aboriginal and Torres Strait Islander Leaders in Mental Health
Submission on the National Mental Health Commission’s Review of Mental Health
Services and Programmes, 17 April 2014
The review’s Terms of Reference require it to address the ‘specific challenges for Aboriginal and
Torres Strait Islander people[s]’ as they relate to the review’s wider mandate. We start our
submission by setting out those challenges and then focus on how the review could address
these in a systematic fashion.
1. What are the specific challenges facing Aboriginal and Torres Strait Islander peoples?
The rates of mental health conditions and suicide among Aboriginal and Torres Strait Islander
peoples are almost double that of other Australians and are of national concern (see Appendix).
We refer to this as the ‘mental health gap’. The reasons for this are:

The impact of colonisation and ensuing adverse social determinants. Aboriginal and Torres
Strait Islander mental health is underpinned by a broader, and uniquely Aboriginal and
Torres Strait Islander construct of health known as social and emotional wellbeing.1 This
includes healthy connections to body, mind and emotions, family, community, the spiritual
dimension of existence and traditional lands. For many communities, such negative factors
are impacting on the healthy connections that comprise their social and emotional
wellbeing and hence the mental health of their members. Some of these determinants are
shared with other Australians – poverty, unemployment, poor housing, alcohol and
substance use among them. Others, however, are unique – including racism, the impacts of
the Stolen Generations’ policies and cultural stress. The importance of social and emotional
wellbeing to Aboriginal and Torres Strait Islander mental health, and health in general, is
recognised in the soon to be renewed National Aboriginal and Torres Strait Islander Social
and Emotional Wellbeing Framework and the 2013 National Aboriginal and Torres Strait
Islander Health Plan.

Aboriginal and Torres Strait Islander peoples, historically and today, enjoy significantly less
access to mental health and related services and programs than other Australians. By
‘accessible services’, we mean by location and cost; services that do not discriminate; and
services that are culturally acceptable to Aboriginal and Torres Strait Islander peoples (or
1
‘culturally competent’). In fact, underlying the mental health gap is also an ‘access gap’
to mental health and related services. In the 2008 ABS National Aboriginal and Torres
Strait Islander Social Survey, 34.5 per cent of respondents reported high or very high
rates of psychological distress also reported access problems to health services.2
According to the Australian Institute of Health and Welfare, In 2009-10, Aboriginal and
Torres Strait Islander as private patients used mental health professionals at significantly
lower rates than other Australians: psychologist care (81 v 135 per 1,000) and
psychiatric care (45 v 87 per 1,000). 3 Further, while a higher percentage of Aboriginal
and Torres Strait Islander encounters with GPs were mental health-related compared
with those for non-Indigenous Australians (15.3% versus 11.8%), taking population size
and age structure into consideration Aboriginal and Torres Strait Islander people had a
lower rate of encounters than non-Indigenous Australians (490.7 and 567.2 per 1,000
population respectively).4
Improving Aboriginal and Torres Strait Islander mental health and reducing suicide requires:

Shifting the focus from providing biomedical forms of treatment for mental health
conditions that are preventable to a genuinely preventative population mental health
approach. Such would involve:
 Improving social and emotional wellbeing including by community empowerment
programs that build on cultural strengths. This is particularly important in relation to
suicide prevention.
 Addressing the adverse determinants that contribute to Aboriginal and Torres Strait
Islander mental health conditions and suicide.

Ensuring Aboriginal and Torres Strait Islander peoples have equal access to mental health
services as other Australians, taking into account their greater levels of need.
Closing the mental health gap should not be a matter of responding to crisis after crisis as they
occur, but rather should involve a preventative address to the determinants that undermine
Aboriginal and Torres Strait Islander mental health in addition to addressing the services gap.
This also involves building on the cultural strengths within families, communities and individuals.
2. Identifying existing funding for social and emotional wellbeing, mental health and suicide
prevention services for Aboriginal and Torres Strait Islander peoples
In the following table are listed services and programs and their private, government and nongovernment funding sources.
Broad type
Commonwealth
Aboriginal and Torres
Strait Islander-specific
programs
National Aboriginal and
Torres Strait Islander
Healing Foundation
Examples

ATAPS (Aboriginal and Torres Strait Islanderspecific) /Medicare Locals

Suicide Prevention funding (through the TATS
package)

Grants for specific programs
Funder
Primary and Mental Health
Care Division of the
Department of Health
Department of Social
Services.
2
Commonwealth
mainstream mental
health, disability and
recovery support
programs










Mental health services
provided by psychologist
and psychiatrists
Mental health services
provided by GPs
Community mental
health services
Mental health services
provided by public and
private hospitals
Mental health workforce
training and
development
Services provided by, or
through, Aboriginal and
Torres Strait Islander
Primary Health Care
Services including
Aboriginal Community
Controlled Services
Mental health services in
prisons
Research
Residential care
Mainstream ATAPS/ Better Access
Access to psychiatrists program
NDIS – support for psychiatric disability
Partners in Recovery, PHaMs, MH Respite, Support
for Day to Day Living
Phone/ internet services
Family mental health services
EEPIC
Headspace
Kidsmatter
Early childhood, men’s, school programs
Department of Health and
the Department of Social
Services
Private, some government
support, health insurance




Emergency departments
Admitted
Ambulatory equivalent
NSW Aboriginal Mental Health Workforce Program



SEWB Program
Link-up
Alcohol and substance abuse services


Psychiatric hospitals
Homes
Medicare, private (gap
payments)
State and territory/
Commonwealth
State and territory/
Commonwealth, private,
health insurance
State/ Commonwealth
Indigenous and Rural Health
Division of the
Commonwealth Department
of Health
State and territory/
Commonwealth
NHMRC, other
State and territory, private,
health insurance
As a necessary first step for the review, we recommend that an audit of spending on Aboriginal
and Torres Strait Islander peoples across all of the above (and programs relevant to the review
Terms of Reference) be carried out. This will provide a needed foundation for the review
process.
3. Securing equitable funding is a challenge facing Aboriginal and Torres Strait Islander mental
health
As noted, the Terms of Reference ask the review to consider the ‘specific challenges for
Aboriginal and Torres Strait Islander people’ as a part of its work. Of relevance here is the
mental health gap we have described and lower access to services. Based on this, we identify
equity as a further challenge facing Aboriginal and Torres Strait Islander peoples, and a question
that must be addressed by the review.
Achieving equitable outcomes and closing the mental health gap requires relative need to be
accounted for: put simply, if “X” has double the mental health needs of “Y”, “X” will likely need
3
twice the resources to enjoy an equitable mental health outcome to ‘Y”. This is far from a new
funding model. Increased expenditure on those with increased need is an established feature of
the health system: for example, older people, though a relatively small proportion of the
population, but have a higher level of need and receive a large proportion of total health
expenditure.
Allocating funding to account for the relative needs of Aboriginal and Torres Strait Islander
peoples has an evolving history. Perhaps the most recent and outstanding success in the health
field has been that of the National Health and Medical Research Council who have committed to
allocating 5% of its total annual allocation to Aboriginal and Torres Strait Islander health
research. The 5% figure was determined by multiplying the Aboriginal and Torres Strait Islander
presence in the population (2.5% at the 2006 Census) by a health needs index (in this case, twice
the non-Indigenous need).5 This approach has been particularly successful in expanding much
needed Aboriginal and Torres Strait Islander health research.
For many years the Commonwealth Grants Commission (CGC) has taken account of the relative
proportions of Aboriginal and Torres Strait Islander peoples versus non-Indigenous people
across Australia to determine Aboriginal and Torres Strait Islander-specific allocations among
jurisdictions. In 2001 the CGC went further, using a resource allocation formula to ensure that
spending on Aboriginal and Torres Strait Islander programs resulted in equitable outcomes for
Aboriginal and Torres Strait Islander people living in urban versus remote areas, taking into
account the relatively greater need of the latter.6 Similar formulae are widely used today including by state and territory Governments for hospitals and area health services.
What is equitable spending on Aboriginal and Torres Strait Islander mental health?
At the Census 2011, Aboriginal and Torres Strait Islander peoples were estimated to comprise
3% of the total population; 7 and Aboriginal and Torres Strait Islander young people to comprise
5% of the total youth cohort (at the 2011 Census, Aboriginal and/or Torres Strait Islander
individuals under 15 years of age comprised 35.8% of the total Aboriginal and Torres Strait
Islander population, compared with 18.3% of the non-Indigenous population).8
As a general rule, and as supported by the data in Appendix 1, this position paper proposes a
mental health needs index for Aboriginal and Torres Strait Islander peoples at least double that
of the non-Indigenous population. In relation to specific mental health areas, actual needs
indices would need to be determined.
This position paper therefore proposes the following as indicative equitable funding allocations
from mainstream programs:


For Aboriginal and Torres Strait Islander peoples as a total population: 6% (3% of population
x 2 mental health and social and emotional wellbeing needs index); and
For Aboriginal and Torres Strait Islander young people: 10% (5% of total youth cohort x 2
mental health and social and emotional wellbeing needs index).
Once an equitable allocation has been determined, the resultant share of mainstream
MH&SEWB funds would be used as identified funds for Aboriginal and Torres Strait Islanderspecific mental health and related programs and services.
4
For mainstream mental health programs that are demand driven, the identified equitable
allocation share could be used as both an expenditure target on Aboriginal and Torres Strait
Islander peoples and a monitoring and accountability tool, and identified shortfalls used to drive
policy initiatives to rectify access and differential use of services.
It is also important to emphasise that this is not a competitive approach but rather to provide an
indication of the proportion of the total allocation for a mainstream program that the Aboriginal
and Torres Strait Islander population, given their size and level of need, ought to receive.
It is against the benchmarks assessed by such a process that the challenge of equity should be
addressed. Clearly, if any given program or services are not funded in an equitable fashion to
benefit Aboriginal and Torres Strait Islander peoples then the cutting of such programs should
be questioned. If anything, the review provides an opportunity to re-direct funds from the
mainstream to Aboriginal and Torres Strait Islander peoples to address inequity where it occurs.
4. The most efficient way to spend Aboriginal and Torres Strait Islander mental health dollars
Implementation of the above methodology requires the review to:

Define an equitable share of funding from mainstream programs for Aboriginal and Torres
Strait Islander peoples in any given context; and

Determine the most efficient way of spending the identified share to produce the best
return on investment in terms of access and quality of service.
We propose the following as parameters for assessing efficiency:
Measure
Prevention v
cure
Holistic v
specific
Examples of the efficient use of funds

Programs that strengthen social and
emotional wellbeing, including by
building on cultural strengths

Programs that build individual
resilience.

Programs that support families and
community functioning

Programs that address the determinants
of mental health conditions and suicide
in communities.

Primary mental health care

Mental health promotion

Focus on children and young people

Integrated services that address many
aspects of a person’s life including
mental health issues – this is the
philosophy underpinning the approach
of the Aboriginal Community Controlled
Health Services

Programs that recognise the importance
of addressing the Aboriginal and Torres
Strait Islander mental health gap if the
broader health gap is to close
Examples of the inefficient use of funds

Hospitalisation for preventable mental health
and related conditions (i.e. that have gone
undetected by primary mental health care)

Programs that address mental health
conditions or suicide after the event

Programs that fail to address the causes of
mental health conditions and suicide

Programs that weaken community control or
otherwise are not supported by the
community

Programs that are not culturally appropriate
and therefore not used by further stress on
cultural practices

Dealing with depression as a biomedical issue
(i.e. with medication) and not addressing the
causal factors

Programs and services from government
siloes
5

Programs delivered across sectors and
governments
Population
(community)
focus v focus
on individuals
Culturally
competent v
mainstream
delivery

Community-wide programs with a
preventative focus

Focusing on individual biomedical
interventions


Programs delivered by mainstream service
providers without language ability or
knowledge of the community they are
serving
Broad multiple
beneficial
impacts v
narrow impact

Programs and services delivered by
Aboriginal Community Controlled
Health Services
Programs delivered by mainstream
service providers who are culturally
competent
Programs designed and delivered by a
community can increase that
community’s capacity for selfgovernance and otherwise help it
address the determinants that
undermine mental health and cause
suicide
Strengthening Aboriginal Community
Controlled Health Services.
Programs that train and employ
Aboriginal and/or Torres Strait Islander
people
Programs that make communities safer
by reducing substance use and violence
Closing the wider health gap in addition
to the mental health gap thus helping to
achieve the COAG Closing the Gap
Targets

Programs and services that are imposed from
outside the community
Programs that employ people from outside a
community
Programs that draw on funding that
otherwise could be used to deliver services
through Aboriginal Community Controlled
Services.







Spending on Aboriginal Community Controlled Health Services is efficient spending
Aboriginal and Torres Strait Islander- mental health and social and emotional wellbeing services
– usually delivered by ACCHS - are not simply ‘mainstream-substitute’- mental health services.
They are a manifestation of the human right of Aboriginal and Torres Strait Islander
communities to control the design and delivery of services that operate within them, and also
ensure community members’ access to culturally competent services.
Aboriginal and Torres Strait Islander-community-controlled mental health and social and
emotional wellbeing services are also important because of market and government failure to
provide, or ensure, services that are accessible in terms of cost, distance/ availability of
transport, and so on. The limited evidence available suggests that ACCHS provide both higher
quality and better access than mainstream services9 and the limited number of mainstream
services that are similarly effective (for example, the Inala Indigenous Health Service under the
extraordinary leadership of Dr Noel Hayman) operate in a similar way to ACCHS services10.
Among the above services there were about 187,000 client contacts with social and emotional
wellbeing staff or psychiatrists working in these services over 2010-11. This is increased from
2009-10 where there were about 175,700 client contacts, suggesting the increasing need for
services.11 These do not include contacts with other staff, such as doctors or Aboriginal and
Torres Strait Islander health workers, who are not designated as social and emotional wellbeing
6
staff. Given this, client contact numbers are likely to underestimate total access to social and
emotional wellbeing and mental health services that are culturally appropriate for Aboriginal
and Torres Strait Islander people within these services.12
Most services (98% or 224) made one or more mental health or social and emotional wellbeing
activities available to their clients. 13 The most common activities were family support and
education, home visits and short-term counselling, provided by about 4 in 5 services (79%, 79%
and 77% respectively), while ongoing counselling programs were run in 3 in 5 services (59% or
132).14 About half of services offered harm reduction and suicide prevention (54%), and mental
health promotion activities (50%).15
It is absolutely critical that funding for these services is maintained, and – if anything – increased
to meet the unmet demand for mental health and related services among Aboriginal and Torres
Strait Islander peoples.
Overuse of hospitals for mental health problems can also indicate the lack of access to services
and particularly primary mental health services where earlier interventions can prevent the
onset of more serious mental health conditions. This includes interventions for substance abuse.
In 2010-11, Aboriginal and Torres Strait Islander people were significantly over-represented in
hospitalization data for mental health conditions. While accounting for 3 per cent of the
population, they accounted for 6 per cent of the mental health-related emergency department
occasions of service, and 4.8 per cent of all emergency department occasions of service.16 It is
also telling that according to the Aboriginal and Torres Strait Islander Health Performance
Framework 2012 In the period July 2008 to June 2010, mental health-related conditions were
the principal reason for 7 per cent of hospitalisations for Aboriginal and Torres Strait Islander
peoples. Males were hospitalised at a rate of 2.2 times that of non-Indigenous males; for
females the rate was 1.5 times that of non-Indigenous females. 17Over 1998-99 – 2009 -10 there
has been a 12 per cent increase in hospitalisations for mental health conditions.18
Likewise, Aboriginal and Torres Strait Islander peoples are significantly over-represented in their
use of residential mental health care settings;19and non-residential support services. 20
All the above indicates the need to re-focus spending on ‘upstream’ and preventative mental
health programs, particularly those provided by ACCHS, rather than make cuts per se.
The focus of the review should be on spending what funds are available in a more productive
way. Preventative and primary health care expenditure offers significant cost-benefits in
Aboriginal and Torres Strait Islander health, whereas ‘downstream’ hospital expenditure is
expensive, and wasteful.
5. Spending on the Aboriginal and Torres Strait Islander workforce must be linked to equity
An Action under the Recommendation 5 of the National Mental Health Commission’s 2012
Report Card is that the:
7
Training and employment of Aboriginal and Torres Strait Islander peoples in mental
health services must increase. There must also be better support for Aboriginal and
Torres Strait Islander families. There must be regular reporting on progress.21
We support this Action for two reasons.
Equity demands that Aboriginal and Torres Strait Islander peoples are present in the mental
health workforce at the same proportion that they are present in the population
Equity demands that Aboriginal and Torres Strait Islander peoples comprise at least 3 per cent of
the total mental health workforce, and particularly across all five mainstream disciplines that
work in mental health: Psychiatry, Psychology, Mental Health Nursing, Social Work and
Occupational Therapy. As discussed, the 3 per cent figure corresponds to the proportion of
Aboriginal and Torres Strait Islander peoples in the general population.
As a first step, the review should audit the mental health workforce to assess the above. Such an
audit would reveal large gaps in the Aboriginal and Torres Strait Islander workforce across all
levels and disciplines. At present, as discussed in Health Workforce Australia’s 2013 Mental
Health Workforce Study: Mental Health Workforce Planning Data Inventory, it is not possible to
gather such data from Census results and the National Health Workforce Data Set. This is
because disaggregation beyond Aboriginal and Torres Strait Islander ‘health worker’ or
‘practitioner’ does not occur in these sources. 22
In the 2011 Census, 1256 people who identified as Aboriginal and Torres Strait Islander peoples
also identified as health workers, but it is not clear how many are mental health workers.23
Based on Census data, the Australian Indigenous Psychologist’s Association estimate that there
were (at the time of the 2011 Census) 81 Aboriginal and Torres Strait Islander psychologists in
Australia, representing about 0.4% of the profession.24
Clearly, if any given workforce training or related program or services is funded to increase the
Aboriginal and Torres Strait Islander mental health workforce, the cutting of such programs
should be questioned. As noted previously, if anything, the review provides an opportunity to
re-direct funds from the mainstream to Aboriginal and Torres Strait Islander peoples to address
inequity where it occurs, including in the mental health workforce.
Greater need must be addressed through workforce measures
There is room for a further audit of mental health and social and emotional wellbeing-worker
need against supply, taking into account the greater needs of Aboriginal and Torres Strait
Islander peoples. This could be in the form of:

an assessment against agreed worker-population ratios. For example, the NSW Aboriginal
Mental Health Policy 2006-10 aimed that there be one Aboriginal and Torres Strait Islander
mental health workers in ‘mainstream’ mental health services for every 1000 Aboriginal
and/or Torres Strait Islander individuals within the service-area by 2020;25 and

an assessment of the cultural competence capacity of the existing workforce.
8
The point is that without an understanding of the capacity of the existing mental health
workforce to meet the needs of Aboriginal and Torres Strait Islander peoples, it is not possible
to move to the next step – which is to consider efficiency.
The mental health workforce must have the capacity to work with Aboriginal and Torres Strait
Islander peoples if expensive, unnecessary hospitalisation for preventable mental health
conditions is to reduce
The review should not result in recommendations that increase the existing demand on the
limited number of Aboriginal and Torres Strait Islander mental health workers. Or should it halt
or slow down the growing (albeit still too small) numbers of non-Indigenous mental health
workers who have trained in cultural competence. (For example, through the program
developed by the Australian Indigenous Psychologists’ Association for workers in the Access to
Allied Psychological Services (ATAPS) programme).
In other words, the review should not result in cuts that have the impact of reducing those
workforce capacities. If anything, as we have noted, resources should be directed to increasing
these capacities.
Reducing these capacities will likely have one effect: increasing numbers of Aboriginal and
Torres Strait Islander peoples attending emergency departments, or being hospitalised, for
mental health conditions that are preventable, or detectable at an early stage, by primary
mental health care. And the latter is only as good as the workforce within it. Increasing
Aboriginal peoples use of hospitals for preventable mental health conditions is perhaps the most
inefficient use of resources across the system.
6. Unfunded strategies must be funded, and funding promise to strategies quarantined
The $17.8 million promised to implement the National Aboriginal and Torres Strait Islander
Suicide Prevention Strategy, should be protected
Over the 2010-11 Budget, $4.5m was allocated to tackling suicide in our communities and
tenders were invited to bid for funding according to agreed criteria. In this process over $100
million of bids were received for consideration suggesting the need for services, and the energy
in Aboriginal and Torres Strait Islander communities to address this terrible issue.
The launch of the National Aboriginal and Torres Strait Islander Suicide Prevention Strategy in
May 2013 went some way to addressing the demonstrated need for services indicated by the
earlier bidding process. In relation to this, $17.8 million was allocated most of which was
intended to support the kinds of services in communities that had bid in the earlier process.
The Strategy implementation funds were also to be used to establish a national research and
‘best and promising practice’ body or network on suicide prevention, ideally with Aboriginal and
Torres Strait Islander leadership. A particularly important focus of this new body could be the
associations of building on cultural strengths and Aboriginal and Torres Strait Islander peoples’
suicide prevention. Such a body could, over time, develop a powerful national approach to
preventing suicide in our communities, but must be given the chance to do so.
9
A strengths-focused research agenda to build the evidence base for social and emotional
wellbeing, and identify protective and risk factors in this context, is an important part of any
comprehensive response to Aboriginal and Torres Strait Islander suicide.
The renewal of the Aboriginal and Torres Strait Islander Social and Emotional Wellbeing
Framework should continue. Funding should be quarantined to ensure that the Framework is
properly implemented.
The existing Social and Emotional Wellbeing Framework is a five-year plan to guide
improvements in the mental health and social and emotional wellbeing of Aboriginal and Torres
Strait Islander peoples. However, it has never been fully implemented and partly as a result
services and programs have not been funded to meet need - as we have discussed.
As part of the implementation of the fourth National Mental Health Plan (2009 - 2014) the
Department of Prime Minister and Cabinet is leading the renewal of the Framework. The
Australian Health Ministers Advisory Council will be signatories to the renewed Framework.
The Framework Renewal Working Group within the Department of Prime Minister and Cabinet
is responsible for its development. This has consulted with the Aboriginal and Torres Strait
Islander Mental Health Advisory Group and the Aboriginal and Torres Strait Islander Mental
Health and Suicide Prevention Advisory Group as part of its work.
Work ceased on the Framework after the calling of the last federal election and the moving of
the then government into caretaker mode. While the first order of business is to finish the
Framework, funding for its implementation should be quarantined at this stage, prior to the
Commission of Audit reports in late March, to ensure that implementation of this important
document occurs.
The National Aboriginal and Torres Strait Islander Health Plan
The July 2013 launch of the Health Plan marked the fulfilment of a major commitment made by
all signatories to the Close the Gap Statement of Intent and completed a year of intense work by
the Aboriginal and Torres Strait Islander health leadership and a senior representative from the
(then) Department of Health and Ageing.
The Health Plan is a framework document that emphasises a whole of life approach with focus
on a number of priority areas including social and emotional wellbeing and mental health. The
continuation of the National Partnership Agreement on Closing the Gap in Indigenous Health
Outcomes and the Health Plan are complementary. Only if supported by necessary funding and
effectively implemented will the Health Plan will play a critical role in closing the health gap.
The next step is the development of a national implementation strategy for the Health Plan that
sets out detailed and comprehensive commitments, with measurable targets and benchmarks
to monitor progress over time.
10
7. Aboriginal and Torres Strait Islander leadership and partnership is critical to the success of
the review
Because of the many challenges set out in this position paper, Aboriginal and Torres Strait
Islander mental health poses unique challenges to the review of mental health services. These
include unique cultural factors. As such these challenges are best met under the leadership, and
in partnership with, Aboriginal and Torres Strait Islander peoples themselves.
The Sydney Declaration was issued following the meeting of state, national and international
mental health commissions and leaders in March 2013. This commits the parties to working in
‘genuine partnership with Indigenous peoples to develop mental health programs…and policy
together,’ guided by the principle of ‘nothing for us, without us’ in relation to decision-making
that touches on Aboriginal and Torres Strait Islander mental health.
In the spirit of the Sydney Declaration it is therefore critical that Aboriginal and Torres Strait
Islander leaders and experts in the fields of mental health, social and emotional wellbeing and
suicide prevention take carriage of those parts of the review that touch on mental health, social
and emotional wellbeing and suicide prevention services.
The establishment of the Aboriginal and Torres Strait Islander Mental Health and Suicide
Prevention Advisory Group (ATSIMHSPAG) in June 2013 marked a significant milestone in
Aboriginal and Torres Strait Islander social and emotional wellbeing, mental health and suicide
prevention, being the first ministerial council advisory group dedicated to these critical areas.
ATSIMHSPAG was designed to enable Aboriginal and Torres Strait Islander leaders, stakeholders
and experts in social and emotional wellbeing, mental health and suicide prevention to partner
with the Australian Government in the design and/or implementation of key strategic responses
at a critical time in their design and/or implementation. This body then is particularly suited to
task of reviewing Aboriginal and Torres Strait Islander services pending its continuation and
ministerial approval.
Further however, the author of this position paper, the National Aboriginal and Torres Strait
Islander Leaders in Mental Health, was founded in March 2014 from the Aboriginal and Torres
Strait Islander membership of the national, New South Wales, Queensland and Western
Australian mental health commissions. It too could oversee the Aboriginal and Torres Strait
Islander-specific parts of the review. Many of its members are also members of ATSIMHSPAG.
Conclusion
In the context of achieving Aboriginal and Torres Strait Islander health and mental health
equality, the ‘false economy’ of short-term savings as been seen in the past eighteen months In
some states and territories must also be critically examined. In fact a dollar saved today may
result in the need to spend many more in years to come. In particular, the national effort to
close the gap requires a shift from expenditure on hospitals to that on primary health care with
its preventative emphasis, as well as preventative health programs per se, and health promotion
activities. The longer-term prospect (i.e. by around 2030) is that spending on Aboriginal and
Torres Strait Islander health will begin to reach parity with the non-Indigenous population as
11
health equality is achieved but at this point in time and for the foreseeable future increased
spending should be expected.
We urge the review to quarantine Aboriginal and Torres Strait Islander mental health spending
at this juncture and otherwise to ensure that any redirected funds are channelled efficiently as
outlined in this paper. Despite competing economic agendas, we must as a nation find these
resources to maintain the momentum of existing efforts to close the gap in Aboriginal and
Torres Strait Islander health and mental health and build on success.
12
Appendix 1: The mental health gap and challenges in Aboriginal and Torres Strait Islander
mental health revealed by recent surveys
An overview of the Aboriginal and Torres Strait Islander population
Based on the 2011 Census, the Australian Bureau of Statistics (ABS) has estimated that the
resident Aboriginal and Torres Strait Islander population of Australia as at 30 June 2011 was
669,900 people, or 3% of the total Australian population.26 They were distributed as follows:
State or Territory
New South Wales
Queensland
Western Australia
Northern Territory
Victoria
South Australia
Tasmania
Australian Capital Territory
Estimated Aboriginal and Torres Strait
Islander population
208500
189000
88270
68,850 - 30% of the population, the highest
proportion of any State or territory
47,333
37,408
24165
6200 (Ibid)
As at 30 June 2011, around one-third of all Aboriginal and Torres Strait Islander peoples lived in
major cities (233,100 people). A further 147,700 people lived in inner regional areas and
146,100 people in outer regional areas. The remainder lived in remote 51,300 people) or very
remote areas (91,600 people)27.
Family stressors
A family stressor is an event or circumstance that a person considers has been a problem for
them, or someone close to them. In the 2012–13 Australian Aboriginal and Torres Strait Islander
Health Survey (AATSIHS 2012-13), among approximately 13,000 respondents, 73% of Aboriginal
and Torres Strait Islander peoples age 15 years and over reported that they, their family or
friends had experienced one or more stressors in the previous year.28 This table highlights the
most commonly reported stressors and some of the significant differences in the experience of
stressors reported by women and men:29
Stressor
Death of a family
member or friend
A serious illness
Inability to get a job
Mental illness
Alcohol-related
problems
Aboriginal and Torres Women
Strait Islander
population (% of
respondents)
37%
39%
Men
23%
23%
16%
Not published
24%
22%
13%
12%
22%
23%
19%
16%
34%
13
Also in the AATSIHS 2012-13:
•
For Aboriginal and Torres Strait Islander young people age 15 – 24 years, the most
common reported stressors were the death of a family member or friend (31%); inability
to get a job (24%); serious illness (19%); pregnancy (16%); mental illness (12%); and
trouble with the police (12%).30
•
In major cities and regional areas, 75% of respondents reported more than one stressor
in the previous year compared to 69% of those in remote and very remote areas.
Differences in the experience of stressors are set out in the table below31:
Stressor
Death of a family
member or friend
A serious illness
Inability to get a job
Mental illness
Overcrowding at
home
Aboriginal and
Torres Strait Islander
population (% of
respondents)
37%
Remote and very
remote
Major cities and
regional areas
42%
35%
23%
23%
16%
Not published
16%
18%
8%
14%
25%
24%
18%
9%
Psychological distress
In the AATSIHS 2012–13, respondents were asked questions about their feelings, and the
frequency of those feelings, to indicate levels of psychological distress. Based on this, the survey
reported 30% of respondents over 18 years of age as having high/very high psychological
distress levels in the four weeks before the survey interview32. This indicates a 3% increase in
Aboriginal and Torres Strait Islander peoples reporting high/very high levels of psychological
distress when compared to the 27% of respondents who reported such in the 2004-05 National
Aboriginal and Torres Strait Islander Health Survey (Ibid)33. Further:
•
Aboriginal and Torres Strait Islander peoples over 18 years were nearly three times as
likely as non-Indigenous people to have experienced high/very high levels of
psychological distress (rate ratio of 2.7). This pattern was evident for both men and
women across all age groups34.
•
Aboriginal and Torres Strait Islander women reported significantly higher levels of
psychological distress than men. Across all age groups, 36% of women compared with
24% of men reported having high/very high levels of psychological distress. Only in
women age 45–54 years was parity with men reported.35
14
•
Aboriginal and Torres Strait Islander peoples living in major cities and regional areas
reported significantly higher levels of high/very high psychological distress than those
living in remote and very remote areas (32% compared with 24%). This difference
existed across all age groups, except for those age 25–34 years.36
Suicidal thoughts and suicide attempts among Aboriginal young people
The 2004-05 Western Australian Aboriginal Child Health Survey included a sample of 1480
‘young people’ (age 12 – 17 years)37. Among these, in the 12-months prior to the survey, it
reported:
•
An estimated 15.6% had seriously thought about ending their own life. Significantly fewer
males had had suicidal thoughts (est. 11.9%) compared with females (est. 19.5%). There
were no statistically significant differences between young people in major cities, regional
areas and remote and very remote areas.38
•
Being female, at high risk of clinically significant emotional or behavioural difficulties or
being exposed to family violence, experiencing racism, and having low self-esteem or friends
who have attempted suicide were all associated with suicidal thoughts. These variables are
also associated with each other39.
•
An estimated 6.5% had tried to end their own life: 9% of females and 4.1% males. The
proportion of young people who had attempted suicide was significantly lower in areas of
extreme isolation (1.2 per cent). All other areas had similar proportions of young people
attempting suicide40.
Suicide
There were 996 Aboriginal and Torres Strait Islander suicide deaths registered across Australia
between 2001 and 2010. Suicides accounted for 4.2% of all registered Aboriginal and Torres
Strait Islander deaths in 2010, compared with 1.6% for all Australians. The overall Aboriginal and
Torres Strait Islander suicide rate was twice that of non-Indigenous people, with a rate ratio of
2.0 for males and 1.9 for females.41 Further:
•
The highest age-specific rate of suicide was among males between 25 and 29 years of
age (90.8 deaths per 100,000 population)42.
•
For females, the highest rate of suicide was amongst 20 to 24 years olds (21.8 deaths
per 100,000 population.43
•
The greatest difference in rates of suicide between Aboriginal and Torres Strait Islander
people and non-Indigenous people was in the 15-19 years age group for both males and
females. Suicide rates for Aboriginal and Torres Strait Islander females aged 15–19 years
were 5.9 times higher than those for non-Indigenous females in this age group, while for
males the corresponding rate ratio was 4.4.44
15
1
Gee, G., Dudgeon, P., Schultz, C., Hart, A. & Kelly. K. (2014) ‘Social and Emotional Wellbeing and Mental Health: An Aboriginal Perspective’. Chapter 4, In Dudgeon, Milroy and
Walker (eds) Working Together: Aboriginal and Torres Strait Islander Mental Health and Wellbeing Principles and Practice – Revised Edition. Commonwealth of Australia,
Canberra, (in press)
2
Australian Bureau of Statistics, The Health and Welfare of Australia's Aboriginal and Torres Strait Islander Peoples Oct 2010 (Accessto health and community services), ABS Cat.
No. 4704.0 (17/2/11), Online publication: http://www.abs.gov.au/AUSSTATS/abs@.nsf/lookup/4704.0Chapter935Oct+2010 (Accessed 18/7/12)
3
AIHW, Mental Health Services in Australia (2012). Online publication: http://mhsa.aihw.gov.au/services/general-practice/patient-characteristics/ (August 2012, accessed
August 2012)
4
AIHW, Mental Health Services in Australia (2012). Online publication: http://mhsa.aihw.gov.au/services/general-practice/patient-characteristics/ (August 2012, accessed
August 2012)
5 At its 144th Session in October 2002, NHMRC’s Council agreed to adopt Indigenous health research as a strategic priority and to implement the NHMRC Road Map. Council also
made a commitment to allocate at least 5% of its future research budget to Indigenous health. The Minister for Health and Ageing endorsed this approach and specific objectives
and performance measures were set out in the NHMRC Strategic Plan 2003 – 2006. See NHMRC, Strategic Plan 2003-2006, only available online at:
http://www.nhmrc.gov.au/guidelines/publications/nh46 (Accessed 19 November 2012).
6 Commonwealth Grants Commission, Inquiry into Indigenous Funding Report, Vol 1, Commonwealth of Australia 2001, Ch6, p122. Available online at:
http://www.cgc.gov.au/publications2/other_inquiries2/indigenous_funding_inquiry2/reports_and_other_documents/indigenous_funding_inquiry__final_report/indigenous_funding_inquiry_final_report_-_volume_1
7 Australian Bureau of Statistics (ABS), Census of Population and Housing - Counts of Aboriginal and Torres Strait Islander Australians, 2011, ABS cat. no. 2075.0, First issue.
Online publication: http://www.abs.gov.au/ausstats/abs@.nsf/Latestproducts/2075.0Main per
cent20Features32011?opendocument&tabname=Summary&prodno=2075.0&issue=2011&num=&view= (21/6/2012, accessed 13/7/12)
8 Australian Bureau of Statistics (ABS), Census of Population and Housing - Counts of Aboriginal and Torres Strait Islander Australians, 2011, ABS cat. no. 2075.0, First issue.
Online publication: http://www.abs.gov.au/ausstats/abs@.nsf/Latestproducts/2075.0Main per
cent20Features32011?opendocument&tabname=Summary&prodno=2075.0&issue=2011&num=&view= (21/6/2012, accessed 13/7/12)
9 ACCHS’s maternal health and early childhood programs have been established over the past three decades and have a track record in improving mother and child health
outcomes. For example, Nganampa Health Council established its Child and Maternal Health Program in the late 1980s in the Anangu Pitjantjatjara Yankunytjatjara Lands. It
comprises an antenatal care program, health education for young mothers, and a childhood health program. A 2005 evaluation reported incremental improvement in all
outcome measures in the years of its operation: from almost negligible numbers of pregnant women presenting for care prior to the end of the second trimester to, in 2005, 60
per cent presenting at, or prior to, 16 weeks of pregnancy. Thirty four percent of this cohort had visited health services over ten times over the duration of their pregnancies.
This had resulted in tangible benefits: six percent of babies were born with low birth weight in 2005 compared to 15 per cent in the late 1980s. (Department of Health and
Ageing, National Aboriginal and Torres Strait Islander Child and Maternal Health Exemplar Site Initiative: Site Reports 2005. Online publication:
http://www.health.gov.au/internet/h4l/publishing.nsf/Content/respack-exemplarsite 1/6/06, accessed 21/08/12)
10 Noel E Hayman, Nola E White and Geoffrey K Spurling, Improving Indigenous patients’ access to mainstream health services: the Inala experience, Med J Aust 2009; 190 (10):
604-606.
11
Australian Institute of Health and Welfare 2012. Aboriginal and Torres Strait Islander health services report 2010-2011: OATSIH Services Reporting key results. Cat. No. IHW 79,
Canberra, p 33. At http://www.aihw.gov.au/WorkArea/DownloadAsset.aspx?id=10737423049
12 Australian Institute of Health and Welfare 2012. Aboriginal and Torres Strait Islander health services report 2010-2011: OATSIH Services Reporting key results. Cat. No. IHW
79, Canberra, p 33. At http://www.aihw.gov.au/WorkArea/DownloadAsset.aspx?id=10737423049
13 Australian Institute of Health and Welfare 2012. Aboriginal and Torres Strait Islander health services report 2010-2011: OATSIH Services Reporting key results. Cat. No. IHW
79, Canberra, p 33. At http://www.aihw.gov.au/WorkArea/DownloadAsset.aspx?id=10737423049
14 Australian Institute of Health and Welfare 2012. Aboriginal and Torres Strait Islander health services report 2010-2011: OATSIH Services Reporting key results. Cat. No. IHW
79, Canberra, p 33. At http://www.aihw.gov.au/WorkArea/DownloadAsset.aspx?id=10737423049
15 Australian Institute of Health and Welfare 2012. Aboriginal and Torres Strait Islander health services report 2010-2011: OATSIH Services Reporting key results. Cat. No. IHW
79, Canberra, p 33. At http://www.aihw.gov.au/WorkArea/DownloadAsset.aspx?id=10737423049
16 Australian Institute of Health and Welfare, Mental Health Services in Australia, Mental health occasions of service, client charactersitics 2012,
http://mhsa.aihw.gov.au/services/disability-support/non-residential/ 17/12/13.
17 Australian Health Ministers’ Advisory Council, 2012, Aboriginal and Torres Strait Islander Health Performance Framework 2012 Report, AHMAC, Canberra, p54.
http://www.health.gov.au/internet/main/Publishing.nsf/Content/F766FC3D8A697685CA257BF0001C96E8/$File/hpf-2012.pdf
18 Australian Health Ministers’ Advisory Council, 2012, Aboriginal and Torres Strait Islander Health Performance Framework 2012 Report, AHMAC, Canberra, p54.
http://www.health.gov.au/internet/main/Publishing.nsf/Content/F766FC3D8A697685CA257BF0001C96E8/$File/hpf-2012.pdf
19 Australian Institute of Health and Welfare, Mental Health Services in Australia, Charscteristics of residential mental health care clients , 2012,
http://mhsa.aihw.gov.au/services/residential-care/client-characteristics/ 17/12/13.
20 Australian Institute of Health and Welfare, Mental Health Services in Australia, Non-residential services , 2012, http://mhsa.aihw.gov.au/services/disability-support/nonresidential/ 17/12/13.
21 National Mental Health Commission (2012), A Contributing Life: the 2012 National Report Card on Mental Health and Suicide Prevention, Sydney: NMHC, p.11.
22
Health Workforce Australia 2013, Mental Health Workforce Planning Data Inventory, Health Workforce Australia: Adelaide, p19.
23
Health Workforce Australia 2013, Mental Health Workforce Planning Data Inventory, Health Workforce Australia: Adelaide, p18.
24
Australian Indigenous Psychologists Association (undated), About AIPA, http://www.indigenouspsychology.com.au/page/2970/about-aipa (17 April 2014).
25
This target is adapted from: NSW Health (2006) NSW Aboriginal Mental Heath Policy 2006 -10, NSW Government, Sydney. Available online at:
http://www0.health.nsw.gov.au/policies/pd/2007/pdf/PD2007_059.pdf.
26 ABS 2013 - Australian Bureau of Statistics, Estimates of Aboriginal and Torres Strait Islander Australians, June 2011, Notes, ABS cat no. 3238.0.55.001, 30/08/13,
http://www.abs.gov.au/AUSSTATS/abs@.nsf/Lookup/3238.0.55.001Main+Features1June%202011?OpenDocument, (17/12/13).
27 Ibid
28 Australian Bureau of Statistics, Australian Aboriginal and Torres Strait Islander Health Survey, First Results, 2012, ABS cat. no. 4727.0.55.001, 13, 27/11/13,
http://www.abs.gov.au/ausstats/abs@.nsf/Latestproducts/4727.0.55.001Main%20Features1201213?opendocument&tabname=Summary&prodno=4727.0.55.001&issue=2012-13&num=&view= (10/1/14).
29 Ibid
30 Ibid
31 Ibid
32 Ibid
33 Ibid
34
Ibid
35
Ibid
36
Ibid
37
Zubrick SR, Silburn SR, Lawrence DM, Mitrou FG, Dalby RB, Blair EM, Griffin J, Milroy H, De Maio JA, Cox A, Li J. The Western Australian Aboriginal Child Health Survey: The
Social and Emotional Wellbeing of Aboriginal Children and Young People. Perth: Curtin University of Technology and Telethon Institute for Child Health Research, 2005.
38
Ibid.
39
Ibid.
40
Ibid.
41
ABS 2012a - Australian Bureau of Statistics, Suicides, Australia, 2010, ABS cat. no. 3309.0, 24/07/12,
http://www.abs.gov.au/ausstats/abs@.nsf/Products/3309.0~2010~Chapter~Aboriginal+and+Torres+Strait+Islander+suicide+deaths?OpenDocument (10/1/14).
16
42
43
44
Ibid.
Ibid.
Ibid.
17