National Guide

Chapter 20 | Mental health

Depression







National Guide to preventive healthcare for Aboriginal and <br/>Torres Strait Islander people
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      2. Depression

Mental health | Depression

Dr Timothy Senior 

Key messages

  • Involvement in cultural and community activities supports and protects social and emotional wellbeing (SEWB).1
  • Healthcare practitioners should be aware of different symptoms and language that may describe depression in Aboriginal and Torres Strait Islander people.
  • Healthcare practitioners should ask about symptoms of depression.2
  • Although there is ongoing work to identify and develop culturally appropriate tools, clinical judgement is advised in the use of assessment tools for depression, and tools that have not been culturally adapted should be used with caution.
  • Although further evidence is needed before most tools can be recommended for routine use, healthcare providers may still find them useful in promoting discussions with patients about their SEWB.
Type of preventive activity - Screening
Who/target population What When Strength of recommendation Key source(s) and reference(s) Rationale/key considerations informing recommendation
Aboriginal and Torres Strait Islander people aged over 15 years

Focus especially on:
  • pregnant and postpartum adults
  • people at higher risk of depression
 Ask about symptoms of depression

If an assessment tool is used, it is recommended that one designed or adapted to include Aboriginal and Torres Strait Islander concepts of depression is used (see Useful resources)		 Opportunistically and as clinically indicated Conditional International guidelines2 No evidence that screening tools for depression work without a more comprehensive screening program

On current evidence these tools may best be used as a guide for further conversation

Practitioners should be aware of different expressions of depression in their communities and be alert to circumstances where depression may be missed
Type of preventive activity - Behavioural
Who/target population What When Strength of recommendation Key source(s) and reference(s) Rationale/key considerations informing recommendation
All people No specific behavioural interventions are recommended

Involvement in local community and cultural activities, and activities that connect people to other people, community, culture and Country, are likely to be beneficial		 Ongoing Good practice point Aboriginal and Torres Strait Islander-specific cohort study1 Evidence is at an early stage but is consistent with longstanding Aboriginal and Torres Strait Islander views on social and emotional wellbeing
Type of preventive activity - Medication
Who/target population What When Strength of recommendation Key source(s) and reference(s) Rationale/key considerations informing recommendation
All people Do not prescribe medication for prevention of depression N/A     There is no evidence of any medication preventing depression.
Type of preventive activity - Environmental 
Who/target population What When Strength of recommendation Key source(s) and reference(s) Rationale/key considerations informing recommendation
All Aboriginal and Torres Strait Islander people
As per behavioural interventions
 
Support access to and availability of a range of community and cultural activities		 Ongoing Good practice point Aboriginal and Torres Strait Islander-specific cohort study1 Emerging evidence is consistent with longstanding Aboriginal and Torres Strait Islander views on social and emotional wellbeing.
  • Consider how the service can have good links in to the local Aboriginal and Torres Strait Islander community, and referral pathways to access community and cultural activities.
  • Consider how to record risk factors for depression in the clinical record and use these as reminders to ask about symptoms of depression.
  • Consider Aboriginal and Torres Strait Islander mental health first aid training for staff, particularly for non-clinical staff.
  • Consider strengthening relationships with teachers, sports coaches and other community leaders to enhance the social and emotional wellbeing support in the community.
  • Consider seeking continuing professional development training from a course run by Aboriginal and Torres Strait Islander mental health organisations and providers.
  • Consider ongoing psychological supervision.

Background

Symptoms of major depression are well described (see Box 1), but there is evidence that symptoms associated with depression are expressed differently across different cultures4 and genders.5 Clinicians need to be aware of local cultural and contextual issues in which symptoms that are suggestive of depression (physical and psychological, and mediated through language) might be expressed. There is a need for Aboriginal and Torres Strait Islander-led and community-owned research to be conducted within the Australian context to work towards increasing awareness around the varying expressions of depressive and suicidal behaviours. Clinicians can mitigate this with guidance from local Aboriginal and Torres Strait Islander health practitioners and health workers, and other cultural mentors, in understanding the local context, meaning and expression of symptoms of depression.

Data on what might be called the epidemiology of Aboriginal and Torres Strait Islander wellbeing are influenced by how culturally appropriate the measurement tools are and are derived from two main sources. One of these, the Mayi Kuwayu study, is led by Aboriginal and Torres Strait Islander people and is an ongoing study showing the links between wellbeing and connection to culture.1 The other source is the Australian Bureau of statistics national Aboriginal and Torres Strait Islander health survey (National Health Survey), most recently in 2018–19.6

Although the focus for this topic is on the prevention of depression, it is notable that in the National Health Survey close to 80% of Aboriginal and Torres Strait Islander people described themselves as ‘calm and peaceful’ and ‘full of life’ at least some of the time, whereas 87% described themselves as ‘happy’ at least some of the time compared with a little/none of the time.7

However, 36% of respondents in the Mayi Kuwayu study reported high or very high levels of psychological distress, and a further 29% reported moderate psychological distress.1 There is clear evidence from the Mayi Kuwayu study that experiences of discrimination and racism are linked to poorer SEWB. It is likely that many of the incidences of life stressors reported by Aboriginal and Torres Strait Islander people in previous national Aboriginal and Torres Strait Islander health surveys are underpinned by structural racism,8 resulting in higher rates of poverty, unemployment and exclusion from economic and community resources.

The proportion of Aboriginal and Torres Strait Islander people self-reporting high levels of psychological distress also differs geographically, being higher in non-remote areas (at 31%) than in remote areas (28%).6 Given these levels of psychological distress, it is not surprising that 24% of Aboriginal and Torres Strait Islander people reported having a mental and/or behavioural condition. People living in non-remote areas were threefold more likely than those living in remote areas to report a condition (28% versus 10%, respectively).6 The most common condition reported was anxiety (17%), with depression being the second most common.6 For both these conditions, the rate was higher among women than men.6

Instruments used to assess social and emotional wellbeing

Numerous instruments can be used to assess the psychological distress affecting Aboriginal and Torres Strait Islander people. Most instruments have been used to assess non-Indigenous populations and may not adequately cover Aboriginal and Torres Strait Islander concepts of SEWB.9 This lack of validation of the tools for use with Aboriginal and Torres Strait Islander Australians means their widespread use is not recommended. To quote the Australian Psychological Association, ‘Particular caution should be exercised where tests have not been extensively tried with Indigenous people and where test norms for those Indigenous populations are non-existent’.10 Moreover, Aboriginal and Torres Strait Islander communities in Australia are very diverse, and the use of any instrument requires clinical discretion to accommodate this diversity.

One of the most widely used tools in Australia for monitoring and assessing psychological distress is the Kessler Psychological Distress Scale (K10).11 This tool has not been validated as a screening tool for depression. Moreover, there are concerns from Aboriginal and Torres Strait Islander people that the K10 is not culturally appropriate for use within their communities. For this reason, the K10 was adapted in an Australian Bureau of Statistics stakeholder workshop, including representatives from the National Aboriginal Community Controlled Health Organisation, to make it more appropriate for use in Aboriginal and Torres Strait Islander communities. The resulting questionnaire has five questions and is known as the K5.12 The Mayi Kuwayu study further adapted the K5 questions for their surveys (MK-K5), to include slight modifications to the wording of questions and some clarifying statements. The K5 questions, and the modified version (ie MK-K5) questions are shown in Table 1.13,14 

Table 1. Questions on the modified Kessler five-item (K5) and Mayi Kuwayu modified K5 (MK-K5) questionnaires to measure psychological distress
In the last four weeks, how often have you felt …
K5 MK-K5
Nervous Nervous
Without hope Hopeless (have no hope)
Restless or jumpy Restless or jumpy
That everything was an effort Everything was an effort (have no energy)
So sad that nothing could cheer you up Sad
 

The MK-K5 demonstrated face validity for psychological distress in Aboriginal and Torres Strait Islander people, and a cut-off score of 11/25 identified self-reported depression or anxiety.14 It is likely that the MK-K5 version of the measure is more appropriate for Aboriginal and Torres Strait Islander people, but there is still no evidence for its use as an outcome measure. Similarly, there is no evidence for its use as a screening tool for depression. Even if the MK-K5 does more accurately identify those who are more likely to have depression, its use for individuals presenting to a service will depend on clinical judgement, and it cannot, at this stage, be recommended for widespread use as a community or population screening tool. 

Other non-Indigenous questionnaires have been adapted for use with Aboriginal and Torres Strait Islander peoples. One example is the Pearlin Mastery Scale,15 adapted for use in Arnhem Land with extensive involvement of the Yolgnu Community.

Brown et al adapted the PHQ-9,16 involving the expertise of focus groups of men from primary language groups in Central Australia. Given that the PHQ-9 is one of the most validated tools for screening for depression, this adaptation may prove to be very useful, and some Aboriginal Community Controlled Health Organisations have adopted it for routine use. The adapted PHQ-9 questions are provided in Table 2. 

Table 2. Adapted questions from the Patient Health Questionnaire (PHQ-9), developed for potential use for screening Aboriginal and Torres Strait Islander people for depression
Questions None A little bit Most of the time All of the time
In the last two weeks, how often have you been feeling the following:
1 Have you been feeling slack, not wanted to do anything? 0 1 2 3
2 Have you been feeling unhappy, depressed, really no good, that your spirit was sad? 0 1 2 3
3 Have you found it hard to sleep at night, or had other problems with sleeping? 0 1 2 3
4 Have you felt tired or weak, that you have no energy? 0 1 2 3
5aA Have you not felt like eating much even when there was food around? 0 1 2 3
5bA Have you been eating too much food? 0 1 2 3
6 Have you been feeling bad about yourself, that you are useless, no good, that you have let your family down? 0 1 2 3
7 Have you felt like you can’t think straight or clearly, it’s hard to learn new things or concentrate? 0 1 2 3
8aA Have you been talking slowly or moving around really slow? 0 1 2 3
8bA Have you felt that you can’t sit still; you keep moving around too much? 0 1 2 3
9 Have you been thinking about hurting yourself or killing yourself? 0 1 2 3
    Total score (0–27)  

ANote: Scores for depressive symptoms – record only the highest in each of these subquestions.

Scoring (from the non-adapted PHQ-9): <5 = minimal depression; 5–9 = mild depression; 10–14 = moderate depression; 15–19 = moderately severe depression; 20-27 = severe depression. 

The adapted PHQ-9 has been tested as a screening tool for depression in a range of Aboriginal and Torres Strait Islander communities, and achieved 91% specificity and 54% sensitivity for a cut-off score of 10.17 Importantly, in developing the adapted PHQ-9, seven key features of depression in Aboriginal men were identified that were not covered by the PHQ-9 questionnaire. These were anger, weakened spirit, homesickness, irritability, excessive worry, rumination, and drug or alcohol use. An earlier study of the adapted PHQ-918 also tested a subset of two questions: 

  • ‘Over the past two weeks, have you felt down, depressed or hopeless?’
  • ‘Over the past two weeks have you felt little interest or pleasure in doing things?’  

In that study of Aboriginal and Torres Strait Islander men with ischaemic heart disease attending an Aboriginal Medical Service in Darwin, an answer of ‘Yes’ to either question was 100% sensitive and 12.5% specific for depression.18 This means that a negative result rules out depression, but there are many false positives. It is not known how applicable this result is to other Aboriginal and Torres Strait Islander people without ischaemic heart disease. The cultural appropriateness of these questions has not been assessed more broadly in Aboriginal and Torres Strait Islander communities. However, the use of these tools to screen for depression in Aboriginal and Torres Strait Islander peoples is promising, and may guide clinician assessments, but cannot be currently recommended for widespread implementation.

Numerous tools have been developed specifically by and for Aboriginal and Torres Strait Islander peoples that take a more strengths-based approach to assessing wellbeing, as detailed below.

  • The Strong Souls assessment tool (see Useful resources) was developed by the Menzies School of Health Research as a measure of sSEWB in the Aboriginal Birth Cohort Study. Although the tool is freely available, it has not been validated and there are no guidelines on its scoring. It may be useful to guide conversations in a clinical setting, but it cannot be recommended for use as a screening tool.
  • The Westerman Aboriginal Symptom Checklist (see Useful resources), developed by Nyamal psychologist Dr Tracy Westerman AM, comes in versions for youth (WASC-Y) and adults (WASC-A). These checklists are designed to identify Aboriginal people at risk of depression, suicidal behaviours, drug and alcohol use, impulsivity, anxiety and cultural resilience as a moderator of risk. They show promise as potentially valuable screening tools in the future. The tools are only accessible through accredited training.
  • The Here and Now Aboriginal Assessment (HANAA)19 takes the form of a yarning circle, promoting a conversation in a range of areas relating to SEWB , rather than a series of rated questions. It takes a broad approach to SEWB but is still oriented towards mental health diagnosis and treatment in mental health settings. The HANAA tool has been designed for use by those working in health and mental health services and community-based services. It is a screening tool exploring a range of SEWB domains and is intended to determine whether a formal mental health assessment is needed. It is not intended to be diagnostic for depression. HANAA has been used in various Aboriginal medical services and appears to be useful and culturally appropriate by those using the tool.20 It still requires validation in a broad range of settings.
  • The Kimberley Mum’s Mood Scale (KMMS) is an adaptation of the Edinburgh Postnatal Depression Scale for use in Aboriginal and Torres Strait Islander communities in the Kimberley in north-western Australia, together with a second section to promote a conversation about psychosocial protective and risk factors. Validation studies showed that the KMMS can detect women most at risk of anxiety and depression in the postnatal period.21 It has not been validated in communities outside the Kimberley.

Although further evidence is needed before these tools can be recommended for routine use, healthcare providers may still find them useful in promoting discussions with patients about their social and SEWB. They may be especially useful for clinicians who do not have established relationships within an Aboriginal and Torres Strait Islander community and may lack expertise in assessing SEWB . There are courses that are associated with or are a requirement of using some of the tools, which may further enhance a clinician’s skills. Further, non-Indigenous Australian clinicians must be reminded of the importance of cultural competency and the continual and developmental nature of such awareness when ensuring the safety of their Aboriginal and Torres Strait Islander patients*.

*Note that while acknowledging that some services may prefer the term ‘client’, this chapter uses the term ‘patient’. This is consistent with the rest of the National Guide and does not change any of the recommendations.

The evidence base for screening programs in depression is all taken from high-quality systematic reviews performed overseas. Although there is some evidence of acceptability and validity of specific tools, as discussed above, there are no trials of screening programs for depression in Aboriginal and Torres Strait Islander people. Although this may limit the applicability of the findings in Aboriginal and Torres Strait Islander people, there is still a lot of work done by researchers, services and clinicians to diagnose and treat depression in people in their communities. In this context, using the best available evidence on screening for depression is still important to prevent an approach that denies effective interventions or promotes therapeutic nihilism.
Two systematic reviews found that screening or case-finding instruments for depression had little or no impact on the recognition, management or outcome of depression in primary care or hospital settings.22,23 Evidence of benefit from screening programs for depression has been demonstrated only in settings where there is a substantial degree of supportive infrastructure. Improved outcomes may be achievable where patients identified by the screening program receive intensive support as part of a multifaceted intervention.24

Although it is hard to know how applicable the evidence is for Aboriginal and Torres Strait Islander peoples, the systematic review commissioned by the U.S. Preventive Services Task Force (USPSTF) for the recently updated recommendations found there was evidence that screening for depression was associated with a reduction in symptoms of depression after 6–12 months in those screened.2 The screening programs were very varied in the way they managed those with depression, but generally had a clinician who did further assessment and was able to treat or refer on for further support. The specific USPSTF recommendation is to screen the adult population, including pregnant and postpartum adults, as well as older adults.25
The optimal timing and frequency of screening is unknown. For example, with one screening tool (the Center for Epidemiologic Studies Depression scale, which measures the severity of depression) patient scores indicative of probably depression fluctuated, with 22% of those with probable depression not meeting the criteria two weeks later.26 This is likely to be true of other tools, and repeat screening may be required.

The USPSTF systematic review found no pattern of effects that might worsen outcomes for patients.2 However, there are potential harms from medical treatment. Increased prescription of selective serotonin reuptake inhibitor (SSRI) medications for depression is associated with a small increased risk of suicidal ideation and, in older people or those taking concurrent non-steroidal anti-inflammatory drugs, there is an increased risk of upper gastrointestinal bleeding.24

In Aboriginal and Torres Strait Islander people, screening for depression can be recommended if there is an appropriately skilled workforce and the capacity to diagnose, treat and follow up people with depression. Given that the assessment tools currently available are not appropriate for use in widespread screening, clinicians should use their clinical judgement when using the tools to guide conversations with their patients about their social and emotional wellbeing. If services do not have the capacity to have these conversations with all their patients, they might focus on those at higher risk of depression, including members of the Stolen Generations and their descendants, and those in whom depression is most likely to be missed, such as those who may have cultural expressions of their symptoms unfamiliar to the practitioner.

Despite uncertainties on optimal screening recommendations, the mainstay of depression care should continue to be the use of a careful clinical assessment. In relation to the care of Aboriginal and Torres Strait Islander peoples, this assessment must be guided by culturally appropriate tools assessing social and emotional wellbeing, as described above. Of primary importance is the presence of an ongoing therapeutic relationship. Treatment for depression might include judicious use of antidepressants as part of a management plan that includes ongoing support from skilled healthcare professionals who are aware of the local culture and context. Where available, this will include Aboriginal health practitioners and health workers. Referral pathways to local social and emotional wellbeing teams, psychologists and mental health workers will also be important, and external pathways and services will need to be able to practise in a culturally safe way and have good links to the local Aboriginal and Torres Strait Islander community.
 

The evidence base led by Aboriginal and Torres Strait Islander researchers is now catching up to what Aboriginal and Torres Strait Islander people have been saying for decades: that connection to culture is protective of SEWB. The Mayi Kuwayu study identified six domains of culture,1 as follows:

  • connection to Country
  • cultural beliefs and knowledge
  • language
  • family, kinship and community
  • cultural expression and continuity
  • self-determination and leadership.

There is evidence that each of these domains is linked to aspects of SEWB. The Mayi Kuwayu study is ongoing and likely to develop a much more complete and nuanced description of the relationship between these cultural domains and SEWB. Although it is too early to recommend specific cultural programs for the prevention of depression, it is likely that locally based programs that enhance connection to culture under these domains will be protective and should be encouraged by health professionals at both an individual and a community level.

Much of the evidence focuses on the treatment of depression rather than prevention. There is weak evidence that psychosocial interventions in the elderly may have a small effect on preventing depression27 and there is some evidence that exercise is mildly beneficial in the prevention of depression for children and adolescents,28 although there is no research exploring this impact with regard to Aboriginal and Torres Strait Islander people.

There is currently limited evidence that interventions targeting children and adolescents in other settings, such as communities, schools and workplaces, are effective for children or adolescents in the long term.29 There is weak evidence that social activities for older people can produce statistically significant reductions in symptoms of depression, but the magnitude of effect is unlikely to be clinically significant.27

There is increasing use and recommendation of online or eHealth-based activities to prevent and manage depression.27,30 These are mostly based around cognitive behavioural therapy or interpersonal therapy techniques. The evidence on these technologies for the prevention of depression is inconsistent.29,31 Meanwhile, there is evidence that the literacy levels required to use eMental health resources is beyond that of most Australians,32 and those with low education levels may be more likely to experience a deterioration in their symptoms.33 Once again, there are no specific trials in Aboriginal and Torres Strait Islander people, and no cultural assessment or adaptations of online tools. Although there will be Aboriginal and Torres Strait Islander people for whom the use of an online tool to prevent depression is accessible and appropriate, these tools cannot be recommended for widespread use for the prevention of depression.

Although the use of social media is sometimes reported to cause depression, the picture is complex, and likely depends on the way it is used34 and the degree to which interactions are supportive or harmful. Although it may be appropriate to enquire as to whether people’s online interactions are having an effect, beneficial or harmful, on their mental health, there are no general recommendations that can be made regarding social media use and the prevention of depression.
There is no evidence to support the use of antidepressant medication for the primary prevention of depression in the general population.
 

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