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National guide to a preventive health assessment for Aboriginal and Torres Strait Islander people


Chapter 17: Mental health
Prevention of depression
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☰ Table of contents


Recommendations: Prevention of depression

Preventive intervention type

Who is at risk?

What should be done?

How often?

Level/ strength of evidence

References

Screening

All people aged ≥15 years
 
Universal screening for depression is not recommended. Identify those people in whom the risk of depression is greater (Box 4)
 
As part of annual health assessment
 
IB 22
GPP 30
People in whom depression risk is greater (Box 4) For those with a higher risk of depression, ask about symptoms of depression.

Consider using one of the ‘social and emotional wellbeing’ or mental health assessment tools to guide the conversation. Options include the Kessler Psychological Distress Scale (K-5) (Box 2), the Here and Now Aboriginal Assessment (HANAA) tool, the Patient Health Questionnaire 9 (PHQ-9), PHQ-9 adapted (Box 3), and the PHQ-2 (refer to ‘Resources’)
  GPP 24

Behavioural

All people aged ≥15 years Behavioural interventions are not recommended for primary prevention of depression   ID 27-29

Chemo-prophylaxis

All people aged ≥15 years Medications are not recommended for primary prevention of depression   GPP  

Environmental

All people aged ≥15 years Community-based psychosocial programs are not recommended for primary prevention of depression   IC 27, 29
 

Box 1. Concepts of social and emotional wellbeing2

‘In broad terms, social and emotional wellbeing is the foundation for physical and mental health for Aboriginal and Torres Strait Islander peoples. It is a holistic concept which results from a network of relationships between individuals, family, kin and community. It also recognises the importance of connection to land, culture, spirituality and ancestry, and how these interact and affect the individual.

Social and emotional wellbeing may change across the life course: what is important to a child’s social and emotional wellbeing may be quite different to what is important to an Elder. However, across the life course a positive sense of social and emotional wellbeing is essential for Aboriginal and Torres Strait Islander people to lead successful and fulfilling lives.’

 

Box 2. K-5 questionnaire to measure psychological distress14

Instructions

The following five questions ask about how you have been feeling in the last four weeks. For each question, mark the circle under the option that best describes the amount of time you felt that way.

 

None of the time

A little of the time

Some of the time

Most of the time

All of the time

1. I n the last four weeks, about how often did you feel nervous?

1

2

3

4

5

2.  In the last four weeks, about how often did you feel without hope?

1

2

3

4

5

3.  In the last four weeks, about how often did you feel restless or jumpy?

1

2

3

4

5

4.  In the last four weeks, about how often did you feel everything was an effort?

1

2

3

4

5

5.  In the last four weeks, about how often did you feel so sad that nothing could cheer you up?

1

2

3

4

5

The total score is obtained by adding the score for each item. Minimum score = 5; maximum score = 25.
Psychological distress can be classified as: low: 5–7; moderate: 8–11; high: 12–14; very high: 15–25.

 

Box 3. PHQ-9 questions, adapted for potential screening of Aboriginal men in central Australia 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

5a$

Have you not felt like eating much even when there was food around?

0

1

2

3

5b$

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

8a$

Have you been talking slowly or moving around really slow?

0

1

2

3

8b$

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)

$Note: Scores for depressive symptoms – record only the highest in each of these sub-questions.

Scoring (from the non-adapted PHQ-9):

<5 = minimal; 5–9 = mild; 10–14 = moderate; 15–19 = moderately severe; 20–27 = severe.

Reproduced with permission of Springer Nature from Brown AD, Mentha R, Rowley KG, Skinner T, Davy C, O’Dea K.

Depression in Aboriginal men in central Australia: Adaptation of the Patient Health Questionnaire 9. BMC Psychiatry 2013;13(1):271; published by BioMed Central.

 

Box 4. People in whom depression risk is greater24

  • Exposure to adverse psychosocial events, such as unemployment, divorce or poverty
  • A previous history of depression or suicide attempts
  • A history of physical or sexual abuse
  • A history of substance misuse
  • Presence of other chronic diseases, including chronic pain
  • Multiple presentations to health services may also be an indicator of depression

Factors that make it more likely that depression will be missed include:

  • Limited consultation time
  • Presentations of mostly physical or atypical symptoms
  • Health professional attitudes – for example, the belief that nothing can be done, or that depression is a normal response to stress
  • Communication difficulties



Background


The National Mental Health Plan 2003–08 noted that mental health is an area where ‘diverse views exist and ... terms are used in different ways’.1 The term ‘social and emotional wellbeing’ is often inaccurately considered synonymous with ‘mental health’. Social and emotional wellbeing implies a holistic, strengths- based approach, and is distinguished from a disease-oriented medical model (Box 1).

Social and emotional wellbeing is a key component of the Aboriginal definition of health. It includes concepts of connection to country, kin and community and is applicable across the whole lifecycle.3 However, much of the research in this area is performed in settings outside Aboriginal and Torres Strait Islander communities, without Indigenous ownership, and is grounded within a more Western, individualistic, medical model of health. As such, inclusion criteria and outcomes are determined by Western-centric diagnostic categories, such as those in the Diagnostic and statistical manual of mental disorders, 5th edition (DSM-5),4 and do not incorporate Indigenous perspectives. In looking at evidence to make recommendations for the prevention
of depression and suicide, this chapter recognises there can be tensions between biomedical-oriented and Indigenous-oriented concepts of mental health.
There is increasing evidence that symptoms associated with depression are differently expressed across various cultures5 and by gender.6 Clinicians need to be aware of local cultural and contextual issues in which symptoms suggestive of depression might be expressed. There is a need for Indigenous-led and community- owned studies to be conducted within the Australian context to work towards increasing awareness around the varying expressions of depressive and suicidal behaviours.

Depression is recognised to be a major health and wellbeing issue in Aboriginal and Torres Strait Islander communities. The National Aboriginal and Torres Strait Islander Health Survey (NATSIHS) of 2012–13 showed that 30% of Aboriginal and Torres Strait Islander adults reported high to very high levels of psychological distress. This was 2.7 times the age-adjusted rate for non-Indigenous people. High levels of psychological distress were associated with being unemployed and with education to year 9, compared with reaching year 12.7

The NATSIHS also found high rates of self-reported stress for Aboriginal and Torres Strait Islander adults (aged >18 years), with at least one stressor being reported by Aboriginal and Torres Strait Islander peoples 1.4 times as often as by the non-Indigenous population (Table 1).1 These stressors are interrelated and often linked to the social determinants of health and wellbeing, such as poverty, unemployment, exposure to racism and exclusion from economic and community resources.

The proportion of Aboriginal and Torres Strait Islander people self-reporting psychosocial stress also differs by remoteness. A significantly higher proportion of people reported experiencing one or more stressors (in the previous year), such as the inability to get a job, mental illness, or other serious illness, in non-remote compared with remote areas. However, a higher proportion in remote (than in non-remote) areas cited the death of a family member and overcrowding at home as family stressors.8

The rates of hospitalisation for mental and behavioural disorders are approximately three times as high for Aboriginal and Torres Strait Islander peoples compared to non-Indigenous people.9

The NATSIHS also found high rates of self-reported stress for Aboriginal and Torres Strait Islander adults (aged >18 years) compared to the general population (Table 1).1 These stressors are interrelated, often linked to broader life experiences, and contribute to comorbidity associated with other medical conditions.

The high prevalence of these stressors in adults also has effects on children. The West Australian Aboriginal Child Health Survey found that 70% of children were living in families that had experienced three or more significant life events in the previous 12 months.10

Table 1. Proportion of Aboriginal and Torres Strait Islander people around Australia selfreporting psychological distress and significant life events7,8

Type of stressor

Proportion of Aboriginal/Torres Strait Islander people reporting this stressor in previous year

Death of a family member or friend

37%

Serious illness or disability

23%

Not able to get a job

23%

Alcohol-related problems

14%

Drug-related problems

11%

The person/family member/close friend spent time in jail

10%

Witness to violence

8%

Trouble with police

13%

Treated badly because they are an Aboriginal and/or Torres Strait Islander person

7%

Any stressor

73%

Adapted from Australian Bureau of Statistics. Australian Aboriginal and Torres Strait Islander Health Survey: First results, Australia, 2012–13. Canberra: ABS, 2013.


Conversely, cultural and social factors can have a profound protective effect on Aboriginal and Torres Strait Islander peoples’ social and emotional wellbeing. Continuing connection to country and culture are, for example, protective, as are increasing income, increased level of education and participation in the labour force.11

 

 

Instruments used to assess social and emotional wellbeing



A number of instruments can be used to assess the psychological distress affecting Aboriginal and Torres Strait Islander peoples. Most have been used to assess non-Indigenous populations, and may not adequately cover Indigenous concepts of social and emotional wellbeing.12 This lack of validation of
these 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’.13 Moreover, Aboriginal and Torres Strait Islander communities are very diverse, and use of any instrument will require clinical discretion to account for this diversity.

One of the most widely used tools in Australia for monitoring and assessing psychological distress is the Kessler Psychological Distress Scale (K-10). 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 K-10 is not culturally appropriate for use within their communities. For this reason, the K-10 was adapted in an Australian Bureau of Statistics stakeholder workshop, which included representatives from the National Aboriginal Community Controlled Health Organisation (NACCHO), 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 K-5. The K-5 questions are shown in Box 2.
 
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 and colleagues adapted the Patient Health Questionnaire 9 (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 once it has been further validated. The adapted PHQ-9 questions are contained in Box 3.

 

An adaptation of the PHQ-9 has been tested in Aboriginal and Torres Strait Islander people who have ischaemic heart disease attending an Aboriginal Medical Service in Darwin.17 The adaptation of the PHQ-9 achieved 71% specificity and 80% sensitivity, which is lower than the PHQ-9 in other populations. A subset of just two questions was also tested in this study:17

Over the last 2 weeks how often have you been bothered by any of the following problems?
Never/A little/A lot/All the time

Not enjoying things like you used to.Feeling down, depressed or hopeless.

In this study, a ‘Yes’ answer to either question was 100% sensitive and 12.5% specific for depression. This means that a negative result rules out depression but there are many false positives. It is not clear how applicable this result is to other Aboriginal and Torres Strait Islander communities or peoples without ischaemic heart disease. The cultural appropriateness of these questions has not been assessed more broadly in Aboriginal and Torres Strait Islander communities. Use of these tools to screen for depression in Aboriginal and Torres Strait Islander peoples cannot currently be recommended.

Additional tools have been developed specifically by and for Aboriginal and Torres Strait Islander peoples that take a strengths-based approach to assessing wellbeing. The two most useful for community settings are the Growth and Empowerment Measure and the Here and Now Aboriginal Assessment.
The Growth and Empowerment Measure (GEM)18 takes a positive wellbeing perspective and includes concepts of connectedness to family and cultural identity. It is currently the only tool to include these.

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 social and emotional wellbeing, rather than a series of rated questions. It takes a broad approach to social and emotional wellbeing, but is still oriented toward mental health diagnosis and treatment in mental health settings. The 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 social and emotional wellbeing domains and is intended to determine if a formal mental health assessment is needed. It is not intended to be diagnostic for depression. The HANAA has been used in a variety of 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.

Although further evidence is needed before these tools can be recommended for routine use, healthcare providers may find them useful in promoting discussions with patients about their social and emotional wellbeing. They may be especially useful for clinicians who do not have established relationships within an Indigenous community, and may lack expertise in assessing social and emotional wellbeing. Further, non-Indigenous 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 clients.
 

Evidence for screening programs for depression



A 2005 Cochrane review concluded 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.21 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.22

In a more recent systematic review commissioned by the US Preventive Services Task Force (USPSTF),22,23 the minimum support needed to demonstrate a beneficial effect from depression screening was the availability of a nurse who screened patients, reported the results to the physician, and provided a protocol that facilitated referral for behavioural treatment. Interventions with the greatest beneficial effect tended to be complex.

As a consequence of this review, the USPSTF recommends screening for depression on the basis that the supports and services for intervention are now more widely available. In Australian Aboriginal and Torres Strait Islander communities where there are comprehensive treatment services available, health professionals may wish to screen those at higher risk of depression (Box 4).24

It should also be noted that there is evidence to suggest that scores indicative of probable depression detected with one particular screening tool – the Center for Epidemiologic Studies Depression Scale [CES-D], which measures severity of depression – fluctuate, and that 22% of people will not meet the criteria for probable depression two weeks later.25 Applied more broadly, this suggests that with any screening tool, repeat screening may be needed. The optimal screening frequency is not known.

The USPSTF systematic review found that harms from screening for depression were ‘small to none’.23 However, there are potential harms from medical treatment. Increased prescription of selective serotonin reuptake inhibitor medications for depression is associated with an 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.22

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 people, 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.

A core component to team-based care in Aboriginal and Torres Strait Islander health includes contributions from Aboriginal health practitioners. Referral pathways to local social and emotional wellbeing teams, psychologists and mental health workers will also be important. There is increasing evidence that online therapies based on cognitive behavioural therapy methods are effective,26 and these may be useful for some people where they are able to access it.
 
Given the disproportionately high prevalence of stressors and trauma experienced by Aboriginal and Torres Strait Islander peoples, and the knowledge that current assessment tools are not always culturally appropriate, it is reasonable to ensure that those who are at higher risk are assessed for symptoms of depression. The people in whom depression risk is greater and the situations in which depression is more likely to be missed are outlined in Box 4. These are the people for whom asking about symptoms is recommended.
 

Interventions


There is insufficient evidence to recommend behavioural programs to prevent depression. There is weak evidence that psychosocial interventions in the elderly may have a small effect on preventing depression.27 There is some evidence that exercise is mildly beneficial in the prevention of depression for children and adolescents,28 although there is little 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; however, the magnitude of effect is unlikely to be clinically significant.27

There is no evidence to support the use of antidepressant medication for primary prevention of depression in the general population.

 

Resources

 
National guide to a preventive health assessment for Aboriginal and Torres Strait Islander people

 





 
 
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