'Have you been feeling your spirit was sad?' Culture is key when assessing Indigenous Australians' mental health

If a doctor suspects a patient may be at risk of depression, they will likely ask about the person’s mood, appetite, sleep patterns, and energy and concentration levels, among other questions.

But understandings of mental health differ across cultural groups. So when a doctor is screening for mental illness, it’s important they consider the patient’s culture.

Many Aboriginal and Torres Strait Islander Australians take a holistic view of health, which may differ from non-Indigenous Australians, who often take a more individualistic approach. In terms of mental health, social and emotional well-being is central to the “spirit” of many Aboriginal and Torres Strait Islander peoples.

For Australia’s First Nations peoples, routine screening tools have not always seemed appropriate. Earlier research has found many questions are being lost in translation. Some people who should have scored highly to indicate their risk of depression scored much lower, missing out on potential opportunities for treatment.

Read more: Australia has been silent on Indigenous suicide for too long, and it must change

Where a diagnosis of depression is based on the answers to a set of questions, it’s important the language used in these questions aligns with a person’s understanding of mental illness.

The good news is, we now have a validated culturally specific tool, developed with Aboriginal and Torres Strait Islander community members, to screen for depression in Indigenous Australians.

We anticipate this will allow doctors to identify many Aboriginal and Torres Strait Islander people with mental illness who might have otherwise gone undiagnosed. And the better our capacity to accurately diagnose depression, the better our capacity to treat it.

The new screening tool

The culturally specific screening tool is called the aPHQ-9. It’s an adapted version of the existing tool, called the PHQ-9 – nine questions routinely used by doctors in Australia and overseas to screen for depression.

In our research published today in the Medical Journal of Australia, we’ve shown the culturally specific tool to be effective in screening for depression among Aboriginal and Torres Strait Islander Australians living in urban, rural and remote areas.

Some 500 Aboriginal and Torres Strait Islander participants completed the new questionnaire, then took part in a structured psychiatric interview by a trained clinician who hadn’t seen their answers.

We compared the questionnaire results with the interview results, and found the new tool reliably identified those who need further assessment of their mood and those unlikely to have depression.

The culturally specific tool contains questions about the same topics as the original one, but it’s presented in a way that better aligns with Aboriginal understandings of mental health and well-being.

Read more: Aboriginal Australians want care after brain injury. But it must consider their cultural needs

How do the questions differ?

Alongside differences in understandings of mental health, there are important differences between communication styles used in non-Indigenous Australian culture, and those of Aboriginal and Torres Strait Islander peoples. For example, white Australians will often use a more direct communication style.

This example shows how the new tool factors in the subtle differences in cultural understandings of mental health, and communication styles.

The original questionnaire asks “Over the last two weeks, how often have you been bothered by any of the following problems:

• little interest or pleasure in doing things?
• feeling down, depressed or hopeless?”

The adapted tool asks “Over the last two weeks:

• have you been feeling slack, not wanted to do anything?
• have you been feeling unhappy, depressed, really no good, that your spirit was sad?”

Words like “slack” and “spirit” are more consistent with Aboriginal English. Spirit implies a holistic understanding of health consistent with the definition of health held by many Aboriginal and Torres Strait Islander Australians.

Read more: What do Aboriginal Australians want from their aged care system? Community connection is number one

Another question asks about “letting your family down”. This is also consistent with a holistic view of health and the importance of family in Aboriginal and Torres Strait Islander culture, but might seem out of place in a consultation with a non-Indigenous Australian.

Many Aboriginal and Torres Strait Islander people will recognise that the language in the new tool has been respectfully developed in a culturally appropriate way. They may be more likely to trust the clinician and service administering the questionnaire, and give answers that reflect their true state of mind.

Doctors can now use the new tool

In 2014-15, more than half (53.4%) of Aboriginal and Torres Strait Islander peoples aged 15 years and over reported their overall life satisfaction was eight out of ten or more. Almost one in six (17%) said they were completely satisfied with their life. These positive data are testament to Aboriginal and Torres Strait Islander peoples’ ongoing endurance.

But over the years, events like colonisation, racism, relocation of people away from their lands, and the forced removal of children from family and community have disrupted the resilience, cultural beliefs and practices of many Aboriginal and Torres Strait Islander Australians. In turn, these factors have impacted their social and emotional well-being.

This may explain why Aboriginal and Torres Strait Islander peoples are twice as likely to be hospitalised for mental health disorders and die from suicide than their non-Aboriginal counterparts.

Teenagers aged 15 to 19 are five times more likely than non-Indigenous teenagers to die by suicide.

The importance of being able to more accurately identify those at risk can’t be understated.

Read more: Why are we losing so many Indigenous children to suicide?

While screening all Aboriginal and Torres Strait Islander peoples who present to general practice for depression is not recommended, the new questionnaire is a free, easy to administer, culturally acceptable tool for screening Aboriginal and Torres Strait Islander peoples at high risk of depression.

People who might be at heightened risk of depression include those with chronic disease, a history of depression and those who have been exposed to abuse and other adverse events.

Without a culturally appropriate tool, Aboriginal and Torres Strait Islander people with depression and suicidal thoughts might fly under the radar. This questionnaire will pave the way for important discussions and the provision of treatment and services to those most in need.

If this article has raised issues for you or you’re concerned about someone you know, call Lifeline on 13 11 14. Visit the Beyond Blue website to access specific resources for Aboriginal and Torres Strait Islander people.