NACCHO Aboriginal #MentalHealth Prof Maree Hackett @Mareazles Top moments celebrating 20 years of @georgeinstitute Improving mental health. A New culturally appropriate screening tool for Aboriginal and Torres Strait Islanders


“ Mental health problems experienced by Aboriginal and Torres Strait Islander people have been overlooked, dismissed and marginalised for too long

We recently validated a culturally appropriate tool with and for Aboriginal communities and researchers to help us assess and address the scale of mental health problems in communities.”

Professor Maree Hackett  Up until now, we couldn’t reliably ascertain the scale of mental health problems in communities in a culturally appropriate way, which has remained a huge concern. We hope this tool will be a turning point.

See part 2 below for 20 Years George Institute

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“In Australia, as with many countries around the world, everything is framed around Western understandings, language and methods. Our research recognises the importance of an Aboriginal voice and giving that a privileged position in how we respond to matters of most importance to Aboriginal people themselves.

What we found during this study was that many questions were being lost in translation.

Instead of a person scoring highly for being at risk of depression, they were actually scoring themselves much lower and missing out on potential opportunities for treatment.

It was essential that we got this right and that we took our time speaking with Aboriginal people and ascertaining how the wording needed to be changed so we can begin to tackle the burden of depression.”

Professor Alex Brown, of the South Australian Health and Medical Research Institute, who was co-investigator on the study, said the importance of using culturally appropriate language with First Nations people cannot be underestimated

Part 1 : A culturally-appropriate depression screening tool for Aboriginal and Torres Strait Islander peoples not only works, it should be rolled out across the country, according to a new study.

Researchers at The George Institute for Global Health, in partnership with key Aboriginal and Torres Strait primary care providers conducted the validation study in 10 urban, rural and remote primary health services across Australia.

The screening tool is an adapted version of the existing 9-item patient health questionnaire (PHQ-9) used across Australia and globally accepted as an effective screening method for depression. The adapted tool (aPHQ-9) contains culturally-appropriate questions asking about mood, appetite, sleep patterns, energy and concentration levels. It is hoped the adapted questionnaire will lead to improved diagnosis and treatment of depression in Aboriginal communities.

The results of the validation study were published in the Medical Journal of Australia.

Lead researcher Professor Maree Hackett, of The George Institute for Global Health, said mental health problems experienced by Aboriginal and Torres Strait Islander peoples have been overlooked, dismissed and marginalised for too long.

“This tool, which was developed in conjunction with Aboriginal communities and researchers, will help us address easily treated problems that often go undiagnosed. It will also help us to assess the scale of mental health problems in communities.

Up until now, we couldn’t reliably ascertain this in a culturally appropriate way, which has remained a huge concern.

We need better resources and funding for mental health across Australia, but particularly for Aboriginal and Torres Strait Islander people and within under-resourced health services. We hope this tool will be a turning point.”

The aPHQ-9 is freely available in a culturally-appropriate English version, and can be readily used by translators when working with First Nation communities where English is not the patients first language.

It is estimated up to 20 per cent of Australia’s general population with chronic disease will have a diagnosis of comorbid major depression[1].

Approximately similar proportions will meet criteria for moderate or minor depression. Mental illness and depression are also considered to be key contributors in the development of chronic disease.

Across the nation, chronic disease (cardiovascular disease, cerebrovascular disease, diabetes, chronic kidney disease and chronic obstructive pulmonary disease) accounts for 80 per cent of the life expectancy gap experienced by Aboriginal people [2].

How the tool works

The adapted tool, which was evaluated with 500 Aboriginal and Torres Strait Islander peoples, contains culturally-appropriate questions.

For example, the original (PHQ-9) 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 (aPHQ-9) tool instead 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?

Download: Adapted Patient Questionnaire with scoring (PDF 119 KB)

Download: Adapted Patient Questionnaire without scoring (PDF 119 KB)

Aboriginal psychologist Dr Graham Gee, of the Murdoch Children’s Research Institute, said Aboriginal communities have unacceptably high rates of suicide which need to be addressed.

“Identifying and treating depression is an important part of responding to this major challenge. It’s clear this tool is much needed.”

The new tool will be available for use at primary health centres across Australia.

[1] Mental health services report 2018, Australian Institute of Health and Welfare

[2] Contribution of chronic disease to the gap in mortality between Aboriginal and Torres Strait Islander people and other Australians, Australian Institute of Health and Welfare

Part 2 20 years of improving mental health

Maree’s first major success at the Institute was with the POISE study in 2008, which recruited 441 people under the age of 65 in Australia who had experienced their first ever stroke.

The five-year study’s key aim was to determine whether psychosocial factors were associated with a return to paid work after one year in younger stroke survivors. Its secondary aim was to determine the economic impact of not returning to work for younger stroke survivors and their families.

“What we successfully highlighted in POISE and my PhD was that depression following a stroke is much more common than many people realised – it affects about a third of all stroke survivors,” Maree explains. “At any one time, one-in-three people will experience depression or related clinical concerns after a stroke, and about 50% of people will experience depression in the first year after an event.”

Like other studies done by the Institute, Maree’s past work has included examining the economic and emotional benefits of an intervention in order to advocate for increasing access to treatment.

“We looked at the impact of cataract surgery in Vietnam beyond just curing blindness, and generated evidence to indicate the household economic benefits to improving eyesight, as well as benefits to mood,” she says.

For Maree, one of the key factors that differentiates the Institute from other organisations working on mental health is its global reach and clear focus on the links between mental health and chronic diseases.

She currently leads the Institute’s Australian mental health program, but has carried out successful trials in Sweden and the UK. The George Institute, India’s Deputy Director, Professor Pallab Maulik, is a psychiatrist and is leading a project to integrate mental health screening into the Institute’s SMARThealth app (see page XX).

“We’re also working on a study on emotionalism, which is the tendency to uncontrollably laugh or cry inappropriately after strokes, and strategies for treating depression after a stroke,” she says.

The Australian mental health program has expanded over the years to include mental health challenges facing Aboriginal and Torres Strait Islander people. ( see Part 1 Above )

Dr Anne-Marie Eades, a Noongar woman from Western Australia and a descendant of a Wiilman father and Minang mother, is also working with mothers and children to increase the resilience and strength of Aboriginal women who have experienced some vulnerabilities.

“The aim of her work is to reduce the number of child removals from Aboriginal families and help maintain the wider family unit,” Maree says.

For Maree, the Institute’s biggest contribution to the field of mental health has been the normalisation of mental illness in a chronic disease setting.

“Along with other organisations, we’ve highlighted that depression and anxiety happens after almost every chronic disease, and raised awareness of the consistency of the problem, which is not an excuse to do nothing about it,” she says. “If we can normalise it and say it’s slightly unusual if it doesn’t happen, then people are more likely to seek help and tell us they’re unwell.”

Despite the progress made, Maree is the first to acknowledge that much more remains to be done in terms of screening, treatment and combating discrimination.

“We need affordable, non-threatening, widely applicable interventions for things like depression that people can access – regardless of their location,” she says. “It can be straightforward enough to diagnose someone with a mood disorder, but there might be no supply of antidepressants or access to talking therapy anywhere near that patient. Or perhaps the patient might not be able to afford that antidepressant or therapy, or not for very long.”

“We also need to get rid of the stigma and make sure that when people visit a doctor or other healthcare professional, they can be confident that the healthcare professional knows what to do. We need to make sure they are reassessed if they are prescribed a treatment, so they won’t be left on it forever.”

These challenges require the broader education that comes from high-quality research.

“There’s still a common misunderstanding between symptoms and diagnosis, and what a diagnosis actually means,” she says. “We all experience symptoms of depression, anxiety, and other disorders – sometimes on a daily or weekly basis. But we’re only clinically unwell if the accumulation of those symptoms stops us from being ourselves.”

Celebrating 20 years: Maree’s Top Moments

  • New screening tool for Aboriginal and Torres Strait Islanders: “Up until now, we couldn’t reliably ascertain the scale of mental health problems in communities in a culturally appropriate way, which has remained a huge concern. We hope this tool will be a turning point.”
  • Mentoring: “I really like helping students navigate the system. I love mentoring them, that’s been a constant thing throughout my career because I had some great mentors when I was doing my PhD.”
  • From ideas to impact: “Ideas are born, and we take a bizarre concept and work it through to a fundable grant. It’s quite special when you see the outcome from a completed study.”

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