About this topic
Australian governments, non-government and private organisations provide funding for mental health and suicide prevention-related services for Aboriginal and Torres Strait Islander people (Indigenous Australians). Government-funded services include consultations with specialist medical practitioners, general practitioners and psychologists, residential care in hospital, and community mental health care services (AIHW 2018).
Australian governments provide 78% of all Indigenous Australian health expenditure, compared with 70% for non-Indigenous health care (AIHW 2020a). Non-government and other private-sector organisations also provide services to Indigenous Australians, but data for these are neither nationally collected nor publicly reported.
Access to services compared to need
Indigenous Australians experience poorer health than non-Indigenous Australians, but they do not always have the same level of access to health services and do not share equally in the benefits of health care advances. Indigenous Australians face barriers that other groups do not (AIHW & NIAA 2020). This can be due to remoteness and affordability (AIHW 2021a).
Defining and measuring access to health care is complex. Measures must consider the availability and supply of services as well as financial, organisational, social and cultural barriers that limit the use of services (Gulliford et al. 2002).
Levesque and others (2013) identified 2 main factors that affect access to health services:
- characteristics that facilitate access (approachable, acceptable, available, affordable and appropriate)
- the individual’s abilities to interact with services, such as the ability to perceive, seek, reach, pay and engage with services.
Historically, Indigenous Australians have experienced mistreatment by mainstream health services. Diagnoses of mental illness have been used to disempower marginalised groups, including Indigenous peoples (Dudgeon et al. 2014). These historical factors have contributed to distrust and avoidance of mainstream health services (Canuto et al. 2018; Dudgeon et al. 2014).
There are also cultural differences in the understanding of mental health conditions, which can discourage Indigenous Australians from seeking help from clinical services.
Indigenous and non-Indigenous Australians may have different understandings of the causes, expressions and treatments of mental health conditions, such as depression (Brown et al. 2012; Vicary & Westerman 2004). For example, spiritual healing from a cultural healer may be needed for a mental health condition that is seen to have a spiritual cause (Ypinazar et al. 2007). Services that do not recognise these issues may offer ineffective treatments that cause Indigenous Australians to feel disempowered when seeking help (Bishop et al. 2012).
Indigenous Australians must have access to culturally appropriate care. This can establish an environment that is responsive and respectful to any social, political, linguistic, economic and spiritual concerns of Indigenous Australians (Kirmayer 2012; McGough et al. 2018). An Indigenous mental health workforce can build trust in mental health services and improve mental health outcomes for Indigenous Australians by enabling self-determination (Dudgeon et al. 2014).
Connection to community, body and culture
Connection to community, body and culture are 3 of the 7 domains of social and emotional wellbeing for Indigenous Australians.
Social and emotional wellbeing is a holistic way of looking at relationships between individuals, family, kin and community in the context of land, culture, spirituality and ancestry. Cultural groups and individuals each have their own interpretation of social and emotional wellbeing (Gee et al. 2014).
Self-governance and community-controlled services can support community wellbeing. These services also support physical health and connection to body by providing access to culturally safe, culturally competent and eﬀective health services and professionals.
Mental health care must be conducted in a culturally safe and supportive way. Services that are not culturally safe are a risk factor for connection to culture. Health care that is provided in a way that is respectful of cultural practices can better facilitate feelings of safety and understanding.
In Australian research, there are various definitions of cultural safety and what it means in relation to the provision of health care.
The Cultural Respect Framework 2016–26 defines cultural safety as: ‘not [being] defined by the health professional, but is defined by the health consumer’s experience—the individual’s experience of care they are given, ability to access services and to raise concerns’.
The framework outlines the essential features of cultural safety, including:
- understanding one’s culture
- acknowledging difference, and requiring caregivers to be actively mindful and respectful of differences
- being informed by a theory of power relations
- appreciating the historical context of colonisation, the practices of racism at individual and institutional levels, and their effects on Indigenous Australians’ living and wellbeing, both in the present and past (AHMAC 2016).
The cultural safety of Indigenous Australian health care users cannot be improved in isolation. The structures, policies and processes across the health system all play a role in delivering culturally respectful health care. They require:
- organisational commitments to provide culturally safe care
- appropriate communication and services
- Indigenous workforce development and training
- client and community feedback
- collaboration with Indigenous organisations.
The extent to which health care systems and providers are aware of and responsive to Indigenous Australians’ perspectives determines health care outcomes.
Self-determination is the process by which communities control their destinies, particularly in relation to political status and economic, social and cultural development (AHRC 2010). For the people in those communities, this means the freedom to live well and according to their own values and beliefs (AHRC 2010).
In Australia, this is particularly important for Indigenous Australian communities, many of which have experienced destruction of traditional governance structures through colonisation and dispossession (Salmon et al. 2019).
Aboriginal Community Controlled Health Organisation/Service (ACCHO, ACCHS)
Community control is a process that allows the local community to be involved in its affairs in accordance with whatever protocols or procedures are determined by the community.
Aboriginal community control has its origins in Aboriginal peoples’ right to self-determination. This includes the right to be involved in health service delivery and decision-making according to protocols or procedures determined by Aboriginal communities based on their holistic definition of health.
An ACCHO is:
- an incorporated Aboriginal organisation
- initiated by a local Aboriginal community
- based in a local Aboriginal community
- governed by an Aboriginal body that is elected by the local Aboriginal community
- delivering a holistic and culturally appropriate health service to the community that controls it.
In 2018–19, Indigenous Australians:
- had contact with community mental health care services at more than 3 times the rate for non-Indigenous Australians
- experienced episodes in residential mental health care facilities at more than double the rate for non-Indigenous Australians
- had higher rates of same-day and overnight hospital separations for specialised psychiatric care than non-Indigenous Australians (AIHW 2021b).
In 2019–20, Indigenous Australians presented in emergency departments for mental health-related diagnoses at more than 4 times the rate for non-Indigenous Australians.
The rate of community mental health care service contacts by Indigenous Australians has increased from 558.5 per 1,000 population (366,125 contacts) in 2008–09 to 1,197.4 per 1,000 population (962,284 contacts) in 2018–19. The rate of residential mental health care episodes by Indigenous Australians also increased from 1.4 per 10,000 population (81 episodes) in 2008–09, to 7.5 per 10,000 population (524 episodes) in 2018–19 (AIHW 2021b).
In 2017–18, approximately 2 out of 3 (68% or 134 organisations) Indigenous primary health organisations reported access to mental health and social and emotional health and wellbeing services as a gap faced by the community they served. The proportion of Indigenous primary health organisations reporting this gap has increased from 54% (110 organisations) in 2013–14 (AIHW 2020b).
In New South Wales, Victoria and Queensland in 2018–19, most surveyed Indigenous and non-Indigenous mental health consumers reported a positive experience of service in ambulatory and admitted care settings. In ambulatory care settings, 72% of Indigenous respondents in New South Wales (439 people), 79% in Queensland (317 people), and 73% in Victoria (32 people) reported a positive experience of service. In admitted care settings, 69% of Indigenous respondents in New South Wales (1,168 people), 56% in Queensland (81 people) and 44% in Victoria (16 people) reported a positive experience of service (AIHW 2021b).
Admitted care settings are specialised mental health services that provide overnight care in a psychiatric hospital. They can also be specialised mental health units in an acute hospital (AIHW 2021b).
Ambulatory care settings are specialised mental health services that provide services to people who are not currently admitted to a mental health or residential service (AIHW 2021b).
Community mental health care refers to government‑funded and operated specialised mental health care provided by community mental health care services and hospital‑based ambulatory care services, such as outpatient and day clinics (AIHW 2021b).
Residential mental health care refers to residential care provided by residential mental health services. A residential mental health service is a specialised mental health service that:
- employs mental health trained staff on‑site
- provides rehabilitation, treatment or extended care to residents for whom the care is intended to be on an overnight basis and in a domestic‑like environment
- encourages the residents to take responsibility for their daily living activities (AIHW 2021b).
These services include those that employ mental health trained staff onsite 24 hours per day and other services with less intensive staffing. However, all these services employ onsite mental health trained staff for some part of the day (AIHW 2021b).
Specialised psychiatric care: A separation is classified as having had specialised psychiatric care if the patient was reported as having spent 1 or more days in a specialised psychiatric unit or ward (AIHW 2021b).
This information was compiled from the following data sources: National Non-Admitted Patient Emergency Department Care Database (NNAPEDCD) 2017–18, National Hospital Morbidity Database, National Residential Mental Health Care Database (NRMHCD), National Community Mental Health Care Database (NCMHCD), Online Services Report (OSR) and the Your Experience of Service (YES) Survey. More information about these data sources and their data quality is available in Data sources.
For more information about the mental health services in Australia, see the AIHW report: Mental health services in Australia.
For more information about Indigenous primary health care organisations, see the AIHW report: Indigenous primary health care: results from the OSR and nKPI collections.
Mental health-related emergency department presentations are defined as presentations in public hospital emergency departments that have a principal diagnosis of mental and behavioural disorders. However, this does not include presentations of self-harm, which may have a principal diagnosis relating to the injury (AIHW 2021b).
Mental health care can be provided by a range of services. While information about the use of some services is presented above, there are other services for which data are either not currently nationally collected or publicly reported. As a result, Indigenous Australians’ use of the mental health services from the following service providers is not reported above:
- non-government organisations funded by the states, territories and the Australian Government
- Aboriginal Community Controlled Health Services and other Indigenous Australian primary health care services funded by state, territory and Australian governments
- telehealth and digital services
- use of pharmaceuticals for mental health conditions.
There is a lack of nationally collected outcomes data for mental health consumers. For example, diagnosis, treatment and experiences of care for Australians accessing mental health services at emergency departments, general practitioners, and private services is unknown.
Information on the effects of the COVID-19 pandemic on mental health service use in Australia has not yet been nationally reported for all services. There is little Indigenous specific information about the use of telehealth and digital mental health, barriers to accessing these services (for example Internet access), and therapeutic impacts of the transition from in-person to virtual consultation.
Information from the Online Service Report and National Key Performance Indicator data collections present information on Aboriginal Community Controlled Health Services (ACCHS) and other Indigenous Australian primary health care services funded by state, territory and Australian governments. These data collections do not currently contain information about mental health. They contain data for:
- a wide range of physical health attributes
- type of service delivery
- gaps faced by the community
- clinical care
- number of clients and episodes of care and remoteness.
Indigenous primary health organisations were asked to select up to 5 health service gaps faced by the community they serve. This information does not necessarily represent the views of the community.
A positive experience of service refers to mental health consumers who completed the Your Experience of Service (YES) survey whose experience of service score is equal to or higher than 80 (out of 100) (AIHW 2021b).
AHMAC (Australian Health Ministers’ Advisory Council) 2016. Cultural Respect Framework 2016–26 for Aboriginal And Torres Strait Islander Health: A National Approach To Building A Culturally Respectful Health System. Canberra: AHMAC.
AHRC (Australian Human Rights Commission) 2010. Community reference guide to the UN Declaration on the Rights of Indigenous Peoples. Canberra: AHRC.
AIHW (Australian Institute of Health and Welfare) 2018. Australia’s health 2018. Australia’s health series no. 16. AUS 221. Canberra: AIHW.
AIHW 2020a. Expenditure on Aboriginal and Torres Strait Islander health, 2015–16, unpublished. Canberra.
AIHW 2020b. Aboriginal and Torres Strait Islander-specific primary health care: results from the OSR and nKPI collections. Cat. no. IHW 227. Canberra: AIHW. Viewed 26 May 2021.
AIHW 2021a. Cultural safety in health care for Indigenous Australians: monitoring framework. Cat. no. IHW 222. Canberra: AIHW. Viewed 25 May 2021.
AIHW 2021b. Mental health services in Australia. Canberra: AIHW. Viewed 26 May 2021. https://www.aihw.gov.au/reports/mental-health-services/mental-health-services-in-australia/report-contents/summary-of-mental-health-services-in-australia
AIHW & NIAA (Australian Institute of Health and Welfare and National Indigenous Australians Agency) 2020. Aboriginal and Torres Strait Islander Health Performance Framework 2020 web report. Canberra: AIHW. Viewed 09 June 2021, https://www.indigenoushpf.gov.au/measures
Bishop BJ, Vicary DA, Mitchell JR & Pearson G 2012. Aboriginal concepts of place and Country and their meaning in mental health. The Australian Community Psychologist 24:26–42.
Brown A, Scales U, Beever W, Rickards B, Rowley K & O'Dea K 2012. Exploring the expression of depression and distress in Aboriginal men in central Australia: a qualitative study. BMC Psychiatry 12:97. doi:10.1186/1471-244X-12-97
Canuto K, Brown A, Wittert G & Harfield S 2018. Understanding the utilization of primary health care services by Indigenous men: a systematic review. BMC Public Health 18(1).
Dudgeon P, Rickwood D, Garvey D & Gridley H 2014. A history of Indigenous psychology. In Dudgeon P, Milroy H & Walker R (eds) Working together: Aboriginal and Torres Strait Islander mental health and wellbeing principles and practice (Second Edition) Canberra: Australian Government Department of Prime Minister and Cabinet, Part 2:pp 39–54.
Gee G, Dudgeon P, Schultz C, Hart A & Kelly K 2014. Aboriginal and Torres Strait Islander social and emotional wellbeing. In: Dudgeon P, Milroy H & Walker R (eds). Working together: Aboriginal and Torres Strait Islander mental health and wellbeing principles and practice. 2nd edn. Canberra: Australian Government, pp. 55-68.
Gulliford M, Figueroa J, Morgan M, Hughes D, Gibson B, Beech R et al. 2002. What does 'access to health care' mean? Journal of Health Services Research & Policy 7:186–8.
Kirmayer LJ 2012. Rethinking cultural competence. Transcultural Psychiatry 49(2):149–164. doi:10.1177/1363461512444673
Levesque J-F, Harris MF & Russell G 2013. Patient-centred access to health care: conceptualising access at the interface of health systems and populations. International Journal for Equity in Health 12:18.
McGough S, Wynaden D & Wright M 2018. Experience of providing cultural safety in mental health to Aboriginal patients: a grounded theory study. International Journal of Mental Health Nursing 27(1):204–13.
Salmon M, Doery K, Dance P, Chapman J, Gilbert R, Williams R & Lovett R 2019. Defining the indefinable: descriptors of Aboriginal and Torres Strait Islander Peoples’ cultures and their links to health and wellbeing. Canberra: The Australian National University.
Vicary D & Westerman T 2004. 'That’s just the way he is’: some implications of Aboriginal mental health beliefs. Australian e-Journal for the Advancement of Mental Health 3(3):103–112.
Ypinazar VA, Margolis SA, Haswell-Elkins M & Tsey K 2007. Indigenous Australians’ understandings regarding mental health and disorders. Australian & New Zealand Journal of Psychiatry 41:467–78.