Viewpoint: Evidence and practice in Indigenous mental health

Abstract

A decade ago the author published a commentary on the content relating to Aboriginal and Torres Strait Islander populations in the RANZCP clinical practice guidelines for the treatment of schizophrenia and related disorders. The recently released ANZJP guidelines bring a fresh framework – the GRADE approach – but, in relation to consideration of Indigenous Australians, not much else. The author reflects on considerations a decade ago and now, and what has changed in relation to the social determinants of Indigenous vulnerability over that time. A decade ago I wrote a commentary (Hunter, 2016) on the Indigenous content of the (then) recently published guidelines for the management of schizophrenia (Galletly et al., 2016). The updated guidelines (Suetani et al., 2026) bring a fresh orientation, being informed by the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach. That shift is consequential for consideration of Aboriginal and Torres Strait Islander populations which are consigned – with Māori – to a brief section – ‘special populations’ – the salient recommendation being: ‘we advocate for universal cultural safety in mental health systems’.

As defined in the National Aboriginal and Torres Strait Islander Health Plan 2021–2031 (Australian Government Department of Health, 2021):

Cultural safety is about how care is provided. It requires practitioners to deliver safe, accessible and responsive health care that is free of racism by:

recognising and responding to the power imbalance between practitioner and patient

reflecting on their knowledge, skills, attitudes, practising behaviours, and conscious and unconscious biases. (p. 52)

Is this no more than should be expected from any clinician approaching a patient with integrity – regardless of cultural background? Maybe we need to be reminded. But if, after stripping aside anecdotal experience and opinions in pursuit of evidence, that is all there is to say, then one could be excused for wondering if it need be said at all.

In thinking that through I’ve re-visited my 2016 commentary and reflected on what has changed. My take home points from 2016 were as follows: Indigenous Australians experience higher burdens of mental disorders (including psychosis), each of which has increased from very low baseline levels within living memory, with new issues – such as from stimulant abuse – likely to emerge (as has occurred). I reasoned that the key drivers reflect social changes and their impacts on the neurodevelopmental environment. In relation to relevant service contexts, I noted the accelerating process of outsourcing roles and responsibilities across remote Indigenous Australia, part of the wider neoliberal transformations impacting nationally and beyond (Hunter, 2020). My concluding message was,

clinicians should be guided by best practice in the wider society with the ‘how’ being informed by a nuanced appreciation of application given local circumstances and practices . . . That demands local knowledge and relationships that will facilitate diagnosis (avoiding both the pathologizing of cultural expressions and the cultural rationalization of pathology), initiation of appropriate and least restrictive treatments, maintaining cooperation and compliance and supporting recovery. (p. 1106)

Some might argue that is simply a long-winded way of talking about cultural safety. However, while the earlier-quoted definition of cultural safety relates to practitioner attitude, my comments were about relationships of trust – that is, to the application of right attitude to developing meaningful connection – which, at least in Indigenous contexts, is as much about connecting to the community as it is to an individual. That is something that is worked on in place and built over time.

So – what’s changed? Certainly not the social and developmental forces informing vulnerability in Indigenous settings. As an indicator, the Productivity Commission’s summary of the National Agreement on Closing the Gap (Productivity Commission, 2024) summarises,

Overall, data is available to report progress on 15 out of the 19 socio-economic targets. Five targets are on track, five targets show improvement but are not on track, progress for four targets is worsening and one has shown no change from the baseline. (p. 3)

By contrast, as the Guidelines demonstrate, the treatment space has not stood still – there are novel drugs, new therapies – and technological wizardry. My sense is that we will need it all not to go backward with the foundations of relationships of trust challenged as permanent staff become a memory in remote settings. In the (large) community in which I have worked most over the last few years, none of the primary care staff (at last visit) were permanent. This is compounded by the rapid turnover of for-profit (and competing) agencies addressing collateral mental health needs (training, work readiness, well-being, disability, juvenile justice, etc.) – where activity trumps outcomes (Hunter et al., 2014).

Regardless of evidence supporting the benefits of the therapeutic alliance in the care of patients suffering from psychosis (Browne et al., 2019), the workforce and systems transformations impacting remote service delivery in Australia are here to stay. While that will not be tested by research, there is certainly a need for improved data. That will include not only the cultural validity of assessment tools and processes (O’Gradey-Lee et al., 2026) but also developing better understandings of and responses to local circumstances informing vulnerability and response to interventions (i.e., embracing the complex contextual confounders controlled out in pursuit of hard evidence). As much as that will be a challenge, more so will be ensuring data fit for purpose for use by those who are able to make a difference at that local level – the councils and community leaders with policy responsibilities that encompass vulnerability (childhood exposure to adversity and trauma, substance misuse role models, etc.) and resilience/recovery (effective early education, youth programmes to encourage engagement, and positive relationships). To that end, it is arguably more important to have metrics that provide reliable measures of local change over time rather than the aggregated comparisons that are the basis of the National Agreement on Closing the Gap (Lovett et al., 2020), issues that fall within the rubric of data sovereignty.

Aboriginal and Torres Strait Islander data sovereignty as a movement dates back a decade with a key event being the Indigenous Data Summit in 2018 (Maiam nayri Wingara Indigenous Data Sovereignty Collective and the Australian Indigenous Governance Institute) (https://static1.squarespace.com/static/5b3043afb40b9d20411f3512/t/63ed934fe861fa061ebb9202/1676514134724/Communique-Indigenous-Data-Sovereignty-Summit.pdf) (Lovett et al., 2020). It has been broadly embraced including in the National Aboriginal and Torres Strait Islander Health Plan, 2021–2031 (Australian Government Department of Health, 2021), and is Priority Reform 4 in the Commonwealth’s Closing the Gap initiative (Commonwealth of Australia, 2025). While health service providers and researchers will come and go, local leaders in remote communities stay – that is their home. If, as seems the case, we are not making much of a dent in the increasing rates of serious mental illness across these communities through ‘treatment’ then it may be in everyone’s best interest that we think about how to empower those with the greatest vested interests. In doing so researchers (and clinicians) should be mindful of the important shift in conceptualising ethical research practice in Indigenous populations, introduced to the NHMRC guidelines over two decades ago (National Health and Medical Research Council, 2003). That shift was, in essence, from ‘what’ to ‘how’; that is, from proscriptive and prescriptive injunctions, to ‘ethical relationships’ in research. I contend that message is equally relevant to clinicians working in disadvantaged Indigenous communities with patients suffering serious mental disorders.

Were I to summarise my thoughts in 2026 it would read much like that, earlier quoted, from 2016. I have here noted a continuation of those social adversity factors informing Indigenous vulnerability – and of service transformations that, at least in remote settings, are compromising access in a flurry of activity. I argue that, if our tools are inadequate in the face of social complexity, rather than anodyne recommendations about ‘how care is provided’, we might better reconsider what constitutes evidence and for whom – data democracy. To that end, I believe our responsibilities and influence – as researchers and clinicians – extend beyond the clinic. We should invest in the institutional and personal relationships that enable data to empower those with the capacity to influence the determinants of vulnerability.