CARPA Standard Treatment Manual

The Central Australian Rural Practitioners Association (CARPA)  Standard Treatment Manual (CARPA STM) was developed by a small group of practitioners from Central Australia in recognition of the need to support practice in remote and rural communities in Central Australia. The seventh edition of the CARPA Standard Treatment Manual was produced as part of the suite of Remote Primary Health Care Manuals, through a collaboration between the Central Australian Rural Practitioners Association, Central Australian Aboriginal Congress, CRANAplus, and the Centre for Remote Health. The manual is designed to be used primarily in remote (largely Aboriginal and Torres Strait Islander) communities, and rural and urban Aboriginal Medical Services.

Section 3 of the CARPA Manual focuses on Mental health and drug problems. The first part of Section 3 includes a protocol, for assessing mental health problems. This describes what to cover in an interview, taking a full history, checking for physical signs, a mental status examination, a list of risks to assess, and interpretation.

The section on depression also runs through a series of questions to ask and things to check. It includes the K10 as a tool for practitioners to use. Although elsewhere the K6 is preferred

Download the CARPA Primary Healthcare Manuals here.

Further reading

CARPA Standard Treatment Manual 7th Edition

Depression, Anxiety Stress Scales (DASS)

The Depression Anxiety Stress Scales (DASS, Lovibond & Lovibond, 1995) is a well-validated, widely-used self-report measure of depression, anxiety, and stress.  The DASS is available in two forms: the 21-items DASS-21 and the 42-item DASS-42. The DASS is easy to administer or score. The DASS is a useful tool for screening, assessment and tracking progress over time. The DASS has not been validated for use with Aboriginal and Torres Strait Islander people.

Further reading

Lovibond, S.H., & Lovibond, P.F. (1995). Manual for the Depression Anxiety Stress Scales (2nd. ed). Sydney, Australia: Psychology Foundation.

Indigenous Risk Impact Screen (IRIS)

The IRIS (Schlesinger et al. 2007) is a 13-item questionnaire designed to screen for the presence of alcohol and other drugs and mental health risk in Aboriginal and Torres Strait Islander people. The first 7 questions address substance use and the remainder ask about depression and anxiety.  Research has shown good reliability and validity of the IRIS as a screening tool.

The tool can be accessed at the link.

Further reading

Queensland Health. (2011). Indigenous risk impact screen (IRIS) and brief intervention project: screening instrument (pp. 3). Brisbane: Queensland Health.

Ober, C. , Dingle, K. , Clavarino, A. , Najman, J. M., Alati, R. & Heffernan, E. B. (2013), Mental health screen for ATSI inmates. Drug and Alcohol Review, 32, 611-617. doi:10.1111/dar.12063

Schlesinger, C. M., Ober, C., McCarthy, M. M., Watson, J. D. & seinen, a. (2007), The development and validation of the Indigenous Risk Impact Screen (IRIS): a 13‐item screening instrument for alcohol and drug and mental health risk. Drug and Alcohol Review, 26, 109-117. doi:10.1080/09595230601146611

Kessler Psychological Distress Scales (K10, K6, K5)

The Kessler K10 is widely used in population health surveys and clinical practice both as a screening tool and a measure of psychological distress. It consists of 10 questions on levels of negative emotional states experienced in the past 4 weeks.

The K6, a subset of six items of the K10, has also been culturally adapted (Brown et al.,  2015) and retains an item on “worthlessness” identified as culturally inappropriate by Stewart (2003, in LeGrande et al., 2017).

Although the K10 has been used in a number of population health surveys which found higher rates of psychological distress in Aboriginal and Torres Strait Islander people, concerns about item wording (e.g., a question about worthlessness) have led to the development of the K5 which is considered culturally appropriate for Indigenous Australians.

A study by McNamara et al. (2014) found both versions to be promising tools for older (over 45 years) Indigenous Australian but respondents more likely to complete the shorter 5-item version.

Interviewer administered versions of the K10 and K6 are available, but we could not find research that explicitly studied these with Aboriginal and Torres Strait Islander people.

A K10 app is available for android phones:

Download the K5 and scoring instructions here.

Further reading

Brown, A., O’Shea, R. L., Mott, K., McBride, K. F., Lawson, T., Jennings, G. L. R., & On behalf of the Essential Service Standards for Equitable National Cardiovascular Care for Aboriginal and Torres Strait Islander people (ESSENCE) Steering Committee (2015). A Strategy for Translating Evidence into Policy and Practice to Close the Gap – Developing Essential Service Standards for Aboriginal and Torres Strait Islander Cardiovascular Care. Heart Lung and Circulation, 24(2), 119-125.

Furukawa, T.A., Kessler, R.C., Slade, T., Andrews, G. (2003). The performance of the K6 and K10 screening scales for psychological distress in the Australian National Survey of Mental Health and Well-Being Psychological Medicine, 33, 57-362

Jorm, A. F., Bourchier, S. J., Cvetkovski, S. & Stewart, G. (2012). Mental health of Indigenous Australians: A review of findings from community surveys. Medical Journal of Australia, 196, 118-121.

Kessler, R.C., Barker, P.R., Colpe, L.J., Epstein, J.F., Gfroerer, J.C., Hiripi, E., Howes, M.J, Normand, S-L.T., Manderscheid, R.W., Walters, E.E., Zaslavsky, A.M. (2003). Screening for serious mental illness in the general population. Archives of General Psychiatry. 60(2), 184-189

McNamara, B. J., Banks, E., Gubhaju, L., Williamson, A., Joshy, G., Raphael, B., & Eades, S. J. (2014). Measuring psychological distress in older Aboriginal and Torres Strait Islanders Australians: A comparison of the K-10 and K-5. Australian and New Zealand Journal of Public Health, 38(6), 567-573

This research used the K-5

Williamson, A., Andersen, M., Redman, S., Dadds, M., D’este, C., Daniels, J., Raphael, B. (2014). Measuring mental health in Indigenous young people: A review of the literature from 1998–2008. Clinical Child Psychology and Psychiatry, 19(2), 260-272.

Young, C., Hanson, C., Craig, J., Clapham, K., & Williamson, A. (2017). Psychosocial factors associated with the mental health of indigenous children living in high income countries: A systematic review. International Journal for Equity in Health, 16(1), 153.

Zubrick, SR, Lawrence, D, De Maio, J, Biddle, N. Testing the reliability of a measure of Aboriginal children’s mental health. Canberra: Australian Bureau of Statistics, 2006. [cited 21 March 2009.]

Kimberley Assessment of Depression of Older Indigenous Australians (KICA-dep)

The Kimberley Assessment of Depression of Older Indigenous Australians (KICA-dep) is an 11-item questionnaire designed as a culturally acceptable and valid tool for screening for depression in Indigenous people over the age of 45.  The KICA-dep was developed for and studied with adults living in the Kimberley region. The KICA-dep was found to have excellent reliability and face validity, and to be a sensitive screening tool for depression. The KICA tool is now widely used in rural and remote locations in Western Australia, Northern Territory and Queensland. An evaluation of the tool highlighted the dependability of the instrument for measuring cognitive deficiencies in older traditionally living Aboriginal and Torres Strait Islander Australians.

Health professionals using outcome tools indicated that they were reporting results to GPs usually following clients second and sixth visits. A number of organisations also reported collecting qualitative data on the services provided across all mental health and/or allied health services provided.

The KICA-dep is available in the article below.

Further reading

Almeida, O. P., Flicker, L., Fenner, S., Smith, K., Hyde, Z., Atkinson, D., …LoGiudice, D. (2014). The Kimberley assessment of depression of older indigenous Australians: prevalence of depressive disorders, risk factors and validation of the KICA-dep scale.

Kimberley Mum’s Mood Scale (KMMS)

The KMMS is a 10-item screening tool for postnatal depression and anxiety adapted from the Edinburgh Postnatal Depression Scale. It was originally validated for women in the Kimberley region in Western Australia but has also been adapted for Northern Queensland language groups (Mt Isa and Townsville). The KMMS also includes a psychosocial discussion which provides opportunity for new mothers to talk about issues of interest and concern to them.

Further Reading

Kotz, J., Munns, A., Marriott, R., Marley, JV. (2016). Perinatal depression and screening among Aboriginal Australians in the Kimberley. Contemporary Nurse, 52(1),42–58.

Marley, J. V., Kotz, J., Engelke, C., Williams, M., Stephen, D., Coutinho, S., & Trust, S. K. (2017). Validity and acceptability of Kimberley mum’s mood scale to screen for perinatal anxiety and depression in remote aboriginal health care settings.

Patient Health Questionnaire: PHQ-9; PHQ-2 ; aPHQ

The PHQ-9 is a 9-item self-report depression module of the Primary Care Evaluation of Mental Disorders. The PHQ has been validated for primary care settings and can be used for screening, diagnosing, monitoring and measuring the severity of depression. It includes 9 questions relating to each of the nine DSM-IV depression criteria. Item 9 screens for the presence and duration of suicidal ideation. The PHQ-9 can also be used to monitor outcomes over time.  The PHQ-2 comprises the first two questions of the PHQ-9 and is intended as an initial screening for depression.

The PHQ-9 was initially adapted for use with Indigenous Australians by Esler et al. (2007), resulting in a 10-item version.  The adapted version, including a 2-item “mini” version showed good reliability and validity and was considered a useful screening tool.

Brown et al. (2013) further modified the PHQ and translated the items into 5 widely spoken Aboriginal dialects in Central Australia.

The modified PHQ-9 version is available in Esler (2007) below.

The a-PHQ is available in Brown et al. (2013) below.

Further reading

Brown AD, Mentha R, Rowley KG, et al. (2013). Depression in Aboriginal men in central Australia: Adaptation of the patient health questionnaire 9. BMC Psychiatry

Brown, A., Mentha, R., Howard, M., Rowley, K., Reilly, R., Paquet, C., & O’Dea, K. (2016). Men, hearts and minds: Developing and piloting culturally specific psychometric tools assessing psychosocial stress and depression in central Australian Aboriginal men. Social Psychiatry and Psychiatric Epidemiology, 51(2), 211-223.

Esler, D. M., Johnston, F. and Thomas, D. (2007), The acceptability of a depression screening tool in an urban, Aboriginal community‐controlled health service. Australian and New Zealand Journal of Public Health, 31: 259-263.

Esler, D., Johnston, F., Thomas, D., & Davis, B. ( 2008). The validity of a depression screening tool modified for use with Aboriginal and Torres Strait Islander people. Australian and New Zealand Journal of Public Health, 32, 317– 321.

Farnbach, S., Evans, J., Eades, A., Gee, G., Fernando, J., Hammond, B., . . . Hackett, M. (2017). Process evaluation of a primary healthcare validation study of a culturally adapted depression screening tool for use by Aboriginal and Torres Strait Islander people: Study protocol. BMJ Open, 7(11) doi:http://dx.doi.org.ezproxy1.acu.edu.au/10.1136/bmjopen-2017-017612

The Getting it Right Collaborative Group (2019). Getting it right: Validating a culturally specific tool for depression (aPHD-9) in Aboriginal and Torres Strait Islander AustraliansMedical Journal of Australia, 211 (1), 24-30.

Strengths and Difficulties Questionnaire (SDQ)

The SDQ is a brief 25-item screening questionnaire for children and adolescents and young people aged between 4-18 years. The SDQ covers five areas: emotional symptoms, hyperactivity, conduct problems, peer problems and prosocial behaviour. The SDQ can be completed by parents, teachers and young people over age 11 years.

While the SDQ has not been validated with Indigenous youth, the scale’s reliability and validity have been examined in several studies with large samples in Western Australia (Zubrick et al, 2006) and New South Wales (Williamson, et al., 2014), with results indicating that the SDQ was reliable and valid, except for the peer relationships scale, with these two groups of Indigenous young people. The SDQ has been used to support mental health workers to make decisions quickly and acts as a guide when planning treatment. In a review by the Department of Health, feedback from social workers confirmed that the questionnaire ‘gave a more in-depth look at the young person’, and that it served as a ‘springboard for therapeutic action’ (Department of Health, pp. 2b). However, as the SDQ is self-report in nature, the validity of the tool is not always ensured, and should therefore used as part of a wider assessment process and not as a standalone tool.

The study by Williamson and colleagues (2014) is the first to examine the validity of the standard Australian version of the SDQ for Aboriginal children their results suggest that the SDQ is likely to be a useful screening tool for clinicians and researchers working with Aboriginal young people. They recommend that clinicians continue to employ the SDQ TDS as a useful screening tool for the presence of any psychiatric disorder as recommended for all general population samples (Niclasen et al., 2012). They suggest that clinicians may gain useful insights into the social and emotional well‐being of urban Aboriginal children based on the results of the prosocial behaviours scale. These behaviours appear to important to Aboriginal parents and may be vital in assessing how well Aboriginal children are considered by their families to interact with others and conduct themselves appropriately.

Overall they found the standard parent report version of the SDQ an acceptable and appropriate screening tool for Aboriginal children living in urban communities in New South Wales. The hypothesised five‐factor model of the SDQ is an acceptable fit and the acceptability, internal consistency reliability, and convergent validity of the instrument are all satisfactory, suggesting the SDQ is a promising tool for assessing the social and emotional well‐being of Aboriginal children living in urban communities.

Download the tool here.

Further Reading

Jorm, A. F., Bourchier, S. J., Cvetkovski, S. & Stewart, G. (2012), Mental health of Indigenous Australians: A review of findings from community surveys. Medical Journal of Australia, 196, 118-121.

Williamson, A. , McElduff, P. , Dadds, M. , D’ Este, C. , Redman, S. , Raphael, B. , Daniels, J. & Eades, S. (2014), Validity of the SDQ for urban Aboriginal children. Australian Psychologist, 49,  163-170.

Zubrick, SR, Lawrence, D, De Maio, J, & Biddle, N. (2006).Testing the reliability of a measure of Aboriginal children’s mental health. Canberra: Australian Bureau of Statistics, 2006.

 Structured Diagnostic Interview for Mental Disorders (SCID)

The Structured Diagnostic Interview for Mental Disorders (SCID) is a semi-structured interview schedule designed to help making diagnoses according to the Diagnostic and Statistical Manual of Mental Disorders (DSM). The SCID-5 complements the 5th edition of the DSM, whereas the SCID-4 can be used to elicit DSM-IV-TR diagnoses.

Several recent studies have used the SCID-4. (Toombs, et al. 2019; Nasir et al 2018).  A pilot study explored issues of cultural appropriateness and all participants were invited to complete questionnaires on their experience with the interview process and the questions themselves.  Toombs and colleagues found that a large percentage (>95%)  of research participants (N=498) were comfortable with both the interview and non-Indigenous psychologist interviewers and concluded that the SCID-4 was culturally acceptable and provided good to moderate concordance of diagnoses based on the SCID-4 and made by psychiatrists with experience in Indigenous mental health.

Further reading

Nasir, B. F., Toombs, M. R., Kondalsamy-Chennakesavan, S., Kisely, S., Gill, N. S., Black, E., . . . Nicholson, G. C. (2018). Common mental disorders among indigenous people living in regional, remote and metropolitan Australia: A cross-sectional study. BMJ Open, 8(6), 1.

Toombs, M., Nasir, B., Kisely, S., Ranmuthugala, G., Gill, N. S., Beccaria, G., Hayman, N., Kondalsamy-Chennakesavan, S. N. (2019). Cultural validation of the structured clinical interview for diagnostic and statistical manual of mental disorders in Indigenous Australians. Australasian Psychiatry, 1-4.

Westerman Aboriginal Symptom Checklists (WASC-Y, WASC-A)

Westerman (2003) developed two self-report symptom checklists, the 53-item Westerman Aboriginal Symptom Checklist-Youth (WASC-Y) for youths ages 13 to 17 and the 56-item Westerman Aboriginal Symptom Checklist – Adults (WASC-A).  The WASC-Y was designed to as an indicator of risk and to assess the effects of cultural resilience with Aboriginal youth at risk of anxiety, depression and suicidal behaviours. The WASC-Y has six subscales: depression, suicidal behaviour, substance abuse, impulsivity, anxiety and cultural resilience.

The Westerman Aboriginal Symptom Checklist – Adults (WASC-A) comprises 56 items grouped in the same six subscales as the Youth checklist: depression, suicidal behaviour, substance abuse, impulsivity, anxiety and cultural resilience.  A validation study by Bright (2012) found support for a six-factor structure of the scale and satisfactory reliability and validity in a sample of 370 adults who completed the scales.

Both scales are available for purchase after completing accreditation training via Indigenous Psychological Services.

Information on purchasing the tests can be found here.

Further Reading

Bright, C., (2012). Initial Validation of the Westerman Aboriginal Symptom Checklist – Adults (WASC-A). Retrieved from Indigenous Psychology Services.

Westerman, T. G. (2003). The development of the Westerman Aboriginal symptom checklist for youth: A measure to assess the moderating effects of cultural resilience with Aboriginal youth at risk of depression, anxiety and suicidal behaviours. Unpublished doctoral thesis: Curtin University, WA.

Westerman T. (2004). Engagement of indigenous clients in mental health services: what role do cultural differences play? Australian e-Journal for the Advancement of Mental Health, 3, 1–7.

Westerman, T. (2010). Engaging Australian Aboriginal youth in mental health services. Australian Psychologist, 45, 212-222.