Indigenous Australians' understandings regarding mental health and disorders

The prevelance of psychosis in indigenous populations in Australia: A review of the literature using systematic methods

OBJECTIVES

To understand the prevalence of psychosis in Aboriginal and Torres Strait Islander populations.

METHODS

A systematic review of the literature was conducted using PubMed, Embase and Cochrane.

RESULTS

Eight studies were reviewed. The prevalence of psychosis appeared higher in Aboriginal and Torres Strait Islanders, compared with non-Aboriginal and Torres Strait Islander populations.

CONCLUSION

Although the literature suggests the prevalence of psychosis in Aboriginal and Torres Strait Islander populations is substantial, there are few studies and limited scope. Cultural competency is essential to understanding psychosis in this context.

Hepatitis C treatment outcomes for Australian First Nations Peoples: equivalent SVR rate but higher rates of loss to follow-up

Background

First Nations Peoples of Australia are disproportionally affected by hepatitis C (HCV) infection. Through a prospective study we evaluated the outcome of direct-acting antiviral (DAA) therapy among First Nations Peoples with HCV infection.

Methods

Adults who initiated DAA therapy at one of 26 hospitals across Australia, 2016–2019 were included in the study. Clinical data were obtained from medical records and the Pharmaceutical and Medicare Benefits Schemes. Outcomes included sustained virologic response (SVR) and loss to follow-up (LTFU). A multivariable analysis assessed factors associated with LTFU.

Results

Compared to non-Indigenous Australians (n = 3206), First Nations Peoples (n = 89) were younger (p < 0.001), morel likely to reside in most disadvantaged (p = 0.002) and in regional/remote areas (p < 0.001), and had similar liver disease severity. Medicines for mental health conditions were most commonly dispensed among First Nations Peoples (55.2% vs. 42.8%; p = 0.022). Of 2910 patients with follow-up data, both groups had high SVR rates (95.3% of First Nations Peoples vs. 93.2% of non-Indigenous patients; p = 0.51) and ‘good’ adherence (90.0% vs. 86.9%, respectively; p = 0.43). However, 28.1% of First Nations Peoples were LTFU vs. 11.2% of non-Indigenous patients (p < 0.001). Among First Nations Peoples, younger age (adj-OR = 0.93, 95% CI 0.87–0.99) and treatment initiation in 2018–2019 vs. 2016 (adj-OR = 5.14, 95% CI 1.23–21.36) predicted LTFU, while higher fibrosis score was associated with better engagement in HCV care (adj-OR = 0.71, 95% CI 0.50–0.99).

Conclusions

Our data showed that First Nations Peoples have an equivalent HCV cure rate, but higher rates of LTFU. Better strategies to increase engagement of First Nations Peoples with HCV care are needed.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12876-022-02416-5.

Cultural determinants of health for Aboriginal and Torres Strait Islander people - a narrative overview of reviews

INTRODUCTION

The cultural determinants of health centre an Indigenous definition of health, and have been linked to positive health and wellbeing outcomes. There is growing evidence for the importance of the cultural determinants of health; however, to date, no high-level overview of the evidence-base has been provided. Synthesising existing literature on cultural determinants of health for Aboriginal peoples in a single manuscript will highlight what we know, and what needs to be explored in future research. It will also contribute to global efforts to capture the evidence of cultural determinant approaches amongst Indigenous populations. We therefore endeavoured to identify cultural determinants and highlight their impact on Aboriginal health and wellbeing outcomes, and outline the relationship and interconnection of different cultural determinants of health.

METHODS

An overview of reviews was conducted. Medline (Ovid) and Scopus were searched using terms related to 'cultural determinants of health' and an 'Aboriginal definition of health'. The database search was complemented by a web-based search of grey literature. Nine reviews were retrieved and included in our overview.

RESULTS

Family/community, Country and place, cultural identity and self-determination were strongly identified across reviews as having a positive impact on the health and wellbeing outcomes of Aboriginal peoples. Family/community and Country and place were found to be components of 'culture' that shaped cultural identity. Self-determination was outlined as a requirement for Aboriginal peoples to pursue their cultural, social, and economic rights.

DISCUSSION/CONCLUSIONS

Cultural determinants are associated with health benefits for Indigenous peoples. A causal framework, developed to discuss the relationship and interconnection of the cultural determinants of health, demonstrates that cultural identity at an individual-level is important to benefiting from other cultural determinants of health. While self-determination and connection to culture and community-controlled organisations are integral factors to increase Aboriginal resilience and resistance and improve health and wellbeing outcomes. Further research is required to shift towards a multi-level understanding of the cultural determinants of health and to develop an Indigenous-led evidence-base around causal pathways. Such a shift would ensure priorities important to Indigenous peoples are captured in policy and practice.

"Ghost on the Coast": Persistent hallucinations through the prism of cultural concepts of distress

There is minimal literature and case reports on cultural concepts of distress, especially on ghost sickness. The aim of this article is to educate clinicians to culture-bound syndromes/cultural concepts of distress when assessing people from culturally and linguistically diverse backgrounds. This case report describes an elderly male of Papua New Guinea who presented with psychotic symptoms, shaped by the cultural concept of distress from experiencing loss. This paper describes the importance of utilizing of cultural liaison officers to provide culturally-informed care and before diagnosing a patient with the culture concept of distress, every effort should be made to thoroughly investigate to exclude an organic cause for the presentation.

Intergenerational Trauma and Its Relationship to Mental Health Care: A Qualitative Inquiry

Intergenerational trauma is a discrete form of trauma which occurs when traumatic effects are passed across generations without exposure to the original event. This qualitative study aimed to explore how psychiatrists understand intergenerational trauma in respect to their practice, for the purposes of identifying interventions for addressing intergenerational trauma in public mental health services. Findings revealed that psychiatrists observe intergenerational trauma frequently in their roles and try to opportunistically promote awareness of trauma with adults, and refer families to external services for supportive interventions. They feel powerless when faced with directly intervening with intergenerational trauma and required restructuring of their roles to adequately address it in public settings. Findings have implications for training, advocacy and research on the relationship between trauma and mental illness. Alongside this, there is an indicated need for examination of how systems can ensure access to appropriate services once organisations become trauma-informed.

Drafting the Aboriginal and Islander Mental Health Initiative for Youth (AIMhi-Y) App: Results of a formative mixed methods study

BACKGROUND

Culturally responsive, strengths-based early-intervention mental health treatment programs are considered most appropriate to influence the high rates of psychological distress and suicide experienced by Aboriginal and Torres Strait Islander youth. Few early intervention services effectively bridge the socio-cultural and geographic challenges of providing sufficient and culturally relevant services in rural and remote Australia. Mental Health apps provide an opportunity to bridge current gaps in service access if co-designed with Aboriginal and Torres Strait Islander youth to meet their needs.

AIMS

This paper reports the results of the formative stage of the AIMhi-Y App development process which engaged Aboriginal and Torres Strait Islander youth in the co-design of the new culturally informed AIMhi-Y App.

METHODS

Using a participatory design research approach, a series of co-design workshops were held across three sites with five groups of young people. Workshops explored concepts, understanding, language, acceptability of electronic mental health tools (e-mental health) and identified important characteristics of the presented applications and websites, chosen for relevance to this group. An additional peer supported online survey explored use of technology, help seeking and e-mental health design elements which contribute to acceptability.

RESULTS

Forty-five, Aboriginal and Torres Strait Islander youth, aged 10-18 years, from three sites in the Northern Territory (NT) were involved in the workshops (n = 29). Although experiencing psychological distress, participants faced barriers to help seeking. Apps were perceived as a potential solution to overcome barriers by increasing mental health literacy, providing anonymity if desired, and linking young people with further help. Preferred app characteristics included a strength-based approach, mental health information, relatable content and a fun, appealing, easy to use interface which encouraged app progression. Findings informed the new AIMhi-Y App draft, which is a strengths-based early intervention wellbeing app for Aboriginal and Torres Strait Islander youth.

CONCLUSIONS

Research findings highlight the need, feasibility and potential of these types of tools, from the perspective of Aboriginal and Torres Strait Islander youth.

'Having a Quiet Word': Yarning with Aboriginal Women in the Pilbara Region of Western Australia about Mental Health and Mental Health Screening during the Perinatal Period

Despite high rates of perinatal depression and anxiety, little is known about how Aboriginal women in Australia experience these disorders and the acceptability of current clinical screening tools. In a 2014 study, the Kimberley Mum’s Mood Scale (KMMS) was validated as an acceptable perinatal depression and anxiety screening tool for Aboriginal women in the Kimberley region of Western Australia. In the current study, we explored if it was appropriate to trial and validate the KMMS with Aboriginal women in the Pilbara. Yarning as a methodology was used to guide interviews with 15 Aboriginal women in the Pilbara who had received maternal and child health care within the last three years. Data were analysed thematically, the results revealing that this cohort of participants shared similar experiences of stress and hardship during the perinatal period. Participants valued the KMMS for its narrative-based approach to screening that explored the individual’s risk and protective factors. While support for the KMMS was apparent, particular qualities of the administering health care professional were viewed as critical to the tool being well received and culturally safe. Building on these findings, we will work with our partner health services in the Pilbara to validate the KMMS with Pilbara Aboriginal women.

Aboriginal and Torres Strait Islander people's domains of wellbeing: A comprehensive literature review

There are significant health and social disparities between the world's Indigenous and non-Indigenous people on factors likely to influence quality of life (QOL) and wellbeing. However, these disparities in wellbeing are not captured in conventional QOL instruments, as they often do not include dimensions that are likely to be relevant to Indigenous people. The objective of this comprehensive literature review was to identify these wellbeing domains for Aboriginal and Torres Strait Islander people in Australia (hereafter, respectfully referred to collectively as Indigenous Australians). We searched PsycINFO, MEDLINE, Econlit, CINAHL, and Embase (from inception to June 2017, and updated in March 2019), and grey literature sources using keywords relating to adult Indigenous Australians' QOL and wellbeing. From 278 full-text articles assessed for eligibility, 95 were included in a thematic analysis. This synthesis revealed nine broad interconnected wellbeing dimensions: autonomy, empowerment and recognition; family and community; culture, spirituality and identity; Country; basic needs; work, roles and responsibilities; education; physical health; and mental health. The findings suggest domains of wellbeing relevant to and valued by Indigenous Australians that may not be included in existing QOL and wellbeing instruments, domains that may be shared with Indigenous populations globally. This indicates the need for a tailored wellbeing instrument that includes factors relevant to Indigenous Australians. Developing such an instrument will ensure meaningful, culturally-relevant measurement of Indigenous Australians' wellbeing.

Developing a reporting guideline to improve meta-ethnography in health research: the eMERGe mixed-methods study

Background

Meta-ethnography is a commonly used methodology for qualitative evidence synthesis. Research has identified that the quality of reporting of published meta-ethnographies is often poor and this has limited the utility of meta-ethnography findings to influence policy and practice.

Objective

To develop guidance to improve the completeness and clarity of meta-ethnography reporting.

Methods/design

The meta-ethnography reporting guidance (eMERGe) study followed the recommended approach for developing health research reporting guidelines and used a systematic mixed-methods approach. It comprised (1) a methodological systematic review of guidance in the conduct and reporting of meta-ethnography; (2) a review and audit of published meta-ethnographies, along with interviews with meta-ethnography end-users, to identify good practice principles; (3) a consensus workshop and two eDelphi (Version 1, Duncan E, Swinger K, University of Stirling, Stirling, UK) studies to agree guidance content; and (4) the development of the guidance table and explanatory notes.

Results

Results from the methodological systematic review and the audit of published meta-ethnographies revealed that more guidance was required around the reporting of all phases of meta-ethnography conduct and, in particular, the synthesis phases 4–6 (relating studies, translating studies into one another and synthesising translations). Following the guidance development process, the eMERGe reporting guidance was produced, comprising 19 items grouped into the seven phases of meta-ethnography.

Limitations

The finalised guidance has not yet been evaluated in practice; therefore, it is not possible at this stage to comment on its utility. However, we look forward to evaluating its uptake and usability in the future.

Conclusions

The eMERGe reporting guidance has been developed following a rigorous process in line with guideline development recommendations. The guidance is intended to improve the clarity and completeness of reporting of meta-ethnographies, and to facilitate use of the findings within the guidance to inform the design and delivery of services and interventions in health, social care and other fields. The eMERGe project developed a range of training materials to support use of the guidance, which is freely available atwww.emergeproject.org(accessed 26 March 2018). Meta-ethnography is an evolving qualitative evidence synthesis methodology and future research should refine the guidance to accommodate future methodological developments. We will also investigate the impact of the eMERGe reporting guidance with a view to updating the guidance.

Study registration

This study is registered as PROSPERO CRD42015024709 for the stage 1 systematic review.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

Common mental disorders among Indigenous people living in regional, remote and metropolitan Australia: a cross-sectional study

OBJECTIVE

To determine, using face-to-face diagnostic interviews, the prevalence of common mental disorders (CMD) in a cohort of adult Indigenous Australians, the cultural acceptability of the interviews, the rates of comorbid CMD and concordance with psychiatrists' diagnoses.

DESIGN

Cross-sectional study July 2014-November 2016. Psychologists conducted Structured Clinical Interviews for Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision Axis I Disorders (SCID-I) (n=544). Psychiatrists interviewed a subsample (n=78).

SETTING

Four Aboriginal Medical Services and the general community located in urban, regional and remote areas of Southern Queensland and two Aboriginal Reserves located in New South Wales.

PARTICIPANTS

Indigenous Australian adults.

OUTCOME MEASURES

Cultural acceptability of SCID-I interviews, standardised rates of CMD, comorbid CMD and concordance with psychiatrist diagnoses.

RESULTS

Participants reported that the SCID-I interviews were generally culturally acceptable. Standardised rates (95% CI) of current mood, anxiety, substance use and any mental disorder were 16.2% (12.2% to 20.2%), 29.2% (24.2% to 34.1%), 12.4% (8.8% to 16.1%) and 42.2% (38.8% to 47.7%), respectively-6.7-fold, 3.8-fold, 6.9-fold and 4.2-fold higher, respectively, than those of the Australian population. Differences between this Indigenous cohort and the Australian population were less marked for 12-month (2.4-fold) and lifetime prevalence (1.3-fold). Comorbid mental disorder was threefold to fourfold higher. In subgroups living on traditional lands in Indigenous reserves and in remote areas, the rate was half that of those living in mainstream communities. Moderate-to-good concordance with psychiatrist diagnoses was found.

CONCLUSIONS

The prevalence of current CMD in this Indigenous population is substantially higher than previous estimates. The lower relative rates of non-current disorders are consistent with underdiagnosis of previous events. The lower rates among Reserve and remote area residents point to the importance of Indigenous peoples' connection to their traditional lands and culture, and a potentially important protective factor. A larger study with random sampling is required to determine the population prevalence of CMD in Indigenous Australians.

Developing a culturally appropriate branding for a social and emotional wellbeing intervention in an Aboriginal community

ISSUE ADDRESSED

An initial consultation process to implement a culturally appropriate social and emotional wellbeing campaign in an Aboriginal community indicated that the fundamental principles of the Act-Belong-Commit mental health promotion campaign were acceptable, but that a cultural adaptation of the branding should be sought.

METHODS

A competition was held inviting community members to design a brand logo for the campaign in their community. Local judges selected "winners" in various categories, and six of the submissions were selected for testing in the broader community via street intercept interviews. Respondents were asked which logo they liked best, their perceived meanings of the designs and the perceived appropriateness of the designs for a social and emotional wellbeing campaign.

RESULTS

A convenience sample of N = 26 local Aboriginal people who lived and/or worked in Roebourne completed the questionnaire. There was a clear majority preference for logo "D," which communicated appropriate meanings of pride and strength in standing together, and reflected the underlying strengths and capacities of Aboriginal people which this project seeks to harness and support.

CONCLUSIONS

The approach of using a logo competition to develop the campaign brand was highly successful and enabled further meaningful engagement with the community and other service providers in the town. The success of the competition process resulted from an emphasis on relationship building, listening to the local community and involving the community in decision-making. So what? By conforming to established, but not always adhered to, recommendations for community consultation, successful and more enduring outcomes are likely.

Assessing service use for mental health by Indigenous populations in Australia, Canada, New Zealand and the United States of America: a rapid review of population surveys

BACKGROUND

Indigenous people in Australia, Canada, New Zealand and the United States of America experience disproportionately poor mental health compared to their non-Indigenous counterparts. To optimally allocate resources, health planners require information about the services Indigenous people use for mental health, their unmet treatment needs and the barriers to care. We reviewed population surveys of Indigenous people to determine whether the information needed to guide service development is being collected.

METHODS

We sought national- or state-level epidemiological surveys of Indigenous populations conducted in each of the four selected countries since 1990 that asked about service use for mental health. Surveys were identified from literature reviews and web searches. We developed a framework for categorising the content of each survey. Using this framework, we compared the service use content of the surveys of Indigenous people to each other and to general population mental health surveys. We focused on identifying gaps in information coverage and topics that may require Indigenous-specific questions or response options.

RESULTS

Nine surveys met our inclusion criteria. More than half of these included questions about health professionals consulted, barriers to care, perceived need for care, medications taken, number, duration, location and payment of health professional visits or use of support services or self-management. Less than half included questions about interventions received, hospital admissions or treatment dropout. Indigenous-specific content was most common in questions regarding use of support services or self-management, types of health professionals consulted, barriers to care and interventions received.

CONCLUSIONS

Epidemiological surveys measuring service use for mental health among Indigenous populations have been less comprehensive and less standardised than surveys of the general population, despite having assessed similar content. To better understand the gaps in mental health service systems for Indigenous people, systematically-collected subjective and objective indicators of the quality of care being delivered are needed.

A systematic review of evaluated suicide prevention programs targeting indigenous youth

BACKGROUND

Indigenous young people have significantly higher suicide rates than their non-indigenous counterparts. There is a need for culturally appropriate and effective suicide prevention programs for this demographic.

AIMS

This review assesses suicide prevention programs that have been evaluated for indigenous youth in Australia, Canada, New Zealand, and the United States.

METHOD

The databases MEDLINE and PsycINFO were searched for publications on suicide prevention programs targeting indigenous youth that include reports on evaluations and outcomes. Program content, indigenous involvement, evaluation design, program implementation, and outcomes were assessed for each article.

RESULTS

The search yielded 229 articles; 90 abstracts were assessed, and 11 articles describing nine programs were reviewed. Two Australian programs and seven American programs were included. Programs were culturally tailored, flexible, and incorporated multiple-levels of prevention. No randomized controlled trials were found, and many programs employed ad hoc evaluations, poor program description, and no process evaluation.

CONCLUSION

Despite culturally appropriate content, the results of the review indicate that more controlled study designs using planned evaluations and valid outcome measures are needed in research on indigenous youth suicide prevention. Such changes may positively influence the future of research on indigenous youth suicide prevention as the outcomes and efficacy will be more reliable.

Use of prescription stimulant for Attention Deficit Hyperactivity Disorder in Aboriginal children and adolescents: a linked data cohort study

BACKGROUND

Increasing recognition of Attention Deficit Hyperactivity Disorder (ADHD) among Aboriginal children, adolescents and young adults is a public health challenge. We investigated the pattern of prescription stimulants for ADHD among Aboriginal individuals in Western Australia (WA).

METHODS

Using a whole-population-based linked data we followed a cohort of individuals born in WA from 1980-2005, and their parents were born in Australia, to identify stimulant prescription for ADHD derived from statutory WA stimulant prescription dispensing between 2003 and 2007. Parental link was ascertained through WA Family Connections Genealogical Linkage System. Cox proportional hazards regression (HR) models were performed to determine the association between stimulant use and Aboriginal and non-Aboriginal status.

RESULTS

Of the total cohort of 186,468, around 2% (n = 3677) had prescription stimulants for ADHD. Individuals with both Aboriginal parents were two-thirds (HR 0.33, 95 % CI 0.26-0.42), and with only Aboriginal mother were one-third (HR 0.69, 95% CI 0.53-0.90) less likely to have stimulants, compared to individuals with non-Aboriginal parents. HR in Aboriginals was 62% lower (HR 0.35, 95% CI 0.25-0.49) in metropolitan areas, and 72% lower (HR 0.28, 95% CI 0.20-0.38) in non-metropolitan areas, than non-Aboriginals. The risk for simulant use was four times higher among Aboriginal boys than Aboriginal girls (HR 4.08, 95% CI, 2.92-5.69).

CONCLUSION

Aboriginal cultural understanding of ADHD and attitude towards stimulant medication serve as a determinant of their access to health services. Any ADHD intervention and policy framework must take into account a holistic approach to Aboriginal culture, beliefs and individual experience to provide optimal care they need.

Acute mental health service delivery to Indigenous women: What is known?

The Australian College of Mental Health Nurses directs that mental health nurses must 'enable cultural safety in practice, taking into account age, gender, spirituality, ethnicity and health values'. The present study is a review of the existing literature undertaken in order to identify current knowledge and knowledge gaps regarding the experience of Indigenous women in acute mental health inpatient facilities. In particular, studies that identified environments and practices promoting the development of culturally-safe healing spaces for Indigenous women, and studies that identified women's experience of seclusion, were sought. The results showed that there is little literature directly relevant to Indigenous women's experiences of inpatient mental health units in Australia. The present study consolidates existing knowledge and knowledge gaps, and advances the argument for gender-disaggregated future research. Implications for professional practice and service development are also noted.

Ten years of suicide mortality in Australia: Socio-economic and psychiatric factors in Queensland

BACKGROUND

With the exception of the United States, in recent years suicide rates have been declining in most western countries. Notoriously, suicide rates fluctuate - especially in males - in response to a range of socio-political and environmental factors, some of them difficult to identify. Our aim was to obtain an updated profile of main commonalities in suicide cases of Queensland residents between 2002 and 2011 to inform prevention strategies.

METHODS

Data were obtained from the Queensland Suicide Register (QSR), including police and toxicology reports, post-mortem autopsy and Coroner's findings. Data are crosschecked with records from the National Coronial Information System. Age-standardised rates (ASR) of suicide, Poisson regression and Chi(2) tests are presented.

RESULTS

A total of 5752 suicides by Queensland residents was registered between 2002 and 2011; 76.9% by males and 23.1% by females. The average ASR was 14.3 per 100,000, with a significant decrease between 2002 and 2011. Rates declined significantly in males, not in females. On average, rates were 3.41-times higher in males. ASR for Aboriginal and Torres Strait Islander peoples was significantly higher than for other Australians. Overall, male suicide rates were particularly high in remote areas, as well as in the most disadvantaged ones. One third of suicide cases presented history of previous suicidal behaviour, and half a detected and treated mental disorder. Hanging was the most common method.

CONCLUSIONS

Suicide rates have declined in Queensland, Australia. It is problematic to say if this was due to suicide prevention programs or other factors.

Aboriginal medical services cure more than illness: a qualitative study of how Indigenous services address the health impacts of discrimination in Brisbane communities

Background

Aboriginal and Torres Strait Islanders persistently experience a significantly lower standard of health in comparison to non-Indigenous Australians. The factors contributing to this disparity are complex and entrenched in a history of social inequality, disempowerment, poverty, dispossession and discrimination. Aboriginal medical services (AMS) provide a culturally appropriate alternative to mainstream medical services as a means to address this health disparity and also advocate for Indigenous rights and empowerment. This study provides a vignette of lay perspectives of Aboriginal and Torres Strait Islanders accessing community and government controlled AMS in Brisbane, Queensland with the intention of identifying self-perceived health determinants to inform the post-2015 international development goals.

Methods

Focus group discussions and semi-structured interviews were held with clients of a government-controlled AMS and an Aboriginal community controlled health service (ACCHS) in order to identify their self-identified essential health needs. Conversations were audio recorded, transcribed verbatim and de-identified for analysis. Common themes were identified to highlight important issues around community health needs, how they can be addressed and what lessons can be extended to inform the post-2015 development goals.

Findings and discussion

Participants acknowledge the complexity of health determinants faced by their peoples. Thematic analysis highlighted the pervasive influence of racism through many perceived health determinants; resulting in reduced healthcare seeking behaviour, unhealthy lifestyles and mental health issues. Participants emphasised the marked health improvements seen due to the establishment of Aboriginal medical services in their communities and the importance of the AMS’ role in addressing the negative effects of discrimination on Indigenous health.

Conclusion

It is concluded from this study that AMS are crucial in addressing the negative impacts of continued discrimination on Indigenous health by providing comprehensive, culturally appropriate, community empowering health services. Such services improve Indigenous healthcare seeking rates, provide invaluable health education services and address mental health concerns in communities and must be supported in order to address health inequalities in Australia. Community driven and culturally informed health services should be encouraged globally to address health disparities.

Aborigines, colonizers and newcomers: the landscape of transcultural psychiatry research in Australia

The authors present an analysis of transcultural psychiatry research in relation to three main population groups in Australia: Aboriginal Australians, documented immigrants, and refugees. The pioneering reports produced by Western psychiatrists in Aboriginal communities are examined in this article. Additional quantitative and qualitative studies developed with Aboriginal people in the context of a traumatic acculturation process are also reviewed. Subsequently, the authors examine the challenges faced by immigrants with mental disorders in a health care system still unequipped to treat a new array of clinical presentations unfamiliar to the clinical staff. The authors also highlight the development of policies aimed at providing quality mental health care to a mosaic of cultures in an evolving multicultural society. Lastly, the psychiatric manifestations of refugees and asylum seekers are analysed in the context of a series of vulnerabilities and deprivations they have experienced, including basic human rights.

Help seeking by Aboriginal men who are mentally unwell: a pilot study

AIMS

Mental illness is widespread among Aboriginal men in Australia. However, they do not access mental health services in proportion to their need. Although several reports implicate cultural differences of mental health services as the cause of underutilization, very little is known about help seeking by Aboriginal men who are mentally unwell. This study explores the help-seeking behaviour of Aboriginal men who are mentally unwell in a rural Victorian community.

METHODS

The study was carried out using a combination of culturally appropriate research methodologies. Within a Qualitative Description design, semi-structured interviews were conducted with a range of Aboriginal people including men, carers and those involved in service delivery. A total of 17 Aboriginal people were interviewed, of whom 15 were men. Data were analysed thematically.

RESULTS

Four themes emerged from the data collected. They included 'Difficulty in recognizing mental health problems', 'Barriers to disclosing one's problems', 'Reluctance to contact services' and 'Alternate coping strategies'.

CONCLUSIONS

These findings suggest that there is a need for programmes that aim to improve mental health literacy and promote help seeking among Aboriginal men who are mentally unwell. Such programmes need to be developed jointly by mental health services as well as Aboriginal stakeholders, and implemented in a culturally sensitive and acceptable way.

Maternal mental health: pathways of care for women experiencing mental health issues during pregnancy

Perinatal mental health has become the focus for policymakers, government, research, the acute health sector, and health practitioners. The aim of this clinical data-mining study ( Epstein, 2010 ) was to undertake a retrospective exploration into the primary mental health and psychosocial issues experienced by women who were pregnant and accessing obstetric care at one of the largest maternity hospitals in Australia. The study also investigated service pathways and gaps. Aboriginal women were overrepresented, demonstrating their ongoing disadvantage, whereas other linguistically and culturally diverse women were underrepresented, suggesting the existence of barriers to service. Although psychosocial factors tend to be underreported ( Buist et al., 2002 ), the findings highlighted the integral rather than peripheral nature of these factors during pregnancy ( Vilder, 2006 ) and suggest the need for change to systems that work to support women's perinatal mental health.

Mental health of Australian Aboriginal women during pregnancy: identifying the gaps

Despite Australia's high standard of health care provision, Australian Aboriginal women continue to experience poor pregnancy outcomes in terms of maternal and foetal morbidity and mortality. In an attempt to improve these outcomes, health care providers have developed targeted antenatal programmes that aim to address identified health behaviours that are known to contribute to poor health during pregnancy. While some areas of improvement have been noted in rates of engagement with health services, the rates of premature births and low birth weight babies continue to be significantly higher than in the non-Aboriginal population. It appears that Australian researchers have been focused on the behaviour of the individual and have failed to fully consider the impact that social and emotional well-being has on both health behaviours and pregnancy outcomes. This review has highlighted the need for an approach to both research and clinical practice that acknowledges the Aboriginal view of health which encompasses mental, physical, cultural and spiritual health. Until clinicians and Aboriginal women have a shared understanding of how social and emotional well-being is experienced by Aboriginal women, in other words their explanatory model, it is unlikely that any meaningful improvements will be seen.

Mental disorders and communication of intent to die in indigenous suicide cases, Queensland, Australia

In comparing Indigenous to non-Indigenous suicide in Australia, this study focussed on the frequency of the association between some psychiatric conditions, such as depression and alcohol abuse, and some aspect of suicidality, in particular communication of suicide intent. Logistic regression was implemented to analyze cases of Indigenous (n = 471) versus non-Indigenous suicides (n = 6,655), using the Queensland Suicide Register as a data source. Compared to non-Indigenous suicides, Indigenous cases had lower odds of being diagnosed with unipolar depression, seeking treatment for psychiatric conditions or leaving a suicide note. Indigenous suicides had greater odds of verbally communicating suicide intent and having a history of alcohol and substance use. The magnitude of these differences is remarkable, underscoring the need for culturally sensitive suicide prevention efforts.

Preliminary development and content validity of a measure of Australian Aboriginal cultural engagement

OBJECTIVES

Aboriginal people form one of the populations most in need of mental health and substance abuse services within Australia, although many services are not adequately sensitive to, or inclusive of, relevant aspects of Aboriginal culture in their programmes. The Aboriginal Cultural Engagement Survey (ACES) was developed with the objective of assessing the level of cultural engagement of Aboriginal clients. A measure of cultural engagement is an important step in establishing an association between culture and health benefits, so that future interventions may be designed which better meet the cultural needs of Aboriginal Australians within health services.

DESIGN

The process of development of the ACES involved four stages of scale development utilising a series of group discussions and reviews with Aboriginal consultants. Assessment of content validity is conducted using the Content Validity Index (CVI).

RESULTS

The ACES was found to have excellent content validity with CVIs over 0.80 for all items in the final version.

CONCLUSION

The ACES shows promise for being a useful tool in assessing the cultural engagement of Australian Aboriginal clients. There is a need for further psychometric assessment and field trials to assess its utility.

Acceptability of an emotional and behavioural screening tool for children in Aboriginal Community Controlled Health Services in urban NSW

OBJECTIVE

To assess the acceptability and face validity of the Strengths and Difficulties Questionnaire (SDQ) in Aboriginal community controlled health services (ACCHOs) located in the greater Sydney region.

METHODS

A qualitative study was conducted in three ACCHOs located within the greater Sydney region in 2008-2009. A semi-structured approach was used in focus groups and small group interviews (n = 47) to elicit participants' views on the appropriateness of the SDQ and any additional issues of importance to Aboriginal child and adolescent mental health.

RESULTS

The SDQ was found to cover many important aspects of Aboriginal child and adolescent mental health, however, the wording of some questions was considered ambiguous and some critical issues are not explored. The peer relationships subscale did not appear to fit well with Aboriginal concepts of the relative importance of different interpersonal relationships.

CONCLUSION

Overall the SDQ was acceptable in ACCHOs in Sydney; however, changes to the wording of some questions and the response scale may be indicated to improve cultural appropriateness and clarity. A further set of issues which are not covered by any commonly used screening tools but are of critical importance to Aboriginal child and adolescent mental health should also be considered by clinicians.

Emerging themes in Aboriginal child and adolescent mental health: findings from a qualitative study in Sydney, New South Wales

OBJECTIVE

To explore emerging themes related to the mental health of Aboriginal children and adolescents ("young people") arising from focus groups conducted in Sydney, New South Wales.

DESIGN, SETTING AND PARTICIPANTS

A qualitative study was conducted between April 2008 and September 2009 in three Aboriginal community-controlled health organisations in Sydney. A semi-structured approach was used in focus groups and small group interviews to elicit the views of 15 Aboriginal parents and 32 Aboriginal workers from a variety of health and social work backgrounds on important factors surrounding the mental health of Aboriginal young people.

RESULTS

Major themes identified were the centrality of family and kinship relationships, the importance of identity, confounding factors in the mental health of Aboriginal young people, and issues related to service access and implementation.

CONCLUSION

Clinicians working with Aboriginal young people should be mindful of the critical importance of family and identity issues and should assess possible physical health or social factors that may complicate a diagnosis. Improvements in access to mental health services for Aboriginal families and a more holistic approach to mental health treatment are urgently required.

Mental health first aid for Indigenous Australians: using Delphi consensus studies to develop guidelines for culturally appropriate responses to mental health problems

BACKGROUND

Ethnic minority groups are under-represented in mental health care services because of barriers such as poor mental health literacy. In 2007, the Mental Health First Aid (MHFA) program implemented a cultural adaptation of its first aid course to improve the capacity of Indigenous Australians to recognise and respond to mental health issues within their own communities. It became apparent that the content of this training would be improved by the development of best practice guidelines. This research aimed to develop culturally appropriate guidelines for providing first aid to an Australian Aboriginal or Torres Strait Islander person who is experiencing a mental health crisis or developing a mental illness.

METHODS

A panel of Australian Aboriginal people who are experts in Aboriginal mental health, participated in six independent Delphi studies investigating depression, psychosis, suicidal thoughts and behaviours, deliberate self-injury, trauma and loss, and cultural considerations. The panel varied in size across the studies, from 2024 participants. Panellists were presented with statements about possible first aid actions via online questionnaires and were encouraged to suggest additional actions not covered by the survey content. Statements were accepted for inclusion in a guideline if they were endorsed by > or = 90% of panellists as essential or important. Each study developed one guideline from the outcomes of three Delphi questionnaire rounds. At the end of the six Delphi studies, participants were asked to give feedback on the value of the project and their participation experience.

RESULTS

From a total of 1,016 statements shown to the panel of experts, 536 statements were endorsed (94 for depression, 151 for psychosis, 52 for suicidal thoughts and behaviours, 53 for deliberate self-injury, 155 for trauma and loss, and 31 for cultural considerations). The methodology and the guidelines themselves were found to be useful and appropriate by the panellists.

CONCLUSION

Aboriginal mental health experts were able to reach consensus about culturally appropriate first aid for mental illness. The Delphi consensus method could be useful more generally for consulting Indigenous peoples about culturally appropriate best practice in mental health services.

The insidious problem inside: mental health problems of Aboriginal and Torres Strait Islander People in custody

OBJECTIVE

Despite recognition of the extremely high rates of mental illness among custodial populations and the fact that Indigenous people represent around one-quarter of Australia's custodial population, little is known about the mental health of Aboriginal and Torres Strait Islander people in custody. Mental health is an important component of social and emotional wellbeing for Indigenous people and this paper considers current evidence regarding the mental health status of Indigenous Australians in custody.

METHOD

A systematic review was undertaken of the quantitative literature relating to the mental health problems of Indigenous people in custody in Australia.

RESULTS

Despite high incarceration rates for Indigenous people and evidence that both mental health problems and rates of mental illness are extremely high in this group, studies in this area are few and limited in scope.

CONCLUSION

The first step toward addressing the marked social and mental health problems for Indigenous people in custody is to systematically identify the nature and extent of these problems.

Listening, sharing understanding and facilitating consumer, family and community empowerment through a priority driven partnership in Far North Queensland

OBJECTIVES

This paper provides an example of a mental health research partnership underpinned by empowerment principles that seeks to foster strength among community organizations to support better outcomes for consumers, families and communities. It aims to raise awareness among researchers and service providers that empowerment approaches to assist communities to address mental health problems are not too difficult to be practical but require long-term commitment and appropriate support.

METHODS

A collaborative research strategy that has become known as the Priority Driven Research (PDR) Partnership emerged through literature review, consultations, Family Wellbeing Program delivery with community groups and activities in two discrete Indigenous communities. Progress to date on three of the four components of the strategy is described.

RESULTS

The following key needs were identified in a pilot study and are now being addressed in a research-based implementation phase: (i) gaining two-way understanding of perspectives on mental health and promoting universal awareness; (ii) supporting the empowerment of carers, families, consumers and at-risk groups through existing community organizations to gain greater understanding and control of their situation; (iii) developing pathways of care at the primary health centre level to enable support of social and emotional wellbeing as well as more integrated mental health care; (iv) accessing data to enable an ongoing process of analysis/sharing/planning and monitoring to inform future activity.

CONCLUSION

One of the key learnings to emerge in this project so far is that empowerment through partnership becomes possible when there is a concerted effort to strengthen grassroots community organizations. These include social health teams and men's and women's groups that can engage local people in an action orientation.

Liaison psychiatry with Aboriginal and Torres Strait Islander peoples

OBJECTIVE

The aim of the present study was to describe the referral patterns, assessment and suggested management of Aboriginal and Torres Strait Islander peoples referred to an inner-city general hospital psychiatry service. The overarching goal was quality improvement.

METHOD

Participants were identified from the consultation-liaison psychiatry database of all referrals to the service from the general hospital and Emergency Department. All people over 18 identifying as Aboriginal and/or Torres Strait Islander seen during the period 1 July 2004-30 June 2007 were included. Information regarding referral and liaison patterns, suggested psychiatric management, disposition and follow up were gathered retrospectively from the medical records, with a particular focus on cultural references.

RESULTS

There were 162 referrals to the consultation-liaison psychiatry team of people identifying as Aboriginal and/or Torres Strait Islander. The rate of referral to consultation-liaison psychiatry was 3%. The Emergency Department had the highest rate of referral followed by Obstetrics and Gynaecology. The most common reason for referral was assessment of risk. The patient's Aboriginal ethnicity was mentioned in 52.5% of consultation-liaison assessments. An Aboriginal health worker was consulted in 48.1% of cases. The most common management approach involved pharmacotherapy. The consultation-liaison service instigated legal interventions in 25% of cases. Forty-five patients were referred for psychiatric admission following their assessment. Mental health follow up was arranged in 43.8% of cases.

CONCLUSIONS

The range of mental health problems referred and types of diagnoses made in Aboriginal and Torres Strait Islander peoples reflect what has been previously reported, particularly in relation to comorbidity. Aboriginal ethnicity was variably identified and Aboriginal health workers, general practitioners and families were not routinely involved in consultation-liaison psychiatry assessments, highlighting an opportunity to improve communication and the quality of patient care.

Two-way approaches to Indigenous mental health literacy

This study was designed to provide important new information about relapse prevention in Indigenous 1 people with chronic mental illness. It aimed to explore Indigenous mental health promotion with Aboriginal mental health workers (AMHW) in order to develop strategies for effective mental health intervention. The research was conducted in three remote Indigenous communities in the top end of the Northern Territory with AMHW. Assessment, psycho-education, and care-planning resources were developed with local AMHW through exploration of local Indigenous perspectives of mental health promotion. Qualitative research methods and an ethnographic approach were used to elicit information, and data included key informant interviews, participant observation, music, photography and story telling. The study confirms that Indigenous people in remote communities prefer to use story telling and local language, local artwork and local music to convey health information. It also confirms that family and local practitioners are key cultural informants and that indirect, holistic and ‘two-way’ messages are preferred.

Classification of mood disorders in DSM-V and DSM-VI

For any diagnostic system to be clinically useful, and go beyond description, it must provide an understanding that informs about aetiology and/or outcome. DSM-III and DSM-IV have provided reliability; the challenge for DSM-V and DSM-VI will be to provide validity. For DSM-V this will not be achieved. Believers in DSM-III and DSM-IV have impeded progress towards a valid classification system, so DSM-V needs to retain continuity with its predecessors to retain reliability and enhance research, but position itself to inform a valid diagnostic system by DSM-VI. This review examines the features of a diagnostic system and summarizes what is really known about mood disorders. The review also questions whether what are called mood disorders are primarily disorders of mood. Finally, it provides suggestions for DSM-VI.