Prevalence of mental disorders among Māori in Te Rau Hinengaro: the New Zealand Mental Health Survey

Hauora hinengaro o takatāpui: analysing the effectiveness of mental health policies in addressing the needs of Takatāpui in Aotearoa New Zealand

Many studies have documented the effect that colonisation has had on takatāpui, that is, Māori (the Indigenous peoples of New Zealand) with diverse gender identities, sex characteristics and sexualities. In this paper, we explore whether current Aotearoa New Zealand (hereafter Aotearoa) mental health policies meet the needs of takatāpui. We identified five mental health policy needs, informed by the literature. We then explored policy documents from government ministries, district health boards and non-government organisations to see the extent to which policy met these needs. Four themes were present in the literature analysed: an overall lack of acknowledgment of takatāpui and intersectionality; promising engagement with the needs of takatāpui by NGOs; symbolic commitment to Te Tiriti o Waitangi; and some limited engagement with Māori health models. The findings show promise in some areas but demonstrate a lack of engagement by policy to meet the needs of takatāpui.

Correlates of mental disorder and harmful substance use in an indigenous Australian urban sample: an analysis of data from the Queensland Urban Indigenous Mental Health Survey

PURPOSE

Limited data exists on the relationship between sociodemographic and cultural variables and the prevalence of specific mental and substance use disorders (MSDs) among Indigenous Australians, using diagnostic prevalence data. This paper utilises data from the Queensland Urban Indigenous Mental Health Survey (QUIMHS), a population-level diagnostic mental health survey, to identify socioeconomic and cultural correlates of psychological distress and specific MSDs in an urban Indigenous Australian sample.

METHODS

Using a mixture of household sampling (door-knocking) and snowball sampling (promotion of the survey in the community), 406 participants aged 18 to 89 were recruited across key locations in Southeast Queensland. The study investigated various demographic, socioeconomic, and cultural factors as predictors of psychological distress (measured by the Kessler-5) and MSD diagnoses (utilising the Composite International Diagnostic Interview, CIDI 3.0) using a series of univariate logistic regressions.

RESULTS

Individuals in unstable housing (homeless, sleeping rough) and those reporting financial distress were more likely to experience an MSD in the past 12 months and throughout their lifetime. Individuals reporting lower levels of connection and belonging, limited participation in cultural events, and lower empowerment were more likely to have a lifetime mental disorder.

CONCLUSION

This data emphasises the importance of addressing systemic and social determinants of health when designing and delivering community mental health services and underscores the need for holistic approaches when working with Indigenous communities.

Well-being and cultural identity for Māori: Knowledge of iwi (tribal) affiliations does not strongly relate to health and social service outcomes

Research indicates that experiences in health and social services vary depending on identity. For Indigenous groups, identity and affiliation is complex. This paper explores ethnicity and knowledge of tribal (iwi) affiliations for Māori (the Indigenous peoples of Aotearoa New Zealand), and links this to health and social service outcomes in administrative data, the national Census, and Māori social survey data. While many initiatives have sought to connect Māori to iwi - where such knowledge has been severed by colonization - we find surprisingly few differences in data between those who named tribal affiliations and those who did not, across sole- and mixed-Māori ethnicity groups. Those who did not name an iwi were less likely to live in overcrowded homes, but were less likely to own that home, and more likely to be a smoker. Unsurprisingly, those who did not name tribal affiliations were less likely to find Māori culture as important, although many still did. These groups also had slightly less contact with social networks and support, plus felt lonelier. The results also point to sole-ethnic identification as Māori as a key marker of experiences of inequity and suggest that connections to tribal affiliations are more complicated than a binary of "connected" or "disconnected". However, in some indicator areas, affiliation differences should be followed up with future work. We argue these results give further weight to the need for good quality data and indicators designed with Māori populations in mind to measure and monitor inequity.

Well-being app to support young people during the COVID-19 pandemic: randomised controlled trial

OBJECTIVES

To evaluate the efficacy and acceptability of 'Whitu: seven ways in seven days', a well-being application (app) for young people.

DESIGN

Prospective randomised controlled trial of Whitu against waitlist control, with 45 participants in each arm.

PARTICIPANTS

90 New Zealand young people aged 16-30 recruited via a social media advertising campaign.

SETTING

Participants' homes.

INTERVENTIONS

Developed during the COVID-19 pandemic, and refined from a prototype version that was evaluated during a smaller qualitative study, 'Whitu: seven ways in seven days' is a well-being app that, as its name suggests, contains seven modules to help young people (1) recognise and rate emotions, (2) learn relaxation and mindfulness, (3) practice self-compassion and (4) gratitude, (5) connect with others, (6) care for their physical health and (7) engage in goal-setting. It can be completed within a week or as desired.

MAIN OUTCOME MEASURES

Primary outcomes were changes in well-being on the WHO 5-item Well-Being Index and Short Warwick-Edinburgh Mental Well-Being Scale. Secondary outcomes were changes in depression on the Centre for Epidemiological Studies Depression Scale, anxiety on the Generalised Anxiety Disorder 7-item Scale, self-compassion on the Self Compassion Scale-Short Form, stress on the 10-item Perceived Stress Scale, sleep on the single-item Sleep Quality Scale and user engagement on the end-user version of the Mobile Application Rating Scale and via qualitative feedback during an online survey. Outcomes were evaluated at baseline, 4 weeks (primary study endpoint) and 3 months, and analysed using linear mixed models with group, time and a group-time interaction.

RESULTS

At 4 weeks, participants in the Whitu group experienced significantly higher emotional (Mean difference (md) 13.19 (3.96 to 22.42); p=0.005) and mental (md 2.44 (0.27 to 4.61); p=0.027) well-being, self-compassion (md 0.56 (0.28 to 0.83); p<0.001) and sleep (md 1.13 (0.24 to 2.02); p=0.018), and significantly lower stress (md -4.69 (-7.61 to -1.76); p=0.002) and depression (md -5.34 (-10.14 to -0.53); p=0.030), compared with the waitlist controls. Group differences remained statistically significant at 3 months for all outcomes. Symptoms of anxiety were also lower in the intervention group at 4 weeks (p=0.096), with statistically significant differences at 3 months (md -2.31 (-4.54 to -0.08); p=0.042). Usability of Whitu was high (subjective ratings of 4.45 (0.72) and 4.38 (0.79) out of 5 at 4 weeks and 3 months, respectively) and qualitative feedback indicated individual and cultural acceptability of the app.

CONCLUSIONS

Given the evolving psychological burden of the COVID-19 pandemic, Whitu could provide a clinically effective and scalable means of improving the well-being, mental health and resilience of young people. Replication of current findings with younger individuals and in other settings is planned.

TRIAL REGISTRATION NUMBER

Australian New Zealand Clinical Trials Registry (ACTRN12620000516987).

The impact of COVID-19 on eating disorder referrals and admissions in Waikato, New Zealand

BACKGROUND

Several countries have reported increased demand for eating disorder services during the COVID-19 pandemic, particularly for adolescents. Within New Zealand, anecdotal and media reports suggest similar changes but are limited in scope and detail. We assessed eating disorder service demand in the Waikato district in relation to the COVID-19 pandemic.

METHODS

We retrospectively analysed records of eating disorder admissions and referrals for both children (< 18 years) and adults (≥ 18 years) during 2019 and 2020 in the Waikato, a mixed urban-rural province in northern New Zealand (population 435,000). We analysed medical admission and outpatient referral rates, and referral acuity, in relation to the COVID-19 pandemic using Welch's t- and chi-square tests.

RESULTS

106 medical admissions met inclusion criteria (n = 37 in 2019; 69 in 2020). Admissions for eating disorders increased markedly following nationwide lockdown in March 2020 (RR = 1.7, p = 0.01), largely driven by increases in adult admissions (RR 2.0, p = 0.005). The proportion of 'new patient' admissions showed comparable increases for both children (RR = 2.0, p = 0.02) and adults (RR = 2.3, p = 0.03). Following lockdown, outpatient referrals increased in acuity (RR = 1.8, p = 0.047) and volume (RR = 1.6, p = 0.076) for children but not for adults.

CONCLUSIONS

Our study confirms a pandemic-related increase in demand for eating disorder services in the Waikato region of New Zealand, consistent with findings reported overseas. We observed contrasting increases in admissions for adults and outpatient referrals for children, exacerbating resource constraints for already stretched services and compromising provision of timely care. The COVID-19 pandemic has been linked to increased numbers and worsening severity of eating disorders in several settings. In New Zealand, similar trends have been noted anecdotally. We assessed clinical records to calculate rates of eating disorder-related hospital admissions and outpatient referrals during 2019 and 2020. We found significant increases in hospital admissions related to COVID-19, particularly for adults, and greater proportions of both children and adults having a first-ever eating disorder-related admission. In outpatient services, young people were referred more frequently during the pandemic and were more physically unwell when referred. These results indicate increased demand for eating disorder services as a result of the pandemic and complement findings reported overseas.

The physical health of Māori with bipolar disorder

AIMS

There is very little empirical evidence about the relationship between severe mental illness and the physical health of Indigenous peoples. This paper aims to compare the physical health of Māori and non-Māori with a diagnosis of bipolar disorder in contact with NZ mental health services.

METHODS

A cohort of Māori and non-Māori with a current bipolar disorder diagnosis at 1 January 2010 were identified from routine mental health services data and followed up for non-psychiatric hospital admissions and deaths over the subsequent 5 years.

RESULTS

Māori with bipolar disorder had a higher level of morbidity and a higher risk of death from natural causes compared to non-Māori with the same diagnosis, indicating higher levels of physical health need. The rate of medical and surgical hospitalisation was not higher among Māori compared to non-Māori (as might be expected given increased health needs) which suggests under-treatment of physical health conditions in this group may be a factor in the observed higher risk of mortality from natural causes for Māori.

CONCLUSION

This study provides the first indication that systemic factors which cause health inequities between Māori and non-Māori are compounded for Māori living with severe mental illness. Further exploration of other diagnostic groups and subgroups is needed to understand the best approach to reducing these inequalities.

What is the prevalence of current alcohol dependence and how is it measured for Indigenous people in Australia, New Zealand, Canada and the United States of America? A systematic review

BACKGROUND

Alcohol affects Indigenous communities globally that have been colonised. These effects are physical, psychological, financial and cultural. This systematic review aims to describe the prevalence of current (12-month) alcohol dependence in Indigenous Peoples in Australia, New Zealand, Canada and the United States of America, to identify how it is measured, and if tools have been validated in Indigenous communities. Such information can help inform estimates of likely treatment need.

METHODS

A systematic search of the literature was completed in six electronic databases for reports on current alcohol dependence (moderate to severe alcohol use disorder) published between 1 January 1989-9 July 2020. The following data were extracted: (1) the Indigenous population studied; country, (2) prevalence of dependence, (3) tools used to screen, assess or diagnose current dependence, (4) tools that have been validated in Indigenous populations to screen, assess or diagnose dependence, and (5) quality of the study, assessed using the Appraisal Tool for Cross-Sectional Studies.

RESULTS

A total of 11 studies met eligibility criteria. Eight were cross-sectional surveys, one cohort study, and two were validation studies. Nine studies reported on the prevalence of current (12-month) alcohol dependence, and the range varied widely (3.8-33.3% [all participants], 3-32.8% [males only], 1.3-7.6% [females only]). Eight different tools were used and none were Indigenous-specific. Two tools have been validated in Indigenous (Native American) populations.

CONCLUSION

Few studies report on prevalence of current alcohol dependence in community or household samples of Indigenous populations in these four countries. Prevalence varies according to sampling method and site (for example, specific community versus national). Prior work has generally not used tools validated in Indigenous contexts. Collaborations with local Indigenous people may help in the development of culturally appropriate ways of measuring alcohol dependence, incorporating local customs and values. Tools used need to be validated in Indigenous communities, or Indigenous-specific tools developed, validated and used. Prevalence findings can inform health promotion and treatment needs, including funding for primary health care and specialist treatment services.

Pacific models of mental health service delivery in New Zealand: Part I: What do we know about Pacific mental health in New Zealand? A narrative review

OBJECTIVE

To update measures of mental disorders and service use in Pacific people living in New Zealand.

METHOD

A narrative review was conducted of available data on the prevalence of mental disorder, psychotropic drug prescribing and service use by Pacific people.

RESULTS

The 12-month prevalence of mental disorders in Pacific people was similar to European/Other in 2004. Currently Pacific people report high rates of psychological distress but lower levels of psychiatric disorders. Pacific adults have low rates of drinking but many who drink have a hazardous pattern. While Pacific people previously accessed services less than half the rate of European access, access rates in secondary care are now similar. Pacific people have relatively low rates of psychotropic drug use but these are increasing.

CONCLUSION

There is limited evidence about Pacific people's mental health in New Zealand. Patterns of psychopathology and service use may be different from other ethnic groups. Protective factors in Pacific culture should not be undermined when delivering mental health services.

Building workforce capacity in Australia and New Zealand: a profile of psychiatrists with an interest in intellectual and developmental disability mental health

OBJECTIVE:

To describe the characteristics of psychiatrists working in the area of intellectual and developmental disability mental health (IDDMH) across Australia and New Zealand.

METHODS:

A secondary analysis of data collected by the Royal Australian and New Zealand College of Psychiatrists 2014 workforce survey. Characteristics of the IDDMH workforce ( n=146 psychiatrists) were compared with those of the broader psychiatry workforce ( n=1050 psychiatrists).

RESULTS:

The IDDMH workforce were more likely than the broader psychiatry workforce to be working across both the public and private health sectors, be engaged in outreach work, endorse specialty practice areas pertinent to IDDMH, treat younger patients and work more clinical hours per week. Part-time status and retirement plans of the IDDMH workforce matched those of the broader psychiatry workforce.

CONCLUSIONS:

While some elements of the IDDMH workforce profile suggest this workforce is tailored to the needs of the population, the potential shortage of IDDMH psychiatrists highlights the need for the development of a specific training programme and pathway in this area.

Royal Australian and New Zealand College of Psychiatrists clinical practice guidelines for the treatment of panic disorder, social anxiety disorder and generalised anxiety disorder

Objective:

To provide practical clinical guidance for the treatment of adults with panic disorder, social anxiety disorder and generalised anxiety disorder in Australia and New Zealand.

Method:

Relevant systematic reviews and meta-analyses of clinical trials were identified by searching PsycINFO, Medline, Embase and Cochrane databases. Additional relevant studies were identified from reference lists of identified articles, grey literature and literature known to the working group. Evidence-based and consensus-based recommendations were formulated by synthesising the evidence from efficacy studies, considering effectiveness in routine practice, accessibility and availability of treatment options in Australia and New Zealand, fidelity, acceptability to patients, safety and costs. The draft guidelines were reviewed by expert and clinical advisors, key stakeholders, professional bodies, and specialist groups with interest and expertise in anxiety disorders.

Results:

The guidelines recommend a pragmatic approach beginning with psychoeducation and advice on lifestyle factors, followed by initial treatment selected in collaboration with the patient from evidence-based options, taking into account symptom severity, patient preference, accessibility and cost. Recommended initial treatment options for all three anxiety disorders are cognitive–behavioural therapy (face-to-face or delivered by computer, tablet or smartphone application), pharmacotherapy (a selective serotonin reuptake inhibitor or serotonin and noradrenaline reuptake inhibitor together with advice about graded exposure to anxiety triggers), or the combination of cognitive–behavioural therapy and pharmacotherapy.

Conclusion:

The Royal Australian and New Zealand College of Psychiatrists clinical practice guidelines for the treatment of panic disorder, social anxiety disorder and generalised anxiety disorder provide up-to-date guidance and advice on the management of these disorders for use by health professionals in Australia and New Zealand.

The Associations Between Cultural Identity and Mental Health Outcomes for Indigenous Māori Youth in New Zealand

Objectives: To explore the relationships between Māori cultural identity, ethnic discrimination and mental health outcomes for Māori youth in New Zealand.

Study Design: Nationally representative, anonymous cross-sectional study of New Zealand secondary school students in 2012.

Methods: Secondary analysis of Māori students (n = 1699) from the national Youth'12 secondary school students survey was undertaken. Theoretical development and exploratory factor analysis were undertaken to develop a 14-item Māori Cultural Identity Scale (MCIS). Māori students reporting > 8 items were classified as having a strong MCIS. Prevalence of indicators were reported and logistic regression models were used to explore how wellbeing (WHO-5), depressive symptoms (Reynolds Adolescent Depression Scale-SF), and suicide attempts were associated with the MCIS.

Results: After adjusting for age, sex, ethnic discrimination and NZ Deprivation Index (NZDep), a strong Māori cultural identity (MCIS) was associated with improved wellbeing scores (OR 1.53, 95% CI 1.18–2.01) and fewer depressive symptoms (OR 0.53, 95% CI 0.38–0.73). Experiencing discrimination was associated with poorer wellbeing scores (OR 0.50, 95% CI 0.39–0.65), greater depressive symptoms (OR 2.2, 95% CI 1.55–3.18), and a previous suicide attempt (OR 2.47, 95% CI 1.71–3.58). Females less frequently reported good (WHO-5) wellbeing (OR 0.33, 95% CI 0.26–0.42), increased (RADS-SF) depressive symptoms (2.61, 95% CI 1.86–3.64) and increased suicide attempts [OR 3.35 (2.07–5.41)] compared to males. Wellbeing, depressive symptoms and suicide attempts did not differ by age or neighborhood level socio-economic deprivation, except those living in neighborhoods characterized as having medium level incomes, were less likely to have made a suicide attempt (OR 0.49, 95% CI 0.27–0.91).

Conclusions: Māori youth who have a strong cultural identity were more likely to experience good mental health outcomes. Discrimination has a serious negative impact on Māori youth mental health. Our findings suggest that programmes, policies and practice that promote strong cultural identities and eliminate ethnic discrimination are required to improve mental health equity for Māori youth.

The rate of mental health service use in New Zealand as analysed by ethnicity

OBJECTIVES

To compare by ethnicity the rates of apparent new referrals and admissions to mental health services for selected major diagnostic groupings.

METHOD

Using a Ministry of Health database covering all referrals and admissions to New Zealand's Mental Health services in 2014 and who had not been patients in the preceding six years, population adjusted rates of presentation were calculated and compared across the two major New Zealand ethnic groupings.

RESULTS

Population corrected rates of apparently new cases of schizophrenia are more than twice as common in Māori as in non-Māori. Major depression is also significantly more common in Māori. That same trend was not evident for bipolar patients.

CONCLUSIONS

These ethnically associated apparent differences in the rates of schizophrenia and depression need both confirmation and explanation.

Diversity in eMental Health Practice: An Exploratory Qualitative Study of Aboriginal and Torres Strait Islander Service Providers

BACKGROUND

In Australia, mental health services are undergoing major systemic reform with eMental Health (eMH) embedded in proposed service models for all but those with severe mental illness. Aboriginal and Torres Strait Islander service providers have been targeted as a national priority for training and implementation of eMH into service delivery. Implementation studies on technology uptake in health workforces identify complex and interconnected variables that influence how individual practitioners integrate new technologies into their practice. To date there are only two implementation studies that focus on eMH and Aboriginal and Torres Strait Islander service providers. They suggest that the implementation of eMH in the context of Aboriginal and Torres Strait Islander populations may be different from the implementation of eMH with allied health professionals and mainstream health services.

OBJECTIVE

The objective of this study is to investigate how Aboriginal and Torres Strait Islander service providers in one regional area of Australia used eMH resources in their practice following an eMH training program and to determine what types of eMH resources they used.

METHODS

Individual semistructured qualitative interviews were conducted with a purposive sample of 16 Aboriginal and Torres Strait Islander service providers. Interviews were co-conducted by one indigenous and one non-indigenous interviewer. A sample of transcripts were coded and thematically analyzed by each interviewer and then peer reviewed. Consensus codes were then applied to all transcripts and themes identified.

RESULTS

It was found that 9 of the 16 service providers were implementing eMH resources into their routine practice. The findings demonstrate that participants used eMH resources for supporting social inclusion, informing and educating, assessment, case planning and management, referral, responding to crises, and self and family care. They chose a variety of types of eMH resources to use with their clients, both culturally specific and mainstream. While they referred clients to online treatment programs, they used only eMH resources designed for mobile devices in their face-to-face contact with clients.

CONCLUSIONS

This paper provides Aboriginal and Torres Strait islander service providers and the eMH field with findings that may inform and guide the implementation of eMH resources. It may help policy developers locate this workforce within broader service provision planning for eMH. The findings could, with adaptation, have wider application to other workforces who work with Aboriginal and Torres Strait Islander clients. The findings highlight the importance of identifying and addressing the particular needs of minority groups for eMH services and resources.

Cortisol Awakening Response and Acute Stress Reactivity in First Nations People

First Nations people globally have a higher incidence of mental disorders and non-communicable diseases. These health inequalities are partially attributed to a complex network of social and environmental factors which likely converge on chronic psychosocial stress. We hypothesized that alterations in stress processing and the regulation of the hypothalamic-pituitary-adrenal axis might underlie health disparities in First Nations people. We assessed the cortisol awakening response and the dynamic response to a laboratory induced psychosocial stress of young Indigenous tertiary students (n = 11, mean age 23.82 years) and non-Indigenous students (n = 11) matched for age and gender. Indigenous participants had a blunted cortisol awakening response (27.40 (SD 35.00) vs. 95.24 (SD 55.23), p = 0.002), which was differentially associated with chronic experience of stress in Indigenous (r = -0.641, p = 0.046) and non-Indigenous (r = 0.652, p = 0.03) participants. The cortisol response to the laboratory induced psychosocial stress did not differ between groups. Self-reported racial discrimination was strongly associated with flattened cortisol response to stress (r = -0676, p = 0.022) and with heart rate variability (r = 0.654, p = 0.040). Our findings provide insight into potential biological factors underlying health discrepancies in ethnic minority groups.

Cognitive neuropsychological functioning in New Zealand Māori diagnosed with schizophrenia

OBJECTIVE

Previous research suggests that New Zealand Māori may have an elevated rate of schizophrenia. However, there is limited evidence on important clinical features of the illness in this population. This study examined cognitive neuropsychological functioning in 54 adult Māori diagnosed with schizophrenia and 56 Māori controls. This study also examined associations between cognition, medication and symptoms of psychosis in the schizophrenia group.

METHOD

The groups were matched on socio-demographic variables, handedness and premorbid cognitive ability. Participants were assessed on neuropsychological tests of attention, executive ability, motor, premorbid ability, verbal/non-verbal memory and verbal fluency (English/Māori versions). The Positive and Negative Syndrome Scale was used to assess psychotic symptoms. Information on cultural identity, duration of illness, duration of untreated psychosis, medication and substance abuse was collected.

RESULTS

The performance of the schizophrenia group was significantly lower than the control group on all the neuropsychological tests, except the test of attention. The effect sizes were moderate to large: 0.78 for motor function; 1.3 for executive ability, verbal fluency and visual memory; 1.6 for verbal learning and 1.8 for verbal memory. These differences remained after adjustment for multiple comparisons and covariates. A higher dose of antipsychotic medication and a higher anticholinergic load were associated with greater verbal memory impairment (r = -0.38 and r = -0.38, respectively). A longer duration of illness was associated with greater impairment of verbal memory (rho = -0.48), verbal learning (rho = -0.41) and visual memory (rho = -0.44).

CONCLUSION

The findings for the schizophrenia group show a profile of generalised cognitive impairment with greater impairment of verbal memory. The cognitive impairment in this group was independent of psychotic symptoms, but was associated with a higher antipsychotic dose, higher anticholinergic load and longer duration of illness. These findings have implications for clinical prescribing practices and rehabilitation for New Zealand Māori diagnosed with schizophrenia.

Considerations for Culturally Responsive Cognitive-Behavioural Therapy for Māori With Depression

A strong case can be made for adapting cognitive-behavioural therapy (CBT) for ethnic and cultural minority groups. In North America, literature is readily available for CBT practitioners wishing to adapt their practice when working with ethnic minority groups (e.g., Latino, African-American, and Native American groups). In other countries such as New Zealand, literature of this sort is scarce, and the empirical foundation for CBT adaptation in these parts of the world is weak. This article documents the core tenets of an empirically validated CBT treatment protocol tailored for individual delivery to Māori clients suffering from depression in New Zealand and developed through consultation with an expert advisory group consisting of senior clinicians and Māori cultural experts. The result is a series of considerations for clinicians endeavouring to provide culturally responsive CBT with Māori clients, who are identified and organised into four domains. Two case studies are presented to illustrate the practical application of the proposed techniques. Links are made to international literature related to the adaptation of CBT in pursuit of cultural responsiveness.

Royal Australian and New Zealand College of Psychiatrists clinical practice guidelines for mood disorders

OBJECTIVES

To provide guidance for the management of mood disorders, based on scientific evidence supplemented by expert clinical consensus and formulate recommendations to maximise clinical salience and utility.

METHODS

Articles and information sourced from search engines including PubMed and EMBASE, MEDLINE, PsycINFO and Google Scholar were supplemented by literature known to the mood disorders committee (MDC) (e.g., books, book chapters and government reports) and from published depression and bipolar disorder guidelines. Information was reviewed and discussed by members of the MDC and findings were then formulated into consensus-based recommendations and clinical guidance. The guidelines were subjected to rigorous successive consultation and external review involving: expert and clinical advisors, the public, key stakeholders, professional bodies and specialist groups with interest in mood disorders.

RESULTS

The Royal Australian and New Zealand College of Psychiatrists clinical practice guidelines for mood disorders (Mood Disorders CPG) provide up-to-date guidance and advice regarding the management of mood disorders that is informed by evidence and clinical experience. The Mood Disorders CPG is intended for clinical use by psychiatrists, psychologists, physicians and others with an interest in mental health care.

CONCLUSIONS

The Mood Disorder CPG is the first Clinical Practice Guideline to address both depressive and bipolar disorders. It provides up-to-date recommendations and guidance within an evidence-based framework, supplemented by expert clinical consensus.

MOOD DISORDERS COMMITTEE

Professor Gin Malhi (Chair), Professor Darryl Bassett, Professor Philip Boyce, Professor Richard Bryant, Professor Paul Fitzgerald, Dr Kristina Fritz, Professor Malcolm Hopwood, Dr Bill Lyndon, Professor Roger Mulder, Professor Greg Murray, Professor Richard Porter and Associate Professor Ajeet Singh.

INTERNATIONAL EXPERT ADVISORS

Professor Carlo Altamura, Dr Francesco Colom, Professor Mark George, Professor Guy Goodwin, Professor Roger McIntyre, Dr Roger Ng, Professor John O'Brien, Professor Harold Sackeim, Professor Jan Scott, Dr Nobuhiro Sugiyama, Professor Eduard Vieta, Professor Lakshmi Yatham.

AUSTRALIAN AND NEW ZEALAND EXPERT ADVISORS

Professor Marie-Paule Austin, Professor Michael Berk, Dr Yulisha Byrow, Professor Helen Christensen, Dr Nick De Felice, A/Professor Seetal Dodd, A/Professor Megan Galbally, Dr Josh Geffen, Professor Philip Hazell, A/Professor David Horgan, A/Professor Felice Jacka, Professor Gordon Johnson, Professor Anthony Jorm, Dr Jon-Paul Khoo, Professor Jayashri Kulkarni, Dr Cameron Lacey, Dr Noeline Latt, Professor Florence Levy, A/Professor Andrew Lewis, Professor Colleen Loo, Dr Thomas Mayze, Dr Linton Meagher, Professor Philip Mitchell, Professor Daniel O'Connor, Dr Nick O'Connor, Dr Tim Outhred, Dr Mark Rowe, Dr Narelle Shadbolt, Dr Martien Snellen, Professor John Tiller, Dr Bill Watkins, Dr Raymond Wu.

Animal models of gene-environment interaction in schizophrenia: A dimensional perspective

Schizophrenia has long been considered as a disorder with multifactorial origins. Recent discoveries have advanced our understanding of the genetic architecture of the disease. However, even with the increase of identified risk variants, heritability estimates suggest an important contribution of non-genetic factors. Various environmental risk factors have been proposed to play a role in the etiopathogenesis of schizophrenia. These include season of birth, maternal infections, obstetric complications, adverse events at early childhood, and drug abuse. Despite the progress in identification of genetic and environmental risk factors, we still have a limited understanding of the mechanisms whereby gene-environment interactions (G × E) operate in schizophrenia and psychoses at large. In this review we provide a critical analysis of current animal models of G × E relevant to psychotic disorders and propose that dimensional perspective will advance our understanding of the complex mechanisms of these disorders.

Modular Approach to Therapy for Anxiety, Depression, Trauma, or Conduct Problems in outpatient child and adolescent mental health services in New Zealand: study protocol for a randomized controlled trial

BACKGROUND

Mental health disorders are common and disabling for young people because of the potential to disrupt key developmental tasks. Implementation of evidence-based psychosocial therapies in New Zealand is limited, owing to the inaccessibility, length, and cost of training in these therapies. Furthermore, most therapies address one problem area at a time, although comorbidity and changing clinical needs commonly occur in practice. A more flexible approach is needed. The Modular Approach to Therapy for Children with Anxiety, Depression, Trauma, or Conduct Problems (MATCH-ADTC) is designed to overcome these challenges; it provides a range of treatment modules addressing different problems, within a single training program. A clinical trial of MATCH-ADTC in the USA showed that MATCH-ADTC outperformed usual care and standard evidence-based treatment on several clinical measures. We aim to replicate these findings and evaluate the impact of providing training and supervision in MATCH-ADTC to: (1) improve clinical outcomes for youth attending mental health services; (2) increase the amount of evidence-based therapy content; (3) increase the efficiency of service delivery.

METHODS

This is an assessor-blinded multi-site effectiveness randomized controlled trial. Randomization occurs at two levels: (1) clinicians (≥60) are randomized to intervention or usual care; (2) youth participants (7-14 years old) accepted for treatment in child and adolescent mental health services (with a primary disorder that includes anxiety, depression, trauma-related symptoms, or disruptive behavior) are randomly allocated to receive MATCH-ADTC or usual care. Youth participants are recruited from 'mainstream', Māori-specific, and Pacific-specific child and adolescent mental health services. We originally planned to recruit 400 youth participants, but this has been revised to 200 participants. Centralized computer randomization ensures allocation concealment. The primary outcome measures are: (i) the difference in trajectory of change of clinical severity between groups (using the parent-rated Brief Problem Monitor); (ii) clinicians' use of evidence-based treatment procedures during therapy sessions; (iii) total time spent by clinicians delivering therapy.

DISCUSSION

If MATCH-ADTC demonstrates effectiveness it could offer a practical efficient method to increase access to evidence-based therapies, and improve outcomes for youth attending secondary care services.

TRIAL REGISTRATION

Australian and New Zealand Clinical Trials Registry ACTRN12614000297628 .

Royal Australian and New Zealand College of Psychiatrists clinical practice guidelines for the treatment of eating disorders

OBJECTIVES

This clinical practice guideline for treatment of DSM-5 feeding and eating disorders was conducted as part of the Royal Australian and New Zealand College of Psychiatrists (RANZCP) Clinical Practice Guidelines (CPG) Project 2013-2014.

METHODS

The CPG was developed in accordance with best practice according to the National Health and Medical Research Council of Australia. Literature of evidence for treatments of anorexia nervosa (AN), bulimia nervosa (BN), binge eating disorder (BED), other specified and unspecified eating disorders and avoidant restrictive food intake disorder (ARFID) was sourced from the previous RANZCP CPG reviews (dated to 2009) and updated with a systematic review (dated 2008-2013). A multidisciplinary working group wrote the draft CPG, which then underwent expert, community and stakeholder consultation, during which process additional evidence was identified.

RESULTS

In AN the CPG recommends treatment as an outpatient or day patient in most instances (i.e. in the least restrictive environment), with hospital admission for those at risk of medical and/or psychological compromise. A multi-axial and collaborative approach is recommended, including consideration of nutritional, medical and psychological aspects, the use of family based therapies in younger people and specialist therapist-led manualised based psychological therapies in all age groups and that include longer-term follow-up. A harm minimisation approach is recommended in chronic AN. In BN and BED the CPG recommends an individual psychological therapy for which the best evidence is for therapist-led cognitive behavioural therapy (CBT). There is also a role for CBT adapted for internet delivery, or CBT in a non-specialist guided self-help form. Medications that may be helpful either as an adjunctive or alternative treatment option include an antidepressant, topiramate, or orlistat (the last for people with comorbid obesity). No specific treatment is recommended for ARFID as there are no trials to guide practice.

CONCLUSIONS

Specific evidence based psychological and pharmacological treatments are recommended for most eating disorders but more trials are needed for specific therapies in AN, and research is urgently needed for all aspects of ARFID assessment and management.

EXPERT REVIEWERS

Associate Professor Susan Byrne, Dr Angelica Claudino, Dr Anthea Fursland, Associate Professor Jennifer Gaudiani, Dr Susan Hart, Ms Gabriella Heruc, Associate Professor Michael Kohn, Dr Rick Kausman, Dr Sarah Maguire, Ms Peta Marks, Professor Janet Treasure and Mr Andrew Wallis.

Stability and change in the mental health of New Zealand secondary school students 2007-2012: results from the national adolescent health surveys

OBJECTIVE

To describe the self-reported mental health of New Zealand secondary school students in 2012 and to investigate changes between 2007 and 2012.

METHODS

Nationally representative health and wellbeing surveys of students were completed in 2007 (n=9107) and 2012 (n=8500). Logistic regressions were used to examine the associations between mental health and changes over time. Prevalence data and adjusted odds ratios are presented.

RESULTS

In 2012, approximately three-quarters (76.2%, 95% CI 74.8-77.5) of students reported good overall wellbeing. By contrast (also in 2012), some students reported self-harming (24.0%, 95% CI 22.7-25.4), depressive symptoms (12.8%, 95% CI 11.6-13.9), 2 weeks of low mood (31%, 95% CI 29.7-32.5), suicidal ideation (15.7%, 95% 14.5-17.0), and suicide attempts (4.5%, 95% CI 3.8-5.2). Between 2007 and 2012, there appeared to be slight increases in the proportions of students reporting an episode of low mood (OR 1.14, 95% CI 1.06-1.23, p=0.0009), depressive symptoms (OR 1.16, 95% CI 1.03-1.30, p=0.011), and using the Strengths and Difficulties Questionnaire - emotional symptoms (OR 1.38, 95% CI 1.23-1.54, p<0.0001), hyperactivity (OR 1.16, 95% CI 1.05-1.29, p=0.0051), and peer problems (OR 1.27, 95% CI 1.09-1.49, p=0.0022). The proportion of students aged 16 years or older reporting self-harm increased slightly between surveys, but there was little change for students aged 15 years or less (OR 1.29, 95% CI 1.15-1.44 and OR 1.10, 95% 0.98-1.23, respectively, p=0.0078). There were no changes in reported suicidal ideation and suicide attempts between 2007 and 2012. However, there has been an improvement in self-reported conduct problems since 2007 (OR 0.78, 95% CI 0.70-0.87, p<0.0001).

CONCLUSIONS

The findings suggest a slight decline in aspects of self-reported mental health amongst New Zealand secondary school students between 2007 and 2012. There is a need for ongoing monitoring and for evidence-based, accessible interventions that prevent mental ill health and promote psychological wellbeing.

Frequent mental distress (FMD) in Irish Travellers: discrimination and bereavement negatively influence mental health in the All Ireland Traveller Health Study

Travellers are an indigenous minority group in Ireland, with poorer life expectancy and health status than the general population. Recent data have shown that Travellers are at increased risk of poor mental health and sequelae from same. We aimed to examine the associations between sociodemographic and lifestyle factors with poor mental health in Irish Travellers. A census survey of all Travellers was undertaken, with 8,492 enumerated families (80% response rate). A random subset of 1,796 adults completed an adult health survey. Traveller peer researchers employed a novel oral-visual computer-aided data collection tool. Frequent mental distress (FMD) was defined as 14 or more days of poor mental health in the preceding 1 month. Prevalence ratios for typical associates of FMD were estimated using a Poisson regression model, adjusted for age and sex. FMD was present in 11.9% of Traveller respondents, and prevalence increased with age. After age and sex adjustment, FMD was more prevalent in those whose quality of life was impaired by physical health, by those who were recently bereaved of a friend or family member, and by those who had greater experiences of discrimination. This study shows that Travellers experience discrimination and bereavement, which negatively influence their mental health. The findings have implications for the mental healthcare needs of indigenous ethnic minorities worldwide.

Social gradients in the health of Indigenous Australians

The pattern of association between socioeconomic factors and health outcomes has primarily depicted better health for those who are higher in the social hierarchy. Although this is a ubiquitous finding in the health literature, little is known about the interplay between these factors among indigenous populations. We begin to bridge this knowledge gap by assessing evidence on social gradients in indigenous health in Australia. We reveal a less universal and less consistent socioeconomic status patterning in health among Indigenous Australians, and discuss the plausibility of unique historical circumstances and social and cultural characteristics in explaining these patterns. A more robust evidence base in this field is fundamental to processes that aim to reduce the pervasive disparities between indigenous and nonindigenous population health.

Estimating the prevalence of schizophrenia among New Zealand Maori: a capture-recapture approach

OBJECTIVE

The aim of the present study was to estimate the 12 month prevalence of schizophrenia in the Maori population of New Zealand.

METHOD

Mental health data from two national sources were obtained for the period 2000-2003. A simple count of unique individuals with schizophrenia was used to estimate contact prevalence and a four-list capture-recapture procedure to estimate population prevalence.

RESULTS

Contact prevalence was significantly lower than the estimated population prevalence for both groups. The estimated 12 month prevalence of schizophrenia for Maori (0.97%) was significantly higher than for non-Maori (0.32%), even after adjustment for age, case under-ascertainment, and socioeconomic deprivation.

CONCLUSIONS

The prevalence of schizophrenia among Maori appears to be elevated, although limitations in diagnostic reliability and recording of ethnicity must be considered. This adds further evidence of worldwide variation in the prevalence of schizophrenia. Capture-recapture provides a reliable cost-effective alternative to epidemiological surveys for estimating the prevalence of low-prevalence disorders such as schizophrenia.

Twelve-month and lifetime health service use in Te Rau Hinengaro: The New Zealand Mental Health Survey

OBJECTIVE

To estimate the 12 month and lifetime use of health services for mental health problems.

METHOD

A nationwide face-to-face household survey carried out in 2003-2004. A fully structured diagnostic interview, the World Health Organization Composite International Diagnostic Interview (CIDI 3.0) was used. There were 12 992 completed interviews from participants aged 16 years and over. The overall response rate was 73.3%. In this paper, the outcomes reported are 12 month and lifetime health service use for mental health and substance use problems.

RESULTS

Of the population, 13.4% had a visit for a mental health reason in the 12 months before interview. Of all 12 month cases of mental disorder, 38.9% had a mental health visit to a health or non-health-care provider in the past 12 months. Of these 12 month cases, 16.4% had contact with a mental health specialist, 28.3% with a general medical provider, 4.8% within the human services sector and 6.9% with a complementary or alternative medicine practitioner. Most people with lifetime disorders eventually made contact if their disorder continued. However, the percentages seeking help at the age of onset were small for most disorders and several disorders had large percentages who never sought help. The median duration of delay until contact varies from 1 year for major depressive disorder to 38 years for specific phobias.

CONCLUSIONS

A significant unmet need for treatment for people with mental disorder exists in the New Zealand community, as in other comparable countries.