Translating research into action: The design and development of an Indigenous specific suicide intervention skills training program (I-ASIST).

Note: We respectfully refer to Aboriginal and Torres Strait Islander people as Indigenous in this study. OBJECTIVE: To design and develop an Indigenous specific suicide intervention skills program that focuses on education and intervention training as an effective suicide prevention strategy. METHOD: Using a co-designed wrap-around framework, we developed a program in collaboration with >90 communities, stakeholders and service providers across Australia to understand knowledge, awareness and sense of connectedness between at-risk groups and health services or support groups. RESULTS: The I-ASIST training provides participants with the necessary skills and knowledge to apply a suicide intervention model. The framework behind the intervention model provides caregivers the awareness to recognise when someone may be at risk of suicide. It then gives them the skills to connect with a person at risk of suicide and to understand and clarify that risk, steps to keep that person safe for a specific period and then provide them with the resources or links required for further help. The program enables the development of knowledge through interactive strategies through cultural recognition and empowerment of participants. Based on a social-enterprise model, I-ASIST has been translated into a certified program supported by LivingWorks Australia. CONCLUSION: Based on a strengths-based and self-determination model of co-design, this grass roots innovative framework creates suicide safer communities.

Indian psychiatrists in the Australian workforce - From brain drain to brain exchange.

Worldwide doctors have been migrating from low- and middle-income countries to high-income countries for decades. This contributes to dearth of doctors, especially psychiatrists, in low- and middle-income countries - often referred to as 'brain drain'. Australia has a fair share of psychiatrists of Indian origin in its workforce. This article endeavours to re-formulate the migration phenomenon as 'brain exchange' through the experiential insight of the authors along with published literature and discusses the contribution of substantial number of psychiatrists of Indian origin to the Australian society. Furthermore, the article highlights the potential for the Royal Australian and New Zealand College of Psychiatrists to be a leader in this area by facilitating globally responsible practice by giving back to countries from which psychiatrists originate. The key observations and recommendations are transferrable to other similar countries and equally to other medical specialities.

A community-led design for an Indigenous Model of Mental Health Care for Indigenous people with depressive disorders.

OBJECTIVE: To generate outcomes for the development of a culturally appropriate mental health treatment model for Indigenous Australians with depression. METHODS: Three focus group sessions and two semi-structured interviews were undertaken over six months across regional and rural locations in South West Queensland. Data were transcribed verbatim and coded using manual thematic analyses. Transcripts were thematically analysed and substantiated. Findings were presented back to participants for authenticity and verification. RESULTS: Three focus group discussions (n=24), and two interviews with Elders (n=2) were conducted, from which six themes were generated. The most common themes from the focus groups included Indigenous autonomy, wellbeing and identity. The three most common themes from the Elder interviews included culture retention and connection to Country, cultural spiritual beliefs embedded in the mental health system, and autonomy over funding decisions. CONCLUSIONS: A treatment model for depression must include concepts of Indigenous autonomy, identity and wellbeing. Further, treatment approaches need to incorporate Indigenous social and emotional wellbeing concepts alongside clinical treatment approaches. Implications for public health: Any systematic approach to address the social and cultural wellbeing of Indigenous peoples must have a community-led design and delivery.

Opening the doors: Critically examining the locked wards policy for public mental health inpatient units in Queensland Australia.

The Queensland Government issued a policy directive to lock all acute adult public mental health inpatient wards in 2013. Despite criticism from professional bodies and advocacy for an alternative, the policy has been retained to this day. A blanket directive to treat all psychiatric inpatients in a locked environment without individualised consideration of safety is inconsistent with least restrictive recovery-oriented care. It is against the principles of the United Nations Convention on the Rights of Persons with Disabilities, to which Australia is a signatory. It is also contrary to the main objects of the Mental Health Act 2016 (Qld). Queensland Health has reported a reduction in 'absences without permission' from psychiatric inpatient wards after the introduction of the locked wards policy; however, no in-depth analysis of the consequences of this policy has been conducted. It has been argued that patients returning late or not returning from approved leave is a more common event than patients 'escaping' from mental health wards, yet all may be counted as 'absent without permission' events. A review of the international literature found little evidence of reduced absconding from locked wards. Disadvantages for inpatients of locked wards include lowered self-esteem and autonomy, and a sense of exclusion, confinement and stigma. Locked wards are also associated with lower satisfaction with services and higher rates of medication refusal. On the contrary, there is significant international evidence that models of care like Safewards and having open door policies can improve the environment on inpatient units and may lead to less need for containment and restrictive practices. We recommend a review of the locked wards policy in light of human rights principles and international evidence.

How the statutory health attorney provision in Mental Health Act 2016 (Qld) is incompatible with human rights.

OBJECTIVE: Mental Health Act 2016 (Qld) (MHA 2016) includes many 'less restrictive ways' to minimise involuntary/compulsory treatment. One such measure, the statutory health attorney, has been adopted from the Powers of Attorney Act 1998 (Qld). This paper analyses the statutory health attorney provision against the human rights framework adopted by the United Nations Convention on the Rights of Persons with Disabilities (CRPD). METHOD: The statutory health attorney provision was analysed against the CRPD article 12 (equal recognition before the law). RESULTS: The statutory health attorney provision is not based on the will and preferences of the individual, is not free from conflict of interest and is not subject to the required safeguards. CONCLUSION: The use of a statutory health attorney brings mental health and physical health under the same provision (the fusion law/proposal). However, the statutory health attorney provision is not compatible with the contemporary human rights framework adopted by the CRPD.

Measuring the impact of revised mental health legislation on human rights in Queensland, Australia.

The Convention on the Rights of Persons with Disabilities (2006) (CRPD) has been instrumental for initiating and shaping the reform of mental health legislation in many countries, including the eight Australian jurisdictions. Multiple approaches have been proposed to assess and monitor the compliance of States Parties' mental health legislation with the CRPD, and to evaluate its success in protecting and promoting the human rights of people with disabilities. This article reports an effort to index the impact of legislation on human rights by measuring changes in the prevalence of compulsory treatment orders applied to people with mental illness after the introduction of CRPD influenced mental health legislation in the Australian state of Queensland. We found that despite reforms intended to enhance patient autonomy, the prevalence of compulsory treatment orders increased after implementation of the new legislation. Possible reasons behind this unintended consequence of the legislative reform may include a lack of systematized voluntary alternatives to compulsory treatment, a paternalistic and restrictive culture in mental health services and risk aversion in clinicians and society. We recommend that the reforms in mental health policy as well as legislation need to go further in order to achieve the goals embodied in the human rights framework of the CRPD.

How can mobile applications support suicide prevention gatekeepers in Australian Indigenous communities?

RATIONALE: Suicide prevention training in Aboriginal and Torres Strait Islander communities is a national health priority in Australia. OBJECTIVE: This paper describes a qualitative study to increase understanding of how a mobile application (app) could be used to support suicide prevention gatekeepers in Indigenous communities. We respectfully use the term Indigenous to refer to Australian peoples of Aboriginal and/or Torres Strait Islander descent. METHOD: Two participatory design workshops were held with 12 participants who were either Indigenous health workers or community members. The workshops first explored what knowledge, skills, and support suicide prevention gatekeepers in Indigenous communities may require, as well as how technology, specifically mobile apps, could be used to support these needs. RESULTS: Qualitative analysis identified four themes related to perceptions of who gatekeepers are, their role requirements, technology and supporting resources, as well as broader community issues. Participants thought training programs should target key, accessible, and respected people from diverse, designated, and emergent groups in Indigenous communities to act as gatekeepers, but requested an alternative, more culturally appropriate term to 'gatekeeper' (e.g., responder). Training should prepare gatekeepers for multifaceted suicide prevention roles, including the identification and management of at-risk Indigenous persons, the provision of psychoeducation and ongoing support, as well as facilitate integrated care in collaboration with community services. A combination of multiple support resources was recommended, including multi-platform options in the technology (e.g., mobile applications, social media) and physical domains (e.g., wallet cards, regular meetings). Recommended app features included culturally appropriate refresher content on suicide intervention, training recall, integrated care, how to access gatekeeper peer support, and debriefing. Broader community concerns on gatekeeper support needs were also considered.

The future of community psychiatry and community mental health services.

PURPOSE OF REVIEW: The aim of this article is to provide a framework and analysis of a series of critical components to inform the future design, development, sustaining, and monitoring of community mental health services. RECENT FINDINGS: Many mental health services remain too hospital-centric, often without adequate outreach services. On the basis of outcome evidence, we need to shift the balance of mental health services from hospital-centered with community outreach when convenient for staff, to community-centered and mobile, with in-reach to hospital only when necessary. Too few training programs those with emphasize the macroskills of public advocacy, working with service users, families, social movements, and the media to improve mental health and wellbeing of regional and local communities. SUMMARY: We should adopt a health ecosystems approach to mental healthcare and training, encompassing nano to macrolevels of service in every region. Catchment mental health services should be rebuilt as community-centric mental health services, integrating all community and inpatient components, but led and integrated from community sites. Community psychiatrists and mental health professionals of the future will need to be well trained in the nano to macroskills required to take responsibility for the mental health and wellbeing of their catchment communities and to provide leadership in service-planning, management, and continuing revision on the basis of rigorous evaluation. These approaches should be the core of all training in psychiatry and all mental health professions prior to any subspecialization.

Human rights implications of introducing a new mental health act - principles, challenges and opportunities.

OBJECTIVE: The United Nations Convention on the Rights of Persons with Disabilities (CRPD), 2006 has influenced the evolution of mental health legislation to protect and promote human rights of individuals with mental illness. This review introduces how the human rights agenda can be systematised into mental health services. Exploration is made of how some principles of CRPD have been incorporated into Queensland's Mental Health Act 2016. CONCLUSION: Although progress has been made in some areas, e.g. heavier reliance on capacity assessment and new supported decision-making mechanisms, MHA 2016 has continued to focus on involuntary treatment. A Human Rights Act 2019 has been passed by the Queensland parliament, which may fill in the gap by strengthening positive rights.

Cultural validation of the structured clinical interview for diagnostic and statistical manual of mental disorders in Indigenous Australians.

OBJECTIVE: This study determined the cultural appropriateness of the Structured Clinical Interview for the DSM-IV Axis I Disorders (SCID-I) as an acceptable tool for diagnosing mental illness among Indigenous people. METHODS: De-identified qualitative feedback from participants and psychologists regarding the cultural appropriateness of the SCID-I for Indigenous people using open-ended anonymous questionnaires was gathered. Aboriginal Medial Service staff and Indigenous Support Workers participated in a focus group. RESULTS: A total of 95.6% of participants felt comfortable during the 498 questionnaires completed. Psychologists also provided qualitative feedback for 502 (92.3%) interviews, of whom 40.4% established a good rapport with participants. Of the participants, 77.7% understood the SCID-I questions well, while 72.5% did not require any cultural allowances to reach a clinical diagnosis. CONCLUSION: When administered by a culturally safe trained psychologist, SCID-I is well tolerated in this group.

Mortality in hospital patients with and without mental disorders: A data-linkage cohort study.

OBJECTIVE: In the general population, people with mental disorders have increased mortality. This association, however, has not been explored in a population who at some time were inpatients of a public hospital. METHODS: The sampling frame was patients admitted to an Australian regional public hospital 1996-2010. Those with known mental disorder were compared with an equal number of randomly selected patients without known mental disorder, matched for age, sex, and year of admission. Mortality outcomes were determined by linkage of hospital data and the National Death Index. RESULTS: We identified 15,356 patients with mental disorder and 15,356 without known mental disorder, 25.2% of the former and 17.3% of the latter died during the study period. The odds ratio (OR) for death in those with mental disorder was 2.20 (95% confidence interval: 2.01-2.41) after adjusting for confounders, and their mean age at death was 4.6 years younger (p < 0.001). Other independent risk factors for mortality were being Indigenous (OR 1.72, 1.32-2.24), not partnered (OR 1.55, 1.36-1.76) or having multiple comorbidities (OR 1.65, 1.43-1.90). In the model that included multiple interactions, the ORs for death in Indigenous patients with mental disorder were markedly higher (6.6-9.5), regardless of other risk factors. DISCUSSION: Among patients with a history of public hospital admission, those with mental disorders have higher mortality than those without mental disorders. This gap in life expectancy mandates increased attention, by clinicians and health services alike, to preventable causes of death in people with mental illness.

The efficacy of cognitive behavioural therapy in somatoform disorders and medically unexplained physical symptoms: A meta-analysis of randomized controlled trials.

BACKGROUND: This systematic review and meta-analysis aimed to update and give an overview of the evidence from published literature that focused on the efficacy of cognitive behaviour therapy (CBT) in the management of somatoform disorders and medically unexplained physical symptoms (MUPS). METHODS: A comprehensive literature search was carried out through an electronic search of various databases on randomized controlled trials (RCTs). Primary outcome was the severity of somatic symptoms. Secondary outcomes were also measured based on severity of anxiety symptoms, severity of depressive symptoms, social functioning, physical functioning, doctor visits and the compliance with CBT, as well as follow-up visits. Effects were summarized by a random effects model using mean differences or odds ratio with 95% confidence intervals (CIs). RESULTS: A total of 15 RCTs comprising 1671 patients with somatoform disorders or MUPS were enrolled in our systematic review and meta-analysis. The main analysis revealed that CBT could alleviate somatic symptoms: -1.31 (95% CI: -2.23 to -0.39, p = 0.005); anxiety symptoms: -1.89 (95% CI: -2.91 to -0.86; p < 0.001); depressive symptoms: -1.93 (95% CI: -3.56 to -0.31; p = 0.020); improve physical functioning: 4.19 (95% CI: 1.90 to 6.49; p < 0.001). The efficacy of CBT on alleviating somatic symptoms, anxiety and depressive symptoms were sustained on follow-up. CBT may not be effective in reducing the number of doctor visits: -1.23 (95% CI: -2.97 to 0.51; p = 0.166); and improving social functioning: 3.27 (95% CI: -0.08 to 6.63; p = 0.056). The results of subgroup analysis indicated that CBT was particularly beneficial when the duration of session was more than 50 min to reduce the severity of somatic symptoms from pre to post treatment time, when it was group based and applied affective and developed good interpersonal strategy during the treatment. Longer duration and frequency such as more than 10 sessions and 12 weeks treatments had significant effect on reduction of the comorbid symptoms including depression and anxiety, but they may underpin low level of compliance of CBT based treatments. CONCLUSIONS: CBT is effective for the treatment of somatoform disorders and MUPS by reducing physical symptoms, psychological distress and disability.

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.

An Australian Indigenous community-led suicide intervention skills training program: community consultation findings.

BACKGROUND: Little is known of the appropriateness of existing gatekeeper suicide prevention programs for Indigenous communities. Despite the high rates of Indigenous suicide in Australia, especially among Indigenous youth, it is unclear how effective existing suicide prevention programs are in providing appropriate management of Indigenous people at risk of suicide. METHODS: In-depth, semi-structured interviews and focus groups were conducted with Indigenous communities in rural and regional areas of Southern Queensland. Thematic analysis was performed on the gathered information. RESULTS: Existing programs were time-intensive and included content irrelevant to Indigenous people. There was inconsistency in the content and delivery of gatekeeper training. Programs were also not sustainable for rural and regional Indigenous communities. CONCLUSIONS: Appropriate programs should be practical, relevant, and sustainable across all Indigenous communities, with a focus on the social, emotional, cultural and spiritual underpinnings of community wellbeing. Programs need to be developed in thorough consultation with Indigenous communities. Indigenous-led suicide intervention training programs are needed to mitigate the increasing rates of suicide experienced by Indigenous peoples living in rural and remote locations.

Electroconvulsive therapy in Lorazepam non-responsive catatonia.

AIM: To compare the efficacy of electroconvulsive therapy (ECT) with risperidone in the treatment of lorazepam non-responsive catatonia. MATERIALS AND METHODS: Inpatients with non-affective catatonia (n= 18) non-responsive to at least five-day trial of lorazepam (6-8 mg/day) were randomised into two groups in a double blind randomised design. Written informed consent was obtained. Four were dropped from the trial as they were found to have depressive catatonia. One group received true ECT (thrice weekly, n=8) plus oral placebo while the other received sham ECT plus risperidone (4-6 mg/ day). Bush-Francis Catatonia Rating Scale (BFCRS) was administered twice weekly to assess improvement in catatonic symptoms over a period of three weeks. The two groups were compared using two-way RMANOVA. RESULTS: BFCRS scores reduced markedly over treatment course and this reduction was more profound in the ECT group (p=0.035). Shorter the duration of illness greater was the response (lower scores of BFCRS). CONCLUSIONS: Superior clinical efficacy of ECT over neuroleptics in catatonia is confirmed by this randomized clinical trial.