Multimorbidity and vulnerability among those living with psychosis in Indigenous populations in Cape York and the Torres Strait.

OBJECTIVE: Previous research has found an alarmingly high rate of psychosis in Indigenous1 patients from remote communities of Cape York and the Torres Strait with the treated prevalence of psychosis four times higher than that found for the Australian population. This study assesses comorbid illness and risk factors among this same cohort of psychosis patients. METHODS: Data were collated from a clinical database that contains complete psychiatric records from 1992 to 2015, extracted for all Indigenous patients who received treatment for a psychotic disorder from the Remote Area Mental Health Service. Descriptive analysis and logistic regression models explored differences across subgroups of ethnicity and sex, and relationships between co-morbid disorders and risk factors. All multivariate models included variables of age, year of birth, sex and ethnicity. RESULTS: Sixty per cent of participants (n = 256) experienced a comorbid mental or substance use disorder. Forty-five per cent (n = 192) of participants experienced a physical comorbidity. The most frequent physical health outcomes were injury (29%, n = 93), diabetes (18%, n = 58) and cardiovascular disease (21%, n = 68). Risk factors considered to play a potential biological or neurodevelopmental role in the development of psychosis were approximately three times more likely in Aboriginal (odds ratio = 3.2; 95% confidence interval = [2.0, 4.9]) versus Torres Strait Islander patients, and those born after 1980 (odds ratio = 2.5; 95% confidence interval = [1.6, 3.9]) versus those born prior to 1980. Environmental or contextual factors were associated with significantly greater risk among Aboriginal (odds ratio = 3.8; 95% confidence interval = [2.4, 6.0]) compared with Torres Strait Islander patients. CONCLUSION: Our data expose the perinatal and early environment of Indigenous children who later developed a psychotic disorder. As risk factors for schizophrenia may be cumulative and interactive, both with each other and with critical periods of neurodevelopmental vulnerability, our results suggest possible causes for the increasing prevalence of psychotic disorders between 1992 and 2015.

Incarceration among adults living with psychosis in Indigenous populations in Cape York and the Torres Strait.

OBJECTIVE: The relationship between psychosis and contact with the criminal justice system for Indigenous people living in rural and remote areas is not well understood. In this study, the authors examine patterns of incarceration among Indigenous people living with psychosis in Cape York and the Torres Strait over two decades. METHODS: Data were collated from a clinical database of complete psychiatric records from 1992 to 2015, extracted for all Indigenous patients with a psychotic disorder from the Remote Area Mental Health Service, and linked to the Queensland Corrections Service database. Descriptive statistics were calculated to compare characteristics between those incarcerated and those not incarcerated during the study period and to quantify patterns of incarceration including types of offences, time spent in custody and frequency of incarceration. Multivariate Cox regression analysis was used to assess associations between reported variables and 'first incarceration'. RESULTS: Forty-five percent of Aboriginal patients (n = 116) were incarcerated compared with 31% of Torres Strait Islanders (n = 41) (p = 0.008), and the proportion of males incarcerated (51%, n = 141) was approximately twice that of females (24%, n = 35; p = 0.001). A cluster of first incarcerations were observed in close time proximity to diagnosis of psychosis. Individuals who had a history of both alcohol and cannabis use had approximately two times higher risk of being incarcerated following positive diagnosis compared to those without a history of substance use (hazard ratio = 1.85; 95% confidence interval: [1.08, 3.17]; p = 0.028). Males accounted for approximately 85% (n = 328) of sentences. The most common most serious offence was causing physical harm to others (assault - n = 122, 31%). CONCLUSION: Our study found that for Aboriginal and Torres Strait Islander people with a psychotic disorder in North Queensland, criminal justice responses with resultant incarceration occurs frequently. Access to appropriate mental health services and diversion options for Indigenous Australians with psychosis should be a key public health and justice priority.

Beasts of burden or organised cooperation: the story of a mental health team in remote, Indigenous Australia.

OBJECTIVE: This paper aims to describe the growth of a regionally-based mental health team providing services to remote Indigenous communities in far north Queensland. CONCLUSIONS: By drawing on their experience, the authors are able to identify factors supporting the development and sustained capacity of integrated mental health teams, working in challenging remote settings.

Psychosis in Indigenous populations of Cape York and the Torres Strait.

OBJECTIVE: To describe and characterise treated psychotic disorders in the Indigenous populations of Cape York and the Torres Strait. DESIGN: Cross-sectional analysis of patients with a psychotic disorder identified by treating psychiatrists. SETTING AND PARTICIPANTS: Indigenous patients aged≥15 years in Cape York and Torres Strait communities receiving treatment for a psychotic disorder over 3 months in 2010. MAIN OUTCOME MEASURES: Prevalence of psychosis diagnoses, intellectual disability, and substance use comorbidities. RESULTS: 171 patients were included. The prevalence rate in this population was 1.68%, higher for males (2.60%) than females (0.89%), and twice as high in the Aboriginal (2.05%) than in the Torres Strait Islander (0.95%) population. High rates of alcohol and cannabis use were found. Comorbid intellectual disability was common and more frequent among Aboriginal patients. CONCLUSIONS: The burden of psychosis in the Indigenous population of Cape York and the Torres Strait is high. Further research is needed to understand the social determinants of these disorders and to design effective social and clinical measures to alleviate this burden.

Ketamine sedation for patients with acute agitation and psychiatric illness requiring aeromedical retrieval.

OBJECTIVE: Aeromedical retrieval services face the difficult problem of appropriate levels of sedation for transport of acutely agitated patients to definitive care. This paper describes a technique using ketamine, which is titratable and avoids problems associated with airway management. METHOD: A 3-year review of a new technique of ketamine sedation by aeromedical retrieval teams from the Cairns base of the Queensland section of the Royal Flying Doctor Service of Australia. Clinical records were systematically reviewed for ketamine administration and signs of adverse events during transport and in the subsequent 72 h. RESULTS: 18 patients were sedated during retrieval with intravenous ketamine. Effective sedation was achieved in all cases, with no significant adverse events noted during retrieval or 72 h afterwards. CONCLUSION: Ketamine sedation is effective and safe in agitated patients with a psychiatric illness in the aeromedical setting and does not lead to worsening agitation in the subsequent 72-h period.

Psychosis and its correlates in a remote indigenous population.

OBJECTIVES: The aim of this study was to describe prevalence and characteristics of psychotic disorders in a remote Indigenous population. METHOD: Clinical review of all patients with an active diagnosis of a psychotic disorder in remote communities of Cape York and the Torres Strait. RESULTS: 170 patients were identified and demographic, social and treatment variables described. CONCLUSIONS: Psychotic disorders are common and more so among young adult Aboriginal men, with high rates of comorbid conditions including substance use, intellectual impairment and diabetes. In parallel to this case complexity, there are high rates of coercive treatments. Certain differences by ethnicity and location are described and possible explanations proposed.

The Epidemiology of Psychosis in Indigenous Populations in Cape York and the Torres Strait.

BACKGROUND: The treated prevalence of psychotic disorders in remote communities of Cape York and the Torres Strait, Australia, has been shown to be elevated compared with the Australian population. Our study used a unique dataset to assess treated incidence and prevalence of psychotic disorders and mortality over a 23-year period in the adult Indigenous population of this region. METHODS: Data was collated from a clinical database that contains complete psychiatric records from 1992 to 2015, extracted for all Indigenous patients who received treatment for a psychotic disorder from the Remote Area Mental Health Service, and linked to the Queensland Deaths Registry. We calculated 12-month treated prevalence and incidence for each calendar year. Mortality rates were compared to the overall and Indigenous population death rates in Queensland. FINDINGS: Between 1992 and 2015, 424 patients were treated for psychosis - an age-standardised 12-month prevalence of 1·7% in 2015, approximately two times higher in men than women, and three times higher in Aboriginal versus Torres Strait Islander populations. The highest treated prevalence was observed in 2015 in Aboriginal men (4.0%). A range of psychotic disorders were detected, including many substance-induced cases (n = 93) and schizophrenia (n = 252). The age-standardised 12-month incidence rate over the study period was 3.61 per 1000 person-years for women and 4.23 per 1000 person-years for men. Treated prevalence increased throughout the study period, largely attributable to increases in incidence of schizophrenia and schizoaffective disorder - in contrast, the incidence and prevalence of bipolar and mood disorders remained low and stable. Increased mortality risk compared to the Queensland Indigenous population (SMR = 1.9; 95% CI 1.4-2.6) was attributable to the elevated risk shown in the Aboriginal population in our study (SMR = 2.6; 95% CI 1.8-3.7). INTERPRETATION: Our results show extremely high prevalence rates of psychosis; increasing prevalence over time; differences in the distribution of psychosis between Aboriginal and Torres Strait Islander populations; and increased mortality risk for Aboriginal people living with psychosis in this region. These observations strongly suggest an aetiological role of environmental and neurodevelopmental factors, and the contribution of social factors to vulnerability and premature mortality. ROLE OF THE FUNDING SOURCE: This study was funded by Queensland Health who are the custodians of this database. The funder had no role in study design, data analysis, data interpretation, writing of the report, or submission for publication. All authors had full access to all the study data. The corresponding author had final responsibility for the decision to submit for publication. FJC is supported by an Australian National Health and Medical Research Council (NHMRC) Early Career Fellowship (APP1138488).

Implementing smoke-free policies in mental health inpatient units: learning from unsuccessful experience.

OBJECTIVE: The aim of this paper is to describe the introduction, trial and termination of a smoke-free policy in an acute mental health unit of a regional hospital, and to consider factors that may contribute to the success of such policies in other settings. METHODS: This analysis is based on key informant interviews and review of correspondence related to the trial, and examination of the relevant incident-reporting database. RESULTS: Planning for implementation is described. The trial itself was terminated after 6 weeks due to perceived increases in aggression by patients towards staff working in the high dependency unit. Staff perceived that these episodes were directly related to these patients not being allowed to smoke. While there was an increase in events during the trial relating to two seriously ill individuals, examination of formal incident reports over a period of 2 years suggests little change in the overall number of incidents. CONCLUSIONS: Despite clear public health benefits, implementation of a smoke-free policy may have untoward behavioural effects in institutional mental health settings. In addition, staff expectations and perceptions are critical. Salient factors appear to be preparation of staff and patients, appropriate training, avoidance of exceptions and inconsistency, considering alternatives to smoking to fill the gap created by the policy, and a culture of critical evaluation in practice. Such processes will facilitate understanding and cooperation so that mental health services are able to participate in important policy processes with implications for the health of patients and staff.