Cancer diagnosis after emergency presentations in people with mental health and substance use conditions: a national cohort study.

BACKGROUND: Cancer survival and mortality outcomes for people with mental health and substance use conditions (MHSUC) are worse than for people without MHSUC, which may be partly explained by poorer access to timely and appropriate healthcare, from screening and diagnosis through to treatment and follow-up. Access and quality of healthcare can be evaluated by comparing the proportion of people who receive a cancer diagnosis following an acute or emergency hospital admission (emergency presentation) across different population groups: those diagnosed with cancer following an emergency presentation have lower survival. METHODS: National mental health service use datasets (2002-2018) were linked to national cancer registry and hospitalisation data (2006-2018), to create a study population of people aged 15 years and older with one of four cancer diagnoses: lung, prostate, breast and colorectal. The exposure group included people with a history of mental health/addiction service contact within the five years before cancer diagnosis, with a subgroup of people with a diagnosis of bipolar disorder, schizophrenia or psychotic disorders. Marginal standardised rates were used to compare emergency presentations (hospital admission within 30 days of cancer diagnosis) in the exposure and comparison groups, adjusted for age, gender (for lung and colorectal cancers), ethnicity, area deprivation and stage at diagnosis. RESULTS: For all four cancers, the rates of emergency presentation in the fully adjusted models were significantly higher in people with a history of mental health/addiction service use than people without (lung cancer, RR 1.19, 95% CI 1.13, 1.24; prostate cancer RR 1.69, 95% CI 1.44, 1.93; breast cancer RR 1.42, 95% CI 1.14, 1.69; colorectal cancer 1.31, 95% CI 1.22, 1.39). Rates were substantially higher in those with a diagnosis of schizophrenia, bipolar disorder or psychotic disorders. CONCLUSIONS: Implementing pathways for earlier detection and diagnosis of cancers in people with MHSUC could reduce the rates of emergency presentation, with improved cancer survival outcomes. All health services, including cancer screening programmes, primary and secondary care, have a responsibility to ensure equitable access to healthcare for people with MHSUC.

'E koekoe te Tui, e ketekete te Kaka, e kuku te Kereru, The Tui chatters, the Kaka cackles, and the Kereru coos': Insights into explanatory factors, treatment experiences and recovery for Maori with eating disorders - A qualitative study.

BACKGROUND: Eating disorders are as common in Maori, the Indigenous people of Aotearoa-New Zealand, as they are in non-Maori; however, research has focused on the experiences of non-Maori. This paper will describe explanatory factors, treatment experiences and what helps with recovery for Maori. METHODS: Kaupapa Maori research methodology informed the methods and analysis. Fifteen semi-structured interviews comprised thirteen Maori participants with eating disorders (anorexia nervosa, bulimia nervosa and binge eating disorder) and two whanau (support network) members. A thematic analysis was undertaken by a first cycle of coding that used deductive structural coding to identify data describing participants' perceived causes of eating disorders, their experience of treatment and recovery. A second cycle of coding used inductive analysis with descriptive and pattern coding. RESULTS: Three overarching themes were antecedents (cumulative exposure), treatment (a system of complexities) and recovery (resource empowerment). Antecedents comprised cumulative exposure to body and sporting ideals and adversity as causal factors of eating disorders. In the treatment theme, a system of complexities critiqued rural settings for generalised mental health services, allocation of Maori cultural support, the economic burden of treatment, culturally incongruent treatment (methods, values) and a weight-focused discharge criterion. Recovery (resource empowerment) found appropriate health information, self-determination and connection to Maori culture and whanau aspirations helped with recovery. CONCLUSION: The diversity of birdcalls reminds us of the individuality of eating disorders. Health practitioners are reminded that just as the Tui, Kaka and Kereru possess their own unique birdcalls, so do Maori with eating disorders and their whanau have their own experiences, needs and required treatment responses.

Experiences of physical healthcare services in Maori and non-Maori with mental health and substance use conditions.

OBJECTIVES: Inequities in physical health outcomes exist for people with mental health and substance use conditions and for Indigenous populations (Maori in Aotearoa New Zealand). These inequities may be partly explained by poorer quality of physical healthcare services, including discrimination at systemic and individual levels. This study investigated the experiences of people with mental health and substance use conditions accessing physical healthcare and differences in service quality for non-Maori relative to Maori. METHODS: A cross-sectional online survey of people with mental health and substance use conditions in New Zealand asked about four aspects of service quality in four healthcare settings: general practice, emergency department, hospital and pharmacy. The quality domains were: treated with respect; listened to; treated unfairly due to mental health and substance use conditions; mental health and substance use condition diagnoses distracting clinicians from physical healthcare (diagnostic and treatment overshadowing). RESULTS: Across the four health services, pharmacy was rated highest for all quality measures and emergency department lowest. Participants rated general practice services highly for being treated with respect and listened to but reported relatively high levels of overshadowing in general practice, emergency department and hospital services. Experiences of unfair treatment were more common in emergency department and hospital than general practice and pharmacy. Compared to Maori, non-Maori reported higher levels of being treated with respect and listened to in most services and were more likely to report 'never' experiencing unfair treatment and overshadowing for all health services. CONCLUSION: Interventions to address discrimination and poor-quality health services to people with mental health and substance use conditions should be tailored to the physical healthcare setting. More needs to be done to address institutional racism in systems that privilege non-Maori.

The role of social support in reducing the long-term burden of cumulative childhood adversity on adulthood internalising disorder.

PURPOSE: Previous research indicates that social support is protective for the mental health outcomes of exposure to childhood adversity. However, the impact of social support as a protective factor following exposure to cumulative childhood adversity is understudied with prospective longitudinal data. The aim of this present study was to examine how social support mediates the impact of cumulative exposure to childhood adversity on internalising disorder in adulthood. METHODS: The Christchurch Health and Development Study (CHDS) is a general population birth cohort, born in 1977 and representative of Christchurch, New Zealand at the time of the cohort members' birth. The present study used a generalised estimating equations (GEE) framework to analyse direct associations between a cumulative measure of childhood adversity (CA) and internalising disorders (major depression, and any anxiety disorder), and indirect associations through social support. RESULTS: Results indicated a dose-dependent relationship between increased exposure to CA and worsened odds of a diagnosis for major depression and any anxiety disorder, respectively. There was also a significant mediating effect of social support on the direct associations between CA and both major depression (OR (95%CI) =0 .98 (0.97, 0.99), p < 001) and any anxiety disorder (OR (95%CI) = .98 (0.97, 0.99), p < 001). CONCLUSION: The findings indicate that social support reduces the impact of childhood adversity on adult mental health, and is therefore a target for future work examining potential interventions following CA.

Non-Indigenous privilege in health, justice and social services preceding first episode psychosis: A population-based cohort study.

BACKGROUND: There is evidence of disparities between non-Indigenous and Indigenous incidence of psychotic disorders. Despite these disparities being a clear signpost of the impact of structural racism, there remains a lack of evidence to target institutional factors. We aimed to investigate non-Indigenous and Indigenous differences in government service use prior to first episode diagnosis as a means of identifying points of intervention to improve institutional responses. METHODS: We used a previously established national New Zealand cohort of 2385 13 to 25-year-old youth diagnosed with psychosis between 2009 and 2012 and a linked database of individual-level multiple government agency administration data, to investigate the differences in health, education, employment, child protection and criminal-justice service use between non-Indigenous (60%) and Indigenous youth (40%) in the year preceding first episode diagnosis. Further comparisons were made with the general population. RESULTS: A high rate of health service contact did not differ between non-Indigenous and Indigenous youth (adjusted rate ratio 1.0, 95% confidence interval [0.9, 1.1]). Non-Indigenous youth had higher rates of educational enrolment (adjusted rate ratio 1.2, 95% confidence interval [1.1, 1.3]) and employment (adjusted rate ratio 1.2, 95% confidence interval [1.1, 1.3]) and were 40% less likely to have contact with child protection services (adjusted rate ratio 0.6, 95% confidence interval [0.5, 0.8]) and the criminal-justice system (adjusted rate ratio 0.6, 95% confidence interval [0.5, 0.7]). Both first episode cohorts had a higher risk of criminal justice contact compared to the general population, but the difference was greater for non-Indigenous youth (risk ratio 3.0, 95% confidence interval [2.7, 3.4] vs risk ratio 2.0, 95% confidence interval [1.8, 2.2]), explained by the lower background risk. INTERPRETATION: The results indicate non-Indigenous privilege in multiple sectors prior to first episode diagnosis. Indigenous-based social disparities prior to first episode psychosis are likely to cause further inequities in recovery and will require a response of health, education, employment, justice and political systems.

Racism, early psychosis and institutional contact: a qualitative study of Indigenous experiences.

There is evidence of Indigenous and ethnic minority inequities in the incidence and outcomes of early psychosis. racism has an important role. This study aimed to use Indigenous experiences to develop a more detailed understanding of how racism operates to impact early psychosis. Critical Race Theory informed the methods used. Twenty-three Indigenous participants participated in 4 family focus group interviews and 13 individual interviews, comprising of 9 youth, 10 family members and 4 mental health professionals. An analysis of the data was undertaken using deductive structural coding to identify descriptions of racism, followed by inductive descriptive and pattern coding. Participant experiences revealed how racism operates as a socio-cultural phenomenon that interacts with institutional policy and culture across systems. This is described across three themes: (1) selective responses based on racial stereotypes, (2) race related risk assessment bias and (3) institutional racism in the mental health workforce. The impacts of racism were reported as inaction in the face of social need, increased coercion and an under resourced Indigenous workforce. These findings indicate that organizational cultures may differentially impact Indigenous and minority people and that social responsiveness, risk discourse and the distribution of workforce expenditure are important targets for anti-racism efforts.

Still in the shadows: a national study of acute mental health unit location across New Zealand hospitals.

BACKGROUND: This study aimed to explore the location of acute mental health inpatient units in general hospitals by mapping their location relative to hospital facilities and community facilities and to compare their proximity to hospital facilities with that of general medical acute units. METHODS: We obtained Google maps and hospital site maps for all New Zealand public hospitals. Geographic data were analysed and mental health units' locations in relation to hospital facilities and public amenities were mapped. Radar plots were constructed comparing acute medical and mental health units' locations in relation to hospital facilities. RESULTS: Twenty-two mental health units were identified. They were located predominantly at the periphery of hospital campuses, but also at a distance from community facilities. Compared to acute medical units, mental health units were almost universally located further from shared hospital facilities - with distances approximately three times further to reach the main hospital entrance (2.7 times distance), the nearest public café (3.4 times), the emergency department (2.4 times), and medical imaging (3.3 times). CONCLUSION: Despite the reforms of the 20th Century, mental health units still appear to occupy a liminal space; neither fully integrated into the hospital, nor part of the community. The findings warrant further investigation to understand the impact of these structural factors on parity of health care provision between mental and physical health care and the ability of mental health care services to support recovery.

Personality disorder prevalence and correlates in a whole of nation dataset.

PURPOSE: The epidemiology of personality disorder is poorly understood. This study aims to describe the population in contact with mental health services with a diagnosis of personality disorder and compare service use between this group and those with a diagnosis of depression. METHODS: Investigation of a routinely collected clinical data set across New Zealand was conducted. We used data from 2008 to 2017 and 1-year data from 2016, the most complete dataset. This allowed for variation over the years and confirmation within a 1-year prevalence. These data were analysed focusing on patients with a primary diagnosis of any personality disorder and the subset with borderline personality disorder (BPD). BPD was chosen as the most common clinical personality disorder diagnosis and that most researched. RESULTS: 8884 (2.8%) of the population in contact with mental health services carried a primary diagnosis of personality disorder. Personality diagnosis other than antisocial personality disorder (ASPD) in men and borderline personality disorder (BPD) in either gender was negligible. Rates of personality pathology increased with social deprivation and were commonest in young adults. Multi-morbidity was the norm, with internalising disorder common. Maori diagnosed with PD were over-represented both in the patient group and by population. CONCLUSION: Borderline personality disorder and antisocial personality disorder are routinely diagnosed in routine clinical practice in New Zealand; however, other categorical diagnoses are not made. Patients with PD are significant users of resources in comparison to depressed patients. Resource utilisation was significantly greater in those with PD, in particular use of inpatient services compared to those with depression.

Eating disorders in New Zealand: Implications for Maori and health service delivery.

OBJECTIVE: Lifetime prevalence rates in Te Rau Hinengaro (The New Zealand Mental Health Survey) suggest eating disorders are at least as common in the Maori population as the non-Maori population, yet little is known at a population level about those accessing specialist mental health treatment for eating disorders in New Zealand. The aim of this study was to describe the population undergoing specialist mental health treatment for eating disorders and compare Maori and non-Maori clinical characteristics and service use. METHOD: This study uses the Programme for the Integration of Mental Health Data data set, managed by the New Zealand Ministry of Health to describe the characteristics of people with eating disorders and their use of specialist mental health services from 2009 to 2016. RESULTS: There were 3,835 individuals with a diagnosed eating disorder who had contact with specialist mental health services in this time period, 7% of whom were Maori. Within the cohort, Maori had a higher prevalence for a bulimia nervosa diagnosis, fewer diagnosed with anorexia nervosa, and a higher prevalence of other psychiatric comorbidity than non-Maori. DISCUSSION: There is discrepancy between the proportion of service users accessing specialist mental health services who are Maori and the assessed crude prevalence of eating disorders for Maori in national estimates. Once Maori are in specialist services; however, their use of services is comparable to non-Maori. Further research is needed to highlight the experiences of those Maori with eating disorders and address barriers to accessing services for Maori with eating disorders.

The physical health of Maori 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 Maori and non-Maori with a diagnosis of bipolar disorder in contact with NZ mental health services. METHODS: A cohort of Maori and non-Maori 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: Maori with bipolar disorder had a higher level of morbidity and a higher risk of death from natural causes compared to non-Maori with the same diagnosis, indicating higher levels of physical health need. The rate of medical and surgical hospitalisation was not higher among Maori compared to non-Maori (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 Maori. CONCLUSION: This study provides the first indication that systemic factors which cause health inequities between Maori and non-Maori are compounded for Maori living with severe mental illness. Further exploration of other diagnostic groups and subgroups is needed to understand the best approach to reducing these inequalities.

Correction to: Cervical and breast cancer screening uptake among women with serious mental illness: a data linkage study.

Following publication of the original article [1], the authors notified us of an error in the reported percentages in Table 3.

Cervical and breast cancer screening uptake among women with serious mental illness: a data linkage study.

BACKGROUND: Breast and cancer screening uptake has been found to be lower among women with serious mental illness (SMI). This study aims to corroborate these findings in the UK and to identify variation in screening uptake by illness/treatment factors, and primary care consultation frequency. METHODS: Linked population-based primary and secondary care data from the London borough of Lambeth (UK) were used to compare breast and cervical screening receipt among linked eligible SMI patients (n = 625 and n = 1393), to those without SMI known only to primary care (n = 106,554 and n = 25,385) using logistic regression models adjusted first for socio-demographic factors and second, additionally for primary care consultation frequency. RESULTS: Eligible SMI patients were less likely to have received breast (adjusted odds ratio (OR) 0.69, 95 % confidence interval (CI), 0.57 - 0.84, p < 0.001) or cervical screening (adjusted OR 0.72, CI: 0.60 - 0.85, p < 0.001). Schizophrenia diagnosis, depot injectable antipsychotic prescription, and illness severity and risk were associated with the lowest odds of uptake of breast (adjusted ORs 0.46 to 0.59, all p < 0.001) and cervical screening (adjusted ORs 0.48 - 0.65, all p < 0.001). Adjustments for consultation frequency further reduced effect sizes for all subgroups of SMI patient, in particular for cervical screening. CONCLUSIONS: Women with SMI are less likely to receive breast and cervical cancer screening than comparable women without SMI. Higher primary care consultation rates among SMI patients is likely a mediating factor between SMI status and uptake, particularly for cervical screening - a service organised in primary care. To tackle health disparities linked to SMI, efforts at increasing screening uptake are key and should be targeted at women with other markers of illness severity or risk, beyond SMI status alone.

Indigenous inequities in the presentation and management of stomach cancer in New Zealand: a country with universal health care coverage.

BACKGROUND: Maori in New Zealand have markedly higher incidence and poorer survival from stomach cancer than non-Maori. We investigated the presentation, management and survival of stomach cancer in a cohort of newly diagnosed Maori and non-Maori patients. METHODS: A clinical notes review of all Maori from the North Island diagnosed between 2006 and 2008, and a random equivalent sample of non-Maori, was conducted (final cohort n = 335). Patient characteristics, tumour characteristics, receipt and timing of treatment and cancer-specific survival were compared. RESULTS: Compared to non-Maori, Maori patients had a younger average age at diagnosis, higher prevalence of congestive heart failure and renal disease, and were more likely to be diagnosed with distal disease (43 % Maori, 26 % non-Maori, p = 0.004). Stage and grade distributions were similar between ethnic groups. Two-thirds (66 %) of stage I-III patients had definitive surgery, with similar rates for Maori (71 %) and non-Maori (68 %). Maori were less likely to have surgery performed by a specialist upper gastrointestinal surgeon (38 % Maori, 79 % non-Maori, p < 0.01) and less likely to be treated in a main centre (44 % Maori, 87 % non-Maori, p < 0.01). After adjusting for age, sex, stage, tumour site and comorbidity, Maori had nonsignificant 27 % poorer survival (hazard ratio 1.27, 95 % CI 0.96-1.68). CONCLUSIONS: There was evidence of differential presentation and access to specialised surgical services, as well as differential survival, for Maori stomach cancer patients compared to non-Maori. These findings support the development of the national stomach cancer treatment standards and highlight the need for an equity focus within these guidelines.

Almost one in five emergency department presentations are by mental health clients: a secondary data analysis.

AIM: Mental health-related emergency department (ED) presentations are steadily increasing, including presentations for both mental health and non-mental health concerns by existing clients of mental health services. The study aim was to examine and compare mental health clients and non-clients' ED presentations, identify data and clinical gaps and make recommendations for improvement. METHOD: De-identified 2017/2018 ED data were used to describe presentations for current and recent (within last 5 years) clients of specialist public mental health and addiction services, compared to presentations of non-mental health clients. RESULTS: Of 49,170 presentations, 18% were by clients of mental health services. Compared to other ED presenters, mental health clients were often younger, female and Maori, required more urgent care and waited longer. Mental health-related International Classification of Diseases (ICD) codes/referrals were most common for presentations by current mental health clients, whereas pain and trauma were often the reason for prior mental health clients' presentations. Discharge diagnoses rarely included self-harm behaviour, and admissions for these clients were more commonly by ED rather than mental health services. CONCLUSION: Mental health clients are common in ED. Enhanced mental health data capture and improved systems and processes are needed to ensure that ED staff can better meet their often-complex needs.

The Right to Equal Health: Best Practice Priorities for Maori with Bipolar Disorder from Staff Focus Groups.

Bipolar disorder (BD) is a serious mental health condition that is clinically complex to monitor and manage. While best practice guidelines exist, they vary internationally lacking consensus. Indigenous peoples, including Maori in New Zealand, experience higher community rates of BD. While New Zealand practice guidelines recommend providing culturally responsive care to Maori, studies show that Maori do not receive best practice. This qualitative study aimed to share the evidence about patterns of health service use and Maori patient experiences with focus group participants involved in the design and delivery of BD services, to discuss and develop guidelines for best practice for Maori with BD and address areas of unmet need. Three focus groups were conducted with 22 participants involved in the delivery of services to Maori with BD across three sites. Willing participants were sent background information and three focus group questions framed to elicit priority solutions to improve clinical, structural and organisational features of mental health service delivery for Maori patients with BD and their whanau (family). The nominal group technique was used to synthesise responses, and then develop a prioritised list of proposed solutions. Results identified system-level changes required at the clinical, structural and organisational levels of healthcare. Findings further evidence the need for healthcare reform in New Zealand, to be responsive to Maori with BD.

Dealing With Discrimination in Physical Health Care Services: Strategies of People With Mental Health and Substance Use Conditions.

Discrimination against people with mental health and substance use conditions (MHSUC) by health professionals contributes to the poor physical health outcomes this group experiences. We surveyed people with MHSUC in Aotearoa New Zealand to explore how they experienced and responded to discrimination from physical health services. Participants identified 6 strategies used to avoid or minimize the impact of discrimination. Avoidance strategies included not seeking help, not disclosing MHSUC diagnoses and changing or seeking out health professionals who did not behave in discriminatory ways. Minimizing strategies were being a "model patient," taking a support person to consultations or advocating for what they needed, even in the face of discrimination. Physical health services must focus on providing non-discriminatory care to reduce the need for compensatory strategies and improve care of physical illness for people with MHSUC.

Reimagining eating disorder spaces: a qualitative study exploring Maori experiences of accessing treatment for eating disorders in Aotearoa New Zealand.

BACKGROUND: Health, illness, and the body are conceptualized within the cultural context of a society. The values and belief systems of a society, including media portrayals, shape how health and illness present. Traditionally, Western portrayals of eating disorders have been prioritized over and above Indigenous realities. This paper explores the lived experiences of Maori with eating disorders and their whanau (family/support system) to identify the enablers and barriers to accessing specialist services for eating disorders in New Zealand. METHOD: Kaupapa Maori research methodology was used to ensure the research supported Maori health advancement. Fifteen semi-structured interviews were completed with Maori participants including; those with an eating disorder diagnosis (anorexia nervosa, bulimia nervosa, and binge eating disorder), and/or their whanau. Structural, descriptive, and pattern coding was undertaken within the thematic analysis. Low's spatializing culture framework was used to interpret the findings. RESULTS: Two overarching themes identified systemic and social barriers to accessing treatment for Maori with eating disorders. The first theme, was space, that described the material culture within eating disorder settings. This theme critiqued eating disorder services, including idiosyncratic use of assessment methods, inaccessible service locations, and the limited number of beds available in specialist mental health services. The second theme, place, referred to the meaning given to social interactions created within space. Participants critiqued the privileging of non-Maori experiences, and how this makes a place and space of exclusion for Maori and their whanau in eating disorder services in New Zealand. Other barriers included shame and stigma, while enablers included family support and self-advocacy. CONCLUSION: More education is needed for those working in the space of primary health settings about the diversity of those with eating disorders to enable them to look beyond the stereotype of what an eating disorder looks like, and to take seriously the concerns of whaiora and whanau who present with disordered eating concerns. There is also a need for thorough assessment and early referral for eating disorder treatment to ensure the benefits of early intervention are enabled for Maori. Attention given to these findings will ensure a place for Maori in specialist eating disorder services in New Zealand.

Eating disorders are at least as common in Maori (Indigenous people of New Zealand) when compared to their non-Maori counterparts, however, a recent study investigating specialist service use data identified lower-than-expected service use for Maori. This paper explores the lived experiences of Maori with eating disorders and their whanau (family/support network) to understand the barriers and enablers to accessing treatment. Participants in this study identified both systemic and social barriers to accessing treatment for eating disorders; Systemic barriers included the idiosyncratic use of assessment methods by health practitioners, and inaccessible service locations, including the number of available inpatient beds. While social barriers included the stereotype of what an eating disorder looks like, shame, stigma, and discrimination; support networks were described as both an enabler and barrier to accessing specialist treatment for eating disorders. The findings from this study suggest thorough assessment and early referrals are needed for Maori presenting with disordered eating concerns. Moreover, more education is needed for those working in primary healthcare settings about the diversity of eating disorders to ensure they move beyond the stereotype of what an eating disorder looks like.

Missed presentations, missed opportunities: A cross-sectional study of mental health presentation undercounting in the emergency department.

OBJECTIVES: The burden of mental illness is increasing across developed countries. EDs are often used as access points by people experiencing mental health crises, with such rising demand in Australasia. Accurate data is critical to track and address this need, but research suggests that current data collection methods undercount mental health presentations to the EDs. The present study aimed to quantify and characterise ED mental health presentations that were not identified by usual clinical coding processes. METHODS: From almost 50 000 presentations to a large regional ED over 12 months, 1988 were mental health-related as identified via discharge diagnoses and ICD-10 codes. For a further 384 presentations, it was ambiguous whether they were mental health-related. For these, free-text clinical notes were reviewed to identify mental health-related presentation missed by clinical coding practices. Demographic information, time of presentation, recent use of secondary mental health services and disposition from ED were extracted and analysed. RESULTS: An additional 91 mental health presentations were found by review of clinical notes; 4.6% (95% confidence interval 3.7-5.6) more presentations than identified via screening of discharge codes. In these 'missed' cases, clinicians had documented clear mental health symptoms but without coding the corresponding diagnosis. Existing clinical coding practices were less accurate for patients who were not current or recent users of mental health services, and for those who were discharged directly from ED. CONCLUSIONS: The present study demonstrates that ED mental health presentations may be underestimated by nearly 5%, revealing greater mental health demand than current figures suggest.

It's not in my head: a qualitative analysis of experiences of discrimination in people with mental health and substance use conditions seeking physical healthcare.

Introduction: Clinician bias contributes to lower quality healthcare and poorer health outcomes in people with mental health and substance use conditions (MHSUC). Discrimination can lead to physical conditions being overlooked (diagnostic overshadowing) or substandard treatment being offered to people with MHSUC. This research aimed to utilise experiences of people with MHSUC to identify discrimination by clinicians, including the role of clinician's beliefs and assumptions in physical health service provision. Methods: We surveyed people with MHSUC who accessed physical healthcare services. Of 354 eligible participants, 253 responded to open-ended questions about experiences of those services. Thematic descriptive analysis of survey responses was completed using existing stigma frameworks and inductive coding. Results: One dominant theme from survey responses was that diagnostic overshadowing by clinicians was driven by clinician mistrust. Another theme was that clinicians assumed respondent's physical symptoms, including pain, were caused by MHSUC. This influenced decisions not to initiate investigations or treatment. Respondents perceived that clinicians focused on mental health over physical health, contributing to suboptimal care. Discussion: Discrimination based on MHSUC leads to poor quality care. Health systems and clinicians need to focus quality improvement processes on access to and delivery of equitable physical healthcare to people with MHSUC, address stereotypes about people with MHSUC and improve integration of mental and physical healthcare.

Do patients with mental health and substance use conditions experience discrimination and diagnostic overshadowing in primary care in Aotearoa New Zealand? Results from a national online survey.

Introduction Quality of health care contributes to poor physical health outcomes for people with mental health and substance use conditions (MHSUC). AIM This study investigated experiences of people with MHSUC who sought help for a physical health condition in primary healthcare services, examining quality of care attributes. Methods An online survey of adults currently or recently accessing services for MHSUC was fielded in 2022. Respondents were recruited nationally through mental health, addiction and lived experience networks and social media. The attributes of service quality assessed were relationships (respect and being listened to), discrimination due to MHSUC, and diagnostic overshadowing (MHSUC diagnosis distracted from physical health care). Results Respondents who had used primary care services were included (n = 335). The majority of respondents reported both being treated with respect (81%) and being listened to (79%) always or most of the time. A minority of respondents reported diagnostic overshadowing (20%) or discrimination due to MHSUC (10%). People with four or more diagnoses or a diagnosis of bipolar disorder or schizophrenia had significantly worse experiences across all quality measures. Those with a diagnosis of substance use disorders had worse experiences for diagnostic overshadowing. Maori had worse experiences for respect and diagnostic overshadowing. Conclusions Although many respondents reported good experiences in primary care, this was not the case for everyone. Quality of care was affected by type and number of diagnoses and the person's ethnicity. Interventions to reduce stigma and diagnostic overshadowing for people with MHSUC are needed in primary care services in New Zealand.