Towards best practice during COVID-19: A responsive and relational program with remote schools to enhance the wellbeing of Aboriginal and Torres Strait Islander students.

Purpose: From 2018, the Schools Up North (SUN) programme worked with three remote Australian schools to enhance their capability and resilience to support the wellbeing and mental health of Aboriginal and Torres Strait Islander students and staff. This paper explores the implementation of SUN during the first two years of COVID-19 (2020-2021). Method: Using grounded theory methods, school staff, other service providers and SUN facilitators were interviewed, with transcripts and programme documents coded and interrelationships between codes identified. An implementation model was developed. Results: The SUN approach was place-based, locally informed and relational, fostering school resilience through staff reflection on and response to emerging contextual challenges. Challenges were the: community lockdowns and school closures; (un)availability of other services; community uncertainty and anxiety; school staff capability and wellbeing; and risk of educational slippage. SUN strategies were: enhancing teachers' capabilities and resources, facilitating public health discussions, and advocating at regional level. Outcomes were: enhanced capability of school staff; greater school-community engagement; student belonging and engagement; a voice for advocacy; and continuity of SUN's momentum. Conclusions: The resilience approach (rather than specific strategies) was critical for building schools' capabilities for promoting students and staff wellbeing and provides an exemplar for remote schools globally.

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.

The cost of hospitalisation for youth self-harm: differences across age groups, sex, Indigenous and non-Indigenous populations.

OBJECTIVE: To report the comparative rates, average length of stay and cost per episode of hospital management for self-harm in three age cohorts: 15-19 years, 20-24 years and 25-29 years; by sex and indigeneity. DESIGN, SETTING, PARTICIPANTS: A secondary data analysis of the Australian Institute of Health and Welfare (AIHW) dataset between 1st January 2014 and 31st December 2014 inclusive. MAIN OUTCOME MEASURES: Cost per episode of hospitalised self-harm and rates by age group, sex and Indigenous status. RESULTS: The rate of hospitalised self-harm among Australian youth was 254.0 per 100,000 population. This rate resulted in an annual cost to the healthcare system of AU$55 million or an average cost per episode of $4649 (95% CI $4488:$4810). Hospitalised self-harm was 21 times higher than the rate of suicide (11,820 episodes of hospitalised self-harm/564 suicides). Indigenous youth had on average a 1.4 times higher rate of hospitalised self-harm and 2.2 times higher rate of suicide than non-Indigenous counterparts. When controlling for age and sex, the average cost per episode was significantly lower for Indigenous youth compared to non-Indigenous youth, estimated marginal means $4538 and $4954, respectively (p < 0.001). CONCLUSIONS: Hospitalised self-harm among Australian youth resulted in a substantial cost to the healthcare system. This cost is only part of the overall burden associated with self-harm. The rate of hospitalised self-harm was significantly higher in Indigenous youth, but the associated cost per episode was significantly lower.

Indigenous mental health: the limits of medicalised solutions.

OBJECTIVE: The excess burden of mental disorders experienced by Indigenous Australians is complexly overdetermined. Social and political factors contributing to the intransigence of vulnerability are reviewed, and the wider arena of neoliberal political change considered. CONCLUSIONS: The dynamic relationship between disadvantage and mental health vulnerability requires that practitioners should be attuned to both the 'big picture' and 'modest and practical ways' to contribute to reducing the developmental embedding of social disadvantage and transgenerational vulnerability.

Creeping towards the mutual: lessons from a modest initiative to improve mental health systems capacity in Pacific Island nations.

OBJECTIVE: To describe the evolution of the Leadership in Mental Health: Island Nations (LMH:IN) course. METHOD: Using Transformation Theory the focus on Island Nations mental health capacity building through seven Creating Futures conferences is explored and directions for the future considered. CONCLUSION: Experience and evaluation identify a set of key factors informing the ongoing development of the LMH:IN course.

Vanuatu Psychiatry Mentorship Programme: a case illustrating cultural and clinical considerations.

OBJECTIVES: The objectives of this article are to describe a case highlighting challenges in managing an acute psychiatric presentation, the process of mentorship and the significance of cultural matters influencing family engagement in Vanuatu. METHOD: Case description. RESULTS: This case highlights resourcing constraints facing a small mental health team in the Pacific, the clinical significance of the concept of tabu in a ni-Vanuatu context and the importance of family decision making processes in ni-Vanuatu culture. CONCLUSION: A structured mentoring programme to foster mental health capacity development in Vanuatu can support psychiatric decision-making in complex cases, reflection on the role of culture in formulation and family engagement, and mutual learning.

The Vanuatu Psychiatry Mentorship Programme: supporting the development of a fledgling mental health service in the Pacific.

OBJECTIVE: To describe the Vanuatu Psychiatry Mentorship Programme (VPMP) set up to support the sole mental health doctor and local nurses developing mental health service capacity in Vanuatu. METHOD: Following a request from Vanuatu, the VPMP was set up under the auspices of the Faculty of Child and Adolescent Psychiatry of the Royal Australian and New Zealand College of Psychiatrists (the College) with three components: regular online supervision, yearly onsite visits and advice over the Internet on an as-required basis. RESULTS: Onsite visits undertaken by three VPMP psychiatrists provided opportunities for mentoring and teaching activities related to clinical psychiatry, community liaison, social and ethical considerations and mental health policy matters. Online supervision sessions were initially hampered by technology difficulties. Ad hoc advice over the Internet allowed more rapid responses in complex acute psychiatry cases. CONCLUSIONS: Structured mentoring programmes can play a role in supporting the development of mental health capacity in low-resourced Pacific nations. Such programmes are likely to be more useful for Pacific participants if they are flexible, ongoing, sustained by support from the College and reviewed regularly.

Advancing social and emotional well-being in Aboriginal and Torres Strait Islander Australians: Clinicians' reflections.

OBJECTIVE: An expert reference group met on four occasions to consider ways forward in terms of Indigenous mental health. This paper summarises the discussion and recommendations. CONCLUSION: While the negative effects of colonisation and trans-generational trauma continue, we propose renewed emphasis on improving access, cultural orientation and trauma-informed care, and a focus on the needs of young Indigenous Australians.

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

BACKGROUND: Indigenous people in Australia, Canada, New Zealand and the United States of America experience disproportionately poor mental health compared to their non-Indigenous counterparts. To optimally allocate resources, health planners require information about the services Indigenous people use for mental health, their unmet treatment needs and the barriers to care. We reviewed population surveys of Indigenous people to determine whether the information needed to guide service development is being collected. METHODS: We sought national- or state-level epidemiological surveys of Indigenous populations conducted in each of the four selected countries since 1990 that asked about service use for mental health. Surveys were identified from literature reviews and web searches. We developed a framework for categorising the content of each survey. Using this framework, we compared the service use content of the surveys of Indigenous people to each other and to general population mental health surveys. We focused on identifying gaps in information coverage and topics that may require Indigenous-specific questions or response options. RESULTS: Nine surveys met our inclusion criteria. More than half of these included questions about health professionals consulted, barriers to care, perceived need for care, medications taken, number, duration, location and payment of health professional visits or use of support services or self-management. Less than half included questions about interventions received, hospital admissions or treatment dropout. Indigenous-specific content was most common in questions regarding use of support services or self-management, types of health professionals consulted, barriers to care and interventions received. CONCLUSIONS: Epidemiological surveys measuring service use for mental health among Indigenous populations have been less comprehensive and less standardised than surveys of the general population, despite having assessed similar content. To better understand the gaps in mental health service systems for Indigenous people, systematically-collected subjective and objective indicators of the quality of care being delivered are needed.

"You didn't tell us what to do": trauma2 and critical incident responses in remote Indigenous settings.

OBJECTIVE: The aim of this paper is to outline engagement and practice principles for psychiatrists contributing to responses to critical incidents, based on three decades of experience in remote Indigenous Australia. CONCLUSION: Psychiatrists have important roles in these settings and situations, which should be considered in advance and informed by cultivated relationships.

Mental health in the island nations of the Western Pacific: a rapid review of the literature.

OBJECTIVES: The aim of the study was to identify mental-health-relevant literature accessible to policy makers and healthcare workers in the island nations of the Western Pacific. METHODS: Material collated to support the inaugural Leadership in Mental Health: Island Nations course held in Cairns in May 2015 was used as the basis of a "rapid review". RESULTS: The rapid review considered 303 documents identified by a search carried out using James Cook University's OneSearch, Google Scholar, and the authors' knowledge. Search terms included mental health and the like, and terms with Pacific and current Pacific island country names. Findings were classified by region/country, year of release/publication, mental health issue addressed, peer-reviewed or grey literature, and type of study. Almost half of the findings had been released in the previous five years. However, only 36% were peer-reviewed publications and only 3.6% of the findings were intervention studies. CONCLUSIONS: There is limited easily accessible documentation to confidently direct practice or policies regarding which strategies are likely to be effective in responding to the high rates of mental ill-health experienced in the Pacific island nations, or to plan for increases as a consequence of rapid social and demographic changes that are transforming Pacific island societies.

Evaluation of a Leadership in Mental Health course for Pacific Island Nation delegates.

OBJECTIVE: We report the background to and preliminary evaluation of the Leadership in Mental Health: Island Nations course, run for the first time in Cairns in conjunction with Creating Futures 2015. CONCLUSION: The course was well attended and well received, with increased confidence in key areas demonstrated and concerns regarding local application identified. In addition to positive comments, content and delivery issues were raised. Future opportunities for expanding upon this initial course are discussed.

Mental health in Indigenous settings. Challenges for clinicians.

BACKGROUND: Mental health problems in Aboriginal and Torres Strait Islander peoples are common, changing and challenging. Particularly in remote settings, doctors will need to untangle the complex interplay of culture, context and clinical significance. OBJECTIVE: This paper emphasises the importance of local knowledge and cultural respect in complementing clinical competence in the management of Aboriginal and Torres Strait Islander peoples with mental health problems. DISCUSSION: Anxiety, depression, psychosis, self-harm and problems of childhood and old age are used to exemplify differences by comparison with practice in non-Indigenous populations.

Indicators of psychoses or psychoses as indicators: the relationship between Indigenous social disadvantage and serious mental illness.

OBJECTIVE: To explore the relationship between Indigenous social disadvantage and serious mental illness. CONCLUSIONS: Rapidly changing patterns of mental disorders in Indigenous populations indicate the importance of social determinants. Canadian research on Native American suicide has demonstrated a clear link between social control factors and one mental health issue - completed suicide - a finding with major social policy implications. This work has not been replicable in Australia, reflecting the particular political and social circumstances of Aboriginal and Torres Strait Islander populations. Recent research motivated by clinicians' observations of an increase in psychotic disorders in the Indigenous populations of Cape York and the Torres Strait has demonstrated that the prevalence is high and that there are within-population differences. Given similar exposure to social disadvantage, these findings raise the possibility of utilising Indigenous psychosis prevalence as a metric to inform a more nuanced understanding of the predictors of wider vulnerability and resilience at a setting level, and as a policy and service development lever.

Voices across the fence: commonality, difference and respectful practice across a half century of change.

OBJECTIVE: To describe changes that have occurred in the field of indigenous mental health over the last 50 years. CONCLUSIONS: The last half-century has seen major advances in psychiatry and in the roles and capacities of the Royal Australian and New Zealand College of Psychiatrists. Over the same period, Aboriginal and Torres Strait Islander Australia has been transformed by social and political forces that have brought both benefits and disappointments to Indigenous Australians. Indigenous mental health has evolved from a marginal interest in an 'exotic' area to a recognised field with its own issues, competencies and training needs. In this paper, two College Fellows consider these decades of change, presenting their reflections through voices that reflect different vantages despite a common destination.

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.