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.

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 physical health and premature mortality of Indigenous Maori following first-episode psychosis diagnosis: A 15-year follow-up study.

BACKGROUND: People experiencing psychosis are at greater risk of physical health conditions and premature mortality. It is likely that Indigenous Maori youth, who experience additional systemic inequities caused by settler-colonisation, face even greater physical health and mortality risks following a diagnosis of first-episode psychosis. OBJECTIVE: Compare Maori and non-Maori for risk of hospitalisation and mortality for up to 15 years following first-episode psychosis diagnosis. METHODS: A cohort (N = 14,122) of young people (16-24 years) with first-episode psychosis diagnosis between 2001 and 2019 were identified. Using crude Kaplan-Meier and adjusted Cox proportional hazards models, Maori (n = 5211) and non-Maori (n = 8911) were compared on hospitalisation and mortality outcomes for up to 15 years. RESULTS: In the 15 years following first-episode psychosis diagnosis, Maori had higher adjusted risk of all-cause mortality (hazard ratio = 1.21, 95% confidence interval = [1.01, 1.45]), hospitalisation with diabetes (hazard ratio = 1.44, 95% confidence interval = [1.15, 1.79]), injury/poisoning (hazard ratio = 1.11, 95% confidence interval = [1.05, 1.16]), general physical health conditions (hazard ratio = 1.07, 95% confidence interval = [1.02, 1.13]) and also appeared to be at greater risk of cardiovascular hospitalisations (hazard ratio = 1.34, 95% confidence interval = [0.97, 1.86]). Kaplan-Meier plots show hospitalisation and mortality inequities emerging approximately 4-7 years following first-episode psychosis diagnosis. CONCLUSIONS: Maori are at greater risk for hospitalisation and premature mortality outcomes following first-episode psychosis. Early screening and intervention, facilitated by culturally safe health service delivery, is needed to target these inequities early.

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.

Improving the physical health of people living with mental illness in Australia and New Zealand.

People diagnosed with mental illness have relatively poor physical health and die earlier than their counterparts in the general population. People living with mental illness in rural Australia have three times the risk of premature death than the total population. This article reviews recent international, Australian and New Zealand research, identifies the increased risk of early death of people living with mental health issues in rural settings and looks at the need for policy and practice responses. The 'Equally Well' national initiatives are described in Australia and New Zealand, which seek to systematically address this inequity as a matter of priority. Finally, it argues for co-design and consumer participation in policy development, program implementation and research. Improved understanding of the perspectives and priorities of people with experience of mental illness is vital if change is to be fully realised.

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.

Whakairo: carving a values-led approach to understand and respond to the mental health and substance use of the New Zealand population.

Nil.

Structural discrimination in the COVID-19 vaccination programme for people with mental health and addiction issues: now is the time to be equally well.

People with mental health and substance use issues (tangata whai ora katoa), regardless of ethnicity, are much more likely to be hospitalised or die from COVID-19 and were identified as a priority population (Priority Group 3) in Aotearoa New Zealand's vaccination roll-out plan. Data released by the Ministry of Health show that, despite tangata whai ora katoa being a priority group, their vaccination rates are well below those of the general population. These inequities are pronounced for Maori with mental health and addiction issues (tangata whai ora Maori). This is not acceptable. To support tangata whai ora physical health and wellbeing, the onus is on all of us in the health system to actively reach out, have conversations, be supportive and provide accessible vaccination for people with mental health and addiction issues. Urgent action is needed. Now is the time to ensure tangata whai ora katoa can be equally well.

Addressing structural discrimination: prioritising people with mental health and addiction issues during the COVID-19 pandemic.

Structural discrimination worsens physical health inequities and significantly reduces life expectancy for people with mental health and addiction issues. Aotearoa has recently made some notable changes in health policy by formally recognising the physical health needs of people with mental health and addiction issues. The COVID-19 vaccination sequencing framework provides an important opportunity to protect and promote the health of people with addiction and mental health issues. An expert advisory group, convened as part of the Aotearoa Equally Well collaborative, considered findings of a literature review on the vulnerability of people with mental health and addiction issues of contracting and dying from COVID-19. Evidence indicates an association between mental health and addiction issues and infection risk and worse outcomes. The group concluded mental health and addiction issues should be recognised as underlying health conditions that increase COVID-19 vulnerability, and that people with these issues should be prioritised for vaccination. For too long the health system has failed to address the life expectancy gap of people with addiction and mental health issues. Now is an opportunity to change the korero. People with mental health and addiction issues experience significant physical health inequities. Addressing these inequities must be integral in modern health policy-including our COVID-19 pandemic response.

Addressing structural discrimination: prioritising people with mental health and addiction issues during the COVID-19 pandemic.

Structural discrimination worsens physical health inequities and significantly reduces life expectancy for people with mental health and addiction issues. Aotearoa has recently made some notable changes in health policy by formally recognising the physical health needs of people with mental health and addiction issues. The COVID-19 vaccination sequencing framework provides an important opportunity to protect and promote the health of people with addiction and mental health issues. An expert advisory group, convened as part of the Aotearoa Equally Well collaborative, considered findings of a literature review on the vulnerability of people with mental health and addiction issues of contracting and dying from COVID-19. Evidence indicates an association between mental health and addiction issues and infection risk and worse outcomes. The group concluded mental health and addiction issues should be recognised as underlying health conditions that increase COVID-19 vulnerability, and that people with these issues should be prioritised for vaccination. For too long the health system has failed to address the life expectancy gap of people with addiction and mental health issues. Now is an opportunity to change the korero. People with mental health and addiction issues experience significant physical health inequities. Addressing these inequities must be integral in modern health policy-including our COVID-19 pandemic response.

Working at the interface between science and culture: The enablers and barriers to individual placement and support implementation in Aotearoa/New Zealand.

OBJECTIVE: To identify the factors that help and hinder the implementation of individual placement and support (IPS) practices in the Aotearoa/New Zealand (Aotearoa/NZ) context. METHODS: An examination of the conceptual and empirical literature on IPS implementation in Aotearoa/NZ and a prospective cohort study of people with mental illnesses and/or methamphetamine addiction participating in a newly established IPS program. RESULTS: IPS programs have been operating in Aotearoa/NZ for more than 10 years, but coverage across the country is patchy and access inequitable. Previous public policy, contracting, and funding systems limited the availability of IPS programs, and in some cases operated as a barrier to the provision of integrated health and employment services. There is an opportunity for change, with a greater focus in government policy on mental health and addiction and achieving equity, a plan for cross-government policy solutions, and a recently established technical assistance organization to support new and existing IPS implementation. Facilitating implementation conditions include technical assistance, service integration, supportive contracting, and attention to culture. In 1 program where these conditions were in place from the outset, IPS fidelity reached 107/125; 41.1% of participants had commenced employment; and the program was achieving equity of engagement and outcomes for indigenous Maori people within 15 months of program establishment. CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: Although IPS programs have been successfully implemented in Aotearoa/NZ, availability and access to them remains limited. Identifying the enablers and barriers to IPS implementation specific to the Aotearoa/NZ context could inform future IPS implementation and national program scale-up. (PsycINFO Database Record (c) 2020 APA, all rights reserved).

A systematic scoping review of interventions to integrate physical and mental healthcare for people with serious mental illness and substance use disorders.

Integrated care approaches have been recommended to remove barriers to healthcare and improve the physical health outcomes of people living with serious mental illness (SMI) and/or substance use disorders (SUDs). The aim of this systematic scoping review was to describe empirical investigations of interventions designed to integrate physical, mental, and addiction healthcare for this population. An iterative and systematic search of five electronic databases (Medline (Ovid), PsycINFO, CINAHL, Embase (Ovid) and Scopus) was conducted to identify peer-reviewed articles published between January 2000 and April 2019. Two reviewers independently screened publications in two successive stages of title and abstract screening, followed by full-text screening of eligible publications. Data from each included publication were extracted independently by two reviewers using a standardised spreadsheet. A total of 28 eligible publications were identified, representing 25 unique studies. Over half of the included studies investigated the use of case managers to provide self-management skills or to coordinate mental and physical healthcare (n = 14). Other interventions examined the co-location of services (n = 9) and the implementation of screening and referral pathways to specialist treatment (n = 2). Less than half of the included studies described a framework, theory or model that was underpinning the intervention tested. While some aspects of integrated care have been identified and addressed by interventions, other key dimensions have not been considered, such as shared decision-making. Identification of a comprehensive model of integrated care is recommended to inform the development and evaluation of future interventions for people with SMI/SUDs.

Policy barriers to evidence-based practices in vocational rehabilitation for people with psychiatric disabilities in New Zealand.

BACKGROUND: Most working-age adults with psychiatric disabilities are not employed yet are interested in being in employment. This goal is achievable for the majority who are interested, with the help of international evidence-based practices in vocational rehabilitation. However, these practices are not widely available in developed countries. OBJECTIVE: To identify whether, and how, the availability of evidence-based vocational rehabilitation is linked to government policy. METHODS: A systematic examination of New Zealand's economic and social policy context to understand how it facilitates or hinders evidence-based vocational rehabilitation for people with psychiatric disabilities. RESULTS: The New Zealand policy context is currently hindering the availability of evidence-based vocational rehabilitation for people with psychiatric disabilities. Whilst policy reform has commenced, it has not yet translated into a purchasing framework free of policy conflicts and barriers. Consequently, the proportion of people with psychiatric disabilities not employed and not participating in the labor market is increasing. CONCLUSIONS: Adopting the policy adjustments identified could expand the availability of evidence-based vocational rehabilitation, reducing the disparity between individual vocational goals and actual labor force activity. This in turn could have national social and economic benefits through reduced welfare dependence, reduced health service utilization, and increased labor force participation.