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

BACKGROUND: There is evidence of Indigenous and ethnic minority inequities in the incidence and outcomes of early psychosis. Racism has been implicated as having an important role. AIM: To use Indigenous experiences to develop a more detailed understanding of how racism operates to impact early psychosis outcomes. METHODS: Critical Race Theory informed the methodology used. Twenty-three Indigenous participants participated in four family focus group interviews and thirteen individual interviews, comprising of 9 Maori youth with early psychosis, 10 family members and 4 Maori 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. RESULTS: Participant experiences revealed how racism operates as a socio-cultural phenomenon that interacts with institutional policy and culture across systems pertaining to social responsiveness, risk discourse, and mental health service structures. This is described across three major 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 use of coercive practices and an under resourced Indigenous mental health workforce. CONCLUSION: The study illustrated the inter-related nature of interpersonal, institutional and structural racism with examples of interpersonal racism in the form of negative stereotypes interacting with organizational, socio-cultural and political priorities. 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.

Health service utilisation by quota, family-sponsored and convention refugees in their first five years in New Zealand.

OBJECTIVE: This study examines and compares health service utilisation patterns between New Zealand's (NZ) three main refugee groups and the general NZ population. METHODS: We used Statistics NZ's Integrated Data Infrastructure to identify quota, family-sponsored and convention refugees arriving in NZ (2007-2013). We analysed contact with primary care, emergency department (ED), and specialist mental health services for the first five years in NZ. Logistic regression models, adjusted for age, sex and deprivation, compared health service use between refugee groups and the general NZ population in years 1 and 5. RESULTS: Quota refugees were more likely to be enrolled and in contact with primary care and specialist mental health services in year 1 than family-sponsored and convention refugees, but differences reduced over time. All refugee groups were more likely than the general NZ population to have presented to ED in year 1. CONCLUSIONS: Quota refugees were better connected with health services in year 1 than the other two refugee groups. The types of frontline health services accessed by refugee groups differed from the general NZ population. IMPLICATIONS FOR PUBLIC HEALTH: There should be systematic and equal support across all NZ regions to help refugees (regardless of visa type) navigate the NZ health system.

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.

Evolution of first episode psychosis diagnoses and health service use among young Maori and non-Maori-A New Zealand national cohort study.

AIMS: The validity of diagnostic classification in early psychosis has important implications for early intervention; however, it is unknown if previously found disparities between Maori (Indigenous people of New Zealand) and non-Maori in first episode diagnoses persist over time, or how these differences impact service use. METHODS: We used anonymized routine mental health service data and a previously established cohort of over 2400 13-25-year-old youth diagnosed with FEP between 2009 and 2012, to explore differences in diagnostic stability of psychosis diagnoses, comorbid (non-psychosis) diagnoses, and mental health service contacts between Maori and non-Maori in the five-year period following diagnosis. RESULTS: Differences in schizophrenia and affective psychosis diagnoses between Maori and non-Maori were maintained in the five-year period, with Maori being more likely to be diagnosed with schizophrenia (51% vs. 35%), and non-Maori with bipolar disorder (28% vs. 18%). Stability of diagnosis was similar (schizophrenia 75% Maori vs. 67% non-Maori; bipolar disorder 55% Maori vs. 48% non-Maori) and those with no stable diagnosis at FEP were most likely to move towards a schizophrenia disorder diagnosis in both groups. Maori had a lower rate of diagnosed co-morbid affective and anxiety symptoms and higher rates of continued face to face contact and inpatient admission across all diagnoses. CONCLUSIONS: Indigenous differences in schizophrenia and affective psychosis diagnoses could be related to differential exposure to socio-environmental risk or assessor bias. The lower rate of co-morbid affective and anxiety disorders indicates a potential under-appreciation of affective symptoms in Maori youth with first episode psychosis.

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.

Exploring indigenous ethnic inequities in first episode psychosis in New Zealand - A national cohort study.

INTRODUCTION: First episode psychosis (FEP) disproportionately affects rangatahi (young) Maori, the Indigenous people of New Zealand, but little is known about factors contributing to this inequity. This study describes a cohort of rangatahi Maori and young non-Maori with FEP, and explores ethnic differences in incidence rates, and the contribution of deprivation, urbanicity and substance use. METHODS: Maori and young non-Maori, aged 13-25 at the time of the first recorded psychosis-related diagnoses, were identified from within Statistics NZ's Integrated Data Infrastructure (IDI), between 2009 and 2012. To estimate age-standardised FEP incidence rates, the population-at-risk was estimated using IDI-based usual resident population estimates for 2009-2012, stratified by ethnicity and single year of age. Poisson regression models were used to estimate ethnic differences in FEP incidence adjusted for age, gender, deprivation, and urban-rural area classification. RESULTS: A total of 2412 young people with FEP (40% Maori, 60% non-Maori) were identified. Maori were younger, and more likely to live in deprived and rural communities and be diagnosed with schizophrenia. Substance induced psychosis was uncommon. The unadjusted age-standardised FEP incidence rate ratio was 2.48 (95% CI: 2.29-2.69) for rangatahi Maori compared with young non-Maori. While adjusting for age, sex, deprivation and urban rural area classification reduced ethnic differences in incidence, rangatahi Maori were still more than twice as likely to have been diagnosed with FEP compared to young non-Maori. CONCLUSIONS: This study confirms previous findings of elevated rates of psychosis among rangatahi Maori. The difference in rates between Maori and non-Maori were attenuated but remained after adjustment for deprivation and urbanicity.

Potential Country-level Health and Cost Impacts of Legalizing Domestic Sale of Vaporized Nicotine Products.

BACKGROUND: The net impact on population health and health system costs of vaporized nicotine products is uncertain. We modeled, with uncertainty, the health and cost impacts of liberalizing the vaporized nicotine market for a high-income country, New Zealand (NZ). METHODS: We used a multistate life-table model of 16 tobacco-related diseases to simulate lifetime quality-adjusted life-years (QALYs) and health system costs at a 0% discount rate. We incorporated transitions from never, former, and current smoker states to, and from, regularly using vaporized nicotine and literature estimates for relative risk of disease incidence for vaping compared with smoking. RESULTS: Compared with continuation of baseline trends in smoking uptake and cessation rates and negligible vaporized nicotine use, we projected liberalizing the market for these products to gain 236,000 QALYs (95% uncertainty interval [UI] = 27,000 to 457,000) and save NZ$3.4 billion (2011 NZ$) (95% UI = NZ$370 million to NZ$7.1 billion) or US$2.5 billion (2017 NZ$). However, estimates of net health gains for 0- to 14-year olds and 65+ year olds had 95% UIs including the null. Uncertainty around QALYs gained was mainly driven by uncertainty around the impact of vaporized nicotine products on population-wide cessation rates and the relative health risk of vaping compared with smoking. CONCLUSIONS: This modeling suggested that a fairly permissive regulatory environment around vaporized nicotine products achieves net health gain and cost savings, albeit with wide uncertainty. Our results suggest that optimal strategies will also be influenced by targeted smoking cessation advice, regulations around chemical constituents of these products, and marketing and age limits to prevent youth uptake of vaping.

Restricting tobacco sales to only pharmacies combined with cessation advice: a modelling study of the future smoking prevalence, health and cost impacts.

OBJECTIVE: Restricting tobacco sales to pharmacies only, including the provision of cessation advice, has been suggested as a potential measure to hasten progress towards the tobacco endgame. We aimed to quantify the impacts of this hypothetical intervention package on future smoking prevalence, population health and health system costs for a country with an endgame goal: New Zealand (NZ). METHODS: We used two peer-reviewed simulation models: 1) a dynamic population forecasting model for smoking prevalence and 2) a closed cohort multi-state life-table model for future health gains and costs by sex, age and ethnicity. Greater costs due to increased travel distances to purchase tobacco were treated as an increase in the price of tobacco. Annual cessation rates were multiplied with the effect size for brief opportunistic cessation advice on sustained smoking abstinence. RESULTS: The intervention package was associated with a reduction in future smoking prevalence, such that by 2025 prevalence was 17.3%/6.8% for Maori (Indigenous)/non-Maori compared to 20.5%/8.1% projected under no intervention. The measure was furthermore estimated to accrue 41 700 discounted quality-adjusted life-years (QALYs) (95% uncertainty interval (UI): 33 500 to 51 600) over the remainder of the 2011 NZ population's lives. Of these QALYs gained, 74% were due to the provision of cessation advice over and above the limiting of sales to pharmacies. CONCLUSIONS: This work provides modelling-level evidence that the package of restricting tobacco sales to only pharmacies combined with cessation advice in these settings can accelerate progress towards the tobacco endgame, and achieve large population health benefits and cost-savings. :.