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 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.

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.

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.

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.

'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.

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.

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.

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.

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.

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.

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.

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.

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.

Mortality after release from incarceration in New Zealand by gender: A national record linkage study.

Background: People who enter and leave places of incarceration experience considerable health inequities and are at increased risk of premature death compared to the general population. Causes of premature death in this population vary markedly between countries and so country-specific information is needed. Additionally, there is a lack of large population-based studies which can disaggregate mortality risk based on person and incarceration factors. This study is the first examination of mortality in the period following release from incarceration in New Zealand. Methods: We linked deidentified administrative data on incarceration and release between 1 January 1998 and 31 December 2016 with national mortality data for the same period to examine mortality after release in those who had been incarcerated for at least 1 day. Age standardised mortality rates and mortality ratios compared to the general New Zealand population were calculated separately for men and women, for releases from remand compared with prison, and by cause of death and time since release. Results: 90,195 individuals (13% women, 49% Maori) were followed up for 9.4 years after release from incarceration, with 4,764 deaths over the follow-up period. The overall standardised mortality ratio was 3.3 (95% CI 3.2, 3.4) compared to the general population, and higher for women (3.8) than men (2.7). The most common causes of death were cardiovascular disease, cancer and suicide. Rates of death were similar following release from remand versus prison, however suicide rates were highest following release from remand. Regardless of the type of incarceration, mortality was highest in the first month after release. Conclusion: Experience of incarceration in New Zealand is associated with high rates of mortality from both chronic conditions and external causes. There are urgent policy imperatives to recognise and actively address the increased health and mortality risks faced by people released from New Zealand prisons.

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.