Australasian Psychiatry

Aboriginal and Torres Strait Islander individuals are overrepresented in mental health services in the state of Queensland (QLD), Australia; indicating greater prevalence and less preventative management of mental illness. This paper describes a project to enhance the model of care to improve mental health, alcohol and other drug outcomes for Aboriginal and Torres Strait Islander Community members in two metropolitan Hospital and Health Services, in Brisbane, Australia.

Individual and focus group consultations were conducted with stakeholders, to determine key themes.

The consultative phase of the project revealed three priority areas for action: governance and supervision arrangements for the workforce in the area of Indigenous mental health, alcohol and other drugs; the cultural capability of non-Indigenous clinicians; and consumer access to services.

The Way Forward project is a broad workforce redesign approach to address these three key areas. This approach is designed to acknowledge the strengths among the Indigenous Aboriginal and Torres Strait Islander workforce and to utilise their specialised cultural knowledge. This strategy will also include working in relationships with key Community-controlled health and other organisations. The approach will be reviewed and evaluated.

Recently, there has been a consistent call for Indigenous health research to be community-driven. However, for a variety of reasons, many projects, such as the one featured here, start as ‘top-down’. Using ten accepted principles for Aboriginal health research, the present article illustrates how a top-down project can be transformed into a ‘bottom-up’ community-driven project.

A table of examples is provided to show how the ten principles were translated into practice to create a bottom-up process.

We suggest that key elements for creating a bottom-up process are iterative conversations and community involvement that goes beyond notional engagement. A feature of community involvement is generating and sustaining ongoing conversations with multiple levels of community (organisations, health professionals, Elders, community members, project-specific groups) in a variety of different forums across the entire duration of a project. Local research teams, a commitment to building capacity in the local Indigenous workforce, and adequate timelines and funding are other factors that we hypothesise may contribute to successful outcomes.

The article contributes to a much-needed evidence base demonstrating how appropriate structures and strategies may create bottom-up processes leading to successful outcomes.

The tripartite framework for principled practice was developed as part of the Wundargoodie Aboriginal Youth and Community Wellbeing Programme. The programme engages natural helpers to enhance critical health literacy. This paper examines the importance of translational research to enhancing critical health literacy for this group of de facto health workers using the work of the Australian Indigenous HealthInfoNet as an example. Translational research provides workforce support for those who are time poor and overburdened. Connecting these concepts and natural helpers will make a positive difference to Aboriginal health outcomes.

There is a need for the development of translational research products that enhance the critical health literacy of natural helpers. The tripartite framework for principled practice supports reflective and accountable practice in the intercultural space to build trust and confidence between Aboriginal and non-Aboriginal people to enhance the opportunity for authentic knowledge production and transfer.

Firstly, to demonstrate the involvement of Aboriginal people in caring-for-country as a case study of how appropriately targeted non-medical primary preventative health strategies can be a cost-effective approach to addressing chronic disease among Indigenous people. Secondly, to demonstrate the use of an analogous approach in addressing the global chronic disease pandemic.

A review of prior biomedical and economic research based on the involvement of Aboriginal people in caring-for-country is used to: (a) exemplifying the cost effectiveness of a non-medical preventative health intervention; and (b) the process by which such an approach might be applied across a broader context.

The presented results demonstrate one non-medical primary preventative health approach to addressing the health burden affecting Indigenous peoples.

The suggested steps in optimising the cost effectiveness of such an approach demonstrate how it could be applied in addressing the global chronic disease pandemic.

Identification of need for specialist assessment and the use of relevant cultural information to inform mental health assessment and care are two key factors in improving Aboriginal and Torres Strait Islander access to and experience of mental health care. This paper describes the Here and Now Aboriginal Assessment tool (HANAA) and the Cultural Information Gathering Tool (CIGT), two instruments developed to be used respectively by non-mental health clinicians and Aboriginal and Torres Strait Islander mental health workers.

Following widespread consultations and feedback, two independent groups of mental health clinicians based in Western Australia and Queensland were involved in developing the HANAA and CIGT.

Both the HANAA and CIGT fill unmet needs in terms of instruments that can be used by non-specialists working with Aboriginal and Torres Strait Islander people.

Preliminary use of the HANAA and CIGT suggests that they are well received, easy to deploy and effective instruments that promote cultural security and communication with Aboriginal and Torres Strait Islander people.

To report the impact of the Indigenous e-mental health training course ‘Yarning about Indigenous Mental Health using the AIMhi Stay Strong App’.

Participants were trained in e-mental health and the use of one of the first culturally adapted e-mental health interventions – The AIMhi Stay Strong App. Between October 2013 and December 2014, 138 participants completed the ‘Yarning about Indigenous Mental Health using the AIMhi Stay Strong App’ training course and 130 completed pre- and post-training questionnaires to explore knowledge and confidence in a number of areas trained.

Paired t-tests showed significant improvements across all measures of skill and knowledge except for confidence in using computers.

E-mental health is a relatively new development that may contribute to improved access to mental health services for rural and remote Indigenous Australians, particularly where such tools are culturally adapted. Whilst current knowledge and use of e-mental health tools in this group of Northern Territory service providers was limited, perceived knowledge and confidence in use was significantly improved following training.

This paper examines the themes of #IHMayDay, a day-long Twitter discussion about Indigenous health led by Aboriginal and Torres Strait Islander peoples on 1 May 2014.

The Symplur analytics tool was used to identify the Twitter activity associated with #IHMayDay. This paper reviews the content of 423 tweets that were tweeted and retweeted by 346 individuals and 108 organisations.

Issues related to social and emotional wellbeing were dominant, and the analysis highlights the empowering nature of the strengths-based discourse.

Twitter-based events such as #IHMayDay and initiatives such as the rotated, curated account @IndigenousX are powerful platforms for learning, exchange, advocacy and dialogue about the social and emotional wellbeing and mental health of Aboriginal and Torres Strait Islander peoples.

Literature on Indigenous Australians (Aboriginal and Torres Strait Islander people) and intellectual disability (ID) is summarized in order to identify current state of knowledge, gaps, and areas for further research.

A selective review of psychiatric literature using relevant medical databases was undertaken. Key articles were identified and their findings described.

ID is reported to be more prevalent in Indigenous Australians. Sociocultural constructs and a lack of validated psychometric measures affect what is considered to be ID in Indigenous communities. Prenatal, perinatal, and postnatal factors impair brain development and contribute to ID in Indigenous communities. Comorbid physical and psychiatric disorders need to be assessed and managed.

ID is an emerging area of health concern for general and mental health professionals working with Indigenous Australians. This important area requires further research, appropriate training, and resourcing.

Mental health, well-being, and social life are intimately related as is evident from the higher incidence of psychiatric illness in individuals exposed to social stress and adversity. Several biological pathways linking social adversity to health outcomes are heavily investigated in the aims of facilitating early identification and prevention of adverse health outcomes. We provide a practice-orientated overview of the allostatic load model and how it relates to metabolic and cardiovascular comorbidity in psychiatric disorders.

Allostatic load brings together a set of neuroendocrine, metabolic, immune and cardiovascular biomarkers that are elevated in individuals with adverse early life experiences and are predictive of cardiovascular and metabolic risk in psychiatric illness of critical importance for Indigenous Australians.

Australia’s prison population is growing at a rate well in excess of population growth. Indigenous Australians are over-represented by a factor of 13. Prisoners are a profoundly marginalised group characterised by complex health and social needs. Despite improvements in health during incarceration, poor health outcomes after release are common, and the net effect of incarceration is usually health depleting. Given the need for effective care coordination, primary care plays a pivotal role in meeting the health needs of this population. In this paper we review what is known about patterns of primary care utilisation in ex-prisoners, identify evidence-based strategies for increasing access to primary care in ex-prisoners, and consider how such contact may shape subsequent health service outcomes.

Primary care is a necessary but not sufficient condition for effective post-release support. Positive outcomes may depend more on the quality than the quantity of care received. Given massive over-representation of Indigenous people in Australia’s prisons, and compelling evidence of preventable morbidity and mortality after release from prison, effective models of care for this population are an important component of closing the gap in Indigenous life expectancy.

To describe the processes undertaken to maximise cultural competence in a complex research project and illustrate how this enhanced the quality of the research and impact of the research outcomes.

An epidemiological survey of the mental health of Indigenous people in custody in Queensland was conducted using culturally informed research processes.

The research process that enhanced cultural competence is described. The research outcomes were positive in terms of participant and community experiences, participation rates, publications and other research outputs, capacity building and translation of research findings.

This paper describes in practical terms how to conduct culturally informed research and how this approach enhanced the scientific rigour of a complex Indigenous health research project. Indigenous health research should be conducted using a culturally competent method.

To describe the impact on mental health and psychosocial wellbeing of the armed conflict that occurred in the Solomon Islands from 1998–2003 and the subsequent political unrest and natural disasters, and the developments in mental health services since 2003.

A literature and document review was conducted, supplemented by the written reflections of senior staff in the Solomon Islands Mental Health Service.

Conflict and natural disaster have had a significant impact on the mental health and functioning of individuals, families and communities. National health system reform has been accompanied by the reorientation of the mental health services from custodial care to care in the community and greater emphasis on mental health promotion and prevention. The dedication of the small group of Solomon Islands mental health professionals, supported by local health service managers and external donors, has been a major strength. However, they face significant challenges.

Continued investment in mental health, including the treatment and prevention of mental and substance use disorders, is essential for mental health and development outcomes. All development stakeholders, including civil society, government, academic and research institutions, and development partners, have a role to play.

The Solomon Islands face significant shortages and geographical imbalances in the distribution of skilled health workers and resources, which severely impact the delivery of mental health services. The government's Integrated Mental Health Service has emphasised the importance of greater community ownership and involvement in community-based mental health care, and of moving from centralised services to increased local and accessible care.

From 2012 to 2014, the Solomon Islands Integrated Mental Health service worked with Asia-Australia Mental Health to build workforce capacity and deliver sustainable community mental health programs.

Supported by the Australian Aid Program’s Public Sector Linkages Program, this project shared resources and fostered links between public sector agencies in Australia, Fiji and the Solomon Islands.

Key learning points from the collaboration included the critical need to establish partnerships with community stakeholders, the importance of sustaining a well-functioning mental health team, and optimising the strengths of the local resources in the Solomon Islands. Through this project, national policies, promotion and service delivery were strengthened, through the exchange of experiences and mobilisation of north-south (Australia-Solomon Islands) and south-south (Solomon Islands-other Pacific nations) technical expertise. This project demonstrates the potential for international partnerships to contribute to the development of culturally-appropriate and integrated mental health services.

We aim to describe the experience and findings of mental health clinics held during medical service camps in the rural settings of Fiji.

Descriptive data collated at the end of the medical camps across 2011–2014 are used to highlight the main findings.

The exposure to mental health assessments and brief interventions at these camps was a validating experience for both individuals and medical students attending the clinics. The most common presentations can be categorised under symptoms of depression, anxiety and relationship problems.

The accessibility of mental health support services is a challenge in Fiji. Medical service camps can form an important pathway in promoting mental health awareness, especially amongst the rural communities of Fiji, and a useful platform for medical students to acquire some clinical exposure.

To examine whether being an organizer in a community organizing program improves personal agency and self-reported mental health outcomes among low-income Pacific Island youth in Auckland, New Zealand.

Counties Manukau Health initiated a community organizing campaign led and run by Pacific Island youth. We used interviews, focus groups and pre- and post-campaign surveys to examine changes among 30 youths as a result of the campaign.

Ten youths completed both pre- and post-campaign surveys. Eleven youths participated in focus groups, and four in interviews. Overall, youths reported an increased sense of agency and improvements to their mental health.

Community organizing has potential as a preventive approach to improving mental health and developing agency over health among disempowered populations.

Mental illness is a major contributor to disease burden in China. Guangdong province has a population of over 104 million. This province’s health information system is inadequate, especially the mental health workforce and service response. This paper describes a field survey to assess the existing mental health workforce and service capacity in Guangdong.

A total of 125 major service providers in Guangdong were identified with the capacity to treat serious mental illness at all levels of the health system. These services were approached to complete a standardised survey based on the WHO Assessment Instrument for Mental Health Systems.

The survey identified 8498 mental health workers with 72.5% working in psychiatric hospitals. Service providers reported a treatment rate of 68.8% of a total of 430,000 people registered for treatment of severe mental illness, and only 28.4% of over a million people estimated to be experiencing severe mental illness. An inadequate mental health workforce was cited as a common barrier to treatment access.

Guangdong province has a significant treatment gap for severe mental illness and a shortage in the mental health workforce. The distribution of the mental health workforce and facilities is imbalanced towards hospital care rather than community care.

The aim of this study is to examine management practices that support the wellbeing of health professionals working in remote regions, which may improve workforce retention.

An online questionnaire was distributed to health professionals working in remote regions of the Kimberley and North Queensland. A response rate of 20% was achieved.

The findings suggest that, for health professionals working in remote regions of northern Australia, accessing adequate support is one of the most challenging aspects of working in remote regions. Hence, in remote regions where turnover is high, retention of competent health professionals may benefit from management practices that provide improved personal and professional support.

Health professionals working in remote Australia face unique pressures due to their geographical and professional isolation. Therefore, providing support improves their professional competence and personal wellbeing, and promotes workforce stability, which benefits the remote community through better access to health services.

To describe the clinical population of women admitted to a Mother–Baby Unit in Adelaide, South Australia and to evaluate changes during admission in both Axes I and II diagnoses of maternal mental health, and in mother–infant relationships.

Both clinical and self-report assessments of maternal mental health were made at admission and discharge, and self-report comparisons of the mother–infant relationship.

Depressive illnesses (46.2%) were found to be the most prevalent conditions leading to admission, with rates of psychosis (10.3%) and bipolar disorder (3.4%) being lower. A high incidence of borderline personality disorder (23.1%) was found clinically, with almost half the admitted women showing features of borderline personality disorder on a self-report measure at admission. Significant improvements in maternal mental health and the mother–infant relationship were found at the time of discharge.

Admission to this Mother–Baby Unit on mothers’ self-report scales showed improvement in mothers’ mental health and the relationship that they have with their infant. Given the high prevalence of borderline personality disorder and emotional dysregulation identified within the population, treatment implications and possible consequences for the infant are discussed for this client group.

This study examines pregnancy and early infant outcomes of pregnant women with a clinical diagnosis of Borderline Personality Disorder presenting for obstetric services to a major metropolitan maternity hospital in Victoria, Australia.

A retrospective case review of pregnancy and early infant outcomes on 42 women who had been diagnosed with Borderline Personality Disorder via psychiatric assessment using DSM-IV-R criteria was undertaken. Outcomes were compared with a control group of 14,313 consisting of women and infants of non-affected women from the same hospital over the same period of time.

Women presenting for obstetric services with a clinical diagnosis of Borderline Personality Disorder experienced considerable psychosocial impairment. They anticipated birth as traumatic and frequently requested early delivery. High comorbidity with substance abuse was found and high rates of referral to child protective services. Mothers with Borderline Personality Disorder were significantly more likely to have negative birth outcomes such as lowered Apgar scores, prematurity and special care nursery referral when compared with controls.

These findings offer preliminary evidence to be considered by clinicians in developing treatments and services for the perinatal care of women with Borderline Personality Disorder and their infants. Further research is required in order to develop evidence informed clinical guidelines for the management of women with Borderline Personality Disorder and their infants.

This paper explores novel training opportunities that the Expanded Setting Training Program (ESTP) provides for advanced psychiatry trainees. It is a reflection of a trainee’s learning experiences during a year-long posting in Aboriginal Perinatal Mental Health, working alongside the Aboriginal Family Birthing Program, coupled with reflection and supervision.

ESTP provided a fertile area to hone an advanced trainee’s skills in the niche areas of Aboriginal mental health, perinatal mental health, culture and psychiatry. In addition, it provided skills in the area of leadership, health advocacy and the establishment and maintenance of successful programs in disadvantaged, culturally and linguistically diverse communities. The ESTP Aboriginal Mental Health rotation provides a unique experience for training, and the learning opportunities are limited only by the creativity of the trainee and supervisor.

This paper aims to describe the issues confronting parents with a history of attachment-related trauma and Borderline Personality Disorder (BPD) and outline contemporary approaches to intervention.

The paper discusses recent reviews of parenting and BPD and outlines recent clinical developments.

BPD raises significant challenges for parents, with potential adverse impact on infant attachment and development.

Approaches to early intervention should focus on improving the parental capacity as an attachment figure and their sensitivity to infant emotional communication.

The aim of this paper is to summarise the new psychiatry Fellowship programme and its rationale, highlighting the new inclusions, revised assessment structure, the benefits and structure of the programme.

The 2012 Fellowship programme is based on the CanMEDs educational framework. The Royal Australian and New Zealand College of Psychiatrists (RANZCP) underwent a comprehensive process, adapting the CanMEDs competencies to a psychiatric framework and mapping the curriculum to Fellowship competencies, learning outcomes and developmental descriptors of the various stages of training. The 2012 Fellowship programme introduced summative entrustable professional activities (EPAs), formative workplace-based assessments (WBAs) and revised external assessments.