Karen AdamsA,D, Chris HalacasB, Marion CincottaB and Corina PesichC
AFaculty ofMedicine,Nursing andHealth Sciences, Building 15,MonashUniversity, Clayton, Vic. 3800, Australia. BVictorian Aboriginal Community Controlled Health Organisation, Public Health and Research Unit, 17–23 Sackville Street, Collingwood, Vic. 3073, Australia.
CRoyal Australian College of General Practitioners, 100Wellington Parade, East Melbourne, Vic. 3002, Australia. DCorresponding author. Email: firstname.lastname@example.org
Abstract. Nationally, Aboriginal people experience high levels of psychological distress, primarily due to trauma from colonisation. In Victoria, Aboriginal Community Controlled Health Organisations (ACCHOs) provide many services to support mental health. The aim of the present study was to improve understanding about Victorian Aboriginal people and mental health service patterns. We located four mental health administrative datasets to analyse descriptively, including Practice Health Atlas, Alcohol and Other Drug Treatment Service (AODTS), Kids Helpline and Close The Gap Pharmaceutical Scheme data. A large proportion of the local Aboriginal population (70%) were regular ACCHO clients; of these, 21% had a mental health diagnosis and, of these, 23% had aMedicare Mental Health Care Plan (MHCP). There were higher rates of MedicareMHCP completion rates where general practitioners (GPs) had mental health training and the local Area Mental Health Service had a Koori Mental Health Liaison Officer. There was an over-representation of AODTS episodes, and referrals for these episodes were more likely to come through community, corrections and justice services than for non-Aboriginal people. Aboriginal episodeswere less likely to have been referred by aGP or police and less likely to have been referrals to community-based or home-based treatment. There was an over-representation of Victorian Aboriginal calls to Kids Helpline, and these were frequently for suicide and self-harm reasons.We recommend primary care mental health programs include quality audits, GP training, non-pharmaceutical options and partnerships. Access to appropriate AODTS is needed, particularly given links to high incarcerations rates. To ensure access to mental health services, improved understanding of mental health service participation and outcomes, including suicide prevention services for young people, is needed.
Received 3 March 2014, accepted 11 June 2014, published online 23 July 2014
Aboriginal1 people across Australia continue to experience trauma as a result of colonisation. Nationally, Aboriginal people are three timesmore likely to experience high andvery high levels of psychological distress than non-Aboriginal people (Australian Bureau of Statistics (ABS) 2013a). Young Aboriginal people are also over-represented in mental health statistics, with substance use and mental disorders explaining much of the health gap between Aboriginal and non-Aboriginal young people aged 15–34 years (Vos et al. 2009). The National Aboriginal and Torres Strait Islander Health Plan advocates for equitable access to health services including mental health services (Australian Government 2013a).
The Victorian Aboriginal Community Controlled Health Organisation (VACCHO) is the peak body for Aboriginal Health in Victoria advocating on behalf of and supporting amembership of 27 Aboriginal Community Controlled Health Organisations (ACCHOs). At regular meetings of the VACCHO membership,
the mental health of Aboriginal community members and access to appropriate mental health services is voiced as a priority issue. Each ACCHO in Victoria is unique in providing various services and creating particular partnership arrangements suited to local need. Holistic support for mental health is provided in two main ways: (1) through programs that address social and cultural determinants, such as housing, justice, cultural knowledge development, early childhood and family support programs; and (2) bymore clinical approaches available in general practice, such as counselling, psychiatry and psychology services. The extent of anyof these services forAboriginal peoplevaries at eachACCHO depending on funding, workforce availability, partnerships and community direction.
Some information onVictorian Aboriginal people andmental health exists. A 1992 analysis of patient data from the Victorian Aboriginal Health Service (VAHS) identified a psychiatric disorder in 54% of patients, with depression being the most common (McKendrick et al.1992).Among172Koori youth aged
1For the purposes of this paper, the term Aboriginal should be read to include Torres Strait Islanders.
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Australian Journal of Primary Health, 2014, 20, 350–355 Research http://dx.doi.org/10.1071/PY14036
12–26 years attending VAHS, the rates of suicide ideation and attempt were 23% and 24%, respectively, and this related to emotional and social well being (Luke et al. 2013). The 2008 Victorian PopulationHealth Survey found thatAboriginal people were significantly more likely to be diagnosed by a doctor with depression or anxiety than non-Aboriginal people (Department of Health 2008). That survey also found significantly higher rates of high and very high levels of psychological distress among Aboriginal people (Department of Health 2008). Similarly, a 2012 survey of Victorian Aboriginal people found that 50% reported high or very high levels of psychological distress, consistent across rural and metropolitan regions (Ferdinand et al. 2012). Almost all (97%) had experienced racism in the previous 12 months, and 70% experienced eight or more racist incidents. People who experienced the most racism recorded the most severe psychological distress. Coping strategies, such as accepting racism or just putting up with it, were associated with higher levels of psychological distress (Ferdinand et al. 2012). Mental illness is also much higher among Aboriginal prisoners and contributes to increased contact with the justice system. In 2012, 81% of male and 92% of female Aboriginal prisoners in Victoria had at least one mental illness, considerably higher than for non-Aboriginal prisoners and much higher than the general population (Ogloff et al. 2013).
In order to understand patterns of access, we reviewed available Victorian Aboriginal data on mental health service utilisation. The hypotheses for this study are detailed in Table 1.
Methods Analyses of four administrative datasets were undertaken with the aim of understanding mental health service patterns for Aboriginal Victorians. Administrative dataset analysis methods
can include: functionality, namely description and visualisation; association and clustering; and classification and estimation (Koh and Tan 2005). These methods have been used previously to understand more about mental health and Aboriginal people (Kisely and Pais 2011). A scoping of State and National Government and VACCHO internal datasets identified four potential collections for descriptive mining. The methods of analysis are outlined below. Hypotheses were written a priori, tested and all results are reported (Table 1).
Practice Health Atlas
Of the 27 VACCHO members, 24 have patient information systems compatible with the Practice Health Axis (PHA; Del Fante et al. 2006). Although all services have quality improvement activities, 10 choose to automate a PHA to assist this process and these 10 were analysed in the present study. Clients included in each PHA were regular clients (two or more visits over the past 3 years) of the service. Data were extracted at each service for a 15-month period in the years 2011–2013.
The aggregate number of regular clients was compared with the 2011 estimates of Aboriginal people (ABS 2013b) for the 21 Local Government Areas making up the catchment areas for the 10 ACCHs. Proportions were calculated of client files containing a depression and anxiety diagnosis. The number of claims for mental health care plans (MHCP) and plans reviewed within the same time period and client base as above were compared. Proportions ofMHCPclaimsmadebygeneral practitioners (GPs) with and without mental health training (Royal Australian College of General Practitioners 2014) were calculated.
There are 11 Koori Hospital Mental Health Liaison Officers (KHMLOs) located in Victorian Area Mental Health Services. The aim of this program is to improveAboriginal people’s access to these services (Victorian Aboriginal Community Controlled Health Organisation 2014). The presence of a KMHLO within 15 km of a service with a PHA was dichotomised and the proportion of mental health plans was analysed by Chi-squared texts in Excel.
Closing The Gap and Pharmaceutical Benefits Scheme
The Closing The Gap (CTG) and Pharmaceutical Benefits Scheme (PBS) Co-payment Measure aims to improve access to PBS medicines for eligible Aboriginal people living with, or at risk of, chronic disease. Registered clients are eligible for reduced-cost medication (Australian Government 2013b).
What is known about the topic? * The level of mental health burdenAboriginal and Torres Strait Islander people experience is high.
What does this paper add? * This paper provides further understanding about how Aboriginal and Torres Strait Islander people are using mental health support services.
Table 1. Hypotheses and associated analyses for each dataset AODTS, Alcohol and Other Drug Treatment Service CI, confidence interval; CTG, Closing The Gap; KMHLO, Koori Hospital Mental Health Liaison Officer;
PBS, Pharmaceutical Benefits Scheme; PHA, Practice Health Atlas
Database Hypothesis Analysis
AODTS Higher proportion of Aboriginal compared with non-Aboriginal episodes Referral, reasons for departure and treatment settings differ for Aboriginal compared with non-Aboriginal
All 95% CI
PHA Differences exist between the number of diagnoses of depression and anxiety and the number of Medicare claimed mental health plans and reviews
PHA and KMHLO That the number ofmental health plans differs according to the presence ofKMHLOswithin 15 kmof the service Chi-squared CTG and PBS Pattern of medication prescribing differs for Victorian Aboriginal people compared with national prescribing
patterns Ranking and
comparison Kids Helpline Aboriginal counselling sessions include mental health issues Descriptive
Mental health and Victorian Aboriginal people Australian Journal of Primary Health 351
National and Victorian CTG prescription data were obtained from the Pharmaceutical Access Branch, Australian Department of Human Services. Medications (cumulative, including all strengths) processed during the period 30 June 2012–30 June 2013were ranked in order of prescription volume.VictorianCTG and National CTG ranked data were compared.
Alcohol and Other Drug Treatment Services National Minimum Dataset
Data pertaining to 52 885 treatment episodes reported forVictoria 2010–11 were analysed on the basis of whether the client was identified as Aboriginal or Torres Strait Islander or not (non- Indigenousplusnot stated). Participation rates used theABS2011 Estimated Resident Populations of Aboriginal and Torres Strait Islanders and all others (non-Indigenous plus not stated; ABS 2013b) for the State’s people over 10 years of age, this being the client age range.Theproportions of people referred fromdifferent sources, reasons for departure, treatment settings and the reason for entering the program were all calculated on the basis of treatment episodes and analysed using SPSS version 19 (SPSS, Chicago, IL, USA).
Kids Helpline is a counselling service for Australian young people aged between 5 and 25 years (BoysTown 2014). Data were requested for all phone counselling sessions with Aboriginal young people from Victoria in 2012. The proportion ofAboriginal callerswas comparedwith theVictorianAboriginal population comparable age group of 5–25 years (ABS 2013b). Each call received was categorised by call line counsellors with multiple categories available to describe one call. Data relating
to mental health calls were analysed. Proportions were calculated for each category of: known mental health concern; counsellor identified mental health concern; suicide related concern; suicide ideation; self-harm; and recent self-harm.
Aggregate data from the PHA included 20% of the estimated number of Aboriginal people in Victoria. Whenmatched to 2011 census estimates for the 21 relevant Local Government Areas (containing 29% of population) the ACCHS saw 70% of this estimated local population.
Of the 9465 regular client records, 6854 were people aged 15years andolder, ofwhom21%(1441) haddiagnoses of anxiety or depression. Of regular clients with an anxiety or depression diagnosis, 23%(334) received amental health care plan.GPswho had completed mental health training were claiming the majority (75%; n= 251) of the mental health care plans. We found a significant positive effect of having an accessible KMHLO on the number of GP mental health care plans (P < 0.01), mental health care plan reviews (P < 0.01), and diagnosis of anxiety and depression (P < 0.03). No significant effect was found on GP mental health consultations.
Victorian CTG data included a higher prescription volume ranking of medications prescribed for anxiety, depression, psychosis and pain management (as highlighted in Table 2). Of note there were no antidepressants or antipsychotics in the top 20 ranked National CTG data, although these drugs were present
Table 2. Ranking of National and Victorian Closing The Gap (CTG) prescription volumes, 2012–13
Rank National CTG Victorian CTG Medication Volume Medication Volume
1 Atorvastatin 119 409 Atorvastatin 7745 2 Metformin 99 042 Salbutamol 7733 3 Salbutamol 96 361 DiazepamA 6535 4 Perindopril 77 121 Paracetamol + codeineC 6495 5 Paracetamol + codeineC 74 815 Metformin 5773 6 Paracetamol 64 462 Esomeprazole 5397 7 Amoxycillin 62 440 Amoxycillin 5056 8 Esomeprazole 51 929 Perindopril 4860 9 Cephalexin 51 315 Paracetamol 4665 10 Rosuvastatin 51 192 OxycodoneC 4337 11 Amoxycillin + clavulanic acid 49 616 Fluticasone + salmeterol 3676 12 OxycodoneC 47 095 Cephalexin 3670 13 Pantoprazole 47 082 Rosuvastatin 3570 14 Fluticasone + salmeterol 45 198 Pantoprazole 3536 15 Ramipril 45 193 MirtazapineB 3519 16 DiazepamA 44 924 Amoxycillin + clavulanic acid 3325 17 Gliclazide 39 352 TramadolC 3149 18 Tramadol 35 464 Ramipril 2746 19 Amlodipine 30 664 TemazepamA 2746 20 Irbesartan 30 631 QuetiapineD 2525
ABenzodiazepine. BAntidepressant. COpioid analgesic. DAntipsychotic.
352 Australian Journal of Primary Health K. Adams et al.
in the Victorian data. Mirtazapine is a restricted benefit PBS item indicated for major depressive disorders (PBS 2013). It is generally not recommended as the preferred first-line pharmacological agent because of its less favourable risk : benefit ratio compared with selective serotonin reuptake inhibitors. Its position in the ranking suggests clients with pharmacotherapy treatment-resistant depression and/or severe depression (PBS 2013).
Alcohol and Other Drug Treatment Services National Minimum Data Set
Treatment episodes were higher (P < 0.001) for Aboriginal (95% confidence interval (CI) 9.34–9.97) than non-Aboriginal (95% CI 1.03–1.05) episodes. Seeking assistance for own drug use (rather than for another person) was also higher (P < 0.05) for Aboriginal (95% CI 0.969–0.980) than non-Aboriginal (95% CI 0.849–0.855) episodes. Sources of referral to, reasons for departure from and settings for alcohol and other drug treatment differed for Aboriginal and non-Aboriginal presentation episodes (Table 3).
In 2012 there was an over-representation of calls to the telephone service by young Aboriginal people living in Victoria. Of the Victorian population aged 5–25 years, 1.2% are Aboriginal
(ABS 2013b); in contrast, 2.7% (450/16 687) of the Victorian calls to Kids Helpline were Aboriginal young people. Although callers may have used the service more than once, assumedly this also happens in the non-Aboriginal caller population. Of the calls from Aboriginal young people, 78% were from metropolitan areas and the remainder were from regional areas. Counsellors categorised 75% of calls as either the young person seeking assistance for a knownmental health concern or as the counsellor identifying the young person as having a mental health concern. Suicide and self-harming were frequent reasons for contacting the call line. Just under half (46%) of calls involved reporting a suicide-related concern or a presentation of suicidal ideation. More than half (59%) of the mental health-related calls involved a young Aboriginal person seeking assistance for a self-injury and/or self-harm concern or the presentation of a recent self- injury.
Consistent with previous studies, we found a burden of Aboriginal mental health presentations. Aboriginal general practice clients had a higher proportion of depression or anxiety (21%) than the 4% previously reported for non-Aboriginal clients (Britt et al. 2009). In addition, for Aboriginal Victorians, there was a high ranking of volume of prescriptions for mental health medications and an over-representation in Alcohol and
Table 3. Episodes of referral, reason for departure and type of treatment setting, Victorian Alcohol and Other Drug Treatment Services, 2010–11, confidence intervals and P-values
ACCHO, Aboriginal Community Controlled Health Organisation; AODTS, Alcohol and Other Drug Treatment Service; LL, lower limit; NS, not significant; UL, upper limit;
Category Aboriginal Remainder Difference LL UL LL UL
Source of referral Self 0.322 0.353 0.358 0.366 NS Court diversion 0.143 0.167 0.041 0.045 P< 0.05 Correctional service 0.128 0.152 0.042 0.045 P< 0.05 AODTS 0.114 0.137 0.129 0.135 NS Community and/or healthcare other (including ACCHO) 0.063 0.081 0.016 0.018 P< 0.05 Medical practitioner 0.022 0.033 0.152 0.159 P< 0.05 Family member and/or friend 0.015 0.024 0.044 0.048 P< 0.05 Mental healthcare 0.009 0.017 0.109 0.115 P< 0.05 Hospital 0.005 0.011 0.003 0.004 P< 0.05 Police diversion 0.004 0.009 0.018 0.021 NS
Reason for departure Completed 0.687 0.718 0.716 0.724 NS By mutual agreement 0.023 0.034 0.016 0.018 P< 0.05 Against advice 0.022 0.033 0.016 0.019 P< 0.05 At expiation 0.009 0.017 0.028 0.031 P< 0.05 Imprisoned, other than drug court sanctioned 0.007 0.013 0.001 0.002 P< 0.05 Died 0.001 0.004 0.006 0.007 P< 0.05 Drug court and/or sanctioned by court diversion service 0.000 0.002 0.008 0.009 P< 0.05
Treatment settings Non-residential treatment facility 0.613 0.646 0.699 0.707 P< 0.05 Residential treatment facility 0.130 0.153 0.138 0.144 NS Home 0.016 0.025 0.031 0.034 P< 0.05 Outreach 0.100 0.121 0.120 0.126 NS Other 0.088 0.108 0.102 0.108 NS
Mental health and Victorian Aboriginal people Australian Journal of Primary Health 353
Other Drug Treatment Services (AODTS) episodes and calls to Kids Helpline.
This burden indicates the need to strengthen preventative approaches. General practice can play an important role in this, particularly through the provision of mental health care plans. GP training in mental health improves the provision of recommended client care in the area (Naismith et al. 2001) and, according to our study, translated to a greater completion of MHCPs. Clinical audits can also improve general practicemental health care and the number of clients with MHCPs (Naismith et al. 2001). The present study also identified that partnerships between ACCHOs andmental health services were important for higher completion of MHCPs. Partnerships such as this have previously been found to enhance the use of mental services by Aboriginal people (New South Wales Department of Health 2010; Fuller et al. 2005).
The provision of MHCPs does rely on referral pathways to accessible and culturally safe services, such as for counselling. Previous studies have found that barriers for Aboriginal people accessing mental health services can be shame, stigma and anxiety about seeking mental health support (South Australian Government 2010) and a lack of accessible services, leading to acute presentations and responses (Fuller et al. 2005). Growing awareness of mental health issues and reducing stigma has increased mental health service usage for non-Aboriginal populations (Beyond Blue 2014). How effective these strategies have been with Aboriginal people is unknown.
Community workers were a significant referral conduit for Aboriginal AODTS episodes, more so than GPs. Whether this is also true for referrals to mental health support is unknown. Community and home-based AODTS episodes were less for Aboriginal people, likely related to social determinants, an important consideration as it indicates a higher need for Aboriginal people to have residential AODTS. There was also a higher rate of Aboriginal people referred to AODTS through corrections and justice services; however, there was a lower rate of referral by police, indicating the important role of AODTS in terms of reducing Aboriginal imprisonment rates.
An over-representation of young Aboriginal people using a call line indicates a need for cultural appropriateness of mental health call lines and partnerships with and referral pathways to ACCHOs. The frequent calls for suicide and self-harm concerns reflect the known prevalence of this issue. The effectiveness of implementation of guidelines to address self-harm among young Aboriginal people is unknown (Australian Institute of Health and Welfare 2013).
Conclusions Improved analysis of participation and outcomes for Aboriginal people using mental health services, including suicide prevention services for young people, is needed to better understand, prevent and manage mental health problems in this group. Provision of mental health GP training, quality audits and partnerships between ACCHOs and mental health services are important for primary health care. Community services are an important referral point to AODTS services. A pattern of AODTS referral from corrections and a lack of police referral
indicate links between AODTS and incarceration rates of Aboriginal people. Incarceration and other poor health and social outcomes may be exacerbated by lower use of community and home-based AODTS and driven by social determinants, such as homelessness. Improved understanding of participation and outcomes forAboriginal people usingmental health services, including services for young people, is needed.
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