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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 Māori, 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., Competing Interests: Nil., (© PMA.)

Background: Eating disorders are as common in Māori, the Indigenous people of Aotearoa-New Zealand, as they are in non-Māori; however, research has focused on the experiences of non-Māori. This paper will describe explanatory factors, treatment experiences and what helps with recovery for Māori., Methods: Kaupapa Māori research methodology informed the methods and analysis. Fifteen semi-structured interviews comprised thirteen Māori participants with eating disorders (anorexia nervosa, bulimia nervosa and binge eating disorder) and two whānau (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 Māori 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 Māori culture and whānau 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 Tūī, Kākā and Kererū possess their own unique birdcalls, so do Māori with eating disorders and their whānau have their own experiences, needs and required treatment responses., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

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., (Copyright © 2023 The Author(s). Published by Elsevier B.V. All rights reserved.)

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 20 th 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., (© 2023. The Author(s).)

Objective: Lifetime prevalence rates in Te Rau Hinengaro (The New Zealand Mental Health Survey) suggest eating disorders are at least as common in the Māori population as the non-Māori population, yet little is known at a population level about those accessing specialist mental health treatment for eating disorders in New Zealand. The aim of this study was to describe the population undergoing specialist mental health treatment for eating disorders and compare Māori and non-Māori clinical characteristics and service use., Method: This study uses the Programme for the Integration of Mental Health Data data set, managed by the New Zealand Ministry of Health to describe the characteristics of people with eating disorders and their use of specialist mental health services from 2009 to 2016., Results: There were 3,835 individuals with a diagnosed eating disorder who had contact with specialist mental health services in this time period, 7% of whom were Māori. Within the cohort, Māori had a higher prevalence for a bulimia nervosa diagnosis, fewer diagnosed with anorexia nervosa, and a higher prevalence of other psychiatric comorbidity than non-Māori., Discussion: There is discrepancy between the proportion of service users accessing specialist mental health services who are Māori and the assessed crude prevalence of eating disorders for Māori in national estimates. Once Māori are in specialist services; however, their use of services is comparable to non-Māori. Further research is needed to highlight the experiences of those Māori with eating disorders and address barriers to accessing services for Māori with eating disorders., (© 2020 Wiley Periodicals LLC.)

Aims: There is very little empirical evidence about the relationship between severe mental illness and the physical health of Indigenous peoples. This paper aims to compare the physical health of Māori and non-Māori with a diagnosis of bipolar disorder in contact with NZ mental health services., Methods: A cohort of Māori and non-Māori with a current bipolar disorder diagnosis at 1 January 2010 were identified from routine mental health services data and followed up for non-psychiatric hospital admissions and deaths over the subsequent 5 years., Results: Māori with bipolar disorder had a higher level of morbidity and a higher risk of death from natural causes compared to non-Māori with the same diagnosis, indicating higher levels of physical health need. The rate of medical and surgical hospitalisation was not higher among Māori compared to non-Māori (as might be expected given increased health needs) which suggests under-treatment of physical health conditions in this group may be a factor in the observed higher risk of mortality from natural causes for Māori., Conclusion: This study provides the first indication that systemic factors which cause health inequities between Māori and non-Māori are compounded for Māori living with severe mental illness. Further exploration of other diagnostic groups and subgroups is needed to understand the best approach to reducing these inequalities.

Integrated care approaches have been recommended to remove barriers to healthcare and improve the physical health outcomes of people living with serious mental illness (SMI) and/or substance use disorders (SUDs). The aim of this systematic scoping review was to describe empirical investigations of interventions designed to integrate physical, mental, and addiction healthcare for this population. An iterative and systematic search of five electronic databases (Medline (Ovid), PsycINFO, CINAHL, Embase (Ovid) and Scopus) was conducted to identify peer-reviewed articles published between January 2000 and April 2019. Two reviewers independently screened publications in two successive stages of title and abstract screening, followed by full-text screening of eligible publications. Data from each included publication were extracted independently by two reviewers using a standardised spreadsheet. A total of 28 eligible publications were identified, representing 25 unique studies. Over half of the included studies investigated the use of case managers to provide self-management skills or to coordinate mental and physical healthcare (n = 14). Other interventions examined the co-location of services (n = 9) and the implementation of screening and referral pathways to specialist treatment (n = 2). Less than half of the included studies described a framework, theory or model that was underpinning the intervention tested. While some aspects of integrated care have been identified and addressed by interventions, other key dimensions have not been considered, such as shared decision-making. Identification of a comprehensive model of integrated care is recommended to inform the development and evaluation of future interventions for people with SMI/SUDs., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2020 Elsevier Ltd. All rights reserved.)

Aims: Older people experiencing mental distress are commonly overlooked in research and policy in New Zealand, partly due to lack of consistent national service provision and collation of information. This study aimed to: 1. Describe service arrangements for older people's mental health; 2. Describe mental health service use from age 65, where data is available., Methods: DHBs were surveyed to determine mental health service delivery and funding models for adults aged 65 and older. PRIMHD was used to explore demographic and clinical characteristics of older people using mental health services in Northern and Midland DHBs between 2009 and 2015., Results: DHBs vary in funding, access and reporting arrangements for older people's mental health services. Most services provide information into PRIMHD, but this is often partially complete. In the Northern and Midland regions, 2.2 % of older adults access specialist mental health services. People aged 65-74 were more likely to have previously used mental health services, live in deprived areas, have functional mental health conditions and have high treatment intensity than older age groups., Conclusions: National consistency in data collection and service delivery for older people is needed. Further investigation is needed to understand the needs of people with prior mental health service contact., Competing Interests: Nil.

Aims: People with experience of mental illness, in particular those accessing mental health services, have increased mortality compared to the general population, but no studies have examined the situation in New Zealand. This study uses a complete national dataset to estimate mortality rates from natural and external causes for adults using psychiatric services compared to the general New Zealand population., Methods: Routinely collected data on adults aged 18-64 using secondary mental health services between January 2002 and December 2010 were linked to death registrations over the same period. Indirect standardisation was used to estimate the mortality ratio (SMR) for those with any contact with mental health services over this period compared to the New Zealand population., Results: Both men and women using mental health services in New Zealand have more than twice the mortality rate of the total population [combined SMR 2.14 (95% CI 2.09-2.19)], with an increased risk of death from cancer and cardiovascular disease [SMRs=1.31(1.24-1.37), and 1.69 (1.60-1.79) respectively], and external causes (suicide and accidents) [SMR 3.11 (3.00-3.23)]. People with a diagnosis of a psychotic disorder had three times the overall death rate of the population., Conclusions: This study confirms that those using mental health services in New Zealand are dying prematurely from both natural and external causes, and provides evidence which supports calls for coordinated action on this issue.

Objectives: Inequities in physical health outcomes exist for people with mental health and substance use conditions and for Indigenous populations (Māori 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-Māori relative to Māori. 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 Māori, non-Māori 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-Māori. [ABSTRACT FROM AUTHOR]

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 Māori in New Zealand, experience higher community rates of BD. While New Zealand practice guidelines recommend providing culturally responsive care to Māori, studies show that Māori do not receive best practice. This qualitative study aimed to share the evidence about patterns of health service use and Māori patient experiences with focus group participants involved in the design and delivery of BD services, to discuss and develop guidelines for best practice for Māori with BD and address areas of unmet need. Three focus groups were conducted with 22 participants involved in the delivery of services to Māori 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 Māori patients with BD and their whānau (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 Māori with BD. [ABSTRACT FROM AUTHOR]

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 Māori youth with early psychosis, 10 family members and 4 Māori 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. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Aims: The validity of diagnostic classification in early psychosis has important implications for early intervention; however, it is unknown if previously found disparities between Māori (Indigenous people of New Zealand) and non‐Māori 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 Māori and non‐Māori in the five‐year period following diagnosis. Results: Differences in schizophrenia and affective psychosis diagnoses between Māori and non‐Māori were maintained in the five‐year period, with Māori being more likely to be diagnosed with schizophrenia (51% vs. 35%), and non‐Māori with bipolar disorder (28% vs. 18%). Stability of diagnosis was similar (schizophrenia 75% Māori vs. 67% non‐Maori; bipolar disorder 55% Māori vs. 48% non‐Māori) and those with no stable diagnosis at FEP were most likely to move towards a schizophrenia disorder diagnosis in both groups. Māori 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 Māori youth with first episode psychosis. [ABSTRACT FROM AUTHOR]

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 Māori with eating disorders and their whānau (family/support system) to identify the enablers and barriers to accessing specialist services for eating disorders in New Zealand. Method: Kaupapa Māori research methodology was used to ensure the research supported Māori health advancement. Fifteen semi-structured interviews were completed with Māori participants including; those with an eating disorder diagnosis (anorexia nervosa, bulimia nervosa, and binge eating disorder), and/or their whānau. 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 Māori 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-Māori experiences, and how this makes a place and space of exclusion for Māori and their whānau 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 whānau 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 Māori. Attention given to these findings will ensure a place for Māori in specialist eating disorder services in New Zealand. Plain English summary: Eating disorders are at least as common in Māori (Indigenous people of New Zealand) when compared to their non-Māori counterparts, however, a recent study investigating specialist service use data identified lower-than-expected service use for Māori. This paper explores the lived experiences of Māori with eating disorders and their whānau (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 Māori 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. [ABSTRACT FROM AUTHOR]

Purpose: The epidemiology of personality disorder is poorly understood. This study aims to describe the population in contact with mental health services with a diagnosis of personality disorder and compare service use between this group and those with a diagnosis of depression.Methods: Investigation of a routinely collected clinical data set across New Zealand was conducted. We used data from 2008 to 2017 and 1-year data from 2016, the most complete dataset. This allowed for variation over the years and confirmation within a 1-year prevalence. These data were analysed focusing on patients with a primary diagnosis of any personality disorder and the subset with borderline personality disorder (BPD). BPD was chosen as the most common clinical personality disorder diagnosis and that most researched.Results: 8884 (2.8%) of the population in contact with mental health services carried a primary diagnosis of personality disorder. Personality diagnosis other than antisocial personality disorder (ASPD) in men and borderline personality disorder (BPD) in either gender was negligible. Rates of personality pathology increased with social deprivation and were commonest in young adults. Multi-morbidity was the norm, with internalising disorder common. Maori diagnosed with PD were over-represented both in the patient group and by population.Conclusion: Borderline personality disorder and antisocial personality disorder are routinely diagnosed in routine clinical practice in New Zealand; however, other categorical diagnoses are not made. Patients with PD are significant users of resources in comparison to depressed patients. Resource utilisation was significantly greater in those with PD, in particular use of inpatient services compared to those with depression. [ABSTRACT FROM AUTHOR]

This study aimed to explore the experiences of women with mental illness who had also experienced breast cancer diagnosis and treatment, in particular, to identify barriers and facilitators to cancer treatment. Semi-structured interviews were conducted with ten breast cancer survivors who had had contact with secondary mental health services prior to their cancer diagnosis. Thematic analysis was used to identify key themes. Participants described positive experiences of cancer treatment, expressing surprise at both how well they coped with diagnosis and treatment and how well they were treated by services. Many contrasted this with their less positive experience of mental illness and mental health services. The women interviewed were active participants in their cancer treatment and did not report feeling stigmatised because of their mental health experiences. A lack of connection between cancer and mental health services was described, but this was not regarded as necessarily a bad thing. This study begins to counter the stereotypes of the difficult patient or the person unable to understand and cooperate in their own care which are prevalent in the literature. Further work is needed to understand the reasons for disparities in cancer outcomes. [ABSTRACT FROM AUTHOR]

Objective: To determine whether contemporary sex-specific cardiovascular disease (CVD) risk prediction equations underestimate CVD risk in people with severe mental illness from the cohort in which the equations were derived. Methods: We identified people with severe mental illness using information on prior specialist mental health treatment. This group were identified from the PREDICT study, a prospective cohort study of 495,388 primary care patients aged 30 to 74 years without prior CVD that was recently used to derive new CVD risk prediction equations. CVD risk was calculated in participants with and without severe mental illness using the new equations and the predicted CVD risk was compared with observed risk in the two participant groups using survival methods. Results: 28,734 people with a history of recent contact with specialist mental health services, including those without a diagnosis of a psychotic disorder, were identified in the PREDICT cohort. They had a higher observed rate of CVD events compared to those without such a history. The PREDICT equations underestimated the risk for this group, with a mean observed:predicted risk ratio of 1.29 in men and 1.64 in women. In contrast the PREDICT algorithm performed well for those without mental illness. Conclusions: Clinicians using CVD risk assessment tools that do not include severe mental illness as a predictor could by underestimating CVD risk by about one-third in men and two-thirds in women in this patient group. All CVD risk prediction equations should be updated to include mental illness indicators. [ABSTRACT FROM AUTHOR]