Ernest Hunter

Aboriginal and Torres Strait Islander suicide in context

Aboriginal and Torres Strait Islander suicide has been an issue of national public health and mental health concern for only one decade, having increased dramatically from levels that were very low in the late 1980s to levels of young adult male suicide that are now substantially higher than for the non-indigenous population. In this review the authors socially and historically contextualize these changes, identifying the causal frameworks adopted in developing interventions, and present an explanation in narrative and pictorial form that draws on critical family-centered trauma.

'Best intentions' lives on: untoward health outcomes of some contemporary initiatives in Indigenous affairs

Objective: A shortened version of a presentation to the Australian Institute of Aboriginal and Torres Strait Islander Studies, this paper raises questions regarding policy and program directions in Indigenous affairs with consequences for Indigenous health. Method: The author notes the inadequate Indigenous mental health database, and describes contemporary conflicts in the arena of Indigenous mental health, drawing on personal experience in clinical service delivery, policy and programme development. Results: Medicalized responses to the Stolen Generations report and constructions of suicide that accompanied the Royal Commission into Aboriginal Deaths in Custody are presented to demonstrate unforeseen health outcomes. Examples are also given of wellintentioned social interventions that, in the context of contemporary Indigenous society appear to be contributing to, rather than alleviating, harm. Problems of setting priorities that confront mental health service planners are considered in the light of past and continuing social disadvantage that informs the burden of mental disorder in Indigenous communities. Conclusions: The importance of acknowledging untoward outcomes of initiatives, even when motivated by concerns for social justice, is emphasized. The tension within mental health services of responding to the underpinning social issues versus providing equity in access to proven mental health services for Indigenous populations is considered.

Implementing smoke-free policies in mental health inpatient units: learning from unsuccessful experience

Objective: The aim of this paper is to describe the introduction, trial and termination of a smoke-free policy in an acute mental health unit of a regional hospital, and to consider factors that may contribute to the success of such policies in other settings. Methods: This analysis is based on key informant interviews and review of correspondence related to the trial, and examination of the relevant incident-reporting database. Results: Planning for implementation is described. The trial itself was terminated after 6 weeks due to perceived increases in aggression by patients towards staff working in the high dependency unit. Staff perceived that these episodes were directly related to these patients not being allowed to smoke. While there was an increase in events during the trial relating to two seriously ill individuals, examination of formal incident reports over a period of 2 years suggests little change in the overall number of incidents. Conclusions: Despite clear public health benefits, implementation of a smoke-free policy may have untoward behavioural effects in institutional mental health settings. In addition, staff expectations and perceptions are critical. Salient factors appear to be preparation of staff and patients, appropriate training, avoidance of exceptions and inconsistency, considering alternatives to smoking to fill the gap created by the policy, and a culture of critical evaluation in practice. Such processes will facilitate understanding and cooperation so that mental health services are able to participate in important policy processes with implications for the health of patients and staff.

Ketamine sedation for patients with acute agitation and psychiatric illness requiring aeromedical retrieval

Objective Aeromedical retrieval services face the difficult problem of appropriate levels of sedation for transport of acutely agitated patients to definitive care. This paper describes a technique using ketamine, which is titratable and avoids problems associated with airway management. Method A 3-year review of a new technique of ketamine sedation by aeromedical retrieval teams from the Cairns base of the Queensland section of the Royal Flying Doctor Service of Australia. Clinical records were systematically reviewed for ketamine administration and signs of adverse events during transport and in the subsequent 72 h. Results 18 patients were sedated during retrieval with intravenous ketamine. Effective sedation was achieved in all cases, with no significant adverse events noted during retrieval or 72 h afterwards. Conclusion Ketamine sedation is effective and safe in agitated patients with a psychiatric illness in the aeromedical setting and does not lead to worsening agitation in the subsequent 72-h period.

Psychosis in Indigenous populations of Cape York and the Torres Strait

Objective: To describe and characterise treated psychotic disorders in the Indigenous populations of Cape York and the Torres Strait.

Perceptions of mental health service delivery among staff and Indigenous consumers: It's still about communication

Objective: A needs analysis was undertaken to determine the quality and effectiveness of mental health services to Indigenous consumers within a health district of Southern Queensland. The study focussed on identifying gaps in the service provision for Indigenous consumers. Tools and methodologies were developed to achieve this. Method: Data were collected through the distribution of questionnaires to the target populations: district health service staff and Indigenous consumers. Questionnaires were developed through consultation with the community and the Steering Committee in order to achieve culturally appropriate wording. Of prime importance was the adaptation of questionnaire language so it would be fully understood by Indigenous consumers. Both questionnaires were designed to provide a balanced perspective of current mental health service needs for Indigenous people within the mental health service. Results: Results suggest that existing mental health services do not adequately meet the needs of Indigenous people. Conclusions: Recommendations arising from this study indicate a need for better communication and genuine partnerships between the mental health service and Indigenous people that reflect respect of cultural heritage and recognises the importance of including Indigenous people in the design and management of mental health services. Attention to the recommendations from this study will help ensure a culturally appropriate and effective mental health service for Indigenous consumers.

Using a socio-historical frame to analyse aboriginal self-destructive behaviour.

The last two decades have seen rapid changes in many facets of Aboriginal society, including morbidity and mortality. The same period has witnessed a dramatic increase in writing about and by Aborigines and this has necessitated a re-examination of the national “history” to include the indigenous people of Australia. Medical workers in Aboriginal Australia should be alert to the historical forces determining patterns of ill-health. Psychiatry in particular must develop this perspective if it is to participate with Aborigines in addressing emergent patterns of behavioural distress including suicide, parasuicide, ludic behaviour and self-mutilation. This paper demonstrates the importance of the socio-historical frame in the examination of these behaviours from one discrete region in isolated Aboriginal Australia: the Kimberley.

Double talk: Changing and conflicting constructions of indigenous mental health

Objective: The method by which psychiatric professionals and the profession itself have addressed the mental health needs of Indigenous Australians is explored. Method: A sociohistorical frame is utilised to explore the changing nature of psychiatric engagement in this field since the Second World War. Results: A series of distinct phases are definable, each of which demonstrates particular characteristics that relate to the social and political circumstances of indigenous Australia and changing investment on the part of mental health professionals. Significant difficulties have emerged at various stages and there exist quite different interpretations and uses of language relating to indigenous mental health. Conclusions: Current relations between mental health professionals and members of indigenous communities in Australia are informed by a history of which we should be aware. It has had and continues to have consequences that include significant differences in the ways in which mental health needs are conceived and articulated. These, in turn, are consequential in terms of policy and practice.

Tools and methodologies for investigating the mental health needs of Indigenous patients: it's about communication

Objective: To undertake a needs analysis to determine the quality and effectiveness of current mental health services to Indigenous patients within a health district of Southern Queensland. The present study focused on identifying gaps in the service provision for Indigenous patients. Tools and methodologies were developed to achieve this. Method: Before commencement of the needs analysis, a review of related national projects was completed. The needs analysis entailed the develop ment and distribution of two separate questionnaires. A major priority of the questionnaire for Indigenous patients was ensuring that effective com munication and cultural respect was achieved. A steering committee of both Indigenous and non-Indigenous experts collaborated on this. The second questionnaire was for employees of the mental health service. Both questionnaires were designed to provide a balanced perspective of current mental health service needs for Indigenous people within the mental health service. Results: The predominant issue that emerged and underpinned all the results was communication. Conclusions: The present study has developed and used procedures for undertaking research involving Indigenous people. It has shown the impor tance of involving Indigenous people to help ensure successful communication, compliance and cooperation by Indigenous mental health patients.

Bridging the triple divide: performance and innovative multimedia in the service of behavioural health change in remote Indigenous settings.

Objectives: The use of innovative information technology is now well established in health. However, while the gap in health status between Indigenous and other Australians is both significant and unchanging, there is limited application of these new approaches to addressing this national health priority. This may in part reflect the ‘digital divide’, which is another facet of Indigenous disadvantage. This paper describes an approach to address both issues in remote Indigenous settings. Results: The Health Interactive Technology Network began as a proof-of-concept study of touchscreen technology in two Indigenous health settings. It has subsequently expanded to a number of remote Indigenous communities and developed new platforms and applications to respond to emerging health issues. In creating narrative, interactive approaches to address choices in relation to health behaviours, the community development and engagement effects of the creative process have been highlighted. These findings suggest that these approaches will be suited to further expansion in the area of mental health.