Tricia Nagel

Approach to treatment of mental illness and substance dependence in remote Indigenous communities: Results of a mixed methods study

OBJECTIVE To develop and evaluate a culturally adapted brief intervention for Indigenous people with chronic mental illness. DESIGN A mixed methods design in which an exploratory phase of qualitative research was followed by a nested randomised controlled trial. SETTING Psycho-education resources and a brief intervention, motivational care planning (MCP), were developed and tested in collaboration with aboriginal mental health workers in three remote communities in northern Australia. PARTICIPANTS A total of 49 patients with mental illness and 37 carers were recruited to a randomised controlled trial that compared MCP (n = 24) with a clinical control condition (treatment as usual, n = 25). INTERVENTION The early treatment group received MCP at baseline and the late treatment group received delayed treatment at six months. MAIN OUTCOME MEASURES The primary outcome was mental health problem severity as measured by the health of the nation outcome scales. Secondary measures of well-being (Kessler 10), life skills, self-management and substance dependence were chosen. Outcome assessments were performed at baseline, six-month, 12-month and 18-month follow up. RESULTS Random effects regression analyses showed significant advantage for the treatment condition in terms of well-being with changes in health of the nation outcome scales (P < 0.001) and Kessler 10 (P = 0.001), which were sustained over time. There was also significant advantage for treatment for alcohol dependence (P = 0.05), with response also evident in cannabis dependence (P = 0.064) and with changes in substance dependence sustained over time. CONCLUSIONS These results suggest that MCP is an effective treatment for Indigenous people with mental illness and provide insight into the experience of mental illness in remote communities.

Study protocol: national research partnership to improve primary health care performance and outcomes for Indigenous peoples

BackgroundStrengthening primary health care is critical to reducing health inequity between Indigenous and non-Indigenous Australians. The Audit and Best practice for Chronic Disease Extension (ABCDE) project has facilitated the implementation of modern Continuous Quality Improvement (CQI) approaches in Indigenous community health care centres across Australia. The project demonstrated improvements in health centre systems, delivery of primary care services and in patient intermediate outcomes. It has also highlighted substantial variation in quality of care. Through a partnership between academic researchers, service providers and policy makers, we are now implementing a study which aims to 1) explore the factors associated with variation in clinical performance; 2) examine specific strategies that have been effective in improving primary care clinical performance; and 3) work with health service staff, management and policy makers to enhance the effective implementation of successful strategies.Methods/DesignThe study will be conducted in Indigenous community health centres from at least six States/Territories (Northern Territory, Western Australia, New South Wales, South Australia, Queensland and Victoria) over a five year period. A research hub will be established in each region to support collection and reporting of quantitative and qualitative clinical and health centre system performance data, to investigate factors affecting variation in quality of care and to facilitate effective translation of research evidence into policy and practice. The project is supported by a web-based information system, providing automated analysis and reporting of clinical care performance to health centre staff and management.DiscussionBy linking researchers directly to users of research (service providers, managers and policy makers), the partnership is well placed to generate new knowledge on effective strategies for improving the quality of primary health care and fostering effective and efficient exchange and use of data and information among service providers and policy makers to achieve evidence-based resource allocation, service planning, system development, and improvements of service delivery and Indigenous health outcomes.

Study protocol: Audit and Best Practice for Chronic Disease Extension (ABCDE) Project

BackgroundA growing body of international literature points to the importance of a system approach to improve the quality of care in primary health care settings. Continuous Quality Improvement (CQI) concepts and techniques provide a theoretically coherent and practical way for primary care organisations to identify, address, and overcome the barriers to improvements. The Audit and Best Practice for Chronic Disease (ABCD) study, a CQI-based quality improvement project conducted in Australias Northern Territory, has demonstrated significant improvements in primary care service systems, in the quality of clinical service delivery and in patient outcomes related to chronic illness care. The aims of the extension phase of this study are to examine factors that influence uptake and sustainability of this type of CQI activity in a variety of Indigenous primary health care organisations in Australia, and to assess the impact of collaborative CQI approaches on prevention and management of chronic illness and health outcomes in Indigenous communities.Methods/designThe study will be conducted in 40–50 Indigenous community health centres from 4 States/Territories (Northern Territory, Western Australia, New South Wales and Queensland) over a five year period. The project will adopt a participatory, quality improvement approach that features annual cycles of: 1) organisational system assessment and audits of clinical records; 2) feedback to and interpretation of results with participating health centre staff; 3) action planning and goal setting by health centre staff to achieve system changes; and 4) implementation of strategies for change. System assessment will be carried out using a System Assessment Tool and in-depth interviews of key informants. Clinical audit tools include two essential tools that focus on diabetes care audit and preventive service audit, and several optional tools focusing on audits of hypertension, heart disease, renal disease, primary mental health care and health promotion.The project will be carried out in a form of collaborative characterised by a sequence of annual learning cycles with action periods for CQI activities between each learning cycle.Key outcome measures include uptake and integration of CQI activities into routine service activity, state of system development, delivery of evidence-based services, intermediate patient outcomes (e.g. blood pressure and glucose control), and health outcomes (complications, hospitalisations and mortality).ConclusionThe ABCD Extension project will contribute directly to the evidence base on effectiveness of collaborative CQI approaches on prevention and management of chronic disease in Australias Indigenous communities, and to inform the operational and policy environments that are required to incorporate CQI activities into routine practice.

AIMHI NT 'Mental Health Story Teller Mob': Developing stories in mental health

Abstract The Australian Integrated Mental Health Initiative in the Northern Territory is one of a number of sites funded by the National Health and Medical Research Council. The project has been working with Aboriginal Mental Health Workers (AMHWs), and the Top End Division of General Practice (TEDGP) to adapt mental health information to the Aboriginal and Torres Strait Islander context through development of mental health stories. The stories focus on personal strengths and family support, and use local artwork and images, local language, metaphors and music. The concepts have been incorporated into service provider training and psychoeducation resources in the Northern Territory. Development and evaluation of mental health literacy initiatives is important in the context of high rates of mental illness and burden of disease in the Aboriginal and Torres Strait Islander community.

High risk alcohol-related trauma among the Aboriginal and Torres Strait Islanders in the Northern Territory

High risk drinking is linked with high rates of physical harm. The reported incidence of alcohol - related trauma among Aboriginal and Torres Strait Islander people in the Northern Territory is the highest in the world. Facial fractures are common among young Aboriginal and Torres Strait Islanders. They are often linked with misuse of alcohol in the Northern Territory and are frequently secondary to assault. This review focuses on alcohol-related trauma in the Territory and draws attention to an urgent need for preventative health approach to address this critical issue.

An approach to treating depressive and psychotic illness in Indigenous communities.

This study is one of the activities of a multi-site research program, the Australian Mental Health Initiative (AIMhi), funded by the National Health and Medical Research Council. AIMhi in the Northern Territory collaborated with Aboriginal mental health workers and Northern Territory remote service providers in developing a range of resources and strategies to promote improved Indigenous mental health outcomes. A brief intervention that combines the principles of motivational interviewing, problem solving therapy and chronic disease self-management is described. The intervention has been integrated into a randomised controlled trial. Early findings suggest that the strategy and its components are well received by clients with chronic mental illness, and their carers, in remote communities.

Yarning about Indigenous mental health: Translation of a recovery paradigm to practice

Abstract Mental health practitioners struggle to translate recovery paradigms into practice. Changing from a focus on remediation of symptoms to a focus on reclaiming life in the community and enhancing protective factors requires a new approach. One new approach that particularly challenges health providers is the equalising of traditional patient-service provider relationships. Given the additional issues of disempowerment and social disadvantage of Indigenous peoples in Australia, equalising relationships and embedding recovery values for Indigenous mental health clients especially require urgent attention. There is also a need to learn more about the meaning of recovery in the Indigenous context and the ways in which it differs from non Indigenous interpretations. The Aboriginal and Islander Mental health initiative (previously the Australian Integrated Mental health initiative) has developed resources and training which seek to address this gap. The resources support a culturally adapted strengths-based approach to assessment and early intervention and are increasing popular in mental health, alcohol and other drug and chronic disease settings. Indigenous people with mental illness are subject to additional complex and toxic combination of social disconnecting factors. Culturally adapted recovery approaches to Indigenous mental illness are thus an important component of closing the gap in Indigenous health.

Two Way Approaches to Indigenous Mental Health Training: Brief Training in Brief Interventions

Abstract This study aimed to train health care professionals in a mental health assessment and care plan package designed for Aboriginal clients and carers and to evaluate the training and the package. The package has been developed over two years of consultation and encourages a collaborative, culturally appropriate approach to mental health assessment and care planning using motivational counselling techniques and relapse prevention strategies. Seventeen workshops were delivered in a range of settings to 261 service providers between 2006 and 2008. The training used the tools developed through the AIMhi ‘Story Telling Project’ and included multimedia resources, and activities designed to bridge the cross cultural and literacy gap in remote communities, including role play and skills practice. The training was well received and pre- and post-workshop evaluations show that participants found the workshops interesting and useful, and significantly improved in their confidence in assessment and communication, and their knowledge of early warning signs and treatment. The findings suggest a need in both the Indigenous and non-Indigenous workforce for further training, in both undergraduate and postgraduate settings, and in specialist and primary care.

The need for relapse prevention strategies in Top End remote Indigenous mental health

Abstract The Australian Integrated Mental Health Initiative in the Northern Territory (AIMHI NT) is one site of a National Health and Medical Research Council (NHMRC) Strategic Partnership initiative seeking to improve remote indigenous mental health outcomes – in a context of increasing hospital admissions and high readmission rates. Remote indigenous mental health service delivery faces challenges of isolation, staff recruitment and retention, and cultural, language and literacy issues. AIMHI NT explored the challenges of mental health service delivery and relapse prevention in Top End remote Aboriginal communities through semistructured interviews with General Practitioners, nurses, and Aboriginal Mental Health Workers. AIMHI NT sought views from a range of different practitioners and health centres, representing each of the three Top End regions - Katherine, East Arnhem and Darwin Rural. Remote service providers reported low levels of confidence in indigenous mental health assessment, and little formal training in mental health. They reported high rates of relapse of mental illness and high rates of comorbidity, but few relapse prevention activities and relapse prevention tools. The development of relapse prevention activities in primary care requires support and change at all levels – community, consumers and carers, service providers, health system, and health policy. AIMHI NT is engaged in a range of activities promoting relapse prevention in remote NT health centres, and has developed a care plan and care plan training package for remote service providers.

Developing a best practice pathway to support improvements in Indigenous Australians’ mental health and well-being: a qualitative study

Objective There is a need to adapt pathways to care to promote access to mental health services for Indigenous people in Australia. This study explored Indigenous community and service provider perspectives of well-being and ways to promote access to care for Indigenous people at risk of depressive illness. Design A participatory action research framework was used to inform the development of an agreed early intervention pathway; thematic analysis Setting 2 remote communities in the Northern Territory. Participants Using snowball and purposive sampling, 27 service providers and community members with knowledge of the local context and the diverse needs of those at risk of depression were interviewed. 30% of participants were Indigenous. The proposed pathway to care was adapted in response to participant feedback. Results The study found that Indigenous mental health and well-being is perceived as multifaceted and strongly linked to cultural identity. It also confirms that there is broad support for promotion of a clear pathway to early intervention. Key identified components of this pathway were the health centre, visiting and community-based services, and local community resources including elders, cultural activities and families. Enablers to early intervention were reported. Significant barriers to the detection and treatment of those at risk of depression were identified, including insufficient resources, negative attitudes and stigma, and limited awareness of support options. Conclusions Successful early intervention for well-being concerns requires improved understanding of Indigenous well-being perspectives and a systematic change in service delivery that promotes integration, flexibility and collaboration between services and the community, and recognises the importance of social determinants in health promotion and the healing process. Such changes require policy support, targeted training and education, and ongoing promotion.