Imprisonment following discharge from mental health units: A developing trend in New Zealand.

Introduction: Contemporary models of care for people with mental disorders continue to shift to community-based care, requiring fewer inpatient mental health beds, shorter inpatient lengths of stay, and less use of coercion. It has been suggested that some mentally unwell people, whose behavior can no longer be safely contained in overstretched mental health units where seclusion and restraint are discouraged, are now left to the criminal justice system to manage. It is unclear whether the risk of imprisonment following discharge from a mental health unit has increased over recent years. Methods: A quantitative, retrospective cohort study design was used to investigate any association between an acute inpatient mental health service admission in Aotearoa (New Zealand), and referral to a prison mental health team within 28 days of hospital discharge, from 2012 to 2020. Data were extracted from the national mental health dataset managed by the Ministry of Health. Results: Risk of imprisonment within 28 days of inpatient discharge increased over the study period. People experiencing this outcome were more likely to be younger, male, of Mâori or Pacific ethnicity, presenting with substance use and psychotic disorders who were aggressive or overactive, and were subject to coercive interventions such as seclusion and compulsory treatment during their admission. Discussion: We concluded that contemporary models of less coercive predominantly community based mental health care may be increasingly reliant on the criminal justice system to manage aggressive and violent behavior driven by mental illness. It is argued from a human rights perspective that mental health inpatient units should retain the capacity to safely manage this type of clinical presentation.

Mental health service users' progression from illicit drug use to schizophrenia in New Zealand.

BACKGROUND: Recently, publications have hypothesised that the demonstrated increase in the incidence of schizophrenia in New Zealand is a side effect of the increased strength of available cannabis derivatives over the last 25+ years and the much more recent increase in the population's use of methamphetamine. AIM: To compare the rates of later schizophrenia between age-matched mental health service users with initial diagnoses as alcohol abusers or illicit drug users. METHOD: From the PRIMHD comprehensive national database, all users of the mental health services over a 5-year period who received an ICD-10 presenting diagnosis of alcohol or substance use/abuse were identified. For each person identified, the database was examined for the following 3 years to determine the numbers later diagnosed with schizophrenia. RESULTS: For the initial alcohol problem people in their twenties, 1.7% were diagnosed as suffering from schizophrenia in the subsequent 3 years. For the initial drug problem people, the rate was 10.9%. Within that drug-using population, the indigenous Maori developed schizophrenia at a higher rate than did the remainder of the population. CONCLUSION: These findings in New Zealand require further research into their generalisability, context and explanation.

Impact of an assertive community treatment model of care on the treatment of prisoners with a serious mental illness.

OBJECTIVES: This study aims to describe the impact of a mental health assertive community treatment prison model of care (PMOC) on improving the ability to identify prisoner needs, provide interventions and monitor their efficacy. METHODS: We carried out a file review across five prisons of referrals in the year before the implementation of the PMOC in 2010 ( n = 423) compared with referrals in the year after ( n = 477). RESULTS: Some improvements in the identification of needs and providing interventions were detected. There was increased use of medication management and clinically significant improvement in addressing engagement with families. Monthly multi-disciplinary team face-to-face contact improved. CONCLUSIONS: Meeting the needs of mentally ill prisoners is challenged by the complexity of the custodial environment. Improvements made resulted from changing the model of care, rather than adding new resources.

The rate of mental health service use in New Zealand as analysed by ethnicity.

OBJECTIVES: To compare by ethnicity the rates of apparent new referrals and admissions to mental health services for selected major diagnostic groupings. METHOD: Using a Ministry of Health database covering all referrals and admissions to New Zealand's Mental Health services in 2014 and who had not been patients in the preceding six years, population adjusted rates of presentation were calculated and compared across the two major New Zealand ethnic groupings. RESULTS: Population corrected rates of apparently new cases of schizophrenia are more than twice as common in Maori as in non-Maori. Major depression is also significantly more common in Maori. That same trend was not evident for bipolar patients. CONCLUSIONS: These ethnically associated apparent differences in the rates of schizophrenia and depression need both confirmation and explanation.

The proposal for a third medical school in New Zealand: a community-engaged graduate entry medical program.

New Zealand has a maldistributed workforce that is heavily dependent on recruiting international medical graduates. Shortages are particularly apparent in high needs communities and in general scope specialties in provincial regions. The University of Waikato in partnership with the Waikato District Health Board has proposed a third medical school for New Zealand which will concentrate on addressing the workforce needs of disadvantaged rural and provincial communities. The proposed program is a community engaged, graduate entry medical course.

From positive screen to engagement in treatment: a preliminary study of the impact of a new model of care for prisoners with serious mental illness.

BACKGROUND: The high prevalence of serious mental illness (SMI) in prisons remains a challenge for mental health services. Many prisoners with SMI do not receive care. Screening tools have been developed but better detection has not translated to higher rates of treatment. In New Zealand a Prison Model of Care (PMOC) was developed by forensic mental health and correctional services to address this challenge. The PMOC broadened triggers for referrals to mental health teams. Referrals were triaged by mental health nurses leading to multidisciplinary team assessment within specified timeframes. This pathway for screening, referral and assessment was introduced within existing resources. METHOD: The PMOC was implemented across four prisons. An AB research design was used to explore the extent to which mentally ill prisoners were referred to and accepted by prison in-reach mental health teams and to determine the proportion of prison population receiving specialist mental health care. RESULTS: The number of prisoners in the study in the year before the PMOC (n = 9,349) was similar to the year after (n = 19,421). 24.6 % of prisoners were screened as per the PMOC in the post period. Referrals increased from 491 to 734 in the post period (Z = -7.23, p < 0.0001). A greater number of triage assessments occurred after the introduction of the PMOC (pre = 458; post = 613, Z = 4.74, p < 0.0001) leading to a significant increase in the numbers accepted onto in-reach caseloads (pre = 338; post = 426, Z = 3.16, p < 0.01). Numbers of triage assessments completed within specified time frames showed no statistically significant difference before or after implementation. The proportion of prison population on in-reach caseloads increased from 5.6 % in the pre period to 7.0 % in the year post implementation while diagnostic patterns did not change, indicating more prisoners with SMI were identified and engaged in treatment. CONCLUSIONS: The PMOC led to increased prisoner numbers across screening, referral, treatment and engagement. Gains were achieved without extra resources by consistent processes and improved clarity of professional roles and tasks. The PMOC described a more effective pathway to specialist care for people with SMI entering prison.

A prison mental health in-reach model informed by assertive community treatment principles: evaluation of its impact on planning during the pre-release period, community mental health service engagement and reoffending.

BACKGROUND: It is well recognised that prisoners with serious mental illness (SMI) are at high risk of poor outcomes on return to the community. Early engagement with mental health services and other community agencies could provide the substrate for reducing risk. AIM: To evaluate the impact of implementing an assertive community treatment informed prison in-reach model of care (PMOC) on post-release engagement with community mental health services and on reoffending rates. METHODS: One hundred and eighty prisoners with SMI released from four prisons in the year before implementation of the PMOC were compared with 170 such prisoners released the year after its implementation. RESULTS: The assertive prison model of care was associated with more pre-release contacts with community mental health services and contacts with some social care agencies in some prisons. There were significantly more post-release community mental health service engagements after implementation of this model (Z = -2.388, p = 0.02). There was a trend towards reduction in reoffending rates after release from some of the prisons (Z =1.82, p = 0.07). CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: Assertive community treatment applied to prisoners with mental health problems was superior to 'treatment as usual', but more work is needed to ensure that agencies will engage prisoners in pre-release care. The fact that the model showed some benefits in the absence of any increase in resources suggests that it may be the model per se that is effective.

Courts' misplaced confidence in psychiatric diagnoses.

In considering psychiatric evidence, criminal justice systems make considerable use of labels from official psychiatric classificatory systems. There are legislated requirements for psychological and/or behavioural phenomena to be addressed in legal tests, however medico-legal use of the current categorical diagnostic frameworks which are increasingly complex is difficult to justify. The lack of validity in large domains of the present classificatory systems is now more openly acknowledged, prompting a critical rethink. Illustrative examples include post-traumatic stress disorder, various personality disorders, and dissociative identity disorder. It follows that the Courts' faith in the present categorical classifications (e.g., DSMIV and ICD10) is misplaced and may be ultimately unhelpful to the administration of justice.

Te Ira Tangata: a Zelen randomised controlled trial of a treatment package including problem solving therapy compared to treatment as usual in Maori who present to hospital after self harm.

BACKGROUND: Maori, the indigenous people of New Zealand, who present to hospital after intentionally harming themselves, do so at a higher rate than non-Maori. There have been no previous treatment trials in Maori who self harm and previous reviews of interventions in other populations have been inconclusive as existing trials have been under powered and done on unrepresentative populations. These reviews have however indicated that problem solving therapy and sending regular postcards after the self harm attempt may be an effective treatment. There is also a small literature on sense of belonging in self harm and the importance of culture. This protocol describes a pragmatic trial of a package of measures which include problem solving therapy, postcards, patient support, cultural assessment, improved access to primary care and a risk management strategy in Maori who present to hospital after self harm using a novel design. METHODS: We propose to use a double consent Zelen design where participants are randomised prior to giving consent to enrol a representative cohort of patients. The main outcome will be the number of Maori scoring below nine on the Beck Hopelessness Scale. Secondary outcomes will be hospital repetition at one year; self reported self harm; anxiety; depression; quality of life; social function; and hospital use at three months and one year. DISCUSSION: A strength of the study is that it is a pragmatic trial which aims to recruit Maori using a Maori clinical team and protocol. It does not exclude people if English is not their first language. A potential limitation is the analysis of the results which is complex and may underestimate any effect if a large number of people refuse their consent in the group randomised to problem solving therapy as they will effectively cross over to the treatment as usual group. This study is the first randomised control trial to explicitly use cultural assessment and management. TRIAL REGISTRATION: Australia and New Zealand Clinical Trials Register (ANZCTR): ACTRN12609000952246.

The contributions of culture and ethnicity to New Zealand mental health research findings.

UNLABELLED: BACKGROUND AND MATERIAL: In the last five years a number of studies have been conducted in specialist psychiatric and primary care populations in New Zealand which have allowed comparisons in terms of clinical phenomena and therapeutic experiences between Mâori (the indigenous people of New Zealand) and non-Mâori. These studies were reviewed in terms of the methodology used, their major findings and their implications. DISCUSSION: In specialist psychiatric services Mâori were more likely to present with hallucinations and/or aggression and less likely to present with depression and/or episodes of self-harm. They were overly represented in those with schizophrenia. Mâori were more likely to be involved in acts of aggression and to be secluded, and an equivalent episode of care for Mâori appeared to be significantly more costly than for non Mâori. Other studies, conducted in prison and community-based samples, suggested that Mâori were less likely to access care and, when given a diagnosis of depression, less likely to be prescribed anti-depressant medication.The rates of depression were significantly higher in Mâori (women) and Mâori were also overly represented in those with anxiety and substance misuse disorders. These differences remained even after the sample was standardised for socio-economic status. Further exploration of the genesis and implications of these findings, derived from a strong and relatively well-defined indigenous people, may usefully inform the more general issues of culture and its significance for diagnosis, classification and service use. CONCLUSIONS: While the methodologies used and the actual results gained differed across studies, there do seem to be differences in phenomenological profiles at presentation, in the diagnostic patterns, the cost of care, and the therapeutic experiences between Mâori and non-Mâori New Zealanders. These differences may reflect actual differences between certain ethnic groups, which then explain the differences in the experiences of those users, or they may reflect inadequacies on the parts of non-MAori clinicians, their diagnostic tools and the services in which they operate, in catering for Mâori patients.

Prevalence of mental disorders among Maori in Te Rau Hinengaro: the New Zealand Mental Health Survey.

OBJECTIVE: To describe the prevalence of mental disorders (period prevalence across aggregated disorders, 12 month and lifetime prevalence) among Maori in Te Rau Hinengaro: The New Zealand Mental Health Survey. METHOD: Te Rau Hinengaro: The New Zealand Mental Health Survey, undertaken between 2003 and 2004, was a nationally representative face-to-face household survey of 12,992 New Zealand adults aged 16 years and over, including 2,595 Maori. Ethnicity was measured using the 2001 New Zealand census ethnicity question. A fully structured diagnostic interview, the World Health Organization World Mental Health Survey Initiative version of the Composite International Diagnostic Interview (CIDI 3.0), was used to measure disorder. The overall response rate was 73.3%. This paper presents selected findings for the level and pattern of mental disorder prevalence among Maori. RESULTS: Maori lifetime prevalence of any disorder was 50.7%, 12 month prevalence 29.5% and 1 month prevalence 18.3%. The most common 12 month disorders were anxiety (19.4%), mood (11.4%) and substance (8.6%) disorders and the most common lifetime disorders were anxiety (31.3%), substance (26.5%) and mood (24.3%) disorders. Levels of lifetime comorbidity were high with 12 month prevalence showing 16.4% of Maori with one disorder, 7.6% with two disorders and 5.5% with three or more disorders. Twelve-month disorders were more common in Maori females than in males (33.6%vs 24.8%) and in younger age groups: 16-24 years, 33.2%; 25-44 years, 32.9%; 45-64 years, 23.7%; and 65 years and over, 7.9%. Disorder prevalence was greatest among Maori with the lowest equivalized household income and least education. However, differences by urbanicity and region were not significant. Of Maori with any 12 month disorder, 29.6% had serious, 42.6% had moderate and 27.8% had mild disorders. CONCLUSION: Mental disorders overall and specific disorder groups (anxiety, mood and substance) are common among Maori and measures of severity indicate that disorders have considerable health impact. Findings provide a platform for informing public health policy and health sector responses to meeting mental health needs of Maori.