Abstract
Objective:
The Mark Sheldon Remote Mental Health Team provides psychiatric services to 29 communities in very remote Central Australia. This study evaluated Mark Sheldon Remote Mental Health Team patient demographics, diagnoses and clinical management.
Methods:
A retrospective cross-sectional review was performed for January 2020. Variables included age, sex, Indigenous status, diagnosis, legal status, medication class and route of administration.
Results:
A total of 180 patients were identified (85.6% Indigenous, 53.3% male). Schizophrenia and delusional disorders were most common (41.1%). A small proportion of patients (2.8%) were involuntary. Psychotropic medication was commonly prescribed (77.4%) with a low threshold for anti-psychotic depot use (51.5%). Oral medication rates varied according to class.
Conclusions:
This study provided insights into the demographic and clinical profile of a unique population. The findings will help to optimise patient management in very remote Central Australia and serve as a foundation for similar evaluations and comparisons with other remote psychiatric services.
Mental illness is a major contributor to disease burden, with a lifetime prevalence of 45% in Australian adults. 1 The Royal Australian and New Zealand College of Psychiatrists (RANZCP) acknowledges the need for high quality mental health services for Indigenous Australians and those who live in remote localities. 2
The Northern Territory (NT) has the highest proportion of Indigenous Australians and many geographically remote communities. Despite this, there is scarcity of research regarding psychiatric services in very remote Central Australia. The most relevant was a descriptive paper published in 2001, which summarised conducting psychiatric assessments in remote Central Australia. 3 Other remotely based psychiatric services have published data from their respective regions; however, these findings cannot be generalised to the unique Central Australian population.4–7
The estimated population of Central Australia is 48,000 with 16,000 residing outside of Alice Springs in very remote communities. 8 The Mark Sheldon Remote Mental Health Team (MSRMHT) services 29 of these communities. The team is named in recognition of the late Dr Mark Sheldon, who worked as a Psychiatry Registrar in Central Australia in 1997. 3
The MSRMHT is geographically responsible for approximately 600,000 square kilometres. The team is required to travel up to 800 km from Alice Springs via four-wheel-drive vehicles and chartered flights. The MSRMHT comprises a mix of psychiatrists, a registrar, registered nurses and Aboriginal Health Practitioners (AHPs). This multidisciplinary approach allows for a blend of clinical, cultural and linguistic expertise (these important aspects of care are the focus of a separate paper). This study aimed to identify MSRMHT patient demographics, diagnoses and clinical management and to compare with national community-based mental health data. 9
Methods
A retrospective cross-sectional review was performed on all active MSRMHT cases. The review captured data from January 2020. Inclusion criteria comprised adults aged over 18 years. Child and adolescent patients were excluded.
Patient demographics included age (mean years, age groups), sex (numbers, proportions) and Indigenous status (numbers, proportions). Although Central Australia has a predominant Aboriginal Australian population, the term Indigenous was the formal nomenclature assigned within the data sources.
Principle diagnosis was recorded in accordance with the International Classification of Diseases 10th Revision (ICD-10) Diagnosis Related Groups (DRGs). 10 Additional variables included legal status (NT Mental Health and Related Services [MHRS] Act), 11 medication class and route of administration (depot versus oral).
Demographic and diagnostic data were accessed from automated reports. Clinical information was extracted from electronic patient records. Data were collated, de-identified and entered into Microsoft Excel for descriptive analyses. Approval was granted by the Central Australian Human Research and Ethics Committee (CA-20-3662).
Results
Demographics
During January 2020, the MSRMHT managed 180 patients. Table 1 outlines Indigenous status, sex and age. Sex distribution varied according to age range (Figure 1).
Patient demographics
Note. *Indigenous status was the formal nomenclature used within data source.
Number of patients by age ranges (years) and sex distribution.
Principal diagnosis by DRG
Of the 180 patients, 175 (97.2%) were assigned a principal ICD-10 diagnosis. Schizophrenia and delusion disorders were common (n = 72, 41.1%), followed by mood disorders (n = 35, 20.0%) and neurotic, stress-related and somatoform disorders (n = 29, 16.6%). Disorders due to psychoactive substance use were recorded in 19 patients (10.9%) followed by mental retardation and disorders of psychological development (n = 5, 2.9%; Table 2).
ICD-10 principal diagnosis
Management
Five patients (2.8%) were treated involuntarily under Community Management Orders (CMOs). The remaining 175 patients (97.2%) were of voluntary legal status.
Psychotropic medication (depot, oral or combination) was prescribed for 134 patients (74.4%). Anti-psychotic depots were prescribed in 69 patients (51.5%) including all five who were treated under a CMO. Second-generation anti-psychotic depots were more common (n = 61, 88.4%) compared to first generation anti-psychotics (n = 8, 11.6%).
Of the 134 patients prescribed psychotropic medications, 84 (62.7%) were prescribed an oral agent (either as monotherapy or combined with a depot or other oral agent). Anti-depressant medication was most common (n = 42, 31.3%) followed by anti-psychotic (n = 36, 26.9%) and mood-stabilising agents (n = 6, 4.5%; Figure 2).
Number of patients prescribed psychotropic agents by class and route.
Discussion
Demographics
National data from 2017–2018 revealed that 9.7% of community-based mental health patients were Aboriginal and/or Torres Strait Islanders. 9 This contrasts with the high proportion (85.6%) of Indigenous patients managed by the MSRMHT and reinforces the need to deliver culturally appropriate psychiatric services in very remote Central Australia.
The overall sex distribution within the MSRMHT patients was similar to national rates, 9 although a higher proportion of males fell within the 18–24 years range. This highlights the burden of mental illness on young adult males in very remote Central Australia and the need for targeted interventions for this vulnerable group.
Principal diagnosis by DRG
The majority of MSRMHT patients (97.2%) were assigned a principal diagnosis. This was higher than the national rate (80% for community-based mental health service contacts). 9
The most common DRGs were schizophrenia, delusional and mood disorders. This is consistent with reports that schizophrenia, schizoaffective and depressive disorders are three of the most common diagnoses in Australia. 9 This study did not differentiate between mood disorders although the results indicate that depression was common. The rate of bipolar disorder and whether those diagnosed with schizophrenia or delusional disorder had possibly experienced a manic psychosis is unknown. This could have implications regarding treatment, prognosis and increased biological risk within this population.
A 2015 systematic review of the prevalence of psychiatric disorders in Indigenous Australians reported a high prevalence of anxiety, post-traumatic stress disorder and alcohol dependence. 12 This is difficult to generalise to the MSRMHT patients as there is some evidence that Indigenous Australians living in remote regions experience lower rates of some mental illnesses compared to their urban counterparts. 13
It is possible that the schizophrenia and delusional disorders recorded in this study were triggered or exacerbated by substance use. 14 This would be consistent with a recent epidemiological study of psychosis in Indigenous populations. 6 Determining types and rates of substance use would help identify the demand for specific alcohol and drug services among MSRMHT patients.
Management
The proportion of MSRMHT patients on CMOs (2.8%) was far lower the national rate (14.5%) for community-based involuntary patients and less than that reported in Far North Queensland remote communities (31.0%).6,9 This could be explained by variations in mental health legislation, service capacity to manage involuntary patients or other contributing factors. The reality of providing adequate CMO oversight when a patient lives 800 km away is challenging and reserved for those with significant non-adherence and risk profiles.
This study highlighted a low threshold for anti-psychotic depot use, which is in keeping with the evidence base for reducing relapse in Schizophrenia. 14 There are also practical arguments to support depot use including geographical and cultural factors, which impact on the ability to facilitate or monitor oral medication adherence. The invasive nature of depots and reduced autonomy associated with CMOs reinforce the need for the MSRMHT to practise trauma-informed care.
The MRSMHT has limited scope to provide non-biological interventions yet recognises the importance of a holistic approach. 15 The team partners with the Central Australian Aboriginal Congress, Walpiri Youth Development Aboriginal Corporation, the Royal Flying Doctor Service and traditional healers (Ngaanyatjarra Pitjantjatjara Yankunytjatjara Women’s Council Ngangkari Program). These partnerships enable access to sociocultural, emotional and spiritual support, and are consistent with the RANZCP Ethical Guideline for Aboriginal and Torres Strait Islander Mental Health. 16 There is also scope to recommend referrals to psychologists via telehealth if warranted.
Limitations
The retrospective cross-sectional study design may not reflect MSRMHT patient variability over time. The small sample size and focus on very remote communities limit the generalisability of the findings. Further, the study does not account for the social drift of patients from very remote communities to larger centres like Alice Springs.
The reporting of principal diagnoses prevented differentiation between mood disorders or consideration of co-morbid substance use, personality and/or developmental disorders. Also, the role of historical and transgenerational trauma can significantly impact on patient presentations. The MSRMHT must strive to better understand these complexities in order to optimise clinical care.
The MSRMHT provides psychiatric services to a geographically isolated and unique patient population. Whilst details regarding staffing resources, cultural knowledge, linguistic capabilities and multidisciplinary collaboration are outside the scope of this study, they are important factors that influence patient care and are the focus of a separate paper.
Conclusion
This is the first study to evaluate demographics, diagnoses and clinical management of psychiatric patients in very remote Central Australia. In January 2020, there were 180 patients managed by the MSRMHT, the majority of whom were Indigenous. Schizophrenia and delusional disorders were most common. A small proportion of patients were treated under CMOs. Prescribed psychotropic medications included depot and oral agents. This evaluation has provided insights into the clinical profile of this unique population. It may form a foundation for similar evaluations of other NT-based mental health teams, longitudinal case studies and more robust comparative analyses with other remote psychiatric services.
