Co-Occurring Mental Health and Substance Use Research Among Aboriginal and Torres Strait Islander People: A Systematic Review

Hobden B., Freund M., Rumbel J., Heard T., Davis R., Ooi J.Y., Newman J., Rose B., Sanson-Fisher R., Bryant J.

AbstractThis scoping review examined the literature on co-occurring mental health conditions and substance use among Indigenous peoples globally across (i) time, (ii) types of conditions examined, (iii) countries, (iv) research designs, and (v) participants and settings. Medline, Embase, PsycInfo, and Web of Science were searched across all years up until October 2022 for relevant studies. Ninety-four studies were included, with publications demonstrating a slight and gradual increase over time. Depressive disorder and alcohol were the most examined co-occurring conditions. Most studies included Indigenous people from the United States (71%). Ninety-seven percent of the studies used quantitative descriptive designs, and most studies were conducted in Indigenous communities/reservations (35%). This review provides the first comprehensive exploration of research on co-occurring mental health and substance use conditions among Indigenous peoples. The information should be used to guide the development of strategies to improve treatment and prevention.

Hobden B., Freund M., Lawson S., Bryant J., Walsh J., Leigh L., Sanson‐Fisher R.

Onaemo V.N., Fawehinmi T.O., D’Arcy C.

Background Suicidal behaviour is commonly associated with major depression (MD) and substance use disorders (SUDs). However, there is a paucity of research on risk for suicide ideation among individuals with comorbid SUDs and MD in the general population. Objectives This study investigated the associated risk of suicide ideation in comorbid SUDs—cannabis use disorder (CUD), alcohol use disorder (AUD), drug use disorder (DUD) with major depressive episode (MDE) in a nationally representative sample. Methods Multilevel logistic regression models were used to analyze the 2012 Canadian Community Health Survey- Mental Health (CCHS-MH) data. This is a cross-sectional survey of nationally representative samples of Canadians (n = 25,113) aged 15 years and older residing in the ten Canadian provinces between January and December 2012. Diagnoses of MDE, AUD, DUD, and CUD were based on a modified WHO-CIDI, derived from DSM-IV diagnostic criteria. Results Comorbidity was found to be the strongest predictor of suicide ideation. Compared to those with no diagnosis of either a SUD or MDE, individuals with a comorbid diagnosis of AUD with MDE, CUD with MDE, or DUD with MDE were 9, 11 and 16 times more likely to have 12-month suicide ideation respectively. A diagnosis of MDE was a significant predictor of 12-month suicide ideation with about a 7-fold increased risk compared with individuals not diagnosed with either MDE or a SUD. Conclusion Suicide is a preventable public health issue. Our study found a significantly increased risk of suicide ideation among persons who have comorbid SUD with MD. Effective integration of mental health and addictions services could mitigate the risk of suicide and contribute to better outcomes.

Buergelt P.T., Mahypilama L.E., Paton D.

Page I.S., Ferrari A.J., Slade T., Anderson M., Santomauro D., Diminic S.

Abstract Aims There is currently little nationally representative diagnostic data available to quantify how many Aboriginal and Torres Strait Islander people may need a mental health service in any given year. Without such information, health service planners must rely on less direct indicators of need such as service utilisation. The aim of this paper is to provide a starting point by estimating the prevalence ratio of 12-month common mental disorders (i.e. mood and anxiety disorders) for Indigenous peoples compared to the general Australian population. Methods Analysis of the four most recent Australian Indigenous and corresponding general population surveys was undertaken. Kessler-5 summary scores by 10-year age group were computed as weighted percentages with corresponding 95% confidence intervals. A series of meta-analyses were conducted to pool prevalence ratios of Indigenous to general population significant psychological distress by 10-year age groups. The proportion of respondents with self-reported clinician diagnoses of mental disorders was also extracted from the most recent survey iterations. Results Indigenous Australians are estimated to have between 1.6 and 3.3 times the national prevalence of anxiety and mood disorders. Sensitivity analyses found that the prevalence ratios did not vary across age group or survey wave. Conclusions To combat the current landscape of inequitable mental health in Australia, priority should be given to populations in need, such as Indigenous Australians. Having a clear idea of the current level of need for mental health services will allow planners to make informed decisions to ensure adequate services are available.

Nasir B.F., Ryan E.G., Black E.B., Kisely S., Gill N.S., Beccaria G., Kondalsamy-Chennakesavan S., Nicholson G.C., Toombs M.

BackgroundExperiencing traumatic life events is associated with an increased risk of common mental disorders (CMDs), but studies investigating this association within Indigenous populations are limited.AimsThe aim of this study was to investigate associations between trauma and CMDs after controlling for other exposures.MethodTrauma exposures and CMD diagnoses were determined in a broadly representative sample of 544 Indigenous Australians, using a diagnostic clinical interview. Associations were determined by multivariate logistic regression.ResultsTrauma exposure independently predicted CMDs. After adjustment for potential confounders, trauma exposure was associated with a 4.01-fold increased risk of a diagnosis of a CMD in the past 12 months. The increased risks were 4.38-, 2.65- and 2.78-fold of having an anxiety disorder, mood disorder or a substance use disorder, respectively. Trauma exposure and comorbid post-traumatic stress disorder was associated with a 4.53-fold increased risk of a diagnosis of a mood disorder, 2.47-fold increased risk of a diagnosis of a substance use disorder, and 3.58-fold increased risk of any diagnosis of a CMD, in the past 12 months. Experiencing both sexual and physical violence was associated with a 4.98-fold increased risk of a diagnosis of an anxiety disorder in the past 12 months.ConclusionsIndigenous Australians experience significantly increased exposure to potentially harmful trauma compared with non-Indigenous Australians. Preventing and healing trauma exposure is paramount to reduce the high burden of CMDs in this population.

Capili B.

Editor's note: This article is one in a series on clinical research by nurses. The series is designed to give nurses the knowledge and skills they need to participate in research, step by step. Each column will present the concepts that underpin evidence-based practice-from research design to data interpretation. The articles will be accompanied by a podcast offering more insight and context from the author. To see all the articles in the series, go to http://links.lww.com/AJN/A204.

Page M.J., McKenzie J.E., Bossuyt P.M., Boutron I., Hoffmann T.C., Mulrow C.D., Shamseer L., Tetzlaff J.M., Akl E.A., Brennan S.E., Chou R., Glanville J., Grimshaw J.M., Hróbjartsson A., Lalu M.M., et. al.

The Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) statement, published in 2009, was designed to help systematic reviewers transparently report why the review was done, what the authors did, and what they found. Over the past decade, advances in systematic review methodology and terminology have necessitated an update to the guideline. The PRISMA 2020 statement replaces the 2009 statement and includes new reporting guidance that reflects advances in methods to identify, select, appraise, and synthesise studies. The structure and presentation of the items have been modified to facilitate implementation. In this article, we present the PRISMA 2020 27-item checklist, an expanded checklist that details reporting recommendations for each item, the PRISMA 2020 abstract checklist, and the revised flow diagrams for original and updated reviews.

Sahle B.W., Reavley N.J., Li W., Morgan A.J., Yap M.B., Reupert A., Jorm A.F.

Adverse childhood experiences (ACEs) are related to increased risk of common mental disorders. This umbrella review of systematic reviews and meta-analyses aimed to identify the key ACEs that are consistently associated with increased risk of mental disorders and suicidality. We searched PsycINFO, PubMed, and Google Scholar for systematic reviews and meta-analyses on the association between ACEs and common mental disorders or suicidality published from January 1, 2009 until July 11, 2019. The methodological quality of included reviews was evaluated using the AMSTAR2 checklist. The effect sizes reported in each meta-analysis were combined using a random-effects model. Meta-regressions were conducted to investigate whether associations vary by gender or age of exposure to ACEs. This review is registered with PROSPERO (CRD42019146431). We included 68 reviews with moderate (55%), low (28%) or critically low (17%) methodological quality. The median number of included studies in these reviews was 14 (2–277). Across identified reviews, 24 ACEs were associated with increased risk of common mental disorders or suicidality. ACEs were associated with a two-fold higher odds of anxiety disorders (pooled odds ratios (ORs): 1.94; 95% CI 1.82, 2.22), internalizing disorders (OR 1.76; 1.59, 1.87), depression (OR 2.01; 1.86, 2.32) and suicidality (OR 2.33; 2.11, 2.56). These associations did not significantly (P > 0.05) vary by gender or the age of exposure. ACEs are consistently associated with increased risk of common mental disorders and suicidality. Well-designed cohort studies to track the impact of ACEs, and trials of interventions to prevent them or reduce their impact should be global research priorities.

Charlson F., Gynther B., Obrecht K., Waller M., Hunter E.

Objective: Previous research has found an alarmingly high rate of psychosis in Indigenous1 patients from remote communities of Cape York and the Torres Strait with the treated prevalence of psychosis four times higher than that found for the Australian population. This study assesses comorbid illness and risk factors among this same cohort of psychosis patients. Methods: Data were collated from a clinical database that contains complete psychiatric records from 1992 to 2015, extracted for all Indigenous patients who received treatment for a psychotic disorder from the Remote Area Mental Health Service. Descriptive analysis and logistic regression models explored differences across subgroups of ethnicity and sex, and relationships between co-morbid disorders and risk factors. All multivariate models included variables of age, year of birth, sex and ethnicity. Results: Sixty per cent of participants ( n = 256) experienced a comorbid mental or substance use disorder. Forty-five per cent ( n = 192) of participants experienced a physical comorbidity. The most frequent physical health outcomes were injury (29%, n = 93), diabetes (18%, n = 58) and cardiovascular disease (21%, n = 68). Risk factors considered to play a potential biological or neurodevelopmental role in the development of psychosis were approximately three times more likely in Aboriginal (odds ratio = 3.2; 95% confidence interval = [2.0, 4.9]) versus Torres Strait Islander patients, and those born after 1980 (odds ratio = 2.5; 95% confidence interval = [1.6, 3.9]) versus those born prior to 1980. Environmental or contextual factors were associated with significantly greater risk among Aboriginal (odds ratio = 3.8; 95% confidence interval = [2.4, 6.0]) compared with Torres Strait Islander patients. Conclusion: Our data expose the perinatal and early environment of Indigenous children who later developed a psychotic disorder. As risk factors for schizophrenia may be cumulative and interactive, both with each other and with critical periods of neurodevelopmental vulnerability, our results suggest possible causes for the increasing prevalence of psychotic disorders between 1992 and 2015.

Franco A., Vidigal M.T., Oliveira M.N., Nascimento C.T., Silva R.F., Paranhos L.R.

This study was performed to review the international techniques for third molar dental age estimation applied to Brazilian adolescents. A systematic literature review was structured according to PRISMA. Six primary electronic databases were searched (PubMed, Scopus, LILACS, SciELO, Embase and Web of Science) and two sources of grey literature (Open Grey and Open Thesis) were screened. Only cross-sectional studies were included. The risk of bias was assessed with Joanna Briggs Institute tool for systematic reviews. The initial search found 2284 studies. Ten studies fulfilled the eligibility criteria. The samples varied between 288 and 2097 individuals. The sampled age interval ranged from 5 to 23 years. Seven techniques were found within the eligible studies. All the studies had low risk of bias. Three techniques: Demirjian (DEM), Nicodemo (NIC) and Cameriere (I3M) were included in the quantitative analysis. For each of the developmental stages of the techniques DEM and NIC, as well as for each measuring ratio of I3M, combined age values between studies were reported. In general, the international techniques for dental age estimation based on the radiographic assessment of the third molars were applicable to the Brazilian population.

Harfield S., Pearson O., Morey K., Kite E., Canuto K., Glover K., Gomersall J.S., Carter D., Davy C., Aromataris E., Braunack-Mayer A.

The lack of attention to Indigenous epistemologies and, more broadly, Indigenous values in primary research, is mirrored in the standardised critical appraisal tools used to guide evidence-based practice and systematic reviews and meta-syntheses. These critical appraisal tools offer no guidance on how validity or contextual relevance should be assessed for Indigenous populations and cultural contexts. Failure to tailor the research questions, design, analysis, dissemination and knowledge translation to capture understandings that are specific to Indigenous peoples results in research of limited acceptability and benefit and potentially harms Indigenous peoples. A specific Aboriginal and Torres Strait Islander Quality Appraisal Tool is needed to address this gap. The Aboriginal and Torres Strait Islander Quality Appraisal Tool (QAT) was developed using a modified Nominal Group and Delphi Techniques and the tool’s validity, reliability, and feasibility were assessed over three stages of independent piloting. National and international research guidelines were used as points of reference. Piloting of the Aboriginal and Torres Strait Islander QAT with Aboriginal and Torres Strait Islander and non-Indigenous experts led to refinement of the tool. The Aboriginal and Torres Strait Islander QAT consists of 14 questions that assess the quality of health research from an Aboriginal and Torres Strait Islander perspective. The questions encompass setting appropriate research questions; community engagement and consultation; research leadership and governance; community protocols; intellectual and cultural property rights; the collection and management of research material; Indigenous research paradigms; a strength-based approach to research; the translation of findings into policy and practice; benefits to participants and communities involved; and capacity strengthening and two-way learning. Outcomes from the assessment of the tool’s validity, reliability, and feasibility were overall positive. This is the first tool to appraise research quality from the perspective of Indigenous peoples. Through the uptake of the Aboriginal and Torres Strait Islander QAT we hope to improve the quality and transparency of research with Aboriginal and Torres Strait Islander peoples, with the potential for greater improvements in Aboriginal and Torres Strait Islander health and wellbeing.

Aromataris E., Munn Z.

Nasir B.F., Toombs M.R., Kondalsamy-Chennakesavan S., Kisely S., Gill N.S., Black E., Hayman N., Ranmuthugala G., Beccaria G., Ostini R., Nicholson G.C.

Objective To determine, using face-to-face diagnostic interviews, the prevalence of common mental disorders (CMD) in a cohort of adult Indigenous Australians, the cultural acceptability of the interviews, the rates of comorbid CMD and concordance with psychiatrists’ diagnoses.Design Cross-sectional study July 2014–November 2016. Psychologists conducted Structured Clinical Interviews for Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision Axis I Disorders (SCID-I) (n=544). Psychiatrists interviewed a subsample (n=78).Setting Four Aboriginal Medical Services and the general community located in urban, regional and remote areas of Southern Queensland and two Aboriginal Reserves located in New South Wales.Participants Indigenous Australian adults.Outcome measures Cultural acceptability of SCID-I interviews, standardised rates of CMD, comorbid CMD and concordance with psychiatrist diagnoses.Results Participants reported that the SCID-I interviews were generally culturally acceptable. Standardised rates (95% CI) of current mood, anxiety, substance use and any mental disorder were 16.2% (12.2% to 20.2%), 29.2% (24.2% to 34.1%), 12.4% (8.8% to 16.1%) and 42.2% (38.8% to 47.7%), respectively—6.7-fold, 3.8-fold, 6.9-fold and 4.2-fold higher, respectively, than those of the Australian population. Differences between this Indigenous cohort and the Australian population were less marked for 12-month (2.4-fold) and lifetime prevalence (1.3-fold). Comorbid mental disorder was threefold to fourfold higher. In subgroups living on traditional lands in Indigenous reserves and in remote areas, the rate was half that of those living in mainstream communities. Moderate-to-good concordance with psychiatrist diagnoses was found.Conclusions The prevalence of current CMD in this Indigenous population is substantially higher than previous estimates. The lower relative rates of non-current disorders are consistent with underdiagnosis of previous events. The lower rates among Reserve and remote area residents point to the importance of Indigenous peoples’ connection to their traditional lands and culture, and a potentially important protective factor. A larger study with random sampling is required to determine the population prevalence of CMD in Indigenous Australians.

James M., Painter J., Buckingham B., Stewart M.W.

Aims and methodThe Health of the Nation Outcome Scales (HoNOS) and its older adults’ version (HoNOS 65+) have been used widely for 20 years, but their glossaries have not been revised to reflect clinicians' experiences or changes in service delivery. The Royal College of Psychiatrists convened an international advisory board, with UK, Australian and New Zealand expertise, to identify desirable amendments. The aim was to improve rater experience by removing ambiguity and inconsistency in the glossary rather than more radical revision.ResultsChanges proposed to the HoNOS are reported. HoNOS 65+ changes will be reported separately. Based on the views and experience of the countries involved, a series of amendments were identified.Clinical implicationsWhile effective clinician training remains critically important, these revisions aim to improve intra- and interrater reliability and improve validity. Next steps will depend on feedback from HoNOS users. Reliability and validity testing will depend on funding.Declaration of interestNone.