Maori Mental HealthNeeds Profile

A review of the evidence

Summary

–

Māori Mental Health Needs Profile

Summary

A Review of the Evidence

Dr Joanne Baxter

ISBN: 978-1-877412-05-9Citation Baxter, J.(2008). Māori Mental Health Needs Profile.

Summary. A Review of the Evidence.Palmerston North: Te Rau MatatiniP.O. Box 12175, Palmerston North

New Zealand.

This workforce development initiative is funded by:The Ministry of Health

WellingtonNew Zealand.

This document is available on the website of Te Rau Matatinihttp://www.matatini.co.nz

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ForewordThis profile of Māori mental health needs represents a detailed analysis of research undertaken over a period of more than ten years such as Ngā Ia o Te Oranga Hinengaro Trends in Māori Mental Health and draws especially on Te Rau Hinengaro – The New Zealand Mental Health Survey, New Zealand Health Information Service (NZHIS), the Mental Health National Collection Data (MHINC) and Hauora Māori Standards of Health IV. It also aligns with Te Puāwaiwhero The Second Māori Mental Health National Strategic Framework 2008 – 2015.

Dr Joanne Baxter has systemically reviewed the research findings so that a comprehensive picture and evidence base of Māori mental health need can be established. From this implications can be drawn and utilised as a planning tool for District Health Boards, Providers of Mental Health and Addiction Services and the Ministry of Health. The report therefore informs health need assessments and future planning to address Māori population mental health needs.

This Profile clarifies the position by documenting the level of need across age groups and across regions. Moreover it uses two sets of data – those relating to community prevalence and those relating to hospital admissions.

The extent of the problem is of sufficient magnitude to raise a number of concerns, not the least of which is the implications for the mental health workforce. In order to provide adequate access to treatment and care, it is obvious that mental health skills and knowledge will not only be necessary for practitioners in the formal mental health services, but will also be required by practitioners working in primary health care settings and in health promotion. It is also apparent that the distinctions between mental health, physical health, and social wellbeing are blurred to the extent that they should be considered together.

Te Rau Matatini is committed to building a strong health workforce that can provide quality services which are both relevant and effective. The Māori Mental Health Needs Profile provides the necessary information to facilitate workforce planning and to foster approaches that will lead to early intervention and more predictable recovery.

Kia maia

Mason Durie

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Contents

Foreword 3

Key Findings 6

Introduction 8

The Sociodemographic Context to Māori Mental Health Need 10

Prevalence and Impact of Mental Disorders in Māori 12

Prevalence of Specific Disorders 14

Ethnic Difference in Mental Disorders 19

Māori Mental Health Pathways to Care 21

Summary of the Evidence and Conclusions 26

References 28

Acknowledgements 31

Appendix A - Sources of Data 32

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Key Findings

This Review reinforces concerns expressed about Māori mental health over the 1980s and 1990s. Updated analysis of hospitalisation data for mental disorders among Māori shows no decrease over recent years, and there are marked disparities with non-Māori.

At a community or population level, the prevalence of mental disorder among young Māori is high. Māori experience the highest levels of mental disorder for overall disorder and for disorder groups.

Furthermore 3 in 5 Māori are predicted to experience a mental illness sometime in their lifetime (59.9%). This is higher than the lifetime prevalence of Māori who have experienced a mental illness sometime in their lifetime to date (50.7%), and indicates that future predicted Māori mental health need is even greater than the current level of need.

With regards to risk of developing any disorder over their lifetime, Māori are 1.7 times more likely to develop a disorder than non-Māori/non-Pacific people.

While findings reinforce concerns about young Māori (aged 16 to 24 years), Māori adults aged 25 to 44 years also have high mental health needs.

Anxiety disorders were common and have had been given little attention as important mental health issues for Māori in the past.

Some disorders, such as post-traumatic stress disorder, had high levels of severity and impact. Mood disorders were also common and have considerable impact.

There is a high association between depression and suicide, and mood disorders also have high levels of severity.

In relation to substance disorders, if Māori were to have the same age structure and level of socioeconomic privilege, the rates for Māori when compared with ‘Others’ (refers to non-Māori/ non-Pacific people throughout this report) would still be 1.2 times higher for any 12-month disorder and 2.0 times higher.

Consideration is needed for mental

health needs within a population perspective alongside

specific mental health conditions,

how disorders coincide with each other, and the best

ways of prevention, early

detection, management, and

treatment.

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Given that half of the Māori

population was aged under 23 years in 2006, significant

investment is needed in Māori

child and adolescent mental health and

broader health services to reduce the prevelance and

impact of mental health needs in adulthood and

attain health equity between Māori and

non-Māori.

The early age of onset of many of these disorders

among Māori suggests

preventive efforts and early detection

need to focus on the young; however,

efforts and early detection also need

to continue into adult ages.

Substance-use disorders are also common and have an onset during adolescence for many. Dependence disorders (i.e., addiction) have high impacts across a range of aspects of the lives of Māori with these disorders. Comorbidity within substance disorders was also common.

While eating disorders were found to be less common overall, they still occur at highest rates among Māori rather than non-Māori in this survey.

Implications for Services and Policy

The implications for policy indicate the need to focus on prioritising Māori across both the range of disorders and overall. In addition, two areas of increased relative needs for Māori were in 12-month serious disorder (Māori rates over 2 times higher) and substance-use disorders (Māori rates 3 times higher).

The adjusted figures highlight that societal inequalities in socioeconomic positions are contributing to Māori mental health needs. This provides powerful evidence for the need to support broader policies that aim to reduce societal inequalities for Māori in social and economic and educational outcomes. It is clear that these broader inequalities impact on Māori mental health.

Initiatives to reduce inequalities in terms of educational outcomes for Māori and reduce physical health inequalities between Māori and non-Māori will bring benefits to reducing inequalities for mental health problems.

These findings also strongly support that while secondary care services have a very important role to play, there is also an urgent need to understand why Māori rates of hospitalisation are so high for schizophrenia and bipolar disorder as well as issues such as access to early intervention services, child and youth services, community mental health care, and alcohol and drug services.

Furthermore, how accessible and effective primary care and psychological services are for Māori who have anxiety or eating disorders alongside mood and alcohol and drug disorders, needs further investigation.

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No single disorder group stands out as creating the greatest need among Māori,

nor is one of the greatest priority.

All groups emerge as having important

impacts on the mental health of Māori as a

population, and on individuals and

whānau.

Mental health promotion and public health approaches to mental health are warranted across a range of strategies and initiatives, including policy, environment, community, iwi, cultural development, the health sector and other sector orientation, and support for enhancing and building on mental health knowledge, awareness and skills at all levels. Here too, the need to identify and address the determinants of mental health and disparities is clearly important.

All of the findings reinforce the importance of the role of policy and strategy to maintain a focus on reducing inequalities, and prioritising strategies and initiatives that will lead to Māori mental health gain, now and into the future.

Introduction

Māori mental health is an area of high priority within both Māori health and mental health.1-3 There is a need for robust data describing Māori mental health and Māori contact with services that can be used as part of the foundation for planning effective responses to Māori mental health needs. Based on epidemiological research and data, this Māori Mental Health Needs Profile describes what is known about the prevalence and pattern of mental disorders among Māori together with what is known about Māori pathways to and through health care for mental health needs.

A specific action of Te Kōkiri 1 and Te Puāwaiwhero - The Second Māori Mental Health National Strategic Framework 2008-2015 is that District Health Boards (DHBs) will take action to provide services based on Māori population mental health need. The specific action requires that DHBs can demonstrate knowledge of Māori population need through, e.g., health needs assessment and use of Te Rau Hinengaro - The New Zealand Mental Health Survey, and plan and deliver services for Māori accordingly.

1 Minister of Health. 2006. Te Kōkiri: The Mental Health and Addiction Action Plan 2006–2015. Wellington: Ministry of Health. http://www.moh.govt.nz/moh.nsf/pagesmh/5014/$File/te-kokiri -mental-health-addicition-action-plan-2006-2015.pdf

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Understanding Māori population

demographic profiles within and between

regions is important to help services identify the nature and level

of Māori mental health need in each area.

However no matter where Māori live and what the population density of Māori is (i.e., the % of the population who is

Māori) there will be a need to address Māori

mental health

This report summarises the key findings of the full Māori Mental Health Profile Needs Report (available at www.matatini.co.nz). The report informs Māori mental health policy and strategy within the Ministry of Health and planning for Māori mental health workforce and service development, mental health service policy and strategy alongside public health approaches to Māori mental health promotion.

The Māori Mental Health Needs Profile:

1. Background factors relevant to understanding Māori mental health needs including demographic and socioeconomic determinants alongside Māori health status

2. Describes a profile of Māori mental health needs

3. Describes patterns of contact with health services for mental health needs, and

4. Summarises findings and key priority areas.

This Review provides a picture of what Māori mental health may look like from an epidemiology perspective. It does not answer questions relative to ‘why does the picture look like this’ or ‘what is the best way of addressing the need’.

The Review draws heavily from Te Rau Hinengaro, the New Zealand Mental Health Survey. Te Rau Hinengaro was carried out in 2003/2004 and provides up-to-date information on the prevalence of more common mental illness among Māori at a population level. This differs from previous data that often stemmed from service use information, i.e., was focussed mainly on consumers of services. Thus Te Rau Hinengaro adds the population perspective for Māori over the age of 16.

More details on the sources of data, scope and limitations of the Review are outlined in Appendix A.

Given that mental disorders also contribute to

socioeconomic disadvantage, the

implications of Māori socioeconomic

positions and how to meet the needs

of Māori with mental health problems are

important

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The Sociodemographic Context to Māori Mental Health Need

Understanding Māori population demographics is important for determining Māori mental health need from a population perspective. In addition, the status of Māori physical health also has implications for mental health19 and there is a relationship between physical health and mental health and wellbeing.

Age Structure

Māori are a relatively young population, with 1 in 3 under the age of 15 years and 1 in 2 Māori were under 22.7 years in 2006. As a population with a relatively young age-structure Māori patterns of mental health needs differ from those of the total population and from non-Māori (which reflects an older population structure).

Given that half of the Māori population was aged under 23 years in 2006, significant investment is needed in Māori child and adolescent mental health and broader health services to reduce the prevelance and impact of mental health needs in adulthood and attain health equity between Māori and non-Māori.

Socioeconomic Position

Socioeconomic position is a determinant of mental health and Māori are disproportionately represented among low socioeconomic groups with 2/3rds of Māori living in deprivation deciles 7 to 10. One in every 3 to 4 people in deciles 9 and 10 is Māori. Māori therefore bear a disproportionate burden of risk for mental ill health issues as a result of socioeconomic risk.

Furthermore, the socioeconomic profile of Māori contributes to the increased risk for mental health problems and increased barriers for access to services, e.g., cost as a barrier both to service access and use and to specific services such as counselling and psychological services.

Holistic approaches to

health and mental health, including

mental health needs for Māori

with physical health disorders

and physical health needs for

Māori with mental health disorders,

will contribute to broader Māori health gains and better outcomes.

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While Māori feature less in the

65+ age group, compared to non-Māori, the mental

health needs of this small

but significant population group

is important.

Locality and Region

While the Māori population is spread across Aotearoa and Te Waipounamu, there is a variation in terms of where Māori live by region and the proportion of each region that is Māori. Māori will have mental health needs whether living in areas of high or low Māori population density, and sometimes areas with low population density, e.g., Canterbury, have high Māori population numbers.

Table 2.3 on the following page shows the number of Māori in each region, the proportion (%) in each region who are Māori, and the percentage of those under 30 years in each region who are Māori under 30.

The table shows:

• Highest populations (numbers) of Māori are in Auckland, Waikato, Bay of Plenty, Wellington, Northland, Manawatu/ Wanganui and Canterbury. The Māori population numbers range from 137,133 in Auckland to 2916 on the West Coast.

• The percentage of a region’s population that is Māori ranges from Gisborne (44.4%) to Otago (6.3%). Māori as a percentage of population is greatest in Gisborne, Northland, Bay of Plenty, Hawke’s Bay, Waikato, Manawatu/Wanganui, Taranaki, Wellington, and Southland.

• The percentage of a region’s population under 30 years that is Māori (aged < 30 years) ranges from over 1 in 2 (56.4%) in Gisborne to 1 in 10 (9.8%) in Otago. Māori (aged <30 years) as a percentage of the population under 30 years is greatest in Gisborne, Northland, Bay of Plenty, Hawke’s Bay, Waikato, Manawatu/Wanganui, Taranaki, Wellington, and Southland.

These findings emphasise the need for mental health and Māori mental health in primary care and

the likely high levels of unmet

needs for mental health problems

among Māori.

Findings from Te Rau Hinengaro

reinforce concerns that not only are mental health problems common among

Māori, particularly younger Māori, they are also

having an impact in terms of the severity and

impairment of functioning and are likely to be

important causes of disability

among Māori.

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Table (2.3): Māori population by region (2006)

Area Number of Māori

Māori as a % of the regions total population

Māori under 30 years %

Northland 43536 29.3% 42.4%Auckland 137133 10.5% 14.5%Waikato 76572 20.0% 28.4%Bay of Plenty 67662 26.3% 38.4%Gisborne 19761 44.4% 56.4%Hawke's Bay 33561 22.7% 33.3%Taranaki 15798 15.2% 23.1%Manawatu-Wanganui

42279 19.0% 28.0%

Wellington 55431 12.3% 17.8%Tasman 3066 6.9% 11.3%Nelson 3615 8.4% 14.1%Marlborough 4281 10.1% 16.2%West Coast 2916 9.3% 15.4%Canterbury 36666 7.0% 11.0%Otago 12273 6.3% 9.8%Southland 10422 11.5% 17.7%

Māori Health Status

Health indicators show Māori are at increased risk of premature mortality, and hospitalisation and mortality due to conditions that are amenable to prevention and treatment. Disparities with non-Māori are evident overall and across age-groups and causes. Māori are disadvantaged relative to non-Māori across a range of health risks and indicators.

Prevalence and Impact of Mental Disorders in Māori

Research findings show mental health disorders are important contributors to poor health among Māori. In the Christchurch Health and Development Study12 over half Māori Rangatahi aged 18 years had at least one mental health disorder from the age of 16.

Disorders are more common among Māori women and both younger adults and rangatahi and those with the least education and lowest household incomes relative to increased poverty, high levels of unemployment, low access to services.

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In the New Zealand Health Survey 2.2% of Māori men and 1.8% of Māori women aged 15 years and older reported a known chronic mental illness. The New Zealand Prisons Survey carried out in 1997/1998 highlights the high rate of mental disorder among Māori prisoners both male and female. This reinforces concerns regarding rangatahi mental health and Māori in high need areas i.e., prisons.

Te Rau Hinengaro revealed that Māori living in secondary areas (i.e., population from 10,000 to under 30,000) had lower prevalence of 12-month disorders (21.9%), and those in rural areas had the lowest prevalence of serious disorders (6.3%). Although there are variations between areas, these are not statistically significantly different for either 12-month disorder or serious disorder.

Some variation between regions was also found. The highest prevalence of both any 12-month disorder and any serious disorder was in Māori in the South region (32.2% and 9.5%). Again, differences between regions was not statistically significant.

Table (3.5): 12-month prevalence of mental disorders in Māori by rural / urban and region (Te Rau Hinengaro)

Locality measures

12-month prevalence of any disorder %

(95% Confidence interval)

12-month prevalence of serious disorder %

(95% Confidence Interval)

Urbanicity* Main 29.8 (26.4, 33.4) 9.0 (7.4, 10.8)Secondary 21.9 (14.6, 30.7) 8.5 (4.1, 15.0)Minor 33.6 (25.3, 43.0) 9.5 (6.0, 14.1)Other (rural) 28.0 (20.6, 37.0) 6.3 (3.1, 11.0)Region** North 31.4 (26.3, 36.8) 8.1 (6.2, 10.5)Midland 29.7 (25.0, 35.0) 9.3 (7.2, 11.9)Central 24.2 (19.4, 29.8) 8.3 (5.5, 11.8)South 32.2 (24.2, 41.4) 9.5 (5.7, 14.7)

These tables confirm that Māori mental health need and health inequalities exist throughout New Zealand and accross all DHB regions.

* Main – minimum 30,000. Secondary 10,000–29,999. Minor 1,000–9,999. Other Rural (i.e., smaller that 1,000)

** Old RHA regions North – Northland, Waitemata, Auckland, Counties-Manukau. Midland- Waikato, Bay of Plenty, Tairawhiti, Lakes and Taranaki. Central – Hawkes Bay, Whanganui, Manawatu, Whanganui, Wairarapa, Hutt, Capital and Coast. South – all South Island areas.

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Prevalence and Impact of Mental Disorders in Māori

Research findings show mental health disorders are important contributors to poor health among Māori. In the Christchurch Health and Development Study over half Māori rangatahi aged 18 years had at least one mental health disorder from the age of 16.

Disorders are more common among Māori women and both younger adults and rangatahi and those with the least education and lowest household incomes relative to increased poverty, high levels of unemployment, low access to services.

In the New Zealand Health Survey 2.2% of Māori men and 1.8% of Māori women aged 15 years and older reported a known chronic mental illness. The New Zealand Prisons Survey carried out in 1997/1998 highlights the high rate of mental disorder among Māori prisoners both male and female. This reinforces concerns regarding rangatahi mental health and Māori in high need areas i.e., prisons.

Key Te Rau Hinengaro findings include:In their lives before being interviewed (lifetime prevalence):1 in 2 Māori had experienced at least one mental disorder (50.7%)1 in every 3–4 Māori had experienced 2 or more mental disorders (30.9%)In the previous 12 months:1 in 3–4 Māori had at least one mental disorder (29.3%)1 in 7–8 Māori had experienced 2 or more disorders (13.1%)1 in 12 Māori had a serious mental disorder (8.4%)In the past 30 days:1 in 6 Māori had experienced at least one mental disorder (18.3%)1 in 18 Māori had experienced two or more disorders (5.6%).

Te Rau Hinengaro found important differences in the prevalence of disorders by gender, age, measures of socio-economic position, geographic locality, and type.

For 12-month disorderIn the past 12 months, at least one mental disorder had occurred in:• 1 in 3 Māori women (33.6%), 1 in 4 Māori men (24.8%)• 1 in 3 Māori aged 16 to 24 years (33.2%), 1 in 3 aged 25 to 44 years (32.9%) , 1 in 4 aged 45 to 64 years (23.7%), and 1 in 12 aged 65 years and over (7.9%)

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• 1 in 4 Māori with school AND post-school qualifications (25%), 1 in 3 Māori with no qualifications (34.2%) • 2 in 5 Māori in households on lowest incomes(40.9%), 1 in 5 Māori in highest income quartile (19.7%). 12-month serious disorderTe Rau Hinengaro found that 12-month serious disorder was also common among Māori, with 8.4% of Māori with a 12-month disorder. As with the prevalence of any 12-month disorder, the prevalence of any 12-month serious disorder also varied by socio-demographic factors.

A 12-month serious disorder was found in: • Over 1 in 10 (11.3%) Māori women, and 1 in 18 (5.7%) Māori men • 1 in 11 (8.6%) Māori aged 16 to 24 years, 1 in 10 (10.2%) aged 25 to 44 years, 1 in 13 (7.4%) aged 45 to 64 years, 1 in 56 (1.8%) Māori aged 65 years and over• 1 in 9 (11.7%) Māori with no qualification, and 1 in 14 (6.9%) Māori with school AND post school qualifications.• 1 in 7 (13.5%) in lowest income households had serious disorder compared with 1 in 20 (4.9%) in highest income households.

There were no significant differences between the prevalence of serious disorder by urbanicity or region.

Again, serious disorder is most common in Māori women, among both young adults and rangatahi, and among those in lowest income households.

Prevalence of Specific Disorders

Research findings (detailed further in full report from page 33) reflect that Māori mental health needs for the more common mental health disorders (of anxiety, mood, substance and eating disorders) are contributed to by high prevalence and the high impact of disorders.

Although these mental health problems and disorders are not common to Māori alone, they do have a considerable impact

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on the lives of Māori. Among Māori with at least one 12-month disorder (shown as Any Disorder in the full technical report on page 37), most were either serious (almost 1 in 3, 29.6%) or moderate (1 in 2.3, 42.6%).

Māori women have a greater burden of mental disorder due to anxiety, mood, and eating disorders. Māori women were also found to have a higher rate of post-natal depression (14.3%) than non-Māori women (6.1%). However, Māori men have increased substance use disorders. For overall lifetime prevalence there is a small difference only by gender.

Comorbidity

The pattern and extent of comorbidity found among Māori in Te Rau Hinengaro highlights that the mental health needs of many Māori individuals are complex, with often multiple, differing mental health problems occurring.

Comorbidity within substance disorders was very common, and clearly many Māori with a drug disorder (primarily marijuana dependence or abuse) also had an alcohol disorder, while around 1 in 3 Māori with an alcohol disorder, also had a drug disorder.

Key findings included:• Considerable overlap between alcohol disorders and drug disorders • Of Māori with any alcohol use disorder, 1 in 3 (31.2%) also had a drug use disorder• Over 1 in 2 (58.3%) Māori with a drug use disorder also had an alcohol disorder • There were high prevalences of dependence disorders among those with abuse disorders, with almost half (46.8%) those Māori with alcohol abuse, also having alcohol dependence, and almost half (45.1%) of those Māori with drug abuse, also having drug dependence.

The high levels and patterns of comorbidity reinforce the need for services and training of primary care and mental health services (total population and Kaupapa Māori) in detecting and effectively managing comorbidity among mental disorders. The needs described provide an imperative for services to have the capacity to identify and manage appropriately comorbidity and

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The pattern and extent of

comorbidity found among Māori in

Te Rau Hinengaro highlights that

the mental health needs of many

Māori individuals are complex with

often multiple, differing mental health problems

occurring.

It is important that those developing

services and working in services are

aware of the need for comprehensive

assessment and appropriate management for multiple mental

health problems.

issues of dual diagnosis among Māori.

It is important that those developing services and working in services are aware of the need for comprehensive assessment and appropriate management for multiple mental health problems.

Anxiety Disorders

• Anxiety disorders were the most common disorders overall among Māori and almost 4 in every 10 Māori (37.3%) will experience an anxiety disorder at some time in their lives. The lifetime risk of specific disorders is highest for specific phobia 16.6%), followed by post-traumatic stress disorder 13.1%)

• In the previous 12 months 1 in 5 (19.4%) Māori will have had at least one anxiety disorder and some will experience more than one

• 3 in 10 (33.3%) Māori with anxiety disorders are considered to have a serious disorder, and 4 in 10 (40.9%) a moderate disorder

• At the time of interview, 1 in 3 (36.7%) Māori women and 1 in 4 (25.0%) Māori men had already experienced at least one anxiety disorder in their lives

• While anxiety disorders are acknowledged to have a very early onset in age overall, this varies between the specific disorders. Overall, half of those Māori with an anxiety disorder will have developed that disorder by the age of 11.

• Among the anxiety disorders post-traumatic stress disorder had the highest impact as measured by interference with life.

Mood Disorders

• Mood disorders affect many Māori, with 1 in every 3 Māori (36.1%) having a mood disorder at some time in their lives, 1 in 4 (24.3%) Māori already having had a mood disorder in their life to date, and 1 in 9 (11.4%) having had a mood disorder in the previous 12 months.

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• Major depression was the most common mood disorder among Māori, almost 1 in 3 (29.8%) Māori will develop a major depression at some point in their lives, and 1 in 14 (6.9%) Māori had a major depression in the past 12 months

• Bipolar disorder was more common than expected, and Te Rau Hinengaro estimated that 1 in 9 (11.0%) Māori were at risk of developing a bipolar disorder at some time in their lives

• Mood disorders had their onset across a great range of ages, and half of Māori with major depression reported its onset at 34 years or younger, while half of Māori with bipolar disorder reported its onset by age 25 • Mood disorders were found to have a significant impact on Māori with disorders. Mood disorders in most Māori were considered serious (51.4%) or moderate (37.4%) in severity.

Substance Use Disorders

Substance use disorders affect many Māori, with 1 in 4 experiencing such disorder in their lives before interview, and 1 in 11 in the past 12 months. Overall, almost 1 in 3 Māori will develop a substance use disorder over their lifetimes (up until age 75).

Drug disorders within Te Rau Hinengaro were primarily marijuana disorders, and these findings highlight an ongoing need to ensure services cater for the needs of those Māori with marijuana abuse and dependence.

When considering the implications of the high prevalence of substance use disorders, it is important to note that alcohol and drug abuse and dependence impact not only on those suffering from the disorder but also on the health, wellbeing and social outcomes of others, including whānau and children. This impact can be experienced through contributions to domestic violence, family relationship disruption, economic adversity, impact on children, and contribution to other forms of injury (e.g., accidents). Thus, reduction in alcohol and drug-related abuse and dependence and access to effective services to address these disorders in Māori have the potential to reduce mental health and wider health and social impacts in the future.

Māori experience the highest levels of mental disorder for overall disorder

and for disorder groups. Māori also

were more likely to have a serious mental disorder when compared

with ‘Other’.

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The age of onset for substance disorder findings indicate that half of all Māori with substance disorders had the onset of their disorder as rangatahi (i.e. around ages 18 or 19 years). This has implications for the likely high level of need among young Māori with substance use disorders as well as highlighting the need for mental health promotion strategies to prevent and address the development of substance use issues in young Māori alongside the broader contexts associated with the development of substance use disorders.

Ethnic Difference in Mental Disorders

Findings within Te Rau Hinengaro showed Māori experienced the highest levels of mental disorder for overall disorder and for disorder groups. Māori also were more likely to have a serious mental disorder when compared with ‘Other’.

For 12 month disorders, when compared with all ‘Other’ (non-Māori/non-Pacific), Māori were:• 1.5 times more likely to have at least one 12-month disorder (29.3% vs 19.3%)• 2.1 time more likely to have 12-month serious disorder (8.4% vs 4.0%)• 1.4 times more likely to have a 12-month anxiety disorder (19.4% vs 14.1%)• 1.6 times more likely to have a 12-month mood disorder (11.6% vs 7.1%)• 3.3 times more likely to have a 12-month substance disorder (9.1% vs 2.7%).

Sex and Age

For sex and age, when compared with ‘Other’ (non-Māori/non-Pacific) counterparts, the relative risk of 12-month disorder for Māori was: • For Māori males: 1.6 times higher (than non-Māori/non- Pacific)• For Māori females: 1.5 times higher• For 16 to 24 year-old Māori: 1.2 times higher• For 25 to 44 year-old Māori: 1.4 times higher• For 45 to 64 year-old Māori: 1.4 times higher

Initiatives to reduce

inequalities in terms of educational

outcomes for Māori and reduce physical health

inequalities between Māori and non-Māori

will bring benefits to reducing

inequalities for mental health

problems.

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• For Māori 65 years and over: 1.1 times higher.

Socioeconomic Indicators

Educational qualificationsThe relative risks of having a 12-month disorder for Māori when compared with ‘Other’ are:

• No qualifications: 1.8 times• School or post-school only: 1.3 times• Both school and post-school:1.4 times.

Equivalised household incomeThe relative risk of having a 12-month disorder for Māori when compared with ‘Other’ is:

• Under half of median: 1.7 times• Half median to median: 1.4 times• Median to one-and–a-half times median: 1.2 times• One-and-a-half times median and over: 1.2 times.

These findings highlight that within each correlate. i.e., age, sex, education and equivalised household income, Māori rates of mental disorder are higher.

In particular, for high levels of socioeconomic need, Māori with no qualifications are 1.8 times more likely to have a mental disorder than non-Māori with no qualifications. Māori with the lowest incomes (i.e., equivalised household income less that half of median) were 1.7 times more likely to have at least one disorder when compared with non-Māori on the same income.

Adjusted Findings

Adjustment for age, sex, equivalised household income and education showed what prevalences would look like if Māori had an age/sex distribution and a socioeconomic profile that were like the total population, i.e., was older overall, and was more socioeconomically advantaged. If Māori were older overall and more advantaged, prevalence differences between Māori and ‘Other’ would be reduced; they would not, however, be eliminated.

If Māori were to have the same age structure and level of socioeconomic privilege, the rates

for Māori when compared with

‘Others’, would still be 1.2 times higher for any 12-month

disorder and 2.0 times higher for substance

disorders.

20

If Māori were to have the same age structure and level of socioeconomic privilege, the rates for Māori when compared with ‘Other’, would be:

1.2 times higher for any 12-month disorder1.4 times higher for 12 month serious disorder1.1 times higher for 12-month anxiety disorders1.2 times higher for 12-month mood disorders2.0 times higher for substance disorders.

The adjusted figures highlight that mental health promotion and prevention should ensure there is support for strategies to reduce relative poverty and socioeconomic disadvantage disproportionately impacting on Māori.

If Māori were to have the same age structure and level of socioeconomic privilege, the rates for Māori when compared with ‘Others’, Māori would still be 1.2 times higher for any 12-month disorder and 2.0 times higher for substance disorders.

Initiatives to reduce inequalities in terms of educational outcomes for Māori and reduce physical health inequalities between Māori and non-Māori will have be a benefit to reduce inequalities for mental health problems.

Māori Mental Health Pathways to Care

Community and Primary Care

The New Zealand Health Surveys37 found that access to primary care generally is likely to be an important barrier for primary care’s capacity to meet the needs of Māori with mental health problems. Almost 1 in 5 (18.9%) Māori reported not seeing a GP when they needed to in 2002/2003. In addition, Māori were 1.6 times more likely to report not seeing a GP when there was need when compared with non-Māori (12.0%). Cost appeared as the single most barrier.

With regards to mental health, barriers to primary care in general will also impact on the ability to care for Māori with mental health needs. Overall these findings are consistent with concerns about access for Māori to health services and to primary care and as well as mental health.

Less than 1 in 3 Māori with a mental health need had any contact with services for

mental health needs and most

Māori with serious or moderate

disorders had no contact with any service for their mental health

needs.

21

While mental health problems are an important cause of health and non-health service contact among Māori, service contact findings reveal significant levels of unmet need among Māori with mental health needs.

Less than 1 in 3 Māori with a mental health need had any contact with services for mental health needs and most Māori with serious or moderate disorders had no contact with any service for their mental health needs.

Overall, 1 in every 7.5 (13.5%) Māori had some kind of contact with services for mental health needs in the 12-months before the survey, with just over 1 in 9 (11.7%) seeing some sort of health care provider for mental health reasons. GPs were the group most seen, with 1 in 12 (8.1%) Māori adults aged 16 and over seeing a GP for mental health reasons in the previous 12 months. Mental health practitioners specifically were seen by 1 in 17 (6.0%) Māori.

General practice services were the service most seen by Māori with mental health needs, and 1 in 5 (20.4%) Māori with a 12-month disorder saw a GP, and 1 in 7 (14.6%) saw a mental health practitioner in the previous 12 months.

The amount of health service contact varied between disorder groups, with health service contact greatest among Māori with mood disorders and lowest among those with substance disorders. However, most Māori in each of the disorder groups had no contact with services. Furthermore most Māori with serious or moderate disorders had no contact with any service for their mental health needs.

Satisfaction with care was favourable among Māori, particularly for non-medical services. The Te Rau Hinengaro health services contact data can only report on which sectors were seen and cannot report on the nature or effectiveness of the treatment received; however, satisfaction with care within the service seen was generally high, with non-health care services providing the greatest degree of satisfaction overall.

To achieve good health outcomes for Māori there is a need for much more information about both the nature and impact of barriers to access of services and about the effectiveness of services.

To achieve good health outcomes for Māori there is a need for much more information

about both the nature and impact

of barriers to access of services

and about the effectiveness of

services.

22

Secondary Care

Māori have different patterns of use of secondary care services in general (The New Zealand Health Survey). However Mental Health Information National Collection (MHINC) now provides new information on Māori use of DHB secondary care services. Until recently there has been limited information on Māori use of non-inpatient parts of the mental health services. In providing information on clients, as well as episodes of care across the spectrum of DHB services, MHINC provides new knowledge on where Māori are being seen within secondary care services.

There are high numbers and rates of Māori who are clients of mental health services; with rates highest among Māori males in the years between 20 and 40, where around 1 in 20 Māori men are mental health service clients.

Findings from MHINC for 2004 show that over 15,000 Māori (1 in every 40 Māori) were seen as clients of mental health services in that year (1 in 36 Māori males and 1 in 46 Māori females).

The relative risk of being a client of mental health services in 2004 was 1.2 times higher for Māori than for non-Māori/non-Pacific people. Māori males aged between 20 and 45 years had the highest rates of mental health service use, with around 5,000 per 100,000 or 1 in 20 Māori males in these age-groups being clients of mental health services in 2004.

The high number of Māori who are clients of mental health services further reinforces the necessity to prioritise Māori mental health needs.

An important finding regarding youth is that Māori women under 20 years and Māori men under 15 years are less likely than non-Māori/non-Pacific people to be clients of mental health services. Given disparities in suicide rates in these age groups this finding may indicate unmet needs and access difficulties for Māori to child and youth services.

There is an average of over 4,000 hospital discharges per

year of Māori with mental disorders,

i.e., at least 1 discharge for

every 150 Māori in the population.

Some individual Māori will have

had more than one hospitalisation in a 12-month period (hospitalisation is

different from clients).

23

Hospitalisation for Mental Disorders

Hospitalisation for mental disorder remains an important indicator of Māori mental health needs. Patterns and rates of hospitalisation for psychiatric disorders have been important indicators of Māori mental health need reflecting serious mental illness.

Past analyses for the 1980s and 1990s highlighted increasing concern about growing rates of hospitalisation for mental disorders among Māori particularly for substance disorders and psychoses. Pathways into services and kinds of services seen have also been concerning, with Māori rates of hospitalisation in secure or forensic services particularly high.

There is an average of over 4,000 hospital discharges per year of Māori with mental disorders, i.e. at least 1 discharge for every 150 Māori in the population. Some individual Māori will have had more than one hospitalisation in a 12-month period (hospitalisation is different from clients).

Hauora Māori Standards of Health IV (capturing the years 2003–2005, similar to the time period when Te Rau Hinengaro was collected) show that Māori mental disorder hospitalisations were high, with an average of over 4,000 hospitalisations for mental disorders per year with a higher proportion among Māori men (54.5% vs 45.5%). The overall hospitalisation rate (658.1 hospitalisation for every 100,000 Māori) is the equivalent of 1 hospital discharge for every 150 Māori.

Māori aged 25–44 years have the highest hospitalisation rates, followed by those aged 16–24. Strikingly, over half (52.9%) of hospitalisations in Māori occurred in 25 to 44 year-olds, and around 1 in 4 (24.7%) hospitalisations were in 15 to 24 year-olds. The age-specific rate was highest in Māori 25 to 44 years, with over 1.2 hospitalisations for every 100 Māori (1,241/100,000) in this age group. This was followed by Māori aged 15 to 24 years.

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Rates of hospitalisation

for schizophrenia among Māori are alarming. Data analysis shows very high rates among Māori of hospitalisation

for schizophrenia, which makes up almost half (47.9%) of all

mental disorder hospitalisations among Māori.

Rates of hospitalisation for schizophrenia among Māori are alarming. Data analysis shows very high rates among Māori of hospitalisation for schizophrenia, which makes up almost half (47.9%) of all mental disorder hospitalisations among Māori.

The age–sex standardised rate of hospitalisation due to schizophrenia is 3 times higher than any other single cause. Manic episodes and bipolar disorder are the next leading causes of hospitalisation among Māori; 1 in 6 (16.1%) hospitalisations in Māori are for these diagnoses. Thus schizophrenia and related conditions, and bipolar disorder and mania must continue to be considered areas of high priority for Māori.

With regards to trends across time in each year from 2000 to 2005, age–sex standardised rates of hospitalisation have been considerably higher among Māori when compared with non-Māori, with little change in rates over time or in disparities between Māori and non-Māori and no evidence that disparities are reducing.

There is considerable disparity in hospitalisation rates for mental disorder between Māori and non-Māori overall; particularly among Māori men (2.2 times higher than non-Māori), and also among Māori women (1.5 times higher).

Other findings include:• Overall, Māori males had the highest rates of hospitalisations followed by Māori females

• Māori male rates were 2.2 times those of non-Māori males, and Māori female rates were 1.5 times higher than those of non-Māori females. The age group of greatest disparity was 25 to 44 years, with Māori rates double those of non-Māori. Māori rates of hospitalisation were higher than non-Māori for schizophrenia (3.5 times), bipolar disorder (2.4 times), ‘Other mood’ (i.e. not depression) (1.4 times), organic disorders (1.3 times), substance disorders (1.3 times), and anxiety disorders (1.2 times higher). Non-Māori rates were greater than Māori for: eating disorders, personality disorders, intellectual disability, and depressive disorders.

Even when age and sex are

standardised, Māori are 3.5

times more likely to be hospitalised for schizophrenia than non-Māori.

25

Rates for Māori aged 15 to 24

years were 90% higher than for

non-Māori in this age group, and rates for Māori aged 45 to 64

years were 60% higher.

It is interesting to see that for depressive disorders and eating disorders, rates of hospitalisation for Māori are lower than for non-Māori, however Te Rau Hinengaro found higher rates of these disorders among Māori. The reasons for this are not clear and it could be speculated that this picture may reflect different patterns of access to services for depression at a primary care level, differences in diagnostic practices or different practice of referral to secondary care for depressive illness. This is an area where further research is needed.

These findings are concerning. Schizophrenia is clearly the leading cause for hospitalisation, and there is a 3.5 times greater rate of hospitalisation for schizophrenia among Māori than non-Māori and hospitalisation data highlight both high levels of need and disparities.

Summary of the Evidence and Conclusions

It is important that the demographic, socioeconomic and health status profile of Māori is considered when planning services to meet Māori mental health needs as across many domains Māori are disproportionately represented.

In 2006 Māori made up 14% of New Zealand’s population, 1 in every 7 persons is Māori and are over-represented in areas of socioeconomic disadvantage, among both those with low education and those with low incomes.

Health indicators show Māori are at increased risk of premature mortality, hospitalisation and mortality due to conditions that are amenable to prevention and health care treatment. There is known association between physical and mental health with both at increased risk.

Māori has a population with young age structure, with a high proportion in those years when mental disorders are first occurring; the impact of unmet mental health needs among young people will have a bigger impact on Māori.

These findings reinforce a need to continue to strive to ensure better

outcomes for Māori with serious

mental illness alongside more accessible and

effective primary care and mental health promotion and public health

approaches.

26

The prevalence of mental disorders among Māori is consistent across urbanicity and regions suggesting having a good understanding of the population in each area will help identify the nature and level of need.

Mental health promotion and prevention should ensure there is support for strategies to reduce relative poverty and socioeconomic disadvantage. Initiatives to reduce inequalities in terms of educational outcomes reduce physical health inequalities between Māori and non-Māori will therefore be beneficial in reducing inequalities for mental health problems.

Implications that emerge from this research include the need to consider overall mental health needs within a population perspective and also to increase the focus on understanding specific mental health conditions and the best ways of prevention, early detection, management and treatment.

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17. Baxter, J. (2007). Mental health: Psychiatric disorder and suicide. In B. Robson & R. Harris, R (Eds.). Hauora Māori standards of health IV: A study of the years 2003 to 2005 (pp. 121–140). Wellington: Te Ropu Rangahau Hauora a Eru Pomare, School of Medicine and Health Sciences, University of Otago, Wellington.18. New Zealand Health Information Service. (2007). Mental health service use in New Zealand 2004. Wellington: Ministry of Health.19. Scott, K. M., Oakley Browne, M. A., McGee, M. A., & Wells, J.E. (2006). Mental-physical comorbidity in Te Rau Hinengaro: The New Zealand Mental Health Survey. Australian and New Zealand Journal of Psychiatry, 40(10), 882–888.20. Ministry of Health. (2006). Tatau Kahukura: Māori health chart book. Public Health Intelligence Monitoring Report No. 5. Wellington: Ministry of Health.21. Ministry of Health. (2004). A portrait of health: Key results of the 2002/03 New Zealand Health Survey. Public Health Intelligence Occasional Bulletin No. 21. Wellington: Ministry of Health.22. Baxter, J., Kingi, T. K., Tapsell, R., Durie, M., & McGee, M.A. (2006). Prevalence of mental disorders among Māori in Te Rau Hinengaro: The New Zealand Mental Health Survey. Australian and New Zealand Journal of Psychiatry, 40(10). 914–923.23. Baxter, J., Kokaua, J., Wells, J. E., McGee, M. A., & Oakley Browne, M. A. (2006). Ethnic comparisons of the 12 month prevalence of mental disorders and treatment contact in Te Rau Hinengaro: the New Zealand Mental Health Survey. Australian and New Zealand Journal of Psychiatry, 40(10), 905–913.24. Wells, J. E., Browne, M. A., Scott, K. M., McGee, M. A., Baxter, J., & Kokaua, J. (2006). Prevalence, interference with life and severity of 12 month DSM-IV disorders in Te Rau Hinengaro: the New Zealand Mental Health Survey. Australian and New Zealand Journal of Psychiatry, 40(10). 845–854.25. Wells, J. E., Oakley Browne, M. A., Scott, K. M., McGee, M. A., Baxter, J., Kokaua, J., & Te Rau Hinengaro. (2006). The New Zealand Mental Health Survey: Overview of methods and findings. Australian and New Zealand Journal of Psychiatry, 40(10), 835–844.26. Foliaki, S. A., Kokaua, J., Schaaf, D., & Tukuitonga, C. (2006). Twelve- month and lifetime prevalences of mental disorders and treatment contact among Pacific people in Te Rau Hinengaro: the New Zealand Mental Health Survey. Australian and New Zealand Journal of Psychiatry, 40(10), 924–934.27. Beautrais, A. L., Wells, J. E., McGee, M. A., & Oakley Browne, M. A. (2006). Suicidal behaviour in Te Rau Hinengaro: The New Zealand Mental Health Survey. Australian and New Zealand Journal of Psychiatry, 40(10), 896–904.28. Oakley Browne, M. A., Wells, J. E., Scott, K.M., & McGee, M. A. (2006). Lifetime prevalence and projected lifetime risk of DSM-IV disorders in Te Rau Hinengaro: The New Zealand Mental Health Survey. Australian and New Zealand Journal of Psychiatry, 40(10),

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865–874.29. Baxter, J., Kingi, T. K., Tapsell, R., Durie, M. (2006). Māori. In M. A. Oakley Browne, J. E. Wells, & K. M. Scott(Eds.), Te Rau Hinengaro: The New Zealand Mental Health Survey (pp. 140–176). Wellington: Ministry of Health.30. Oakley Browne, M.. A., Wells, J. E., McGee, M.A. (2006). Twelve-month and lifetime health service use in Te Rau Hinengaro: The New Zealand Mental Health Survey. Australian and New Zealand Journal of Psychiatry, 40(10), 855–864.31. Scott, K. M., McGee, M. A., Oakley Browne, M. A., & Wells, J.E. (2006). Mental disorder comorbidity in Te Rau Hinengaro: The New Zealand Mental Health Survey. Australian and New Zealand Journal of Psychiatry, 40(10), 875-881.32. Scott, K. M., McGee, M. A., Wells, J.E., & Oakley Browne, M.A. (2006). Disability in Te Rau Hinengaro: The New Zealand Mental Health Survey. Australian and New Zealand Journal of Psychiatry, 40(10), 889–895.33. Brinded, P. M., Simpson, A. I., Laidlaw, T. M., Fairley, N., & Malcolm, F. (2001). Prevalence of psychiatric disorders in New Zealand prisons: a national study. Australian and New Zealand Journal of Psychiatry, 35(2), 166–173.34. Murchie, M. Rapuora. (1984). Health and Māori women. Wellington: Te Ropu Wahine Māori Toko I Te Ora.35. MaGPIe Research Group. (2003). The nature and prevalence of psychological problems in New Zealand primary healthcare: A report on Mental Health and General Practice Investigation (MaGPIe). New Zealand Medical Journal, , 116(1171), U379.36. MaGPIe Research Group. (2001). Psychological problems in New Zealand primary health care: A report on the pilot phase of the Mental Health and General Practice Investigation (MaGPIe). New Zealand Medical Journal, 114(1124), 13–6.37. Ministry of Health. (2006). A comparison of selected findings from the 1996/97 and 2002/03 New Zealand Health Surveys: Public health intelligence. Occasional Bulletin No. 33. Wellington: Ministry of Health.

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Acknowledgements

Many people and groups/organisations have been involved with this profile inclusive of those who have supported the writing, preparation, peer reviewers, researchers, commentators and organisations whose research and data analyses provided knowledge and context to this profile and summary both past and current.

Mason DurieMinistry of Health Population Health DirectorateMelanie SargentJesse KokauaJanice WilsonLorna DyallGeoff BridgemanProject teams from across Aotearoa/Te WaipounamuTe Ropu Rangahau Hauora a Eru PomareBridget RobsonGordon PurdieRicci HarrisResearch team of Te Rau HinengaroThe New Zealand Mental Health SurveyElisabeth WellsMark Oakley-BrowneKate ScottMagnus McGeeRees TapsellTe Kani KingiThe Māori Kaitiaki GroupTe Rau MatatiniTe Rau Matatini TrustMateroa MarSylvia van AltvorstKirsty Maxwell-CrawfordCathy Milne-Turner.

The sources and data have provided a wealth of new knowledge on Māori mental health.

31

Appendix ASources of Data

The following data sources were used:

• Māori population demographics are sourced from Statistics New Zealand based on New Zealand Census Figures for 2001 and 2006.

• The background review of previous analyses provided during each chapter focuses mainly on evidence for the 1980s and 1990s and is based on published reports and research including previous Hauora Māori Standards of Health 6, 10

and Ngā Ia O Te Oranga Hinengaro Māori, Trends in Māori Mental Health 1984-1993.8

• Community prevalence findings are taken from Te Rau Hinengaro, the New Zealand Mental Health Survey 11

undertaken in 2003/2004 in addition to other research.12–15

• Hospitalisation findings are sourced from analyses of National Minimum Data Set (NMDS) published data from 2002/2003 (overall discharges),16 from analyses of NMDS data presented in Hauora Māori Standards of Health IV (2007).17

• Health Sector Contact – involves description of findings from published MHINC data published for 2004.18 Further health sector contact information is included from new analyses of MHINC data undertaken for this report.

32

Scope and Limitations

The data is limited to epidemiological based data and does not include qualitative research, evaluations or other measures.

The frame of the analysis does not have a focus on mental health within an indigenous knowledge or matauranga Māori framework.

The main data and findings presented are recent data and research, although some past data is described briefly.

Many of the data described has already been published, rather than undertaking new analysis for this project review.

The use of routinely collected data sources such as: New Zealand Health Information Service, (NZHIS), hospitalisation and the Mental Health National Collection data (MHINC) 2004 means the quality of analysis if data is impacted on by any issues related to accuracy and consistency of data within these data sets in particular ethnicity data and accuracy of diagnosis that are assigned, coded may affect the quality of these data.

Data from Te Rau Hinengaro, the New Zealand Mental Health Survey 2003/2004 was collected from adults 16 years and over, therefore there is less recent population prevalence information on Māori tamariki and younger rangatahi.

33