By Dr Paul Brown, The Pierre Janet Centre, Melbourne.
In my sojourn as a locum psychiatrist in rural and remote Australia, I was astonished at the rate of diagnosis of schizophrenia in indigenous populations. That condition is characterised by, “abnormal social behaviour and failure to recognize what is real,” and with symptoms that include confused thinking, hallucinations, delusions, social withdrawal and emotional blunting. It is associated with increased rates of suicide and homicide. Schizophrenia is said to have been rare in the pre-colonial era. Today, in indigenous communities, mental disorder is still frequently identified as spiritual disorder. It is treated by traditional healers, often concurrently, alongside Western medical practitioners.
Today schizophrenia is said to be at least as common in Aborigines as in white Australians, if not more so. It and mental illness in general, is said to be under-estimated. A not insignificant proportion of psychosis is to be found in prisons. Indigenous people represent around one-quarter of Australia’s custodial population. In recent prison surveys of Aboriginal prisoners,   the 12-month prevalence of psychotic disorders was: men, 8%; and, women, 23%. The overall prevalence of mental disorder was: 73% among men and 86% among women. Non-psychotic conditions comprised: anxiety disorders (men, 20%; women, 51%); depressive disorders (men, 11%; women, 29%); and substance misuse disorders (men, 66%; women, 69%).
In no small part schizophrenia in Aborigines has been attributed to the post-colonial epidemic of substance abuse afflicting indigenous peoples. However, there are additional explanations for psychosis in Aboriginals, and alternative differential diagnoses. The most important of these is rarely considered, namely stress, and traumatic stress presenting, not as the present zeitgeist, post-traumatic stress disorder (itself of questionable validity), but as depressive psychosis in both its unipolar and bipolar forms. Stimulant abuse appears to be especially associated with the latter. Head injury also plays a part. More importantly, there is the metabolic syndrome, with the neuropsychiatric complications of diabetes, hypertension and heart disease.   
First I must say a few words about psychosis. It is not what it was! After a hundred years of occidental, scientific study, the professional psychiatric community became convinced of the stability of the three principal diagnoses of psychosis: organic, principally as dementia; schizophreniform; and, affective. Cracks then began to appear in the psychopathological edifice. Schizophrenia became clinically milder, and recrudescence was more prominently accompanied by affective disorder leading to an increased diagnosis of schizoaffective disorder. The latter was mostly attributed to increased, depressive affectivity in the context of a schizophreniform psychosis. But prior to that affectivity was a bed-rock of environmental, psychosocial stress sensitivity. Further, the alternative diagnosis of bipolar affective disorder (manic depression) was rarely considered in Aboriginal communities. There is no scientific literature on it!
Today, the stability of the psychosis triumvirate is increasingly questioned by the experts. Rather than discrete disease types, they are seen as the symptomatic (phenotypic) presentation of a very wide range of different organic, affective and schizophreniform pathophysiologies, and varying causal proportions of nature and nurture. Further, it is well accepted that psychosis in psychiatric illness is on a continuum with normality. Psychotic phenomena, including hallucinations and delusions, are prosaic phenomena. They can accompany the exhaustion of sleeplessness, the delirium of an ordinary influenza, and a blow to the head.
So, what is the true psychiatric situation in the aboriginal community? Hunter wrote, “Indigenous Australians have higher rates of serious mental disorders and of mental health problems associated with social disadvantage … compounded by narrowly focused and inadequate mental health services … with children being particularly vulnerable.” Primary prevention is in its infancy. It is mostly carried out by dedicated white Australians, without either special knowledge of Aboriginal culture, or of mental health, Aboriginal or otherwise.
Culturally sensitive community surveys of diagnosis and treatment of psychiatric illness are in their infancy. Methodologies of mental assessment suitable for Indigenous Australians are only just being developed for adults, and for children and youth. A review of eleven Indigenous community surveys found a higher prevalence of self-reported psychological distress. But the distress of Indigenous Australians is not necessarily expressed in the same way as in the non-Indigenous. A cross-cultural study of schizophrenia found that, at the very least, bizarre delusions, social deterioration, illness duration and organicity differentiated Aboriginal from non-Indigenous subjects.
A comprehensive overview of Indigenous health is provided on-line by Deakin University. Mental and behavioural disorders, and circulatory diseases, affect the community equally (5.7%). The only conditions that were more common, were: injury (including motor-vehicle accidents, assaults, self-inflicted harm, and falls) and poisoning (13.9%); pregnancy-related (12.6%); respiratory diseases (11.3%); and, digestive diseases (8.6%). Indigenous adults were almost 1½ times more likely to report experiencing at least one stressor than non-Indigenous people, and the stressors reported most frequently by Indigenous people were death of a family member or close friend (46%), serious illness or disability (31%), and inability to get a job (27%). Hospitalisation for substance abuse was 3 (female) to 4 (male) times higher for Indigenous people, and rates for schizophrenia were more than double that for non-Indigenous subjects. The Indigenous mortality due to suicide was 2- (female) to 5-times (male) higher than the non-Indigenous population, with high rates amongst youth. Socio-historical, causal factors have been cited.
My own impression is that schizophrenia is over-diagnosed and over-treated at the expense of the diagnosis of stress-induced conditions, and especially the whole range of unipolar and bipolar affective conditions. These include both stress- and non-stress induced forms, substance abuse related forms, and those due to metabolic disease and head injury. The treatment consequences are catastrophic. Sufferers from severe mood disorders are denied antidepressants, and mood stabilisers. Instead they receive antipsychotics which mask the affective symptomatology. Those with organic conditions are denied appropriate medical treatment and rehabilitation. Currently, there is a professional movement for early intervention in psychosis. It is contentious, because mis-diagnosis and over-treatment have fateful consequences. How much more so in Aboriginal populations at risk?!
Teasedale recently wrote, “Few data are available on how mainstream drug and alcohol services meet the needs of Aboriginal Australians. Youth are increasingly prone to polydrug abuse. Solvent inhalation is an especially deadly problem. Hunter surveyed alcohol and drug abuse in the Indigenous population of the Kimberleys. Knowledge of this topic is essential, not only in the treatment and prevention of substance abuse, but also in the management of psychosis, since this is often complicated by the use of drugs and alcohol. Hunter found that Aborigines in the Kimberley were less often problem drinkers than the general population, but drinkers were much more likely to drink hazardous amounts.
The pan-Australian split between psychiatric services, and treatment facilities for substance abuse, has been catastrophic. Substance abuse is under-diagnosed and under-treated in mental health facilities, and psychiatric disorder under-diagnosed and under-treated in substance abuse facilities. The net result has been a de-skilling of the whole field vis-à-vis substance abuse and mental illness. Nonetheless, screening tools are in the pipeline for measuring relationships between substance use and psychiatric symptoms in Indigenous Australians, including in prison populations. 
Once, psychiatric wards and hospitals were museums of madness. Symptoms and signs of mental illness were freely displayed. In the old world, the hoy polloy even came to observe the antics of the insane. The more ‘enlightened’ asylum administrations, most famously at Charenton, in France, even trained the inmates to put on pageants and shows. This was even the subject of a contemporary stage production. With the advent of psychotropic medications, a medical straightjacket was slowly but inexorably applied to the insane. The psychiatric potions were not curative. Rather they controlled symptoms, and perhaps facilitated natural recovery.
Today, psychiatric wards are mausoleums of madness. Dosages of psychotropic medications now far exceed those used by previous generations of psychiatrists. The risk of dangerous side-effects, such as tardive dyskinesia and the neuroleptic malignant syndrome, are frequently disregarded. Wards are now quiet places, and psychiatric patients, both Indigenous and non-Indigenous, are only transitorily out of control. They transition from what are called high dependency units to open wards. A generation ago, the latter were busy paces, where the medicated also had access to milieu therapies ranging from group therapy to occupational therapy, art therapy, and activity therapies. Today, these treatments have been phased out. Non-medical therapies are deemed costly and ineffective. The medical model, managerialism and fiscal restraint are regnant.
In mental health for Indigenous subjects, there is a great divide between social activists and the social sciences, and medical activists and the medial sciences. The report, Mental Health and Social and Emotional Wellbeing of Aboriginal and Torres Strait Islander Peoples, Families and Communities (2013), is unlikely to make a difference in the clinical field. Its approach and its vernacular, speak to Westernised, non-clinical conceptualisations. Further, true psychiatric research vis-à-vis the Indigenous populations has hardly reached the coal-face. Mental health clinicians remain far removed from the activists and researchers. A ground-roots movement is required, led by aboriginal psychiatrists and mental health workers,  and funded by the Aboriginal community. It must look after its own, in liaison with mainstream white Australian psychiatry and medicine. Only then will the superficial and often culturally inappropriate regimes characterised by paternalistic academic and professional styles, be forestalled.
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