Equity in Psychiatric Care? | Non-Fiction #1

What does equitable psychiatric care entail? 

Providing psychiatric care extends beyond improving accessibility of mental health services (Gunn and Flehr 2023). While the importance of improving accessibility to mental health professionals and support groups should not be understated (Berry et al. 2022), quality psychiatric care encompasses so much more. 

Psychiatric care should be patient-centered, ensuring that their individual needs are not only understood, but also key in driving their treatment plan (Kilbourne et al. 2018). Establishing a patient’s needs requires an understanding of their demographic factors, as their culture and rurality, for example, may be a continuous influence on their beliefs and values (Sharker et al. 2020; Mennies et al. 2020). Management and treatment plans should therefore be dynamic (Böhmer 2011; Arens et al. 2022), as a patient’s changing beliefs and values may affect their engagement with various treatment options (Eliacin et al. 2014), hence impacting their successful recovery. 

Equitable and quality psychiatric care entails:

1. Improving accessibility to mental health services

2. Understanding each individual’s needs and hence, understanding how a patient envisions their ideal recovery:

   1. Knowing patients’ values, and therefore tailoring a dynamic plan that coalesces their belief system with the best treatment 

   2. Acknowledging and understanding that demographic differences play a role in tailoring psychiatric care

Multiculturalism in Australia

Australia is home to many cultures, including Indigenous Australians and migrants from all over the world (ABS 2022). In this paper, the definition of cultural diversity is defined as diversity in ethnic origin or country of birth, which may give rise to linguistic and religious diversity (ABS 2022). 

Equity for Indigenous Australians 

Many Indigenous Australians are severely impacted by the Stolen Generations, a period in which thousands of Indigenous children were forcibly removed from their families by non-Indigenous members of society (AIATSIS n.d.). Identity loss and crises, breaks in spiritual and family ties are only some of the many pains that have been inflicted onto First Nations Peoples (Darwin et al. 2023). The compounding effect of trauma and discrimination across multiple generations has created an overwhelming gap between non-Indigenous Australians and Indigenous Australians: Indigenous Australians are more likely to suffer from adverse mental health outcomes, substance abuse and poor socioeconomic outcomes (Darwin et al. 2023). To close this gap, equality alone does not suffice (Closing the Gap n.d.). 

Equity is needed to provide quality psychiatric care for Indigenous Australians. In addition to the current standards for general mental healthcare (Victorian Government 2015), there should be a focus on bolstering a strong sense of identity, fostering a sense of belonging and re-instilling purpose (Darwin et al. 2023). This can involve increasing awareness of Aboriginal and Torres Strait Islander-specific mental health programs by ensuring Indigenous Australians are connected to their local Primary HealthNetwork (Australian Government 2024). On an institutional level, this can also include increasing Indigenous-led cultural activities (Black et al. 2024). 

In the consultation room, Indigenous Australians should be provided with culturally competent care by a healthcare professional who embraces clinical yarning: a two-way dialogue between patient and healthcare provider that allows for an informal exchange of stories pertinent to their medical condition (Burke et al. 2022). Healthcare practices should also ensure all staff members are culturally competent and contribute towards cultivating a safe environment for patients (Venkataramu et al. 2020). 

Ultimately, trust comes from within. Without prioritizing the retention and recruitment of Indigenous healthcare workers, it would be impossible to achieve equity. Aboriginal and Torres Strait Islander healthcare professionals and liaison officers are key to communicating culturally sensitive and clinically accurate information to patients, and are thus prone to burn out as key and frequent mediators of clinical discussion (Deroy and Schütze 2019). Healthcare practices should therefore mandate formal recognition and appropriate remuneration of the significant role Indigenous workers play in bridging the gap between the healthcare community and the Indigenous community (Deroy and Schütze 2019). 

Addressing re-traumatisation for Indigenous Australians

Perhaps the biggest challenge in addressing equity may be the re-traumatisation Indigenous Australians face as they are undergoing psychiatric treatment (Darwin et al. 2023). Repeated exposure to strings of traumatic events can be detrimental to a patient’s biopsychosocial health (Nadew 2012). As such, management plans should be periodically reviewed and refined in consultation with Indigenous patients. We can thus strive to prevent the detriments of repeated trauma and the regression of a patient’s recovery (Nadew 2012). 

Equity for migrants

Over the last year, Australia became home to 446,000 new immigrants (ABS 2023, 2024). We thus observe an increase in cultural (thus, linguistic and religious) diversity over the last decade (ABS n.d.).

In order to provide quality psychiatric care, as aforementioned, a thorough understanding of a patient’s needs must be established, which can be difficult if a language barrier subsists. Professional translation services have been made accessible to some healthcare professionals and patients to address language barriers (Ohtani et al. 2015). Whilst professional translators can capture the nuances of each language and allow for accurate translation of clinical information, there are limitations with regards to the affordability and convenience of booking professional translators (Jaeger et al. 2019; Sela-Sheffy 2023:5). Involving a third person in a sensitive consultation can often thwart the patient-healthcare professional dynamic, affecting the healthcare professional’s ability to accurately determine their patients’ needs for recovery (Bauer and Alegría 2010; Jaeger et al. 2019). 

In addition, mental health illnesses are more prevalent in migrants who have suffered from unemployment or low incomes and are hence unlikely able to afford quality psychiatric care (Furler and Kokanovic 2010). 

On an institutional level, we can strive for equity by ensuring that professional translation services are readily available and subsidised for immigrants who require them (Arpin-Gemme et al. 2023; Nielsen and Jervelund 2023). In some cases, telephone translation services have encouraged patients to be more open with the healthcare physician, as compared to face-to-face interpretive services (Jensen et al. 2014). Bulk-billing incentives should also be considered for low-income or unemployed immigrants (Gould et al. 2010). Mental health professionals and organisations can trial the implementation of digital mental health interventions, such as artificial intelligence applications, to provide linguistically diverse patients with an accessible method of psychiatric support (Ministry for Ethnic Communities 2024; Mabil-Atem et al. 2024). 

As part of providing equitable psychiatric care, healthcare professionals should be aware of the social customs, “syndromes” and religious practices of various cultures (Latif 2020). Cultural diversity adds a layer of complexity, particularly with regards to the assessment of various psychiatric factors, such as distress tolerance, emotional regulation and family dynamics (Fogel et al. 2024). Mental health professionals should thus engage in continuous learning of their patients’ cultural backgrounds (NSW Government n.d.). 

Equity for rural and remote areas 

Having worked in rural and remote areas across East Gippsland, I have seen first-hand how difficult it can be to access psychiatric care. Counsellors, psychologists and psychiatrists are scarce, with the majority of services provided by an overburdened mental health triage system and limited to mostly teleconsults. Other rural areas across Australia experience similar issues, with regards to the limited provision of mental health services (Judd et al. 2002). Moreover, patients in rural areas are subjected to fewer employment opportunities and natural disasters (NRHA 2021). 

In an isolating environment with limited resources, “a culture of self-reliance” and stigma against mental health, it is important that we continue to address these inequities with new and innovative solutions, so that rural and remote patients are eventually able to access the same quality of psychiatric care as their metropolitan counterparts (RANZCP 2023; Mental Health Commission of NSW 2023). As it stands, suicide rates in rural and remote areas are significantly higher than metropolitan areas (Kaukiainen and Kõlves 2020).

During consultations, mental health professionals should address factors that are more likely pertinent to those who live rurally and remotely, including stoicism, distrust, stigma and isolation (Kaukiainen and Kõlves 2020). While there has been much work on an institutional level to increase rural psychiatric training positions and support (RANZCP 2022), shorter-term solutions would also be beneficial to the rural and remote community. Metropolitan and rural services, for example, can work towards the recruitment of metropolitan-based clinicians and multidisciplinary teams to work in a rural/remote area for a certain duration and frequency (Stevens 2023). 

In terms of strengthening prevention strategies, local councils can work with schools and community centres to identify individuals who may need early psychiatric intervention by employing mental health liaison workers (Guerrero et al. 2018). Increasing participation in preventative programs, such as Mental Health First Aid training courses, can also improve mental health literacy in rural and remote areas (El-Amin et al. 2018). 

Whilst artificial intelligence should not replace consultations with mental health professionals, perhaps there is an avenue for artificial intelligence to be used in conjunction with mental health services, whilst a patient is waiting for their next appointment (Cross et al. 2024). Applications, such as ChatGPT, have shown some effects with regards to providing patients with stress management strategies, active listening and more informative resources (Prazeres 2023). 

Conclusion

This paper does not address how equitable psychiatric care can be achieved across all areas of diversity, including neurodiversity and diversity in education levels of patients. Nevertheless, this paper establishes what quality and equitable psychiatric care should entail. Achieving equity is certainly not a short-term solution, however, taking the time to understand a patient’s demographic factors, values, beliefs and needs can not only allow for stronger rapport, but also increase the patient’s chances of a successful recovery. 

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Submitted to the 2024 PIF Australian Essay Competition.