Commentary on Galletly et al. (2016),The Royal Australian and New Zealand College of Psychiatrists clinical practice guidelines for the management of schizophrenia and related disorders

While it is known that Indigenous Australians experience a greater burden of mental ill health than the wider Australian population, reliable prevalence rates are elusive and data on effective treatments essentially absent. That noted, as the clinical practice guidelines (CPGs) for the management of schizophrenia and related disorders (Galletly et al., 2016) record, there is evidence of substantially higher prevalence rates for psychotic disorders among Indigenous people in particular settings, such as in prisons and remote Aboriginal communities. However, this burden is part of a historical cascade of mental health and behavioural issues that have serially buffeted Indigenous communities over the last five decades. Alcohol misuse, violence, adult suicide, cannabis use, child suicide, psychotic disorders and foetal alcohol spectrum disorder have, in succession, become major problems with ice and its consequences simply the next wave that if not there already in remote settings, is coming.

While it might be argued that this simply reflects trends in the wider Australian population, it should be noted that the baselines for all those conditions were almost certainly extremely low, that the rates of increase were dramatic and that the circumstances of Aboriginal communities were and remain such that the consequences are broadly, if not universally, felt. Manifestly, such changes reflect social context, the historical forces informing those contexts and their effects on neuropsychological development through the environments of pregnancy and early childhood. Ultimately, definitive improvements will require major social change and population-level interventions.

As the continuing nationwide publicity about intractable problems in places like Aurukun demonstrates, that is hard – very hard – and, even if sufficiently resourced, will take a long, long time – probably longer than the increasingly short-term focus of political investment, a situation compounded by the outsourcing of public sector activities and the progressive devolution of responsibilities to local providers of which the move to Primary Health Networks is the latest iteration. At least in terms of First Nations populations across Anglo-settler societies (Australia, New Zealand, Canada and the United States), their health interests have historically been best represented and protected where responsibility is vested at national rather than provincial or local authorities (Kunitz, 1994).

By and large, medical professionals have not been effective social change agents, and as Leonard Syme (1998) pragmatically emphasized, ‘In my view, moral outrage about inequality is appropriate, but it may also be self-indulgent. Changing the world may require a more modest, practical beginning’ (p. 503). And for those practitioners working in the field, that ‘modest, practical beginning’ is good clinical care. In terms of schizophrenia and related disorders, that is critical not only to address the needs of, and improve outcomes for, Indigenous Australians with psychotic disorders but also to support the families and communities in which those people live. Good clinical care is modest, practical social change.

The challenge, then, is not so much what to do, but ensuring appropriate application and equitable access – how and how much. In relation to ‘what’, as the CPGs suggest, clinicians should be guided by best practice in the wider society with the ‘how’ being informed by a nuanced appreciation of application given local circumstances and practices (in relation to comorbid chronic disease burden, home health hardware, clinical and social support systems, trauma exposure, etc.). That demands local knowledge and relationships that will facilitate diagnosis (avoiding both the pathologizing of cultural expressions and the cultural rationalization of pathology), initiation of appropriate and least restrictive treatments, maintaining cooperation and compliance and supporting recovery. Relationships of trust, based on local experience and knowledge, will facilitate improving the use of effective treatments for which barriers exist as a consequence of attitudes and preconceptions of Indigenous capacity (such as clozapine) and the use of psychological treatments for which access remains limited through primary mental health care (Reifels et al., 2015).

The reader will note that all of the ancillary recommendations for working with Aboriginal and Torres Strait Islander people are about the ‘how’ and are based on clinical experience and expert consensus (as are those for Maori and Pacific Islander populations). That is a consequence of the difficulty of the evaluation challenge in disadvantaged populations with complex comorbidities and multiple social confounders. It should not be read as suggesting that ‘how’ is less important than ‘what’. Rather, it might be understood that best practice demands being able to engage and maintain relationships with Indigenous Australians and comes with experience. And to that end, there is much to be said for a cup of tea (Hunter, 2008).