Meta-analysis of Australian Indigenous psychiatric treatment,critiqued

To the Editor

In response to Leske et al. (2016), meta-analysis of treatments is generally wont to criticize its study group for recruiting insufficient subjects. The meta-analysis which is the subject of this letter could be critiqued for a comparable shortcoming: too few studies were found eligible. It must be judged not for what it found so much as what is needed to be done in the field. It compared treatment outcome in 16 studies of mental and substance abuse disorders (4 in Australia; 4 in New Zealand; 1 in Canada; 7 in United States) which met study criteria. They were classified as culturally unadapted, culturally adapted or culturally based. All reported improvement. Studies were deemed ineligible for the meta-analysis on account of insufficient diagnostic information. It is by no means clear, however, how reliable was the diagnostic data in the studies which were included.

This points to one of the main drawbacks of the field of mental health service delivery to Indigenous populations: the poor validation of diagnoses and the unreliability of diagnostic practices. It has by no means been established that Indigenous peoples are well served by the Diagnostic and Statistical Manual of Mental Disorders (DSM) or International Classification of Diseases (ICD). The author’s impression is that schizophrenia is over-diagnosed, especially drug- and alcohol-induced psychoses. Depression, especially bipolar affective disorder, is under diagnosed. Stress disorders, a considerable component of indigenous psychopathology, are hardly acknowledged, since subjects are fitted into pre-existing putatively universal diagnostic categories. The authors note that despite the fact that the rate is extraordinarily high, comorbidity was not addressed. The authors call for increased quality of research. But first must come increased quality of treatment and service delivery. This meta-analysis was probably premature.