Zealand Mental Health Research Articles

Hauora hinengaro o takatāpui: analysing the effectiveness of mental health policies in addressing the needs of Takatāpui in Aotearoa New Zealand

Many studies have documented the effect that colonisation has had on takatāpui, that is, Māori (the Indigenous peoples of New Zealand) with diverse gender identities, sex characteristics and sexualities. In this paper, we explore whether current Aotearoa New Zealand (hereafter Aotearoa) mental health policies meet the needs of takatāpui. We identified five mental health policy needs, informed by the literature. We then explored policy documents from government ministries, district health boards and non-government organisations to see the extent to which policy met these needs. Four themes were present in the literature analysed: an overall lack of acknowledgment of takatāpui and intersectionality; promising engagement with the needs of takatāpui by NGOs; symbolic commitment to Te Tiriti o Waitangi; and some limited engagement with Māori health models. The findings show promise in some areas but demonstrate a lack of engagement by policy to meet the needs of takatāpui.

Do compulsory mental health patients have a right to receive a second opinion on their treatment under Australian mental health legislation?

We reviewed Australian mental health legislation to determine what obligations it places on psychiatrists to facilitate second opinions for compulsory patients who request them. Only four jurisdictions-Australian Capital Territory, Queensland, Victoria, and Western Australia-have legislated for 'patient-initiated' second opinions. Within these four regimes, there is variation in important aspects of the second opinion process, and there is a general absence of direction given to the second opinion providers. Based on research showing the variability of second opinion provision under New Zealand mental health legislation, we argue that this absence is likely to result in significant variation in the quality and depth of second opinions provided in Australia. We argue that New South Wales, the Northern Territory, South Australia, and Tasmania should consider formal provision for patient-initiated second opinions in their mental health legislation. We believe that such legislation ought to be aware of the barriers patients may face in accessing second opinions, and avoid exacerbating these barriers as Queensland's legislation appears to. Also, we argue that research on current practice in Australia should be conducted to better understand the effects of legislation on second opinions, and to help determine what amounts to best practice.

Unlocking the Digital Toolbox — A Mixed Methods Survey of New Zealand Mental Health Clinicians’ Knowledge, Use and Attitudes Towards Digital Mental Health Interventions

AbstractTo assess New Zealand mental health clinicians and trainees’ knowledge, usage patterns, and attitudes towards digital mental health tools and their potential role in clinical practice. Participants recruited through professional organisations and training programs completed an online survey (August 2021 to February 2022). Eligible participants included Registered Health Professionals working in mental health or those enrolled in relevant training programs. The survey explored their knowledge, use of digital interventions, and perspectives on incorporating digital tools into clinical practice. Quantitative responses were summarised for the entire sample, and free-text responses regarding perceived benefits and concerns were coded to establish their relative importance. One hundred forty-four people started the survey and a total of 118 participants (77% female, 68% NZ European) completed it. Key findings indicated that 81% of the respondents had used digital tools, 65% rated their knowledge as moderate or higher, and 86% expressed interest in utilising digital tools. The primary advantages included ease of access and empowerment for clients, while concerns centred around the digital divide and the threat that digital tools may be used to replace traditional services. Clinicians demand more support and training including access to locally accredited tools. Blended (digital interwoven with in-person) support was highly favoured too. New Zealand mental health clinicians generally hold favourable views towards digital tools, with a significant proportion already trying them in their clinical practice. Clinicians are wary of digital approaches exacerbating existing inequities and want free of charge, secure, user-friendly, and evidence-based tools.

Seclusion within the first 24 h following admission into inpatient mental health services and associations with referral pathways, recent service contact and HoNOS ratings.

WHAT IS KNOWN ON THE SUBJECT?: Seclusion is a harmful and traumatising intervention for people accessing mental health services. People who are subject to seclusion in inpatient mental health services often first experience this within the first 24 h following admission. There is limited research examining how recent contact with services impacts the likelihood of seclusion when people are admitted to inpatient services. WHAT THE PAPER ADDS TO EXISTING KNOWLEDGE?: Males, Māori and Pasifika experience higher rates of seclusion within the first 24 h following inpatient admission. People perceived by clinicians as overactive, aggressive, disruptive or agitated are seven times more likely to be secluded within the first 24 h. People referred from police or justice services are three times more likely to be secluded within the first 24 h. People who had frequent contact with community mental health services prior to inpatient admission were less likely to be secluded. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: The first 24 h of inpatient admission is a critical focus for eliminating the use of seclusion. Initial interactions with people recently admitted should focus on nurturing relationships and reducing distress. Mental health staff should consider the person's cultural needs, referral pathway, recent service contact and baseline ratings on the Health of the Nation Outcomes Scales (HoNOS) when working proactively to prevent the use of seclusion in the first 24 h following admission. Strengthening the focus on nurturing relationships, cultural understanding and non-coercive de-escalation approaches requires leadership support and strategic workforce development. ABSTRACT: Introduction People who experience seclusion in inpatient mental health services often do so within the first 24 h following admission. There is limited research examining the potential contributing factors, particularly recent contact with services. Aim/Question To identify factors associated with seclusion within the first 24 h following admission into acute inpatient mental health services. Method A retrospective analysis was undertaken using routinely collected data from Aotearoa New Zealand mental health services. Results A higher likelihood of seclusion within the first 24 h following admission was associated with: males, Māori, Pasifika, referrals from police/justice services, inpatient transfers, recent contact with crisis assessment teams and clinician perceptions of aggression, problematic substance use, cognitive problems and hallucinations or delusions. Recent contact with community mental health services was associated with a lower likelihood. Discussion People's cultural needs, referral pathway, recent service contact and HoNOS scores should be considered when working to prevent the use of seclusion in the first 24 h following admission. Implications for Practice The first 24 h following inpatient admission is a critical period for preventing the use of seclusion. Nurturing relationships, cultural understanding and use of non-coercive de-escalation approaches can support better outcomes for people recently admitted.

Global Implications From the Rise and Recession of Telehealth in Aotearoa New Zealand Mental Health Services During the COVID-19 Pandemic: Mixed Methods Study.

The COVID-19 pandemic accelerated the adoption of telehealth services for remote mental health care provision. Although studies indicate that telehealth can enhance the efficiency of service delivery and might be favored or even preferred by certain clients, its use varied after the pandemic. Once the pandemic-related restrictions eased, some regions curtailed their telehealth offerings, whereas others sustained them. Understanding the factors that influenced these decisions can offer valuable insights for evidence-based decision-making concerning the future of telehealth in mental health services. This study explored the factors associated with the uptake of and retreat from telehealth across a multiregional outpatient mental health service in Aotearoa New Zealand. We aimed to contribute to the understanding of the factors influencing clinicians' use of telehealth services to inform policy and practice. Applying an interpretive description methodology, this sequential mixed methods study involved semistructured interviews with 33 mental health clinicians, followed by a time-series analysis of population-level quantitative data on clinician appointment activities before and throughout the COVID-19 pandemic. The interviews were thematically analyzed, and select themes were reframed for quantitative testing. The time-series analysis was conducted using administrative data to explore the extent to which these data supported the themes. In total, 4,117,035 observations were analyzed between September 2, 2019, and August 1, 2022. The findings were then synthesized through the rereview of qualitative themes. The rise and recession of telehealth in the study regions were related to 3 overarching themes: clinician preparedness and role suitability, population determinants, and service capability. Participants spoke about the importance of familiarity and training but noted differences between specialist roles. Quantitative data further suggested differences based on the form of telehealth services offered (eg, audiovisual or telephone). In addition, differences were noted based on age, gender, and ethnicity; however, clinicians recognized that effective telehealth use enabled clinicians' flexibility and client choice. In turn, clinicians spoke about system factors such as telehealth usability and digital exclusion that underpinned the daily functionality of telehealth. For telehealth services to thrive when they are not required by circumstances such as pandemic, investment is needed in telehealth training for clinicians, digital infrastructure, and resources for mental health teams. The strength of this study lies in its use of population-level data and consideration of a telehealth service operating across a range of teams. In turn, these findings reflect the voice of a variety of mental health clinicians, including teams operating from within specific cultural perspectives.

Organizational factors to optimize mental health nurses' wellbeing in the workplace: An integrative literature review.

Mental health nursing is a privilege and a rewarding profession. There has been a call for transformational change in mental health services to improve outcomes for the people of New Zealand, with mental health nurses integral to this. However, with predicted nursing shortages, high levels of burnout, and increasing demands in the workplace, an organizational focus on wellbeing for mental health nurses is needed to sustain the workforce, implement change and improve outcomes for people using mental health services. An integrative review of the literature was undertaken to explore how organizations can optimize mental health nurses' wellbeing in the workplace and to identify measures for organizations to support mental health nurses' wellbeing with a focus on New Zealand. Seven articles were included in this review after a search, data extraction and evaluation. Data were synthesized and categorized using thematic analysis. The findings indicate organizations can invest in several initiatives to enhance mental health nurses' wellbeing in the workplace. These include professional development, skills to build resilience, enabling time to reflect on practice, enhancing professional supervision, having the right managerial support and focusing on individual's strengths. Organizations need to prioritize mental health nurses' wellbeing by embedding the practical strategies this review identified and by addressing organizational barriers to wellbeing. Organizations should consider implementing multileveled organizational wellbeing initiatives to nurture and grow the New Zealand mental health nursing workforce which in turn will contribute to quality care and enable mental health nurses to have long meaningful careers. Time, investment and resources are essential for these initiatives to be effective.

Not heading in the right direction: Five hundred psychiatrists' views on resourcing, demand, and workforce across New Zealand mental health services.

To explore the views of psychiatrists (including trainees) regarding the current state and future direction of specialist mental health and addictions services in Aotearoa New Zealand. Psychiatrists and trainee psychiatrists (registrars) in Aotearoa New Zealand were surveyed in August 2021. Of 879 eligible doctors, 540 participated (83% qualified and 17% trainee psychiatrists), a response rate of over 60%. Data were analysed quantitatively and with content analysis. Psychiatrists thought specialist mental health and addictions services had been neglected during recent reforms, with 94% believing current resourcing was insufficient, and only 3% considering future planning was heading in the right direction. The demand and complexity of on-call work had markedly increased in the preceding 2 years. Ninety-eight percent reported that people needing specialist treatment were often (85%) or sometimes (13%) unable to access the right care due to resourcing constraints. The pressures were similar across sub-specialties. A key theme was the distress (sometimes termed 'moral injury') experienced by psychiatrists unable to provide adequate care due to resource limitations, 'knowing what would be a good thing to do and being unable to do it . . . is soul destroying'. Recommendations were made for addressing workforce, service design and wider issues. Most psychiatrists in Aotearoa New Zealand believe the mental health system is not currently fit for purpose and that it is not heading in the right direction. Remedies include urgently addressing identified staffing challenges and boosting designated funding to adequately care for the 5% of New Zealanders with severe mental health and addiction needs.

Staff perceptions of the quality of care delivered in a New Zealand mental health and addiction service: Findings from a qualitative study.

In New Zealand, people receiving care from specialist mental health and addiction services experience poorer health outcomes compared to the general population. Māori (Indigenous) specialist mental health and addiction service users experience disproportionate inequities. This study aims to: (1) Describe and understand mental health staff perspectives on the quality of care delivered to specialist mental health and addiction service users in their service - including specifically for Māori; and (2) Identify areas staff report as opportunities for quality improvement. In 2020, Southern District Health Board (now Te Whatu Ora - Southern) mental health staff were invited to participate in a cross-sectional study assessing their perceptions of a range of service aspects. This paper presents quantitative and qualitative analyses about quality of care. Among the 319 staff who completed the questionnaire; 272 provided quality-of-care responses. Among these, 78% reported the quality of care delivered to service users as 'good' or 'excellent'; only 60% reported this for Māori service users. Participants identified individual, service and broader system level factors influencing the quality of care delivered to service users, including factors specific for Māori. This study has identified, for what appears to be the first time, empirical and concerning differences in staff ratings of the quality of care delivered to Māori and SMHAS users overall. Findings highlight the need for institutional and managerial prioritization of hauora Māori, and incorporating tikanga Māori and Te Tiriti into practice.

Are mental health nurses meeting the requirements of second health professionals in presenting opinions to the court?

WHAT IS KNOWN ON THE SUBJECT?: Mental health legislation is currently under review following recommendations for repeal and replacement. Through the statutory role of the second health professional, mental health nurses are in a strong position to offer a unique clinical perspective, engagement and advocacy for tangata whaiora (person seeking wellness) and whānau. Māori are more likely to be subject to a compulsory treatment order than non-Māori. Whānau involvement in care is a core element to well-being from a Te Ao Māori (Māori world view) perspective. WHAT THIS PAPER ADDS TO EXISTING KNOWLEDGE?: Understanding the level of whānau involvement in the MHA process. Understanding challenges for nursing practice for consideration in the current review of MHA legislation. Identification of the opportunity nurses have to contribute to reducing high rates of Māori under CTOs. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: The current MHA review needs to include the resourcing required to support the clinicians practising in statutory roles. More emphasis is needed to build the cultural knowledge and capability of the nursing workforce to integrate principles of a Te Ao Māori worldview into care delivery. These learnings highlight the importance of nursing responsibility in the SHP role. ABSTRACT: Introduction Clinical practice within statutory roles is an important issue for the nursing profession. There is increasing involvement of nurses undertaking statutory roles and opportunities for nurses to advocate and offer their unique clinical opinion regarding the need for restrictive measures imposed by mental health act legislation. Aim The aim of this study was to analyse whether registered nurses who undertake the role of second health professional (SHP) within New Zealand's Mental Health (Compulsory Assessment and Treatment) Act (1992) (MHA) are meeting the expectations of that role. Method A retrospective analysis of 156 cases was undertaken of clinical reports completed by registered nurses. The reports were measured against an established competency framework modified to include MHA expectations for whānau (family) involvement. Results From a sample of 156 cases, 22 were identified as reviews of initial orders for assessment and treatment while 134 were opinions related to the application for a compulsory treatment order (CTO). In most cases, reports achieved a good standard. There were limitations in nurses completing the documentation to the required standard, and adaptations were evident in efforts to meet clinical and legal expectations. There was a significant absence of evidence of whānau consultation. Discussion Resourcing through education, support and ongoing development are required to ensure that nurses are equipped to meet the expectations of the legislation. There is an opportunity for nurses to influence decision-making and support the reduction in use of community treatment orders. A review of the existing competency framework is required to include cultural approaches and involvement of whānau. Implications for Practice It is important to understand the factors that strengthen nursing practice to improve health outcomes and tangata whaiora and whānau experience. This study uses methods of clinical audit to describe current practice and establish an evidence base to measure change. It also offers important learnings for consideration within MHA legislation review and for nursing workforce development.

COVID-19 related innovation in Aotearoa/New Zealand mental health helplines and telehealth providers - mapping solutions and discussing sustainability from the perspective of service providers.

BackgroundThe coronavirus disease 2019 (COVID-19) pandemic and associated interventions resulted in changes in both the demand and supply of mental health services and necessitated agile adaptation and innovation from service providers.AimsThe aim of this study was to explore what innovative solutions were adopted in response to COVID-19 and the pandemic control measures, what opportunities and challenges were associated with these innovations, as well as to critically reflect on the longer-term sustainability of the innovations in the context of Aotearoa/New Zealand mental healthcare.Materials and methodsWe used thematic analysis to analyse the data from the 23 in-depth interviews with helpline employees and general practitioners from 18 service providers that regularly engage in mental healthcare.ResultsTwo key themes related to COVID-19 and the pandemic control measures were identified from respondents’ accounts. These were “Technological innovations” and “Process innovations” where providers noted types of innovative solutions, and opportunities and challenges associated with those. The themes culminated in a meta theme “Sustainability of changes to service delivery” that appeared consistently in each theme and asks to consider how sustainable these innovative solutions might be in the long-term. Namely, sustainability of innovation was questioned in respect to the (a) innovative solutions being the emergency solutions with little or no impact analysis, (b) “returning back to normal” due to limited future funding and innovation as a sunk cost, and (c) sporadic and inconsistent innovation between service providers that does not contribute to quality and continuity of care from the systems perspective.ConclusionCOVID-19 and the measures of pandemic control were associated with an increase in innovative solutions from service providers. There were both opportunities and challenges associated with these innovative efforts and the sustainability of innovation was questioned. Future research about COVID-19 related innovation of service provision should focus on service user experiences and empirically measure the innovation safety and efficacy.

An exploration of New Zealand mental health nurses' personal physical activities.

This study assessed the physical activities of Mental Health Nurses (MHN) in New Zealand against the 2018 World Health Organization recommended minimum levels of moderate‐to‐vigorous physical activity. The research design was exploratory and descriptive as there were no previous studies about physical activity levels of MHNs in New Zealand. Quantitative and qualitative data were collected using the International Physical Activity Questionnaire (IPAQ, Long Version) which included options for free‐text responses. Data were analysed using descriptive and inferential statistics. A total of 266 participants returned the survey, a response rate of 4%, and a limitation of the study. More than 50% of MHNs reported <150 min of moderate‐to‐vigorous exercise per week for each of the four physical activity domains. When individual physical activity domains were combined, only 10% spent <150 min on moderate‐to‐vigorous physical activity. Work‐related physical activities were higher for those working in the inpatient area than in community settings. Transport‐related physical activities were higher for those working in community settings. Participants registered from 6 to 20 years had more time sitting than other groups. Nurses aged 55 years and above showed the highest total physical activity levels. Moreover, healthcare organizations and nurse leaders need to promote physical activity and provide wellness intervention for their staff. Nurses who are physically active may be more effective in supporting their patients to increase their physical activity.

‘It absolutely needs to move out of that structure’: Māori with bipolar disorder identify structural barriers and propose solutions to reform the New Zealand mental health system

ABSTRACT Objectives This paper synthesises critique from Māori patients with Bipolar Disorder (BD) and their whānau to identify barriers and propose changes to improve the structure and function of the New Zealand mental health system. Design A qualitative Kaupapa Māori Research methodology was used. Twenty-four semi-structured interviews were completed with Māori patients with BD and members of their whānau. Structural, descriptive and pattern coding was completed using an adapted cultural competence framework to organise and analyse the data. Results Three key themes identified the impact of structural features of the New Zealand mental health system on health equity for Māori with BD. Themes involved the accessibility, delivery and scope of the current health system, and described how structural features influenced the quality, utility and availability of BD services for Māori patients and whānau. Structural barriers in the existing design, and potential changes to improve the accessibility, delivery and scope of BD services for Māori, were proposed including a redesign of operational, environmental, staffing, and navigation points (information, transition, fatigue) to better meet the needs of Māori with BD. Conclusion A commitment to equity when implementing structural change is needed, including ongoing evaluation and refinement. This paper provides specific recommendations that should be considered in health service redesign to ensure the New Zealand mental health system meets the needs of Māori patients with BD and their whānau.

Restricted patients in New Zealand: A failed social experiment with a hybrid form of civil/forensic compulsory mental health treatment

IntroductionIn 1992, New Zealand's mental health legislation created the distinct concept of a ‘restricted patient’ – effectively creating a pathway into forensic patient status, but via the civil committal process, without the patient passing through the criminal justice system en route. This regime was aimed at civilly committed patients who present “special difficulties” because of the danger they pose to others. It remains in force but has attracted little scrutiny. ObjectiveThis paper traverses the background to restricted patient status, and the legal regime, before describing and analysing, in anonymous form, the circumstances of all those declared to be restricted patients, and their outcomes, since the regime began. It then considers the continuing appropriateness of this legal regime in light of contemporary human rights principles. MethodsWe reviewed the records of every person placed under restricted patient status since the legislation came into force over a nearly 30-year-period. ResultsNew Zealand's restricted patient status is rarely used. Only eight people have been subject to such orders (seven male, median age 45 years at the making of the order). All had a history of violent offending and had previously been forensic patients. None re-offended after becoming a restricted patient, but they spent longer as compulsory inpatients than patients unfit to stand trial or not guilty by reason of insanity. There is no evidence they were uniquely dangerous. The legal criteria, namely, that the person presented with “special difficulties”, are unclear and have been interpreted differently by the judiciary. They have sometimes included the risk of inadequate care being provided by mental health services. ConclusionGiven the rarity with which restricted patient status has been used in New Zealand, the subsequent evolution and development of forensic services providing alternative pathways through care, and its problematic human rights aspects, we would not recommend equivalent restricted patient provisions to other countries. We suggest this hybrid form of civil/forensic compulsory mental health treatment is a form of arbitrary detention and incompatible with human rights norms. It should be omitted from New Zealand's next Mental Health Act.

Mental health of people of diverse genders and sexualities in Aotearoa/New Zealand: Findings from the New Zealand Mental Health Monitor.

To examine the mental health inequities, and social exclusion and isolation and protective factor differences between people of diverse genders and sexualities (lesbian/gay, bisexual, gender diverse and takatāpui) and cisgender and heterosexual people in Aotearoa/New Zealand. We employed data from the pooled probability sample of 2016 and 2018 New Zealand Mental Health Monitor. The sample comprised of 2938 people at least 15years old, of which 93 had diverse gender and sexuality identities. Generalised linear models were used to test for differences in mental health (current and lifetime mental distress, depression, anxiety, self-harm and suicide), social exclusion and isolation, and friend and family support for people of diverse genders and sexualities. We also conducted exploratory linear regression analyses to examine whether mental health difficulties were associated with social exclusion and isolation and friend/family support. People of diverse genders and sexualities had high rates of mental health difficulties across all variables we examined. For example, people identifying as diverse genders and sexualities had three times the risk of considering self-harm and suicide than their cisgender and heterosexual counterparts (22% vs 5%; RR=3.12). People of diverse genders and sexualities also scored an average of 6.08 points higher on the 27-point PHQ-9 depression scale when they had experienced social isolation, and 4.01 points higher when they experienced social exclusion. Our results are consistent with current literature on the large mental health inequities faced by people of diverse genders and sexualities. SO WHAT?: Policy makers and health care providers in Aotearoa/New Zealand should consider the negative mental health consequences of social exclusion and isolation for people of diverse genders and sexualities.

Disability Rights and Compulsory Psychiatric Treatment: The Case for a Balanced Approach under the Mental Health (Compulsory Assessment and Treatment) Act 1992

This article argues the New Zealand Government's current approach to compulsory psychiatric treatment is unjustifiable in a human rights context. Under s 59 of the Mental Health (Compulsory Assessment and Treatment) Act 1992, clinicians are empowered to administer compulsory psychiatric treatment to individuals without, or contrary to, their consent. This article analyses s 59, and its underlying justifications, in light of the New Zealand Government's commitments under the United Nations Convention on the Rights of Persons with Disabilities (UNCRPD). Further, it analyses the approach for compulsory psychiatric treatment advocated by the UNCRPD in light of Aotearoa New Zealand's mental health context to evaluate whether this approach would be more desirable than the current approach under s 59. The article then advocates for a more balanced approach to compulsory psychatric treatment which puts the rights of disabled individuals at the forefront and also ensures there are limits to these rights which are justifiable within a human rights context.

Development and initial evaluation of the ICD-11 personality disorder severity scale: PDS-ICD-11.

No measure has formally been developed to assess the published ICD-11 model of Personality Disorder (PD) severity. We therefore set out to develop and evaluate the 14-item Personality Disorder Severity ICD-11 (PDS-ICD-11) scale. A representative U.S. community sample (N = 428; 50.9% women) and a New Zealand mental health sample (N = 87; 61.5% women) completed the PDS-ICD-11 scale along with a series of established PD and impairment measures. Item response theory supported the unidimensionality of PDS-ICD-11 (median item loading of 0.68) and indicated that a PDS-ICD-11 score of 17.5 may serve as a benchmark for pronounced dysfunction. Correlation and regression analyses supported both criterion validity and incremental validity in predicting impairment and PD symptoms. The PDS-ICD-11 was particularly associated with measures of Level of Personality Functioning Scale (LPFS), Global PD severity, and Borderline PD symptom score. A comparison between clinical individuals diagnosed with an ICD-11 PD vs. no PD supported diagnostic validity. This initial construction study suggests that the PDS-ICD-11 constitutes a promising instrument that provides a quick impression of the severity of personality dysfunction according to the official ICD-11 PD guidelines. Clearly, more research is needed to corroborate its validity and utility. The PDS-ICD-11 scale is provided as online supporting information.

Embedding lived experience expertise across the mental health tertiary education sector: An integrative review in the context of Aotearoa New Zealand.

WHAT IS KNOWN ON THE SUBJECT?: An important step towards improving mental health outcomes is the realignment of tertiary mental health education and research in a way which places strategic value on experience-driven involvement in mental health and addiction-related care. One of the most widely recognized ways of achieving this is by increasing representation of individuals with first-hand experience of mental health and addiction distress (also known or referred to as Experts by Experience or EBE) within the tertiary sector. WHAT THIS PAPER ADDS TO EXISTING KNOWLEDGE?: Benefits of tertiary EBE representation such as improving student's preparedness for practice and the empowerment of mental health consumers are consistently reported throughout the literature. In striving towards these outcomes, it is crucial we remain mindful of relevant and often-reported hurdles such as stigma and improper implementation. By using Aotearoa New Zealand as a case study, the need for approaches to increasing EBE representation which is conscious of diverse cultural contexts, perspectives and identities is highlighted. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: This review draws together a broad range of factors associated with improving clinical practice. These include the potential for EBE representation to improve outcomes for trainee clinicians, and the incorporation of consumer-driven perspectives into evidence-based practice. This review further highlights the need for EBE representation to be implemented in a way which is responsive to the cultural needs and nuances of mental health education and practice in Aotearoa New Zealand, and, similarly in other countries. ABSTRACT: Introduction There is potential value in increasing representation of expert by experience (EBE) involvement in mental health education sectors. This approach to improving mental health outcomes is here explored in the context of Aotearoa New Zealand's tertiary education sector. Aim/Question This review sought to identify potential outcomes, benefits and barriers associated with EBE representation in tertiary institutions, whilst critically analysing these strategies in the context of Aotearoa New Zealand's mental health education sector. Method Data retrieved from electronic databases were subjected to critical appraisal and thematic analysis. The integrative review drew from a final data set of 113 articles. Results An integrative review of our search results indicated that moving towards a tertiary mental health model in which lived experience plays a central role has the potential to benefit both teaching and research in the tertiary sector. Discussion The interplay between contemporary perspectives on tertiary EBE representation and the cultural needs and nuances of Aotearoa New Zealand's tertiary sector highlights the need for critical and careful approaches to EBE representation. Implications for clinical practice Findings surrounding tertiary EBE representation have direct implications for the training of mental health practitioners and the evaluation and development of clinical practice outcomes and procedures.

The experience and meaning of recovery-oriented practice for nurses working in acute mental health services.

Since the 1990s, New Zealand mental health policy has shifted from a focus on the management of symptoms and risk to the recovery of psychological, social, cultural, and physical well-being. Despite a vision for recovery-oriented services being integrated within national and regional policies, there is growing concern that barriers to recovery-oriented service provision continue to exist. Such barriers include the attitudes, skills, and knowledge of front-line staff, as well as system issues. This study explored the experience and meaning of recovery-oriented practice for 10 nurses working in an acute inpatient mental health service. A phenomenological and hermeneutic lens was used to explore the nurses' experience of working in a recovery-focused manner alongside service users. Stories of practice were collected from participants through open-ended conversational interviews. Transcribed narratives were analysed to explore taken-for-granted aspects of working in acute mental health care and to uncover the meaning of being recovery-oriented in this setting. Findings revealed that although the experience and meaning of recovery-focused care varied among nurses, there were common elements in the practice accounts. The accounts highlighted the nurses' role in creating different therapeutic spaces to promote safety, relational commitment, and healing for service users. However, the nurses faced challenges to recovery-oriented care within the team hierarchical culture and the broader service systems. The nurses were, at times, fearless in advocating for service users and recognized that this was essential for developing recovery-focused services. The findings have implications for nursing practice, as well as training and service development.

Eating disorders in New Zealand: Implications for Māori and health service delivery.

Lifetime prevalence rates in Te Rau Hinengaro (The New Zealand Mental Health Survey) suggest eating disorders are at least as common in the Māori population as the non-Māori population, yet little is known at a population level about those accessing specialist mental health treatment for eating disorders in New Zealand. The aim of this study was to describe the population undergoing specialist mental health treatment for eating disorders and compare Māori and non-Māori clinical characteristics and service use. This study uses the Programme for the Integration of Mental Health Data data set, managed by the New Zealand Ministry of Health to describe the characteristics of people with eating disorders and their use of specialist mental health services from 2009 to 2016. There were 3,835 individuals with a diagnosed eating disorder who had contact with specialist mental health services in this time period, 7% of whom were Māori. Within the cohort, Māori had a higher prevalence for a bulimia nervosa diagnosis, fewer diagnosed with anorexia nervosa, and a higher prevalence of other psychiatric comorbidity than non-Māori. There is discrepancy between the proportion of service users accessing specialist mental health services who are Māori and the assessed crude prevalence of eating disorders for Māori in national estimates. Once Māori are in specialist services; however, their use of services is comparable to non-Māori. Further research is needed to highlight the experiences of those Māori with eating disorders and address barriers to accessing services for Māori with eating disorders.

MoodJumper: An Exploration of Game Interface Preferences in Users With/Out Mood Disorder.

Mental health conditions pose a major challenge to healthcare providers and society at large. The World Health Organization predicts that by 2030 mental illnesses will be the leading disease burden globally. Mental health services are struggling to meet the needs of users and arguably fail to reach large proportions of those in need. According to New Zealand Mental Health Foundation, one in five will experience a serious mood disorder, including depression, at some time in their life. Games for Health including those supporting mental health have recently gained a lot of attention. However, game interface preferences for users with a history of mental health conditions have not been systematically studied, making it difficult to determine what game features may attract and further engage users affected by mental health conditions. We present MoodJumper, a prototype Android mobile game, which enables players to jump to the top of the level by steering the avatar from platform to platform, gradually gaining height and collecting coins on the way up. We conducted a preliminary study (n = 25), in which participants were able to modify different settings of the game (background color, dark/light, character movement, gender, and music), while their gaming behavior was tracked. The results show that regardless of self-reported history of mood disorder, the majority of participants prefer the dark and colored layout setting and there were no differences in gaming variables including session duration and high scores. This represents a first indication that history of mood disorder does not affect user preferences for game interface settings. It will be important to follow up with data on users currently affected by low mood. Systematic study of game interface preferences in users with mood disorder constitutes a vital step in being able to harness the potential power of games for supporting mental health.