3. Referrals

Referrals are made by the Psychiatry Ward at Alice Springs Hospital when patients are discharged, community clinic nursing staff, AHWs and the three Aboriginal Mental Health Workers (AMHWs), the District Medical Officers and occasionally the Family Youth and Community Services and Disability Services. This broad range of referral sources works well in the remote setting as it may take weeks for the next DMO visit to allow a doctorto-psychiatrist referral. Also it encourages more autonomy and involvement from the AHWs and AMHWs. The clinic nursing staff were quite comfortable in referring as they are used to working with a high degree of autonomy and referring to other specialist health services.

In the remote Kimberley, McLaren (1995) accepted referrals from 'anybody in a responsible position' including police and prison officers, solicitors, school teachers and cattle station owners. But in my experience referrals from people outside health services did not occur except in very small communities which did not have any health personnel based there, for example the community of Bonya where the local station owners referred to us as well as being involved in monitoring the progress of patients with chronic mental illness. The relatives and other community members were as 'responsible' as the station owners but did not have access to the telephone or the language skills to arrange a referral.

Referrals were seldom made with the conventional referral letter, but mostly via a telephone call or other verbal request. A flexible approach to referrals that were 'inappropriate' in conventional terms often presented an opportunity for us to gain credibility within the community.

For example, a young Aboriginal man was referred by the AHW for no apparent reason other than having permanent neurological deficits from past petrol sniffing (which had been fully assessed medically) and which had left him wheelchair bound some years before. We responded to the referral and found no psychiatric disorder but the patient was cheered by our visit and we were able to provide some psychological support for his family carers. On subsequent visits to the community we called in to say hello. Through Western eyes, little therapeutic benefit was given to the patient through our interaction, but the community saw it as a valuable interaction and it enhanced our acceptance. So was it an 'inappropriate' referral after all or just a reflection that the role of a psychiatrist in a remote Aboriginal community is somewhat different, in that there is a greater need to address the community needs and concerns rather than focusing exclusively on the individual's pathology? My fears of being asked to see a string of physically disabled people were shown to be unfounded.

Additionally, an AHW may not be able to articulate the reason for referral in my language or in my cultural frame. But this does not mean that there is no mental suffering at hand, so that I am loath to decline a request by an AHW to see someone even without a clearly defined 'presenting complaint'. The only patient I declined to see was a 'shaky baby' of two years of age who had already been assessed by the Paediatrician.

This is not to suggest that there are no boundaries when it comes to accepting requests in Aboriginal communities, but rather that the boundaries are different. I have declined requests to assess serious medical presentations such as a woman with an acute abdomen (given that the usual practice of clinic nurse liaising with RFDS doctor was able to go ahead). But I have taken on the occasional request for assessing ear infections and rashes in communities with no permanent health staff. In cases where ongoing psychiatric intervention is not useful for the individual or the community, then it is appropriate to terminate one's involvement otherwise the patient's name will be continually placed on the list of patients to see.

The latter can sometimes be difficult as once seen by the service, the patient's problems can be viewed as belonging to the service. This has occurred in cases of dementia which I had diagnosed but then had difficulty handing on to medical and geriatric services.

Table 2 outlines the new referrals that I assessed. There is a predominance of psychotic disorders, severe depression often with psychotic features and comorbid substance abuse. There are relatively few cases of anxiety disorder, bipolar disorder, personality disorder or substance abuse/dependence where the substance abuse/dependence was the sole diagnosis and the presenting problem.

Table 2 Diagnostic Groups (DSM 4) of New Referrals assessed by the Senior Registrar in Remote Regions (November 1996 to July 1997 inclusive).

	Male		Female
	Non-Aboriginal	Aboriginal	Non-Aboriginal	Aboriginal
Patient Numbers (62)*	4	24	5	30
Schizophreniform Psychosis	1	0	3	1
Schizophrenia	1	2	0	3
Brief Psychotic Disorder	0	1	0	0
Psychotic Disorder NOS	0	1	0	1
Substance Induced Psychotic Disorder	0	2	0	l
Bipolar Disorder	0	l	0	l
Major Depressive Disorder+	0	4	2	6
Dementia	0	3	0	l
Adjustment Disorder	1	0	0	2
Anxiety Disorder	0	1	1	0
Obsessive Compulsive Disorder	l	0	l	0
Bereavement	0	l	0	2
Stress Reaction	0	0	l	2
Somatoforrn Disorder	0	l	0	l
Personality Disorder	0	l	0	2
Substance Dependence (includes petrol and alcohol)	0	2	0	1
Substance Abuse (includes petrol and alcohol)	0	6	0	4
Polysubstance Withdrawal	0	1	0	1
Mental Retardation	0	1	0	2
Partner Relational Problem	0	0	0	2
ParentChild Relational Problem	0	0	0	0
No Psychiatric Disorder	0	3	0	3

* Includes 16 patients with more than one primary diagnosis

+ Includes 4 patients with moodcongruent psychotic features

While the numbers are too low for statistical analysis and there is some diagnostic doubt with some cases (see chapter on Diagnosis and Formulation), questions arise as to which cases are referred, which are not and why. My impressions from my work are as follows:

1. Psychiatric disturbance which is disruptive to others tends to be referred more than disturbance that involves social withdrawal or purely intrapsychic suffering. This may be because referrals come via the family rather than an individual coming forward to seek help. (note that family decisions are of great importance in Aboriginal cultures, as will be expanded on in later chapters). Alternatively, it has been suggested by Cowdy (33) that various psychiatric syndromes present with more acting out behaviours in Aboriginal people, for example he describes many cases of major depression which presented with impulsive and indiscriminate aggression (an unusual presentation in whites).
2. Disorders are referred quite late in their course, for example the cases of schizophrenia and schizophreniform psychosis referred have had florid psychotic symptoms for weeks or months which contrasts greatly to mainstream English speaking western societies where prodromal cases or early subtle psychosis will be referred. This may be that there is greater tolerance within the Aboriginal community for disturbed behaviour and that they have a great sense of family duty to care for the disturbed individual. Also, understandable suspicion and fear of having the sick relative taken away to Alice Springs Hospital could delay families seeking help from health services until they absolutely cannot cope any longer. In fact, when families do finally come forward it is often to urge that their floridly psychotic relative be taken to Alice Springs Hospital immediately. (Once again this is where a family decision has been reached after much discussion within the family. As will be discussed later, such family decisions guide the clinician a great deal in whether to choose admission and/or the Mental Health Act).
3. Psychosis is referred much more than anxiety disorders (that is, phobias, obsessive compulsive disorder, panic disorder, PTSD). This phenomena has been reported by every psychiatrist who has done epidemiological work in remote Aboriginal communities. See Appendix 3 from Eastwell (15) which summarises these findings.

The reasons for this are unclear, but some suggest a low prevalence of neurotic disorders. Eastwell (15) theorises that 'extreme permissiveness of Aboriginal mothering reduces the formation of infantile anxiety' or that 'anxiety states are projected to become a fear of sorcery'. But perhaps anxiety disorders are not seen by the community as needing 'white fella help' and that white people may be less able to pick up psychological distress in traditional Aboriginal people, as Cawte et al (7) describes in his study where white health staff underestimated psychological discomfort in Mornington Island Aborigines. Morice (2425) showed that the Pintubi and Luritja languages have words pertaining to various types of anxiety, panic and somatic symptoms of anxiety.

In the urban Aboriginal population PTSD, other trauma related disorders, dysthymia and pathological grief are referred much more frequently than psychosis (personal communication from Dr Michael Paton, Psychiatrist for the Aboriginal Medical Service, Sydney).

4. Similarly severe major depression (with psychotic features and/or gross dysfunction) appears to be referred at a greater rate than mild to moderate depression. At a workshop at Yuendumu conducted by my predecessor, community members stated that the latter did not exist in their community. This may reflect a lower incidence of depression or that the mild to moderate depressions present in different ways (ea. Cowdy (33) describes depression presenting with aggression).
5. Substance abuse/dependence is seldom referred as the primary problem, probably due to a sense of shame in the family. This is especially so for petrol sniffing which is currently on the rise again in Central Australia. Substance related problems often arise as a comorbid condition or precipitating factor.
6. Somatisation is a common presentation to the community clinics (personal communication from clinic staff informs me of this) but rarely does Mental Health Services become involved. This is an interesting issue which is discussed later.
7. Anecdotally, stress related problems are high in both Aboriginal and nonAboriginal health staff but are only occasionally referred (self referral or otherwise) largely because of fear of disclosure amongst coworkers (especially with nonAboriginal staff where the ethic of selfreliance is strong). Informal psychological support is often given.
8. Referral patterns are beginning to change in response to the Remote Mental Health Team taking a higher profile over the last 18 months. There is a greater rate of referral and more subtle presentations are being picked up (for example two recent cases of major depression which had presented to the clinic with vague somatic complaints and were recognised by clinic staff as possible depression).
9. Very few children are referred, as childhood behaviour problems are very well tolerated by families. The only case referred to me was a 10 year old boy with moderate developmental delay with gross acting out behaviours in the context of minimal limit setting by family.

Can the referral process be improved? I suggest the following issues need consideration:

1. Further involvement of AHWs and AMHWs may aid case finding of individuals with anxiety disorders;
2. Consultation with community representatives may be useful in determining what role Mental Health Services should play in substance related disorders especially petrol sniffing;
3. Continued education of clinic staff, both formally and informally is likely to improve the referral process.
4. There may be a role in becoming involved in the more severe cases of somatisation which drain the resources of the clinics.

Australian Academy of Medicine and Surgery