The bottom of the pit

I assessed Ofato in the visitor section of Silverwater jail in Sydney's western suburbs. Anxious, expectant relatives were directed, by stern guards, towards a large room filled with plastic chairs and tables, where they waited for their precious minutes with loved ones lost to the criminal justice system.

I was there at the request of a lawyer who had discovered his Samoan-born client had prior contact with mental health services. Ofato is not tall, but like many with his heritage, he is muscular and has an intimidating presence. He has black curly hair, a flat nose and partially Mongoloid eyes. He sat dressed in his green jumper and tracksuit pants, the correctional centre's uniform for inmates, across a battered, chipped office table. He bowed his head, avoided eye contact and answered my questions softly, but with never more than a few words, with a Kiwi accent. He smiles only when talking about a visit from his parents and five siblings the day before.

He was charged with 'break and enter' with three other men of Samoan heritage. Unusually for a case involving young men and crime, there were no drugs involved. I read through the pile of legal documents and noticed a shoplifting offence years earlier. This was his first time in jail.

A week earlier in a hospital I assessed Eli, a nineteen-year-old boy of Samoan heritage living in Mt Druitt, who had become withdrawn and mute. He had previously worked at a Woolworths distribution centre, but felt pressure to stay home with a sick grandmother when his father and uncle left to take jobs as fruit pickers. He had completed his school certificate but further study didn't interest him. Eli was difficult to diagnose, offering the briefest of answers to my questions. I discovered he liked rap music. Fifty Cent and Kanye West were his favorite artists. His presentation was consistent with the criteria for depression – laboured speech, disengaged manner, slowed memory and concentration – yet was also culturally appropriate.

Ofato and Eli are two of an emerging community of Pacific Islanders increasingly falling through the cracks of respectable, prosperous Australian society, most commonly from Samoa, Tonga and Fiji. Pacific Islanders have been described as statistically invisible in Australia, because most have migrated either through or from New Zealand, and are identified as New Zealanders. Ancestry data from the 2011 Census is more accurate and tallies 85,000 people with Pacific Islander ancestry, a 15 per cent increase since 2006.

In January, riots in Logan, on the southern outskirts of Brisbane, between Pacific Islanders and Aboriginal teenagers, drew attention to this group and their growing representation among the deprived and disenfranchised.

'They're competing over not wanting to be bottom of the pit,' says Gail Ker, CEO of Access Community Services in Logan, who explains that some Aboriginal and Torres Strait Islander residents in the area feel African refugees and Pacific Islanders are competing with them for subsidised housing and welfare. Pacific Islanders often lacked access to resources such as HECS and the disability pension. 'We are denigrating them to an underclass,' she says.

Pacific Islanders are increasingly over-represented in juvenile justice system, they are more likely to drop out of the educational system and be unemployed. In Victoria Pacific Islanders make up just 0.1 per cent of the population, but 8.5 per cent of young people in youth detention centres. NSW, Queensland and Victorian correctional services have special advice booklets about dealing with Pacific Islanders for workers in the juvenile justice system, acknowledgement of their over-representation and specific cultural context.

In Mt Druitt, long synonymous with deprivation in Sydney, a boisterous church for Samoans meets every Sunday. My patient Eli used to attend regularly, playing keyboard in accompaniment with the church choir. The congregation of several hundred people echoes the missionary history and strong Christian traditions of the Pacific. Speeches are short and performances are long, with passionate choirs taking their cues from American gospel singers.

Young people attend with their older relatives. The men dress formally in shirts and trousers, the curvaceous women favour floral dresses. Traces of their external life are visible, from baseball caps to headphones attached to mobile phones. I watch several elders chide their children playing with their smartphones.

At church the cracks in the community elsewhere are not obvious.

A legal assessment in jail allows for only one encounter, but Ofato becomes more comfortable as the interview progresses. He is guarded about his prior interaction with mental health services but eager to please his lawyer too. He first used marijuana a year ago, and it made him paranoid. Convinced he was being persecuted by Sudanese and Aboriginal youth, he hid behind crates at a local shop. Police were called and he was taken to emergency and later diagnosed with drug-induced psychosis. He was discharged a day later, but didn't return for follow up. He says he has not tried drugs again. I found no evidence of any underlying psychiatric abnormalities during my interview.

His paranoid delusions were not so outlandish when local history was taken into account. In February 2011, Islanders, Aboriginal and African youth rioted in Mt Druitt. Ofato says he was not involved.

But Ofato says he was once associated with a bikie group, where he worked as a standover man. He describes his role, rather euphemistically, as an assistant debt collector. He felt proud when other gang members admired his physicality and the warrior heritage of his ancestors. 'They kept going on about how I could scare the shit of people without having to do anything.' he says, a little bemused.

He refuses to elaborate, but says he never needed to get violent. He left the gang because he didn't want to carry guns.

Ofato still attended church with his family, another Samoan Pentecostal group in Granville, also in Sydney's west. He says he went to please his family, but spent the rest of the week with friends playing football, listening to music and window shopping at the nearby mall. When pressed about why he tried to rob a convenience store, he says his band of merry Samoan brothers, who referred to themselves as Islanders in Da House, wanted to 'show the Lebs' – a local bikie group. He also says his parents were threatening to send him back to Samoa for a year, punishment for his past truancy at school and lack of direction.

Unlike Ofata, I assessed Eli several times after our first encounter. I considered prescribing an anti-depressant to help lift his mood, but he resisted the idea, having heard from others that 'happy pills', as he calls them, turned people into vegetables.

I organised a family meeting, a psychiatrist's way of attempting to intervene in social systems associated with the patient's milieu. Two of his siblings attended with his mother, aunt and grandmother. They all lived together in a three-bedroom townhouse, which they rented for $250 a week, cheap for Sydney. His father and uncle were absent – his father working in a country town, his uncle had returned to Samoa. The family had been in Australia for close to a decade, and in New Zealand two decades before that. His grandmother spoke in broken English of an idyllic life on the islands with plentiful food and strong families, but lamented the current poverty there.

Eli was embarrassed that his family was involved, he worried it would affect their health. His mother and aunt had both been diagnosed with diabetes and were on the verge of requiring insulin injections if their sugar levels did not stabilise. Samoa and five other Pacific Islands are among the top ten fattest countries in the world, according to a list compiled by the British Medical Journal in 2012. In spite of his anxiety, Eli jokes that the Samoa airport was full of relatives transporting buckets of Kentucky Fried Chicken from American Samoa.

My treatment focused on providing the family some insight into Eli's mental state and how it might relate to family dynamics. I describe how strong clan expectations and hierarchies could make it difficult for young men to communicate distress or disenchantment. Improving the mental health of patients from 'collective cultures' depended on building greater autonomy for the sufferers. Unfortunately, I did not see Eli again after the family meeting, despite an apparently optimistic encounter.

Mental health nurse and academic from Auckland's Massey University, Dr Sione Vaka, says my experience is far from unique; most Islander patients disappear from treatment early. 'It is a collective culture that simply does not see their distress through the lens of mental health, although this can change with latter generations,' says Dr Vaka, who is of Tongan descent.

When I describe Ofato and his legal predicament, Dr Vaka says the two patients have much in common, despite their differing presentations. 'Youth gangs are often a way of expressing their cultural identity. They are not always able to make autonomous decisions within the expectations of their clan structure.'

There is no direct translation in Tongan for the English word depression, but Dr Vaka says that a growing proportion of patients from the Cook Islands and Tonga ask if their children have ADHD. 'If Islanders develop emotional symptoms it is more likely to be seen as punishment for rebelling against clan expectations or having an overlap with evil spirits.' Tongan elders usually interpret mental illness as being overtaken by spooks, an experience called avanga .

Wellington-based psychiatrist and social researcher Dr Siale Folaiki, whose family is from the Cook Islands, sees the community's problems beginning several decades ago and rooted in socio-economics. 'If the first generation do not get economic foothold, it is the latter generations that start showing up in markers of disadvantage, particularly in the third generation.'

Most of the initial migration of Pacific Islanders to New Zealand occurred in the 1970s, just as the islands were beginning to industrialise and New Zealand was also undergoing significant economic change. The islands provided plentiful resources to feed small communities, but didn't equip them well for competitive, urban life. 'It's not dog eat dog. The culture didn't prepare us. We didn't emphasise education as vigorously,' says Dr Folaiki, noting that Asian cultures focused on small families and targeted all the family's resources on the children's education. 'Our families are often way too big and live in overcrowded conditions.'

The biggest predictors of juvenile justice presentations is being in the bottom tier of literacy and numeracy – in 2012, more than a third of Pacific Islanders in New Zealand did not complete the National Certificate of Education Achievement (NCEA), equivalent to the Year 10 school certificate in Australia.

There are no comparable statistics available from the NSW Department of Education.

Dr Folaiki says Cook Islanders value education, but are rarely engaged in the process. One successful program in Wellington targeted Pacific Islanders and trialed alternative education programs incorporating song and dance techniques as a possible source of optimism. He remains very guarded about the future prognosis. 'My community is just tracking along. Our practices are simply not conducive to creating an environment that can lead to meaningful roles for the twenty-first century economy.'

It's not clear that Ofato and Eli can escape such a pessimistic scenario. Having just turned eighteen, Ofato was fortunate to avoid jail. He was placed on parole and is attempting a TAFE course in graphic design. Eli had no further contact, which may have indicated recovery from his psychological symptoms, but did not necessarily ensure a viable future.