Pacific culture can be overlooked by western designed health services in New Zealand leaving Pasifika suffering from mental illness feeling increasingly disconnected. Advocates are calling on health services to adapt their practices. Koro Vaka'uta examines the issue.
Some of Salote's* earliest memories are full of sadness.
"Sharing this really tiny flat with my family. We were all crunched up into this two bedroom flat," she says.
"There was about 12 of us and I remember feeling sad and thinking, 'is this how my life is going to be?'
"And I was just not happy at all and I remember hoping that I would wake up and be somewhere else, somewhere else richer, because to me, being poor was not a nice thing."
Salote, born in New Zealand to Tongan and Samoan parents, struggled to find an identity of her own in her early years, which led to depression and later suicidal thoughts.
"When you are half-caste, quarter-caste, whatever, it is hard when it comes to identity because you have all these people trying to say to you, 'oh, who are you?'," she says.
"I remember growing up and having both families - one family going 'oh, you are not really a Samoan because you can't speak the language', 'oh, you are not really Tongan because you can't speak the language' or 'you can't do this' and it was hard enough to grow up in New Zealand as an islander anyway."
One in five people in New Zealand are said to suffer from depression of some form - many are dealing with depression triggered by trauma.
Feleti* was a teenager when a tragic death in the family led to the breakdown of his relationship with his father and the start of his mental distress.
However, he found solace initially in a new relationship with his Samoan soon-to-be-wife, before being led to seek help with a university counsellor.
He has seen a lot of the Pasifika community suffering.
"It's kind of in some ways like a virus, it doesn't discriminate and it is wide-ranging and it is pervasive and soul destroying," Feleti says.
"It doesn't matter if you live in Remuera or whether you live in Flaxmere. We are susceptible as human beings to some form of depression or feeling down or not being able to cope."
Anita is a Samoan woman brought up in the Hawkes Bay, where a traumatic experience, during her school years, triggered what she later learnt was clinical depression.
She didn't feel she could share what she was going through with her family at the time.
"It's a big burden for a kid, for a teenage 12 year old, to think you don't want to sadden your parents. You have to pretend everything is OK. Being the eldest I also had to look out for my sisters."
However she says she was helped by the cultural concept of tama toa - the idea that everyone is a warrior and a fighter.
"That was very important because my parents certainly were survivors and they were fighters," Anita says.
"That is the thing they taught. That you have to fight for what you want. We are warriors, descendants of warriors.
"The only thing that kept me going when I have fallen into a terrible state of depression was that I am not going to let this beat me."
The impact of culture on mental health is no surprise to Monique Faleafa, the CEO of Le Va, an NGO specialising in Pasifika health issues.
"We've got really strong evidence for young Pacific people, the stronger their cultural identity, the stronger their mental well-being," she says.
"I get people asking, 'well is it culture? Is it mental wellness?' For me, they are inseparable. They are both intertwined, so the stronger the culture, the stronger the well-being."
Mary Maringikura Campbell, a mental health consumer consultant, agrees that knowing family history is important as depression often involves feelings of dislocation and disconnection.
She points out that young people needed to be equipped with coping mechanisms to deal with bad times.
"We bring up our children for example to think that life is going to be great," she says.
"We don't bring up our children to actually say life is going to be great but there is going to be some really hard times where life is shit. And it is about learning about coping with all the bumps on the road."
Ms Maringikura Campbell says Pasifika, along with Maori, are some of the most stigmatised patient groups in New Zealand.
"We don't have the same stigma when someone gets cancer, they get a lot of support. People feel very sad for them, but there is still that sort of feeling that people with mental illness have done something to deserve it, have done something wrong, maybe they have breached a tapu, whatever it is, it is their fault."
Blame, followed by guilt is a real problem in Pasifika communities says a Wellington-based community worker Andrew Leilua.
"A lot of them feel guilt, if they weren't able to make the family proud, and I know with Pacific islanders as well, there is a real pride thing," he says.
"Like if you were to do something [bad] you were a real disgrace to your family. What comes with disgrace is unworthiness and that can come across really harsh."
Mr Leilua says there was a need for youth to be given a voice.
"I know within the Samoan culture, when you were young, you were never able to have the opportunity to speak what you felt and a lot of the people now feel like they are trapped in terms of wanting to speak and to voice their opinions.
"Some of their opinions, they hold them to themselves, with the whole mindset that 'I was taught not to speak when I was little'."
Mary Maringikura Campbell uses poetry as an outlet to express her feelings on mental health
Ms Maringikura Campbell says if people were looked at holistically, as emotional and spiritual, rather than just a physical body, there may be a reduction of stigma.
In the meantime she says the sector should customise its approach to Pasifika, as psychiatric care is based on a western model which doesn't always meld well with the community.
Shortage of Pasifika mental health workers
Auckland has a dedicated Pacific team, but Ms Maringikura Campbell says the rest of the country had a shortage of Pasifika nurses, doctors and psychologists.
"Slowly we are getting more and more Pacific psychiatric nurses coming through but you have to also understand that forensic and psychiatric nursing is not a very attractive pathway for many nurses so a lot of the nurses we get come from England, so they are imported , so they are a totally different culture."
A lack of health literacy meant staff and consumers could often talk past each other and people felt intimidated when entering the system.
Dr Faleafa, says specific programmes must be produced for Pasifika communities and most importantly, services must make themselves more accessible.
"The biggest problem we have in New Zealand is that our Pacific families and communities seem to have extremely high rates of mental illness but really low rates of access to services and what we see is Pacific families accessing in crisis when we could have saved so much grief and disruption and distress for that family if we had intervened really early," she says.
Salote hit rock bottom before approaching the Plunket Society, triggering the child health provider's concern for her welfare and that of her three children.
She was surprised by what was available and insists she will make sure her children understand there is help.
"I want them to be able to see and understand that there is help there, there is support there, that it is OK to be depressed, because there is still that negative stigma around depression ... that it is not OK to be depressed. It's not OK to have a mental illness. What's wrong with you now?"
Feleti encourages people to look for assistance.
"Seek help ... and I know within Pacific island culture there is a real sense of pride of doing it yourself and standing on your own two feet with your head held high but mental illness is such a serious problem and it can manifest later on in life into attitudes and behaviours that can really destroy."
Depressing times are to be expected but Anita no longer fears them.
"My particular mental illness has actually driven me forward because as much as I do have those moments, I also want to overcome those moments, become a better person and to create a life where I am a happier person and more satisfied," she says.
"So it is always that one dark moment that can push me to create better moments."
*Names have been changed to protect privacy.
Where to get help:
Lifeline: 0800 543 354
Suicide Crisis Helpline: 0508 828 865 / 0508 TAUTOKO (24/7). This is a service for people who may be thinking about suicide, or those who are concerned about family or friends.
Depression Helpline: 0800 111 757 (24/7)
Samaritans: 0800 726 666 (24/7)
Youthline: 0800 376 633 (24/7) or free text 234 (8am-12am), or email email@example.com
What's Up: online chat (7pm-10pm) or 0800 WHATSUP / 0800 9428 787 children's helpline (1pm-10pm weekdays, 3pm-10pm weekends)
Kidsline (ages 5-18): 0800 543 754 (24/7)
Rural Support Trust Helpline: 0800 787 254
Healthline: 0800 611 116
Rainbow Youth: (09) 376 4155
If it is an emergency and you feel like you or someone else is at risk, call 111.