depression through chinese eyes: a window into public mental health in multicultural australia...
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Depression ThroughDepression Through Chinese Eyes: Chinese Eyes:
a window into public a window into public mental health in mental health in
multicultural Australiamulticultural AustraliaBibiana Chan, SPHCM Bibiana Chan, SPHCM
PhD thesis supervisors: Prof. Maurice PhD thesis supervisors: Prof. Maurice Eisenbruch, Prof Gordon Parker, A/Prof Eisenbruch, Prof Gordon Parker, A/Prof
Jan Ritchie Jan Ritchie
Roadmap of presentationRoadmap of presentation
Why study depression?Why study depression? Migration, Acculturation, Transcultural Migration, Acculturation, Transcultural
PsychiatryPsychiatry Cultural Construction of Illness & TCMCultural Construction of Illness & TCM MethodologyMethodology Quan statistical findings & Qual thematic Quan statistical findings & Qual thematic
analysis analysis Cultural Competent Psychiatry Cultural Competent Psychiatry LimitationsLimitations Where do we go from here?Where do we go from here?
Why study depression?Why study depression?
1. 1. WHO named ‘clinical depression’ as the WHO named ‘clinical depression’ as the 22ndnd greatest burden of disease (DIYS) greatest burden of disease (DIYS) Mathers and Loncar, 2006Mathers and Loncar, 2006
2. High prevalence of Major Depression in 2. High prevalence of Major Depression in Western culturesWestern cultures Kessler et al. 1994, 2005.Kessler et al. 1994, 2005.
3. Low prevalence in Chinese at different 3. Low prevalence in Chinese at different sitessites
Chen et al 1993, HK; Hwa et al 1996, Taiwan; Murray & Lopez Chen et al 1993, HK; Hwa et al 1996, Taiwan; Murray & Lopez 1999, Shen et al. 2006, China.1999, Shen et al. 2006, China.
4. 4. Cross-cultural studies: high prevalence Cross-cultural studies: high prevalence Centre w’ low threshold, low prevalence Centre w’ low threshold, low prevalence Centre w’ high thresholdCentre w’ high threshold Simon et al. 2001.Simon et al. 2001.
Help-Help-seekingseeking
Western Culture Chinese Culture
DepressiDepressionon
MigrationAcculturation
Chinese in Sydney
Cultural construction of illnessCultural construction of illness
Kleinman seminal study in Hunan, China in 80s, Kleinman seminal study in Hunan, China in 80s, coined the term ‘coined the term ‘Explanatory Models’. Explanatory Models’.
‘‘Somatisation Vs PsychologisationSomatisation Vs Psychologisation’ (Kirmayer, ’ (Kirmayer, Cheng, Parker)Cheng, Parker)
SJSR gains popularity in 80s but declined in SJSR gains popularity in 80s but declined in 1990s1990s when CCMD-II became widely used in when CCMD-II became widely used in China (Lee & Kleinman 1997)China (Lee & Kleinman 1997)
Body-Mind LinkBody-Mind Link - Conceptualization of - Conceptualization of Depression in Chinese (Ying 2002) Depression in Chinese (Ying 2002)
Examples in other cultures Examples in other cultures (Major Depression, (Major Depression, Evil eyes, Evil eyes, nervos, susto)nervos, susto)
Traditional Chinese MedicineTraditional Chinese Medicine
Harmony and Harmony and Yin/Yang BalanceYin/Yang Balance at cosmological, society, family at cosmological, society, family and individual’s physical leveland individual’s physical level
Body-mind link Excessive EmotionsExcessive Emotions as cause of as cause of
‘illness’ (threaten harmony of ‘illness’ (threaten harmony of ‘group’)‘group’)
‘‘Nourish Life’’ as the long term as the long term goal (c.f. treating acute illness) fit goal (c.f. treating acute illness) fit well with viewing mental illness as well with viewing mental illness as chronic chronic
Pre-migration
Migration
Post-migration
Vu
lner
abil
ity
Res
ilie
nce
AcculturationMental Disorder
Su
pp
ort
Self
Bhugra’s Model
Receiving country
Country of origin
Mixed methods Mixed methods
Quantitative Quantitative ToolsTools Depression stateDepression state
DMI-10DMI-10 AcculturationAcculturation
Suinn-Lew scaleSuinn-Lew scale Self-depression?Self-depression?
Y/N itemY/N item Help-seekingHelp-seeking
5-choice item5-choice item
Qualitative ToolsQualitative Tools A projective testA projective test
2 scenarios, 1F & 1 M2 scenarios, 1F & 1 M AcculturationAcculturation
Suinn-Lew scaleSuinn-Lew scale Self-depression?Self-depression?
Narrative, disclosureNarrative, disclosure Help-seekingHelp-seeking
Narrative, disclosureNarrative, disclosure The meaning of The meaning of
‘emotional ‘emotional distress’ :MDEMSdistress’ :MDEMS
AssumptionsAssumptions Migrants are disposed to Migrants are disposed to high
acculturation stress likely to trigger likely to trigger clinical depression clinical depression
Low acculturated Chinese less familiar Low acculturated Chinese less familiar with Western medical model of with Western medical model of depression, thus in structuring Survey, depression, thus in structuring Survey, avoid pre-disposing informants to one model or another.
No-help sought? (missing data): No-help sought? (missing data): definitive list of possible help-seeking definitive list of possible help-seeking strategies in survey.strategies in survey.
Demographics & Depression (survey group)Demographics & Depression (survey group)
ChineseChinese ControlControlss
Showing degree of Showing degree of acculturationacculturation
LowLow
n= 243n= 243
High High
n = 115n = 115 n = 143n = 143
AgeAge 43.343.3 31.431.4 41.541.5Bachelor DegreeBachelor Degree 21%21% 42%42% 22%22%Not in workforceNot in workforce 39%39% 10%10% 9%9%Age at MigrationAge at Migration 32.832.8 13.813.8 N/AN/ASLASSLAS 2.052.05 2.722.72 N/AN/ADepressive Depressive Episode*Episode*
27.9%27.9% 37.6%37.6% 49.2%49.2%
Episode >4 wk*Episode >4 wk* 14.4%14.4% 16.8%16.8% 28.8%28.8%
Recognition of depressive symptoms Recognition of depressive symptoms among Low-Acc and High-Acc Chineseamong Low-Acc and High-Acc Chinese
Core symptom
s
Depressed, loss of interest, motivation, and helpless
Somatic Symptoms
Insomnia, heaviness in chest, body-ache pain…Salient to Low-Acc Chinese
Non-somatic (Cognitive) Symptoms
Suicidal thoughts, feelings of worthlessness,Salient to High-Acc Chinese
ChineseRecognition
of symptoms
Most Troubling SymptomsMost Troubling Symptoms (self-(self-nominated)nominated)
Low-AccLow-Acc
Chinese Chinese n=71 Weighted n=71 Weighted scorescore
High-AccHigh-Acc
Chinese Chinese n=47 Weighted n=47 Weighted
scorescore
Aust Aust n=65 n=65 Weighted Weighted
scorescore
InsomniaInsomnia 67 (1)67 (1) 20 (2)20 (2) 18(6)18(6)
depressedepressedd
42 (2)42 (2) 39(1)39(1) 24 (5)24 (5)
Anxious & Anxious & tensetense 31 (31 (3)3) 25(5)25(5) 46 (1)46 (1)
XX motivationmotivation
20 (4)20 (4) 27(4)27(4) 29(2)29(2)
withdrawwithdrawnn
18 (5a)18 (5a) 14(6)14(6) 25 (3a)25 (3a)
HopelessHopeless 18 (5b)18 (5b) 11(10)11(10) 10 (11)10 (11)
SadnessSadness 9 (12)9 (12) 29 (3)29 (3) 16 (7)16 (7)
FatigueFatigue 7 (14)7 (14) 20(6)20(6) 25 (3b)25 (3b)
Most nominated EMsMost nominated EMsLow-Low-Acc Acc n=59n=59
High-Acc High-Acc n=44n=44
AustAustn=60n=60
χχ 2 2
df = 2df = 2
Life StressLife Stress 11.911.9 15.915.9 23.323.3 2.822.82Work Work StressStress
16.916.9 15.915.9 8.38.3 2.192.19
RelationshiRelationshipp
15.315.3 22.722.7 20.020.0 0.970.97
Study-Study-relatedrelated
11.911.9 13.613.6 3.33.3 4.014.01
Health-related
10.210.2 4.54.5 20.020.0 6.01*6.01*
Family Challenges
20.320.3 22.722.7 6.76.7 6.21*6.21*
FinanceFinance 6.86.8 9.19.1 1.71.7 2.962.96MigrationMigration 11.911.9 4.54.5 N/AN/A 1.69 1.69 df=1df=1
Episode less than 4 Episode less than 4 weeksweeks
0246
8101214
161820
X GP Rx Psy't Herb't F/F
C-Chin
C-Eng
Control
No. of Inform’t
Episode more than 4 Episode more than 4 weeksweeks
0
10
20
30
40
50
60
70
80
X GP Rx Psy't Herb't F/F
C-Chin
C-Eng
Control
%
Diagrammatic representation of the detail help-seeking pathway of
Low-Acc Chinese.
(1)Herbalist
Only
(2) Rx
(1)Rx
Low-Acc Chinese (n = 47)
(13)No help(34) Help Sought
(5) Informal Help (30) Prof Help
(3)Herbalist (24) GPs(12) Psychologist
(7) Specialist (17)No-specialist
(5) Anti-Depressant
(2) No Anti-Depressant
(2) Anti-Depressant
(15) No Anti-Depressant
(2)(2)Anti-Depressant
(3) No Anti-Depressant
(2)Rx(1)
Rx
(1)
(4) no Otherhelp
(1)(1)
Help-seeking PuzzleHelp-seeking Puzzle
Self-helpFamily
& Friends
Cultural
ValuesSpiritual
Chinese
Medicine
GP
Psycho Therapy
Counselling
Community
Support
Psychiatrist
Normalize Depression
Multisectoral Collaborat’n
Em
powerm
entof consum
ers
Reco
gn
ition
of
pro
fessio
nal h
elp
Lay Illness ConceptLay Illness ConceptSick in the body
Unwell in the mind
Permanentserious
Attacked by pathogens
Mental Illness
Psychological Mind State
EmotionalUps & Downs
ImbalanceNot Physical
SJSR
Schizophrenia
ManicDepressives
Highly Stigmatized
Start to attract stigmaSelf-talk, suicidal
Mad,
Crazy Violent, out
of control
Could snap out
Short course
Could get worse
Could it be SJSR?
ImplicationsImplications ((a) If Chinese are good at recognising symptoms how can they be
encouraged to
report these symptoms to their doctors? (b) If Chinese GPs are the first port of call in many
depression cases, how can GPs be better equipped to make accurate diagnoses?
(c) If Low-Acc Chinese are more likely to talk about emotional distress with Chinese herbalists, how will these herbalists then refer their patients to mainstream mental health services?
(d) Focus group informants expressed their wish to learn more about clinical depression and its treatment.
Cultural Competent Cultural Competent PsychiatryPsychiatry
Health system
(doctors, hospitals
, etc)
Culturally Competen
tPsychiatr
y
Chinese GPs &
Herbalists
Psychotherapy Counselling, CBT* & Family Therapy
referral
Support groups,
Community services
Socio-culturalSupportFamily &Friends
Where do we go from Where do we go from here?here?
Population mental health – suicide Population mental health – suicide prevention & health promotion (c.f. prevention & health promotion (c.f. infant immunization)infant immunization)
Normalisation & de-stigmatization – given Normalisation & de-stigmatization – given permission to talk about negative emotionspermission to talk about negative emotions
Building social capital (resilience, family and Building social capital (resilience, family and cultural values, social inclusion & consumer cultural values, social inclusion & consumer participation)participation)
Holistic approach – healthy person, healthy Holistic approach – healthy person, healthy family, healthy school/work place and health family, healthy school/work place and health society society
Evaluation of Cultural Competency in practiceEvaluation of Cultural Competency in practice
AcknowledgementAcknowledgement All professional & lay helpers who walked along the journey of recovery with me. NHMRC for the funding to make this research possible. My research supervisors Professor Maurice Eisenbruch, Professor Gordon Parker, A/Professor Jan Ritchie for their intellectual input. All participating GPs, Chinese herbalists, medical centres, and community organizations to facilitate data collection.