Presentation on theme: "Depression Through Chinese Eyes: a window into public mental health in multicultural Australia Bibiana Chan, SPHCM PhD thesis supervisors: Prof. Maurice."— Presentation transcript:
1Depression Through Chinese Eyes: a window into public mental health in multicultural Australia Bibiana Chan, SPHCMPhD thesis supervisors: Prof. Maurice Eisenbruch, Prof Gordon Parker, A/Prof Jan Ritchie
2Roadmap of presentation Why study depression?Migration, Acculturation, Transcultural PsychiatryCultural Construction of Illness & TCMMethodologyQuan statistical findings & Qual thematic analysisCultural Competent PsychiatryLimitationsWhere do we go from here?
3Why study depression?1. WHO named ‘clinical depression’ as the 2nd greatest burden of disease (DIYS) Mathers and Loncar, 20062. High prevalence of Major Depression in Western cultures Kessler et al. 1994, 2005.3. Low prevalence in Chinese at different sitesChen et al 1993, HK; Hwa et al 1996, Taiwan; Murray & Lopez 1999, Shen et al. 2006, China.4. Cross-cultural studies: high prevalence Centre w’ low threshold, low prevalence Centre w’ high threshold Simon et al
4Migration Depression Acculturation Chinese in Sydney Help-seeking Chinese CultureWestern CultureHelp-seeking
6Time Chart of Important Events 1900-2003 end of 19th C.Gold Rush May 4 Student Movement 1919R.C 1911People’s Republic of China 1949Culture Revolution/Riots in HKWhite Australian Policy Abolished (Whitlam)1974Sino-British Talks( )Tienanman Square Student Movements 1989Global Economic Recession/Migration Peak(1991-2)Taiwan-China Conflict/Hansonism (Anti-immigration)The New Millennium & GST 2000Sept. 11, 2001War on Iraq & SARS,2003l....l....l….l….l….l….l….l….l….l….l….l….l….l….l….l….l….l….l….l….l….l….l….l…l….lNew Australian Citizenship Test, Sept 2007
7Cultural construction of illness Kleinman seminal study in Hunan, China in 80s, coined the term ‘Explanatory Models’.‘Somatisation Vs Psychologisation’ (Kirmayer, Cheng, Parker)SJSR gains popularity in 80s but declined in 1990s when CCMD-II became widely used in China (Lee & Kleinman 1997)Body-Mind Link - Conceptualization of Depression in Chinese (Ying 2002)Examples in other cultures (Major Depression, Evil eyes, nervos, susto)
8Traditional Chinese Medicine Harmony and Yin/Yang Balance at cosmological, society, family and individual’s physical levelBody-mind linkExcessive Emotions as cause of ‘illness’ (threaten harmony of ‘group’)‘Nourish Life’ as the long term goal (c.f. treating acute illness) fit well with viewing mental illness as chronic
9Bhugra’s Model Country of origin Pre-migration Vulnerability ResilienceMigrationSupportPost-migrationMentalDisorderAcculturationReceivingcountrySelf
10Mixed methods Qualitative Tools Quantitative Tools Depression state DMI-10AcculturationSuinn-Lew scaleSelf-depression?Y/N itemHelp-seeking5-choice itemQualitative ToolsA projective test2 scenarios, 1F & 1 MAcculturationSuinn-Lew scaleSelf-depression?Narrative, disclosureHelp-seekingThe meaning of ‘emotional distress’ :MDEMS
11AssumptionsMigrants are disposed to high acculturation stress likely to trigger clinical depressionLow acculturated Chinese less familiar with Western medical model of depression, thus in structuring Survey, avoid pre-disposing informants to one model or another.No-help sought? (missing data): definitive list of possible help-seeking strategies in survey.
12Demographics & Depression (survey group) ChineseControlsShowing degree of acculturationLown= 243Highn = 115n = 143Age43.331.441.5Bachelor Degree21%42%22%Not in workforce39%10%9%Age at Migration32.813.8N/ASLAS2.052.72Depressive Episode*27.9%37.6%49.2%Episode >4 wk*14.4%16.8%28.8%
13Berry’s 4-fold Acculturation Model Level of identification with host cultureAssimilationIntegrationMarginalizationSeparationLevel of Identification with heritage culture
15Recognition of depressive symptoms among Low-Acc and High-Acc Chinese Core symptomsDepressed, loss of interest, motivation, and helplessSomatic SymptomsInsomnia, heaviness in chest, body-ache pain…Salient to Low-Acc ChineseNon-somatic (Cognitive) SymptomsSuicidal thoughts, feelings of worthlessness,Salient to High-Acc ChineseChineseRecognition of symptoms
20Diagrammatic representation of the detail help-seeking pathway of Low-Acc Chinese.
21Diagrammatic representation of the detail help-seeking pathway of Australians (5)Rx(1)Australians (n = 38)(2) No help(36) Help Sought(6) Informal Help(35) Prof Help(2)Herbalist(27) GPs(14) Psychologist(15) Specialist(12) No-specialist(14) Anti-Depressant(1) No Anti-(6) Anti-(6) No Anti-(2) Anti-(2) No Anti-(2)(1) nootherhelp(4)No Rx(9)
22Help-seeking Puzzle Recognition of professional help Empowerment Self-helpFamily& FriendsCulturalValuesSpiritualChineseMedicineGPPsychoTherapyCounsellingCommunitySupportPsychiatristNormalize DepressionMultisectoral Collaborat’nEmpowermentof consumersRecognition of professional help
23Start to attract stigma Lay Illness ConceptSick in the bodyCould snap outUnwell in the mindShort coursePsychologicalMind StateAttacked bypathogensCould get worseEmotionalUps & DownsCould it be SJSR?SJSRImbalanceNot PhysicalPermanentseriousMental IllnessStart to attract stigmaSelf-talk, suicidalDepressivesMad, CrazyManicViolent, out of controlSchizophreniaHighly Stigmatized
24Implications(a) If Chinese are good at recognising symptoms how can they be encouraged toreport 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 thenrefer their patients to mainstream mental health services?(d) Focus group informants expressed their wish tolearn more about clinical depression and its treatment.
25Cultural Competent Psychiatry Health system (doctors, hospitals, etc)Culturally CompetentPsychiatryChinese GPs &HerbalistsPsychotherapyCounselling,CBT* & Family TherapyreferralSupport groups,CommunityservicesSocio-culturalSupportFamily &Friends
26Limitations of QUAN survey ‘Have your ever seen a doctor 4 emotional unease?’ : researcher’s expected response Vs respondents’ interpretation? Mismatch?Literate (more educated) subjects only “medical sample, limited generalizability”Recognition of depressive symptoms: “projected response? Intelligent guess?”Self-report Vs interview“social desirability Vs Subject-interviewer power differential”Self-selected subjects (response rate = 64.8%)“those not interested or preferred not to disclose personal info might not have returned the survey”
27Limitations of QUAL study Focus groups attracted female participants. ‘Talking’ is a preferred activity for female. Explore other format to collect male voices.Retold stories – informants told stories of friends or family. People who are currently depressed are too ‘sick’ to take part.Purposeful sampling recruit those interested to express their views: a research methodology to collect ‘informative’ data.Embedding life events into scenario; some Chinese could not cope with ‘ambiguity’. The balance of giving adequate contents for discussion without being too directive.
28General limitationsInsider Research (both as Chinese and consumer) insights into asking the right questions; could overlook 2nd generation perspective,Subjective view of one researcher, countered by co-researchers as ‘sounding board’Setting up scenario from Chinese migrant’s perspective, applied well in non-Chinese group; these common life events serve as universal triggersDual users of TCM & Western Medicine: observed in both GP & herbalist rooms. Future research should ask any previous GP visit or herbalist visit.
29Limitations involving ethnicity Self-identified as ChineseNon-Chinese controls - have lived in Australia for at least 20 years or locally bornLimited generalization to Chinese outside SydneyParticipants recruited from bilingual Chinese GP clinics: majority preferred Chinese questionnaires (low-acculturation)
30Where do we go from here?Population mental health – suicide prevention & health promotion (c.f. infant immunization)Normalisation & de-stigmatization – given permission to talk about negative emotionsBuilding social capital (resilience, family and cultural values, social inclusion & consumer participation)Holistic approach – healthy person, healthy family, healthy school/work place and health societyEvaluation of Cultural Competency in practice
31AcknowledgementAll 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.