1. Depression Through Chinese Eyes: a window into public mental health in multicultural Australia
Bibiana Chan, SPHCM
PhD thesis supervisors: Prof. Maurice Eisenbruch, Prof Gordon Parker, A/Prof Jan Ritchie

2. Roadmap of presentation
Why study depression?
Migration, Acculturation, Transcultural Psychiatry
Cultural Construction of Illness & TCM
Methodology
Quan statistical findings & Qual thematic analysis
Cultural Competent Psychiatry
Limitations
Where do we go from here?

3. Why study depression?
1. WHO named ‘clinical depression’ as the 2nd greatest burden of disease (DIYS) Mathers and Loncar, 2006
2. High prevalence of Major Depression in Western cultures Kessler et al. 1994, 2005.
3. Low prevalence in Chinese at different sites
Chen 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

4. Migration Depression Acculturation Chinese in Sydney Help-seeking
Chinese Culture
Western Culture
Help-seeking

5. Cross-cultural Comparisons%
Chin-China
Control
Chin-Aust M2 M1 Mo
English
Language
confidence

6. Time Chart of Important Events 1900-2003
end of 19th C.
Gold Rush May 4 Student Movement 1919
R.C 1911
People’s Republic of China 1949
Culture Revolution/Riots in HK
White Australian Policy Abolished (Whitlam)1974
Sino-British Talks( )
Tienanman Square Student Movements 1989
Global Economic Recession/Migration Peak(1991-2)
Taiwan-China Conflict/Hansonism (Anti-immigration)
The New Millennium & GST 2000
Sept. 11, 2001
War on Iraq & SARS,2003
l....l....l….l….l….l….l….l….l….l….l….l….l….l….l….l….l….l….l….l….l….l….l….l…l….l
New Australian Citizenship Test, Sept 2007

7. Cultural 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)

8. Traditional Chinese Medicine
Harmony and Yin/Yang Balance at cosmological, society, family and individual’s physical level
Body-mind link
Excessive 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

9. Bhugra’s Model Country of origin Pre-migration Vulnerability
Resilience
Migration
Support
Post-migration
Mental
Disorder
Acculturation
Receiving
country
Self

10. Mixed methods Qualitative Tools Quantitative Tools Depression state
DMI-10
Acculturation
Suinn-Lew scale
Self-depression?
Y/N item
Help-seeking
5-choice item
Qualitative Tools
A projective test
2 scenarios, 1F & 1 M
Acculturation
Suinn-Lew scale
Self-depression?
Narrative, disclosure
Help-seeking
The meaning of ‘emotional distress’ :MDEMS

11. Assumptions
Migrants are disposed to high acculturation stress likely to trigger clinical depression
Low 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.

12. Demographics & Depression (survey group)
Chinese
Controls
Showing degree of acculturation
Low
n= 243
High
n = 115
n = 143
Age
43.3
31.4
41.5
Bachelor Degree
21%
42%
22%
Not in workforce
39%
10% 9%
Age at Migration
32.8
13.8
N/A
SLAS
2.05
2.72
Depressive Episode*
27.9%
37.6%
49.2%
Episode >4 wk*
14.4%
16.8%
28.8%

13. Berry’s 4-fold Acculturation Model
Level of identification with host culture
Assimilation
Integration
Marginalization
Separation
Level of Identification with heritage culture

14. Australian Vs Chinese Self-Identity

15. Recognition of depressive symptoms among Low-Acc and High-Acc Chinese
Core symptoms
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
Chinese
Recognition of symptoms

16. Most Troubling Symptoms (self-nominated)
Low-Acc
Chinese
n=71 Weighted score
High-Acc
Chinese n=47 Weighted score
Aust
n=65 Weighted score
Insomnia
67 (1)
20 (2)
18(6)
depressed
42 (2)
39(1)
24 (5)
Anxious & tense
31 (3)
25(5)
46 (1)
X motivation
20 (4)
27(4)
29(2)
withdrawn
18 (5a)
14(6)
25 (3a)
Hopeless
18 (5b)
11(10)
10 (11)
Sadness
9 (12)
29 (3)
16 (7)
Fatigue
7 (14)
20(6)
25 (3b)

17. Most nominated EMs Low-Acc High-Acc Aust χ 2 11.9 15.9 23.3 2.82 16.9
df = 2
Life Stress
11.9
15.9
23.3
2.82
Work Stress
16.9
8.3
2.19
Relationship
15.3
22.7
20.0
0.97
Study-related
13.6
3.3
4.01
Health-related
10.2
4.5
6.01*
Family Challenges
20.3
6.7
6.21*
Finance
6.8
9.1
1.7
2.96
Migration
N/A
1.69 df=1

18. Episode less than 4 weeks
No. of
Inform’t

19. Episode more than 4 weeks%

20. Diagrammatic representation of the detail help-seeking pathway of Low-Acc Chinese.

21. Diagrammatic 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) no
other
help
(4)
No Rx
(9)

22. Help-seeking Puzzle Recognition of professional help Empowerment
Self-help
Family
& Friends
Cultural
Values
Spiritual
Chinese
Medicine GP
Psycho
Therapy
Counselling
Community
Support
Psychiatrist
Normalize Depression
Multisectoral Collaborat’n
Empowerment
of consumers
Recognition of professional help

23. Start to attract stigma
Lay Illness Concept
Sick in the body
Could snap out
Unwell in the mind
Short course
Psychological
Mind State
Attacked by
pathogens
Could get worse
Emotional
Ups & Downs
Could it be SJSR?
SJSR
Imbalance
Not Physical
Permanent
serious
Mental Illness
Start to attract stigma
Self-talk, suicidal
Depressives
Mad, Crazy
Manic
Violent, out of control
Schizophrenia
Highly Stigmatized

24. Implications
(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.

25. Cultural Competent Psychiatry
Health system (doctors, hospitals, etc)
Culturally Competent
Psychiatry
Chinese GPs &
Herbalists
Psychotherapy
Counselling,
CBT* & Family Therapy
referral
Support groups,
Community
services
Socio-cultural
Support
Family &
Friends

26. Limitations 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”

27. Limitations 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.

28. General limitations
Insider 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 triggers
Dual users of TCM & Western Medicine: observed in both GP & herbalist rooms. Future research should ask any previous GP visit or herbalist visit.

29. Limitations involving ethnicity
Self-identified as Chinese
Non-Chinese controls - have lived in Australia for at least 20 years or locally born
Limited generalization to Chinese outside Sydney
Participants recruited from bilingual Chinese GP clinics: majority preferred Chinese questionnaires (low-acculturation)

30. Where 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 emotions
Building social capital (resilience, family and cultural values, social inclusion & consumer participation)
Holistic approach – healthy person, healthy family, healthy school/work place and health society
Evaluation of Cultural Competency in practice

31. Acknowledgement
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.