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Depression Through Chinese Eyes: a window into public mental health in multicultural Australia Bibiana Chan, SPHCM PhD thesis supervisors: Prof. Maurice.

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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:

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.

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