Chinese-Australians' knowledge of depression and schizophrenia in the context of their under-utilization of mental health care: an analysis of labelling.

BACKGROUND: Low knowledge of and discrimination regarding mental disorders (MDs) may underpin lower access to mental health care by ethnic minority groups. AIMS: In Chinese-Australians, in relation to schizophrenia and depression, to assess (a) labels attached to MDs, (b) conceptual distinctiveness of MDs, (c) labelling accuracy against an Australian representative sample, (d) how syndrome variations may influence labelling, and (e) effects of exposure to MDs on labelling. METHOD: 418 subjects were asked to indicate the labels they would apply to vignettes of depression and schizophrenia and whether they were exposed to these disorders personally or socially. RESULTS: The sample was broadly representative of the Australian-Chinese community: 51% and 47% 'correctly' labelled the vignettes. Depression and schizophrenia labels were consistently discriminated and clustered with different other labels. Labelling accuracy surpassed Australians'. Labelling did not vary substantially between syndromes. Exposure related to increased labelling accuracy for depression. CONCLUSIONS: Accuracy in labelling major forms of MDs does not appear low in Chinese-Australians and seems higher than in the Australian community. MDs were discriminated although syndrome variations were not. Findings dispute that low mental health care access and uptake is due to low recognition and discrimination of MDs in Chinese-Australians.

Depression in multicultural Australia: policies, research and services.

BACKGROUND: Depression is one of the leading causes of disability in Australia. The cultural and linguistic diversity of the Australian population poses a significant challenge to health policy development, service provision, professional education, and research. The purpose of this study is to explore the extent to which the fact of cultural and linguistic diversity has influenced the formulation of mental health policy, the conduct of mental health research and the development of mental health services for people with depression from ethnic minority communities. METHODS: The methods used for the different components of the study included surveys and document-based content and thematic analyses. RESULTS: Policy is comprehensive but its translation into programs is inadequate. Across Australia, there were few specific programs on depression in ethnic minority communities and they are confronted with a variety of implementation difficulties. The scope and scale of research on depression in Ethnic minority communities is extremely limited. CONCLUSION: A key problem is that the research that is necessary to provide evidence for policy and service delivery is lacking. If depression in Ethnic minority communities is to be addressed effectively the gaps between policy intentions and policy implementation, and between information needs for policies and practice and the actual research that is being done, have to be narrowed.

Illness causal beliefs in Turkish immigrants.

BACKGROUND: People hold a wide variety of beliefs concerning the causes of illness. Such beliefs vary across cultures and, among immigrants, may be influenced by many factors, including level of acculturation, gender, level of education, and experience of illness and treatment. This study examines illness causal beliefs in Turkish-immigrants in Australia. METHODS: Causal beliefs about somatic and mental illness were examined in a sample of 444 members of the Turkish population of Melbourne. The socio-demographic characteristics of the sample were broadly similar to those of the Melbourne Turkish community. Five issues were examined: the structure of causal beliefs; the relative frequency of natural, supernatural and metaphysical beliefs; ascription of somatic, mental, or both somatic and mental conditions to the various causes; the correlations of belief types with socio-demographic, modernizing and acculturation variables; and the relationship between causal beliefs and current illness. RESULTS: Principal components analysis revealed two broad factors, accounting for 58 percent of the variation in scores on illness belief scales, distinctly interpretable as natural and supernatural beliefs. Second, beliefs in natural causes were more frequent than beliefs in supernatural causes. Third, some causal beliefs were commonly linked to both somatic and mental conditions while others were regarded as more specific to either somatic or mental disorders. Last, there was a range of correlations between endorsement of belief types and factors defining heterogeneity within the community, including with demographic factors, indicators of modernizing and acculturative processes, and the current presence of illness. CONCLUSION: Results supported the classification of causal beliefs proposed by Murdock, Wilson & Frederick, with a division into natural and supernatural causes. While belief in natural causes is more common, belief in supernatural causes persists despite modernizing and acculturative influences. Different types of causal beliefs are held in relation to somatic or mental illness, and a variety of apparently logically incompatible beliefs may be concurrently held. Illness causal beliefs are dynamic and are related to demographic, modernizing, and acculturative factors, and to the current presence of illness. Any assumption of uniformity of illness causal beliefs within a community, even one that is relatively culturally homogeneous, is likely to be misleading. A better understanding of the diversity, and determinants, of illness causal beliefs can be of value in improving our understanding of illness experience, the clinical process, and in developing more effective health services and population health strategies.

Cultural attribution of mental health suffering in Chinese societies: the views of Chinese patients with mental illness and their caregivers.

AIMS AND OBJECTIVES: This study examined the cultural attribution of distress in the Chinese, the special role of the family in distress and the specific emotional reactions within distress dictated by culture. METHODS: This phenomenological study illustrated the narrative representation of the experiences of suffering by the Chinese patients with mental illness. Twenty-eight Chinese-Australian patients and their caregivers were interviewed together in their homes. They were invited to talk about the stories of the patients' experiences of suffering from mental illness. The interviews were recorded and transcribed to be further analysed according to the principles of narrative analysis. RESULTS: The results of case narration indicated that (1) because of the influence of Confucian ideals, interpersonal harmony was the key element of maintaining the Chinese patients' mental health, (2) Chinese patients' failure to fulfil cultural expectations of appropriate behaviours as family members contributed to disturbance of interpersonal relationships and (3) Chinese patients' failure to fulfil their familial obligations contributes to their diminished self-worth and increased sense of guilt and shame. CONCLUSIONS: The findings of the present study suggest that Chinese people's well-being is significantly determined by a harmonious relationship with others in the social and cultural context. Psychotherapy emphasizing an individual's growth and autonomy may ignore the importance of maintaining interpersonal harmony in Chinese culture. The results of this study contribute to the essential knowledge about culturally sensitive nursing practices. An understanding of patient suffering that is shaped by traditional cultural values helps nurses communicate empathy in a culturally sensitive manner to facilitate the therapeutic relationship and clinical outcomes.

Mental health research, ethics and multiculturalism.

In this paper we examine ethical issues relevant to conducting mental health research with refugees and immigrant communities that have cultural orientations and social organisation that are substantially different to those of the broader Australian community, and we relate these issues to NH&MRC Guidelines. We describe the development and conduct of a mental health research project carried out recently in Melbourne with the Somali community, focusing on ethical principles involved, and relating these to the NH&MRC National Statement on Ethical Conduct in Research Involving Humans, and the NH&MRC document Values and Ethics: Guidelines for Ethical Conduct in Aboriginal and Torres Strait Islander Health Research. The experience of conducting mental health research with the Somali community highlights the fact that the principles of inclusion and benefit enunciated in the NH&MRC document Values and Ethics are particularly pertinent when conducting research with refugees and immigrant communities that are culturally distant to those of the broader Australian community. These principles inform issues of research design and consent, as well as guiding respectful engagement with the participating community and communication of the research findings.

Folk concepts of mental disorders among Chinese-Australian patients and their caregivers.

AIM: This paper reports a study of (a) popular conceptions of mental illness throughout history, (b) how current social and cultural knowledge about mental illness influences Chinese-Australian patients' and caregivers' understanding of mental illness and the consequences of this for explaining and labelling patients' problems. BACKGROUND: According to traditional Chinese cultural knowledge about health and illness, Chinese people believe that psychotic illness is the only type of mental illness, and that non-psychotic illness is a physical illness. Regarding patients' problems as not being due to mental illness may result in delaying use of Western mental health services. METHODS: Data collection took place in 2001. Twenty-eight Chinese-Australian patients with mental illness and their caregivers were interviewed at home, drawing on Kleinman's explanatory model and studies of cultural transmission. Interviews were tape-recorded and transcribed, and analysed for plots and themes. FINDINGS: Chinese-Australians combined traditional knowledge with Western medical knowledge to develop their own labels for various kinds of mental disorders, including 'mental illness', 'physical illness', 'normal problems of living' and 'psychological problems'. As they learnt more about Western conceptions of psychology and psychiatry, their understanding of some disorders changed. What was previously ascribed to non-mental disorders was often re-labelled as 'mental illness' or 'psychological problems'. CONCLUSION: Educational programmes aimed at introducing Chinese immigrants to counselling and other psychiatric services could be made more effective if designers gave greater consideration to Chinese understanding of mental illness.

Ethnic minority community patients and the Better Outcomes in Mental Health Care initiative.

OBJECTIVE: To compare general practitioners registered under the Better Outcomes in Mental Health Care initiative (BOiMHC) and those not registered, in addressing mental disorders in members of ethnic minority communities (EMCs). METHODS: We conducted a cross-sectional survey of 597 Melbourne metropolitan general practitioners, leading to 311 meeting criteria for having seen EMC patients with a mental disorder in the last 3 months. Comparisons were made between those registered (n = 61) and those not registered (n = 205) within the BOiMHC on measures of difficulties in: accessing bilingual allied health, accessing interpreters, accessing translated materials, patient compliance, accessing guidelines for working effectively with interpreters, accessing guidelines on cultural and migration factors affecting mental health. RESULTS: Significantly less of those registered in the BOiMHC endorsed problems of access to bilingual allied health, interpreters and translated materials compared with those not registered. No differences between groups were observed in relation to access to guidelines and patient compliance. Those registered with the BOiMHC reported significantly less problems than those not registered. The most prevalent problems of the full sample included lack of access to bilingual allied health (70%), access to translated materials (58%) and low EMC patient compliance with mental health assessment and treatment (64%). CONCLUSIONS: Possible impacts of the BOiMHC appear to be modest in relation to EMC patients with mental disorders. The BOiMHC may require additional strategies for its application to EMCs, especially for patient engagement in mental health assessment and treatment. There is a need for a more comprehensive evaluation of EMC issues within the BOiMHC.

'Nobody can help me...i am living through it alone': experiences of caring for people diagnosed with mental illness in ethno-cultural and linguistic minority communities.

Caregivers of people diagnosed with mental illness in ethno-cultural and linguistic minority communities (ECLMCs) face considerable demands and difficulties in their day-to-day caring role. Data from interviews with 20 caregivers from Polish, Croatian, Bosnian, and Chinese communities, undertaken in Perth, Western Australia, explore the roles caregivers play in the lives of their relatives and illustrate their use and non-use of support services. A diverse array of challenges confronts caregivers across the different ECLMCs. Although not an unequivocally negative experience, caring for a relative diagnosed with mental illness was found to frequently disrupt family relationships and to lead to physical and mental exhaustion as well as social isolation. The stigma associated with mental illness in ECLMCs is a significant factor dissuading people from seeking assistance from external agencies. Many mainstream services are seen as inappropriate, which appears to be a factor in their under-utilization. If mental health policies and community services are to seriously address the issue of appropriate support for caregivers from ECLMCs, it is important that they are aware of the nature of the considerable demands placed on such caregivers as they endeavor to support their dependent relatives.

A comparative study of sertraline dosages, plasma concentrations, efficacy and adverse reactions in Chinese versus Caucasian patients.

This prospective 6-week study examined the differences in dosage and steady state plasma concentrations of sertraline in Chinese versus Caucasian depressed patients. Two groups of Chinese patients from different geographical sites and a group of Caucasian patients were evaluated with clinical measures during an initial dose of 50 mg/day, with subsequent doses adjusted clinically. The results of 17 Australian Chinese (ACHI), 13 Malaysian Chinese (MCHI) and 15 Australian Caucasians (AC) were analysed. Despite controlling for weight, the AC subjects received a significantly higher dose than both the ACHI (P = 0.002) and the MCHI groups (P = 0.012). However, the mean sertraline concentration to dose ratios at weeks 1 and 6 were not significantly different between the three groups. Sertraline was effective and well tolerated in both ethnic groups with few adverse events. Although there was a lack of difference between groups in the pharmacokinetic results, Chinese depressed patients appeared to require lower dosages with consequently lower plasma concentrations of sertraline compared to Caucasian patients to achieve clinical efficacy. Further studies of the dosages, kinetics and adverse effects of selective serotonin reuptake inhibitors linked with genotyping are necessary.

Mental health research in general practice.

OBJECTIVE: To explore problems in carrying out a mental health research project in the general practice setting. METHOD: Open-ended interviews were conducted with general practice stakeholders, focusing on impediments to the conduct of mental health research in general practice and possible means for improving the participation of general practitioners in such research. Participants in the consultations were members of five divisions of general practice, senior staff within an academic department of general practice, four general practitioners and a research group engaged with general practice research. The discussions were recorded in detailed interview notes, and key issues and themes emerging from consultations were derived by the researchers. RESULTS: Three main themes summarized most of the issues reported through the consultations, including structural issues (e.g. disruption of practice, time limitations and lack of remuneration), process issues (e.g. researcher-general practice communication, researcher-imposed issues and need for partnerships) and content issues (e.g. study design, study procedures and methods). CONCLUSIONS: The consultations revealed similar findings to previously published reports concerning general practice research, with an emphasis on the need for partnerships between researchers and general practice organizations in the conduct of such research.

Managing mental illness in patients from CALD backgrounds.

BACKGROUND: Australian general practitioners are often the first point of call for people seeking mental health care including those from culturally and linguistically diverse (CALD) backgrounds, some of whom may be more at risk of having a mental illness but are failing to access the appropriate mental health care. OBJECTIVE: This article is intended to assist GPs in the recognition, diagnosis and management of mental illness in patients from CALD backgrounds by providing current research evidence and presenting some practical recommendations. More attention is paid to the larger CALD populations such as the southern European and Asian communities, and does not deal with indigenous Australians. DISCUSSION: There is an increasing call for GPs to have a key role in the detection, diagnosis and management of mental illness, including for patients from CALD backgrounds. Effective care requires that GPs are aware of, and understand how culture may influence recognition, diagnosis and management of mental illness in this group of patients.

Depression and anxiety: a comparison of older-aged Greek-born immigrants and Anglo-Australians.

OBJECTIVE: To compare depressive and anxiety illness in an older-aged sample of Greek-born (GB) immigrants who were likely to have been excluded from the National Survey of Mental Health and Wellbeing due to their lack of fluency in the English language and for whom rates of mental disorder are unknown, with a comparably recruited sample of Anglo-Australians (AA). METHOD: One hundred and forty-six GB and 146 AA respondents with a mean age of 68 years living in Melbourne and recruited through social clubs, completed the Beck Depression Inventory-II (BDI-2) and the State-Trait Anxiety Inventory (STAI) in addition to socio-demographic and other background questions. RESULTS: Greek-born respondents exhibited higher depression and anxiety scores and reported more depressive and anxiety symptomatology than the AA respondents. More GB respondents (17.1%) were likely to be included in the moderate to severe BDI-2 depression categories than AA (4.1%). Greek-born respondents (43.1%) were more likely to be included in the higher anxiety categories (i.e. score 41-80) of the STAI than the AA (15.8%). However, when controlling for health, economic and social factors there was no difference in the BDI-2 measures between the two groups. Despite controlling for these factors the GB still scored more highly on STAI measures than AA respondents. CONCLUSIONS: No differences were found between groups on measures of depression once controlling for age, education and occupational level, current financial status, marital status, household composition, current work status, physical health and stress. Such factors were also shown to influence group-differences anxiety but they not entirely explain group differences. Higher anxiety in GB respondents were likely to have been determined through the effects of additional but unmeasured cultural and immigrant status factors. Psychological morbidity in immigrants is best accounted for by considering the influence of social, health and other living conditions in addition to the effects of culture or immigrant status.

Ethnic matching of clients and clinicians and use of mental health services by ethnic minority clients.

OBJECTIVES: Research in the United States has indicated that matching clients from a minority group with clinicians from the same ethnic background increases use of community mental health services and reduces use of emergency services. This study assessed the effects of matching clients from a non-English-speaking background with bilingual, bicultural clinicians in a mental health system in Australia that emphasizes community-based psychiatric case management. METHODS: In an overall sample of 2,935 clients served in the western region of Melbourne from 1997 to 1999, ethnic minority clients from a non-English-speaking background who received services from a bilingual, bicultural case manager were compared with ethnic minority clients who did not receive such services and with clients from an English-speaking background. The clients' engagement with three types of services-community care teams, psychiatric crisis teams, and psychiatric inpatient services-was assessed. RESULTS: Compared with ethnic minority clients who were not matched with a bilingual clinician, those who were matched generally had a longer duration and greater frequency of contact with community care teams and a shorter duration and lower frequency of contact with crisis teams. Clients born in Vietnam who were matched with a bilingual clinician had a shorter annual mean length of hospital stay and a lower annual mean frequency of hospital admission than Australian-born clients. CONCLUSIONS: The benefits of matching clients with psychiatric case managers on the basis of ethnic background include a lower level of need for crisis intervention and, for clients from some ethnic groups, fewer inpatient interventions. These Australian results support findings of the effectiveness of client-clinician ethnic matching in the United States.

Prevalence of psychiatric disorder following the 1988 Yun Nan (China) earthquake--the first 5-month period.

BACKGROUND: There is a continuing need to examine the psychiatric impact of natural disasters for the development of an understanding of the determinants of morbid outcomes. The study of culturally distinct groups provides evidence as to the robustness of psychopathology emerging in the context of traumatic exposures. METHOD: In this study, 1294 people were examined at 5 months after the 1988 Yun Nan earthquake in order to explore the psychiatric impact of this disaster. They were assessed with a number of instruments, including the General Health Questionnaire (28-item version), the Life Event Inventory, and the Post-traumatic Stress Disorder section of the Diagnostic Interview Schedule. Three groups were examined according to their distance from the epicenter of the quake. Their responses were compared with an additional sample of 908 people from a general population living 520 kilometers away from the epicenter. RESULTS: GHQ 'caseness' in the three disaster groups, from those closest to those more distant from the epicenter, were 60.4, 48.2 and 44.0%. These rates were significantly higher than the non-exposed control group (36.2). Among the three disaster groups, taking those who achieved GHQ 'caseness' criteria, the PTSD prevalence was 23, 13 and 16%, respectively. For the overall population experiencing the earthquake (the combined disaster group), a conservative estimate of disaster-related PTSD prevalence was 8.9%. CONCLUSION: The varied rate of morbidity (both general and PTSD-specific) could be attributed to the relative impact of the earthquake as represented by epicenter proximity and as measured by the rate of property damage and loss in the three earthquake-affected areas.