Depression Through Chinese Eyes: a window into public mental health in multicultural Australia

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 culturesKessler 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 thresholdSimon et al. 2001.

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

5. 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)

6. 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

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

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

9. 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.

10. Demographics & Depression (survey group)

11. Somatic Symptoms Insomnia, heaviness in chest, body-ache pain… Salient to Low-Acc Chinese Chinese Recognition of symptoms Core symptoms Depressed, loss of interest, motivation, and helpless Non-somatic (Cognitive) Symptoms Suicidal thoughts, feelings of worthlessness, Salient to High-Acc Chinese Recognition of depressive symptoms among Low-Acc and High-Acc Chinese

12. Most Troubling Symptoms(self-nominated)

13. Most nominated EMs

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

15. Episode more than 4 weeks %

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

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

18. 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 Start to attract stigma Mental Illness Self-talk, suicidal Depressives Mad, Crazy Manic Violent, out of control Schizophrenia Highly Stigmatized

19. 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.

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

21. 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

22. 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.