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Depression Through Chinese Eyes: a Window Into Public Mental Health in Multicultural Australia

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Depression Through Chinese Eyes: a Window Into Public Mental Health in Multicultural Australia Depression through Chinese eyes: a window into public mental health in multicultural Australia ƝƝnȴŋūnȴŋūnȴŋū˹˹˹ΥːYΥːYΥːYšɃȾšɃȾ, ˠȶɺʥƙdžƧǀɃřɋɉ< This thesis is submitted in fulfillment of the requirements for admission to the degree of Doctor of Philosophy, School of Public Health and Community Medicine and School of Psychiatry, University of New South Wales Bibiana Chan March, 2007 For all my informants who honestly and courageously shared their thoughts and experiences with me. To my LORD who gives me HOPE. Acknowledgment The quantitative research design adopted some of the earlier research methodologies developed by the Black Dog Institute. The author drafted the survey form of the current study (both the Chinese and English versions). Co-researchers Professor Gordon Parker (GP) and Professor Maurice Eisenbruch (ME) provided input to revise the initial drafts before pilot studies were conducted to test the instruments. The author collected and analysed ALL the data. The qualitative research design was developed while the author was attending a series of qualitative seminars by A/Professor Jan Ritchie (JR). The conceptual frameworks and ethnographic methods were also crystallised through participation in the Culture, Health and Illness program and by other activities of the Centre for Culture and Health under the direction of ME. The author then developed the two vignettes with input from ME. Subsequently five pilot focus groups was conducted to establish the protocols for facilitating focus groups using different languages. The author collected qualitative data by facilitating a total of 16 focus groups. JR provided some input regarding the framework for conducting theme analysis. The author then perform ALL coding and theme analyses using NVivo 2. My most sincere thanks to: All professional and lay helpers who walked along the journey of recovery with me. The National Health and Medical Research Council for the funding to make this research possible. My research supervisors Professor Maurice Eisenbruch, Professor Gordon Parker and Associate Professor Jan Ritchie for their intellectual input. All participating general practitioners, Chinese herbalists, medical centres, and community organizations to facilitate data collection. My parents and those who instilled the love for Chinese culture into me. My son, Jonathan who shared his daily encounters as an ABC (Australian-born Chinese) with me. My friends and colleagues from cultural and linguistically diverse backgrounds who taught me the spirit of multiculturalism. Professor S Lee, Dr I Blignault, Dr G. Denham, Dr A. Demirkolster, Dr Y. Lucire, Mrs T. Chow and Mr Z. Steel for their invaluable comments on earlier drafts. Dr. E Dryland and Ms P Gundelach who proof-read and edited my thesis. i List of publications and conference presentations arising from the work reported in this thesis Chan B. (2003) Cross-cultural Issues in Depressive Illness: Implications for Mental Health Services among Migrant Communities in Australia. The “Diversity in Health: Innovation, Creativity and Harmony” conference, October, 2003, Sydney. (Part of chapter 2) Chan, B. (2003) Healthy family, a cross-cultural perspective: An innovative project to promote mental health to the Chinese community. The "Diversity in Health: Innovation, Creativity and Harmony” conference, October, 2003, Sydney. Chan, B., and Parker, G. (2004) Some recommendations to assess depression in Chinese people in Australasia. Australian & New Zealand Journal of Psychiatry, 38, 141-147. (Part of chapter 2) Chan, B., Parker, G., and Eisenbruch, M. (2005a). Depression through Chinese eyes and the implications for Australian multicultural health policy, The First International Congress of Qualitative Inquiry, May 2005. Urbana-Champaign: University of Illinois. Retrieved 30-Jan- 07 from http://www.c4qi.org/qi2005/papers/chan.pdf (Part of chapter 5) Chan, B., Parker, G., and Eisenbruch, M. (2005b). Help-seeking in Chinese in Sydney - Does Acculturation make a difference? (Abstract). Australian & New Zealand Journal of Psychiatry, 39 (S2), A51-52. (Part of chapter 6) Chan, B. (2005c) High Price of Migration - voices from focus group participants. Action Research Conference, October, 2005, University of Technology, Sydney. (Part of chapter 5) Chan, B. and Parker, G. (2006). Values of cross-cultural research: Insights gained from the validation of the depression screening measure DMI-10 Chinese version. Poster presented at the ASPR 2006 conference, Sydney, December, 2006. (Part of chapter 4) Chan, B., Parker, G., Tully, L., and Eisenbruch, M. (2007). Cross-cultural validation of DMI-10 measure of state depression: The validation of a Chinese language version. Journal of Nervous & Mental Disease, 195 (1), 20-25. (Part I of chapter 4) Chan, B. Parker, G. and Proudfoot, J. (in review) Does acculturation make a difference? Help-seeking for emotional distress among Chinese Australians? MJA. (Part of chapter 6) Eisenbruch, M., Chan, B., and Parker, G. (2005). The meaning of suffering - a Chinese explanatory model tool for depressive episode (Abstract). Australian & New Zealand Journal of Psychiatry, 39 (S2), A51. (Part of chatper 4) Eisenbruch, M., Chan, B., and Parker, G. (in review). The meaning of emotional distress - a Chinese explanatory model tool. Social Science and Medicine. (Part II of chapter 4) Parker, G., & Chan, B. (2004). Depression in Australian Chinese. How acculturation informs us about the detection and manifestation of clinical depression. (Abstract). XXIV CINP Congress, Paris, June 20-24. The International Journal of Neuropsychopharmacology, 7:S77. (Part of chapter 5) Parker, G., Chan, B., Tully, L., and Eisenbruch, M. (2005). Depression in the Chinese: the impact of acculturation. Psychological Medicine, 35(10), 1475-1483. (Part of chatper 6) Parker, G., Chan, B., Tully, L., and Eisenbruch, M. (2005b). Depression in the Chinese: the impact of acculturation (abstract). Australian & New Zealand Journal of Psychiatry, 39 (S2), A51. Parker, G., Chan, B., and Tully, L. (2006). Recognition of depressive symptoms by Chinese subjects: the influence of acculturation and depressive experience. Journal of Affective Disorders, 93(1-3), 141- 147. (Part of chapter 7) Parker, G., Chan, B., and Tully, L. (2006). Depression and help-seeking in a western sample of highly acculturated Chinese and controls. Journal of Affective Disorders, 94 (1-3), 239-242. In bold - Papers presented at Conferences ii Abstract Under-utilisation of mental health services is widespread globally and within Australia, especially among culturally and linguistically diverse (CALD) communities. Improving service access is a priority, as is the need to deliver culturally competent services to the CALD communities. Having migrated to Australia in waves for approximately 150 years from China and South East Asia for various social, political and economic reasons, the Chinese population in Sydney is now the fastest growing non-English speaking ethnic group. There is a need to better understand the impact of culture on the emotional experiences of these Chinese in Australia. How do Chinese make sense of their depressive episodes? To address this question, this study explored the ways participants reach out for medical and/or non-medical help. Lay concepts of illness underpin these decisions and were thus unveiled. Mixed-method research design provided the opportunity to bring together multiple vantage points of investigation: population mental health, transcultural psychiatry and medical anthropology. A study combining quantitative survey and qualitative focus groups was undertaken in metropolitan Sydney. Narratives on symptoms, explanatory models and help-seeking strategies were articulated by focus group informants. Surveys covered demographics, symptom-recognition, previous depressive experiences and professional help sought. Depression measurement tools were cross-culturally validated. Self-ratings of ethnic identities and the Suinn-Lew Self-Identity Acculturation Scale were used to quantify Chinese participants’ acculturation level. This allowed comparisons between ‘low-acculturated’ Chinese’, ‘highly-acculturated’ Chinese and Australians. Survey results showed comparable levels of symptom-recognition in all subgroups. Focus group discussions provided rich data on informants’ help-seeking strategies. Highly acculturated Chinese closely resembled the Australians in many study variables, yet qualitative data suggested cultural gaps beyond language barriers in influencing service use. Participants believed that trustful relationships could work as the bridge to link services with those in need. The implications for Australia’s mental health policy include recognising the importance of rapport- building and the existence of cultural gaps. The study indicated professionals can benefit from acquiring information about the mental health beliefs both of individual clients and the wider ethnic communities in which they belong, and respecting the cultural differences between helper and helped as the first step towards cultural competency. Table of Contents Chapter 1 Introduction 1 1.1 A glance at mental health issues 1 1.2 My stance as researcher 4 1.3 Chinese migrants in Australia 6 1.4 Meaning of emotional distress 8 1.5 Acculturation 11 1.6 Research propositions 12 1.6.1 Do Chinese and Australians experience similar depressive episodes? 12 1.6.2 Are Chinese less susceptible to depression than the Australians? 12 1.6.3. How do Chinese conceptualise their depressive episodes
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