Zachary Steel
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MENTAL DISORDER AMONGST PEOPLE OF VIETNAMESE BACKGROUND: PREVALENCE, TRAUMA AND CULTURE Zachary Steel A thesis submitted in fulfilment of the requirements for the degree of Doctor of Philosophy School of Psychiatry Faculty of Medicine, University of New South Wales Sydney Australia June 2008 ii Abstract The role that culture and trauma plays in shaping mental health outcomes continues to dominate debate in the field of transcultural and post-conflict mental health. The broad aim of this thesis is to investigate key issues relevant to these two factors in relation to the Vietnamese. A meta-analysis of international epidemiological research indicated that countries of North and South East Asia appear to manifest low rates of mental disorder compared to English-speaking countries. A meta-regression analysis of research undertaken specifically with refugee and conflict-affected populations, confirmed a robust association between torture and general trauma and risk to mental disorder. The thesis then examines data from three population-based mental health surveys: 1,161 Vietnamese-Australian residents in the state of New South Wales; 3,039 Vietnamese resident in the Mekong Delta region of Vietnam; and 7,961 Australian-born persons drawn from a national survey. All surveys applied the Composite International Diagnostic Interview, with the Vietnamese surveys also applying the Phan Vietnamese Psychiatric Rating Scale, an indigenously-derived measure of mental disorder. The ICD-10 classification system yielded lowest rates amongst Vietnamese in the Mekong Delta, intermediate amongst Vietnamese in NSW; and highest rates amongst the Australian-born population. The Phan Vietnamese Psychiatric Rating Scale added a substantial number of cases in both Vietnamese samples. The findings suggest that sole reliance on a western-derived measure of mental disorder may fail to identify a cases of mental disorder across cultures. Trauma remained a substantial risk factor for mental disorder amongst Australian Vietnamese accounting for a substantial portion of the total burden of mental disorder in that population. The implications of these findings in developing a more refined model for understanding the mental health consequences of mass trauma across cultures are discussed. iii iv Certificate of Originality I hereby declare that this submission is my own work and to the best of my knowledge it contains no materials previously published or written by another person, nor material which to a substantial extent has been accepted for the award of any other degree or diploma at UNSW or any other educational institution, except where due acknowledgement is made in the thesis. Any contribution made to the research by others, with whom I have worked at UNSW or elsewhere, is explicitly acknowledged in the thesis. I also declare that the intellectual content of this thesis is the product of my own work, except to the extent that assistance from others in the project’s design and conception or in style, presentation and linguistic expression is acknowledged. Signed: …………………………………… Zachary Steel Date: 23 June 2008 v vi Acknowledgements I would like to express my sincere gratitude to my supervisor Professor Derrick Silove who has tirelessly supported and encouraged me in completing this thesis. His sense of humour, penetrating insight, and commitment to human rights are a constant inspiration. I also extend my sincere thanks to my co-supervisor Professor Adrian Bauman. Your advise and support have been greatly appreciated. I hope that we will have many more opportunities to collaborate together in the future. A very special thanks to Tien Chey who has provided ongoing invaluable statistical assistance and analysis. I would also like to extend my thanks to Claire Marnane who assisted with the systematic review and data extraction for the meta-analyses reported herein and to Mr Kham Vilaythong who worked with me for many hours to produce a software package that could reliably be used in the field by lay-interviewers. This surveys reported in this project would not have been possible without the collaboration of the Vietnamese community in Australia and Vietnam. I especially extend my thanks to Ms Thuy Thi Bich Phan who coordinated the projects in both Australia and Vietnam. Your dedication, skill and enthusiasm have been instrumental in making these projects successful. My profound thanks also to Dr Nguyen Mong Giao the former director of the psychiatric services in Cần Thơ City and Hậu Giang Province and Professor of Psychiatry at Cần Thơ University. It has been great honour to work with you. I hope we shall have a chance to meet again soon. My deep thanks also to Professor Tuong Phan who inspired us to proceed with this research. vii To the Vietnamese interviewers who worked with such dedication and commitment with us in Australia and Vietnam I extend my deep and warm thanks. It was a joy to share this time with you. To Pat Coughlan, your guidance and support across good times and bad will always be remembered. Thank you. To my wife Catherine and my children, Jacob, Natasha and Rebecca. Thank you for being so tolerant. I hope to spend many Sundays with you now. All my love. The NSW Vietnamese Survey was in part supported by an Australian National Health and Medical Research Council Special Initiative Grant No: 980067. The Mekong Delta survey was supported in part by an Australian National Health and Medical Research Council Program Grant (300304). viii List of publications arising from this thesis 1. Steel, Z., Silove, D., Phan, T., & Bauman, A. (2002). Long-term effect of psychological trauma on the mental health of Vietnamese refugees resettled in Australia: a population-based study. Lancet, 360(9339), 1056-1062. 2. Steel, Z., Silove, D., Chey, T., Bauman, A., Phan, T., & Phan, T. (2005). Mental disorders, disability and health service use amongst Vietnamese refugees and the host Australian population. Acta Psychiatrica Scandinavica, 111(4), 300-309. 3. Silove, D., Steel, Z., Bauman, A., Chey, T., & McFarlane, A. (2007). Trauma, PTSD and the longer-term mental health burden amongst Vietnamese refugees. Social Psychiatry and Psychiatric Epidemiology, 42, 467-476. 4. Silove, D., Steel, Z., & Bauman, A. (2007). Mass psychological trauma and PTSD: Epidemic or Cultural Illusion? In J. P. Wilson & C. So-kum Tang (Eds.), Cross-Cultural Assessment of Psychological Trauma and PTSD (pp. 319-336). New York: Springer. 5. Steel, Z., Silove, D., Giao, M.G., Phan, T.T.B., Chey, T., Whelan, A. Bauman, A. & Bryant, R.A. (In press).International and indigenous diagnoses of mental disorder amongst Vietnamese living in Vietnam and Australia. British Journal of Psychiatry ix x List of acronyms ABS Australian Bureau of Statistics CIDI Composite International Diagnostic Interview DIS Diagnostic Interview Schedule DSM Diagnostic and Statistical Manual of the American Psychiatric Association ECA Epidemiological Catchment Area Study GHQ General Health Questionnaire HSCL-25 Hopkins Symptom Checklist-25 HTQ Harvard Trauma Questionnaire ICD International Classification of Diseases LGA Local Government Area MCS Mental Component Summary Score of SF-12 NCS / NCS-R National Comorbidity Survey / National Comorbidity Survey Replication NSW The State of New South Wales in Australia PCS Physical Component Summary Score of SF-12 PTSD Posttraumatic stress disorder PVPS Phan Vietnamese Psychiatric Scale SCID Structured Clinical Interview for DSM SF-12 Medical Outcomes Short Form 12 item version US United States of America USSR Union Soviet Socialist Republics WHO World Health Organization WMH World Mental Health Survey WW I / WW II World War I / World War II xi xii Table of contents Abstract.............................................................................................................................................iii Acknowledgements........................................................................................................................vii List of publications arising from this thesis ..................................................................................ix List of acronyms ..............................................................................................................................xi Table of contents...........................................................................................................................xiii List of tables.................................................................................................................................. xvii List of figures.................................................................................................................................. xxi PART 1: INTRODUCTION AND LITERATURE REVIEW ................................................................ 1 CHAPTER 1 STUDYING MENTAL DISORDER ACROSS DIVERSE CULTURES..........................................3 Classification, culture and mental disorder: a synopsis..............................................................3 Implications of the Kraepelinian tradition......................................................................................4 CHAPTER 2 DEVELOPING A CLASSIFICATION FOR MENTAL DISORDER ...............................................7 The evolution of psychiatric classification.....................................................................................7 WW II and the rise and dominance of the DSM nosology .........................................................8 CHAPTER 3 TRANSCULTURAL