Culture & Mental Health Research Unit Report No. 6 (Part 1) Pathways and Barriers to Mental Health Care in an Urban Multicultural Milieu: An Epidemiological and Ethnographic Study Laurence J. Kirmayer, M.D. Guillaume Galbaud du Fort, M.D., Ph.D. Allan Young, Ph.D. Morton Weinfeld, Ph.D. Jean-Claude Lasry, Ph.D. Culture & Mental Health Research Unit Sir Mortimer B. Davis—Jewish General Hospital Adress correspondence to the first author at: Institute of Community Psychiatry 4333 Côte Ste. Catherine Rd. Montréal, Québec H3T 1E4 514-340-8222 X5246, Fax 514-340-7503 2 Table of Contents Preface...............................................................................................viii ................................................................................................................ ................................................................................................................ Résumé............................................................................................... ix Summary............................................................................................ xii Chapter 1. Introduction.............................................................................. 1 Rationale.........................................................................................16 Review of Literature ...........................................................................18 Afro-Caribbean Anglophone Immigrants ..............................................19 Migration History .....................................................................19 Demography & Family Composition. ..............................................20 Psychiatric Symptoms & Syndromes...............................................21 Indigenous Explanations & Treatment of Mental Illness ........................22 Utilization of Mental Health Care...................................................22 Vietnamese Immigrants...................................................................23 Migration History .....................................................................23 Demography & Family Composition. ..............................................23 Psychiatric Symptoms & Syndromes...............................................25 Indigenous Explanations & Treatment of Mental Illness ........................25 Utilization of Mental Health Care...................................................26 Filipino Immigrants........................................................................27 Migration History .....................................................................27 Demography & Family Composition. ..............................................27 Psychiatric Symptoms & Syndromes...............................................28 Health Care Utilization and Barriers to Care ......................................28 Chapter 2 . Methods ................................................................................29 Overview ........................................................................................29 Design and Sampling ..........................................................................29 Measures.........................................................................................35 Stage 1 Interview ..........................................................................35 Stage 2 Interview ..........................................................................36 Procedure........................................................................................38 Training and Supervision of Interviewers ..............................................39 Data Collection and Modification of Instruments and Procedures..................39 3 Data Checking ............................................................................. 40 Ethical Considerations ........................................................................ 40 Chapter 3. Sociodemographic Characteristics of Sample..................................... 42 The Côte Des Neiges Area ................................................................... 42 The Sample ..................................................................................... 45 Anglophone Canadian-Born ............................................................. 45 Francophone Canadian-Born ............................................................ 52 Other Canadians ........................................................................... 53 Caribbeans.................................................................................. 54 Vietnamese................................................................................. 56 Filipinos .................................................................................... 57 Other Immigrants (Non-Canadian Born)............................................... 58 Chapter 4. Symptoms, Life Events & Health Care Utilization............................... 60 Somatic Symptoms ............................................................................ 60 Psychological Distress: The General Health Questionnaire.............................. 63 Life Events In Last 12 Months............................................................... 66 Health Care Service Utilization.............................................................. 69 Multivariable Analysis of Health Care Utilization ........................................ 84 Barriers to Care ................................................................................ 87 Chapter 5. Somatization ........................................................................... 94 Correlates of Nonspecific Somatic Symptoms............................................. 97 Medically Undiagnosed Symptoms ........................................................100 Chapter 6. Acculturation .........................................................................107 Method .........................................................................................108 Results..........................................................................................109 Acculturation Style Across Ethnocultural Groups...................................113 Symptomatology, Health Care Utilization & Barriers to Mental Health Care...115 Chapter 7. Illness Narrative Interviews.........................................................120 Help-Seeking and The Social Meaning of Symptoms ...................................121 Method .........................................................................................124 Measures...................................................................................124 Sample & Procedure .....................................................................125 Results..........................................................................................125 4 Interim Conclusions......................................................................... 127 5 Chapter 8. Conclusion ............................................................................130 Limitations.....................................................................................130 Utilization of Mental Health Services......................................................131 Somatization...................................................................................132 Acculturation ..................................................................................134 Illness Narratives..............................................................................135 References..........................................................................................136 Appendix ...........................................................................................124 1. Summary of Stage I and Stage II Phonecalls According to Strata 6 List of Figures Figure 2-1. Sampling Strategy .............................................................................................31 Figure 2-2. Map of CDN region .....................................Error! Bookmark not defined. Figure 5-1. Prevalence of Symptoms with No Medical Diagnosis...............................105 Figure 6-1. Acculturation Style of Ethnocultural Groups .............................................114 List of Tables Table 2-1. Proportion of Vietnamese and Blacks in CLSC Côte-des-Neiges Catchment by Census tract (1991 Census) Area..................................................32 Table 2-2. Summary of Stage 1 Interviews According to Postal Code................................33 Table 2-3. Summary of Stage 1 Interviews According to Census Tract ..............................33 Table 2-4. Summary of Stage 2 Interviews According to Strata...........................................34 Table 2-5. Summary of Stage 2 Interviews According to Ethnic Group .............................34 Table 3-1a. Composition of Côte des Neiges Area: Linguistic Groups...............................44 Table 3-1b. Composition of Côte des Neiges Area: Ten Largest Ethnic Groups ...............44 Table 3-3. Description of Sample by Ethnic Group...............................................................47 Table 3-4. Canadian-born Sample Parents’ Country of Birth...............................................51 Table 3-5. Language Use Among Anglo-Canadians.............................................................51 Table 3-6. Language Use Among Franco-Canadians.............................................................52 Table 3-7. Countries of Birth of Second Generation Canadian Subjects’ Parents..............53