DEVELOPING A CLINICAL TOOL TO TREAT DEPRESSION IN SPANISH-SPEAKING LATIN AMERICAN IMMIGRANTS IN CANADA: APPLYING A GLOBAL MENTAL HEALTH PERSPECTIVE FOR IMPROVED MENTAL HEALTH OUTCOMES by Bertha Carolina Vidal MD, Universidad Nacional Autónoma de Honduras, 1991 MA, The University of Western Ontario, 1999 Post-graduate training in Psychiatry, The University of British Columbia (Vancouver), 2006 A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF DOCTOR OF PHILOSOPHY in The Faculty of Graduate and Postdoctoral Studies (Interdisciplinary Studies) THE UNIVERSITY OF BRITISH COLUMBIA (Vancouver) October 2013 © Bertha Carolina Vidal 2013 ABSTRACT This dissertation considers the implications of applying a global mental health perspective to guide the development of culturally appropriate mental health services in Canada. Recognizing that forces of globalization can affect both determinants of health that vulnerable populations face and the kind of mental health services that are available, I focus on the situation of Latin American immigrants in the Greater Toronto Area, a population that has been prioritized for increased access to equity-driven health services. I draw on my personal and professional positionality with the issues examined. This study specifically examines Latin American immigrants, a group that has been identified as a high-growth population at-risk for mental health difficulties. An extensive and comprehensive review of social determinants of health as it relates to the mental health of Latin American immigrants in Canada is conducted. The availability and effectiveness of patient-centered care for Latin American populations is also reviewed, with particular attention to the standard delivery versus the cultural adaptation of cognitive behavioral therapy – currently regarded as the ‘gold standard’ in psychotherapeutic treatment. Social policy issues that may arise in providing culturally appropriate, patient- centered care are exemplified in the findings of a secondary qualitative analysis of focus groups that were conducted for a feasibility study for a culturally adapted cognitive behavioral therapy (CA-CBT) for Latin American immigrants in Canada. A key contribution of this work is the synthesis of the foregoing evidence to conclude that the provision of culturally adapted mental health services is necessary but not sufficient to promote the health equity of Latin American immigrant populations in Canada. Recommendations for policy, future research, and changes to the philosophy of psychiatric practice are discussed, and the findings are related to debates on the concept of “global mental health” that are currently underway. ii PREFACE The secondary data analysis component of this dissertation was approved by the Behavioral Research Ethics Board at the University of British Columbia in Vancouver, Canada (Certificate #: H11-01709). iii TABLE OF CONTENTS ABSTRACT ..................................................................................................................................... i PREFACE ...................................................................................................................................... iii TABLE OF CONTENTS ............................................................................................................... iv LIST OF TABLES ........................................................................................................................ vii LIST OF FIGURES ..................................................................................................................... viii ACKNOWLEDGEMENTS ........................................................................................................... ix PROLOGUE .................................................................................................................................. 1 Researcher Positionality.............................................................................................................. 2 Trajectory of Doctoral Studies .................................................................................................... 9 Purpose of the Work ................................................................................................................. 15 CHAPTER 1 Introduction ................................................................................................................................. 18 Statement of the Problem .......................................................................................................... 20 Study Objectives ....................................................................................................................... 22 CHAPTER 2 Globalization and Global Mental Health .................................................................................. 26 Globalization: Contextualizing Global Mental Health ............................................................. 26 Global Burden of Disease and Treatment Gap in Mental Health: Initiatives for Action ......... 34 The Critical Psychiatry Network .............................................................................................. 39 Globalization and the Practice of Psychiatry in Canada ........................................................... 49 Globalization and the Practice of Psychiatry in Cuba .............................................................. 55 Global Mental Health: The Social Determinants of Health ...................................................... 62 Income and Income Distribution .......................................................................................... 63 Education .............................................................................................................................. 63 Unemployment and Job Security .......................................................................................... 63 Employment and Working Conditions ................................................................................. 64 Early Childhood Development ............................................................................................. 64 Food Insecurity ..................................................................................................................... 64 Housing ................................................................................................................................. 65 Social Exclusion.................................................................................................................... 65 Social Safety Network .......................................................................................................... 65 Health Services ..................................................................................................................... 66 Aboriginal Status .................................................................................................................. 66 Gender ................................................................................................................................... 66 Race....................................................................................................................................... 67 Disability ............................................................................................................................... 67 CHAPTER 3 Latin American Immigrants in Canada: Applying a Global Mental Health Perspective ... 71 Latin American Immigration to Canada ................................................................................... 71 Addressing the Mental Health Needs of Latin American Populations ..................................... 72 iv Latin American Immigrants in Canada and the Social Determinants of Health....................... 75 Income and Social Status ...................................................................................................... 75 Social Support Networks ...................................................................................................... 76 Education and Literacy ......................................................................................................... 76 Employment and Working Conditions ................................................................................. 77 Social Environments ............................................................................................................. 78 Physical Environments.......................................................................................................... 79 Personal Health Practices and Coping .................................................................................. 80 Healthy Child Development ................................................................................................. 81 Biology and Genetic Endowment ......................................................................................... 81 Health Services ..................................................................................................................... 82 Gender ................................................................................................................................... 83 Culture................................................................................................................................... 84 CHAPTER 4 Adapting Cognitive Behavioral Therapy for the Treatment of Depression among Latin American Immigrants in Canada .............................................................................................