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Report 1: Suicide in Canadian Aboriginal Populations: Emerging Trends in Research and Intervention

A Report Prepared for the Royal Commission on Aboriginal Peoples

Laurence J. Kirmayer, MD, FRCPC
with
Barbara Hayton, MD, CCFP
Michael Malus, MD
Vania Jimenez, MD, CCFP
Rose Dufour, RN, PhD
Consuelo Quesney, MA
Yeshim Ternar, PhD
Terri Yu, MD
Nadia Ferrara, MAT

Scope and outline of report

Suicide is an index of the severe social problems faced by Aboriginal peoples in Canada. The aboriginal suicide rate is three times that of the total Canadian population. From the ages of 10 to 29, Aboriginal youth on reserves are 5 to 6 times more likely to die of suicide than their peers in the general population (Medical Services Branch Steering Committee on Native Mental Health, 1991). Despite widespread concern about these alarming statistics, there continues to be a lack of epidemiological data, ethnocultural information on suicide and evaluation studies of intervention programs. Our aim in this report is to review the scientific literature to situate the problems of Aboriginal peoples within the larger context of suicide in Canadian society so as to identify those features that are shared in common with the dominant society and those that are distinctive for Aboriginal groups. In such comparisons, there is a tendency to attribute any difference between groups to distinctive cultural or historical factors but economic problems, geographic differences and issues of scale (i.e. the size of communities and the degree of infrastructure) may also account for observed differences. Hence, comparative studies with statistical techniques that control for other possible explanations are needed. This document is based on Medline, PsyLit and SocLit searches of the literature on suicide and Native peoples conducted in February and March of 1993 as well as consultations with researchers and review of the Royal Commission hearing transcript extracts on suicide. We have focused on more recent literature although we are indebted to earlier reviews of the literature on suicide (Hawton, 1986; Maris, Berman, Maltsberger & Yufit, 1992) and suicide among Native peoples in particular (May, 1990; Peters, 1981; Thompson & Walker, 1990). In many cases, we have had to rely on research in the U.S. since comparable Canadian studies are lacking. We have made no attempt to survey or assess popular and self-help literature on topics related to suicide as this has been undertaken by other groups for the Royal Commission. Many issues pertaining to Aboriginal culture and mental health that are only touched on in this report are discussed in more detail in a second report we have prepared for the Royal Commission entitled "Emerging Trends in Research on Mental Health Among Canadian Aboriginal Peoples."

Outline

In subsequent parts of this introductory section, we provide definitions of technical terminology and offer some general comments on the integration of social and psychiatric perspectives in models of suicide. The second major section addresses basic demographic data on Aboriginal peoples and descriptive epidemiological statistics on suicide in North America. We summarize variations in the prevalence of suicide and attempted suicide by age, gender, socioeconomic status, and other demographic factors. Particular attention is given to the marked changes in suicide rate that have occurred in recent times as well as to variations across geographical location and ethnocultural group. Section 3 summarizes research on risk and protective factors for suicide. Subsections address factors involving: the physical and social environment; constitution, temperament or developmental experiences; interpersonal relationships; alcohol and substance abuse; suicidal ideation and previous attempts; psychiatric disorders; social structure and economy; cultural traditions; and the impact of culture change. In Section 4, we summarize what is known about the efficacy of interventions for suicide prevention. The introductory subsection presents a table outlining types of interventions that have been proposed. We then consider detection, primary, secondary and tertiary prevention, and postvention (that is, the treatment of survivors). The conclusion to this section presents a summary of a comprehensive #state-of-the-art# approach to prevention. In the concluding section, we sketch a sociocultural perspective on suicide. We then summarize the gaps in our knowledge, emerging trends in research and promising approaches to intervention. Appendix A presents a brief summary of research methods to orient the interested reader.

Report 2: Emerging Trends in Research on Mental Health Among Canadian Aboriginal Peoples

A Report Prepared for the Royal Commission on Aboriginal Peoples

Laurence J. Kirmayer, MD, FRCPC
with
Kathryn Gill, PhD
Christopher Fletcher, BES
Yeshim Ternar, PhD
Lucy Boothroyd, MSc
Consuelo Quesney, MA
Andr Smith, MSW
Nadia Ferrara, MAT
Barbara Hayton, MD, CCFP

Introduction

Requested by the Royal Commission on Aboriginal Peoples, our aim in this report is to review the scientific literature on the mental health problems of Canadian Aboriginal peoples to identify emerging trends in research themes and methods. The topics to be covered include the following:

  1. an overview of epidemiological data on Aboriginal mental health in Canada;
  2. a critical review of existing literature on the topic of prevention and treatment among Aboriginal peoples in Canada;
  3. a comprehensive discussion of emerging trends in this field;
  4. guidelines for future research.

This report is organized in accordance with these themes. We have endeavoured to include specific material on women, status and non-status Indian, Inuit and Mtis peoples. Unfortunately, in most cases there is very little information available. Given that the problems we address cut across groups, we have not created separate sections for each important subgroup. The index provides a way to track down specific mention of groups, geographical regions or other specific interests. The index can also function as a glossary since many technical terms are defined on their first occurrence. In this introductory section, we provide definitions of technical terminology and offer some general comments on research methods to orient the reader. The second major section addresses basic epidemiological statistics on common psychiatric disorders. The third section summarizes research issues on alcohol and substance abuse, particularly as they relate to other psychiatric disorders. The fourth section considers traditional and contemporary healing practices and addresses problems in the assessment of helping interventions. The fifth section identifies emerging trends in the field. Finally, we present a summary of the major conclusions and guidelines for future research based on our reading of the literature.

Report 3: Risk Factors for Attempted Suicide Among Inuit Youth: A Community Survey

M. Malus, L. J. Kirmayer and L. Boothroyd

(See French version below)

Summary

In 1992, we conducted a survey of 100 Inuit young people aged 14-25 years, residing in a community on the Hudson Bay Coast in Northern Quebec, in order to estimate the prevalence and risk factors for suicide attempts. The interview questionnaire was adapted from a self-report instrument used in the 1988 Adolescent Health Survey of the Indian Public Health Service in the United States (Grossman, Milligan & Deyo, 1991). We focused on a community rather than a school-based sample and used both bivariate and multivariate statistical methods to study risk factors. Our sample of 100 youth represented about 40% of the target population.

Thirty-four percent of survey respondents reported a past suicide attempt, and 20% had attempted suicide more than once. In terms of severity, a suicide attempt resulted in injury for about 11% of the persons surveyed. Prevalence of suicidal ideation and exposure to suicide were also very high: 43% reported past thoughts of suicide (26% in the month before the survey) and over 40% had friends who had attempted or completed suicide in the past. Suicidal ideation was highly associated with having a friend who had attempted or completed suicide. The strongest risk factors for suicide attempts were male gender, having a friend who had attempted suicide, experience of physical abuse, a history of solvent abuse, and having a parent with an alcohol or drug problem. Older age and a family history of having received treatment for a psychiatric problem were protective factors.

These findings indicate that individuals at high risk for suicide in the community can be identified for help; however, a broader emphasis on family health and well-being is also essential in preventive measures.

Our study also explored the prevalence of substance use, patterns of help-seeking, prevalence of worries and health problems, and interest in activities and programs. For several potential problems (e.g., anger, friendship break-up), many youth could not identify persons to whom they would go for help. These findings point to the need for effective treatment programs for alcohol and substance abuse, skills training to aid in interpersonal problem solving and dealing with life events, and development of social programs and activities for young people in the community.

This study, as well as recent review of the suicide literature with an emphasis on Aboriginal peoples, supports interventions targeted at the community and political level as well as at the level of the family and the vulnerable individual. In all cases, measures to prevent suicide by improving mental health must be culturally sensitive and broadly based, including sociocultural and spiritual dimensions of well-being.

搁茅蝉耻尘茅

En 1992, nous avons fait une enqu锚te aupr猫s de 100 jeunes Inuits, 芒g茅s entre 14 et 25 ans, demeurant dans une communaut茅 sur le littoral de la Baie d'Hudson, au nord du Qu茅bec, afin d'茅valuer la pr茅valence et les facteurs de risque associ茅s aux tentatives de suicide. Le questionnaire de l'entrevue est bas茅 sur un instrument qui a 茅t茅 utilis茅 aux 脡tats-Unis en 1988 par le Indien Public Health Service ("Adolescent Health Survey," Grossman, Milligan & Deyo, 1991). Nous nous sommes concentr茅s sur une 茅chantillon provenant de la communaut茅 plut么t que du milieu scolaire et avons utilis茅s 脿 la fois des analyses statistiques bivari茅es et multivari茅es afin d'茅tudier les facteurs de risque. Notre 茅chantillon de 100 jeunes repr茅sente environ 40% de la population cible.

Trente-quatre pour cent des participants ont rapport茅 une tentative de suicide dans le pass茅 et 20% ont rapport茅 avoir tent茅 de se suicider plus d'une fois. En terme de s茅v茅rit茅, la tentative de suicide a entra卯n茅 une blessure pour environ 11% des personnes questionn茅es. La pr茅valence des id茅es suicidaires ainsi que le taux d'exposition au ph茅nom猫ne du suicide 茅taient 茅galement tr猫s 茅lev茅s: 43% t茅moignent avoir eu des id茅es suicidaires dans le pass茅 (26% au cours du mois qui pr茅c猫de l'enqu锚te) et plus de 40% avaient des ami-e-s qui avaient tent茅 ou s'茅taient suicid茅s dans le pass茅. Les id茅es suicidaires 茅taient grandement associ茅es au fait d'avoir un-e ami-e qui avait tent茅 ou s'茅tait suicid茅. Les facteur de risque les plus importants associ茅s aux tentatives de suicide 茅taient le fait d'锚tre un homme, d'avoir un-e ami-e ayant tent茅 de se suicider, d'avoir 茅t茅 victime d'abus physique, l'abus de solvants et le fait d'avoir un parent ayant des probl猫mes d'alcool ou de drogues. Le fait d'锚tre plus 芒g茅 et d'avoir une histoire familiale de consultations psychiatriques 茅taient des facteurs de protection.

Ces r茅sultats signifient que les individus ayant un risque 茅lev茅 de suicide dans la communaut茅 peuvent 锚tre identifi茅s afin d'锚tre aid茅s; toutefois, une emphase sur la sant茅 et le bien-锚tre de la famille est 茅galement essentielle comme mesure pr茅ventive.

Notre 茅tude explore 茅galement la pr茅valence d'usage de drogues et d'alcool, les styles de recherche de soins, la pr茅valence d'inqui茅tudes et de probl猫mes de sant茅 ainsi que les int茅r锚ts dans les activit茅s et les programmes. Dans le cas de nombreux probl猫mes possibles (e.g., col猫re, rupture avec un-e ami-e), plusieurs jeunes 茅taient incapables d'identifier des gens vers qui ils pourraient se tourner pour obtenir de l'aide. Ces r茅sultats d茅montrent le besoin de traitements efficaces pour l'abus de drogues et d'alcool, d'entra卯nement afin d'aider la r茅solution de probl猫mes interpersonnels et d'aider 脿 faire face aux 茅v茅nements de la vie, et le d茅veloppement de programmes sociaux et d'activit茅s pour les jeunes dans la communaut茅.

Cette 茅tude, ainsi que les revues r茅centes de la litt茅rature s'int茅ressant aux aborig猫nes, est en faveur des interventions visant le niveau communautaire et politique de m锚me que le niveau de la famille et de l'individu vuln茅rable. Dans tous les cas, les mesures de pr茅vention du suicide, telle que l'am茅lioration de la sant茅 mentale, doivent 锚tre sensibles 脿 la culture et bas茅es sur un ensemble de dimensions telles que les dimensions socioculturelle et spirituelle de bien-锚tre.

Report 4: Inuit Concepts of Mental Health and Illness

L. J. Kirmayer, C. Fletcher, E. Corin and L. Boothroyd

(See French version below)

Summary

The concepts of mental health and illness of the Inuit of Nunavik (Northern Qubec) were studied through ethnographic interviews, participant observation and a questionnaire survey. The aim was to document Inuit knowledge and practices in order to inform mental health workers and planners working in Nunavik of the range of different perspectives and identified needs. The research involved the participation of the community in the selection of survey sites and the identification of appropriate problems for study. Three communities differing in their existing resources and average level of acculturation were studied.

Three types of research interview were conducted, corresponding to distinct parts of the project:

  1. problem identification interviews with Inuit health care and community workers identified the range of problems in the community and the usual terminology used to describe them, resulting in a list of specific registers of potentially problematic behavior;
  2. problem register interviews with key informants from the community identified the perceived prevalence of problems in the community and the typical signs and symptoms associated with each type of behavior or problem;
  3. case history interviews with key informants reconstructed detailed accounts of cases with which they were personally familiar.

Major findings of the study include:

  • There is no general term for mental health or illness in Inuktitut. When pressed, informants either used an English term ('mental health problem') or offered two terms with different connotations: Isumaluttuq and Isumaqanngituq. Isumaluttuq implies thinking too much while Isumaqanngituq means 'having no mind' or not thinking at all.
  • According to informants, the most prevalent mental health problems were alcohol and drug abuse, family violence and abuse, and suicidal behavior.
  • Most people were not very familiar with mental health problems. Although many had heard of demon possession, only a small number of cases were actually described.
  • Although some people who completed suicide were described as withdrawn, isolated, depressed, having heavy thoughts, low self-esteem or hating themselves prior to their suicide, in many cases their suicide came as a complete surprise even to close friends and relatives.
  • Inuit recognized four broad types of causes of mental health problems:
  1. physical and environmental;
  2. psychological or emotional;
  3. demon or spirit possession; and,
  4. culture change and social disadvantage.
    In many cases, multiple causes were offered for the same problem.
  • The presence of hallucinations or bizarre behavior prompted people to think of mental illness or demon possession.
  • Violence, drug abuse and suicide were all commonly attributed to abuse and neglect in childhood or to ongoing family violence.
  • Inuit tended to label behaviors or states of mind rather than individuals. This left open the possibility that someone who had an affliction or troublesome behavior could change and improve.
  • People tended to be very tolerant of others' unusual behavior. This may improve the integration and prognosis for people with psychiatric disorders. It may also, however, delay the recognition of depression, psychosis and suicidality.
  • Talking with others was widely recognized as a good way to prevent and/or resolve mental health problems.
  • Religious exorcism was viewed as an appropriate treatment in cases of demon possession by people who believed this was a cause of unusual behavior or illness.

From the interviews and survey, a model of indigenous concepts of and attitudes toward mental health and illness was developed. An Inuktitut/English lexicon of mental health related terms was also prepared. The model and lexicon can be used in future research on the prevalence, causes and consequences of specific social and psychiatric problems.

The research also has more immediate implications for the design and delivery of mental health care among the Inuit, including community education programs to improve the recognition, treatment and rehabilitation of people with major psychiatric disorders and community and professional interventions for people facing life crises.

搁茅蝉耻尘茅

Les concepts de sant茅 mentale et de maladie chez les Inuits de Nunavik (au nord du Qu茅bec) ont 茅t茅 茅tudi茅s 脿 l'aide d'entrevues ethnographiques, d'observation par des participants et d'une enqu锚te par questionnaire. La recherche impliquait la participation de la communaut茅 dans la s茅lection des sites de l'enqu锚te et dans l'identification de probl猫mes appropri茅s pour l'茅tude. Trois communaut茅s se distinguant par leurs ressources et leur niveau d'acculturation ont 茅t茅 茅tudi茅es.

Trois types d'entrevues ont 茅t茅 faits, correspondant 脿 des sections distinctes du projet听:

  1. des entrevues d'identification de probl猫mes aupr猫s d'Inuits, pr茅pos茅s aux soins de sant茅 et individus travaillant pour la communaut茅, ont identifi茅 l'茅tendue des probl猫mes dans la communaut茅 et la terminologie habituelle employ茅e pour d茅crire ceux-ci. Il en a r茅sult茅 des registres sp茅cifiques de comportements probl茅matiques;
  2. des entrevues d'enregistrement de probl猫mes aupr猫s d'informateurs-cl茅s provenant de la communaut茅 ont identifi茅 la perception par rapport 脿 la pr茅valence des probl猫mes dans la communaut茅 et les signes typiques associ茅s 脿 chacun des comportements ou probl猫mes;
  3. des entrevues d'histoire de cas aupr猫s d'informateurs-cl茅s ont permis de recr茅er les r茅cits d茅taill茅s avec lesquels ils 茅taient familiers.

Les r茅sultats principaux de cette 茅tude incluent听:

  • Il n'y a pas de terme g茅n茅ral afin de d茅crire la sant茅 ou la maladie mentale en Inuktitut. Forc茅s, les informateurs utilisent soit un terme anglophone ('mental health problem') soit deux termes ayant des connotations diff茅rentes: Isumaluttuq et Isumaqanngituq. Isumaluttuq implique le fait de trop penser tandis que Isumaqanngituq voulait dire 'having no mind ' ou le fait de ne pas penser du tout.
  • Selon les informateurs, les probl猫mes de sant茅 mentale les plus fr茅quents 茅taient l'abus d'alcool et de drogues, la violence familiale, une famille abusive et les comportements suicidaires.
  • La plupart des gens n'茅taient pas familiers avec les probl猫mes de sant茅 mentale. Bien que plusieurs aient entendu parl茅 de possession d茅moniaque, seul un petit nombre de cas a 茅t茅 d茅crit.
  • Malgr茅 le fait que certaines personnes s'茅tant suicid茅es 茅taient d茅crites comme retir茅es, isol茅es, d茅pressives ainsi qu'ayant des id茅es lourdes, une estime de soi basse et ha茂ssant leur propre personne et ce, juste avant leur suicide, dans plusieurs cas leur suicide 茅tait tout 脿 fait inattendu m锚me pour les amis-es proches ou la famille.
  • Les Inuits reconnaissent 4 grands types de causes des probl猫mes de sant茅 mentale:
  1. les causes physiques et environnementales;
  2. les causes psychologiques et 茅motionnelles;
  3. le fait d'锚tre poss茅d茅 par un d茅mon ou par un esprit;
  4. les changements d'ordre culturel et les d茅savantages sociaux.
    Dans de nombreux cas, de multiple causes 茅taient offertes pour le m锚me probl猫me.
  • La pr茅sence d'hallucinations ou de comportements bizarres 茅taient associ茅s 脿 la maladie mentale ou 脿 la possession d茅moniaque.
  • La violence, l'abus de drogues et le suicide 茅taient tous fr茅quemment attribu茅s au fait d'avoir 茅t茅 victime d'abus et de n茅gligence 茅tant enfant ou 脿 de la violence familiale perp茅tuelle.
  • Les Inuits avaient tendance 脿 茅tiqueter les comportements ou les 茅tats mentaux plut么t que les individus. Ceci rendait possible le fait qu'un individu atteint d'une maladie ou d'un trouble de comportement puisse changer et s'am茅liorer.
  • Les gens avaient tendance 脿 锚tre tr猫s tol茅rants face aux comportements inhabituels des autres. Ceci pourrait bien am茅liorer l'int茅gration et le pronostique des individus atteints de troubles psychiatriques. Par contre, ceci pourrait 茅galement retarder l'identification des probl猫mes de d茅pression, de psychoses et de tendances suicidaires.
  • La fait de parler avec les autres 茅tait largement reconnu comme un bon moyen afin de pr茅venir et/ou de r茅soudre les probl猫mes de sant茅 mentale.
  • L'exorcisme religieux 茅tait per莽u comme un traitement appropri茅 dans le cas o霉 les gens poss茅d茅s par le d茅mon 茅taient des gens qui croyaient que ceci 茅tait une cause possible du comportement inhabituel ou de la maladie.

A l'aide des entrevues et de l'enqu锚te, nous avons d茅velopp茅 un mod猫le de concepts indig猫nes d'attitudes envers la sant茅 et la maladie mentale. Un lexique inuktitut/anglais de termes reli茅s 脿 la sant茅 mentale a 茅galement 茅t茅 pr茅par茅. Ce mod猫le ainsi que ce lexique pourra 锚tre utilis茅 dans des recherches ult茅rieures sur la pr茅valence, les causes et les cons茅quences de probl猫mes sociaux et psychiatriques sp茅cifiques.

Cette recherche poss猫de 茅galement des cons茅quences imm茅diates sur la fa莽on de d茅velopper et d'administrer les soins de sant茅 mentale 脿 la population Inuite, incluant des programmes communautaires d'茅ducation ayant pour but d'am茅liorer l'identification, le traitement et la r茅habilitation des individus atteints de troubles psychiatriques majeurs ainsi que des interventions aupr猫s de la communaut茅 et des professionnels afin d'aider les gens faisant face 脿 des crises au cours de leur vie.

Report 5: Development and Validation of a Structured Diagnostic Interview for Functional Somatic Syndromes

L.J. Kirmayer, J.M. Robbins, and S. Taillefer

(See French version below)

Summary

Medical specialists and primary care physicians are often presented with symptoms and syndromes that are 'functional'that is, due to disturbances in function rather than biological structure. The three most common functional somatic syndromes (FSS) are fibromyalgia (chronic widespread musculoskeletal aches and pains and tenderness), irritable bowel (abdominal discomfort, distension and alteration of bowel habits), and chronic fatigue (easy fatigability and cognitive impairment). Health conditions such as fibromyalgia, irritable bowel and chronic fatigue often receive unclear or contradictory medical explanations. This puts patients in a social and psychological quandary that may lead to excessive illness worry, 'doctor-shopping,' use of non-conventional practitioners, increased social stigma and disability. Because diagnostic criteria have relied on extensive medical investigations to rule out organic disease, there are few studies of these conditions in the general population that adequately address their personal and social consequences. Recent refinements in the diagnostic criteria for fibromyalgia, irritable bowel and chronic fatigue make it possible to approximate the diagnosis of these syndromes on the basis of specific symptom clusters and a few simple physical signs. Further, evidence that these putatively discrete syndromes share many common features suggests the value of a common research approach.

In this research program, we developed a structured diagnostic interview for functional somatic syndromes (the DIFS) based on the consensual diagnostic criteria of recent international working groups. This interview was then tested against known groups of patients with fibromyalgia, irritable bowel and chronic fatigue syndromes from specialty clinics and private practices. Patients with each functional syndrome were matched with patients with a disease with similar symptomatology: rheumatoid arthritis, inflammatory bowel disease and multiple sclerosis, respectively. There was moderate diagnostic agreement between clinician and interview-based diagnoses (kappa = .37 to .58). The DIFS showed good specificity but low sensitivity to the functional somatic syndromes.

The sample collected to validate the DIFS also allowed us to study the co-occurrence, psychological characteristics and health impact of FSS. We found high levels of co-occurrence of the syndromes, ranging from 33% of irritable bowel patients and 53% of fibromyalgia patients to 89% of chronic fatigue patients meeting criteria for at least one other syndrome. Most clinicians did not recognize this high degree of syndrome co-occurrence in their patients.

To examine psychological characteristics and illness impact we compared patients grouped according to referral diagnosis. We also aggregated functional syndrome patients and non-functional syndrome patients into two groups for some comparisons. On a measure of the five-factor theory of personality, there were no differences between functional syndrome patients taken as a group and the aggregate control group. There was some tendency for fibromyalgia patients to score higher on Neuroticism. Functional syndrome patients (chronic fatigue syndrome patients in particular) had higher levels of hypochondriacal worry than other groups. There were few significant differences among groups in symptom attributional style. While fibromyalgia patients acknowledged emotional distress as an important contributor to their illness, chronic fatigue patients tended to reject this explanation, emphasizing infectious and immune causes instead.

Functional syndromes were highly disabling and were associated with higher degrees of social and emotional distress-related disability compared to other illnesses. Chronic fatigue syndrome was associated with the highest levels of self-perceived burden on the family and social stigma. In general, compared to the non-functional disease groups, functional syndromes were associated with higher levels of help-seeking and utilization of both conventional and alternative health care. This high utilization was associated with lower rates of perception of care as helpful and practitioners as understanding. This pattern was especially marked for patients with chronic fatigue syndrome and suggested that patients may keep seeking help until they find someone who understands them and something that works. If so, then the high rates of utilization by functional somatic syndrome patients should not be interpreted as 'abnormal illness behaviour', excessive help-seeking or over-utilization of services but as a pragmatic search for an effective response to poorly understood and managed conditions.

The development of the Diagnostic Interview for Functional Syndromes (DIFS) will allow researchers to conduct community epidemiological studies to trace the evolution and social consequences of these disorders before and after they are labeled by practitioners. This will enable the study of health coping and stigmatization of non-validated illness. In the clinic, improved diagnosis of functional somatic syndromes and their early recognition may reduce needless laboratory investigations with their excess cost and risk of iatrogenic morbidity. Future epidemiological applications will include reliable estimates of the prevalence and co-occurrence of functional somatic syndromes in the community, estimates of their co-occurrence with psychiatric disorders and tracking of changes in the prevalence of these conditions over time.

搁茅蝉耻尘茅

Les m茅decins sp茅cialistes ainsi que les m茅decins de soins de premi猫re ligne sont souvent confront茅s 脿 des sympt么mes et 脿 des syndromes dits 'fonctionnels'- c'est 脿 dire qui sont caus茅s par un probl猫me de fonctionnement plut么t que par un probl猫me au niveau de la structure biologique. Les trois syndromes somatiques fonctionnels (SSF) les plus r茅pandus sont la fibromyalgia (douleurs musculaires et squelettiques r茅pandues et chroniques, et sensibilit茅), l'intestin irritable (inconfort abdominal, ballonnement et changement au niveau des selles) et la fatigue chronique (fatigue facile et d茅t茅rioration cognitive). Des conditions telles que la fibromyalgia, l'intestin irritable et la fatigue chronique re莽oivent fr茅quemment des explications m茅dicales confuses ou contradictoires. Ceci met les patients dans une situation sociale et psychologique probl茅matique qui peut engendr茅e des soucis associ茅s 脿 la maladie, un 'magasinage m茅dical' accru, l'utilisation de sp茅cialistes non traditionnels, une augmentation des stigma sociaux et de l'invalidit茅. Compte tenu du fait que les crit猫res diagnostiques d茅pendent d'une investigation m茅dicale approfondie afin d'茅liminer les maladies de type organique, il existe tr猫s peu d'茅tudes de ces conditions dans la population g茅n茅rale qui examinent avec justesse les cons茅quences personnelles et sociales qui y sont rattach茅es. Les r茅centes am茅liorations au niveau des crit猫res diagnostiques de la fibromyalgia, des intestins irritables et de la fatigue chronique rendent possible l'approximation du diagnostic de ces syndromes en se basant sur des regroupements de sympt么mes sp茅cifiques et sur quelques signes physiques particuliers. De plus, la preuve que ces suppos茅s syndromes ind茅pendants aient plusieurs choses en commun sugg猫rent l'utilisation d'une m茅thode de recherche commune.

Dans le cadre de ce projet de recherche, nous avons d茅velopp茅 une Entrevue Diagnostique Structur茅e pour les Syndromes Somatiques Fonctionnels (le EDSS) bas茅e sur des crit猫res diagnostiques faisant l'unanimit茅 de groupes de travail internationaux. Cette entrevue fut alors test茅e aupr猫s de groupes de patients connus comme souffrant de fibromyalgia, d'intestin irritable et de fatigue chronique, provenant de cliniques sp茅cialis茅es et de pratiques priv茅es. Des patients souffrant de chacun des syndromes ont 茅t茅 appari茅s 脿 des patients souffrant d'une symptomatologie similaire: arthrite rhumato茂de, maladie inflammatoire de l'intestin et scl茅rose en plaques, respectivement. L'entente entre le diagnostic des cliniciens et le diagnostic bas茅 sur l'entrevue est moyenne (kappa=.37 脿 .58). Le EDSS a d茅montr茅 une bonne sp茅cificit茅 mais une sensibilit茅 basse aux syndromes somatiques fonctionnels.

L'茅chantillonnage afin de valider le EDDS nous permet 茅galement d'茅tudier la cooccurrence, les caract茅ristiques personnelles et l'impact sur la sant茅 associ茅s aux SSF. Nous avons trouv茅 une niveau 茅lev茅 de cooccurrence des syndromes, variant de 33% des patients souffrant d'intestin irritable et 53% des patients souffrant de fibromyalgia 脿 89% des patients souffrant de fatigue chronique satisfaisaient les crit猫res d'au moins un autre syndrome. La plupart des cliniciens n'ont pas reconnu le degr茅 茅lev茅 de cooccurrence chez leurs patients.

Afin d'examiner les caract茅ristiques psychologiques et l'impact de la maladie, nous avons compar茅 les patients regroup茅s selon le diagnostic au moment de la r茅f茅rence. Nous avons 茅galement compar茅 tous les patients souffrant d'un syndrome 脿 tous ceux ne souffrant pas d'un syndrome. Les r茅sultats de l'茅chelle de la personnalit茅 bas茅e sur la th茅orie des cinq facteurs indiquent aucunes diff茅rences entre les syndromes somatiques fonctionnels et les groupes contr么les. Seuls les patients souffrant de Fibromyalgia ont tendance 脿 obtenir un score sup茅rieur sur l'茅chelle de "Neuroticism." Les patients souffrant de syndromes fonctionnels (et plus particuli猫rement ceux souffrant de fatigue chronique) ont un taux sup茅rieur de soucis d'ordre hypochon-driaque comparativement aux autres groupes. Il y a quelques diff茅rences significatives entre les groupes au niveau du style d'attribution des sympt么mes. Les patients souffrant de Fibromyalgia ont reconnu la d茅tresse 茅motionnelle comme ayant contribu茅 de fa莽on importante 脿 la maladie, tandis que les patients souffrant de fatigue chronique ont rejet茅 cette explication, mettant plut么t l'emphase sur les infections et sur des causes immunitaires.

Les syndromes fonctionnels sont la cause d'une grande incapacit茅 et sont associ茅s 脿 des degr茅s sup茅rieurs de d茅tresse sociale et 茅motionnelle et ce, comparativement aux autres groupes. Le syndrome de fatigue chronique est associ茅 au taux le plus 茅lev茅 de fardeau sur la famille per莽u par le patient et de stigma sociaux. En g茅n茅ral, comparativement aux groupes souffrant de troubles non fonctionnels, les syndromes fonctionnels sont associ茅s 脿 un taux sup茅rieur de consultation et d'utilisation des soins de sant茅 脿 la fois traditionnels et alternatifs. Ce taux 茅lev茅 d'utilisation est associ茅 脿 un taux inf茅rieur de perception des soins comme 茅tant utiles et des praticiens comme 茅tant compr茅hensifs. Ceci est particuli猫rement marqu茅 chez les patients souffrant du syndrome de fatigue chronique et sugg猫re que les patients persistent 脿 chercher de l'aide jusqu'脿 ce qu'ils trouvent quelqu'un qui les comprennent et quelque chose qui fonctionne. Si ceci est le cas, le taux 茅lev茅 de consultations observ茅 chez les patients souffrant de syndromes fonctionnels ne devrait pas 锚tre interpr茅t茅 comme un "abnormal illness behaviour", comme une recherche excessive d'aide ou comme une surutilisation des services de sant茅, mais plut么t comme une recherche pragmatique d'une r茅ponse efficace 脿 des conditions incomprises et mal diagnostiqu茅es.

Le d茅veloppement de l'Entrevue Diagnostique Structur茅e pour les Syndromes Somatiques Fonctionnels (EDSS) permettra aux chercheurs d'entreprendre des 茅tudes 茅pid茅miologiques communautaires afin de retracer l'茅volution et les cons茅quences sociales de ces troubles avant et apr猫s que ceux-ci soient cat茅goris茅s par les praticiens. Ceci contribuera 脿 aider l'茅tude des m茅canismes de coping et de stigmatisation des maladies non valid茅es. En clinique, un meilleur diagnostique des syndromes somatiques fonctionnels et une identification plus rapide de ceux-ci peuvent 茅viter des investigations inutiles et co没teuses en laboratoire et tout ce qui en d茅coule. Les applications 茅pid茅miologiques futures incluront un estim茅 digne de confiance de la pr茅dominance et de la cooccurrence des syndromes somatiques fonctionnels dans la communaut茅, un estim茅 de leur cooccurrence avec des troubles psychiatriques et une fa莽on de suivre l'茅volution des changements dans la pr茅dominance de ces conditions aux cours des ann茅es.

Report 6: Pathways and Barriers to Mental Health Care in an Urban Multicultural Milieu: An Epidemiological and Ethnographic Study

Laurence J. Kirmayer, MD
Guillaume Galbaud du Fort, MD, PhD
Allan Young, PhD
Morton Weinfeld, PhD
Jean-Claude Lasry, PhD

(See French version below)

Summary

We conducted a community survey of the general population in an urban multicultural neighborhood (Cte des Neiges), defined as the catchment area of a community clinic (CLSC). The focus was on three groups of immigrants to Canada (Anglophone Caribbeans, Vietnamese and Filipinos) and Canadian-born comparaison groups. The objectives included:

  1. to identify the health care utilization of individuals with current depressive, anxiety or somatoform symptomatology or with recent social problems;
  2. to determine the perceived barriers to mental health care in primary care and specialty mental health sectors;
  3. to examine the relationship between cultural models of illness and healing and (A) patterns of symptom expression, help-seeking and health care utilization; (B) variations in the resolution of common mental disorders and social problems;
  4. to examine the relationship between patterns of acculturation and (A) the prevalence and symptomatic expression of somatization, depression and anxiety, and (B) help-seeking and health care utilization.

The study had a two-stage design:

  1. telephone interview of 2246 persons, designated as the "Stage 1 interview"; and
  2. follow-up telephone interview at three months of 576 persons divided approximately equally into five cultural groups (Anglophone Canadian-born, Francophone Canadian-born, Vietnamese, Caribbean, and Filipino), designated as the "Stage 2 interview."

A third, ethnographic component was also part of the study, for which 117 in depth semi-structured interviews were completed face-to-face with a sub-sample from Stage 2, containing approximately equal numbers of persons from the five cultural groups. This report presents preliminary findings from the Stage 1 and Ethnographic interviews.

All instruments were translated into French and Vietnamese by fluently bilingual speakers and checked for semantic equivalence by blind back-translation. The principal findings include

Overall rates of utilization of medical services in the past year were similar in immigrant (78.1%) and non-immigrant (76.4%) groups. However, rates of utilization of health care services for psychological distress were significantly lower among immigrants (5.5 vs. 14.7%, p<0.001). This difference was attributable both to a significantly lower rate of utilization of specialty mental health services by immigrants (2.6 vs. 11.6%, p<0.001) and to differential use of medical services for psychological distress (3.5 vs. 5.8%, p=0.02).

Higher rates of utilization of mental health services were associated with greater emotional distress (on the GHQ), more somatic symptoms and more life events. Individuals with more than high school education were also more likely to use services for a psychological problem.

The lower rates of utilization were found for all three ethnocultural groups but were most marked for Vietnamese and Filipino groups. Within the three immigrant groups, length of stay in Canada was not related to the tendency to use mental health services.

Multivariate analyses showed that the lower rate of utilization by immigrants could not be explained entirely by differences in sociodemographics or levels of somatic or psychological symptoms, or life events.

For respondents with at least one symptom of psychological distress in the last year on the GHQ we explored the reasons why they did not seek help. The most important factors were a tendency to minimize, normalize and deal with problems on one's own (common to all groups but especially marked among the immigrant groups) and perceived ethnic mismatch among the immigrants. Ethnic mismatch involved the perception that available care providers would not understand or be prejudiced against the respondent's culture and that professionals from their cultural background were not available. Other important barriers to care included the fear of stigmatization, mistrust of the health care system and practical obstacles, including getting time away from work.

Taken together, these analyses suggest substantial under-utilization of mental health services by immigrant groups that cannot be entirely attributed to differences in gender, level of education, employment status, level of distress, or alternative sources of care. The most important factors appear to be the understanding and interpretation of psychological symptoms, the desire to deal with personal problems on one's own or within the family and the perception that health care professionals who understand the immigrants' cultural background are not available.

Somatic symptoms were found to be more frequently reported by Vietnamese compared to all other groups. When age, gender, educational level, and employment status were controlled in multiple regression models, age, female gender, lower level of education, unemployment and Vietnamese origin were all found to be independent contributors to increased reporting of common somatic symptoms. When level of psychological distress as measured by the GHQ-12 was added to the model, it was strongly associated with somatic symptoms and the effects of age, female gender and Vietnamese origin persisted, while the effects of education and employment were reduced to insignificance.

In contrast to these differences in levels of somatic symptoms, there was no difference in the presence of medically unexplained symptoms across ethnocultural groups. These results indicate that the broad generalization that "non-Western" ethnocultural groups tend to somatize is incorrect. In the present study, only the Vietnamese gave clear evidence of elevated rates of somatic symptoms which might be indicative of some form of somatization.

We also examined the acculturation style (Marginalization, Separation, Integration, Assimilation) of the immigrant groups based on their ratings of identification with their own ethnic group of origin and the host Canadian society. The results confirmed the bidimensional model of ethnic identityin which individuals identify independently with their country of origin (or heritage ethnic group) and the culture of the host society.

Acculturation style was not associated with levels of somatic or psychological symptomatology overall. Integration was associated with a lower frequency of life events overall but this effect did not reach significance for any specific ethnocultural group. Acculturation style was also unrelated to the rate of utilization of GP and specialist medical care and to percentage seeking any service for mental health overall. Marginalization and Separation were associated with significantly higher levels of barriers to care overall.

The ethnographic component of the present study was designed (1) to develop and refine a specific method for collecting and analyzing illness narratives; (2) to clarify and validate specific questionnaire items from the epidemiological study; (3) to examine the illness experience and hierarchies of resort of individuals from different ethnocultural groups with (a) medically unexplained symptoms; (b) multiple somatic symptoms; or (c) symptoms of psychological distress on the GHQ; (4) to clarify the cognitive and interpersonal processes that contribute to the discursive production of illness narratives; and (5) to identify issues for future ethnographic and epidemiological research.

Preliminary results indicate the usefulness of the illness narrative protocols. They also indicate the importance of prototypical experiences and sequences (chain complexes) in accounts of symptoms and illness. Two versions of the illness narrative protocols have been developed for clinical and community settings and further data collection and analysis are currently underway.

搁茅蝉耻尘茅

Nous avons men茅 une enqu锚te communautaire aupr猫s de la population d'un secteur urbain multi-culturel, d茅fini comme le territoire du CLSC C么te-des-Neiges. Nous avons focalis茅 notre recherche sur trois groupes d'immigrants (Antillais anglophones, Vietnamiens et Philippins) et des groupes de comparaison constitu茅s d'individus n茅s au Canada. Les objectifs incluent:

  1. identifier l'utilisation des soins de sant茅 des individus souffrant actuellement de sympt么mes de d茅pression, d'anxi茅t茅 et de somatisation, ou 茅prouvant des probl猫mes sociaux r茅cents;
  2. d茅terminer les entraves per莽ues 脿 l'obtention de soins en sant茅 mentale, au niveau des soins de premi猫re ligne et des secteurs sp茅cialis茅s en sant茅 mentale;
  3. examiner la relation entre les mod猫les culturels de la maladie et de la gu茅rison et (A) des types d'expression de sympt么mes, de recherche d'aide et d'utilisation des services de soins de sant茅; (B) les variations dans la r茅solution de troubles mentaux et sociaux fr茅quents;
  4. examiner la relation entre des types d'acculturation et (A) la pr茅valence et l'expression symptomatique de la somatisation, de la d茅pression et de l'anxi茅t茅 et (B) la recherche et l'utilisation des soins de sant茅.

La recherche comporte deux 茅tapes听:

  1. une entrevue t茅l茅phonique aupr猫s de 2246 personnes, 茅tape d茅finie comme "Entrevue-Stade I" et
  2. un suivi t茅l茅phonique, trois mois apr猫s, aupr猫s de 576 personnes divis茅es approximativement en cinq groupes culturels 茅gaux (anglophones natifs du Canada, francophones natifs du Canada, Vietnamiens, Antillais et Philippins), 茅tape d茅finie comme "Entrevue-Stade II".

Une troisi猫me composante ethnographique fait 茅galement partie de l'茅tude et consiste en 117 entrevues face-脿-face, semi-structur茅es, faites aupr猫s d'un sous-茅chantillon provenant du deuxi猫me stade, r茅parties approximativement de fa莽on 茅gale 脿 travers les cinq groupes ethniques. Ce rapport pr茅sente des r茅sultats pr茅liminaires du stade I et des entrevues ethnographiques.

Tous les instruments ont 茅t茅 traduits en fran莽ais et en vietnamien par des personnes parlant couramment les deux langues, et leur 茅quivalence linguistique a 茅t茅 v茅rifi茅 par le biais d'une contretraduction faite par des traducteurs ignorant tout du texte original. Les r茅sultats principaux incluent-

Les taux globaux d'utilisation des services m茅dicaux au cours de la derni猫re ann茅e sont similaires chez les groupes d'immigrants (78.1%) et de non-immigrants (76.4%). Toutefois, les taux d'utilisation des services de soins de sant茅 pour des probl猫mes de d茅tresse psychologique sont significativement inf茅rieurs chez les immigrants (5.5 vs. 14.7%, p<.001). Cette diff茅rence est attribuable 脿 la fois 脿 un taux significativement plus bas d'utilisation de services sp茅cialis茅s en sant茅 mentale chez les immigrants (2.6 vs. 11.6%, p<.001) et 脿 une diff茅rence dans l'utilisation de services m茅dicaux pour des probl猫mes de d茅tresse psychologique (3.5 vs. 5.8%, p=0.02).

Des taux d'utilisation de services de sant茅 mentale sup茅rieurs sont associ茅s 脿 une plus grande d茅tresse 茅motionnelle (selon leGHQ), 脿 un plus grand nombre de sympt么mes somatiques et 脿 plus d'茅v茅nements stressants. Les individus ayant un niveau d'茅ducation sup茅rieur 脿 une 12i猫me ann茅e ont 茅galement tendance 脿 utiliser davantage des services pour des probl猫mes psychologiques.

Les taux d'utilisation sont inf茅rieurs chez les trois groupes ethniques, et particuli猫rement bas chez les Vietnamiens et les Philippins. Parmi les trois groupes d'immigrants, la dur茅e de s茅jour au pays n'est pas reli茅e 脿 la tendance 脿 utiliser les services de sant茅 mentale.

Les analyses multivari茅es d茅montrent que le taux inf茅rieur d'utilisation chez les immigrants ne peut pas 锚tre enti猫rement expliqu茅 par des diff茅rences socio-d茅mographiques ou par diff茅rents niveaux de sympt么mes somatiques ou psychologiques, ou par les 茅v茅nements stressants de la vie.

Nous avons examin茅 les raisons invoqu茅es par les personnes pr茅sentant au moins un sympt么me de d茅tresse psychologique au cours de la derni猫re ann茅e 脿 l'茅chelle du GHQ, et qui n'avaient pas consult茅. Le facteur le plus important est la tendance 脿 minimiser, 脿 normaliser et 脿 faire face aux probl猫mes seul-e (facteur commun chez tous les groupes, mais plus particuli猫rement chez les immigrants) et, chez les immigrants, 脿 percevoir une disparit茅 d'ordre ethnique. La disparit茅 ethnique consiste 脿 percevoir les fournisseurs des soins comme incapables de comprendre ou ayant des pr茅jug茅s envers leur culture, les professionnels provenant de leur propre culture 茅tant per莽us comme non disponibles. D'autres barri猫res importantes 脿 l'obtention de soins comprennent la peur d'锚tre stigmatis茅, le manque de confiance dans le syst猫me m茅dical et des obstacles d'ordre pratique, incluant l'absence du milieu de travail.

Ces analyses sugg猫rent une sous-utilisation marqu茅e des soins de sant茅 mentale par les groupes d'immigrants, ce qui ne peut pas 锚tre enti猫rement attribu茅 aux diff茅rences de genre, de niveau d'茅ducation, de statut d'emploi, de d茅tresse ou d'utilisation de sources alternatives de soins. Les facteurs les plus importants semblent 锚tre la compr茅hension et l'interpr茅tation des sympt么mes psychologiques, le d茅sir de faire face aux probl猫mes personnels seul-e ou au sein de la famille, et la perception que les professionnels de la sant茅 qui pourraient comprendre la culture des immigrants ne sont pas disponibles.

Les sympt么mes somatiques sont plus fr茅quemment rapport茅s par les Vietnamiens. Quand on contr么le l'芒ge, le niveau d'茅ducation et le statut d'emploi dans des 茅quations de r茅gression multiple, le fait d'锚tre une femme, l'芒ge, un niveau d'茅ducation inf茅rieur, le fait d'锚tre sans emploi ou d'锚tre d'origine vietnamienne contribuent de fa莽on ind茅pendante au fait de rapporter davantage de sympt么mes somatique communs. Quand le niveau de d茅tresse psychologique, tel que mesur茅 par le GHQ-12, est rajout茅 au mod猫le, il est fortement associ茅 aux sympt么mes somatiques, et les effets de l'芒ge, du genre et de l'origine vietnamienne persistent, tandis que les effets de l'茅ducation et de l'emploi ne sont plus significatifs.

Contrairement aux diff茅rences dans les niveaux de sympt么mes somatiques, il n'y a pas de diff茅rence quant 脿 la pr茅sence de sympt么mes sans explication m茅dicale entre les groupes. Ces r茅sultats d茅montrent que la g茅n茅ralisation affirmant que les groupes ethno-culturels non-occidentaux ont tendance 脿 somatiser est incorrecte. Dans la pr茅sente 茅tude, seuls les Vietnamiens ont d茅montr茅 clairement des taux 茅lev茅s de sympt么mes somatiques prouvant peut-锚tre l'existence d'une forme de somatisation.

Nous avons 茅galement examin茅 le style d'acculturation (Marginalisation, S茅paration, Int茅gration, Assimilation) des groupes d'immigrants en fonction de leur identification avec leur propre groupe ethnique et avec la soci茅t茅 canadienne. Les r茅sultats confirment le mod猫le d'identit茅 ethnique 脿 deux dimensions - selon lequel les individus s'identifient de fa莽on ind茅pendante 脿 leur pays d'origine (ou groupe ethnique familial) et 脿 la culture de la soci茅t茅 d'accueil.

Le style d'acculturation n'est pas associ茅 aux niveaux de symptomatologie somatique ou psychologique. L'Int茅gration est associ茅e 脿 une fr茅quence inf茅rieure d'茅v茅nements stressants, mais cet effet n'est significatif pour aucun des groupes ethnoculturels. Le style d'acculturation n'est 茅galement pas li茅 au nombre de visites chez un omnipraticien ou un sp茅cialiste, ni au pourcentage de consultation d'un quelconque service pour probl猫me de sant茅 mentale. La Marginalisation et la S茅paration sont associ茅es 脿 des niveaux significativement plus 茅lev茅s d'entraves 脿 l'obtention de soins en g茅n茅ral.

La composante ethnographique de la pr茅sente 茅tude a 茅t茅 con莽ue afin de

  1. d茅velopper et de raffiner une m茅thode sp茅cifique de collection et d'analyse de r茅cits concernant la maladie;
  2. de clarifier et valider des items sp茅cifiques du questionnaire de l'茅tude 茅pid茅miologique;
  3. d'examiner l'exp茅rience quant 脿 la maladie et les hierarchies des recours d'individus appartenant 脿 diff茅rents groupes ethnoculturels et souffrant (a) de sympt么mes sans explication m茅dicale; (b) de multiple sympt么mes somatiques; ou (c) de sympt么mes de d茅tresse psychologique selon le GHQ;
  4. de clarifier les processus cognitifs et interpersonnels qui contribuent 脿 la production de r茅cits d茅cousus sur la maladie; et
  5. d'identifier les probl猫mes pour les 茅tudes ethnographiques et 茅pid茅miologiques futures.

Les r茅sultats pr茅liminaires d茅montrent l'utilit茅 des protocoles de r茅cits de maladies. Ils d茅montrent 茅galement l'importance des prototypes d'exp茅riences et de s茅quences dans les r茅cits des sympt么mes et de la maladie. Deux versions du protocole de r茅cits de maladies ont 茅t茅 d茅velopp茅es 脿 des fins cliniques et communautaires, et la collecte de donn茅es compl茅mentaires ainsi que des analyses additionnelles sont pr茅sentement en cours.

Report 7: Health Care Utilization and Child Care Practices among Chinese-Canadian Women in a Pediatric Practice

Alice Chan-Yip, MD, FRCPC
Laurence J. Kirmayer, MD, FRCPC

(See French version below)

Summary

One hundred Chinese women who brought their child for a health check-up at a community-based pediatric practice, were given structured interviews on their own general health and health care utilization, and on infant and child care experiences. The objectives of the survey included:

  1. to assess the pattern of health care utilization among mothers in a pediatric practice;
  2. to assess the quality of the following maternal-child health maintenance issues:
    • pattern of utilization of perinatal services
    • family attitudes and practices concerning childbirth and infant care
    • discipline styles
    • family recreation
    • school preparation;
  3. to identify: (a) the prevalence of beliefs in yin-yang and hot-cold concepts of balance in the body and food as contributing to health and illness; and (b) the pattern of utilization of traditional Chinese medicine including acupuncture, herbal and alternative medicine, in relation to acculturation style;
  4. to pilot test a series of instruments for use in future community surveys in the Montreal Chinese community.

More than half of the women in this study were employed. In encounters with health professionals or social workers, respondents were evenly divided in thirds into those who used exclusively Cantonese or only English and those who used a combination. There was little use of French in the group. The retention of Chinese language and its substantial use at work and with health professionals points to the need for linguistic and ethnospecific services to meet the needs of this population.

The most common somatic symptoms reported were fatigue (18%), dizziness (13%), and excessive gas or bloating (12%). On a scale of psychological symptoms of distress, the most frequently endorsed symptoms were felt unhappy and depressed (34%), constantly under strain (30%), and couldn't overcome difficulties (20%). A factor analysis of somatic and psychological symptoms yielded a dimension of distress corresponding to neurasthenia with principal symptoms of weakness; sickly for most of one's life; not able to concentrate; and fatigue.

While 26 women had scores of 3 or more on the General Health Questionnaire (GHQ) indicating significant levels of distress, only 2 had talked to their family doctors about mental health issues in the past 12 months, and none had visited a social worker, psychiatrist, psychologist or any other type of professional for a problem with nerves, worries, emotional or mental health or a stress-related problem. When women with at least one symptom on the GHQ were asked why they had not gone for help most of the reasons reflected a tendency to minimize and deal with problems on one's own, perhaps because the problems were mild or self-limited for many. It is of note, however, that time constraints were a common reason for not seeking help.

Almost 1/3 of the women made use of some Traditional Chinese Medicine at home in the last year and almost 1/4 saw a Chinese medical practitioner. Other forms of alternative or complementary medicine were not used by the women in this study. Chinese medicine (principally herbs) was used at similar rates for children's health problems. About 1/4 of respondents had taken their children to see a traditional Chinese doctor. The most common reasons for consultation were colds and stomach problems. One third of mothers used over-the-counter Chinese medicines for similar purposes.

Of the 100 Chinese women surveyed in this study, 51 had attended a prenatal course. While 12% claimed they had worried about childbirth often, 44% had worried at least some of the time. The most common reason for both mothers and fathers to not participate in a prenatal course was time limitation. This suggests the need to develop reading materials and brief courses that are practical and accessible for couples with heavy work or family obligations.

In this sample of mothers, 19% recalled being sad and depressed for up to 2 weeks or more after childbirth and 14% experienced prolonged fatigue during the postpartum period.

A majority of women (73%) had intended during at least one of their pregnancies to breast feed. Despite these intentions, however, almost half (43%) did not breast feed any of their children. Prenatal classes (29%) and reading materials (19%) were cited most frequently as factors that influenced the decision to initiate breast feeding.

In summary, the results of this study indicate

  1. the continuing need for ethnospecific services among this group of recent immigrants, and
  2. the need for further development and promotion of perinatal education.

Postnatal distress appears to be expressed primarily in terms of depressed mood and a neurasthenic syndrome that may go unrecognized and under-treated in both mental health and primary care sectors. Further research with a community sample may clarify the nature and impact of this distress and lead to better identification and treatment by physicians.

搁茅蝉耻尘茅

Une centaine de chinoises ayant amen茅 leur-s enfant-s pour un examen de routine 脿 une clinique communautaire prodiguant des soins p茅diatriques ont 茅t茅 interrog茅es au sujet de leur sant茅 en g茅n茅ral, de leur utilisation des soins de sant茅, ainsi qu'au sujet de leurs exp茅riences avec les soins de leur-s b茅b茅-s et/ou enfant-s. Les buts de l'enqu锚te inclus听:

  1. l'茅valuation des patterns d'utilisation des soins de sant茅 chez les m猫res dans le cadre d'une pratique p茅diatrique;
  2. l'茅valuation des probl猫mes suivants associ茅s 脿 la qualit茅 des maintients de la sant茅 des m猫res et des enfants:
    • pattern d'utilisation des services en p茅rinatalit茅
    • attitudes et pratiques familiales en ce qui a trait 脿 l'accouchement et aux soins infantiles
    • styles de discipline
    • passe-temps familiaux
    • pr茅paration scolaire;
  3. identifier听: (a) la pr茅valence des croyances concernant les notions de yin-yang et de chaud-froid (hot-cold), dans le corps et la nourriture, comme facteurs contribuant 脿 la sant茅 et 脿 la maladie; et (b) les patterns d'utilisation de la m茅decine traditionnelle chinoise, incluant l'acupuncture, les herbes et la m茅decine alternative et ce, en relation avec le style d'acculturation;
  4. tester une s茅rie d'instruments destin茅s 脿 锚tre utilis茅s dans des enqu锚tes communautaire chez la communaut茅 chinoise montr茅alaise.

Plus de la moiti茅 des femmes de l'茅tude occupait un emploi. Au niveau des rencontres avec des professionnels de la sant茅 ou travailleurs sociaux, le nombre de r茅pondantes se divisait 茅galement en trois groupes: celles qui utilisaient exclusivement le chinois, l'anglais et une combinaison des deux. Le fran莽ais n'茅tait pas utilis茅 fr茅quemment dans le groupe de femmes. Le fait de maintenir la langue chinoise et son importante utilisation au travail et avec les professionels de la sant茅 viennent confirmer le besoins de services linguistiques et ethnosp茅cifiques afin de satisfaire les besoins de cette population.

Les sympt么mes somatiques les plus r茅pandus sont fatigue (18%), 茅tourdissements (13%) et gaz excessifs et ballonnement (12%). Sur une 茅chelle de sympt么mes psychologiques de d茅tresse, les sympt么mes endoss茅s le plus souvent sont sentiment d'锚tre malheureux et d茅prim茅 (34%), constamment tendu ou stress茅 (30%), et sentiment de ne pas pouvoir surmonter les difficult茅s (20%). Une analyse factorielle des sympt么mes somatiques et psychologiques a identifi茅 une dimension de d茅tresse s'apparentant 脿 la neurasth茅nie, avec comme sympt么mes principaux faiblesse, impression d'avoir presque toujours eu une mauvaise sant茅, incapacit茅 de se concentrer et fatigue.

Bien que 26 femmes avaient des scores de 3 ou plus 脿 l'茅chelle du General Health Questionnaire (GHQ) indiquant une taux de d茅tresse 茅lev茅, seulement 2 avaient parl茅 脿 leur omnipraticien de leurs probl猫mes de sant茅 mentale au cours des 12 derniers mois, et aucune avait visit茅 un travailleur social, psy-chiatre, psychologue ou autres types de professionnels pour un probl猫me mental, 茅motionel ou de stress. Quand on a demand茅 aux femmes ayant au moins un sympt么me 脿 l'茅chelle du GHQ pourquoi elles n'avaient pas consul-t茅, la majorit茅 des r茅ponses refl茅taient une tendance 脿 minimizer et 脿 faire face aux probl猫mes seules, peut-锚tre parce que les probl猫mes n'茅taient pas graves ou se r猫gleraient par eux-m锚mes. Il faut noter toutefois, que les limites dans le temps 茅tait une raison fr茅quemment invoqu茅es afin de justifier la non-utilisation des soins de sant茅 dans ce cas.

Presqu'un tier des femmes a utilis茅 une forme ou une autre de m茅decine chinoise traditionnelle 脿 la maison au cours de la derni猫re ann茅e et un quart ont vu un m茅decin chinois. D'autres formes de m茅decine alternative ou compl茅mentaire n'ont pas 茅t茅 utilis茅es par les participantes de l'茅tude. Des m茅dicaments chinois (principalement des herbes) ont 茅t茅 utilis茅s de fa莽on similaire afin de contrer les probl猫mes de sant茅 chez les enfants. Environ un quart des participantes ont amen茅 leurs enfants chez un m茅decin chinois traditionnel. La consultation 茅tait le plus souvent motiv茅e par des grippes et des probl猫mes d'estomac. Un tier des m猫res a utilis茅 des m茅dicaments chinois disponibles sans ordonnance pour soulager des probl猫mes similaires.

Parmi les 100 femmes chinoises interrog茅es dans cette 茅tude, 51 ont assist茅 脿 des cours pr茅natals. Douze pour cent des femmes avouent s'锚tre inqui茅t茅es souvent au sujet de l'accouchement, et 44% se sont inqui猫t茅es au moins quel-ques fois. La raison la plus populaire invoqu茅e par les m猫res et les p猫res afin d'expliquer pourquoi ils n'avaient pas particip茅 脿 des cours pr茅natals 茅tait le manque de temps. Ceci sugg猫re le besoin de d茅velopper du mat茅riel 茅crit et des cours abr茅g茅s, pratiques et accessibles aux couples ayant d'importantes obligations au niveau du travail et de la famille. Dans cet 茅chantillon de jeunes m猫res, 19% se souviennent avoir 茅t茅 d茅prim茅es ou d茅pressives jusqu'脿 2 semaines ou plus suite 脿 la naissance de leur enfant ou de l'un de leurs enfants et 14% ont exp茅riment茅 de la fatigue durant la p茅riode post-natale.

Une majorit茅 de femmes (73%) ont envisag茅 d'allaiter au moins une fois au cours de leurs grossesses. Malgr茅 ces intentions, toutefois, presque la moiti茅 (43%) n'ont pas allait茅 aucun de leurs enfants. Les cours pr茅natals (29%) et le mat茅riel de lecture (19%) sont les facteurs qui ont influenc茅 le plus la d茅cision d'initier l'allaitement.

En r茅sum茅, les r茅sultats de cette 茅tude indiquent

  1. le besoin soutenu de ser-vices ethnosp茅cifiques parmi ce groupe d'immigrants r茅cents et
  2. le besoin de d茅velopper et de promouvoir davantage l'茅ducation p茅rinatale.

La d茅tresse post-natale semble s'exprimer principalement en terme d'humeur d茅pressive et d'un syndrome neurasth茅nique pouvant passer inaper莽us et sous-trait茅s, 脿 la fois dans les secteurs de la sant茅 mentale et des soins de premi猫res lignes. Des recherches accrues 脿 l'aide d'un 茅chantillon cummunautaire pourront peut-锚tre clarifier la nature et l'impact de cette d茅tresse et aider les m茅decins 脿 mieux identifier et traiter celle-ci.

Report 8: Widening the Circle: Collaborative Research for Mental Health Promotion in Native Communities

Preface and acknowledgement

This report presents the proceedings of a conference on developing partnerships for research on mental health and illness in Native communities. The conference took place September 26 to 28th, 1997 at the Institute of Community of Family Psychiatry of the Sir Mortimer B. DavisJewish General Hospital. Funding for the conference came from a grant from the Conseil qubecois de la recherche sociale to the Native Mental Health Team. Co-sponsors were Waseskun House and the Native Women's Shelter of Montreal.

The purpose of the conference was to bring together university-based researchers and people working in First Nations and Inuit communities and organizations, to discuss and improve understanding of issues related to mental health and social services. It was hoped that this exchange would contribute to communities and organizations attaining the results they desire in terms of enhanced mental heath, fewer social problems and more effective services.

For various social problems or mental illnesses, the conference participants attempted to answer the following questions:

  • What kinds of programs are being delivered in Aboriginal communities to deal with the problem?
  • Has research shown that particular types of programs are more effective than others and if so, is this applicable among First Nations and Inuit?
  • How can research contribute to improving services or preventing mental health and social problems in Aboriginal populations?

The conference was organized by members of the Native Mental Health Research Team. The organizing committee consisted of Kathryn Gill, Laurence Kirmayer, Elizabeth Robinson, Caroline Oblin, Wayne Romansky and Jo-ann Stacey.

Marie-Anik Gagn coordinated the conference planning with great skill and energy. Staff of the Culture and Mental Health Research Unit worked with commitment and enthusiasm to make the conference go smoothly: Lucy Boothroyd, Consuelo Quesney, Suzanne Taillefer and Kay Berckmans.

We would like to thank all of the staff at the Department of Psychiatry of the Jewish General Hospital who assisted with preparations and arrangements, especially Louise Veillieux.

Rapporteurs at the conference enabled us to summarize some of the oral presentations for which no written text or tape was available; Greg Brass, Kaha:wi Joslyn Jacobs, Natalie Lloyd, Elizabeth Robinson, and Lara Stern ably performed this task.

Tapes of the conference were transcribed by Kay Berckmans and reviewed by the presenters. The text was copy-edited by Isabelle Fieschi, Marlene Caplan, Lucy Boothroyd, and Kathryn Gill.

We hope that the publication of these proceedings will contribute to the formation of partnerships between researchers and community-based practitioners, so that when it is appropriate to do research around a particular issue, the work will be done in a collaborative manner.

Montreal, September 1998

Native Mental Health Research Team

The Native Mental Health Research Team is a collaboration between workers at Native organizations and researchers from 9I制作厂免费 and other academic institutions to promote the development and evaluation of effective and culturally appropriate mental health programs for Native populations and communities in Quebec. The team is funded by the CQRS (Conseil qubcois de la recherche sociale) under a special program as a partnership between practice and academic institutions. The principal co-investigators of the Native Mental Health Research Team are:

  • Laurence Kirmayer, Division of Social & Transcultural Psychiatry, 9I制作厂免费
  • Serge Dry, Nunavik Regional Board of Health and Social Services (since 1997)
  • Steve Hodgins, Nunavik Regional Board of Health and Social Services (1995-1997)
  • Kathryn Gill, Addictions Unit, Montreal General Hospital
  • Elizabeth Robinson, Public Health Module, Cree Region of James Bay
  • Liesel Urtnowski, School of Social Work, 9I制作厂免费
  • Naomi Adelson, Department of Anthropology, York University, Toronto
  • Adrian Tanner, Department of Anthropology, Memorial University, Newfoundland

Other organizations collaborating with the Native Mental Health Research Team include:

  • Module du Nord Qubcois
  • Native Friendship Centre of Montreal
  • Native Women's Shelter of Montreal
  • Maison Waseskun House
  • Centre de sant publique de la rgion de Qubec
  • Department of Anthropology, St. Mary's University, Halifax

Report 9: Prevention and Mental Health Promotion in First Nations and Inuit Communities

Laurence J. Kirmayer, MD
Lucy J. Boothroyd, MSc
Arlene Lalibert, BA
Brenda Laronde Simpson, MEd

(See French version below)

Summary

This report sets out a rationale and guidelines for suicide prevention in Native communities. Suicide prevention must be part of a larger, multi-faceted mental health promotion strategy that is the responsibility of the whole community, band or region. A comprehensive program requires a central coordinating group to insure there are no gaps in the system and to avoid duplication of efforts.

Primary suicide prevention strategies for Aboriginal communities should include:

  1. training youth to act as peer counsellors;
  2. a school curriculum with mental health and cultural heritage components;
  3. recreational and sports programs;
  4. workshops on life skills, problem solving, and communication;
  5. parenting skills workshops;
  6. support groups for individuals and families at risk;
  7. cultural programs for the community at large;
  8. collaboration between community workers in health, social services and education; and
  9. training in mental health promotion for lay and professional helpers.

Intervention services should form part of the prevention strategy and include:

  1. training of primary care providers;
  2. development of a regional crisis hotline;
  3. development of a crisis centre;
  4. availability of immediate crisis intervention; and
  5. assessment and intervention services for parents of youth at risk.

There is also a need for postvention services to help family and friends cope with a loss due to suicide. The overall prevention strategy and its major elements should be systematically evaluated. The results of ongoing evaluation can be used to identify useful or detrimental aspects of the strategy, uncover gaps or new possibilities for prevention, and refine the programs.

搁茅蝉耻尘茅

Ce rapport 茅nonce la raison d'锚tre ainsi que les directives pour pr茅venir le suicide chez les communaut茅s autochtones. La pr茅vention du suicide doit faire partie d'une strat茅gie de promotion de la sant茅 mentale, plus globale et d'aspects multiples, qui rel猫ve de la responsabilit茅 de toute la communaut茅, de la tribut ou de la r茅gion. Un programme bien 茅labor茅 requiert un groupe de coordination centralis茅 afin d'assurer qu'il n'y ait aucune lacune dans le syst猫me et afin d'茅viter une r茅p茅tition inutile d'efforts.

Les strat茅gies fondamentales pour la pr茅vention du suicide chez les communaut茅s autochtones devraient inclure听:

  1. la formation des jeunes afin qu'ils puissent agir comme conseillers aupr猫s de leurs pairs;
  2. un curriculum scolaire incluant des notions de sant茅 mentale et d'h茅ritage culturel;
  3. des programmes r茅cr茅atifs et sportifs;
  4. des ateliers d'habilet茅s en mati猫re de vie quotidienne, de r茅solution de probl猫mes et de communication;
  5. des ateliers d'habilet茅s parentales;
  6. des groupes de support s'adressant aux individus et familles 脿 risque;
  7. des programmes culturels pour la communaut茅 en g茅n茅ral;
  8. la collaboration entre les travailleurs communautaires 艙uvrant dans le domaine de la sant茅, des services sociaux et de l'茅ducation; et
  9. de la formation de travailleurs profanes et professionnels en sant茅 mentale.

Les services d'intervention devraient faire partie des strat茅gies de pr茅vention et inclure听:

  1. la formation des intervenants de premi猫re ligne;
  2. le d茅veloppement r茅gional d'une ligne d'茅coute de crise;
  3. l'茅laboration d'un centre de crise;
  4. l'accessibilit茅 imm茅diate 脿 une intervention de crise; et
  5. des services d'茅valuation et d'intervention destin茅s aux parents de jeunes 脿 risque.

Il existe aussi un besoin de services de suivi afin d'aider la famille et les amis 脿 faire face 脿 un d茅c猫s d没 脿 un suicide. La strat茅gie globale d'intervention et ses principaux 茅l茅ments devraient 锚tre syst茅matiquement 茅valu茅s. Les r茅sultats d'une telle 茅valuation pourraient 锚tre utilis茅s afin d'identifier les aspects positifs ou n茅gatifs de la strat茅gie, en identifier les lacunes ou de nouvelles possibilit茅s de pr茅vention, et am茅liorer les programmes.

Report 10: The Mental Health of Indigenous Peoples

Proceedings of the Advanced Study Institute
The Mental Health of Indigenous Peoples
9I制作厂免费 Summer Program in Social & Cultural Psychiatry
and the Aboriginal Mental Health Research Team
May 29 May 31, 2000
Montreal, Quebec

Editors
Laurence J. Kirmayer
Mary Ellen Macdonald
Gregory M. Brass

Institute of Community and Family Psychiatry Sir Mortimer B. Davis Jewish General Hospital

&

Division of Social and Transcultural Psychiatry Department of Psychiatry, 9I制作厂免费

2001
Division of Social & Transcultural Psychiatry
9I制作厂免费

Contents

Preface & Acknowledgement - pg. 3

  1. Introduction
    The Mental Health of Aboriginal Peoples
    Laurence J. Kirmayer, Gregory M. Brass & Caroline L. Tait - pg. 5
    听
  2. Social Origins of Distress
    "The Deep Sleep of Forgetfulness": Reflecting on Disremembering
    Ernest Hunter - pg. 26
    Health Implications of Political Violence, Ethnic Conflict and Contemporary Wars In Latin America
    Duncan Pedersen - pg. 47
    The Legacy of the 'Stolen Generations' in Australia
    Jane H. Mckendrick - pg. 69
    听
  3. Individual And Collective Responses To Suffering
    An Overview of Suicide in Indigenous Australia
    Ernest Hunter - pg. 81
    Aboriginal Identity and the Construction of Fetal Alcohol Syndrome
    Caroline L. Tait - pg. 95
    听
  4. Transformations of Identity & Community
    Healing the Aboriginal Offender: Identity Construction Through Therapeutic Practice
    Gregory M. Brass - pg. 112
    Towards A Recuperation of Souls and Bodies: Community Healing听and the Complex Interplay Of Faith And History
    Naomi Adelson - pg. 120
    Negotiating Health: Meanings of Building a Healthy Community in Igloolik
    Kristiann Allen - pg. 135
    The Problem of "Culture" and the Counseling of Aboriginal Peoples
    James B. Waldram - pg. 145
    听
  5. Models For Collaborative Research & Mental Health Services
    Working in Partnership: Innovative Collaborative Research听Between Aboriginal Communities and an Academic Unit
    Jane H. Mckendrick - pg. 160
    Comments on Hollow Water Community Healing
    Joseph Couture - pg. 173
    An Overview of Six Nations Mental Health Services
    Cornelia Wieman - pg. 177

Contributors & Discussants - pg. 186
Contact Information - pg. 190
Conference Schedule - pg. 192
Annual 9I制作厂免费 Summer Program in Social & Cultural Psychiatry - pg. 193
Aboriginal Mental Health Research Team - pg. 194

Preface and acknowledgement

This report presents the proceedings of a conference on "The Mental Health of Indigenous Peoples" organized by the Aboriginal Mental Health Team of the Culture & Mental Health Unit, Sir Mortimer B. DavisJewish General Hospital in Montreal May 29-31, 2000. The conference was organized in conjunction with the Annual Summer Program in Social and Cultural Psychiatry of the Division of Social & Transcultural Psychiatry, 9I制作厂免费.

The aim of the meeting was to bring together experts on mental health research among indigenous peoples in Canada, the US and Australia to exchange perspectives, methods and models for research and service delivery. The meeting was supported by grants from the Conseil qubecois de la recherche sociale.

Many people assisted with the organization of the conference and the subsequent preparation of these proceedings. We thank all of our colleagues and the staff of the CMHRU for their help and support.

It is our hope that this report will help those working in and with Aboriginal communities in Canada and elsewhere to conduct meaningful research and promote culturally responsive mental health services.

Laurence J. Kirmayer
Montreal, January 2001

1. Introduction

The Mental Health of Aboriginal Peoples:
Transformations of Identity and Community
Laurence J. Kirmayer, Gregory M. Brass, and Caroline L. Tait

Abstract

This paper reviews some recent research on the mental health of the First Nations, Inuit and Mtis of Canada. We summarize evidence for the social origins of mental health problems and illustrate the ongoing responses of individuals and communities to the legacy of colonization. Cultural discontinuity and oppression have been linked to high rates of depression, alcoholism, suicide, and violence in many communities, with the most dramatic impact on youth. Despite these challenges, many communities have done well and research is needed to identify the factors that promote wellness. Cultural psychiatry can contribute to rethinking mental health services and health promotion for Indigenous populations and communities.

搁茅蝉耻尘茅

Cet article examine un certain nombre de recherches r茅centes portant sur la sant茅 mentale des Premi猫res Nations, des Inuits et des M茅tis du Canada. Nous r茅capitulons les preuves militant en faveur des origines sociales des probl猫mes de sant茅 mentale et illustrons les r茅ponses actuelles d'individus et de communaut茅s face 脿 l'h茅ritage de la colonisation. La discontinuit茅 culturelle et l'oppression ont 茅t茅 associ茅es 脿 des taux 茅lev茅s de d茅pression, d'alcoolisme, de suicide, et de violence dans de nombreuses communaut茅s, avec l'impact le plus dramatique exerc茅 sur la jeunesse. En d茅pit de ces d茅fis, nombre de communaut茅s s'en sont tr猫s bien tir茅es et de la recherche s'av猫re n茅cessaire afin de pouvoir identifier les facteurs qui favorisent le bien-锚tre. La psychiatrie culturelle peut contribuer 脿 repenser les services de soins en sant茅 mentale et la promotion de la sant茅 pour les populations et communaut茅s autochtones.

For more information, contact:

AMHRT
Culture & Mental Health Research Unit
Sir Mortimer B. Davis Jewish General Hospital
4333 Cte Ste Catherine Road
Montreal, Quebec
H3T 1E4

Tel.: 514-340-8222 x 5246
Fax: 514-340-7503
Email: cmhru [at] mail.mcgill.ca
Web: www.mcgill.ca/amh

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