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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.

Rsum

En 1992, nous avons fait une enqute auprs de 100 jeunes Inuits, gs entre 14 et 25 ans, demeurant dans une communaut sur le littoral de la Baie d'Hudson, au nord du Qubec, afin d'valuer la prvalence et les facteurs de risque associs aux tentatives de suicide. Le questionnaire de l'entrevue est bas sur un instrument qui a t utilis aux tats-Unis en 1988 par le Indien Public Health Service ("Adolescent Health Survey," Grossman, Milligan & Deyo, 1991). Nous nous sommes concentrs sur une chantillon provenant de la communaut plutt que du milieu scolaire et avons utiliss la fois des analyses statistiques bivaries et multivaries afin d'tudier les facteurs de risque. Notre chantillon de 100 jeunes reprsente environ 40% de la population cible.

Trente-quatre pour cent des participants ont rapport une tentative de suicide dans le pass et 20% ont rapport avoir tent de se suicider plus d'une fois. En terme de svrit, la tentative de suicide a entran une blessure pour environ 11% des personnes questionnes. La prvalence des ides suicidaires ainsi que le taux d'exposition au phnomne du suicide taient galement trs levs: 43% tmoignent avoir eu des ides suicidaires dans le pass (26% au cours du mois qui prcde l'enqute) et plus de 40% avaient des ami-e-s qui avaient tent ou s'taient suicids dans le pass. Les ides suicidaires taient grandement associes au fait d'avoir un-e ami-e qui avait tent ou s'tait suicid. Les facteur de risque les plus importants associs aux tentatives de suicide taient le fait d'tre un homme, d'avoir un-e ami-e ayant tent de se suicider, d'avoir t victime d'abus physique, l'abus de solvants et le fait d'avoir un parent ayant des problmes d'alcool ou de drogues. Le fait d'tre plus g et d'avoir une histoire familiale de consultations psychiatriques taient des facteurs de protection.

Ces rsultats signifient que les individus ayant un risque lev de suicide dans la communaut peuvent tre identifis afin d'tre aids; toutefois, une emphase sur la sant et le bien-tre de la famille est galement essentielle comme mesure prventive.

Notre tude explore galement la prvalence d'usage de drogues et d'alcool, les styles de recherche de soins, la prvalence d'inquitudes et de problmes de sant ainsi que les intrts dans les activits et les programmes. Dans le cas de nombreux problmes possibles (e.g., colre, rupture avec un-e ami-e), plusieurs jeunes taient incapables d'identifier des gens vers qui ils pourraient se tourner pour obtenir de l'aide. Ces rsultats dmontrent le besoin de traitements efficaces pour l'abus de drogues et d'alcool, d'entranement afin d'aider la rsolution de problmes interpersonnels et d'aider faire face aux vnements de la vie, et le dveloppement de programmes sociaux et d'activits pour les jeunes dans la communaut.

Cette tude, ainsi que les revues rcentes de la littrature s'intressant aux aborignes, est en faveur des interventions visant le niveau communautaire et politique de mme que le niveau de la famille et de l'individu vulnrable. Dans tous les cas, les mesures de prvention du suicide, telle que l'amlioration de la sant mentale, doivent tre sensibles la culture et bases sur un ensemble de dimensions telles que les dimensions socioculturelle et spirituelle de bien-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.

Rsum

Les concepts de sant mentale et de maladie chez les Inuits de Nunavik (au nord du Qubec) ont t tudis l'aide d'entrevues ethnographiques, d'observation par des participants et d'une enqute par questionnaire. La recherche impliquait la participation de la communaut dans la slection des sites de l'enqute et dans l'identification de problmes appropris pour l'tude. Trois communauts se distinguant par leurs ressources et leur niveau d'acculturation ont t tudies.

Trois types d'entrevues ont t faits, correspondant des sections distinctes du projet: (1) des entrevues d'identification de problmes auprs d'Inuits, prposs aux soins de sant et individus travaillant pour la communaut, ont identifi l'tendue des problmes dans la communaut et la terminologie habituelle employe pour dcrire ceux-ci. Il en a rsult des registres spcifiques de comportements problmatiques; (2) des entrevues d'enregistrement de problmes auprs d'informateurs-cls provenant de la communaut ont identifi la perception par rapport la prvalence des problmes dans la communaut et les signes typiques associs chacun des comportements ou problmes; (3) des entrevues d'histoire de cas auprs d'informateurs-cls ont permis de recrer les rcits dtaills avec lesquels ils taient familiers.

Les rsultats principaux de cette tude incluent:

  • Il n'y a pas de terme gnral afin de dcrire la sant ou la maladie mentale en Inuktitut. Forcs, les informateurs utilisent soit un terme anglophone ('mental health problem') soit deux termes ayant des connotations diffrentes: 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 problmes de sant mentale les plus frquents taient l'abus d'alcool et de drogues, la violence familiale, une famille abusive et les comportements suicidaires.

  • La plupart des gens n'taient pas familiers avec les problmes de sant mentale. Bien que plusieurs aient entendu parl de possession dmoniaque, seul un petit nombre de cas a t dcrit.

  • Malgr le fait que certaines personnes s'tant suicides taient dcrites comme retires, isoles, dpressives ainsi qu'ayant des ides lourdes, une estime de soi basse et hassant leur propre personne et ce, juste avant leur suicide, dans plusieurs cas leur suicide tait tout fait inattendu mme pour les amis-es proches ou la famille.

  • Les Inuits reconnaissent 4 grands types de causes des problmes de sant mentale: (1) les causes physiques et environnementales; (2) les causes psychologiques et motionnelles; (3) le fait d'tre possd par un dmon ou par un esprit; (4) les changements d'ordre culturel et les dsavantages sociaux. Dans de nombreux cas, de multiple causes taient offertes pour le mme problme.

  • La prsence d'hallucinations ou de comportements bizarres taient associs la maladie mentale ou la possession dmoniaque.

  • La violence, l'abus de drogues et le suicide taient tous frquemment attribus au fait d'avoir t victime d'abus et de ngligence tant enfant ou de la violence familiale perptuelle.

  • Les Inuits avaient tendance tiqueter les comportements ou les tats mentaux plutt 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'amliorer.

  • Les gens avaient tendance tre trs tolrants face aux comportements inhabituels des autres. Ceci pourrait bien amliorer l'intgration et le pronostique des individus atteints de troubles psychiatriques. Par contre, ceci pourrait galement retarder l'identification des problmes de dpression, de psychoses et de tendances suicidaires.

  • La fait de parler avec les autres tait largement reconnu comme un bon moyen afin de prvenir et/ou de rsoudre les problmes de sant mentale.

  • L'exorcisme religieux tait peru comme un traitement appropri dans le cas o les gens possds par le dmon taient des gens qui croyaient que ceci tait une cause possible du comportement inhabituel ou de la maladie.

A l'aide des entrevues et de l'enqute, nous avons dvelopp un modle de concepts indignes d'attitudes envers la sant et la maladie mentale. Un lexique inuktitut/anglais de termes relis la sant mentale a galement t prpar. Ce modle ainsi que ce lexique pourra tre utilis dans des recherches ultrieures sur la prvalence, les causes et les consquences de problmes sociaux et psychiatriques spcifiques.

Cette recherche possde galement des consquences immdiates sur la faon de dvelopper et d'administrer les soins de sant mentale la population Inuite, incluant des programmes communautaires d'ducation ayant pour but d'amliorer l'identification, le traitement et la rhabilitation des individus atteints de troubles psychiatriques majeurs ainsi que des interventions auprs de la communaut et des professionnels afin d'aider les gens faisant face 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.

Rsum

Les mdecins spcialistes ainsi que les mdecins de soins de premire ligne sont souvent confronts des symptmes et des syndromes dits 'fonctionnels'- c'est dire qui sont causs par un problme de fonctionnement plutt que par un problme au niveau de la structure biologique. Les trois syndromes somatiques fonctionnels (SSF) les plus rpandus sont la fibromyalgia (douleurs musculaires et squelettiques rpandues et chroniques, et sensibilit), l'intestin irritable (inconfort abdominal, ballonnement et changement au niveau des selles) et la fatigue chronique (fatigue facile et dtrioration cognitive). Des conditions telles que la fibromyalgia, l'intestin irritable et la fatigue chronique reoivent frquemment des explications mdicales confuses ou contradictoires. Ceci met les patients dans une situation sociale et psychologique problmatique qui peut engendre des soucis associs la maladie, un 'magasinage mdical' accru, l'utilisation de spcialistes non traditionnels, une augmentation des stigma sociaux et de l'invalidit. Compte tenu du fait que les critres diagnostiques dpendent d'une investigation mdicale approfondie afin d'liminer les maladies de type organique, il existe trs peu d'tudes de ces conditions dans la population gnrale qui examinent avec justesse les consquences personnelles et sociales qui y sont rattaches. Les rcentes amliorations au niveau des critres 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 symptmes spcifiques et sur quelques signes physiques particuliers. De plus, la preuve que ces supposs syndromes indpendants aient plusieurs choses en commun suggrent l'utilisation d'une mthode de recherche commune.

Dans le cadre de ce projet de recherche, nous avons dvelopp une Entrevue Diagnostique Structure pour les Syndromes Somatiques Fonctionnels (le EDSS) base sur des critres diagnostiques faisant l'unanimit de groupes de travail internationaux. Cette entrevue fut alors teste auprs de groupes de patients connus comme souffrant de fibromyalgia, d'intestin irritable et de fatigue chronique, provenant de cliniques spcialises et de pratiques prives. Des patients souffrant de chacun des syndromes ont t apparis des patients souffrant d'une symptomatologie similaire: arthrite rhumatode, maladie inflammatoire de l'intestin et sclrose en plaques, respectivement. L'entente entre le diagnostic des cliniciens et le diagnostic bas sur l'entrevue est moyenne (kappa=.37 .58). Le EDSS a dmontr une bonne spcificit mais une sensibilit basse aux syndromes somatiques fonctionnels.

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

Afin d'examiner les caractristiques psychologiques et l'impact de la maladie, nous avons compar les patients regroups selon le diagnostic au moment de la rfrence. Nous avons galement compar tous les patients souffrant d'un syndrome tous ceux ne souffrant pas d'un syndrome. Les rsultats de l'chelle de la personnalit base sur la thorie des cinq facteurs indiquent aucunes diffrences entre les syndromes somatiques fonctionnels et les groupes contrles. Seuls les patients souffrant de Fibromyalgia ont tendance obtenir un score suprieur sur l'chelle de "Neuroticism." Les patients souffrant de syndromes fonctionnels (et plus particulirement ceux souffrant de fatigue chronique) ont un taux suprieur de soucis d'ordre hypochon-driaque comparativement aux autres groupes. Il y a quelques diffrences significatives entre les groupes au niveau du style d'attribution des symptmes. Les patients souffrant de Fibromyalgia ont reconnu la dtresse motionnelle comme ayant contribu de faon importante la maladie, tandis que les patients souffrant de fatigue chronique ont rejet cette explication, mettant plutt l'emphase sur les infections et sur des causes immunitaires.

Les syndromes fonctionnels sont la cause d'une grande incapacit et sont associs des degrs suprieurs de dtresse sociale et motionnelle et ce, comparativement aux autres groupes. Le syndrome de fatigue chronique est associ au taux le plus lev de fardeau sur la famille peru par le patient et de stigma sociaux. En gnral, comparativement aux groupes souffrant de troubles non fonctionnels, les syndromes fonctionnels sont associs un taux suprieur de consultation et d'utilisation des soins de sant la fois traditionnels et alternatifs. Ce taux lev d'utilisation est associ un taux infrieur de perception des soins comme tant utiles et des praticiens comme tant comprhensifs. Ceci est particulirement marqu chez les patients souffrant du syndrome de fatigue chronique et suggre que les patients persistent chercher de l'aide jusqu' ce qu'ils trouvent quelqu'un qui les comprennent et quelque chose qui fonctionne. Si ceci est le cas, le taux lev de consultations observ chez les patients souffrant de syndromes fonctionnels ne devrait pas tre interprt comme un "abnormal illness behaviour", comme une recherche excessive d'aide ou comme une surutilisation des services de sant, mais plutt comme une recherche pragmatique d'une rponse efficace des conditions incomprises et mal diagnostiques.

Le dveloppement de l'Entrevue Diagnostique Structure pour les Syndromes Somatiques Fonctionnels (EDSS) permettra aux chercheurs d'entreprendre des tudes pidmiologiques communautaires afin de retracer l'volution et les consquences sociales de ces troubles avant et aprs que ceux-ci soient catgoriss par les praticiens. Ceci contribuera aider l'tude des mcanismes de coping et de stigmatisation des maladies non valides. En clinique, un meilleur diagnostique des syndromes somatiques fonctionnels et une identification plus rapide de ceux-ci peuvent viter des investigations inutiles et coteuses en laboratoire et tout ce qui en dcoule. Les applications pidmiologiques futures incluront un estim digne de confiance de la prdominance et de la cooccurrence des syndromes somatiques fonctionnels dans la communaut, un estim de leur cooccurrence avec des troubles psychiatriques et une faon de suivre l'volution des changements dans la prdominance de ces conditions aux cours des annes.


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.

Rsum

Nous avons men une enqute communautaire auprs de la population d'un secteur urbain multi-culturel, dfini comme le territoire du CLSC Cte-des-Neiges. Nous avons focalis notre recherche sur trois groupes d'immigrants (Antillais anglophones, Vietnamiens et Philippins) et des groupes de comparaison constitus d'individus ns au Canada. Les objectifs incluent:

  1. identifier l'utilisation des soins de sant des individus souffrant actuellement de symptmes de dpression, d'anxit et de somatisation, ou prouvant des problmes sociaux rcents;

  2. dterminer les entraves perues l'obtention de soins en sant mentale, au niveau des soins de premire ligne et des secteurs spcialiss en sant mentale;

  3. examiner la relation entre les modles culturels de la maladie et de la gurison et (A) des types d'expression de symptmes, de recherche d'aide et d'utilisation des services de soins de sant; (B) les variations dans la rsolution de troubles mentaux et sociaux frquents;

  4. examiner la relation entre des types d'acculturation et (A) la prvalence et l'expression symptomatique de la somatisation, de la dpression et de l'anxit et (B) la recherche et l'utilisation des soins de sant.

La recherche comporte deux tapes: (1) une entrevue tlphonique auprs de 2246 personnes, tape dfinie comme "Entrevue-Stade I" et (2) un suivi tlphonique, trois mois aprs, auprs de 576 personnes divises approximativement en cinq groupes culturels gaux (anglophones natifs du Canada, francophones natifs du Canada, Vietnamiens, Antillais et Philippins), tape dfinie comme "Entrevue-Stade II". Une troisime composante ethnographique fait galement partie de l'tude et consiste en 117 entrevues face--face, semi-structures, faites auprs d'un sous-chantillon provenant du deuxime stade, rparties approximativement de faon gale travers les cinq groupes ethniques. Ce rapport prsente des rsultats prliminaires du stade I et des entrevues ethnographiques.

Tous les instruments ont t traduits en franais et en vietnamien par des personnes parlant couramment les deux langues, et leur quivalence linguistique a t vrifi par le biais d'une contretraduction faite par des traducteurs ignorant tout du texte original. Les rsultats principaux incluent-

Les taux globaux d'utilisation des services mdicaux au cours de la dernire anne 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 pour des problmes de dtresse psychologique sont significativement infrieurs chez les immigrants (5.5 vs. 14.7%, p<.001). Cette diffrence est attribuable la fois un taux significativement plus bas d'utilisation de services spcialiss en sant mentale chez les immigrants (2.6 vs. 11.6%, p<.001) et une diffrence dans l'utilisation de services mdicaux pour des problmes de dtresse psychologique (3.5 vs. 5.8%, p=0.02).

Des taux d'utilisation de services de sant mentale suprieurs sont associs une plus grande dtresse motionnelle (selon leGHQ), un plus grand nombre de symptmes somatiques et plus d'vnements stressants. Les individus ayant un niveau d'ducation suprieur une 12ime anne ont galement tendance utiliser davantage des services pour des problmes psychologiques.

Les taux d'utilisation sont infrieurs chez les trois groupes ethniques, et particulirement bas chez les Vietnamiens et les Philippins. Parmi les trois groupes d'immigrants, la dure de sjour au pays n'est pas relie la tendance utiliser les services de sant mentale.

Les analyses multivaries dmontrent que le taux infrieur d'utilisation chez les immigrants ne peut pas tre entirement expliqu par des diffrences socio-dmographiques ou par diffrents niveaux de symptmes somatiques ou psychologiques, ou par les vnements stressants de la vie.

Nous avons examin les raisons invoques par les personnes prsentant au moins un symptme de dtresse psychologique au cours de la dernire anne l'chelle du GHQ, et qui n'avaient pas consult. Le facteur le plus important est la tendance minimiser, normaliser et faire face aux problmes seul-e (facteur commun chez tous les groupes, mais plus particulirement chez les immigrants) et, chez les immigrants, percevoir une disparit d'ordre ethnique. La disparit ethnique consiste percevoir les fournisseurs des soins comme incapables de comprendre ou ayant des prjugs envers leur culture, les professionnels provenant de leur propre culture tant perus comme non disponibles. D'autres barrires importantes l'obtention de soins comprennent la peur d'tre stigmatis, le manque de confiance dans le systme mdical et des obstacles d'ordre pratique, incluant l'absence du milieu de travail.

Ces analyses suggrent une sous-utilisation marque des soins de sant mentale par les groupes d'immigrants, ce qui ne peut pas tre entirement attribu aux diffrences de genre, de niveau d'ducation, de statut d'emploi, de dtresse ou d'utilisation de sources alternatives de soins. Les facteurs les plus importants semblent tre la comprhension et l'interprtation des symptmes psychologiques, le dsir de faire face aux problmes personnels seul-e ou au sein de la famille, et la perception que les professionnels de la sant qui pourraient comprendre la culture des immigrants ne sont pas disponibles.

Les symptmes somatiques sont plus frquemment rapports par les Vietnamiens. Quand on contrle l'ge, le niveau d'ducation et le statut d'emploi dans des quations de rgression multiple, le fait d'tre une femme, l'ge, un niveau d'ducation infrieur, le fait d'tre sans emploi ou d'tre d'origine vietnamienne contribuent de faon indpendante au fait de rapporter davantage de symptmes somatique communs. Quand le niveau de dtresse psychologique, tel que mesur par le GHQ-12, est rajout au modle, il est fortement associ aux symptmes somatiques, et les effets de l'ge, du genre et de l'origine vietnamienne persistent, tandis que les effets de l'ducation et de l'emploi ne sont plus significatifs.

Contrairement aux diffrences dans les niveaux de symptmes somatiques, il n'y a pas de diffrence quant la prsence de symptmes sans explication mdicale entre les groupes. Ces rsultats dmontrent que la gnralisation affirmant que les groupes ethno-culturels non-occidentaux ont tendance somatiser est incorrecte. Dans la prsente tude, seuls les Vietnamiens ont dmontr clairement des taux levs de symptmes somatiques prouvant peut-tre l'existence d'une forme de somatisation.

Nous avons galement examin le style d'acculturation (Marginalisation, Sparation, Intgration, Assimilation) des groupes d'immigrants en fonction de leur identification avec leur propre groupe ethnique et avec la socit canadienne. Les rsultats confirment le modle d'identit ethnique deux dimensions - selon lequel les individus s'identifient de faon indpendante leur pays d'origine (ou groupe ethnique familial) et la culture de la socit d'accueil.

Le style d'acculturation n'est pas associ aux niveaux de symptomatologie somatique ou psychologique. L'Intgration est associe une frquence infrieure d'vnements stressants, mais cet effet n'est significatif pour aucun des groupes ethnoculturels. Le style d'acculturation n'est galement pas li au nombre de visites chez un omnipraticien ou un spcialiste, ni au pourcentage de consultation d'un quelconque service pour problme de sant mentale. La Marginalisation et la Sparation sont associes des niveaux significativement plus levs d'entraves l'obtention de soins en gnral.

La composante ethnographique de la prsente tude a t conue afin de (1) dvelopper et de raffiner une mthode spcifique de collection et d'analyse de rcits concernant la maladie; (2) de clarifier et valider des items spcifiques du questionnaire de l'tude pidmiologique; (3) d'examiner l'exprience quant la maladie et les hierarchies des recours d'individus appartenant diffrents groupes ethnoculturels et souffrant (a) de symptmes sans explication mdicale; (b) de multiple symptmes somatiques; ou (c) de symptmes de dtresse psychologique selon le GHQ; (4) de clarifier les processus cognitifs et interpersonnels qui contribuent la production de rcits dcousus sur la maladie; et (5) d'identifier les problmes pour les tudes ethnographiques et pidmiologiques futures.

Les rsultats prliminaires dmontrent l'utilit des protocoles de rcits de maladies. Ils dmontrent galement l'importance des prototypes d'expriences et de squences dans les rcits des symptmes et de la maladie. Deux versions du protocole de rcits de maladies ont t dveloppes des fins cliniques et communautaires, et la collecte de donnes complmentaires ainsi que des analyses additionnelles sont prsentement 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:
    1. pattern of utilization of perinatal services
    2. family attitudes and practices concerning childbirth and infant care
    3. discipline styles
    4. family recreation
    5. 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.

Rsum

Une centaine de chinoises ayant amen leur-s enfant-s pour un examen de routine une clinique communautaire prodiguant des soins pdiatriques ont t interroges au sujet de leur sant en gnral, de leur utilisation des soins de sant, ainsi qu'au sujet de leurs expriences avec les soins de leur-s bb-s et/ou enfant-s. Les buts de l'enqute inclus:

  1. l'valuation des patterns d'utilisation des soins de sant chez les mres dans le cadre d'une pratique pdiatrique;

  2. l'valuation des problmes suivants associs la qualit des maintients de la sant des mres et des enfants:
    1. pattern d'utilisation des services en prinatalit
    2. attitudes et pratiques familiales en ce qui a trait l'accouchement et aux soins infantiles
    3. styles de discipline
    4. passe-temps familiaux
    5. prparation scolaire;
  3. identifier: (a) la prvalence des croyances concernant les notions de yin-yang et de chaud-froid (hot-cold), dans le corps et la nourriture, comme facteurs contribuant la sant et la maladie; et (b) les patterns d'utilisa-tion de la mdecine traditionnelle chinoise, incluant l'acupuncture, les herbes et la mdecine alternative et ce, en relation avec le style d'accultu-ration;

  4. tester une srie d'instruments destins tre utiliss dans des enqutes communautaire chez la communaut chinoise montralaise.

Plus de la moiti des femmes de l'tude occupait un emploi. Au niveau des rencontres avec des professionnels de la sant ou travailleurs sociaux, le nombre de rpondantes se divisait galement en trois groupes: celles qui utili-saient exclusivement le chinois, l'anglais et une combinaison des deux. Le franais n'tait pas utilis frquemment 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 viennent confirmer le besoins de services linguis-tiques et ethnospcifiques afin de satisfaire les besoins de cette population.

Les symptmes somatiques les plus rpandus sont fatigue (18%), tourdis-sements (13%) et gazs excessifs et ballonnement (12%). Sur une chelle de symptmes psychologiques de dtresse, les symptmes endosss le plus souvent sont sentiment d'tre malheureux et dprim (34%), constamment tendu ou stress (30%), et sentiment de ne pas pouvoir surmonter les diffi-cults (20%). Une analyse factorielle des symptmes somatiques et psycholo-giques a identifi une dimension de dtresse s'apparentant la neurasthnie, avec comme symptmes principaux faiblesse, impression d'avoir presque toujours eu une mauvaise sant, incapacit de se concentrer et fatigue.

Bien que 26 femmes avaient des scores de 3 ou plus l'chelle du General Health Questionnaire (GHQ) indiquant une taux de dtresse lev, seulement 2 avaient parl leur omnipraticien de leurs problmes de sant mentale au cours des 12 derniers mois, et aucune avait visit un travailleur social, psy-chiatre, psychologue ou autres types de professionnels pour un problme mental, motionel ou de stress. Quand on a demand aux femmes ayant au moins un symptme l'chelle du GHQ pourquoi elles n'avaient pas consul-t, la majorit des rponses refltaient une tendance minimizer et faire face aux problmes seules, peut-tre parce que les problmes n'taient pas graves ou se rgleraient par eux-mmes. Il faut noter toutefois, que les limites dans le temps tait une raison frquemment invoques afin de justifier la non-utilisation des soins de sant dans ce cas.

Presqu'un tier des femmes on utilis une forme ou une autre de mdecine chinoise traditionnelle la maison au cours de la dernire anne et un quart ont vu un mdecin chinois. D'autres formes de mdecine alternative ou complmentaire n'ont pas t utilises par les participantes de l'tude. Des mdicaments chinois (principalement des herbes) ont t utiliss de faon similaire afin de contrer les problmes de sant chez les enfants. Environ un quart des participantes ont amen leurs enfants chez un mdecin chinois traditionnel. La consultation tait le plus souvent motive par des grippes et des problmes d'estomac. Un tier des mres ont utilis des mdicaments chinois disponibles sans ordonnance pour soulager des problmes similaires.

Parmi les 100 femmes chinoises interroges dans cette tude, 51 ont assist des cours prnatals. Douze pour cent des femmes avouent s'tre inquites souvent au sujet de l'accouchement, et 44% se sont inquites au moins quel-ques fois. La raison la plus populaire invoque par les mres et les pres afin d'expliquer pourquoi ils n'avaient pas particip des cours prnatals tait le manque de temps. Ceci suggre le besoin de dvelopper du matriel crit et des cours abrgs, pratiques et accessibles aux couples ayant d'importantes obligations au niveau du travail et de la famille. Dans cet chantillon de jeunes mres, 19% se souviennent avoir t dprimes ou dpressives jusqu' 2 semaines ou plus suite la naissance de leur enfant ou de l'un de leurs enfants et 14% ont expriment de la fatigue durant la priode post-natale.

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

En rsum, les rsultats de cette tude indiquent (1) le besoin soutenu de ser-vices ethnospcifiques parmi ce groupe d'immigrants rcents et (2) le besoin de dvelopper et de promouvoir davantage l'ducation prinatale. La dtresse post-natale semble s'exprimer principalement en terme d'humeur dpressive et d'un syndrome neurasthnique pouvant passer inaperus et sous-traits, la fois dans les secteurs de la sant mentale et des soins de premires lignes. Des recherches accrues l'aide d'un chantillon cummunautaire pourront peut-tre clarifier la nature et l'impact de cette dtresse et aider les mdecins 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 McGill University 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, McGill University
  • 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, McGill University
  • 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.

Rsum

Ce rapport nonce la raison d'tre ainsi que les directives pour prvenir le suicide chez les communauts autochtones. La prvention du suicide doit faire partie d'une stratgie de promotion de la sant mentale, plus globale et d'aspects multiples, qui relve de la responsabilit de toute la communaut, de la tribut ou de la rgion. Un programme bien labor requiert un groupe de coordination centralis afin d'assurer qu'il n'y ait aucune lacune dans le systme et afin d'viter une rptition inutile d'efforts.

Les stratgies fondamentales pour la prvention du suicide chez les communauts autochtones devraient inclure:

  1. la formation des jeunes afin qu'ils puissent agir comme conseillers auprs de leurs pairs;

  2. un curriculum scolaire incluant des notions de sant mentale et d'hritage culturel;

  3. des programmes rcratifs et sportifs;

  4. des ateliers d'habilets en matire de vie quotidienne, de rsolution de problmes et de communication;

  5. des ateliers d'habilets parentales;

  6. des groupes de support s'adressant aux individus et familles risque;

  7. des programmes culturels pour la communaut en gnral;

  8. la collaboration entre les travailleurs communautaires uvrant dans le domaine de la sant, des services sociaux et de l'ducation; et

  9. de la formation de travailleurs profanes et professionnels en sant mentale.

Les services d'intervention devraient faire partie des stratgies de prvention et inclure :

  1. la formation des intervenants de premire ligne;

  2. le dveloppement rgional d'une ligne d'coute de crise;

  3. l'laboration d'un centre de crise;

  4. l'accessibilit immdiate une intervention de crise; et

  5. des services d'valuation et d'intervention destins aux parents de jeunes risque.

Il existe aussi un besoin de services de suivi afin d'aider la famille et les amis faire face un dcs d un suicide. La stratgie globale d'intervention et ses principaux lments devraient tre systmatiquement valus. Les rsultats d'une telle valuation pourraient tre utiliss afin d'identifier les aspects positifs ou ngatifs de la stratgie, en identifier les lacunes ou de nouvelles possibilits de prvention, et amliorer les programmes.


Report 10: The Mental Health of Indigenous Peoples

Proceedings of the Advanced Study Institute
The Mental Health of Indigenous Peoples
McGill 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, McGill University

2001
Division of Social & Transcultural Psychiatry
McGill University

Contents

Preface & Acknowledgement - pg. 3

1. Introduction
The Mental Health of Aboriginal Peoples
Laurence J. Kirmayer, Gregory M. Brass & Caroline L. Tait - pg. 5

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

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

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
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

5. Models For Collaborative Research & Mental Health Services
Working in Partnership: Innovative Collaborative Research
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 McGill 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, McGill University.

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.

Rsum: Cet article examine un certain nombre de recherches rcentes portant sur la sant mentale des Premires Nations, des Inuits et des Mtis du Canada. Nous rcapitulons les preuves militant en faveur des origines sociales des problmes de sant mentale et illustrons les rponses actuelles d'individus et de communauts face l'hritage de la colonisation. La discontinuit culturelle et l'oppression ont t associes des taux levs de dpression, d'alcoolisme, de suicide, et de violence dans de nombreuses communauts, avec l'impact le plus dramatique exerc sur la jeunesse. En dpit de ces dfis, nombre de communauts s'en sont trs bien tires et de la recherche s'avre ncessaire afin de pouvoir identifier les facteurs qui favorisent le bien-tre. La psychiatrie culturelle peut contribuer repenser les services de soins en sant mentale et la promotion de la sant pour les populations et communauts 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 [dot] mcgill [dot] ca
Web: http://www.mcgill.ca/amh