Understanding immigrants' reluctance to use mental health services: a qualitative study from Montreal

Southampton Adaptation Framework to Culturally Adapt Cognitive Behavior Therapy: An Update

Cultural values, traditions, and norms influence the practice of psychotherapy. It is now widely accepted that modern evidence-based therapies such as CBT need to be culturally adapted for them to be successfully applied to clients from a non-Western background. There are multiple factors to support cultural adaptations, such as evidence from research and an increase in cultural awareness and globalization. A number of meta-analyses supporting culturally adapted interventions have been published across the globe. A review of these meta-analyses reported that culturally adapted interventions have moderate to high effect sizes in favor of culturally adapted psychological interventions. We provide a brief background on cultural differences and suggest ways to address these differences. We also discuss the current state of science in this area. We also provide a brief description of factors that are generally accepted as important components of culturally adapted interventions. We discuss the Southampton Adaptation Framework widely used to Culturally adapt CBT (SAF-CaCBT). This framework has been used in South Asia, the Middle East, China, England, Africa, and Canada. More than 20 studies have used the framework to adapt CBT culturally. The framework has evolved based on lessons learned from research and consists of 3 major areas of concern: awareness of culture and religion, assessment and engagement, and adjustments in therapy. Each area has 8 subareas to consider when culturally adapting CBT. Finally, we discuss the limitations and barriers in this area and recommendations for future work. There is a need to develop universal guidelines on cultural adaptation as well as areas of adaptation, more research with better methodology and the use of active comparators in the assessment of culturally adapted interventions. There is also a need to further strengthen the evidence base by robust meta analyses.

Experiences of racial microaggression among immigrant and Canadian-born young adults: Effects of double stigma on mental health and service use

BACKGROUND

Significant disparities in utilization of mental health services exist among immigrant and Canadian-born populations. These gaps may be associated with a 'double stigma' - stigma related to being from a racialized background exacerbated by mental health stigma. Immigrant young adults may be particularly susceptible to this phenomenon, given developmental and social transitions from adolescence to adulthood.

AIMS

To investigate the joint effects of racial microaggression and mental health stigma on mental health and service use among first-generation immigrant and Canadian-born university students.

METHOD

We conducted an online cross-sectional study among first-generation immigrant and Canadian-born university students (N = 1,280, Mage = 19.10, SD = 1.50).

RESULTS

Despite no differences in anxiety or depression symptoms, first-generation (foreign-born) immigrants were less likely to have received therapy and to have taken medication for mental health issues compared to Canadian-born participants. First-generation immigrants also reported experiencing higher levels of racial microaggression and stigma toward service use. Results suggest the presence of a double stigma, mental health stigma and racial microaggression, each explained significant additional variance in symptoms of anxiety and depression and medication use. No effects of double stigma for therapy use were found - while higher mental health stigma predicted lower use of therapy, racial microaggression did not predict unique variance in therapy use.

CONCLUSIONS

Our findings highlight the joint effects of racial microaggression and stigma toward mental health and service as barriers to help-seeking among immigrant young adults. Mental health intervention and outreach programmes should target overt and covert forms of racial discrimination while incorporating culturally sensitive anti-stigma approaches to help reduce disparities in mental health service use among immigrants in Canada.

Why are African immigrants in Montreal reluctant to use mental health services?: a systematic inventory of reasons

PURPOSE

Previous research has shown that non-Caucasian immigrants in Western countries are less likely than native-born people to use mental health services. This study examined the reasons underlying reluctance to use mental health services among African immigrants in Montreal, Canada.

METHODS

The study participants were 280 African immigrants who had experienced symptoms suggesting depression but did not use formal mental health services. They were presented with a questionnaire that contained 65 statements referring to reasons for not using formal mental health services while experiencing those symptoms and were asked to indicate their degree of agreement with each of the statements on a scale of 0-10. Responses were then analyzed using factor analysis.

RESULTS

An eight-factor structure of reasons was found: "Minimizing symptoms and perceived self-efficacy" (61% of the sample), "Relying on spiritual care" (56% of the sample), "Cost and waiting time" (45% of the sample), "Influence of significant others" (34% of the sample), "Lack of cultural competence" (32% of the sample), "Fear of stigmatization" (23% of the sample), "Nature of the consultation" (10% of the sample) and "Social models" (8% of the sample). Scores on these factors were related to participants' demographics.

CONCLUSION

Effectively addressing the underutilization of mental health services among African immigrants requires a multifaceted approach rather than one focused on a single barrier. Our findings suggest critical points that could help develop tailored interventions to address the various barriers to care.

Double stigma in mental health service use: Experience from ethnic minorities in Hong Kong

BACKGROUND

Ethnic minorities (EMs) typically underutilise mental health services (EMs) with issues that are not shared by the local population. Understanding the underlying perceived factors could help reduce their mental health disparities.

AIMS

This is a qualitative study aiming to examine the barriers that prevent EMs from seeking mental health services in Hong Kong.

METHODS

Six semistructured focus groups with 31 EMs who resided in Hong Kong were conducted from May 31 to June 26, 2021. The outcome measures were the themes and subthemes of perspectives on mental health service use.

RESULTS

Among 31 adults (20 [64.5%] women, 11 [35.5%] men; 17 [54.8%] aged 25-39 years) who participated, most participants self-identified as Indian (13 [41.95]) or Pakistani (10 [32.3]). There were 16 individuals (51.6%) who reported severe or higher levels of anxiety or depressive symptoms, while 12 individuals (38.7%) reported moderate levels. Three emerging themes identified for the barriers to help-seeking for psychiatric intervention were (1) preexisting problems, (2) psychaitric service lacks cultural sensitivity and (3) personal or family limitation, while that for the recommendations to improve help-seeking had six themes: (1) improve cultural sensitivity, (2) make EM mental health practitioners available, (3) improve professional conduct, (4) improve on-site support, (5) improve financial support and (6) improve mental health promotion in schools.

CONCLUSION

This study found that EMs in Hong Kong experience double stigma, which keeps them away from seeking professional mental health care. There were also disparities in the use of mental health services by ethnicity. The study also made recommendations for promoting EM help-seeking at the individual, governmental and community levels.

Disparities in Healthcare Accessibility and Discrimination Faced by Black Quebecers: a Race and Language Perspective

The Black population in Canada is characterized by its long-established history and diversity. The present study aims to expand our current understanding of the relation between discrimination and disparities in healthcare by including race and language as determinants of health. We recruited 531 Black adults who are currently living in Quebec, Canada, to complete a survey measuring socio-demographic characteristics, mental and physical health, accessibility to healthcare, and experiences of discrimination. Results showed that being a racialized and linguistic minority population in Quebec, English-speaking Black participants experienced more discrimination, fewer healthcare providers, less access to COVID-19 information during the COVID-19 pandemic, and were more dissatisfied with the healthcare system than French-speaking Black participants. Furthermore, the negative impacts of healthcare access associated with being a racialized and linguistic minority population in Quebec (e.g., the English-speaking Black population) were shown to be mediated by experiences of discrimination and dissatisfaction with the healthcare system.

Depression, diabetes and immigration status: a retrospective cohort study using the Canadian Longitudinal Study on Aging

BACKGROUND

A bidirectional association between depression and diabetes exists, but has not been evaluated in the context of immigrant status. Given that social determinants of health differ between immigrants and nonimmigrants, we evaluated the association between diabetes and depression incidence, depression and diabetes incidence, and whether immigrant status modified this association, among immigrants and nonimmigrants in Canada.

METHODS

We employed a retrospective cohort design using data from the Canadian Longitudinal Study on Aging Comprehensive cohort (baseline [2012-2015] and 3-year follow-up [2015-2018]). We defined participants as having diabetes if they self-reported it or if their glycated hemoglobin A_1c level was 7% or more; we defined participants as having depression if their Center for Epidemiological Studies Depression score was 10 or higher or if they were currently undergoing depression treatment. We excluded those with baseline depression (Cohort 1) and baseline diabetes (Cohort 2) to evaluate the associations between diabetes and depression incidence, and between depression and diabetes incidence, respectively. We constructed logistic regression models with interaction by immigrant status.

RESULTS

Cohort 1 (n = 20 723; mean age 62.7 yr, standard deviation [SD] 10.1 yr; 47.6% female) included 3766 (18.2%) immigrants. Among immigrants, 16.4% had diabetes, compared with 15.6% among nonimmigrants. Diabetes was associated with an increased risk of depression in nonimmigrants (adjusted odds ratio [OR] 1.27, 95% confidence interval [CI] 1.08-1.49), but not in immigrants (adjusted OR 1.12, 95% CI 0.80-1.56). Younger age, female sex, weight change, poor sleep quality and pain increased depression risk. Cohort 2 (n = 22 054; mean age 62.1 yr, SD 10.1 yr; 52.2% female) included 3913 (17.7%) immigrants. Depression was associated with an increased risk of diabetes in both nonimmigrants (adjusted OR 1.39, 95% CI 1.16-1.68) and immigrants (adjusted OR 1.60, 95% CI 1.08-2.37). Younger age, male sex, waist circumference, weight change, hypertension and heart disease increased diabetes risk.

INTERPRETATION

We found an overall bidirectional association between diabetes and depression that was not significantly modified by immigrant status. Screening for diabetes for people with depression and screening for depression for those with diabetes should be considered.

Systemic and Individual Factors That Shape Mental Health Service Usage Among Visible Minority Immigrants and Refugees in Canada: A Scoping Review

There exists considerable research which reports that mental health disparities persist among visible minority immigrants and refugees within Canada. Accessing mental health care services becomes a concern which contributes to this, as visible minority migrants are regarded as an at-risk group that are clinically underserved. Thus, the purpose of this review is to explore the following research question: "what are the barriers and facilitators for accessing mental health care services among visible immigrants and refugees in Canada?". A scoping review following guidelines proposed by Arksey and O'Malley (International Journal of Social Research Methodology 8(1): 19-32, 2005) was conducted. A total of 45 articles published from 2000 to 2020 were selected through the review process, and data from the retrieved articles was thematically analyzed. Wide range of barriers and facilitators were identified at both the systemic and individual levels. Unique differences rooted within landing and legal statuses were also highlighted within the findings to provide nuance amongst immigrants and refugees. With the main layered identity of being a considered a visible minority, this yielded unique challenges patterned by other identities and statuses. The interplay of structural issues rooted in Canadian health policies and immigration laws coupled with individual factors produce complex barriers and facilitators when seeking mental health services. Through employing a combined and multifaceted approach which address the identified factors, the findings also provide suggestions for mental health care providers, resettlement agencies, policy recommendations, and future directions for research are discussed as actionable points of departure.

Albanian Migrants in Cyclades: Contact with Mental Health Services and Implications for Practice

The purpose of this study was to examine the potential differences between Albanian migrants and Greeks in the islands of Paros and Antiparos with regard to seeking help from the local public mental health service, namely the Mobile Mental Health Unit of NE Cyclades Islands (EPAPSY-NGO). The study’s instruments include the Global Assessment of Functioning (GAF) and a questionnaire for recording psychosocial profile data and information concerning contact with the services. The results showed that significantly less Albanian migrants contacted the mental health services in the past in comparison to Greeks. When using the service, the Albanians were more likely to see a psychiatrist in the Unit, rather than a psychologist-psychotherapist, and they more often received prescriptions for medication. There was a significantly higher dropout rate among Albanian migrants. This study highlights the different aspects of access and use of mental health services among Albanian migrants compared with native residents. Further research should focus on the factors related to early dropouts and difficulties accessing mental health services in rural areas, in order to develop more focused and effective interventions and improve the quality of care provided.

Parity and Psychosocial Risk Factors Increase the Risk of Depression During Pregnancy Among Recent Immigrant Women in Canada

Prior investigations have examined risk factors associated to postpartum depression in immigrant women, but depression during pregnancy has received less attention. This study describes the prevalence and early determinants of antenatal depression among recent (≤ 5 years) and long-term immigrants (> 5 years), compared to Canadian-born women. 503 women completed standardized self-report questionnaires measuring sociodemographics and psychosocial factors. Multivariate logistic regressions identified first trimester risk factors for depression in each immigrant group. The prevalence of depressive symptoms was highest for recent immigrant (25.3-30.8%) compared to long-term immigrant (16.9-19.2%) and Canadian-born women (11.7-13.8%). Among recent immigrants, multiparity, higher stress and pregnancy-specific anxiety in early pregnancy increased the risk of antenatal depression. Among long-term immigrants, stress in the first trimester was significantly associated with antenatal depressive symptoms. Knowledge of modifiable risk factors (pregnancy-specific anxiety and stress) may help improve antenatal screening and inform the development of tailored interventions to meet the mental health needs of immigrant women during the perinatal period.

Willingness to Use Mental Health Services for Depression Among African Immigrants and White Canadian-Born People in the Province of Quebec, Canada

Studies suggest that non-Caucasian immigrants to Canada are less likely than Canadian-born people to use mental health services. To meet the mental health needs of ethnocultural minorities, insights into their help-seeking attitudes are of great concern. This study examined the willingness of African immigrants and White Canadian-born to seek care for depression from conventional mental health services.  African immigrants (N = 262) and White Canadian-born people (N = 250) living in Montreal, Canada, indicated their willingness to use mental health services under different conditions varying as a function of four factors: the severity of symptoms, the waiting time for first consultation, the type of care offered in the mental health service, and whether informal sources of help were available.  Seven qualitatively different positions were identified: Never Consult (18% of the African immigrants and 1% of the White Canadian-born people); Hesitant (18% of the African immigrants and 7% of the White Canadian-born people); Depends on Waiting Time (16% of the African immigrants); Depends on Waiting Time and Symptoms (22% of the African immigrants); Depends on Symptoms (36% of the White Canadian-born people and 6% of the African immigrants); Willing to consult (33% of the White Canadian-born people and 2% of the African immigrants); Certain to Consult (9% of the White Canadian-born people and 4% of the African immigrants), while 14% of participants in each group did not express any position. African immigrants were more likely to underuse mental health services, compared with White Canadian-born people. The above diversity of positions strongly suggests that the design and implementation of interventions to reduce disparities in African immigrants' use of mental health care must not be "one size fits all" but must be tailored to address these immigrants' differing attitudes and needs.

Depression and anxiety disorders among immigrants living in Finland: Comorbidity and mental health service use

BACKGROUND

The aims of this study were to (1) compare differences in psychiatric comorbidity of depression and anxiety disorders between immigrants and native Finns and to (2) compare differences in the intensity of psychiatric care received by different immigrant groups and Finnish-born controls with depression and/or anxiety disorders.

METHODS

The study uses registered-based data, which includes all immigrants living in Finland at the end of 2010 and matched Finnish-born controls. For this study, we selected individuals who had received a diagnosis of depression and/or an anxiety disorder during the follow-up (2011-2015) (immigrants n = 6542, Finnish-born controls n = 9281). We compared differences in comorbidity between the immigrants and the Finnish-born controls using chi-squared tests. Multinomial logistic regression was used to predict psychiatric treatment intensity by immigrant status, region of origin, and other background factors.

RESULTS

In both diagnosis groups, Finnish-born participants exhibited greater comorbidity of other psychiatric disorders. Immigrants more often received lower intensity treatment and less often higher intensity treatment. These differences were most striking among those from Eastern Europe, the Middle East, and Africa.

LIMITATIONS

We did not have the information on the perceived need for the services, which limits us from drawing further conclusions about the mechanisms behind the observed patterns.

CONCLUSIONS

Immigrants in Finland receive less intensive treatment for depression and anxiety disorders compared to the Finnish-born population. Since lower symptom levels can unlikely alone explain these differences, they could reflect a need for improvement in the psychiatric services for immigrants.

Inspiring Muslim Minds: Evaluating a Spiritually Adapted Psycho-educational Program on Addiction to Overcome Stigma in Canadian Muslim Communities

The stigma of addiction in Muslim communities is a significant barrier to accessing mental health services. The objective of this study was to evaluate the impact of a newly developed spiritually-adapted addictions psychoeducational program with adult Muslims in the mosque setting. Ninety-three individuals were recruited from nine different mosques within Toronto, Canada. Ninety-minute seminars were presented. This study used a convergent mixed method design. There was a significant increase in the participants' self-reported knowledge (t = 3.6; p < 0.001), a more positive attitude on two scales (t = 3.7; p < 0.001 and t = 2.9; p = 0.005) and an increase in willingness to seek help from a medical doctor and mental health professional (t = 4.4; p < 0.001 and t = 2.2; p = 0.03, respectively) post-seminar as compared to baseline. Qualitative data confirmed these changes. Evidence-informed spiritually-adapted outreach program in the mosque setting can help reduce addiction related stigma in Muslim communities.

Understanding the health and housing experiences of refugees and other migrant populations experiencing homelessness or vulnerable housing: a systematic review using GRADE-CERQual

BACKGROUND

A growing number of migrants experience precarious housing situations worldwide, but little is known about their health and housing experiences. The objective of this study was to understand the enablers and barriers of accessing fundamental health and social services for migrants in precarious housing situations.

METHODS

We conducted a systematic review of qualitative studies. We searched the databases of MEDLINE, PsycINFO, CINAHL, Scopus, Web of Science, Social Sciences, Canadian Business & Current Affairs and Sociological Abstracts for articles published between Jan. 1, 2007, and Feb. 9, 2020. We selected studies and extracted data in duplicate, and used a framework synthesis approach, the Bierman model for migration, to guide our analysis of the experiences of migrant populations experiencing homelessness or vulnerable housing in high-income countries. We critically appraised the quality of included studies using the Critical Appraisal Skills Programme checklist and assessed confidence in key findings using the Grading of Recommendations Assessment, Development and Evaluation Confidence in the Evidence from Reviews of Qualitative Research (GRADE-CERQual) approach.

RESULTS

We identified 1039 articles, and 18 met our inclusion criteria. The studies focused on migrants from Asia and Africa who resettled in Canada, Australia, the United States, the United Kingdom and other European countries. Poor access to housing services was related to unsafe housing, facing a family separation, insufficient income assistance, immigration status, limited employment opportunities and lack of language skills. Enablers to accessing appropriate housing services included finding an advocate and adopting survival and coping strategies.

INTERPRETATION

Migrants experiencing homelessness and vulnerable housing often struggle to access health and social services; migrants may have limited proficiency with the local language, limited access to safe housing and income support, and ongoing family insecurities. Public health leaders could develop outreach programs that address access and discrimination barriers.

PROSPERO REGISTRATION

CRD42018071568.

Global Mental Health and Services for Migrants in Primary Care Settings in High-Income Countries: A Scoping Review

Migrants are at a higher risk for common mental health problems than the general population but are less likely to seek care. To improve access, the World Health Organization (WHO) recommends the integration of mental health services into primary care. This scoping review aims to provide an overview of the types and characteristics of mental health services provided to migrants in primary care following resettlement in high-income countries. We systematically searched MEDLINE, EMBASE, PsycInfo, Global Health, and other databases from 1 January 2000 to 15 April 2020. The inclusion criteria consisted of all studies published in English, reporting mental health services and practices for refugee, asylum seeker, or undocumented migrant populations, and were conducted in primary care following resettlement in high-income countries. The search identified 1627 citations and we included 19 studies. The majority of the included studies were conducted in North America. Two randomized controlled trials (RCTs) assessed technology-assisted mental health screening, and one assessed integrating intensive psychotherapy and case management in primary care. There was a paucity of studies considering gender, children, seniors, and in European settings. More equity-focused research is required to improve primary mental health care in the context of global mental health.

Undiagnosed depression, persistent depressive symptoms and seeking mental health care: analysis of immigrant and non-immigrant participants of the Canadian Longitudinal Study of Aging

AIMS

Early diagnosis and treatment of depression are associated with better prognosis. We used baseline data of the Canadian Longitudinal Study on Aging (2012-2015; ages 45-85 years) to examine differences in prevalence and predictors of undiagnosed depression (UD) between immigrants and non-immigrants at baseline and persistent and/or emerging depressive symptoms (DS) 18 months later. At this second time point, we also examined if a mental health care professional (MHCP) had been consulted.

METHODS

We excluded individuals with any prior mood disorder and/or current anti-depressive medication use at baseline. UD was defined as the Center for Epidemiological Studies Depression 10 score ⩾10. DS at 18 months were defined as Kessler 10 score ⩾19. The associations of interest were examined in multivariate logistic regression models.

RESULTS

Our study included 4382 immigrants and 18 620 non-immigrants. The mean age (standard deviation) in immigrants was 63 (10.3) years v. 65 (10.7) years in non-immigrants and 52.1% v. 57.1% were male. Among immigrants, 12.2% had UD at baseline of whom 34.2% had persistent DS 18 months later v. 10.6% and 31.4%, respectively, among non-immigrants. Female immigrants were more likely to have UD than female non-immigrants (odds ratio 1.50, 95% confidence interval 1.25-1.80) but no difference observed for men. The risk of persistent DS and consulting an MHCP at 18 months did not differ between immigrants and non-immigrants.

CONCLUSIONS

Female immigrants may particularly benefit from depression screening. Seeking mental health care in the context of DS should be encouraged.

Association of neighbourhood migrant density and risk of non-affective psychosis: a national, longitudinal cohort study

BACKGROUND

Elevated risk of psychotic disorders in migrant groups is a public mental health priority. We investigated whether living in areas of high own-region migrant density was associated with reduced risk of psychotic disorders among migrants and their children, and whether generation status, probable visible minority status, or region-of-origin affected this relationship.

METHODS

We used the Swedish registers to identify migrants and their children born between Jan 1, 1982, and Dec 31, 1996, and living in Sweden on or after their 15th birthday. We tracked all included participants from age 15 years or date of migration until emigration, death, or study end (Dec 31, 2016). The outcome was an ICD-10 diagnosis of non-affective psychosis (F20-29). We calculated own-region and generation-specific own-region density within the 9208 small areas for market statistics neighbourhoods in Sweden, and estimated the relationship between density and diagnosis of non-affective psychotic disorders using multilevel Cox proportional hazards models, adjusting for individual confounders (generation status, age, sex, calendar year, lone dwelling, and time since migration [migrants only]), family confounders (family income, family unemployment, and social welfare), and neighbourhood confounders (deprivation index, population density, and proportion of lone dwellings), and using the Akaike information criterion (AIC) to compare model fit.

FINDINGS

Of 468 223 individuals included in the final cohort, 4582 (1·0%) had non-affective psychotic disorder. Lower own-region migrant density was associated with increased risk of psychotic disorders among migrants (hazard ratio [HR] 1·05, 95% CI 1·02-1·07 per 5% decrease) and children of migrants (1·03, 1·01-1·06), after adjustment. These effects were stronger for probable visible minority migrants (1·07, 1·04-1·11), including migrants from Asia (1·42, 1·15-1·76) and sub-Saharan Africa (1·28, 1·15-1·44), but not migrants from probable non-visible minority backgrounds (0·99, 0·94-1·04). Among migrants, adding generation status to the measure of own-region density provided a better fit to the data than overall own-region migrant density (AIC 36 103 vs 36 106, respectively), with a 5% decrease in generation-specific migrant density corresponding to a HR of 1·07 (1·04-1·11).

INTERPRETATION

Migrant density was associated with non-affective psychosis risk in migrants and their children. Stronger protective effects of migrant density were found for probable visible minority migrants and migrants from Asia and sub-Saharan Africa. For migrants, this risk intersected with generation status. Together, these results suggest that this health inequality is socially constructed.

FUNDING

Wellcome Trust, Royal Society, Mental Health Research UK, University College London, National Institute for Health Research, Swedish Research Council, and FORTE.

Immigrants' mental health service use compared to that of native Finns: a register study

PURPOSE

Many aspects related to migration might predispose immigrants to mental health problems. Yet immigrants have been shown to underuse mental health services. The aim of this study was to compare the intensity of psychiatric care, as an indicator of treatment adequacy, between natives and immigrants living in Finland.

METHODS

We used nationwide register data that included all the immigrants living in Finland at the end of 2010 (n = 185,605) and their matched controls. Only those who had used mental health services were included in the analyses (n = 14,285). We used multinomial logistic regression to predict the categorized treatment intensity by immigrant status, region and country of origin, length of residence, and other background variables.

RESULTS

Immigrants used mental health services less than Finnish controls and with lower intensity. The length of residence in Finland increased the probability of higher treatment intensity. Immigrants from Eastern Europe, sub-Saharan Africa, the Middle East, and Northern Africa were at the highest risk of receiving low-intensity treatment.

CONCLUSIONS

Some immigrant groups seem to persistently receive less psychiatric treatment than Finnish-born controls. Identification of these groups is important and future research is needed to determine the mechanisms behind these patterns.

Reframing resilience: Strengthening continuity of patient care to improve the mental health of immigrants and refugees

Refugee and immigrant populations experience many pre- and post-migration risk factors and stressors that can negatively impact their mental health. This qualitative study aimed to explore the system-level issues that affect the access to, as well as quality and outcomes of mental health care for immigrants and refugees, with a particular focus on challenges in the continuity of patient care. A multidisciplinary group of health providers, including nurses, identified six themes including (i) perceived access to care; (ii) coordination amongst health care providers; (iii) patient connections with community organizations; (iv) coordinated care planning; (v) organizational protocols, policies and procedures and (vi) systemic and health care training needs. Although patient resilience is seen as a pivotal way for vulnerable populations to cope with hardship, there is a clear need for creating a resilient health care system that is able to anticipate and adapt to adverse situations. The findings from this study have implications for nurses, who are uniquely positioned to advocate for public health policy that improves the continuity of health care by creating systemic resilience.

Migrant status and identification as ultra-high risk for psychosis and transitioning to a psychotic disorder

BACKGROUND

Certain migrant groups are more likely to develop a psychotic disorder compared to the native-born populations, and a younger age at migration is associated with greater risk. However, it is not known at which stage migration has an effect on the development of psychotic disorders. We examined whether migrants were more likely to be identified as ultra-high risk for psychosis (UHR) compared to native-born young people and whether migrant status was associated with the risk of transition to a full-threshold psychotic disorder.

METHODS

The cohort included all young people aged 15-24 who were identified as UHR at a specialist clinic over a five-year period (2012-16). Australian census data were used to obtain the at-risk population. Poisson regression was used to calculate rate ratios and Cox regression analysis determined hazard ratios.

RESULTS

467 young people were identified as UHR, of which 13.5% (n = 63) were born overseas. First-generation migrants were 2.6-fold less likely to be identified as UHR compared to Australian-born young people (IRR = 0.39, 95% CI [0.30, 0.51], P < 0.001). There was no difference between migrant and native-born young people in their risk of transitioning to a psychotic disorder (HR = 0.90, 95% CI [0.39, 2.08], P = 0.81).

CONCLUSIONS

UHR first-generation migrants may be under-accessing mental health services.

Usage of healthcare services and preference for mental healthcare among older Somali immigrants in Finland

Objectives: The aims of the study were, first, to describe and analyze healthcare services utilization patterns of older immigrants in Finland, and particularly to compare the availability and accessibility of health services between older Somalis and Finns. The second aim was to examine the preferences for mental healthcare within the group of Somalis. The third aim was to test the existence of a service usage gap expected to be characteristic of the Somali group, in which high levels of mental health problems occur alongside simultaneous low levels of mental health service usage. Design: The participants were 256 men and women between the ages of 50-85; half were Somali migrants and the other half Finnish matched pairs. The participants were surveyed regarding their usage of somatic, mental, and preventive health services, as well as symptoms of depression, general distress, and somatization. The Somali participants were also surveyed regarding their usage of traditional healing methods and preferences for mental healthcare. Results: The Somali group had significantly lower access to personal/family doctors at healthcare centers as well as a lower availability of private doctors and occupational health services than the Finns. Instead, they used more nursing services than Finnish patients. The Somali participants attended fewer age-salient preventive check-ups than the Finns. The majority of the Somalis preferred traditional care, most commonly religious healing, for mental health problems. The hypothesized service gap was not substantiated, as a high level of depressive symptoms was not associated with a low usage of health services among the Somalis, but it was found unexpectedly among the Finns. Conclusion: Our findings call for culturally appropriate general and mental health services for older immigrants, which requires awareness of clients' preferences, needs, and alternative healing practices. Somali participants encountered institutional barriers in accessing healthcare, and they preferred informal mental healthcare, especially religious healing instead of Western practices.

Co-morbid Non-communicable Diseases and Associated Health Service Use in African and Caribbean Immigrants with HIV

We sought to characterize non-communicable disease (NCD)-related and overall health service use among African and Caribbean immigrants living with HIV between April 1, 2010 and March 31, 2013. We conducted two population-based analyses using Ontario's linked administrative health databases. We studied 1525 persons with HIV originally from Africa and the Caribbean. Compared with non-immigrants with HIV (n = 11,931), African and Caribbean immigrants had lower rates of hospital admissions, emergency department visits and non-HIV specific ambulatory care visits, and higher rates of health service use for hypertension and diabetes. Compared with HIV-negative individuals from these regions (n = 228,925), African and Caribbean immigrants with HIV had higher rates of health service use for chronic obstructive pulmonary disease [rate ratio (RR) 1.78; 95% confidence interval (CI) 1.36-2.34] and malignancy (RR 1.20; 95% CI 1.19-1.43), and greater frequency of hospitalizations for mental health illness (RR 3.33; 95% CI 2.44-4.56), diabetes (RR 1.37; 95% CI 1.09-1.71) and hypertension (RR 1.85; 95% CI 1.46-2.34). African and Caribbean immigrants with HIV have higher rates of health service use for certain NCDs than non-immigrants with HIV. The evaluation of health services for African and Caribbean immigrants with HIV should include indicators of NCD care that disproportionately affect this population.

Cultural adaptation of cognitive–behavioural therapy

The study of cultural factors in the application of psychotherapy across cultures – ethnopsychotherapy – is an emerging field. It has been argued that Western cultural values underpin cognitive–behavioural therapy (CBT) as they do other modern psychosocial interventions developed in the West. Therefore, attempts have been made to culturally adapt CBT for ethnic minority patients in the West and local populations outside the West. Some frameworks have been proposed based on therapists’ individual experiences, but this article describes a framework that evolved from a series of qualitative studies to culturally adapt CBT and that was field tested in randomised controlled trials. We describe the process of adaptation, details of methods used and the areas that need to be focused on to adapt CBT to a given culture. Further research is required to move the field forward, but cultural adaptation alone cannot improve outcomes. Access to evidence-based psychosocial interventions, including CBT, needs to be improved for culturally adapted interventions to achieve their full potential.

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Childhood Adversity and Psychosocial Health Outcomes in Later Life Among Immigrants in Canada

Childhood adversity is known to have an enduring effect on health outcomes of victims. The objective of the study was to examine the association between childhood adversity and psychosocial health outcomes among immigrants in Canada. Using descriptive and inferential statistics and fitting negative loglog regression models to the 2014 General Social Survey, the paper examined the relationship between experience of childhood adversity (i.e. physical and sexual abuse before age 15) and its association with psychosocial health outcomes (i.e. psychological-mental condition and self-rated mental health) among immigrants in Canada. After accounting for relevant socioeconomic and demographic factors, the results show that physical abuse during childhood resulted in 29% and 31% increased likelihood of having a psychological mental condition and poor self-rated mental health, respectively. Also, sexual abuse during childhood was associated with 28% increased likelihood of poor self-rated mental health. In conclusion, the findings show that experience of physical and sexual abuse during childhood is associated with negative mental health outcomes in later life.

"If One Does Not Fulfil His Duties, He Must Not Be a Man": Masculinity, Mental Health and Resilience Amongst Sri Lankan Tamil Refugee Men in Canada

Refugee men face unique mental health stressors in the pre- and post-migratory periods. However, there has been little in-depth research on the mental health of refugee men in Canada. Given this situation, the overall aim of this study is to explore the psycho-social experience of Sri Lankan Tamil refugee men in Canada. Particular objectives include better understanding any inter-relationship between war-trauma, migration, concepts of masculinity and mental health. The study employed a two-phase participatory action research design based on the grounded theory approach. Phase 1 involved an 8-month ethnography conducted in Sri Lanka. Phase 2 consisted of qualitative interviews with 33 Sri Lankan Tamil refugee men living in Canada. Consistent with grounded theory, analysis was conducted inductively and iteratively. Four specific themes emerged from the data (i) gendered helplessness of war: participants commonly reported ongoing negative rumination regarding experiences where they were unable to adequately protect loved ones from physical suffering or death; (ii) reduced capacity: participants frequently felt unable to fulfill culturally sanctioned duties, such as supporting their family, due to ongoing pre- and post-migratory stress; (iii) redundancy: many participants felt that they were useless in Canada, as they could not fulfill typical masculine social roles (e.g. provider) due to factors such as unemployment and underemployment; (iv) intimate criticism: some participants reported that their spouses would often attempt to 'shame' them into greater achievement by constantly reminding them of their 'failures'. Many found this distressing. These various failures culminated in a state that we label "depleted masculinity", which participants linked to emotional and behavioural problems. Participants reported that they actively tried to rebuild their masculine identity, for example by adopting leadership roles in community organizations, which fostered resiliency. Results suggest a need to review and rebuild masculine identity to support the mental health of refugee men.

A Return to "The Clinic" for Community Psychology: Lessons from a Clinical Ethnography in Urban American Indian Behavioral Health

Community psychology (CP) abandoned the clinic and disengaged from movements for community mental health (CMH) to escape clinical convention and pursue growing aspirations as an independent field of context-oriented, community-engaged, and values-driven research and action. In doing so, however, CP positioned itself on the sidelines of influential contemporary movements that promote potentially harmful, reductionist biomedical narratives in mental health. We advocate for a return to the clinic-the seat of institutional power in mental health-using critical clinic-based inquiry to open sites for clinical-community dialogue that can instigate transformative change locally and nationally. To inform such works within the collaborative and emancipatory traditions of CP, we detail a recently completed clinical ethnography and offer "lessons learned" regarding challenges likely to re-emerge in similar efforts. Conducted with an urban American Indian community behavioral health clinic, this ethnography examined how culture and culture concepts (e.g., cultural competence) shaped clinical practice with socio-political implications for American Indian peoples and the pursuit of transformative change in CMH. Lessons learned identify exceptional clinicians versed in ecological thinking and contextualist discourses of human suffering as ideal partners for this work; encourage intense contextualization and constraining critique to areas of mutual interest; and support relational approaches to clinic collaborations.

Disengagement in immigrant groups receiving services for a first episode of psychosis

OBJECTIVE

Although early intervention (EI) programs for psychosis invest in clients remaining engaged in treatment, disengagement remains a concern. It is not entirely clear whether immigrants are likelier to disengage. The rates and predictors of disengagement for immigrant vis-à-vis non-immigrant clients in a Canadian EI setting were analyzed.

METHOD

297 clients were included in a time-to-event analysis with Cox Proportional Hazards regression models. Immigrant status (first- or second-generation immigrant or non-immigrant), age, gender, education, substance abuse, family contact, social and material deprivation and medication non-adherence were tested as predictors of service disengagement.

RESULTS

24.2% (n=72) of the clients disengaged from services before completing two years. Disengagement rates did not differ between first-generation immigrants (23.3%), second-generation immigrants (22.7%) and non-immigrants (25.3%). For all clients, only medication non-adherence predicted disengagement (HR=3.81, 95% CI 2.37-6.14). For first-generation immigrants, age (HR=1.17, 95% CI 1.02-1.34) and medication non-adherence (HR=2.92, 95% CI 1.09-7.85) were significant predictors. For second-generation immigrants, material deprivation (HR=1.03, 95% CI 1.00-1.05) and medication non-adherence (HR=11.07, 95% CI 3.20-38.22) were significant.

CONCLUSION

Disengagement rates may be similar between immigrants and non-immigrants, but their reasons for disengagement may differ. Medication adherence was an important predictor for all, but the role of various sociodemographic factors differed by group. Sustaining all clients' engagement in EI programs may therefore require multi-pronged approaches.

The emotional distress of asylum seekers in Israel and the characteristics of those seeking psychiatric versus medical help

Israel has become a destination for asylum seekers. Asylum seekers often experience emotional distress, but have limited access to health services and rarely use psychiatric services. This study sought to understand and characterize the use of psychiatric versus medical services by asylum seekers in Israel. We compared the emotional distress, stressful life events and previous treatment consultations of 21 psychiatric service users (PSU) and 55 medical service users (MSU) at the Open Clinic of Physicians for Human Rights in Tel-Aviv. Participants completed a socio-demographic questionnaire, the General Health Questionnaire (GHQ-12), the Stressful Life Events Scale and the Health Care Utilization Questionnaire. PSU and MSU did not have significantly different levels of emotional distress. PSU reported significantly more stressful life events during the past year than MSU ( M = 5.81, SD 3.47 vs. M = 3.8, SD 2.35, p < 0.01). In comparison to MSU, PSU utilized more medical ( M = 4.33, SD 2.28) and non-medical ( M = 2.38, SD 1.92) services ( p < 0.001) than MSU. Asylum seekers who consulted multiple treatment agencies in the last year were 1.55 times more likely to seek psychiatric treatment than those who had consulted only a few treatment agencies. Emotional distress in asylum seekers appears to be under-diagnosed in the Open Clinic and under-treated by mental health professionals. To better detect this distress, a thorough screening is recommended at assessment. Collaboration with mental health professionals and community and religious leaders consulted in the past is important and can contribute to good health care outcomes in this population.

Examining the impact of migrant status on ethnic differences in mental health service use preceding a first diagnosis of schizophrenia

PURPOSE

Some ethnic groups have more negative contacts with health services for first-episode psychosis, likely arising from a complex interaction between ethnicity, socio-economic factors, and immigration status. Using population-based health administrative data, we sought to examine the effects of ethnic group and migrant status on patterns of health service use preceding a first diagnosis of schizophrenia or schizoaffective disorder among people aged 14-35 over a 10-year period.

METHODS

We compared access to care and intensity of service use for first-generation ethnic minority groups to the general population of Ontario. To control for migrant status, we restricted the sample to first-generation migrants and compared service use indicators for ethnic minority groups to the European migrant group.

RESULTS

Our cohort included 18,080 people with a first diagnosis of schizophrenia or schizoaffective disorder, of whom 14.4% (n = 2607) were the first-generation migrants. Our findings suggest that the magnitude of ethnic differences in health service use is reduced and no longer statistically significant when the sample is restricted to first-generation migrants. Of exception, nearly, all migrant groups have lower intensity of primary care use, and Caribbean migrants are consistently less likely to use psychiatric services.

CONCLUSIONS

We observed fewer ethnic differences in health service use preceding the first diagnosis of psychosis when patterns are compared among first-generation migrants, rather than to the general population, suggesting that the choice of reference group influences ethnic patterning of health service use. We need a comprehensive understanding of the mechanisms behind observed differences for minority groups to adequately address disparities in access to care.

Evaluation of cultural responsiveness using a transcultural secondary consultation model

This article describes the expansion of a transcultural secondary consultation model run by a state-wide transcultural unit. The model aims to enhance cultural responsiveness in partnership with mental health services. We discuss a series of 12 consultations that occurred between 2011 and 2012. We outline the processes of setting up the structure of secondary consultation, the actual consultation-facilitation format, and methods of evaluation. Evaluations were done in two phases: the first immediately after the consult and the second after a period of 3-6 months. The discussion highlights the usefulness of a transcultural model of consultation and, based on the evaluations, identifies the benefits the model brings to understanding and intervening with clients, culture, and systems. The results emphasise the need for multidisciplinary collaboration and a facilitated space for clinical teams to explore culturally responsive therapeutic practices.

Mental Health Status, Health Care Utilisation, and Service Satisfaction among Immigrants in Montreal: An Epidemiological Comparison

OBJECTIVE

To examine variations between immigrants and nonimmigrants in 1) prevalence of common mental disorders and other mental health variables; 2) health service utilisation for emotional problems, mental disorders, and addictions, and 3) health service satisfaction.

METHODS

This article is based on a longitudinal cohort study conducted from May 2007 to the present: the Epidemiological Catchment Area Study of Montreal South-West (ZEPSOM). Participants were followed up at 4 time points (T1, n = 2433; T4, n = 1095). Core exposure variables include immigrant status (immigrant vs. nonimmigrant), duration of residence, and region of origin. Key outcome variables included mental health status, health service utilisation, and health service satisfaction. Data were analysed both cross-sectionally and longitudinally.

RESULTS

Immigrants had been in Canada for 20 years on average. Immigrants had significantly lower rates of high psychological distress (32.6% vs. 39.1%, P = 0.016), alcohol dependence (1.4% vs. 3.9%, P =0.010), depression (5.2% vs. 9.2%, P = 0.008), and various other mental disorders. They had significantly higher scores of mental well-being (48.9 vs. 47.1 score, P = 0.014) and satisfaction with social (34.0 vs. 33.4 score, P = 0.021) and personal relationships (16.7 vs. 15.6 score, P < 0.001). Immigrants had significantly lower rates of health service utilisation for emotional problems, mental disorders, and addictions and significantly higher rates of health service satisfaction at all time points. Asian and African immigrants had particularly low rates of utilisation and high rates of satisfaction.

CONCLUSIONS

Immigrants had better overall mental health than nonimmigrants.

Maternal depression in Syrian refugee women recently moved to Canada: a preliminary study

BACKGROUND

Refugee women are almost five times more likely to develop postpartum depression than Canadian-born women. This can be attributed to various difficulties they faced before coming to Canada as well as during resettlement. Moreover, refugee women usually face many obstacles when accessing health services, including language and cultural barriers, as well as unique help-seeking behaviors that are influenced by various cultural and practical factors. There has been a recent, rapid influx of Syrian refugees to Canada, and many of them are childbearing women. However, little is known about the experiences that these women have encountered pre- and post-resettlement, and their perceptions of mental health issues. Thus, there is an urgent need to understand refugee women's experiences of having a baby in Canada from a mental health perspective.

METHODS

A mixed methods research design included 12 Syrian refugee women who migrated to Saskatoon in 2015-16 and who were either pregnant or 1 year postpartum. The data were collected during a single focus group discussion and a structured questionnaire.

RESULTS

Our results showed that more than half of participants have depressive symptoms, half of them have anxiety symptoms, and one sixth have PTSD symptoms. Three major themes emerged from the qualitative data: 1) Understanding of maternal depression; 2) Protective factors for mental health; and 3) Barriers to mental health services.

CONCLUSIONS

Maternal depression is an important feature in Syrian refugee women recently resettled in Canada. Reuniting these women with their families and engaging them in culturally appropriate support programs may improve their mental health outcomes.

Toward a Culturally Responsive Model of Mental Health Literacy: Facilitating Help-Seeking Among East Asian Immigrants to North America

Studies have consistently found that East Asian immigrants in North America are less likely to use mental health services even when they experience levels of distress comparable to Euro-Americans. Although cultural factors that may prevent East Asian immigrants from seeking mental health care have been identified, few studies have explored ways to foster appropriate help-seeking and use of mental health services. Recent work on mental health literacy provides a potential framework for strategies to increase appropriate help-seeking and use of services. This paper reviews the literature on help-seeking for mental health problems among East Asian immigrants living in Western countries to critically assess the relevance of the mental health literacy approach as a framework for interventions to improve appropriate use of services. Modifications needed to develop a culturally responsive framework for mental health literacy are identified.

Ethno-Racial Variation in Recovery From Severe Mental Illness: A Qualitative Comparison

OBJECTIVE

Purpose-driven studies examining the relationship between ethnicity, culture, and recovery are absent from the empirical literature. As such, the overall aim of this study was to examine ethno-racial variations in recovery perspectives. Specific objectives consist of comparing and contrasting ethno-racial variations in 1) definitions of recovery, 2) barriers to recovery, and 3) facilitators of recovery.

METHODS

We recruited people with severe mental illness from 2 broad ethno-racial groups (Caribbean-Canadian and Euro-Canadian) to partake in a qualitative interview on recovery (n = 47). Participants were asked to give their own definitions of recovery, as well as self-perceived barriers and facilitators. Interview transcripts were then subjected to thematic analysis. We compared and contrasted the distribution and salience of emerging themes between the Euro-Canadian and Caribbean-Canadian participants.

RESULTS

Recovery was consistently defined as a gradual process involving progress in key life domains including employment, social engagement, and community participation by both groups. This was underpinned by a growing future orientation. Stigma, financial strain, and psychiatric hospitalization were considered major barriers to recovery in both groups. Participants from both groups generally considered stated definitions of recovery to be simultaneous facilitators of recovery-employment and social engagement being the most frequently mentioned. God and religion were key facilitators for the Caribbean-Canadian group but not for Euro-Canadians.

CONCLUSIONS

Definitions, barriers, and facilitators to recovery were generally shared among our sample, regardless of ethno-racial status, with the exception of God and religion.

Creating a cultural analysis tool for the implementation of Ontario's civil mental health laws

Ethno-racial people with mental health disabilities experience multiple inequities and differential outcomes when interacting with Ontario's civil mental health laws. Given the increasing multi-racial population in Ontario, there is a need to develop mechanisms to address these intersecting issues. Other countries that have created evaluative tools for mental health legislation include the United Kingdom and Australia. Australia's Rights Analysis Tool, the United Kingdom's Race Equality Impact Assessment, the Scottish Recovery Tool, and the World Health Organization's Mental Health and Human Rights checklist are examples of evaluative tools developed for mental health legislation. Such a tool does not exist in Canada, let alone in Ontario specifically. Thus, this study developed a Cultural Analysis Tool (CAT) consisting of specific and meaningful thematic questions that can be used by practitioners when addressing issues of culture and equity for ethno-racial people with mental health disabilities interacting with Ontario's civil mental health laws. It is hoped that the CAT, and the research underlying its development, will enable practitioners to critically question whether cultural and intersecting concerns are being appropriately addressed within an ethno-racial client's case and, furthermore, how equitable outcomes can be achieved. This article describes and analyzes the methodology, research and qualitative data used to develop the CAT. It then presents and examines the CAT itself. The qualitative data was drawn from thirty-five semi-structured interviews with seven members of each of the following groups: (1) ethno-racial people with mental health disabilities including in-patients and ex-patients, (2) lawyers who practice in the area of mental health law, (3) health care professionals including psychiatrists, nurses and social workers, (4) service providers such as front-line case workers at mental health agencies and (5) adjudicators, government advisors and academics. After an analysis of these data, the CAT's questions were refined through an expert review (involving the qualitative technique of member-checking) using three focus groups comprised of ethno-racial people with mental health disabilities, mental health lawyers and service providers and health care professionals.

Utilization of a mental health collaborative care model among patients who require interpreter services

Background

Immigrants and refugees to the United States have a higher prevalence of depression compared to the general population and are less likely to receive adequate mental health services and treatment. Those with limited English proficiency (LEP) are at an even higher risk of inadequate mental health care. Collaborative care management (CCM) models for depression are effective in achieving treatment goals among a wide range of patient populations, including patients with LEP. The purpose of this study was to assess the utilization of a statewide initiative that uses CCM for depression management, among patients with LEP in a large primary care practice.

Methods

This was a retrospective cohort study of patients with depression in a large primary care practice in Minnesota. Patients who met criteria for enrollment into the CCM [with a provider-generated diagnosis of depression or dysthymia in the electronic medical records, and a Patient Health Questionnaire-9 (PHQ-9) score ≥10]. Patient-identified need for interpreter services was used as a proxy for LEP. Rates of enrollment into the DIAMOND (Depression Improvement Across Minnesota, Offering A New Direction) program, a statewide initiative that uses CCM for depression management were measured. These rates were compared between eligible patients who require interpreter services versus patients who do not.

Results

Of the 7561 patients who met criteria for enrollment into the DIAMOND program during the study interval, 3511 were enrolled. Only 18.2 % of the eligible patients with LEP were enrolled into DIAMOND compared with the 47.2 % of the eligible English proficient patients. This finding persisted after adjustment for differences in age, gender and depression severity scores (adjusted OR [95 % confidence interval] = 0.43 [0.23, 0.81]).

Conclusions

Within primary care practices, tailored interventions are needed, including those that address cultural competence and language navigation, to improve the utilization of this effective model among patients with LEP.

The physical and psychological problems of immigrants to Japan who require psychosomatic care: a retrospective observation study

Background

As the number of immigrants to Japan increases, the health problems of foreign nationals also have an increasing impact on Japanese medical institutions. The aim of this study was to clarify the Japan–specific health problems related to both the physical and psychological symptoms of foreign nationals from the viewpoint of psychosomatic medicine. The second aim was to clarify the measures that should be taken in Japan and similar countries where immigration may still be considered less than common.

Case Presentation

The study period was from June 2004 to May 2015. The data of non-Japanese patients who had visited the Department of Psychosomatic Medicine, Kinki University Hospital and its branches, Sakai Hospital and Nihonbashi Clinic, were collected. All patients were aged 16 years or over. Multiple factors, such as age, sex, nationality, length of stay, marital status, employment status, level of Japanese proficiency, clinical symptoms, physical and psychiatric diagnosis, psycho-social factors and therapy were retrospectively analyzed from the medical charts of 20 non-Japanese patients. Cases were divided into two groups; early onset and late onset cases. This study showed that multiple factors related to the health problems of non-Japanese patients were combined and had a mutual influence, however, they can be summarized into two important clinical observations. These are 1) cultural differences, and 2) language barriers related to both the physical and psychological symptoms of non-Japanese patients from the viewpoint of psychosomatic medicine.

Conclusions

Future efforts should focus on sensitizing health care professionals in Japan to the psychosomatic problems of non-Japanese patients as well as on facilitating medical systems with services such as medical professional interpreters and liaison-consultation models. It is essential to take measures against language barriers and to promote the field of transcultural psychiatry and psychosomatic medicine in Japan. In addition, the Japanese government should introduce a more comprehensive social support system for non-Japanese people.

Issues and Options for Improving Services for Diverse Populations

International migration has led to increasingly diverse populations in many high-income countries. With approximately 250,000 newcomers each year, it should be no surprise that developing services that meet the needs of immigrants, refugees, ethnocultural, and racialized populations (IRER) is a major priority in the Mental Health Strategy for Canada. The published Canadian literature on the mental health of diverse populations concludes that differences in the exposure to social risk factors lead to differences in rates of illness for some groups. Whether rates of illness are high or low in a particular group, however, problems in accessing services are ubiquitous. Improving the service response will require political will, leadership, strategic planning, and data, and must include people with lived experience and the populations at highest risk. This paper outlines the “Issues and Options” paper commissioned by the Mental Health Commission of Canada, which used a thorough literature review and a national consultation to develop a model for service development. A health equity approach that utilizes local-population-based planning and the evidence-based interventions that are available for diverse groups could improve services for IRER groups in Canada.

Social support, social conflict, and immigrant women's mental health in a Canadian context: a scoping review

ACCESSIBLE SUMMARY

Social support has positive and negative dimensions, each of which has been associated with mental health outcomes. Social networks can also serve as sources of distress and conflict. This paper reviews journal articles published during the last 24 years to provide a consolidated summary of the role of social support and social conflict on immigrant women's mental health. The review reveals that social support can help immigrant women adjust to the new country, prevent depression and psychological distress, and access care and services. When social support is lacking or social networks act as a source of conflict, it can have negative effects on immigrant women's mental health. It is crucial that interventions, programmes, and services incorporate strategies to both enhance social support as well as reduce social conflict, in order to improve mental health and well-being of immigrant women.

ABSTRACT

Researchers have documented the protective role of social support and the harmful consequences of social conflict on physical and mental health. However, consolidated information about social support, social conflict, and mental health of immigrant women in Canada is not available. This scoping review examined literature from the last 24 years to understand how social support and social conflict affect the mental health of immigrant women in Canada. We searched MEDLINE, PsycINFO, CINAHL, Healthstar, and EMBASE for peer-reviewed publications focusing on mental health among immigrant women in Canada. Thirty-four articles that met our inclusion criteria were reviewed, and are summarized under the following four headings: settlement challenges and the need for social support; social support and mental health outcomes; social conflict and reciprocity; and social support, social conflict, and mental health service use. The results revealed that social support can have a positive effect on immigrant women's mental health and well-being, and facilitate social inclusion and the use of health services. When social support is lacking or social networks act as a source of conflict, it can have negative effects on immigrant women's mental health. The results also highlighted the need for health services to be linguistically-appropriate and culturally-safe, and provide appropriate types of care and support in a timely manner in order to be helpful to immigrant women.

Immigrant Mental Health, A Public Health Issue: Looking Back and Moving Forward

The Mental Health Commission of Canada's (MHCC) strategy calls for promoting the health and wellbeing of all Canadians and to improve mental health outcomes. Each year, one in every five Canadians experiences one or more mental health problems, creating a significant cost to the health system. Mental health is pivotal to holistic health and wellbeing. This paper presents the key findings of a comprehensive literature review of Canadian research on the relationship between settlement experiences and the mental health and well-being of immigrants and refugees. A scoping review was conducted following a framework provided by Arskey and O'Malley (Int J Soc Res Methodol 8:19-32, 2005). Over two decades of relevant literature on immigrants' health in Canada was searched. These included English language peer-reviewed publications from relevant online databases Medline, Embase, PsycInfo, Healthstar, ERIC and CINAHL between 1990 and 2015. The findings revealed three important ways in which settlement affects the mental health of immigrants and refugees: through acculturation related stressors, economic uncertainty and ethnic discrimination. The recommendations for public health practice and policy are discussed.

Mental health service use by recent immigrants from different world regions and by non-immigrants in Ontario, Canada: a cross-sectional study

Background

Given that immigration has been linked to a variety of mental health stressors, understanding use of mental health services by immigrant groups is particularly important. However, very little research on immigrants’ use of mental health service in the host country considers source country. Newcomers from different source countries may have distinct experiences that influence service need and use after arrival. This population study examined rates of use of primary care and of specialty services for non-psychotic mental health disorders by immigrants to Ontario Canada during their first five years after arrival. Service use by recent immigrants in broad source region groups representing all world regions was compared to use by age-matched Canadian-born or long term immigrants (called long term residents).

Method

This matched population-based cross-sectional study assessed likelihood of any use and counts of visits for each of primary care, psychiatric care and hospital care (emergency department visits or inpatient admissions) for non-psychotic mental health disorders from 1993–2012. Adult immigrants living in urban Ontario (n = 912,114) were categorized based on their nine world regions of origin. Sex-stratified conditional logistic regression models and negative binomial models were used to compare service use by immigrant region groups to their age-matched long term residents.

Results

Immigrant were more or less likely to access primary mental health care compared to age-matched long term residents, depending on their world region of origin. Regarding specialty mental health care (psychiatry and hospital care), immigrants from all regions used less than long term residents. Across the three mental health services, estimates of use by immigrant region groups compared to long term residents were among the lowest for newcomers from East Asian and Pacific (range: 0.16–0.82) and among the highest for persons from Middle East and North Africa (range: 0.56–1.23).

Conclusion

This population-based study showed lower use of mental health services by recent immigrants than long-term immigrants or native born individuals, with variation in immigrants’ use linked to world region of origin and type of mental health care. Variation across source region groups underscores the importance of identifying underlying individual characteristics that affect service use to make services more responsive to newcomers.

Electronic supplementary material

The online version of this article (doi:10.1186/s12913-015-0995-9) contains supplementary material, which is available to authorized users.

Access to psychiatrists by French-speaking patients in Ontario hospitals: 2005 to 2013

There has been a limited amount of research suggesting that cultural and linguistic variables may affect access to health services, but no study has examined the access of French-speaking Canadians to psychiatrists. The present study used data from the Ontario Mental Health Reporting System to examine patterns of daily contact with psychiatrists in the first 3 days of admission to mental health facilities in Ontario. The results showed that after controlling for a broad range of covariates, French-speaking Ontarians were about one-third as likely to have daily contact with psychiatrists in that time period compared to English-speaking patients. These results were not explained by regional differences. Instead, they point to the possibility that language poses an important barrier to specific and highly specialized mental health services in this province.

Pathways to First-Episode Care for Psychosis in African-, Caribbean-, and European-Origin Groups in Ontario

OBJECTIVE

To compare the pathways to care and duration of untreated psychosis (DUP) for people of Black-African, Black-Caribbean, or White-European origin with first-episode psychosis (FEP).

METHODS

We recruited a sample of 171 patients with FEP of Black-African, Black-Caribbean, and White-European origin from hospital- and community-based early intervention services (EIS) in the cities of Toronto and Hamilton. We compared the 3 groups on DUP and key indicators of the pathway to care.

RESULTS

We observed differences in pathways to care across the 3 groups. Black-Caribbean participants had an increased odds of referral from an inpatient unit to EIS (OR 3.33; 95% CI 1.46 to 7.60) and a decreased odds of general practitioner involvement on the pathway to care (OR 0.17; 95% CI 0.07 to 0.46), as well as fewer total contacts (exp[β] 0.77; 95% CI 0.60 to 0.99) when compared with White-European participants. Black-African participants had an increased odds of contact with the emergency department at first contact (OR 3.78; 95% CI 1.31 to 10.92). The differences in the DUP between groups were not statistically significant.

CONCLUSIONS

Our findings suggest that there are significant differences in the pathways to EIS for psychosis for people of African and Caribbean origin in our Canadian context. It is essential to gain a comprehensive understanding of the pathways that different population groups take to mental health services, and the reasons behind observed differences, to inform the development of equitable services, targeting patients in the critical early stages of psychotic disorder.

Examining the relationship between neighbourhood deprivation and mental health service use of immigrants in Ontario, Canada: a cross-sectional study

OBJECTIVE

While newcomers are often disproportionately concentrated in disadvantaged areas, little attention is given to the effects of immigrants' postimmigration context on their mental health and care use. Intersectionality theory suggests that understanding the full impact of disadvantage requires considering the effects of interacting factors. This study assessed the inter-relationship between recent immigration status, living in deprived areas and service use for non-psychotic mental health disorders.

STUDY DESIGN

Matched population-based cross-sectional study.

SETTING

Ontario, Canada, where healthcare use data for 1999-2012 were linked to immigration data and area-based material deprivation scores.

PARTICIPANTS

Immigrants in urban Ontario, and their age-matched and sex-matched long-term residents (a group of Canadian-born or long-term immigrants, n=501,417 pairs).

PRIMARY AND SECONDARY OUTCOME MEASURES

For immigrants and matched long-term residents, contact with primary care, psychiatric care and hospital care (emergency department visits or inpatient admissions) for non-psychotic mental health disorders was followed for 5 years and examined using conditional logistic regression models. Intersectionality was investigated by including a material deprivation quintile by immigrant status (immigrant vs long-term resident) interaction.

RESULTS

Recent immigrants in urban Ontario were more likely than long-term residents to live in most deprived quintiles (immigrants--males: 22.8%, females: 22.3%; long-term residents--both sexes: 13.1%, p<0.001). Living in more deprived circumstances was associated with greater use of mental health services, but increases were smaller for immigrants than for long-term residents. Immigrants used less mental health services than long-term residents.

CONCLUSIONS

This study adds to existing research by suggesting that immigrant status and deprivation have a combined effect on recent immigrants' care use for non-psychotic mental health disorders. In settings where immigrants are over-represented in deprived areas, policymakers focused on increasing immigrants' access of mental health services should broadly address the influence of structural and cultural factors beyond the disadvantage.