Canada's growing population of immigrants and visible minorities face mental health challenges that are often very different from those of other citizens. Although many are at increased risk of mental illness, they have poorer access to care, and their issues are often poorly understood. Dr. Kwame McKenzie is a psychiatrist and researcher who specializes in redesigning mental health services for visible minority groups. Last year he moved to Toronto from London, England, to join the staff of the Centre for Addiction and Mental Health. This week Margaret Wente asked him to explain why understanding ethno-cultural differences is so important for improving mental health care.
What is cross-cultural psychiatry all about?
The work of cross-cultural psychiatry is to move to a more diverse view of mental health services that allows individuals with different ways of looking at the world to find their niche and find treatment. They won't follow you unless it makes sense to them.
What drew you to Toronto?
Toronto is an exciting place for me, because it's got such incredible diversity. For anybody who's interested in cross-cultural mental health, this is the biggest laboratory in the world. You can compare groups and try to parcel out what it is about the environment that makes some people more at risk of developing mental illness.
What are some of the distinct problems experienced by minority groups?
They vary with the group. People from areas where there has been torture and war are more likely to suffer from post-traumatic stress issues. There's a huge Tamil population in Toronto that has very high rates of PTSD. Among South Asian groups, depression is a problem among older South Asian women, and alcohol misuse - probably caused by depression - is a problem among some South Asian men. People of African and Afro-Caribbean origin will tell you that racism and thwarted aspirations are a terrible problem that leads to depression, suicide and psychosis.
Are certain groups more at risk of developing mental illness than others?
Yes. In the U.K., for example, we've found that people of Afro-Caribbean origin are significantly more likely to develop psychosis. But they delay getting services. When they do, they are sicker and more likely to go into the hospital.
Your key message is that we can't treat people effectively unless we understand cultural differences. Can you give us some examples?
A good one is depression. Most doctors here in Canada would probably say that the most common symptom of depression is depressed thinking. But the experience of depression in other cultures is very different. People don't say 'I feel depressed.' They say, 'I feel tired. I'm thinking too much. I feel heavy.' They don't have the mind-body-split that we do. Women of South Asian origin are only half as likely to have their depression noticed by their GP. They have all the symptoms, but the GP doesn't understand the cross-cultural presentation of depression.
Do these differences also have implications for the way we deliver services?
Yes. The Latino population is a good example. They're very much into credibility, heart and warmth. If you are a Latino looking into services, you want a warm greeting. You don't want a receptionist saying, 'Here's a form to fill in.' Then there's the difference between individualist and collectivist societies. A lot of people don't want individual therapy. They want family therapy. Some people from East Asian societies don't want their son going off into a room and talking to someone by himself.
Apart from the obvious issues of fairness and equity, why should we care?
If you don't do the preventive stuff and don't support these communities, you're going to spend more money on health care and poor work performance. It's a no-brainer.
Researchers are finding that racism and discrimination can literally make you sick. Please explain.
Depression, anxiety and psychosis are all linked to discrimination. That discrimination doesn't have to be racial. It can be sex discrimination, or discrimination based on sexual preference. Numerous studies have shown that people who have been victims of racism are about twice as likely to suffer from depression. Studies from the U.S. also show that the lower the level of racial respect, the shorter the lifespan for both African-Americans and whites. Certain groups also have a higher rate of social risk. They have jobs with low pay and high levels of stress, poorer housing and more exposure to traumatic life events. Some of the social factors in mental distress are also the things that lead to high rates of gun crime.
In other words, you're saying that mental health is connected to much broader social issues?
That's right. There was a beautiful piece of work done around 20 years ago in Canada, called After the Door has been Opened, about how to improve mental health services for immigrants. Only a handful of the recommendations had anything to do directly with mental health. Most were about education, housing and social supports.
What are we learning about the interaction between discrimination, brain chemistry and mental distress?
Here's one of the interesting things about discrimination. If you've been attacked because of your race, you're at increased risk of mental illness. But your risk is higher even if you've experienced verbal abuse or stress. If you haven't been threatened or attacked, but you think that most employers discriminate, you're also at higher risk - about 60 or 70 per cent higher. Even if it hasn't happened to you, you're worried that it might. Discrimination eats away at you - and increases your chance of mental illness. The adrenalin is flowing because something nasty has happened to you. Then you realize it's unfair, and your adrenalin increases again. If you can do something about it, your adrenalin goes down. But if you can't, it goes up again. You get three loads of stress for the same problem. That's why racism and discrimination are particularly pernicious in the social realm.
Is there any one simple thing we could do right now to help minority groups get better mental health care?
Even though 12 or 14 per cent of Canadians in Ontario don't speak English, there's no real funding for interpretation services. It's a big problem. When people get ill, and especially when they become mentally distressed, they want to speak their own language. If everybody's supposed to get equal treatment, then you have to have a provincewide language competency strategy. It's very simple.
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The Globe and Mail's award-winning series Breakdown: Canada's Mental Health Crisis, elicited an overwhelming response from Canadians. Readers flooded The Globe with stories about their struggles with mental illness, and their struggles to get help from a broken health-care system. This Saturday the series returns to break new ground.
The original series, published in June, can be found at globeandmail.com/breakdown
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