Ethnic elders are commonly reluctant to access mental health services and their mental health problems are often overlooked and detected late in the course of illness. Prior studies identified major barriers to ethnic seniors accessing appropriate mental health care demonstrating that language and cultural beliefs cannot be ignored if effective mental health services are to be provided to patients from diverse cultural groups. These are particularly important when care is needed by less acculturated immigrant ethnic seniors for whom language barriers are often greatest. Differences in conceptions of mental distress affect ethnic seniors' choice of help-seeking and often discourage or divert aged persons from utilizing mainstream conventional psychiatric care. Despite the extensive need for appropriate service models for ethnic populations, there have been limited data and models to illustrate how these programs can be systematically and effectively integrated within the mainstream mental health service framework. This paper describes an innovative, mainstream, community-based psychogeriatric service delivery model developed for Chinese seniors in Toronto, Canada, aiming at improving their access to care and enhancing earlier mental health problem detection. The important concepts and strategies of designing and operating a culturally acceptable program are illustrated supported by program data and the challenges analyzed. 1. Introduction Canada’s visible-minority population including its geriatric age group is growing at a much faster rate than the general population. Between 2001 and 2006 it grew by 27% [1]. It is estimated that by 2017, one in five Canadians will be a visible minority, and half of them will be Chinese and South Asian [2]. This ethnic diversity is particularly notable in large urban centers such as Toronto and Vancouver. North American studies have consistently revealed a high prevalence of mental disorders among Chinese elders compared to their general population counterparts but their mental health problems are often underdiagnosed and undertreated [3–5]. Barriers to care are largely explained by eight key factors: stigma [6]; poor knowledge of resources [7]; reliance on family’s support for care-seeking and tendency of families to contain problems until they turn into crisis [7]; lack of linguistic and culturally appropriate service [2, 7, 8]; worries over medication side effects and the dominance of drug therapy [8]; underdetection at the primary care level [9, 10]; geographical inaccessibility of services [7, 11]; challenges in
References
[1]
“Human resources and skills development Canada-SPRD labour market and skills forecasting and analysis unit 2006 reference scenario,” 2010, http://www.hrsdc.gc.ca/eng/publications_resources/research/categories/labour_market_e/sp_615_10_06/page06.shtml.
[2]
B. A. Mitchell, “Canada's growing visible minority population: generational challenges, opportunities and federal policy considerations. Canada 2017 policy forum—serving Canada’s multicultural population for the future,” 2005.
[3]
D. Lai, “Impact of culture on depressive symptoms of elderly Chinese immigrants,” Canadian Journal of Psychiatry, vol. 49, no. 12, pp. 820–827, 2004.
[4]
O. M. Lum, “Health status of Asians and Pacific Islanders,” Clinics in Geriatric Medicine, vol. 11, no. 1, pp. 53–67, 1995.
[5]
Y. W. Ying, “Depressive symptomatology among Chinese-Americans as measured by the CES-D,” Journal of Clinical Psychology, vol. 44, no. 5, pp. 739–746, 1988.
[6]
C. H. Ng, “The stigma of mental illness in Asian cultures,” Australian and New Zealand Journal of Psychiatry, vol. 31, no. 3, pp. 382–390, 1997.
[7]
J. Sadavoy, R. Meier, and A. Y. M. Ong, “Barriers to access to mental health services for ethnic seniors: the Toronto study,” Canadian Journal of Psychiatry, vol. 49, no. 3, pp. 192–199, 2004.
[8]
P. L. Li, S. Logan, L. Yee, and S. Ng, “Barriers to meeting the mental health needs of the Chinese community,” Journal of Public Health Medicine, vol. 21, no. 1, pp. 74–80, 1999.
[9]
A. Bradford, M. E. Kunik, P. Schulz, S. P. Williams, and H. Singh, “Missed and delayed diagnosis of dementia in primary care: prevalence and contributing factors,” Alzheimer Disease and Associated Disorders, vol. 23, no. 4, pp. 306–314, 2009.
[10]
P. S. German, S. Shapiro, and E. A. Skinner, “Detection and management of mental health problems of older patients by primary care providers,” Journal of the American Medical Association, vol. 257, no. 4, pp. 489–493, 1987.
[11]
N. G. Choi and J. M. Gonzalez, “Barriers and contributors to minority older adults' access to mental health treatment: perceptions of geriatric mental health clinicians,” Journal of Gerontological Social Work, vol. 44, no. 3-4, pp. 115–135, 2005.
[12]
C. Weaver and D. Sklar, “Diagnostic dilemmas and cultural diversity in emergency rooms,” Western Journal of Medicine, vol. 133, no. 4, pp. 356–366, 1980.
[13]
K. C. Chan and J. Sadavoy, “Evidence-based approach in delivering psychogeriatric care for ethnic elders,” Canadian Journal of Geriatrics, vol. 12, pp. 46–47, 2009.
[14]
T. A. Abramson, L. Trejo, and D. W. L. Lai, “Culture and mental health: providing appropriate services for a diverse older population,” Generations, vol. 26, no. 1, pp. 21–27, 2002.
[15]
E. Lee and M. R. Mock, “Chinese families,” in Ethnicity and Family Therapy, M. McGolddrick, J. Giordiano, and N. Gracia-Preto, Eds., pp. 302–318, Guildford Press, New York, NY, USA, 3rd edition, 2005.
[16]
P. Root Maria, “Guidelines for facilitating therapy with Asian-American clients,” Psychotherapy: Theory, Research, Practice, Training, vol. 22, no. 2, pp. 349–356, 1985.
[17]
A. Antonovsky, “The salutogenic model as a theory to guide health promotion,” Health Promotion International, vol. 11, no. 1, pp. 11–18, 1996.
[18]
A. Tannahill, “Health promotion—policy into action,” Radiography Today, vol. 60, pp. 18–20, 1994.
[19]
D. R. Atkinson and R. H. Gim, “Asian-American cultural identity and attitudes toward mental health services,” Journal of Counseling Psychology, vol. 36, no. 2, pp. 209–212, 1989.
[20]
M. J. Stein, M. Smith, and K. Wallston, “Cross-cultural issues of health locus of control beliefs,” Psychological Science, vol. 29, no. 1, pp. 112–117, 1984.
[21]
K. M. Lin and F. Cheung, “Mental health issues for Asian Americans,” Psychiatric Services, vol. 50, no. 6, pp. 774–780, 1999.
[22]
T. Y. Lin, “Psychiatry and Chinese culture,” Western Journal of Medicine, vol. 139, no. 6, pp. 862–867, 1983.
[23]
A. Kleinman, L. Eisenberg, and B. Good, “Culture, illness, and care. Clinical lessons from anthropologic and cross-cultural research,” Annals of Internal Medicine, vol. 88, no. 2, pp. 251–258, 1978.
[24]
S. P. Hinshaw, The Mark of Shame: Stigma of Mental Illness and an Agenda for Change, Oxford University Press, New York, NY, USA, 2007.
[25]
W. Tseng and D. Y. H. Wu, Chinese Culture and Mental Health, Academic Press, Orlando, Fla, USA, 1985.
[26]
W. J. Doherty and H. I. McCubbin, “Families and health care: an emerging arena of theory, research, and clinical intervention,” Family Relations, vol. 34, pp. 5–11, 1985.
[27]
A. Shah, “The psychiatric needs of ethnic minority elders in the UK,” Age and Ageing, vol. 27, no. 3, pp. 267–269, 1998.
[28]
Health Quality Council, Mental Health Care in Primary Care setting: Challenges, Successes and Opportunity for Improvement, HQC, Saskatoon, Canada, 2004.
[29]
S. Sue, “Community mental health services to minority groups. Some optimism, some pessimism,” The American Psychologist, vol. 32, no. 8, pp. 616–624, 1977.
[30]
M. J. O'Sullivan, P. D. Peterson, G. B. Cox, and J. Kirkeby, “Ethnic populations: community mental health services ten years later,” American Journal of Community Psychology, vol. 17, no. 1, pp. 17–30, 1989.
[31]
D. T. Takeuchi, S. Sue, and M. Yeh, “Return rates and outcomes from ethnicity-specific mental health programs in Los Angeles,” American Journal of Public Health, vol. 85, no. 5, pp. 638–643, 1995.
[32]
F. H. Norris and M. Alegria, “Mental health care for ethnic minority individuals and communities in the aftermath of disasters and mass violence,” CNS Spectrums, vol. 10, no. 2, pp. 132–140, 2005.
[33]
C. Siegel, E. Davis-Chambers, G. Haugland, R. Bank, C. Aponte, and H. Mccombs, “Performance measures of cultural competency in mental health organizations,” Administration and Policy in Mental Health, vol. 28, no. 2, pp. 91–106, 2000.
[34]
H. Minas, S. Klimidis, and R. Kokanovic, “Depression in multicultural Australia: policies, research and services,” Australia and New Zealand Health Policy, vol. 4, no. 1, article 16, pp. 1–11, 2007.
