Chinese Canadians in a cross-cultural psychiatry outpatient clinic: Some exploratory findings

Introduction

Multiculturalism is an integral component in Canadian society. However, cultural diversity brings with it challenges in meeting the health care needs of different ethno-cultural groups. Reitz[1] concluded that “recent immigrant groups experience low rates of utilization of many important social and health services, despite evidence of significant need.” Barriers that may impede ethno-cultural groups from accessing health services include a lack of awareness of the availability of services, financial restraints, language barriers, cultural insensitivity by service providers, and cultural patterns of help-seeking behaviors. Lin and Lin[2] studied help-seeking behaviors of psychiatric patients from different ethnic backgrounds. Chinese patients tend to deal with psychiatric illness initially through family supports and alternative naturopathic modalities. Only when extensive family efforts and resources within the Chinese community support network are exhausted would the family physician be consulted. This arises from traditional Chinese collectivist ideology and pervasive social stigma of mental illness that may lead to delayed clinical presentation. 

The study of mental illness in Chinese-Canadian populations is an area of very limited research. Previous research by Lai[3] suggests that use of mental health services is extremely low. Often, mainstream mental health services are not designed for cross-cultural counseling or treatment. Chinese Canadians who use mainstream services are a minority group. 

The Chinese accounted for 27% of all visible minorities in 1996, the largest visible minority group in Canada. In 2001, the Chinese-speaking population was by far the biggest immigrant group in British Columbia, representing 26% of the population in Vancouver and 15.2% in the Lower Mainland. The use of mainstream psychiatric services offered by the Greater Vancouver Mental Health Services by Chinese people has risen from 7.5% in 1990 to 9% in 1993 and 12.3% in 1999.[4] Reitz[1] advocated improvements in the awareness of service availability in conjunction with relocation of services to areas with high populations of target minority groups with multicultural training for service providers and “ethnic match,” which refers to “ethnic-appropriate minority-group service providers,” with ethnically specific agencies established to work alongside mainstream agencies. Other researchers have also shown that many clients prefer ethnically similar therapists,[5,6] particularly among African Americans. On the other hand, one should not overlook the fact that individuals from similar ethnic backgrounds have many differences as well. 

In recognition of the need for ethnically specific mental health services, the Cross-Cultural Psychiatry Outpatient Clinic was set up at the Vancouver General Hospital in 1988. The Clinic’s mandate is to provide “culturally sensitive and language-specific comprehensive psychiatric assessment including diagnosis, medication recommendations, and consideration of other resources available at the hospital as well as in the community.” Ethnically matched psychiatrists provide mental health services in 20 languages. 

Methods

A retrospective consecutive chart review was conducted on 370 Chinese Canadians who attended the Cross-Cultural Psychiatry Outpatient Clinic between 1998 and 2001. Patient demographic variables such as sex, age, occupation, residence, referral source, language ability, years spent in Canada, country of origin, and status in Canada (citizen or permanent resident) were recorded. The DSM-IV diagnosis was noted as were treatment modalities including medications, psychotherapy, and referrals to other mental health agencies and community resources in Greater Vancouver. Data were analyzed using univariate and bivariate statistics with P<0.05 as the significant level.

Profile of patients

A demographic profile of the patients in this study is provided in Table 1 and the cultural characteristics of the patients are provided in Table 2. A total of 370 patients received services from the program during the 3-year period of this study. Family physicians referred 83.2% (n=308). A total of 14.9% (n=55) were referred indirectly by the Insurance Corporation of British Columbia, either directly through their family physicians or indirectly as a clinical recommendation from a specialist after an independent medical examination had been conducted.

The age range was from 10 to 89 years old. It was normally distributed with both the mean and median ages being at 42.47 years and 42 years (SD=15.5 years).

Statistical analyses

Major depressive episode was the most commonly reported diagnosis (Figure 1), occurring in over half of the patients (60.5%, n=224) and especially in those who were separated or divorced (70%). Psychosis was the second most common disorder, diagnosed among 10.8% (n=40) of patients. Post-traumatic stress disorder and other anxiety disorders were diagnosed in 9.5% (n=35) of patients. Other significant diagnoses included adjustment disorder (6.5%, n=24) and major depressive disorder (6.2%, n=23). Eighty percent of patients reported a single diagnosis. Co-morbidity was found in 19.7% (n=73). The majority (87.8%, n=325) of patients received both psychotherapy and pharmacotherapy (Figure 2). About 9% (n=34) of patients received only psychotherapy. In addition to the treatments received, 32.4% were referred to other services. Among those, 21.7% of them were referred to support groups and 19.2% were referred to counselors or psychologists. As shown in Figure 3, more than one-third of patients (38.1%, n = 141) were fully recovered and discharged back to the care of the original referral source, another one-third (34.3%, n = 127) were lost in follow-up, and the remainder received regular follow-up care.

No significant differences were found between males and females in terms of diagnosis or types of treatment received. In terms of treatment outcomes, significantly more male patients were fully recovered than female patients (40.8% vs 36.7%). In addition, more females than males were lost in follow-up (39.2% vs 25.4%) (chi-square=8.3, P<.05). However, significantly more younger patients (18 years or under) received psychotherapy as the only treatment method than other age groups (30.4% vs 10.5%, chi-square=16.77, P<.05). Major depressive episode was the major diagnosis in all language groups. The Mandarin-speaking group tended to have a higher rate of losing contact in follow-up. The Cantonese-speaking group had lower rates of loss to follow-up (33.2%). Canadian-born English-speaking patients reported the lowest attrition rate at 13.6%. (chi-square = 30.15, P<.01).

In general, no significant association was found between place of origin of the patients and the diagnosis and types of treatment. However, Mandarin-speaking patients who emigrated from Taiwan and Mainland China reported higher attrition rates (60% and 38.2%, chi-square=32.95, P<.01) than either those who emigrated from Hong Kong or the Canadian-born patients. More permanent residents (63.9%) had a major depressive episode than the Canadian citizens (56.7%, chi square=35.45, P<.05), which could be due to acculturation issues for new immigrants.

Discussion

This preliminary descriptive study provides information regarding the use of ethnically sensitive mental health services by Chinese Canadians in a major Canadian city. Given the small sample size of this study, our results and statistical findings are limited and refer to trends within the Chinese population in Vancouver. It is possible that similar valid findings may emerge from studies involving larger population groups. 

Tsang[7] discussed the intra-group diversity within the Chinese population in North America. Our findings help to dispel the misconception that all Chinese people are the same. There are differences in terms of how various Chinese subgroups respond to mental health services. A major ethnicity-related finding is the higher drop-out rate for Mandarin speakers (originally from Mainland China and Taiwan). The differences highlight cultural and possibly systemic barriers that Mandarin-speaking patients have experienced in the existing mental health system.

With Hong Kong being a British Colony prior to 1997, Hong Kong Canadians were taught English as a second language from an early age. On the other hand, immigrants from Mainland China and Taiwan may have relatively limited English language skills, and therefore may run into comparatively more difficulties with acculturation during the initial phase of adjusting to a new life in Canada, which can affect treatment outcomes.

The differences in language groups could also be explained by intra-ethnic and background differences between the mental health providers and the patients. Despite ethnic and language matching, mental health providers who share the same ethnic origin as patients may still have different cultural traits—such as values, traditions, upbringing, and immigration experiences—than the patients. Therefore, the findings indicate the importance of culturally sensitive practice that goes beyond language and ethnic matching. While ethnic matching is definitely an important factor in enhancing accessibility of services, other “invisible” cultural characteristics and variations within the same ethnic group should not be overlooked. 

The English-speaking Canadian-born Chinese patients reported the lowest attrition rate. This small group, on the whole, tended to be younger patients. Such patients are more ready to seek help for their emotional condition at an earlier opportunity. They commonly experience intergenerational conflicts, where Westernized upbringing clashes with traditional Chinese values. They present early with adjustment disorders and psychotherapy alone is often the only treatment modality.

Gender is another outstanding factor associated with treatment outcome. While the traditional cultural limitations and gender barriers for Chinese women may account for the higher drop-out rate, gender differences between the psychiatrists and patients and its impact on treatment outcome should be examined in the future research. 

Recent trends have shown an increase in Chinese Canadians seeking psychiatric help in Vancouver over the past decade (Greater Vancouver Mental Health Services and our data). Continuing public psychoeducation through the media and the National Depression Screening Day, informal presentations to ethnic family physicians and community-based agencies, provision of information pamphlets in Chinese, further research into intra-group diversity and gender differences, and the training and recruitment of Chinese-speaking psychiatrists will help address the increasing demand and further enhance the use of services in our program.

Competing interests
None declared
 

Table 1. Demographic profile of the Chinese patients (N = 370).

Table 2. Cultural characteristics of the Chinese patients (N =370). 

Hiram Mok, MB, FRCPC, Daniel W.L. Lai, PhD, Daniel Lin, BSc, Michelle P. Wong, BSc, and Soma Ganesan, MD, FRCPC

Dr Mok is a consultant psychiatrist at Vancouver General Hospital and clinical assistant professor in the Department of Psychiatry, University of British Columbia. Dr Lai is an associate professor in the Faculty of Social Work, University of Calgary. Mr Lin and Ms Wong are medical students at UBC. Dr Ganesan is the medical director of CPU Psychiatry at the Vancouver General Hospital and a clinical professor in the Department of Psychiatry, UBC.