Recognizing and appropriately treating mental health problems among new immigrants and refugees in primary care poses a challenge because of differences in language and culture and because of specific stressors associated with migration and resettlement. We aimed to identify risk factors and strategies in the approach to mental health assessment and to prevention and treatment of common mental health problems for immigrants in primary care.
We searched and compiled literature on prevalence and risk factors for common mental health problems related to migration, the effect of cultural influences on health and illness, and clinical strategies to improve mental health care for immigrants and refugees. Publications were selected on the basis of relevance, use of recent data and quality in consultation with experts in immigrant and refugee mental health.
The migration trajectory can be divided into three components: premigration, migration and postmigration resettlement. Each phase is associated with specific risks and exposures. The prevalence of specific types of mental health problems is influenced by the nature of the migration experience, in terms of adversity experienced before, during and after resettlement. Specific challenges in migrant mental health include communication difficulties because of language and cultural differences; the effect of cultural shaping of symptoms and illness behaviour on diagnosis, coping and treatment; differences in family structure and process affecting adaptation, acculturation and intergenerational conflict; and aspects of acceptance by the receiving society that affect employment, social status and integration. These issues can be addressed through specific inquiry, the use of trained interpreters and culture brokers, meetings with families, and consultation with community organizations.
Systematic inquiry into patients' migration trajectory and subsequent follow-up on culturally appropriate indicators of social, vocational and family functioning over time will allow clinicians to recognize problems in adaptation and undertake mental health promotion, disease prevention or treatment interventions in a timely way.
This paper reports results from the evaluation of a cultural consultation service (CCS) for mental health practitioners and primary care clinicians. The service was designed to improve the delivery of mental health services in mainstream settings for a culturally diverse urban population including immigrants, refugees, and ethnocultural minority groups. Cultural consultations were based on an expanded version of the DSM-IV cultural formulation and made use of cultural consultants and culture brokers.
We documented the service development process through participant observation. We systematically evaluated the first 100 cases referred to the service to establish the reasons for consultation, the types of cultural formulations and recommendations, and the consultation outcome in terms of the referring clinician's satisfaction and recommendation concordance.
Cases seen by the CCS clearly demonstrated the impact of cultural misunderstandings: incomplete assessments, incorrect diagnoses, inadequate or inappropriate treatment, and failed treatment alliances. Clinicians referring patients to the service reported high rates of satisfaction with the consultations, but many indicated a need for long-term follow-up.
The cultural consultation model effectively supplements existing services to improve diagnostic assessment and treatment for a culturally diverse urban population. Clinicians need training in working with interpreters and culture brokers.
The Working with Culture seminar is offered as a course during the month long Annual McGill Summer Program for Social and Transcultural Psychiatry, attended by local and international participants each May since 1994. The article outlines some of the premises and pedagogical approaches of this clinically oriented biweekly seminar series with discussions and didactic teaching on cultural dimensions of mental health care. The course readings, seminar topics and invited speakers focus mainly on therapist client encounters constructed by the multiple voices with dimensions of psychiatric, social, historical, legal, ethical, political, systemic and intra-psychic domains. The dual leadership emphasizes the gaps and complementarity amongst voices, and it invites and supports a destabilizing decentering process and the creation of solidarities amongst participants. Applying a bio-psychosocial case study method, each 3-h seminar engages the participants in a critical dialogue on apprehending the enmeshment of social suffering with psychiatric disorders whilst examining the usefulness and the limits of cultural formulation models. The seminar working group and teaching approach acknowledges cultural hybridity as a dynamic process marked by continuous therapist attunement to uncertainty or 'not knowing' which implies a dethroning of an expert position.
Comment In: Cult Med Psychiatry. 2013 Jun;37(2):390-723564248