Laurence J. Kirmayer

The mental health of Aboriginal peoples: transformations of identity and community.

This paper reviews some recent research on the mental health of the First Nations, Inuit, and Métis of Canada. We summarize evidence for the social origins of mental health problems and illustrate the ongoing responses of individuals and communities to the legacy of colonization. Cultural discontinuity and oppression have been linked to high rates of depression, alcoholism, suicide, and violence in many communities, with the greatest impact on youth. Despite these challenges, many communities have done well, and research is needed to identify the factors that promote wellness. Cultural psychiatry can contribute to rethinking mental health services and health promotion for indigenous populations and communities.

Three forms of somatization in primary care: prevalence, co-occurrence, and sociodemographic characteristics.

Three definitions of somatization were operationalized: (a) high levels of functional somatic distress, measured by the Somatic Symptom Index (SSI) of the Diagnostic Interview Schedule; (b) hypochondriasis measured by high scores on a measure of illness worry in the absence of evidence for serious illness; and (c) exclusively somatic clinical presentations among patients with current major depression or anxiety. Of 685 patients attending two family medicine clinics, 26.3% met criteria for one or more forms of somatization. While DSM-III somatization disorder had a prevalence of only 1% in this population, 16.6% of the patients met abridged criteria for subsyndromal somatization disorder (SSI 4,6). Hypochondriacal worry had a prevalence of 7.7% in the clinic sample. Somatized presentations of current major depression or anxiety disorder had a prevalence of 8%. The three forms of somatization were associated with different sociodemographic and illness behavior characteristics. A majority of patients met criteria for only one type of somatization, suggesting that distinct pathogenic processes may be involved in each of the three types.

Common mental health problems in immigrants and refugees: general approach in primary care

Background: 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. Methods: 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. Results: 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. Interpretation: 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.

Healing Traditions: Culture, Community and Mental Health Promotion with Canadian Aboriginal Peoples:

Objective: To identify issues and concepts to guide the development of culturally appropriate mental health promotion strategies with Aboriginal populations and communities in Canada. Methods: We review recent literature examining the links between the history of colonialism and government interventions (including the residential school system, out-adoption, and centralised bureaucratic control) and the mental health of Canadian Aboriginal peoples. Results: There are high rates of social problems, demoralisation, depression, substance abuse, suicide and other mental health problems in many, though not all, Aboriginal communities. Although direct causal links are difficult to demonstrate with quantitative methods, there is clear and compelling evidence that the long history of cultural oppression and marginalisation has contributed to the high levels of mental health problems found in many communities. There is evidence that strengthening ethnocultural identity, community integration and political empowerment can contribute to improving mental health in this population. Conclusions: The social origins of mental health problems in Aboriginal communities demand social and political solutions. Research on variations in the prevalence of mental health disorders across communities may provide important information about community-level variables to supplement literature that focuses primarily on individual-level factors. Mental health promotion that emphasises youth and community empowerment is likely to have broad effects on mental health and wellbeing in Aboriginal communities.

Attributions of common somatic symptoms

Three studies explored the causal attributions of common somatic symptoms. The first two studies established the reliability and validity of a measure of attributional style, the Symptom Interpretation Questionnaire (SIQ). Three dimensions of causal attribution were confirmed: psychological, somatic and normalizing. The third study examined the antecedents and consequences of attributional style in a sample of family medicine patients. Medical and psychiatric history differentially influenced attributional style. Past history and attributional style independently influenced clinical presentations over the subsequent 6 months. Symptom attributional style may contribute to the somatization and psychologization of distress in primary care.

Explaining Medically Unexplained Symptoms

Patients with medically unexplained symptoms comprise from 15% to 30% of all primary care consultations. Physicians often assume that psychological factors account for these symptoms, but current theories of psychogenic causation, somatization, and somatic amplification cannot fully account for common unexplained symptoms. Psychophysiological and sociophysiological models provide plausible medical explanations for most common somatic symptoms. Psychological explanations are often not communicated effectively, do not address patient concerns, and may lead patients to reject treatment or referral because of potential stigma. Across cultures, many systems of medicine provide sociosomatic explanations linking problems in family and community with bodily distress. Most patients, therefore, have culturally based explanations available for their symptoms. When the bodily nature and cultural meaning of their suffering is validated, most patients will acknowledge that stress, social conditions, and emotions have an effect on their physical condition. This provides an entree to applying the symptom-focused strategies of behavioural medicine to address the psychosocial factors that contribute to chronicity and disability.

Cultural variations in the response to psychiatric disorders and emotional distress

Culture influences the experience and expression of distress from its inception. While Western psychiatry has identified several universal patterns of distress, there are significant geographical variations in the prevalence, symptomatology, course and outcome of psychiatric illness. Indirect evidence suggests that cultural differences in the recognition, labelling and interpretation of deviant behaviour affect the outcome of major psychiatric disorders as well as milder forms of distress. Emotion theory and the cultural concept of the person provide links between social and cognitive processes that contribute to the natural history of emotional distress. However, many current studies of ethnopsychology confound psychology (mechanisms of behaviour) and meta-psychology (theories of the self). Further advances in understanding the impact of culture on distress depend on the development of psychological and social theory that is neither ethnocentric nor naive about the wellsprings of action. Three arenas for further study are identified: (1) the handling of the gap between experience and expression; (2) the labelling of deviant behaviour and distress as voluntary or accidental; and, (3) the interpretation of symptoms as symbols or as meaningless events. Attention to these themes can guide re-thinking the assumptions of Western psychological and social theory.

Evidence-based clinical guidelines for immigrants and refugees

(see Appendix 2, available at [www.cmaj.ca/lookup/suppl/doi:10.1503/cmaj.090313/-/DC1][1] for summary of recommendations and clinical considerations) There are more than 200 million international migrants worldwide,[1][2] and this movement of people has implications for individual and

Fatigue in primary care: prevalence, psychiatric comorbidity, illness behavior, and outcome.

Objectives:To identify the prevalence, psychiatric comorbidity, illness behavior, and outcome of patients with a presenting complaint of fatigue in a primary care setting.Methods:686 patients attending two family medicine clinics on a self-initiated visit completed structured interviews for presenting complaints, self-report measures of symptoms and hypochondriasis, and the Diagnostic Interview Schedule (DIS). Fatigue was identified as a primary or secondary complaint from patient reports and questionnaires completed by physicians.Results:Of the 686 patients, 93 (13.6%) presented with a complaint of fatigue. Fatigue was the major reason for consultation of 46 patients (6.7%). Patients with fatigue were more likely to be working full or part time and to be French Canadian, but did not differ from the other clinic patients on any other sociodemographic characteristic or in health care utilization. Patients with fatigue received a lifetime diagnosis of depression or anxiety disorder more frequently than did other clinic patients (45.2% vs. 28.2%). Current psychiatric diagnoses, as indicted by the DIS, were limited to major depression, diagnosed for 16 (17.2%) fatigue patients. Patients with fatigue reported more medically unexplained physical symptoms, greater perceived stress, more pathologic symptom attributions, and greater worries about having emotional problems than did other patients. However, only those fatigue patients with coexisting depressive symptoms differed significantly from nonfatigue patients. Patients with fatigue lasting six months or longer compared with patients with more recent fatigue had lower family incomes and greater hypochondriacal worry. Duration of fatigue was not related to rate of current or lifetime psychiatric disorder. One half to two thirds of fatigue patients were still fatigued one year later.Conclusions:In a primary care setting, only those fatigue patients who have coexisting psychological distress exhibit patterns of abnormal illness cognition and behavior. Regardless of the physical illnesses associated with fatigue, psychiatric disorders and somatic amplification may contribute to complaints of fatigue in less than 50% of cases presented to primary care.

Somatoform disorders : Personality and the social matrix of somatic distress

Personality traits that may contribute to somatization are reviewed. Negative affectivity is associated with high levels of both somatic and emotional distress. Agreeableness and conscientiousness may influence interactions with health care providers that lead to the failure of medical reassurance to reduce distress. Absorption may make individuals more liable to focus attention on symptoms and more vulnerable to suggestions that induce illness anxiety. More proximate influences on the selective amplification of somatic symptoms include repressive style, somatic attributional style, and alexithymia; however, data in support of these factors are scant. Most research on somatoform disorders confounds mechanisms of symptom production with factors that influence help seeking. Longitudinal community studies are needed to explore the interactions of personality with illness experience and the stigmatization of medically unexplained symptoms.