Research Projects 2004-2005
The development and evaluation of an intervention aimed at improving the mental health of a group of refugee women presenting to the Royal Women's Hospital for obstetric care.
Investigators:
Dr Schwarz, R.G., Royal Women's Hospital; Dr Fisher, J., Key Centre for Women's Health in Society, University of Melbourne, A/Professor Minas, I.H., CIMH
Funding body: beyondblue
Women refugees present many complex physical, social and psychological problems and are recognised as being at increased risk of long term physical and psychiatric morbidity. There is evidence that two thirds of refugees experience anxiety or depression. The refugee experience and the experience of trauma and torture often associated with it have profound effects on the individual, the family and the community. In addition to the acute trauma reaction there can be delayed onset of psychiatric disorders or emotional distress. Despite this, many refugee groups have little or no comprehension of emotional responses. There may be no cultural concept, for instance of depression or mood illness. Psychiatric diagnosis or treatment may best be seen as useless and at worst seen as threatening. Somatization is common, with emotional distress presenting as physical symptoms. As a result they rarely seek active treatment for emotional problems. Treatment is often precipitated by crisis or the needs of practical interventions.
Pregnancy and the post natal period are times of increased emotional vulnerability and lability for all women. It is also a time when women have contact with the health care system and are therefore available for intervention should that be deemed appropriate. Refugee women are in the very high risk group for post natal depression.
This study deals with a group of Iraqi women, who come from a Middle Eastern culture and have fled from a country with a prolonged history of social dislocation, war and violent and repressive regime. It can be anticipated that Iraqi women presenting for antenatal care in Australia will almost all be refugees, asylum seekers or those who have fled under duress although not officially meeting the criteria for refugee status.
This project will:
- identify a group of refugee women presenting for obstetric care at the Royal Women's Hospital who are likely to be at heightened psychiatric risk,
- develop specific interventions appropriate to the obstetric care setting, which are aimed at improving mental health outcomes for these women, their families, and therefore providing long term benefits to the community,
- evaluate the acceptability of these interventions to the women, their partners and the obstetric treating team,
- evaluate the effect of the interventions on the mental health status of the women, in the post natal period.
- increase the awareness in the obstetric treatment team of the impact of the womenâs culture and experiences as a refugee on their psychological health and their physical health,
- evaluate the connection of physical complaints during pregnancy (eg. for pain) and to determine if somatic complaints are associated with mental health problems, and
- evaluate the effect of the interventions on the understanding of the obstetric team of the significance of a biopsychological approach to providing obstetric care to refugee women.
The Emotional and Lifestyle Impact of Type 2 Diabetes: Exploring the association between diabetes and depression
Investigators:
Professor Manderson, L., The Key Centre for Women's Health in Society, University of Melbourne; Dr Kokanovic, R. CIMH; A/Professor Klimidis, S., CIMH
Funding body: beyondblue
Little attention has been paid to the links between disability and degenerative conditions, depression and well-being, or on how depression might complicate adaptation and adjustment in the event of chronic illness, either for a majority population or for particular communities, nor research on how socio-cultural factors might influence the management of the two. This is despite recognition of the role of cultural diversity in physical and mental health and its impact on access to and use of health services.
Chronic disease can affect individuals psychologically, personally and socially, and managing an ongoing condition requires considerable adjustment. The relationship of chronic illness and depression remains to be tested. Our interest is to explore popular understandings of chronic health, using diabetes as the example, and on individual management of the condition and its complications, and concurrently assessing the mental health status of individuals with diabetes. Due to different understandings of the condition, the project will explore differences by socioeconomic and cultural background to adjustment to diagnosis, the maintenance of its regular management including through diet and effective treatment adherence, and vulnerability to complications over the longer term, and the impact of the condition on an individual's mental, emotional and social life. There are added complexities in relation to how socio-cultural factors affect depressive status, including the nature of its experience, its expressions, pathways to care, and attitudes towards illness. An aim of this project is to explore how such divergence might be understood, and how this understanding might provide a basis for the development of appropriate interventions.
The project will describe and analyse social aspects of co-morbidity in depression and chronic illness (diabetes), and the extent to which personal, cultural and socio-demographic factors influence the impact by:
- describing and analysing lay understandings of the causes of diabetes and depression,
- comparing experiences, life adjustments and resilience by gender, age and ethno-cultural background, including the personal, social, economic and gender factors that influence adaptation and adjustment,
- examining the role of social support (formal and informal), including social networks and family care giving, and
- examining the role of medical support in managing depression and diabetes within a diversity framework.
Caring for the depressed elderly in the emergency department:
Establishing linkages between sub-acute, primary and community care
Investigators:
Dr Joubert, L., School of Social Work, University of Melbourne; Dr Hunter, P. & Ms Anderson, P., Integrated and Sub-acute Care Directorate, St Vincent's Health ; A/Professor Klimidis, S., CIMH ; Prof Dent, A., Emergency Department, St Vincent's Health, Prof Chiu, E., Department of Geriatric Psychiatry, St Vincent's Health; Dr Isaac, D., GP Consultant, St Vincent's Health
Funding body: beyondblue
Depression in the elderly has been found to be associated with social isolation, carer stress, multiple health issues and barriers to effective access of community resources. A recent data-mining analysis of elderly patients presenting with multiple problems at St Vincent's Health found that although the majority were living alone ( 44%) with 29%living with a primary carer, minimal attention was paid to carer liaison issues, or linkage to community services. Appropriate management of depression in the elderly who present at emergency departments with multiple problems would appear to need an integrated approach across a continuum of care, from presentation to linkages established with primary care and community services.
Projects initiated internationally that focus on the issue of appropriate care of the elderly in emergency, have included the involvement of general practitioners, geriatricians and allied health, and have focused on integrating internal liaison with effective networking with community resources.
St Vincent 's Health has implemented three integrated care programs, ALERT (Assessing, liaison and early referral team), HiT (Holding it together) and TRAAC (Treating the elderly in the right place: facilitating appropriate community care) under the Victorian Hospital Demand Management Strategy which are of special relevance to the elderly. They have a main purpose of developing alternative treatment plans for individuals whose conditions are chronic or complex, and who present frequently at emergency departments. A major goal of the programs is to increase the use of, and linkage with primary health and community services in instances where presentation at emergency could be prevented or more appropriately provided, through timely intervention in the community.
The three projects have cut across professional and skill boundaries, focusing on an integrated systems approach to service delivery. There are no screening tools or management guidelines for depression in the protocols of these three services.
This project will:
- introduce a screening assessment for depression into existing protocols in the three integrated care programs ALERT, HiT and TRAAC at St Vincent's Health, with the aim of improving the identification of depression in the elderly who present with multiple problems at emergency,
- develop a protocol for the management of depression in the elderly who present at the emergency department at St Vincent 's Health which focuses on appropriate linkage to primary care and community resources,
- contribute to knowledge about the appropriate care of the depressed elderly who present at emergency, which would be of interest to all metropolitan hospitals nationally and internationally,
- contribute to the evidence base on key outcome indicators of the management of depression in the elderly who present at emergency, in relation to the hospital service, the patient and their carer, and community providers,
- contribute to knowledge about the social and multi-cultural factors contributing to depression in the elderly, and
- contribute to knowledge about the role and function of practitioners in the management of depression in the elderly, who work across a continuum of care from sub-acute to primary and community care.
The research will evaluate the process and outcome of an assertive outreach model for the management of depression in the elderly presenting at emergency, using a randomly selected experimental research design. The evaluation will focus on two areas: mental health outcomes (outcome evaluation) and management of depression in the elderly who present at emergency within an integrated program (process evaluation).
Research project 2003 - 2004
Mental health care in general practice – ethnic group issues study
Investigators:
A/Professor Minas, I.H., A/Professor Klimidis, S., Dr Kokanovic, R.
Funding body: beyondblue
There is significant direction by the Commonwealth Government to extend effective mental health care within General Practice (GP). Despite policy directions the effective implementation to addressing the needs of ethnic minority groups is unknown. Australia has a substantial bilingual GP workforce which could be drawn to the task of meeting the MH needs of ethnic minority groups. However the extent to which this workforce is interested, is participating and is skilled in addressing such needs is not clear. Additionally, little is known as to how monolingual English-speaking GPs are negotiating these issues.
A significant component of GP, particularly with the increasing national emphasis on community-based treatment of mental illness is dedicated to the management of mental disorders. According to the national Survey of Mental Health and Wellbeing GP is the most common pathway to mental health care with 29 pecent of community members with a mental disorder attending GP.
Little is known about the difficulties that GPs, in general, face in attempting to provide mental health care to members of ethnic minority groups confronted with possible difficulties in communication and cultural barriers. The extent to which current bilingual general practice is addressing mental health problems in these groups is unknown and what problems and preferred solutions that GPs have in this task have not been explored. The study will explore GP's interest in conducting mental health work, their ability to provide consultation in language other than English (for bi-lingual GPs), assess the proportion of mental health work within their practice, assess a frequency of common mental health disorders and other psychiatric conditions, interest and need for additional mental health training, and, general structural issues enabling mental health work in GP.
This study explores the level of mental health care conducted in bilingual and monolingual general practice in relation to patients from ethnic minority groups, the difficulties encountered, needs of practitioners, and opinions on improvements.
The study will achieve insight into the nature of general practice as it negotiates mental disorders in relation to Ethnic Minority Groups. The information to be gained is practical with the view that it can support reforms towards improved mental health care delivery to members of ethnic minority groups.
Research Project 2002 – 2003
Depression and ethnic minority communities in Australia : current situation and future perspectives
Investigators:
A/Professor Minas, I.H., A/Professor Klimidis, S., Dr Kokanovic, R.
Funding body: beyondblue
The study involved a national ‘scooping' of activities in relation to depression and ethnic minority communities. The study incorporated a systemic examination including the policy environment, Australian based research, and service provision activities.
All major relevant policies, strategic plans and related documents under the National Mental Health Strategy, both Commonwealth and State/Territory were examined for their relevance to the development of mental health responses in relation to mental disorder and specifically depression and ethnic minority communities. The analysis revealed a very progressive policy environment with respect to ethnic minority groups and the availability of a strong policy basis for the provision of culturally and linguistically appropriate service responses to members of such communities.
Examination of Australian research included identification of internationally published research literature by Australian researchers and institutions, examination of research priorities and funded research by the major funding bodies, an assessment of completed higher degree theses in Australian tertiary institutions on depression, a survey of current academic departments and research institutions in search for relevant projects incorporating ethnic minority groups in their design, and examination of existing databases that are currently available that could be used for secondary analyses to inform on issues of depression and ethnic minority communities. The main findings from the work is that Australia houses a significant number of researchers who have had experience in cross-national/cross-cultural mental health research with a predominance of work in the international setting rather with Australia's immigrant and refugee groups. Local research was focused in only a few areas including, refugee and asylum seeker issues, post-partum depression, and suicide. A number of other studies were identified on diverse issues related to mental health in ethnic minority groups, but on the whole there has not been a significant body of work that can inform on the wide range of issues affecting mental health (and less so for depression and related disorders specifically) and service delivery practice in relation to ethnic minority groups. Examination of completed higher degree theses submitted to Australian tertiary institutions over the past decade revealed only a trace number of studies with any focus on cultural factors or ethnic minority groups, highlighting the lack of experienced researchers to work with research designs complicated by cultural and linguistic diversity issues. Examination of funding processes revealed that major funding bodies (e.g., NHMRC, ARC, etc.) provided sufficient scope within their research priorities to fund relevant research in this area. In contrast there has been an insufficient number of studies funded over the past five years bearing on the issue of interest. Actual funding reflected the perpetuation of established research topics (e.g., analysis of suicide, refugee issues) with little apparent scope for expanding into the broader areas of clinical and population mental health issues relevant to ethnic minority groups.
Service delivery was examined through a national survey searching for current programs and projects. The survey included ethnic community organizations, health service providers, Divisions of General Practice, community mental health service providers, Victorian Primary Care Partnerships, departments of public health, local government, women's health services, migrant resource centres, transcultural mental health services, and refugee services. In all 1480 organizations were contacted. An effort was made to sample organizations in major regional towns as well as capital cities. The survey screened organizations for relevant programmes and if these were available it requested details for each program and any relevant documents describing the programmes to be sent to us. The overall number of relevant programmes were few (98 programmes from 91 organizations of 422 organizations) with variable focus on depression/or mental health and ethnic minority groups. Of the 98 programs 65% were specifically focused on ethnic minority groups, the rest being mainstream programmes. Relevant programmes were analysed in relation to reported activities and strategies; reported barriers; strategies and support that are required to overcome barriers, perceived role in future work on depression in ethnic minority communities, partnerships and programme involvement of ethnic minority consumers/carers/other ethnic minority community members. Qualitative analysis indicated several broad themes that need to be addressed in meeting the mental health needs of ethnic minority communities. These include ‘information needs' of organizations, ‘organizational needs' particularly in the establishment and maintenance of partnerships, ‘resource needs', and ‘process barriers' to both service delivery and engagement of ethnic communities in effective collaborations.