Culturally Adapted Cognitive Behaviour Therapy (CaCBT) to Improve Community Mental Health Services for Canadians of South Asian Origin: A Qualitative Study.

BACKGROUND: South Asian (SA) Canadians are disproportionately affected by higher rates of mood and anxiety disorders. SA Canadians with depression report significant barriers to accessing mental health care and the highest proportion of unmet mental health needs. The Mental Health Commission of Canada (MHCC) advocates for culturally and linguistically relevant services for SA Canadians. Culturally adapted cognitive behavior therapy (CaCBT) has shown to be more effective than standard cognitive behavior therapy (CBT). Adapting CBT for the growing SA population in Canada will ensure equitable access to effective, culturally-appropriate mental health interventions. METHOD: The study used a qualitative design to elicit stakeholder consultation via in-depth interviews. This study is reported using the criteria included in Consolidated Criteria for Reporting Qualitative Studies (COREQ). The analysis follows an ethnographic approach and was informed by the principles of emergent design. RESULTS: Five themes were identified from the analysis, (i) Awareness and preparation: factors that impact the individual's understanding of therapy and mental illness. (ii) Access and provision: SA Canadians' perception of barriers, facilitators, and access to treatment. (iii) Assessment and engagement: experiences of receiving helpful treatment. (iv) Adjustments to therapy: modifications and suggestions to standard CBT. (v) Ideology and ambiguity: racism, immigration, discrimination, and other socio-political factors. CONCLUSIONS: Mainstream mental health services need to be culturally appropriate to better serve SA Canadians experiencing depression and anxiety. Services must understand the family dynamics, cultural values and socio-political factors that impact SA Canadians to reduce attrition rates in therapy.

Neighbourhood-level social capital, marginalisation, and the incidence of schizophrenia and schizoaffective disorder in Toronto, Canada: a retrospective population-based cohort study.

BACKGROUND: Studies have shown mixed results regarding social capital and the risk of developing a psychotic disorder, and this has yet to be studied in North America. We sought to examine the relationship between neighbourhood-level marginalisation, social capital, and the incidence of schizophrenia and schizoaffective disorder in Toronto, Canada. METHODS: We used a retrospective population-based cohort to identify incident cases of schizophrenia and schizoaffective disorder over a 10 year period and accounted for neighbourhood-level marginalisation and a proxy indicator of neighbourhood social capital. Mixed Poisson regression models were used to estimate adjusted incidence rate ratios (aIRRs). RESULTS: In the cohort (n = 649 020) we identified 4841 incident cases of schizophrenia and schizoaffective disorder. A 27% variation in incidence was observed between neighbourhoods. All marginalisation dimensions, other than ethnic concentration, were associated with incidence. Compared to areas with low social capital, areas with intermediate social capital in the second [aIRR = 1.17, 95% confidence interval (CI) 1.03-1.33] and third (aIRR = 1.23, 95% CI 1.08-1.40) quintiles had elevated incidence rates after accounting for marginalisation. There was a higher risk associated with the intermediate levels of social capital (aIRR = 1.18, 95% CI 1.00-1.39) when analysed in only the females in the cohort, but the CI includes the possibility of a null effect. CONCLUSIONS: The risk of developing schizophrenia and schizoaffective disorder in Toronto varies by neighbourhood and is associated with socioenvironmental exposures. Social capital was not linearly associated with risk, and risk differs by sex and social capital quintile. Future research should examine these relationships with different forms of social capital and examine how known individual-level risk factors impact these findings.

"But I survived": A phenomenological study of the health and wellbeing of aging Black women in the Greater Toronto Area, Canada.

Studies that assess the association between race and health have focused intently on the cumulative impact of continuous exposure to racism over an extended period. While these studies have contributed significantly to the general understanding of the life experiences and health status of racialized people, few studies have explicitly bridged the experiences of aging with gender and the wide structural barriers and social factors that have shaped the lives of racialized older women. This study aimed to investigate the origins of health inequities to highlight factors that intersect to affect the health and wellbeing of older Black women across their life course. Descriptive phenomenology was used to describe older Black women's health and wellbeing, and factors that impact their health across their life course. Criteria-based sampling was used to recruit study participants (n = 27). To be eligible women needed to be 55 years or older, speak English, self-identify as a Black female, and live in the Greater Toronto Area. Data analysis was guided by phenomenology. Themes identified demonstrated that participants' health and wellbeing were influenced by gender bias, racism, abuse, and retirement later in life. Participants reported having poor mental health during childhood and adulthood due to anxiety and depression. Other chronic illnesses reported included hypertension, diabetes, and cancer. Qualitative methods provided details regarding events and exposures that illuminate pathways through which health inequities emerge across the life course.

The Incidence of Psychotic Disorders and Area-level Marginalization in Ontario, Canada: A Population-based Retrospective Cohort Study.

BACKGROUND: There is limited Canadian evidence on the impact of socio-environmental factors on psychosis risk. We sought to examine the relationship between area-level indicators of marginalization and the incidence of psychotic disorders in Ontario. METHODS: We conducted a retrospective cohort study of all people aged 14 to 40 years living in Ontario in 1999 using health administrative data and identified incident cases of psychotic disorders over a 10-year follow-up period. Age-standardized incidence rates were estimated for census metropolitan areas (CMAs). Poisson regression models adjusting for age and sex were used to calculate incidence rate ratios (IRRs) based on CMA and area-level marginalization indices. RESULTS: There is variation in the incidence of psychotic disorders across the CMAs. Our findings suggest a higher rate of psychotic disorders in areas with the highest levels of residential instability (IRR = 1.26, 95% confidence interval [CI], 1.18 to 1.35), material deprivation (IRR = 1.30, 95% CI, 1.16 to 1.45), ethnic concentration (IRR = 1.61, 95% CI, 1.38 to 1.89), and dependency (IRR = 1.35, 95% CI, 1.18 to 1.54) when compared to areas with the lowest levels of marginalization. Marginalization attenuates the risk in some CMAs. CONCLUSIONS: There is geographic variation in the incidence of psychotic disorders across the province of Ontario. Areas with greater levels of marginalization have a higher incidence of psychotic disorders, and marginalization attenuates the differences in risk across geographic location. With further study, replication, and the use of the most up-to-date data, a case may be made to consider social policy interventions as preventative measures and to direct services to areas with the highest risk. Future research should examine how marginalization may interact with other social factors including ethnicity and immigration.

Inequities in the delivery of mental health care: a grounded theory study of the policy context of primary care.

BACKGROUND: Strengthening capacity for mental health in primary care improves health outcomes by providing timely access to coordinated and integrated mental health care. The successful integration of mental health in primary care is highly dependent on the foundation of the surrounding policy context. In Ontario, Canada, policy reforms in the early 2000's led to the implementation of a new interprofessional team-model of primary care called Family Health Teams. It is unclear the extent to which the policy context in Ontario influenced the integration of mental health care in Family Health Teams emerging from this period of policy reform. The research question guiding this study was: what were key features of Ontario's policy context that influenced FHTs capacity to provide mental health services for mood and anxiety disorders? METHODS: A qualitative study informed by constructivist grounded theory. Individual interviews were conducted with executive directors, family physicians, nurse practitioners, nurses, and the range of professionals who provide mental health services in interprofessional primary care teams; community mental health providers; and provincial policy and decision makers. We used an inductive approach to data analysis. The electronic data management programme NVivo11 helped organise the data analysis process. RESULTS: We conducted 96 interviews with 82 participants. With respect to the contextual factors considered to be important features of Ontario's policy context that influenced primary care teams' capacity to provide mental health services, we identified four key themes: i) lack of strategic direction for mental health, ii) inadequate resourcing for mental health care, iii) rivalry and envy, and, iv) variations across primary care models. CONCLUSIONS: As the first point of contact for individuals experiencing mental health difficulties, primary care plays an important role in addressing population mental health care needs. In Ontario, the successful integration of mental health in primary care has been hindered by the lack of strategic direction, and inconsistent resourcing for mental health care. Achieving health equity may be stunted by the structural variations for mental health care across Family Health Teams and across primary care models in Ontario.

Global Climate Implications for Homelessness: A Scoping Review.

Homelessness is a persistent global challenge with significant health impacts on those affected. Homeless people are by definition the most exposed to weather conditions and the social and economic problems caused by extreme weather and climate change and variability. This systematic review was designed to synthesize the academic literature that addresses the health and social implications of global climate change for homelessness. The question examined in this systematic scoping review is the following: What is the current state of knowledge in the scientific literature on the health and social implications of global climate change for homelessness? A systematic scoping review method was used to identify and synthesize the peer-reviewed literature relevant to this question. The databases searched were PsycINFO, Medline, Scopus, and Google Scholar. Of the 26 papers identified in this review, 20 employed original data analyses with conclusions largely inferred from cross-sectional associations. Themes included the potential influence of climate change on homelessness prevalence, climate impacts that exacerbate specific vulnerabilities of homeless populations (e.g., chronic illness, exposure, stigmatization), and health and social outcomes. Service use and design implications were also addressed. Given the scale of the impacts of climate change on homelessness, the literature on this topic poses promising directions but is under-developed in its current state to adequately inform risk mitigation and response planning. A systems framework is proposed here to inform future research and service design.

Guidelines for Training in Cultural Psychiatry.

This position paper has been substantially revised by the Canadian Psychiatric Association (CPA)'s Section on Transcultural Psychiatry and the Standing Committee on Education and approved for republication by the CPA's Board of Directors on February 8, 2019. The original position paper1 was first approved by the CPA Board on September 28, 2011.

Patient perspectives on quality of care for depression and anxiety in primary health care teams: A qualitative study.

BACKGROUND: Widespread policy reforms in Canada, the United States and elsewhere over the last two decades strengthened team models of primary care by bringing together family physicians and nurse practitioners with a range of mental health and other interdisciplinary providers. Understanding how patients with depression and anxiety experience newer team-based models of care delivery is essential to explore whether the intended impact of these reforms is achieved, identify gaps that remain and provide direction on strengthening the quality of mental health care. OBJECTIVE: The main study objective was to understand patients' perspectives on the quality of care that they received for anxiety and depression in primary care teams. METHODS: This was a qualitative study, informed by constructivist grounded theory. We conducted focus groups and individual interviews with primary care patients about their experiences with mental health care. Focus groups and individual interviews were recorded and transcribed verbatim. Grounded theory guided an inductive analysis of the data. RESULTS: Forty patients participated in the study: 31 participated in one of four focus groups, and nine completed an individual interview. Participants in our study described their experiences with mental health care across four themes: accessibility, technical care, trusting relationships and meeting diverse needs. CONCLUSION: Greater attention by policymakers is needed to strengthen integrated collaborative practices in primary care so that patients have similar access to mental health services across different primary care practices, and smoother continuity of care across sectors. The research team is comprised of individuals with lived experience of mental health who have participated in all aspects of the research process.

Depression-level symptoms among Syrian refugees: findings from a Canadian longitudinal study.

BACKGROUND: Canada launched the Syrian Refugee Resettlement Initiative in 2015 and resettled over 40,000 refugees. AIM: To evaluate the prevalence of depression-level symptoms at baseline and one year post-resettlement and analyze its predictors. METHODS: Data come from the Syrian Refugee Integration and Long-term Health Outcomes in Canada study (SyRIA.lth) involving 1924 Syrian refugees recruited through a variety of community-based strategies. Data were collected using structured interviews in 2017 and 2018. Depression symptoms were measured using Patient Health Questionnaire 9 (PHQ-9). Analysis for associated factors was executed using multinomial logistic regression. RESULTS: Mean age was 38.5 years (SD 13.8). Sample included 49% males and 51% females settled in Ontario (48%), Quebec (36%) and British Columbia (16%). Over 74% always needed an interpreter, and only 23% were in employment. Prevalence of depression-level symptoms was 15% at baseline and 18% in year-2 (p < 0.001). Significant predictors of depression-level symptoms at year-2 were baseline depression, sponsorship program, province, poor language skills, lack of satisfaction with housing conditions and with health services, lower perceived control, lower perceived social support and longer stay in Canada. CONCLUSION: Increase in depression-level symptoms deserves attention through focusing on identified predictors particularly baseline depression scores, social support, perceived control and language ability.

Social capital and psychosis: a scoping review.

PURPOSE: Social capital has been studied as a risk factor for psychotic disorders. The purpose of this scoping review was to scope the literature and synthesize findings on the association between social capital and psychosis. METHODS: Three electronic databases were searched to identify relevant studies. Studies were included if they examined the association between social capital and either diagnosed psychotic disorders or symptoms of psychosis. RESULTS: Of 191 studies reviewed, 12 met the inclusion criteria. Ten studies measured social capital at the ecological level. Seven studies focused on risk of psychotic disorders or symptoms of psychosis, three studies focused on course of psychotic illness, and two studies focused on both risk and course of illness. A variety of social capital measures were used including scales, surveys, and census-based measures. The association between social capital and both the incidence of psychosis and patterns of service use varied based on measures used and study population. There was no association between social capital and recovery or duration of untreated illness. CONCLUSIONS: Prior literature has examined the impact of social capital on the incidence of psychotic disorders, as well as symptoms and course of illness. Based on the scant literature to date, it is difficult to make firm conclusions regarding the role of social capital in psychotic disorders. Heterogeneous measures of social capital make comparisons between studies challenging. Further specificity in measuring and defining dimensions of social capital is required for meaningful study of social capital and its association with psychotic disorders.

Austerity and COVID-19.

A scientific paper published in the BMJ Open made international headlines by claiming that austerity policies led to 120,000 deaths in the UK (Watkins et al. 2017).

Towards Understanding the Relationship Between Psychosocial Factors and Ego Resilience Among Primary School Children in a Kenyan Setting: A Pilot Feasibility Study.

Ego resilience in childhood is linked to positive mental health outcomes but varies across cultures. Kenya presents a unique context in which children are vulnerable to adversity. We therefore hypothesized that Ego resilience traits are found in Kenya. We aimed to: (i) demonstrate Ego resilience in Kenya, (ii) determine associated social-demographic and psychological factors in a non-clinical population of primary school going children, (iii) contribute to the global data base with Kenyan data and (iv) lay the grounds for informed future and more focused studies in Kenya. We used a socio-demographic questionnaire, Ego Resilience scale (ER-89) and the Youth Self Report (YSR). Multivariate analyses showed the only independent predictors of Ego resilience were female gender (p < 0.001) and peri-urban region (p < 0.001). We did not find any association between Ego resilience and YSR syndrome scores in this non-clinical population study. We achieved our aims.

Psychological capital and life satisfaction of refugees in Canada: Evidence from a community-based educational support program.

Drawing on a 2-year community-based participatory research project, and grounded in the theories of positive psychology, this article examines the effects of targeted educational support on refugee participants' psychological capital (PsyCap)-hope, self-efficacy, resilience, and optimism-as well as life satisfaction. Two groups of participants attended a 14-week trauma-informed, educational support program in 2 consecutive sessions. The program was designed in collaboration with George Brown College, the Centre for Addiction and Mental Health, Wellesley Institute, and the Canadian Centre for Victims of Torture. The study aimed to understand the link between psychological capital and life satisfaction among refugees. Findings show that the participants' psychological capital-particularly PsyCap-resilience and PsyCap-optimism-improved consistently, which in turn was reflected in the participants' improved life satisfaction. The result also indicated a relationship between the four main characteristics of psychological capital and life satisfaction. We conclude that these indications of a potential positive association between refugees' psychological capital and life satisfaction should be further examined.

Gender role strain, core schemas, and psychotic experiences in ethnically diverse women: A role for sex- and gender-based analysis in psychosis research?

Negative -self and -others core schemas have been implicated in the development and maintenance of psychotic experiences. One component of the self-system is gender-role strain (GRS; perceived discrepancy between actual self and gender-role norms). Although the role of gender in the formation of core schemas has been underscored in social and developmental psychology literatures, GRS has not been investigated in relation to psychosis. We examined whether it might be associated with negative schemas and psychotic experiences in women consistent with the trend toward sex- and gender-based analysis (SGBA) in health research. Forty-four women with a schizophrenia spectrum disorder diagnosis and 48 female nonclinical participants completed a series of questionnaires measuring GRS, femininity ideology, core schemas, childhood trauma, and implicit femininity stereotypes (The Gender Stereotype Implicit Association Test). Half the total sample comprised women with minority-ethnic status. Women in the psychosis group reported higher levels of GRS than comparison participants. Differences in endorsement of femininity ideology between the two groups narrowly missed significance with a trend toward greater femininity ideology in the psychosis group and significantly greater endorsement of the sexual purity domain for minority-ethnic women. There was no difference in implicit femininity stereotypes. Analyses suggested that the relationship between GRS and symptoms was mediated by negative -self and -others schemas. Childhood sexual trauma, though higher for women with psychosis, was associated with gender-role strain in the nonclinical sample only. Findings warrant further investigation with larger samples. SGBA has the potential to fill gaps in our current knowledge with regard to psychosis theory, research, and practice.

Psychosocial stressors contributing to emergency psychiatric service utilization in a sample of ethno-culturally diverse clients with psychosis in Toronto.

BACKGROUND: Understanding the psychosocial stressors of people with psychoses from minority ethnic groups may help in the development of culturally appropriate services. This study aimed to compare psychosocial factors associated with attendance at an emergency department (ED) for six ethnic groups. Preventing crises or supporting people better in the community may decrease hospitalization and improve outcomes. METHOD: A cohort was created by retrospective case note analysis of people of East-Asian, South-Asian, Black-African, Black-Caribbean, White-North American and White-European origin groups attending a specialized psychiatric ED in Toronto with a diagnosis of psychosis between 2009 and 2011. The psychological or social stressors which were linked to the presentation at the ED that were documented by the attending physicians were collected for this study. Logistic regression models were constructed to analyze the odds of presenting with specific stressors. RESULTS: Seven hundred sixty-five clients were included in this study. Forty-four percent of the sample did not have a psychiatrist, and 53% did not have a primary care provider. Social environmental stressors were the most frequent psychosocial stressor across all six groups, followed by issues in the primary support group, occupational and housing stressors. When compared to White-North American clients, East-Asian and White-European origin clients were less likely to present with a housing stressor, while Black-African clients had decreased odds of presenting with primary support group stressor. Having a primary care provider or psychiatrist were predominantly protective factors. CONCLUSION: In Toronto, moving people with chronic mental health conditions out of poverty, increasing the social safety net and improving access to primary care and community based mental health services may decrease many of the stressors which contribute to ED attendance.

The role of ethnicity in pathways to emergency psychiatric services for clients with psychosis.

BACKGROUND: This study investigates the role of ethnicity in pathways to emergency mental health care in Toronto for clients with psychosis, while taking into account neighborhood factors. Previous literature has focused on Afro-Caribbean clients, reporting an increased risk of accessing mental health care through negative pathways. METHODS: A retrospective chart review for clients from 6 different ethnic origin groups presenting with psychosis - East Asian, South Asian, Black African, Black Caribbean, White European, and White North American - was undertaken in a psychiatric emergency department (ED). Logistic regression models were constructed to examine the relationship between pathways to care (involuntary detention under the Mental Health Act (MHA), police or ambulance referral, accompaniment by family or friends) with individual and neighbourhood factors. RESULTS: A total of 765 clients were included in the study. East Asian (OR =2.36, p < 0.01) and South Asian (OR 2.99, p < 0.01) origin clients have increased odds of presenting to the ED while involuntarily detained under the MHA. Involuntary status under the MHA increased the odds of presenting via police or ambulance (OR 8.27, p < 0.001). East Asian origin clients have increased odds of presenting to the ED by police or ambulance (OR =2.10, p < 0.05). Clients from neighbourhoods with higher levels of residential instability have increased odds of presenting by police or ambulance (OR =1.35, p < 0.01), while clients from neighbourhoods with higher levels of ethnic concentration have increased odds of being accompanied to the ED by family or friends (OR =1.33, p < 0.01). CONCLUSION: In contrast to previous studies, East Asian and South Asian origin clients with psychosis have increased odds of a coercive pathway to emergency psychiatric services in Toronto. Black African and Black Caribbean origin clients do not have increased odds of a coercive pathway. Clients living in areas with high levels of residential instability are more likely to encounter a negative pathway. Ethnic concentration may be a supportive factor in family and friend accompaniment.