How public health should address high rates of mental illness in South Asian communities in Canada

It is imperative to address why some populations benefit from health services, while others do not. One example is the persisting low mental health rates among South Asian (SA) groups in Canada, which are significantly due to a lack of service uptake stemming from cultural barriers and lack of trust in the Western health care system. Given that strides have been made in ensuring mental illness awareness and healthcare opportunities, targeted solutions are needed to increase the use of mental health services by SA communities and other racialized populations. 

The Statistics Canada Community Health Survey shows that compared to other ethnic groups, SAs have the lowest rate of seeking treatment for depression (Gadalla, 2010). Further research was prompted by the 2002 Canadian Community Health Survey and included 36,984 Canadian respondents age 15 and older. Compared to White groups, SAs had the lowest odds of getting treatment, followed by Japanese, Chinese, Koreans, and Blacks (Gadalla, 2010). Among individuals who had Major Depressive Episode (MDE), Black groups reported the lowest rate (25.1%) and SAs reported the highest rate (48.2%). Additionally, SAs reported the highest rate of availability barriers (33.3%), compared to Japanese/Chinese/Koreans (2.9%), Aboriginals (5.3%), and Whites (6.3%). An additional survey of SA senior citizens in Calgary discovered that rates of depression were 21%, more than twice the 10% national average for Canada (Islam et al., 2014). A study in Vancouver estimated that between 647 and 1,311 SA women had at least one MDE within a year, based on the national prevalence rates for depression among SA women (Basi, 2013).

A key driver behind these figures is the underutilization of mental health services by SAs, which has been made worse by a lack of culturally competent service providers and a neglect for SA geographic, religious, social, and cultural needs (Thomson, Chaze, George & Guruge, 2015). Low income, language barriers, perceived racism, and the unavailability of culturally sensitive services all contribute to SA populations’ reluctance to seek mental health care. In Toronto, SA communities have commonly identified mental health as highly stigmatized and silenced (Gadalla, 2010). SAs in Toronto claim that tensions between the first- and second-generation communities have created stress, anxiety, and identity loss (Islam et al, 2014). As a result, families are discouraged from obtaining mental health services due to the stigma associated with mental illness and the shame it causes (Gadalla, 2010). 

Underutilization of mental health services by SAs has been especially prevalent in Vancouver (Basi, 2013). Qualitative studies in Vancouver revealed that many SA women favoured alternative therapies over mental health services (Basi, 2013). The Interagency Mental Health Council discovered that only 54.5% of the region's total SA population was reflected in the caseload of the Greater Vancouver Mental Health Services (GVMHS) (Basi, 2013). The utilization rate shows that White Canadians used GVMHS more frequently than SA and Chinese groups. (Basi, 2013). Further, stigma, lack of awareness, family obligations, language barriers, and lack of culturally appropriate services were identified as primary causes for SA women in Vancouver who had depression, of underutilizing mental health services (Basi, 2013).

Due to these reasons, the underutilization of mental health services for SA groups remains a fundamental public health concern. Culturally competent services are a solution that must tailor services to SA groups’ unique needs. 

What do culturally competent mental health and wellness strategies look like?

Religious and cultural needs are often overlooked by healthcare facilities and providers, which leads to the dismissal of health issues, disorganized integration of various services, and pervasive stigma (Islam et al., 2022). A study conducted on service providers for mental health care of SA youth in the Peel Region found that youth and parents frequently harbour mistrust of Western psychiatry and psychotropic drugs (Islam et al., 2022). SA youth also believed that the Cognitive Behavioural Therapy (CBT) treatment approach disregarded their experiences. Instead of emphasising only individualistic behavioural change and goal setting, recommendations were made for more personal narrative-sharing within CBT and for consideration of the interdependent family life structure of SA youth.

This situation has begun to change as of March 2023, with the release of research on Culturally Adapted Cognitive Behavioural Therapy (CACBT) for Canadians of South Asian Origins conducted by the Centre for Addiction and Mental Health (CAMH) alongside the Mental Health Commission of Canada (MHCC). Building on numerous studies showing the effectiveness of CBT for treating mental illness, the study drew on SA community members and organizations to thoroughly understand the experiences, cultural values and opinions of SA groups experiencing mental illness. It then developed a culturally tailored approach to address mental illness in SA populations, which has proven to be more effective than standard CBT in treating anxiety and depression among SA populations. Participants of the study who received CACBT reported experiencing lower levels of mental illness and higher self-reported overall health than those receiving standard CBT. This innovation is ground-breaking in developing health treatments that are culturally tailored to Canada's diverse groups. 

Culturally adapted approaches can, however, raise concerns. These include whether reliance on culturally adapted experiences and beliefs can risk legitimizing problematic communal norms, such as gender inequalities. Alongside providing services that are more culturally competent, it is crucial not to endorse problematic norms. To prevent imposing viewpoints reflecting the biases of a particular demographic, it is important to pay attention to how information is gathered from the community and from which of its member sub-populations.

Next steps for culturally appropriate mental wellness promotion by public health

Despite these challenging issues needing attention, some paths forward are clear. In proposing solutions to improve mental health service utilization, it is crucial to recognise SA groups’ distinct needs, social determinants of health, and values that are important to them. Next steps include: 

• Health workers should be educated in caring for mental health concerns and interacting with patients in a culturally sensitive way. 
• Develop educational workshops for service providers (including those from SA backgrounds) to improve their cultural competency and prepare them for SA needs. 
• The elderly, who have a significant impact on decisions about health care options in SA households, can be best targeted for health advocacy through ethnic media. 
• Ensure that social media outlets use trusted experts to reach SA groups.
• Target diverse generational groups to promote behaviour change by working with well-known SA television channels such as GEOTV, ARYNEWS, and popular drama serials. 
• Community-based programs are necessary to empower community representation in the field of mental health and educate the community through both a medically and culturally informed perspective. 
• Develop culturally appropriate programs (such as the CACBT tool) that incorporate deeply rooted cultural values, while also integrating western medicine. 
• Involve the community itself in decision-making and policy work.

Rida is an MPH student (University of Waterloo) and the Assistant Manager of Operations at CareKW

REFERENCES

Basi, S. (2013). Suffering in silence: Understanding the underutilization of mental health services among South Asian women with depression.
Centre for Addiction and Mental Health. (2023, March 07). CAMH shares new evidence-based tools and training to support mental health of Canadians of South Asian origin. Retrieved March 7, 2023.
Gadalla, T. M. (2010). Ethnicity and seeking treatment for depression: a Canadian national study. Canadian Ethnic Studies, 41(3), 233-245.
Islam, F., Qasim, S., Ali, M., Hynie, M., Shakya, Y., & McKenzie, K. (2022). South Asian youth mental health in Peel Region, Canada: Service provider perspectives. Transcultural Psychiatry, 13634615221119384.
Thomson, M. S., Chaze, F., George, U., & Guruge, S. (2015). Improving immigrant populations’ access to mental health services in Canada: a review of barriers and recommendations. Journal of immigrant and minority health, 17(6), 1895-1905.