1. Psychiatry Victorian Transcultural Psychiatry Unit www.vtpu.org.au Harry Minas Victorian Transcultural Psychiatry Unit Centre for International Mental Health A Transcultural Mental Health Research Agenda Information for Better Decisions

2. Psychiatry Victorian Transcultural Psychiatry Unit www.vtpu.org.au Challenges of Diversity Cultural and linguistic diversity confronts societies with a series of important challenges and potentially divisive questions. These questions include: issues of national, regional, community and personal identity the legitimate role of government distribution of resources the purposes, structure and operations of social institutions - such as health systems Current backlash against multiculturalism

3. Psychiatry Victorian Transcultural Psychiatry Unit www.vtpu.org.au Scope and Content of Transcultural Psychiatry Exploration of similarities and differences in the manifestations of mental illness in different cultures. Identification of cultural factors that predispose to mental illness and mental health. Assessment of the effect of identified cultural factors on the frequency, nature and distribution of mental illness. Attitudes toward the mentally ill in different cultures. Study of the forms of care and treatment practised or preferred in different cultural settings. Culture and clinical practice, including the clinician-patient relationship. Design and evaluation of mental health services in multicultural societies. Human rights concerns

4. Psychiatry Victorian Transcultural Psychiatry Unit www.vtpu.org.au

6. Victoria Burden of Disease Study

7. Psychiatry Victorian Transcultural Psychiatry Unit www.vtpu.org.au Burden: What can and cannot be averted 100% Not avertable with existing interventions Averted with current mix of interventions & population coverage Avertable with improved clinical efficiency (evidence-based practice) and population coverage Avertable with increased resource input Research on health systems & policies 100% 0% Population coverage Research on new interventions Research to reduce the cost of interventions Combined efficacy of intervention mix z xy x - current population coverage y - max achievable population coverage z - efficacy of mix of all interventions Global Forum, 1999

8. Psychiatry Victorian Transcultural Psychiatry Unit www.vtpu.org.au What kinds of research? Agenda-driven research Investigator-initiated research A clear research agenda is a powerful instrument for improving the quality and accessibility of the Victorian public mental health system

9. Psychiatry Victorian Transcultural Psychiatry Unit www.vtpu.org.au MH Services: Some continuing Issues Little high quality epidemiological information ? Needs Inadequate information on risk and resilience -determinants Pre- and post-migration factors Continuing under-use of MH services Inadequate understanding of reasons Inadequate understanding of the pathways to mental health care Initial access to mental services is particularly problematic Significant language/communication barriers Interpreter services are under-utilized Little information on quality of clinical and social outcomes Data that’s available(e.g. HoNOS) is not routinely analysed to explore this issue

10. Psychiatry Victorian Transcultural Psychiatry Unit www.vtpu.org.au Rates of community mental health service use

11. Psychiatry Victorian Transcultural Psychiatry Unit www.vtpu.org.au Basic Questions What are the mental health service needs of Victoria’s diverse communities? Are the needs of various communities the same or different? Does the Victorian mental health system have the capacity to effectively meet the mental health service needs of the population, regardless of language and culture? Does this capacity vary for different communities? Where needs are not being adequately met, what needs to be done? When things are done, how effective are they?

12. Psychiatry Victorian Transcultural Psychiatry Unit www.vtpu.org.au Increased capacity of the Victorian public mental health system to provide clinically effective and culturally appropriate services to Victoria’s culturally and linguistically diverse population. Priority Area 1: Policies and implementation plans (State, AMHS) Priority Areas Priority Area 2: Understanding of CALD communities’ needs for service Priority Area 5: Skilled clinical workforce Priority Area 3: Quality of clinical communication Priority Area 4: Equitable access to services Priority Area 6: Clinical and social outcomes

13. Psychiatry Victorian Transcultural Psychiatry Unit www.vtpu.org.au Increased capacity of the Victorian public mental health system to provide clinically effective and culturally appropriate services to Victoria’s culturally and linguistically diverse population. Priority Area 1: Policies and implementation plans (State, AMHS) Priority Areas Priority Area 2: Understanding of CALD communities’ needs for service Priority Area 5: Skilled clinical workforce Priority Area 3: Quality of clinical communication Priority Area 4: Equitable access to services Priority Area 6: Clinical and social outcomes Objective 2.1 Improved and expanded CCC networks Objective 2.3 Improved levels and processes for participation Objective 1.2 Implementation plans at AMHS and agency level in place Objective 2.4  Understanding of Community needs Objective 5.5 Improvement in relevant clinical skills of workforce Objective 3.5  Quality of clinical communication in cross-cultural clinical encounters Objective 4.5 Improved (equitable) access to services Objective 6.5 Equitable clinical and social outcomes Objective 1.1 Policies in place at State and AMHS levels Objective 3.1  Assessment of English proficiency Objective 3.2  Use of interpreter services Objective 3.3  Training in Working with interpreters Objective 3.4  Training in of mental health interpreters Objective 2.2  Training of CCC in effective participation Objective 4.1  Use of MH services Objective 4.2  Access to non-drug treatments Objective 4.3  Access to disability support and rehab Objective 5.1 Relevant clinical competencies defined Objective 5.2 Competency- based training developed Objective 5.3  % of clinical workforce trained Objective 6.1 Identify unacceptable outcomes Objective 6.2 Institute targetted quality improvement programs Objective 6.3  Employment  DSP rates  Stable accomm

14. Psychiatry Victorian Transcultural Psychiatry Unit www.vtpu.org.au Increased capacity of the Victorian public mental health system to provide clinically effective and culturally appropriate services to Victoria’s culturally and linguistically diverse population. Priority Area 1: Policies and implementation plans (State, AMHS) Objective 1.2 Implementation plans at AMHS and agency level in place Objective 1.1 Policies in place at State and AMHS levels Minas, I.H., Klimidis S, Kokanovic R. Policy, research and services in relation to depression in ethnic minority communities in Australia. Transcultural Psychiatry. (In press)

15. Psychiatry Victorian Transcultural Psychiatry Unit www.vtpu.org.au Increased capacity of the Victorian public mental health system to provide clinically effective and culturally appropriate services to Victoria’s culturally and linguistically diverse population. Priority Area 3: Quality of clinical communication Objective 3.5  Quality of clinical communication in cross-cultural clinical encounters Objective 3.1  Assessment of English proficiency Objective 3.2  Use of interpreter services Objective 3.3  Training in Working with interpreters Objective 3.4  Training in of mental health interpreters Klimidis S, Reddy P, Minas IH, Lewis J. Brief functional English proficiency measure for health survey research. Australian Psychologist. 2004; 39:154–165. Miletic T, Minas H, Stolk Y, Gabb D, Klimidis S, Piu M, Stankovska M. Improving the Quality of Mental Health Interpreting in Victoria. Melbourne, Victorian Transcultural Psychiatry Unit, 2005. Stuart GW, Minas, I.H., Klimidis S, O'Connell S. English language ability and mental health service utilisation: a census. Aust N Z J Psychiatry 1996; 30:270-7.

16. Psychiatry Victorian Transcultural Psychiatry Unit www.vtpu.org.au Increased capacity of the Victorian public mental health system to provide clinically effective and culturally appropriate services to Victoria’s culturally and linguistically diverse population. Priority Area 4: Equitable access to services Objective 4.5 Improved (equitable) access to services Objective 4.1  Use of MH services Objective 4.2  Access to non-drug treatments Objective 4.3  Access to disability support and rehab Stuart GW, Klimidis S, Minas, I.H. The treated prevalence of mental disorder amongst immigrants and the Australian-born: community and primary-care rates. International Journal of Social Psychiatry 1998; 44:22-34. Klimidis S, McKenzie DP, Lewis J, Minas, I.H. Continuity of contact with psychiatric services: immigrant and Australian-born patients. Social Psychiatry and Psychiatric Epidemiology 2000; 35:554-63.

17. Psychiatry Victorian Transcultural Psychiatry Unit www.vtpu.org.au Increased capacity of the Victorian public mental health system to provide clinically effective and culturally appropriate services to Victoria’s culturally and linguistically diverse population. Priority Area 1: Policies and implementation plans (State, AMHS) Priority Areas Priority Area 2: Understanding of CALD communities’ needs for service Priority Area 5: Skilled clinical workforce Priority Area 3: Quality of clinical communication Priority Area 4: Equitable access to services Priority Area 6: Clinical and social outcomes Objective 2.1 Improved and expanded CCC networks Objective 2.3 Improved levels and processes for participation Objective 1.2 Implementation plans at AMHS and agency level in place Objective 2.4  Understanding of Community needs Objective 5.5 Improvement in relevant clinical skills of workforce Objective 3.5  Quality of clinical communication in cross-cultural clinical encounters Objective 4.5 Improved (equitable) access to services Objective 6.5 Equitable clinical and social outcomes Objective 1.1 Policies in place at State and AMHS levels Objective 3.1  Assessment of English proficiency Objective 3.2  Use of interpreter services Objective 3.3  Training in Working with interpreters Objective 3.4  Training in of mental health interpreters Objective 2.2  Training of CCC in effective participation Objective 4.1  Use of MH services Objective 4.2  Access to non-drug treatments Objective 4.3  Access to disability support and rehab Objective 5.1 Relevant clinical competencies defined Objective 5.2 Competency- based training developed Objective 5.3  % of clinical workforce trained Objective 6.1 Identify unacceptable outcomes Objective 6.2 Institute targetted quality improvement programs Objective 6.3  Employment  DSP rates  Stable accomm

18. Psychiatry Victorian Transcultural Psychiatry Unit www.vtpu.org.au Strengthening Capacity Increase demand within Area Mental Health Services for improved transcultural mental health practice and programs Collaborative Work Systematic Training Increased Research Capacity Networks of Skilled Researchers

19. Psychiatry Victorian Transcultural Psychiatry Unit www.vtpu.org.au Increasing transcultural mental health research More systematic and intelligent use of existing data collections e.g. service use and outcomes data Ensure that essential data fields (e.g. country birth, COB of parents in CAMHS, English fluency) are included in routine data collections Promote high quality service evaluation as an essential component of service delivery Confront ethics of exclusion Epidemiological and treatment efficacy studies should be based on truly representative samples of the population (NH&MRC, ARC, etc.) Development of transcultural mental health research instruments and methods Teaching programs in transcultural mental health research methods and ethics Attract an increased number of Master and PhD students who are doing transcultural mental health research projects  transcultural mental health research capacity  competitive research funding for the field  body of useful information

20. Psychiatry Victorian Transcultural Psychiatry Unit www.vtpu.org.au Research and the policy cycle Problem identification Problem identification Option development Option development Political decision Political decision Implementation Evaluation Research