innvirkning av kulturell bakgrunn på psykiske lidelser · kasus ! en kvinne fra thailand på 35...

Transkulturell Psykiatri:

Innvirkning av kulturell bakgrunn på psykiske lidelser

Overlege, dr. med. Suraj Thapa Søndre Oslo DPS

Oslo Universitetssykehus

10.03.2015 Stavanger

Oversikt

n  Introduksjon n  Kultur og sin innvirkning på psykisk helse n  Psykisk helse hos innvandrere i Norge n  Kasus n  Som kliniker n  Oppsummering

Oversikt

n  Introduksjon n  Kultur og sin innvirkning i psykisk helse n  Psykisk helse hos innvandrere i Norge n  Kasus n  Som kliniker n  Oppsummering

Different terminologies n  Transcultural n  Cross-cultural n  Intercultural n  Ecological n  Ethocultural n  Cultural psychiatry

n  Section of Transcultural Psychiatry studies at McGill University by Eric Wittkower in 1955

n  New cross cultural psychiatry as called by Kleinman in 1977

Emic vs Etic approach

n  Culture-specific

n  Cultural relativism

n  How psychiatric disorders are different across culture?

- by anthropologists

n  Culture-universal

n  Bio-psychological universalism

n  How psychiatric disorders are similar across cultures?

- by psychiatrists

Klienman in his book - Rethinking psychiatry (1988)

Dimensions of human existence

Biological

Spiritual

Sociocultural Psychological

Ponce DE (1998). Cultural epistemology and value orientations; clinical applications in transcultural psychiatry

Oversikt


Definitions of culture

n  Williams (1983)- “One of the two or three most complicated words in English language”

n  Kroeber & Kluckhohn (1963)- “Comparable to gravity in physics, disease in medicine and evolution in biology

n  “The customs and beliefs, art, way of life and social organization of particular group or country”, Oxford dictionary.

n  “A blueprint for living that is nongenetically transmitted from one generation to the next”, Samuel Okpaku (1998).

Hva er norskkultur? Norskkultur n  ”Norsk kultur er det komplekse hele

som inkluderer norske tradisjoner for kunnskap, tro, kunst, lover, moral, skikker, ferdigheter og vaner som er utviklet gjennom vår historie og som vi har lært i egenskap av å være medlemmer av det norske samfunn.” www.norskkultur.com

Innvandrerkultur n  Heterogent n  Også heterogent innenfor

eget nasjonalitet n  Flerkulturell Norge

Importance of culture in mental health

n  Normality vs. Abnormality n  (Sykdom og helse i en kontekst)

n  Part of the etiology

n  Clinical presentation and distribution of mental illness n  (Forskjellige utrykk og forståelse for følelser og opplevelser)

n  Recognition and treatment of mental illness n  (e.g. culture bound syndromes)

Cecil Helman (2001) in the book “Culture health and illness”

Når to kulturer møter,

Berry og Kim, 1988 (fra Storholt T, 2006)

Psykiatri i Vest og Øst

Møte mellom vest og øst

Hvem behandler psykiske lidelser i Øst?

n  Familie, naboer, slektninger

n  Fengselslege/ helsepersonell

n  Alternative terapeuter: healer, prest, munk, imam, astrolog, shaman osv

Psykosomatikk?

Fastbundet

Legestudents holdning til psykiske lidelser i Pakistan

Oversikt


Distribution of immigrants according to the region of their origin

Source: Statistics, Norway (2012

What we know and donot know about mental health problem of immigrants in Norway (Abebe D, Lien L, Hjelde KH 2012

• This review aims to map the available knowledge on immigrants' mental health status and its associated risk factors in Norway through databases, such as PUBMED, EMBASE, PsychINFO and MEDLINE.

• About 41 peer-reviewed original articles published since 1990s were included.

• Adult immigrants from low and middle income countries, have been found with a higher degree of mental health problems compared to Norwegians and the general population. • Increased risk for mental illness is primarily linked to a higher risk for acculturative stress, poor social support, deprived socioeconomic conditions, multiple negative life events, experiences of discrimination and traumatic pre-migration experiences.

Premigration traumatic events and psychological distress among 5 immigrant groups

n  3019 immigrants from Turkey, Iran, Pakisthan, Sri Lnaka and Vietnam living in Oslo

n  Highest prevalence of psychological distress among Turkish immigrants and lowest among Sri Lankans

n  Experience of torture, imprisonment and unemployment were associated wit distress.

(Lien et al, 2010)

Other studies from clinical set-ups

n  80 / 415 admitted in acute psychiatric ward were immigrants , whereby there were more men, younger age groups, more with psychosis diagnosis and with forced admission and less with substance abuse (Berg & Johansen, 2004).

n  Use of forced medication /treatment was higher among immigrant patients admitted to acute psychiatric departments in Oslo (34.3% vs 12.0% in age groups 18-29 (Knutzen et al, 2007)

Psykiskhelse hos innvandrere fra HUBRO studien

Prevalence of distress (%) according to gender

0

5

10

15

20

25

30

Male Female Total

Immigrants fromhigh-incomecountriesImmigrants from low-income countries

Prevalence of distress (%) by job status

0

5

10

15

20

25

30

35

40

Employment No employment


Prevalence of distress according to gender and regions

05

101520253035404550

Male Female Total

East EuropeAfricaSoth AsiaSouth/East AsiaSouth AmericaMiddle East

Prevalence of distress (%) according to annual family incomes (x100 NOK)

0

5

10

15

20

25

30

35

40

<200 200-300

300-400

400-500

>500


Rates of traumatic & negative life events (NLE)

0

10

20

30

40

50

60

70

War Impris Tort NLE


OR of distress among immigrants from LI countries compared to HI countries

0

0.5

1

1.5

2

2.5

CrudeOR

Model1

Model2

Model3

Odds ofdistress

Model 1: adjusted for sociodemograpfic chracteristics

Model 2: model 1 + pre-migration experiences

Model 3: model 2 + post-migration experiences

Odds of distress (95% CI) from multivariate models (n=1265)

___________________________________________________________________ Immigrants Unadjusted Model 1 Model 2 Model 3

from OR OR OR OR ________________________________________________________________________

High-income countries (Reference) Low-income countries 2.79 (2.16-3.60) 2.59 (1.60-3.13) 1.99 (1.25-2.55) 1.33 (.88-1.93) p value .001 .002 .001 .176 __________________________________________________________________________________ Model 1: adjusted for gender, age, religion, marital status and education Model 2: adjusted for gender, age, religion, marital status, education, and pre-migration risk factors (traumatic

experiences) Model 3: adjusted for gender, age, religion, marital status, education, pre-migration risk factors, and post-

migration risk factors (negative life events, lack of job, annual family income

Distress in different groups

0

5

10

15

20

25

30

Norwegian born Imm LI Imm HI

Distress %

Imm LI: Immigrants form low-income countries

Imm HI: Immigrrants from high-income countries

Gender differences in factors associated with distress

Risk factors for male immigrants

n  Lack of paid job n  Denial of job n  Negative life events

n  Visit by Norwegians as a protective factor

Risk factors for female immigrants

n  Lack of paid job n  Higher age n  Negative life events n  Living alone n  Denial of housing n  Middle East background

(Thapa & Hauff, 2005)

Factors that can affect mental health of migrants

n  Age Pre-migration n  Gender n  Education n  Ethnicity n  Trauma n  Type of migration n  ---------------------------------------------------------------------------

n  Loss of family member Migration Mental health n  Time for preparation for migration n  Availability of social supports

-------------------------------------------------------------------------------- n  Sosial supports Post-migration n  Economical problems n  Job n  Integration n  Sociocultural factors n  Negative life events n  Discrimination n  Self efficacy n  Acculturation

Oversikt


Kasus

n  En kvinne fra Thailand på 35 år, kom til Norge for 4 år siden, gift med en Nordmann på 60 år, har to barn, kan litt norsk, mor og søstere prostituerte i Thailand, HIV smittet, alkohliserte brødre

n  Henvist fra fastlege med mistanke om bipolar lidelse

n  Ble søkt innlagt på akuttpsykiatrisk avd. til tvungen observasjon

Hva sier pasienten selv?

n  Jeg er en frisk person og hadde det bra før jeg kom til Norge.

n  Mine største problemer er søvnvansker, smerter og mistrivsel i Norge.

n  Har nesten ingen nettverk her og savner mitt nettverk i Thailand

n  100% sikker på at jeg blir helt frisk når jeg flytter tilbake til Thailand.

Oversikt


Hva kan vi gjøre som kliniker?

n  Være nysgjerrig for pasientens kulturell bakgrunn som kan være

forklaring til pasientens symptomer / lidelser

n  Kulturformulering av pasientens psykiske vansker, ta hensyn til det før man stiller en diagnose eller planlegger behandling

n  Spør pas om det finnes noen behandlings metoder i deres kultur for slike symptomer

n  Bruk redskaper /veiledninger som finnes

Retninslinjer/veiledninger

Kulturformulering i DSM IV

n  Personens kulturelle identitet n  Kulturelle forklaring på sykdom n  Kulturelle faktorer relatert til psykososialt miljø og

funksjonsnivå n  Kulturelle faktorer i relasjon mellom pasient og

kliniker n  ------- n  En generell kulturell vurdering med henblikk på

diagnostisering og behandling n  Migrasjon ok akulturasjon

Oppsummering

n  Viktig å huske på kulturforskjeller og likheter når det oppstår kontakt mellom to forskjellige kulturer.

n  Innvandrere har som regel høyre prevalens av psykiske lidelser.

n  Kultursensitive utredningsmetoder n  Bruk av tolk, kulturekspert osv. n  Bruk av redskaper som finnes

.......

Thanks for your attention!

innvirkning av kulturell bakgrunn på psykiske lidelser · kasus ! en kvinne fra thailand på 35...

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