 |
 |
|
|
|
 In the last 2 decades, large-scale epidemiologic surveys across several countries with different health care systems have suggested that mental disorders are prevalent (4.3% to 26.3%) (1) but that only some individuals with mental disorders seek mental health treatment (1–3). The WHO calls for the development of national mental health policies and for research on understanding both the factors related to MHSU and the barriers to help seeking for emotional problems across the world (4). Several countries have developed national mental health care programs. Canada does not yet have a national policy on mental health, although there has been increased attention in the Canadian government to developing a national policy to reduce the number of Canadians with untreated mental illness (5). However, there is little information on the prevalence and correlates of MHSU in Canada. Mental Health Service Use in Canadian Samples There have been 4 previous reports of help seeking in Canadian community samples. In a 2-stage survey in Edmonton, Bland and others found the prevalence of MHSU to be 12.9% in the first stage (n = 3956) and 14.1% in the second stage (n = 1956) (6,7). Lefebvre and others surveyed a random sample in Montreal (n = 893) and found that the rate of MHSU was 12.8% of the sample (8). Lin and others reported that 7.8% of a population-based sample in Ontario (n = 8116) sought mental services in the past year (9). These 4 studies provide important information based on surveys conducted between the late 1980s and the early 1990s and suggest that most individuals with a DSM-IV mental disorder diagnosis (10) do not receive any services. However, the generalizability of these findings to the entire Canadian population may be limited by the large geographic size of the country and by differences in economic and health status among different regions of Canada. Data from the Canadian NPHS demonstrate that, over the last 10 years, there have been large increases in antidepressant use, but not service use, for major depression (11,12). Therefore, there is a need for contemporary, nationally representative information on the prevalence and correlates of MHSU in Canada. Self-Reported Barriers to Mental Health Service Use Currently, there is no published information on self-reported barriers to MHSU in Canada. Data from the US National Comorbidity Survey and a community survey in Chile suggested that the most common reason for not seeking treatment was the high cost of professional care (13,14). However, these findings may not be generalizable to Canada because of the differences in the organization of the Canadian health care system, compared with systems in other countries (2). The Canadian health care system provides universal health coverage, whereas the US and Chile cover services through both the public and private sector (15–17). In the Canadian system, no limits are placed on access to physicians (that is, limits placed by payments for services rendered), although access to other types of mental health professionals is more constrained. Some reports also suggest that Canadian patients experience longer waits for mental health specialist services than do US patients (18). Our study provides the first report of a range of self-reported barriers to MHSU in Canada. Type of Professional Contact Previous studies using Canadian samples have noted heavy reliance on primary care physicians to manage mental health problems (19,20). Access to mental health professionals through primary care physicians is the preferred practice pattern in Canada. Goldberg and Huxley’s model of MHSU in the community hypothesizes that individuals seeking services from mental health professionals have higher levels of clinical severity than those seeking care from primary care physicians (21). However, previous examination of an Ontario survey did not support this hypothesis (22,23). Respondents seeking treatment only from primary care physicians did not display significant differences with respect to level of clinical severity when compared with respondents seeking treatment from mental health professionals only or with respondents seeking care from multiple care providers. Our study aimed to revisit this issue and used a contemporary Canadian survey to understand whether there is a correlation between the level of mental illness severity and the type of professional contacted. Our study used data from the CCHS Cycle 1.1, which is unique in that it is the largest survey ever conducted in any country (n ~ 130 000) that includes an assessment of MHSU. It provides contemporary (collected between 2000 and 2001), nationally representative, Canadian data. Our report had 3 main objectives. First, we examined the prevalence and correlates of MHSU in Canada. Second, we examined the self-reported barriers to mental health services. Last, we examined whether there was a relation between the type of professional contacted for emotional problems and the level of clinical severity. MethodsSubjects for analysis were selected from the CCHS Cycle 1.1. (Details of the survey methodology and data quality policies of Statistics Canada are available at www.statcan.ca/english/concepts/health/index.htm.) A 3-frame, multistage, stratified sample design was used to collect data (24). Subjects were aged 12 years and over, and the response rate was 84.7%. The current analysis is based on the subsample of the survey that agreed to share their information with the provincial ministries of health (97% of the sample, n = 125 493). All respondents were asked the following question about contact with professionals for their mental health: “In the past 12 months, have you seen, or talked on the telephone to, a health professional about your emotional or mental health?” Respondents endorsing this question were categorized as “help seekers for mental health problems” (n = 10 886). Further questions addressed frequency of contact (total number of visits in the past 12 months) and type of professional contacted (specifically, family doctor, psychiatrist, psychologist, nurse, social worker or counsellor, or other). Type of professional contact was categorized into 5 mutually exclusive groups: 1) no contact, 2) family doctor only, 3) psychiatrist only, 4) nonphysician professional only (that is, psychologist, nurse, social worker, counsellor, or other), and 5) contact with multiple professionals (that is, endorsement of 2 or more professionals contacted in the past year). Respondents were asked whether they had perceived a need for mental health treatment that was unmet: “In the past 12 months, was there ever a time when you felt that you needed health care but you didn’t receive it?” Respondents endorsing this question were asked “What was the type of care that was needed?” One of the 4 choices was “treatment of an emotional or mental health problem.” Next, respondents were asked to identify which barriers they endorsed from a list of possible reasons for not seeking care. In this survey, we were able to examine the following sociodemographic correlates of MHSU: age, sex, marital status, education, income, ethnicity, and immigrant status. Ethnicity was dichotomized into white or visible minority. Immigrant status was based on whether the respondent endorsed being born in Canada (that is, Canadian-born or immigrant). A dichotomous variable was developed by Statistics Canada (24) to determine 2 income categories: 1) low household income (11.2% of the total sample) and 2) middle-to-high household income (88.8% of the total sample). The CIDI-SF (25) was used to assess DSM-IV (10) major depression and alcohol dependence. Validation studies have demonstrated the reliability of using the CIDI-SF to diagnose depression and alcohol dependence (26,27). Previous surveys have demonstrated that the presence of one or more physical health conditions is associated with MHSU (13,28). In the current study, chronic conditions were described as any health condition that had been diagnosed by a health care professional and lasted or was expected to last at least 6 months. Respondents were asked whether they had been given the diagnosis for any of 24 specific chronic conditions (Table 1). The individual was given a score of 1 for each diagnosis they had received. From the distribution of this variable in the sample, the number of past chronic physical health conditions was trichotomized into none (36.1% of the total sample), one (26.7% of the total sample), or 2 or more (37.2% of the total sample).
Previous studies have consistently demonstrated that increasing severity of mental illness (2) and self-perceived poor health status (9,13) are positively associated with treatment-seeking behaviour. In our survey, self-perceived general health status was measured by the participant’s subjective assessment of perceived current health as excellent, good, fair, and poor. Current health was dichotomized into fair or poor (11.9% of the sample) and excellent or good (88.1% of the sample). To delineate their perceptions of stress, participants were asked how stressful their life was currently, with ratings being not at all, not very, a bit, quite a bit, and extremely. This variable was dichotomized into high stress (quite a bit or extremely stressful), which was endorsed by 26.1% of the total sample, and low stress (not at all, not very, and a bit stressful), which was endorsed by 73.9% of the total sample. Respondents were asked whether they had reduced the amount or kind of activity “at home,” “at work or at school,” and “in other activities, for example transportation or leisure,” owing to a “long-term (> 6 months) physical or mental condition or health problem.” For each of the 3 areas of reduced functioning, respondents had the choices of sometimes, often, and never. Respondents endorsing never for all 3 areas of functioning were categorized as not restricted (77.1% of the total sample), and the remaining respondents were categorized as restricted. Finally, current disability was derived by totalling the number of days in the past 2 weeks during which the respondent was in bed for all or most of the day and the days during which the respondent cut down on activities for all or most of the day. Analysis The appropriate statistical weights provided by Statistics Canada were applied in all data analysis to ensure that the sample was representative of the Canadian population (29). A bootstrapping technique (30) that incorporated multistage sample design information provided by Statistics Canada to produce the CV and 99%CIs was used. In no cases were CVs greater than 33.3%, the Statistics Canada cut-off that indicates extreme sampling variability. We estimated the past-year prevalence of outpatient contact with mental health services, number of visits, and type of professionals contacted (Table 2). We conducted multivariate logistic regression analyses to evaluate the correlates of past-year MHSU. We simultaneously included all independent variables in the regression analysis to adjust for the effects of each other. Owing to the very large sample size (and thus the highest likelihood of obtaining significant findings) and multiple comparisons, we used a conservative alpha coefficient of P < 0.01.
The bootstrapping program was used to estimate ratio differences with 99%CIs for the type of mental health professional contacted on each measure of severity (that is, DSM-IVdiagnosis of depression, alcohol dependence, restriction in activities, self-perceived health status, and 2-week disability). Meeting DSM-IV criteria for depression and alcohol dependence implies severe and persistent symptoms and therefore constitutes an indicator of severity. It is important to underscore that we compared each of the 5 types of professional contact on each of the 5 measures of clinical severity. ResultsTable 2 shows the prevalence of MHSU across Canada. In the total sample (aged 12 years and over), the prevalence of past-year help seeking for emotional symptoms in the total population was 8.3% (99%CI, 8.10 to 8.55). FPs and psychologists were the professionals most commonly contacted; nurses and other professionals were least commonly contacted. Among those seeking treatment for emotional symptoms in the past year, 19.3% (1.1% of the total population) had 12 or more outpatient visits. The prevalence of past-year DSM-IV major depression (that is, high probability of major depressive disorder according to the CIDI-SF) was 7.3% (99%CI, 7.08 to 7.48). Among those with major depression, 43.0% used any mental health services in the past year. Most individuals seeking treatment for depression had at least 4 outpatient visits in the past year. Table 3 illustrates the correlates of MHSU. Owing to the large sample size, all correlates examined were significantly associated with treatment seeking. The strongest correlates of help seeking for emotional symptoms were as follows: past-year major depression; female sex; being widowed, separated, or divorced; having 2 or more chronic physical health conditions; perceived high stress; long-term disability due to emotional or physical problems; and age range (specifically, 30 to 39 years and 40 to 49 years).
Perceived need for treatment without seeking care was endorsed by 0.6% (99%CI, 0.49 to 0.62) of the population. Table 4 presents self-reported barriers to seeking treatment. The 3 most common barriers to help seeking for emotional problems were “did not get around to it,” “waiting time too long,” and “felt it [treatment] would be inadequate.”
Table 5 illustrates the relation between the type of mental health professional contacted for emotional problems and a range of measures of severity. In the whole sample, the prevalence of contact was as follows: with FPs only, 3.0%; with a psychiatrist only,1.0%; with an NPP only, 3.2%; and with MPCs, 1.1%.
Ratio difference analyses demonstrated a graded relation between number of professionals contacted for emotional symptoms and all measures of clinical severity (that is, DSM-IV major depression, DSM-IV alcohol dependence, long-term restriction in activities, self-perceived fair-to-poor health status, and 2-week disability). The lowest levels of severity were found for respondents without any professional contact in the past year. Intermediate levels of severity were found for respondents with one professional contact. The highest levels of severity were found for respondents with MPCs. Contact with a psychiatrist only was significantly more likely to be associated with higher severity on all measures (except alcohol dependence), compared with contact with an FP only and an NPP only. Respondents contacting an NPP only were significantly more likely to meet criteria for alcohol dependence than were respondents contacting an FP only or a psychiatrist only. DiscussionIn the context of broad access to mental health services and the recent increase in public awareness campaigns regarding mental illness, the past-year prevalence of self-reported MHSU (8.3%) remained essentially unchanged from previous reports based on an Ontario sample collected a decade earlier (8.0%) (9,15). These rates of MHSU are much lower than previously reported in highly urbanized Canadian samples of Edmonton (6,7) and Montreal (8). The discrepancy among these rates of service use may be due to urban–rural differences in the availability of mental health services and the prevalence of disorders (9,31). The rates of service use in Canada were in the middle of the range of service use reported by the WHO for 14 different countries (0.8% to 15.3%) (1). In the current analysis, we found the 12-month prevalence of major depression in Canada (7.3%) to be similar to the recently published US population-based rates (6.6%) (32). Interestingly, only 43% of the individuals with depression received any outpatient mental health services in Canada, compared with 57% in the US (32). Thus a significant proportion of individuals meeting criteria for major depression remained untreated. Because the current survey did not comprehensively assess a wide range of mental disorders, we cannot estimate the proportion of Canadians suffering with mental disorders who received treatment. However, if previous 1-year prevalence estimates that approximately 20% of the Canadian population (7,33) meet criteria for a mental disorder still apply, the current finding that 8.3% of the population sought treatment in the past year for a mental disorder suggests a continuing large gap between those who suffer with mental illness in Canada and those who receive treatment. It is important to underscore that there is enormous controversy about whether meeting diagnostic criteria for a mental disorder is a good proxy of need for treatment. From survey findings across the world demonstrating that most individuals meeting criteria for a mental disorder do not seek treatment or perceive a need for treatment (2,3,16,17), several leaders in the field of psychiatric epidemiology have argued that estimates of need for treatment have been exaggerated by the inclusion of mild, transient disorders (34–36). However, Kessler and others have used longitudinal US community data to demonstrate that “mild” mental disorders are associated with poor outcomes over a 10-year follow-up and may benefit from mental health treatment (37). Irrespective of the controversy related to defining need for mental health treatment in the community, monitoring trends of MHSU in Canada can be done with future waves of the CCHS, which will be collected every 2 years. Correlates of MHSU In addition to the presence of depression and alcohol dependence, sociodemographic characteristics (for example, sex, ethnicity, income, and immigrant status), presence of chronic physical health problems, and disability were demonstrated to be associated with mental health treatment-seeking behaviour. The findings in our survey were similar to those in previous reports suggesting that young male subjects with low education are least likely to seek care (2,13). Also, being from a visible minority or being an immigrant was associated with a lower likelihood of help seeking. These findings are consistent with previous reports demonstrating cultural differences in MHSU (38,39) and are especially relevant in Canada, because visible minorities and (or) immigrants form a significant proportion of the Canadian population (40). Self-Reported Barriers to MHSU Among the list of possible barriers to help seeking offered to respondents, 2 of the 5 most commonly endorsed reasons were related to respondents’ choice not to make the effort to seek treatment (specifically, “did not get around to it” or “decided not to seek care”). These reasons for not seeking treatment may be related to low levels of severity of emotional symptoms and (or) the experience of transient emotional symptoms. Alternatively, the above reasons may reflect a negative attitude to mental health treatment. The third most commonly endorsed barrier was clearly a negative attitude to seeking treatment (that is, “felt it [treatment] would be inadequate”). Previous studies have also reported such negative attitudes toward MHSU (13,41). Further, the lack of available services when they were needed was also commonly endorsed (for example, “waiting time too long” or “not available at the time required”). As hypothesized on the basis of the universal Canadian insurance system, cost was not a commonly endorsed barrier in the current survey. We suggest that a need exists for public awareness campaigns to reduce negative attitudes to mental health treatment and to inform the public about where to access treatment in a timely manner. Readers should keep in mind that the current survey did not assess other important reasons for not seeking care that have been commonly endorsed in previous surveys (for example, fear of stigmatization) (42). Another important issue to consider is that previous surveys have repeatedly demonstrated that most individuals meeting criteria for a mental disorder do not perceive a need for treatment (3). Future studies should more thoroughly assess both the types of service that respondents feel they need and a broader range of barriers to treatment. Type of Professional Contact Among professionals contacted for emotional problems, FPs were most likely to provide care in this sample. These findings are similar to findings from previous studies in Canada (6–9, 22,23) and in other countries (15,17), suggesting that FPs play an important role in treating mental illness in the community. Consistent with Goldberg and Huxley’s model of pathways to psychiatric care (21), we found that individuals seeking treatment from psychiatrists only and from MPCs had higher levels of severity on a range of measures, compared with respondents who did not seek care or who sought care from FPs only or from NPPs. Previous work in Ontario did not find this relation between types of professionals contacted and clinical severity (22,23). Possibly, over the last 10 years since the Ontario Health Survey was undertaken, FPs have acquired greater interest and (or) skill in recognizing and treating severe mental disorders and are able to consult psychiatrists or nonphysician mental health professionals when needed (12). Recent work from the Canadian NPHS found that individuals suffering from depression and with greater number of symptoms and greater levels of impairment were more likely to be referred to mental health professionals (43). The diagnosis of alcohol dependence was more commonly found in respondents endorsing contact with NPPs rather than contact with an FP or psychiatrist (Table 5). This finding is likely due to the historic lack of pharmacologic treatment for substance use problems (44) and the importance of Alcoholics Anonymous in treating alcohol use disorders (45). Some authors have suggested that the specialty sector has increased barriers to treatment for persons with substance use disorders (45). These barriers may be due to perceptions in the community that individuals with substance use disorders are themselves to blame and need to “pull themselves together” (42). Recent evidence suggests the need to implement a range of effective treatments for alcohol use disorders in primary care and specialty settings (46–48). Study Limitations With respect to the limitations of the current investigation, the findings provide self-reported information on health care use that could be biased by recall errors. Another limitation of the current investigation is the lack of thorough questioning on the use of self-help resources for emotional problems. In previous surveys, respondents were asked to endorse seeking treatment from a range of professionals other than health care professionals (for example, priest, minister, spiritualist, and herbalist) (15). It is possible that the current survey might have underestimated the use of other services. Further, the diagnoses of major depression and alcohol dependence were constructed from information obtained by lay interviewers. Although the CIDI-SF has proved to be a reliable instrument (25), it is unlikely to match the validity of trained clinicians. Finally, the current survey is limited to the assessment of major depression and alcohol dependence only. Other major mental illnesses (for example, schizophrenia or anxiety disorders) are likely to influence treatment-seeking behaviour. ConclusionsHealth policy-makers need to be aware of a range of sociodemographic factors, disability variables, and mental and physical health condition diagnoses that are associated with MHSU in Canada. The match between severity of mental illness and type of professional contacted seemed to be appropriate at the aggregate level, although this may not be true for individuals. Public awareness campaigns need to emphasize the treatable nature of mental disorders and provide information about where to access treatment. Funding and SupportThe Manitoba Health Research Council provided funding support for the current investigation. AcknowledgementsThe authors thank Ian Clara, Shay-Lee Belik, and Tom Czyczko for their statistical work related to this manuscript. References1. The WHO World Mental Health Survey Consortium. Prevalence, severity, and unmet need for treatment of mental disorders in the World Health Organization World Mental Health surveys. JAMA 2004;291:2590. 2. Bijl RV, De Graaf R, Hiripi E, Kessler RC, Kohn R, Offord DR, and others. The prevalence of treated and untreated mental disorders in five countries. Health Aff 2003;22:122–33. 3. Andrews G, Henderson S, Hall W. Prevalence, comorbidity, disability and service utilization. Overview of the Australian National Mental Health Survey. Br J Psychiatry 2001;178:145–53. 4. WHO. Mental health: new understanding, new hope. The World Health Report. Geneva: WHO; 2001. 5. Kirby M. Mental health, mental illness, and addiction. Presented at the Canadian Psychiatric Association Annual Meeting; 2003 October; Halifax (NS). 6. Bland RC, Newman SC, Orn H. Health care utilization for emotional problems: results from a community survey. Can J Psychiatry 1990;35:397–400. 7. Bland RC, Newman C, Orn H. Help-seeking for psychiatric disorders. Can J Psychiatry 1997;42:935–42. 8. Lefebvre J, Lesage A, Cyr M, Toupin J, Fournier L. Factors related to utilization of services for mental health reasons in Montreal, Canada. Soc Psychiatry Psychiatr Epid 1998;33:291–8. 9. Lin E, Goering P, Offord DR, Campbell D, Boyle MH. The use of mental health services in Ontario: epidemiologic findings. Can J Psychiatry 1996;41:572–7. 10. American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 4th ed. Washington (DC): American Psychiatric Association; 1994. 11. Patten SB. Progress against major depression in Canada. Can J Psychiatry 2002;2002:775–80. 12. Patten SB, Beck CA. Major depression and mental health care utilization in Canada: 1994 to 2000. Can J Psychiatry 2004;49:303–9. 13. Mojtabai R, Olfson M, Mechanic D. Perceived need and help-seeking in adults with mood, anxiety or substance use disorders. Arch Gen Psychiatry 2002;59:77–84. 14. Saldivia S, Vicente B, Kohn R, Rioseco P, Torres S. Use of mental health services in Chile. Psychiatr Serv 2004;55:71–6. 15. Kessler RC, Frank RG, Edlund M, Katz SJ, Lin E, Leaf P. Differences in the use of psychiatric outpatient services between the United States and Ontario. N Engl J Med 1997;336:551–7. 16. Katz SJ, Kessler RC, Frank RG, Leaf P, Lin E, Edlund M. The use of outpatient mental health services in the US and Ontario: the impact of mental morbidity and perceived need for care. Am J Public Health 1997;87:1136–43. 17. Katz SJ, Kessler RC, Frank RG, Leaf P, Lin E. Mental health care use, morbidity, and socioeconomic status in the United States and Ontario. Inquiry 1997;34(1):38–49. 18. Newell AR, Saltzman GM. Impact of reimbursement systems on child psychiatrists: a comparison of Canada and the United States. J Am Acad Child Adolesc Psychiatry 1995;34:1326–35. 19. Olfson M, Kessler RC, Berglund PA, Lin E. Psychiatric disorder onset and first treatment contact in the United States and Ontario. Am J Psychiatry 1998;155:1415–22. 20. Sullivan RB, Watanabe M, Whitcomb ME, Kindig DA. The evolution of divergences in physician supply policy in Canada and the United States. JAMA 1996;276:704–9. 21. Goldberg D, Huxley P. Mental health in the community: the pathways to psychiatric care. London (UK): Tavistock Publications; 1980. 22. Lesage AD, Goering P, Lin E. Family physicians and the mental health system. Can Fam Physician 1997;43:251–6. 23. Parikh SV, Lin E, Lesage AD. Mental health treatment in Ontario: selected comparisons between the primary care and specialty sectors. Can J Psychiatry 1997;42:929–34. 24. Statistics Canada. Canadian Community Health Survey Cycle 1.1 (2000–2001); public use microdata file documentation. Ottawa (ON): Statistics Canada; 2003. 25. Kessler RC, Andrews G, Mroczek D, Ustun B, Wittchen H. The World Health Organization Composite International Diagnostic Interview-Short Form (CIDI-SF). Int J Methods Psychiatr Res 1998;7:171–85. 26. Patten SB. Long-term medical conditions and major depression in the Canadian population. Can J Psychiatry 1999;44:151–7. 27. Patten SB, Brandon-Christie J, Devji J, Sedmak B. Performance of the Composite International Diagnostic Interview Short Form for major depression in a community sample. Chron Dis Can 2000;21:68–72. 28. Sareen J, Stein MB, Campbell DW, Hassard T, Menec V. Perceived need for care: an optimal criterion for delineating the burden of mental illness in the community. Presented at the Canadian Psychiatric Association 52nd Annual Meeting; 2002 October; Banff (AB). 29. Bailie L, Dufour J, Hamel M. Data quality assurance for the Canadian Community Health Survey. Ottawa (ON): Statistics Canada; 2002. 30. Statistics Canada. Estimation of variance using weights user’s guide for the BOOTVARE V20. SAS Program (Version 2.0). Ottawa (ON): Statistics Canada; 2002. 31. Wang JL. Rural-urban differences in the prevalence of major depression and associated impairment. Soc Psychiatry Psychiatr Epidemiol 2004;39:19–25. 32. Kessler RC, Berglund PC, Demler O, Jin R, Koretz D, Merikangas KR, and others. The epidemiology of major depressive disorder: results from the National Comorbidity Survey Replication. JAMA 2003;289:3095–105. 33. Offord DR, Boyle MH, Campbell D, Goering P, Lin E, Wong M, and others. One-year prevalence of psychiatric disorder in Ontarians 15 to 64 years of age. Can J Psychiatry 1996;41:559–63. 34. Narrow WE, Rae DS, Robins LN, Regier DA. Revised prevalence estimates of mental disorders in the United States: using a clinical significance criterion to reconcile 2 surveys’ estimates. Arch Gen Psychiatry 2002;59:115–23. 35. Spitzer RL. Diagnosis and need for treatment are not the same. Arch Gen Psychiatry 1998;55:120. 36. Regier DA, Kaelber CT, Rae DS, Farmer ME, Knauper B, Kessler RC, and others. Limitations of diagnostic criteria and assessment instruments for mental disorders: implications for research and policy. Arch Gen Psychiatry 1998;55:109–15. 37. Kessler RC, Merikangas KR, Berglund P, Eaton WW, Koretz DS, Walters EE. Mild disorders should not be eliminated from the DSM-V. Arch Gen Psychiatry 2003;60:1117–22. 38. Lin KM, Cheung F. Mental health issues for Asian Americans. Psychiatr Serv 1999;50:774–80. 39. Abe-Kim J, Takeuchi DT, Hwang WC. Predictors of help seeking for emotional distress among Chinese Americans: family matters. J Consult Clin Psychol 2002;70:1186–90. 40. Ali J. Mental health of Canada’s immigrants. Supplement to Health Reports 13, 1–11. Ottawa (ON): Statistics Canada; 2002. 41. Wells JE, Robins LN, Bushnell JA, Jarosz D, Oakley-Browne MA. Perceived barriers to care in St Louis (USA) and Christchurch (NZ): reasons for not seeking professional help for psychological distress. Soc Psychiatry Psychiatr Epidemiol 1994;29:155–64. 42. Crisp AH, Gelder MG, Rix S, Meltzer HI, Rowlands OJ. Stigmatisation of people with mental illnesses. Br J Psychiatry 2000;177:4–7. 43. Wang JL, Langille DB, Patten SB. Mental health services received by depressed persons who visited general practitioners and family doctors. Psychiatr Serv 2003;54:878–83. 44. Schuckit MA. Recent developments in the pharmacotherapy of alcohol dependence. J Consult Clin Psychol 1996;64:669–76. 45. McCrady BS, Langenbucher JW. Alcohol treatment and health care system reform. Arch Gen Psychiatry 1996;53:737–46. 46. Fleming MF, Lawton BK, Manwell LB, Johnson K, London R. Brief physician advice for problem alcohol drinkers: a randomized controlled trial in community-based primary care practices. JAMA 1997;277:1045. 47. Thase ME, Salloum IM, Cornelius JD. Comorbid alcoholism and depression: treatment issues. J Clin Psychiatry 2001;62(Suppl 20):32–41. 48. Johnson BA, Ait-Daoud N, Bowden CL, DiClemente CC, Roache JD, Lawson K, Javors MA, Ma JZ. Oral topiramate for treatment of alcohol dependence: a randomised controlled trial. Lancet 2003;36:1677–85. Author(s)Manuscript received July 2004, revised, and accepted February 2005. 1. Assistant Professor, Department of Psychiatry, University of Manitoba, Winnipeg, Manitoba. 2. Professor, Department of Psychiatry, University of Manitoba, Winnipeg, Manitoba. 3. Graduate Student, Department of Community Health Sciences, University of Manitoba, Winnipeg, Manitoba. 4. Assistant Professor, Department of Community Health Sciences, University of Manitoba, Winnipeg, Manitoba. 5. Professor-in-Residence, Department of Psychiatry, University of California, San Diego, California. Address for correspondence: Dr J Sareen, PZ430–771 Bannatyne Ave Winnipeg, MB R3E 3N4 e-mail: sareen@cc.umanitoba.ca
1 | 2
|
|||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||