With Canadian family size averaging 1.9 children per household in 2011 (Statistics Canada, 2012), immigration remains an economic imperative for Canadaâ€™s continued dominance as one of the worldâ€™s economic power. The country seems to balance its book and meet the shortage of labour through various forms of immigration including skilled migration programs and admitting an increasingly large number of refugees from abroad and those that claim protection from within Canada.
For instance, in 2010, Canada accepted 24,696 refugees in all classes and admitted a total of 280,681 permanent residents in all categories (Citizenship and Immigration Canada-CIC, 2012). This has led the country to become one of the most diverse countries in the world. In 2001, for example, the proportion of foreign-born reached the highest in 70 years, visible minority population increased three-fold since 1981 with more than 200 ethnic groups being reported (Statistics Canada, 2003).
However, with such large number of immigrants and refugees making Canada their second home, the country seems to not care for these segments of the population in a way that it should. This can be evidenced by the fact that immigrantsâ€™ health on arrival is better and decline the longer they stay in the country (Ng, 2011) and the prevalence of certain health conditions disproportionately higher. Supporting this claim, a study conducted by Fenta, Hyman and Noh (2004) suggested that a lifetime prevalence of depression among Ethiopian immigrants and refugees to be 9.8%; slightly higher than the lifetime prevalence rate among Ontarians (7.3%).
Studies have shown that such a disproportionate health status has a significant impact on individualâ€™s ability to contribute to the Canadian economy. (Stansfeld et al. 1995) Adding insult to an injury, however, the current overhaul to the immigration policies and other related service provisions such as health care (specifically the Interim Federal health Program-IFH) (CIC, 2012) may further aggravate these disproportionate health outcomes.In this paper, I will explore the prevalence of depression among immigrants and refugees, its impact and possible implications to Social Work practice.
Impact of depression
In its 2001 World Health Report, the World Health Organization-WHO indicated that mental disorders are growing worldwide and that more than 25% of all people will be affected at some time in their lives. Similar report ranked depression as the fourth leading cause of burden on society (WHO, 2001). The situation in the Canadian context does not seem any different. About 4% of Canadians reported symptoms which suggested that they had suffered an episode of major depressive disorder in the previous year in 1998/99 (Statistics Canada, 2001) Studies related to depression have long existed and engaged attentions of researchers since 1911 (Beck, 1961).
Among refugees and immigrants too, similar interest in the study of depression has been observed. It was investigated more than other mental illnesses among these particular segments of the population. Emily and colleagues (2012) conducted a literature review on rates of mental illness and suicidality in immigrant, refugee, ethno cultural, and racialized groups in Canada. Their analysis indicates that most of the studies they reviewed on mental illnesses of immigrants and refugees focused on depression. Although depression has been given such a due attention, estimates to its prevalence show different rates among the specific studies. Some reported a lower prevalence rate of 4.5% among adult immigrants and refugees while other showed a higher rate of 24.1%. This is evidenced by a study conducted by Lindert and colleagues (2009). Their analysis further indicated that the combined estimated prevalence for depression among refugees was 44%.
The discrepancy in prevalence rate of depression could be explained by inaccurate population counts, demographic differences between groups, the diverse nature of immigrants and refugees who are often lumped a one population group by geographic location (Emily, Tuck, Lurie, and McKenzie 2012). Despite such discrepancy in the prevalence rate of depression among immigrants and refugees, however, studies have shown that immigrantsâ€™ health on arrival is better and decline the longer they stay in the country (Ng, 2011) and that a lower prevalence rate of depression is observed at early stages of migration compared to the Canadian population.
Supporting this, Ali (2002) reported that compared to the Canadian-born population; the odds that immigrants experienced a depressive episode in the previous year were lower for recent cohorts but not for longer-term ones while this advantage was less pronounced with increasing length of residence in Canada. At a national level, this declining trend in mental health status, together with disproportionate disease burden such as depression have significant impact on the level to which immigrants and refugees contribute to Canadaâ€™s socio economic standing; the very reason why the government admits them to the country in the first place. Mirella (2011) indicates that employees with a mental illness have a high probability of experiencing reduced concentration, poor memory and other symptoms, depending on their personal circumstances and this, in the workplace, can impact negatively on their performance and attendance. Globally, the impact of such reduced performance is estimated at 70 billion annually (Tanouye, 2001).
In the Canadian context, the estimated total burden of $14.4 billion places mental health problems among the costliest conditions with the health care system sharing an estimated $278 million due to consultations with psychologists and social workers not covered by public health insurance (Stephens & Joubert, 2001). The mental health commission of Canada (2012), in its recently released national strategy, highlights how the impact of on individuals and family care givers cannot be over estimated. According to the strategy, depression and other similar mental illnesses overtake the lives of individuals and families by grief and distress.
Furthermore, stigma related to these conditions generate a tremendous sense of unwarranted shame and guilt, which can undermine caregiversâ€™ confidence and well-being and have a long-lasting impact. The strategy also notes the negative impact on people living with mental health problems and illnesses, such as depression, affecting all aspects and stages of their livesâ€“ dealings with friends, family, communities, educators, employers, mental health service providers, and health care system. (Mental Health Commission of Canada, 2012)
Implications for Social Work Practice:
Systemic Level Advocacy on policy changes related to Interim Federal Health Program-IFHP Up to and including June 29, 2012, the services covered by the IFHP for all eligible beneficiaries included basic coverage (i.e., treatments normally covered by provincial or territorial health insurance plans); supplemental coverage (i.e., health-care benefits similar to those provided through provincial social assistance plans, such as drugs and dental and vision care); and costs related to the Immigration Medical Examination (IME) (CIC, 2012).
Refugee claimants, resettled refugees, persons detained under the Immigration and Refugee Protection Act, victims of trafficking in persons and the in-Canada dependants of these groups who are unable to pay for health care are eligible for benefits under the IFHP until they become eligible for provincial/territorial or private health plan coverage. Under this program, resettled refugees with provincial/territorial health coverage are provided with supplemental coverage for one year from the date of entry to Canada (CIC, 2011). After the changes are in place, the IFHP will offer only two basic types of coverage.1) Health-care services that are only of urgent or essential nature; medications and vaccines only when needed to prevent or treat a disease posing a risk to public health or a condition of public safety concern or 2) Public Health or Public Safety Health-Care that will cover the cost of products and services only to prevent or treat a disease posing a risk to public health or a condition of public safety concern (CIC,2012).
The changes introduced to the Interim Federal Health Program become of critical importance for mental health status of refugees and new immigrants as they continue to face particular challenges that put their mental health at greater risk. They often have difficulty getting a job that matches their level of skills and education, earning a decent income, obtaining adequate housing, and face significant barriers to their seeking or obtaining help. (Mental Health Commission of Canada, 2012)
The new changes state that refugees and immigrants will receive Health-care services that are only of urgent or essential nature; medications and vaccines only when needed to prevent or treat a disease posing a risk to public health or a condition of public safety concern (CIC, 2012). This means that a refugee who suffers from depression will not be able to receive adequate treatment; further aggravating his/her condition because such condition may not be perceived to be neither urgent nor a danger to the public. Mental health services in general are already given a lesser priority than most other services.
This is clearly reflected by the fact that only one in three people who experience a mental health problem or illnessâ€”and as few as one in four children or youthâ€”report that they have sought and received services and treatment (Mental Health Commission of Canada, 2012). Given these, the restrictions introduced to the Interim Federal Health Program will create additional barrier to an already compromised system; adding insult to an injury.
Furthermore, the changes will gravely affect refugeesâ€™ and immigrantsâ€™ mental health situation in general who are at an even more disadvantage due to their culture and the systemic discrimination they face when it comes to accessing health services in general and mental health services in particular. For instance, a qualitative phenomenological study conducted by Martin and colleagues (2010) indicated that lack of trust in doctors and race of doctors were among factors that were influenced by culture and discrimination that participants faced. Furthermore, Gender and language of immigrants have also been found to greatly impact their access to health care (Pottie et al, 2008) adding more barriers to refugeesâ€™ and immigrantsâ€™ health care access.
Highlighting these significant impacts, Social Workers can and should challenge the governmentâ€™s recent policy related to the interim Federal health Program-IFHP. This is primarily because they are uniquely placed to stress the impacts of such changes; especially through their professional value related to social justice. The validity of this unique Social Workersâ€™ role to affect policies, according to Katz (1961) historically stems from the competency of professional social workers, the goals of social work itself, and its related professional ethics Hence, Social Workers can and should mobilize other professionals in the health field in an inter-professional collaborative manner to reverse these recent policy changes. They, for example can learn from best practices and join the call for action that has already been started by the Canadian Doctors for Refugees (2012).
Individual level Evidence based and culturally competent practice of specific interventions Advocacy and policy change takes time. Furthermore, policy changes might only be attainable through changes in the current political landscape. Social Workers, in the mean time, can have another key role in addressing immediate impacts of these policy changes by providing individual level interventions. As counselors and therapists, they can utilize evidence based and culturally competent approach to find effective intervention strategies that could address such mental illnesses as depression.
For instance, Stressing the fact that Cognitive Behavioral Therapy (CBT) recommended to be among the most effective treatments for major depression, Interian and DÃaz-MartÃnez (2007) outlined a comprehensive analysis and Considerations for culturally competent cognitive-behavioral therapy for the treatment of depression with Hispanic patients. However, although the effectiveness of CBT as a intervention for the treatment of depression, Social workers need to consider other factors and look for more evidence before implementing such interventions. In cases of co-occurring conditions such as substance abuse, for example, the effectiveness has been found to be inconclusive by some studies.
Hides, Samet and Lubman (2010) did systematic review of clinical trials and found only a limited evidence for the effectiveness of CBT either alone or in combination with antidepressant medication for the treatment of co-occurring depression and substance use. Despite this conclusion, however, their study indicated that there is growing evidence that that the effects of CBT are durable and increase over time during follow up. In addition to other co-occurring conditions, some studies found limitations on the effectiveness of CBT for the treatment of depression among specific population too.
A study by Sandil (2006) found no empirical evidence for the efficacy of Cognitive behavioral therapy for adolescent depression among Asian immigrants in the United States and advised on the need to validate the use of CBT with this population. These studies indicate how it is important for practitioners to identify the person in an environment, be cognizant of cultural and individual factors and the extent to which interventions such as CBT must be guided by Evidence.Given their practice model, ethics and professional value, Social Workers remain uniquely placed to deliver on these.
Canada remains a multi-cultural country where immigrants and refugees contribute a great deal. However, studies show that they are at a disadvantage when it comes to their health and mental health status with disproportionate disease burden such as depression. Further aggravating this situation, misguided, recent policy changes seem to put them even at a greater disadvantage. Social workers, through their unique professional values such as Social Justice and effective practice models such as indentifying the person in an environment using a Biopsychosocial lens, can play a key role to effectively address these issues. They have a key role in advocacy and policy change, both as policy makers and implementers, on behalf of the people that they serve. On top of these, they must remain committed to provide culturally competent, effective and evidence based interventions at an individual level. Collaboration with other professional working for the wellbeing of society could greatly add to the effectiveness of these key roles Social Workers have.
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