Transcultural Psychiatry 50(6) 841–857 ! The Author(s) 2013 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/1363461513511181 tps.sagepub.com

Article

Current research in transcultural psychiatry in the Nordic countries Solvig Ekblad Karolinska Institutet

Marianne Carisius Kastrup Centre for Transcultural Psychiatry

Abstract This article discusses major themes in recent transcultural psychiatric research in the Nordic countries from 2008 to 2011: (a) epidemiological studies of migration, (b) indigenous populations, and (c) quality of psychiatric care for migrants. Over the past several decades, the populations of the Nordic countries, Denmark, Finland, Norway, and Sweden, which were relatively homogeneous, have become increasingly culturally diverse. Many migrants to Nordic countries have been exposed to extreme stress, such as threats of death and/or torture and other severe social adversities before, during, and after migration, with potential effects on their physical, mental, social, and spiritual health. Growing interest in transcultural issues is reflected in the level of scientific research and clinical activity in the field by Nordic physicians, psychologists, social scientists, demographers, medical anthropologists, as well as other clinicians and policy planners. Research includes work with migrants and indigenous minorities in the Nordic countries, as well as comparisons with mental health in postconflict countries. We conclude by suggesting future directions for transcultural psychiatry research and providing guidelines for the education and training of future clinicians in the Nordic countries. Keywords immigrants, indigenous minorities, Nordic countries, psychiatry, refugees, research, transcultural

Corresponding author: Solvig Ekblad, Karolinska Institutet, Department of Learning, Informatics, Management and Ethics (LIME) Unit of Cultural Medicine, Tomtebodava¨gen 18 A, plan 3 SE-171 77 Stockholm, Sweden. Email: [email protected]

842

Transcultural Psychiatry 50(6)

Introduction Globalization is putting social cohesion under great stress in many countries, and key constituents of the architecture of contemporary societies may not be equipped to cope with the social stress of rapid urbanization and related changes (World Health Organization [WHO], 2006). A recent WHO report, “Mental Health and Development” (2010), states that people with mental health conditions meet the criteria for vulnerability and thus, “merit targeting by development strategies and plans” (p. xxiv). Similarly, the WHO Ministerial Conference on Mental Health held in Helsinki in 2005 noted that many aspects of European member states are undergoing transformations and there is a need for mental health policy and services to strive to achieve social inclusion and equity. Mental health services must pay particular attention to vulnerable groups, protect the rights and dignity of patients, and tackle stigma and discrimination (WHO, 2005). Cultural diversity contributes to the challenge of developing public mental health activities that address global quality of life (Bhui, 2011). This challenge is evident in the Nordic countries, where profound societal transformations have resulted from globalization in recent decades. In this article, we define Nordic countries as the Scandinavian countries (Denmark, Norway, and Sweden) plus Finland (Munk-Jørgensen, 2007). (Greenland and The Faroe Islands are formally part of the Kingdom of Denmark, but enjoy extensive autonomy.) The Nordic countries have much in common, including history, social structure, social values, and way of life. The 1987 Nordic Language Convention defines basic linguistic rights in Nordic countries to interact in Swedish, Danish, Norwegian, Finnish, and Icelandic in health care, social security, tax, school, employment authorities, and legal arenas. Statistics for these countries are regularly published by the Nordic Council of Ministers in the “Nordic Statistical Yearbook” (Munch Haagensen, 2011). One result of recent changes has been an increase in the number of migrants in the Nordic countries, seeking work, higher education, family unification, as well as asylum seekers, refugees, and adoptees. Historically, indigenous minority groups have always inhabited Nordic countries, particularly in the northern regions. The Sami people are among the largest indigenous ethnic groups in Europe, but among the smallest indigenous groups in the world, officially numbering around 75,000 (www.nordicway.com). The majority of Sami people live in Norway followed by Sweden, Finland, and Russia. Sweden has five nationally recognized minority ethnic groups: Jews, Roma, Sami, Swedish-speaking Finns, and the Tornedal Finnish people. In Denmark, only the German ethnic minority is registered as a national minority. The Inuit are the indigenous majority population in Autonomous Greenland. In Norway, there are six recognized ethnic minorities: Sami, Kvens, forest Finns, Romani, Roma, and Jews. Finland has historical minorities of Swedish-speaking Finns, Sami people, Russians, Roma, and Tatars. It is difficult to get exact figures on the size of the various minority groups, and those who have retained their traditional culture and lifestyle, because of a lack of official

Ekblad and Kastrup

843

records (Munch Haagensen, 2011). Common history, economic reasons, and shared cultural values have led to liberal regulations governing student exchanges between the Nordic countries, and the ability of workers from one country to work in any of the other Nordic countries. The most common migration pattern in the region is between the Nordic countries themselves. In our discussion of migration research, we have excluded nonimmigrant foreign workers and foreign students not intending to settle permanently in Nordic countries. As of December 31, 2010, Sweden had the largest proportion of foreign-born residents (15% of the national population), followed by Iceland with 10%, followed by Denmark and Norway, each with about 8%, and Finland (4%; www.norden.org/en/the-nordic-region/population). The number of foreign-born residents in the Nordic countries, mainly from Iraq and Somalia, has increased recently due to asylum requests and family reunion. Apart from immigrants in Finland from Russia (many of ethnic Finnish origin) and Estonia, Finland has recently been receiving immigration from the south (Somalia, and the Middle East). A study by Sa¨a¨va¨la¨ (2007–2008) examining how locals in Finland identify resident foreigners revealed a general tendency to identify resident foreigners in terms of their ethnic or national groups (e.g., Somalis) rather than referencing migration status or religion. Background factors included in the analysis were region, age, education, gender, and attitude towards the number of foreign residents in Finland. Accordingly, it is understandable that there is an increasing interest in transcultural issues in mental health in the Nordic countries, particularly in the clinical assessment and epidemiology of psychiatric disorders. This interest is reflected in the increasing richness and diversity of research which includes ethnopsychiatric research examining indigenous conceptions of mental states and mental illness within different cultures, especially in postconflict countries. Likewise, there is an increasing awareness of the need for clinical initiatives targeting the migrant population, as well as improved education and training for workers in multicultural care settings.

Recent migration and asylum trends in Nordic countries Over the past four decades, immigration to the Nordic countries, which previously had fairly homogeneous populations, has increased greatly. As well, reasons for migration have changed, and the countries of origin of migrants are more distant from the Nordic region than in earlier decades. Table 1 shows the number of requests for asylum and the number of people granted asylum during the past two decades (1990, 2000, and 2010) in each of the Nordic countries. In summary, the number of asylum requests in the Nordic countries during the last 3 to 4 years has ranged from 45,000 to 50,000 per year. The number of people who have been granted asylum during the same years is between 15,000 and 20,000 annually, or 35% of asylum seekers. Asylum seekers are excluded from national population statistics. Due to political factors in their

844

Transcultural Psychiatry 50(6)

Table 1. Asylum requests and granted asylum in the Nordic countries1 1990, 2000 and 2010.

Population. 1 January 1990 2000 2010 Persons who requested asylum 1990 2000 2010 Persons granted asylum 1990 2000 2010

Denmark

Finland

Norway

Sweden

5,135,409 5,330,020 5,534,738

4,974,383 5,171,302 5,351,427

4,233,116 4,478,497 4,858,199

8,527,036 8,861,426 9,340,682

5,292 10,347 2,844

2,743 3,170 4,018

– 5,402 10,064

29,420 16,303 31,819

– 5,156 2,124

157 458 1,784

– – 5,331

– 7,221 8,640

1 Excluding Iceland, Greenland, and Faroe Islands due to unsecure figures. The immigrants to Iceland are mainly coming from Poland, the Philippines, and Lithuania (www.nationmaster.com; Munch Haagensen, 2011, pp. 36, 49).

countries of origin and immigration reform in the Nordic countries, asylum request patterns have changed. It is thus difficult to predict the number of foreign-born residents in the Nordic countries in future decades. The aim of this article is to present our views on current themes of transcultural psychiatry research in the Nordic countries from 2008 to 2011, as well as related issues such as clinical care, education, and training of future clinicians. Emerging themes, commonly employed methodologies, and future research directions within transcultural psychiatric research in Nordic countries were identified through a literature review. The article concludes with a discussion of current trends in the transcultural field and issues of particular concern to researchers, clinicians, and educators, as well as an assessment of future research directions.

Methods The database of the Centre for Transcultural Psychiatry in Copenhagen was used to extract current themes in the literature published from 2008 to 2011 in the Nordic countries. This database comprises a selection of all relevant transcultural psychiatry literature published in English, German, or the Nordic languages. Literature covering Nordic research published from 2008 to 2011 was selected using the keywords transcultural, psychiatry, Nordic countries, immigrants, refugees, indigenous minorities, and research. General information was excluded, leaving a list of 104 articles that were examined. In addition, the Karolinska Institutet’s library of completed PhD studies in Nordic universities was reviewed

Ekblad and Kastrup

845

for works in psychiatry, clinical neuroscience, public health, and family medicine published from 2008 to 2011 (transcultural psychiatry is not yet a separate subject at Nordic universities).

Results Transcultural psychiatry in the Nordic universities A total of 48 theses in the area of transcultural psychiatry were published at Nordic universities (see the appendix, available online with this article http://tps.sagepub.com). These studies had both epidemiological and qualitative designs. In Denmark, there is no academic affiliation in the field of transcultural psychiatry, but a Centre for Migration Health has been established at Copenhagen University. A Transcultural Competence Centre exists as part of the Copenhagen region’s mental health services, and it has recently merged with the Clinic for Traumatised Refugees, which primarily provides knowledge dissemination, education, and clinical services. All regions are required to establish clinical services for ethnic minority groups, as well as for traumatized refugees. There is limited transcultural psychiatry content in the medical curriculum, but lectures on transcultural issues are a required component of residency training for psychiatrists. The Danish Psychiatric Association and the Danish Psychological Association both have transcultural sections. There is extensive research in progress in the field of traumatized refugees, both within mental health services in the Copenhagen region and at the Dignity Institute (the former Rehabilitation and Research Centre for Torture Victims) in Copenhagen. In Finland, the University of Tampere has an adjunct professorship in transcultural psychiatry. A number of universities (Tampere, Turku, Helsinki, Oulu, and Kuopio) provide lectures on transcultural aspects of psychiatry for medical students and for psychiatry residents. Several national conferences have been organized by the Finnish Medical Association and the Finnish Psychiatric Association; transcultural issues and lectures have been presented in various symposia and seminars. The School of Health Sciences, University of Tampere, offers a one-semester course entitled “Culture and Mental Health” for health sciences students. The Finnish Psychiatric Association has a transcultural section. Research networks have been established in Finland. Publications include a textbook on culture and medicine (Pakaslahti & Huttunen, 2010). In Norway, there is an academic position in transcultural psychiatry at the University of Oslo. There are master’s programs related to culture and health, as well as an Institute for Sami Health Research and a National Academic Institution for Minority Health (NAKMI) that conducts research and training activities. Some universities offer transcultural psychology courses, as part of degree programs. The Norwegian Psychological Association, which is responsible for specialist training for practitioners, now includes a module on intercultural psychology issues in their main courses. Both the Norwegian Medical Association and the Norwegian

846

Transcultural Psychiatry 50(6)

Psychiatric Association have transcultural sections. For the past 4 years, NAKMI has organized annual national conferences on these topics for clinicians, in cooperation with the Transcultural Psychiatry/Child and Adolescent Psychiatry Committee of the Norwegian Medical Association (NMA), The Norwegian Psychological Association (NPF), and the Norwegian Intercultural Psychology Association (FIP). The Norwegian Centre for Violence and Traumatic Stress Studies (NKVTS) develops and disseminates knowledge in the field of traumatic stress. In Sweden, the Karolinska Institutet (KI) has had an associate professorship in transcultural psychology since 1992. Teaching and scientific collaboration with the Harvard Program in Refugee Trauma (www.hprt-cambridge.org) has developed during the past 7 years. Umea˚ University has extensive experience in international collaboration with researchers in Ethiopia, Nicaragua, and Iran, with support from the Swedish International Development Cooperation Agency (SIDA). There is a Transcultural Centre in Stockholm that is part of the Stockholm County Council’s health services (www.sll.se). Some universities include transcultural issues in the medical student curriculum, but this is not mandatory. In Umea˚, lectures on transcultural psychiatry have been included in the curriculum for medical students since 1980. For the past 12 years, KI has included a 1-week course in transcultural psychiatry and refugee psychiatry for psychiatry residents. Starting in 2011, the participants in the course have additional web-based training both before and after the 3-day course, totalling 1 week. For almost two decades, KI coordinated an active national and international scientific network in the fields of migration, social medicine, and global mental health. The Swedish Society of Medicine has included transcultural psychiatry as a theme at its annual autumn meeting. The Swedish Psychological Association has had a section of immigrant clinical psychologists. These national activities are complemented by the Nordic Psychiatric Congresses which have included presentations on transcultural psychiatry by clinicians and researchers in the Nordic countries as well as invited scholars.

Themes in transcultural psychiatric research, 2008–2011 Reviewing the transcultural psychiatry literature from the past 4 years, the following themes were identified: (a) epidemiological studies: mental health of migrants; differences in health between ethnic groups and their relationship to psychosocial factors; surveys of psychological distress among migrants; high-risk groups (especially indigenous populations and refugee women and children); (b) traumatized refugees: chronic pain (relationship to PTSD and depression); prospective study of mass-evacuated refugees; health promotion course for new refugees (health literacy); psychosocial work with refugees; torture survivors (follow-up studies with respect to migrants’ mental health, work opportunities, quality of life, and predictors of mental health status); (c) studies of asylum seekers and undocumented migrants: children with apathy referred for treatment for suicidal behaviour; health

Ekblad and Kastrup

847

promotion interventions; undocumented migrants in primary care; (d) social psychological/psychiatric studies: empowerment activities in migrant communities and collaboration between responsible actors (clinicians and administrators) in the refugee reception programs; abuse (e.g., physical and sexual) among ethnic minorities; gender differences in symptoms of distress in migrants; perceived discrimination; working conditions and mental health status; mental health problems experienced by elderly migrants; (e) studies of quality of psychiatric care for migrants: utilization patterns in different ethnic groups; satisfaction with services experienced by patients from different ethnic backgrounds; models of mental health services in multicultural settings; need for mental health services for migrants with dementia; cultural case formulation in clinical care; psychometric tests—equality, determining equivalence of concepts, metrics and norms; ethno-psychopharmacology; (f) psychotherapy with migrants: cross-cultural aspects; working with interpreters; use of telepsychiatry; (g) adoption: suicidal behaviour in adoptees.

Migration and epidemiology For over three quarters of a century, psychiatric epidemiology has been a flagship discipline in Nordic countries (Munk-Jørgensen, 2007). The Nordic region has a long-standing tradition of epidemiological research based on high-quality and comprehensive national register data. Researchers in the Nordic countries have unique opportunities to obtain valuable research data, given the high standard of national registers recording migration, ethnicity, and health. The extensive use of personal registration numbers makes it possible to trace selected populations and carry out follow-up and linkage studies in which data from specific disease registers may be linked to social data. Large-scale linkage studies have advantages including large samples, longitudinal measures, low loss to follow-up, and possibilities for extensive control of confounders, but also have limitations to data validity because data are collected for nonscientific administrative, purposes (Munk-Jørgensen, 2007, p. 8). The Danish psychiatric register has been used in extensive transcultural psychiatry research, but to our knowledge there is as yet no comparative research between the Nordic countries in this field. In Denmark, registers include the Danish Cancer Registry, the Danish Central Psychiatric Research Register, the Danish National Patient Register, the Danish National Health Service Register, the Danish Injury Register, and the Danish Medical Birth Register. In Denmark “country of birth” is the most commonly used measure of ethnicity (Norredam, Kastrup, & Helweg-Larsen, 2011). Sweden has official registers adapted for research purposes (Allebeck, 2009). Permanent Swedish residents (excluding asylum seekers, undocumented migrants, EU migrants, and tourists) receive a personal identity number in the Population Registration System, Statistics Sweden (www.scb.se). Other relevant registers are from the National Board of Health and Welfare, publicly funded primary health care registers in each county council, and the Swedish Board of Migration. In Norway, the Institute of Public Health is in charge of seven registers, including

848

Transcultural Psychiatry 50(6)

registers for death, birth, cancer, communicable diseases, and drug prescriptions. Finland also has extensive health registers, including births, deaths, and in- and out-patient health care. During 2010–2012, Migrant Health and Wellbeing (MAAMU) gathered information using interviews and health examinations of 3,000 adults of Russian-speaking, Somali, and Kurdish origin, in six Finnish cities. This is the first large-scale Finnish population survey of the health and well-being of ethnic minority adults and their families. It includes information on important aspects of the physical and occupational health needs of migrants, their service and treatment needs, as well as factors influencing these aspects—in other words, transcultural psychiatry in a broad sense. The results will be used to promote the health and well-being of ethnic minorities, improve the quality of services for migrants and their access to services, and promote the labor market potential of foreigners. An 8-year follow-up study by Jasinskaja-Lahti (2008) regarding long-term immigrant adaptation among immigrants from Russia and Estonia living in Finland found that sociocultural adaptation (i.e., proficiency in understanding, speaking, reading, and writing Finnish) was the most significant predictor of two other long-term immigrant adaptation outcomes (i.e., psychological and socioeconomic). An interview study by Schubert and Punama¨ki (2011) at Tampere University in Finland showed that Southern European torture survivors had a higher level of PTSD than cultural groups from non-Western societies, and higher levels of depressive symptoms compared to survivors from Southern Asian countries. In all cultural groups, women suffered more from PTSD and depression than men. The authors concluded that health care providers and policy makers should consider the influence of culture in communication of somatic and psychological symptoms.

Epidemiological surveys A pioneering contribution to transcultural psychiatry was done by Norwegian researcher Ødegaard (1932) who found an increased risk of psychoses among Norwegian immigrants in the United States. He claimed that some immigrants had “schizothymic constitutions” (p. 194) and discussed how these people could be prevented from emigrating. Later epidemiological research on migration, schizophrenia, and other psychoses carried out in Sweden and Denmark by Cantor Graae and others has documented the risk of schizophrenia in secondgeneration immigrants (Cantor-Graae & Pedersen, 2007). A review of research on public health challenges of immigrants in Norway concluded that the higher risk for mental health problems is primarily associated with social and economic deprivation as well as poor social support systems within immigrant communities (Abebe, 2010). Many migrants, especially refugees, have been exposed to extreme stress and other severe social adversities, both pre- and postmigration, influencing their physical and mental health and need for health care (Lindencrona, Ekblad, & Hauff, 2008).

Ekblad and Kastrup

849

A Swedish register study (Hollander, Bruce, Burstrom, & Ekblad, 2011) concluded that the likelihood of psychotropic drug purchase was significantly higher among female refugees from low-income countries than among female nonrefugees from the same regions, while male refugees had the same risk patterns as nonrefugees from low-income countries. Reason for migration is an important determinant of mental health among immigrants, but not primarily country of origin (Hollander et al., 2011). Measures of migration background have been difficult to obtain and this has been an obstacle to research (Nørredam et al., 2011). Studies that have been able to focus on country of origin have reported that the differences in mental health between migrant groups are largely explained by socioeconomic factors (Tingho¨g, Hemmingsson, & Lundberg, 2007). A longitudinal study with the longest follow-up period of any study published internationally (23 years) found that self-reported psychological distress among Vietnamese refugees in Norway decreased significantly over time (Basilier Vaage et al., 2010). However, a substantially higher proportion of the refugee group reached threshold scores for caseness compared to the Norwegian population. The conclusion from the study was “that refugees reaching threshold scores on measures such as the SCL-90-R soon after arrival warrant comprehensive clinical assessment” (p. 122).

Psychiatric research on indigenous populations The Sami population are the indigenous ethnic population of the northern Nordic countries. The Sami population are historically nomadic reindeer herders or smallscale farmers and fishermen. As indigenous people in the northern part of the Nordic countries, they have been exposed to prejudice and discrimination as influenced by colonization and forced assimilation. In a review of data from the Sami population in Sweden that were compared with Norwegian and Finnish Sami populations, the health condition of the Sami population appeared similar to that of the general Swedish population. However, specific problems were found among the reindeer-herding Sami population which originated in their marginalization and corresponding poor knowledge of reindeer husbandry and the Sami culture amongst the majority population (Sjo¨lander, 2011). A study based on interviews with healers and their patients in Finland and Nord-Troms Norway found that although local healing traditions have transformed, they can be seen as an extension of a long-standing tradition with deep roots in the region (Sexton & Buljo Stabbursvik, 2010). A comparative study of posttreatment satisfaction and recovery in the Sami population and Norwegian psychiatric patients found that patients from the Sami population reported less satisfaction with treatment parameters including staff contact, treatment alliance, information received and global treatment satisfaction (Sørlie & Nerga˚rd, 2005). Suicide is common in the Arctic areas inhabited by the Sami as it is for other indigenous populations in the north (e.g., Canada and Greenland). Jacobsson

850

Transcultural Psychiatry 50(6)

(2011) has described the situation in the northern part of Sweden. A systematic review on mental health, substance use, and suicidality among indigenous youth in the Arctic identified the need for comparative longitudinal studies in the Arctic using culturally relevant instruments that measure early childhood mental health (Lehti, Niemela¨, Hoven, Mandell, & Sourander, 2009).

Studies of quality of psychiatric care for migrants Varied communication patterns and cultural and linguistic differences complicate the process of diagnosing and treating patients from immigrant background. Differences in help-seeking behaviours may be due to stigmatization, health disparities, weak health literacy, and the perception that mental illnesses are normal life events. The experience of war- and disaster-related trauma may be less predictive of severe psychological symptoms onset than the experience of personal trauma, for example, accidents, insecurity, and perceived lack of social acceptance. In a qualitative study of psychiatric care, it was suggested that understanding and reflecting on cultural diversity in psychiatry was more important than cultural competence per se (Shahnavaz & Ekblad, 2007). Most mental health practitioners in the Nordic countries have not received formalized training in the assessment and treatment of transcultural and refugee issues. A study by Scarpinati Rosso and Ba¨a¨rnhielm (2012) compared diagnostic practice and treatment plans developed with the DSM-IV Cultural Formulation to standard psychiatric assessment. A Swedish version of the DSM-IV Cultural Formulation (Ba¨a¨rnhielm, Scarpinati Rosso, & Pattyi, 2007) has been translated into other Nordic languages, and is now available in Danish, Norwegian, and Finnish. In Norway, a review by Lustig et al. (2004) emphasized the importance of the child refugee’s culture of origin in influencing the acceptability of psychiatric treatment. The authors stressed the importance of the clinician’s understanding of the patients’ culture including family systems and traumatic life events. Basilier Vaage, Garløv, Hauff, and Hove Thomsen (2007) performed a retrospective comparative case-control study on referrals to a child psychiatry department. They found no significant difference in referral rates or level of service utilization. Compared to Norwegian children, refugee children were more frequently diagnosed with posttraumatic stress disorder and other affective and emotional disorders, and less often with pervasive developmental disorders and attention deficit hyperactivity disorder. One of the results of the study was to set up a multidisciplinary team for the assessment and treatment of refugee children “to create a space of reflection on ‘otherness,’ culture and context, to exchange experiences and build competence in transcultural consultation and clinical care” (2007, p. 454). Qualitative research methods may be most appropriate for exploratory studies in this emerging field. For example, focus group interviews with Somali seniors and interviews with Islamic healers in Finland indicated that Somali migrants may not understand the Finnish biomedical model for assessment and treatment of mental

Ekblad and Kastrup

851

disorders because they may perceive mental disorders as primarily spiritual or social problems (Elmi Mo¨lsa¨, Harsløf Hjelde, & Tiilikainen, 2010). At the same time, transnational connections may augment personal resilience among Somali migrants. These are important topics for future research.

Nordic networks Two Nordic networks have been established that are relevant to research in transcultural psychiatry. The Cultural Psychiatric and Psychological Network (CPPN) is a loosely organized network comprising nearly 50 psychiatrists and psychologists in the Nordic countries who have a research and/or clinical interest in transcultural psychiatry and psychology. The network was created in October 2004, in Stockholm to encourage transcultural research and collaboration among researchers and clinicians. The World Psychiatric Association (WPA) zonal representative for the Nordic region serves as the CPPN coordinator. The network meets annually, rotating between the transcultural centres in the Nordic countries. In addition to serving as a network for mutual inspiration, its main activities have included the organization of several symposia at the Nordic Congresses of Psychiatry in 2006 and 2009, and the WPA World Congresses in 2008 and 2011, as well as participation in the Carl von Linne´ tri-centennial conference in May, 2007. The first Congress on Mental Health of Indigenous Peoples is being planned by the Sami National Centre for Mental Health (SANKS) in Karasjok, Arctic Norway. In recent years, the network has been informal and not project-funded, and its membership has fluctuated. The Nordic Network for Research on Refugee Children aims to bring together people with an interest in research on refugee children’s health and well-being in the Nordic countries. Criteria for participation in the network include affiliation to a Nordic university or research organization, ongoing research in the area of refugee children, and possession of other important competences for such research. A report was published in 2010 regarding reception of refugee children in the Nordic countries using national reports from Iceland, Finland, Norway, Denmark, and Sweden (Wesley Lindahl, 2010). Current tasks for the network are comparison of the reception of refugee children in the Nordic countries and to present different ways of working with refugee children. The network is coordinated from the Nordic School of Public Health, Go¨teborg, with a steering committee member located in each Nordic country.

Discussion This review was limited in scope, covering literature published from 2008 to 2011, but revealed much promising work that addresses local needs in Nordic countries. The studies reviewed in the previous section are consistent with current trends in cultural psychiatry. At the 2006 World Psychiatric Association-Transcultural

852

Transcultural Psychiatry 50(6)

Psychiatry Section (WPA-TPS) meeting in Vienna these trends were identified as cross-cultural comparisons: ethno-psychiatry and migration psychiatry. Doctoral theses on transcultural psychiatry published from 2008 to 2011 in the Nordic countries are not necessarily representative regionally/geographically, since they include studies involving international collaborative projects in which representatives from Nordic countries participated. In future research, the strengths of the Nordic register studies, as well as Nordic community studies, many of which have high methodological quality, should engender further interest and encourage productive research collaboration. Also, a clear distinction needs to be made between refugee, immigrant, and recognized minority ethnic groups including indigenous populations, since the dynamics of stressful factors impacting on mental health vary greatly between these groups. The health and well-being of the increasingly large population of undocumented migrants and EU migrants also merits further consideration. There is a need for future studies validating the psychometric and clinical diagnostic methods used in transcultural psychiatry research to assess mental health status and quality of life in numerous countries around the world. Furthermore, translation and back-translation methods must be used, and the various types of concept and construct equivalence need to be applied with consistency and transparency. Our findings suggest that refugees and other immigrants generally have higher prevalence of mental health problems than the majority ethnic population in the host country, which is consistent with past research findings. In general, refugees and asylum seekers appear to be at higher risk of suffering from mental illness than immigrants are. Compared with other immigrant women and men, refugee women living in the host country have the highest risk of mental illness. Both social determinants of health and trauma should be investigated in future studies. A prerequisite for conducting productive research in an emerging field is adequate funding. The Norwegian Research Council on Mental Health prioritized funding cultural research from 2009 to 2012. The Nordic School of Public Health (NHV) in Go¨teborg, Sweden also received further resources for research and training in the field. Nordic countries that are members of the EU Commission can apply for funding from the EU Refugee Fund. However, the indirect costs at universities exceed what is permitted by this fund, which makes funding in transcultural psychiatry research a challenge, and calls for closer collaboration with NGOs.

Conclusion Globally, early research in transcultural psychiatry, especially on refugee mental health and adaptation in the reception country, has been dominated by life events/ biomedical framework. However, according to Porter (2007), this approach has been reductionistic or exclusionary and he suggests the field can move forward by adopting a broader biopsychosocial approach. This approach can also be criticized as excluding spiritual and trauma domains. The Siebens Domain Management

Ekblad and Kastrup

853

Model (SDMM) is a proposal to include spiritual issues for a practical clinical model that may bridge the gap between the perspectives of health care providers and individuals’ life worlds (Siebens, 2011). This theoretical model integrates biomedical and the holistic biopsychosocial models but does not give explicit attention to traumatic life events. Current research also has implications for the future of education and training of students and clinicians. Among innovative and promising pedagogical methodologies, virtual encounters (virtual patient with refugee trauma, virtual interpreter, and virtual advisor), and their evaluation is an innovative complementary tool for clinicians and medical students in psychiatry and needs further development (Courteille, Ekblad, Pantziaras, Mollica, & Fors, 2010). Telepsychiatry has been used clinically in Greenland and Denmark in the treatment of traumatized refugees, and results are promising (Mucic, 2010). Research on the diagnostic evaluation of dementia (Nielsen, Andersen, Kastrup, Phung, & Waldemar, 2011) demonstrates that dementia diagnoses among ethnic minorities have been based on insufficient investigation and that there is a need to improve the validity of dementia diagnoses. This stresses the importance of developing assessment instruments that adequately account for the ethnically diverse populations residing in the Nordic countries. To date, only the Swedish version of the DSM-IV Cultural Formulation has been used in scientific research. Comparative analyses of the different versions across the region, including their utility in clinical practice, have yet to be undertaken. However, these should be encouraged in order to develop an instrument that specifically addresses transcultural issues relevant for providing optimal clinical care to ethnically diverse groups. According to WPA guidelines, service providers should be culturally sensitive, geographically accessible, and emotionally responsive (Bhugra et al., 2011). To facilitate this, it may be fruitful to study inequalities, social inclusion, and social networks across such variables as age, gender, socioeconomic status, and reason for migration. There is a danger that migrants who do not receive appropriate clinical services will have poor outcomes. Coordination between the Nordic countries concerning available research resources on assistance to developing countries (through the Danish, Finnish, Norwegian, and Swedish agencies for international aid and assistance) could allow for large longitudinal studies of the consequences of war and the impact of interventions in the migrants’ countries of origin. The possibility of register studies, including linkage studies, in the Nordic countries provides unique opportunities for linking health register data with social data, data on ethnicity, and data on employment. The impact of acculturative stress in the context of the entire migration process and differences in mental health outcomes is receiving growing attention (Lindencrona, 2008). Comparative studies of host country strategies for refugee resettlement in the Nordic region are welcomed by policy makers, in particular concerning different countries’ asylum procedures and our knowledge of the impact on mental health of migrants’ length of stay in asylum centers.

854

Transcultural Psychiatry 50(6)

Investigating aspects of migrants’ psychosocial resilience in future research on mental health in multicultural contexts would challenge the focus on vulnerability, and perhaps promote resilience among immigrants and other migrant groups (Ingvarsdotter, 2011). This subject is often overlooked among immigrants and nonpermanent foreign workers and students. They may be better able to cope with acculturative stress related to migration than other migrants, such as refugees and asylum seekers. Data needs to be collected concerning how they adapt in the host country they migrate to, as well as how supportive and effective ethnic enclaves from their countries of origin are in helping these migrants adapt to the host country’s way of life. Another topic of great importance is differences in cultural adaptation across generations. The increasing numbers of unaccompanied refugee children and youth are now also subject to research (Oppedal, Seglem, & Jensen, 2009) and studies of social support and acculturation have become obvious subjects for resilience research. The WPA recommendations for improving mental health and mental health care in migrants should be implemented, in order to assess and monitor pathology such as “regular research into epidemiological factors, along with qualitative approaches” (Bhugra et al., 2011, p. 7). Mental health promotion should be directed to immigrant populations from low-income countries and with trauma experiences. Despite the universal right to health, people who are part of indigenous minority groups as well as those of different ethnic backgrounds experience unjust inequalities in mental health care and this subject needs to be acknowledged by greater focus in future research. Integration of traditional healing methods within traditional health services has been proposed by the World Health Organization. Studies show that such integration is desirable by users of mental health services in Norway from the Sami population, and should be investigated in other Nordic countries. This review underlines the need for formalized education and training for students, residents, psychiatrists, psychologists, and other clinical staff, in order to focus on premigration stress, postmigration stress, and the procedures for empowering refugees and asylum seekers to adapt to their host countries. This is an especially sensitive and important topic among female migrants who have been victims of severe premigration and/or postmigration trauma. Health professionals and researchers who themselves are refugees or immigrants may be able to play a key role in this training process, as well as in the treatment of migrants. Acknowledgements Special thanks to Helle Rasmussen, Librarian at the Centre for Transcultural Psychiatry, Mental Health Services Copenhagen, Denmark, and Johnny Carlsson, Senior Librarian at the Karolinska Institutet Univeristy Library, Stockholm, Sweden.

Funding This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

Ekblad and Kastrup

855

References Abebe, D. S. (2010). Public health challenges of immigrants in Norway: A research review (Norwegian Center for Minority Research [NAKMI] Report 2). Retrieved from http:// www.migrasjonsforskning.no/site-no/04-Publikasjoner/pdf/Public%20Health%20 Challenges.pdf Allebeck, P. (2009). The use of population based registers in psychiatric research. Acta Psychiatrica Scandinavica, 120, 386–391. Ba¨a¨rnhielm, S., Scarpinati Rosso, M., & Pattyi, L. (2007). Kultur, kontext och psykiatrisk diagnostik. Manual fo¨r intervju enligt kulturformuleringen i DSM-IV [Culture, context and psychiatric diagnostics. A manual for interview according to the Cultural Formulation of DSM-IV]. Stockholm, Sweden: Transkulturellt Centrum, Stockholms la¨ns landsting. Basilier Vaage, A., Garløv, I., Hauff, E., & Hove Thomsen, P. (2007). Psychiatric symptoms and service utilization among refugee children referred to a child psychiatry department: A retrospective comparative case note study. Transcultural Psychiatry, 44(3), 440–458. Basilier Vaage, A., Thomsen, P. H., Silove, D., Wentzel-Larsen, T., van Ta, T., & Hauff, E. (2010). Long-term mental health of Vietnamese refugees in the aftermath of trauma. British Journal of Psychiatry, 196, 122–125. Bhugra, D., Gupta, S., Bhui, K., Craig, T., Dogra, N., Ingleby, D. J., . . . Tribe, R. (2011). WPA guidance on mental health and mental health care in migrants. World Psychiatry, 10, 2–10. Bhui, K. (2011). Cultural psychiatry and epidemiology: Researching the means, methods and meanings. Transcultural Psychiatry, 48, 90–103. Cantor-Graae, E., & Pedersen, C. B. (2007). Risk of schizophrenia in second-generation immigrants: A Danish population-based cohort study. Psychological Medicine, 37, 485–494. Courteille, O., Ekblad, S., Pantziaras, I., Mollica, R., & Fors, U. (2010, April). Virtual encounter: A socio-educational training model to challenge patient-centered interviewing skills. Oral presentation at the Karolinska Institutet’s 12th Educational Congress, Stockholm, Sweden. Elmi Mo¨lsa¨, M., Harsløf Hjelde, K., & Tiilikainen, M. (2010). Changing conceptions of mental distress among Somalis in Finland. Transcultural Psychiatry, 47(2), 276–300. Hollander, A.-C., Bruce, D., Burstrom, B., & Ekblad, S. (2011). Gender-related mentalhealth differences between refugees and non-refugee immigrants: A cross-sectional register-based study. BMC Public Health, 11, 180. Retrieved from http://www.biomedcentral.com/1471-2458/11/180 Ingvarsdotter, K. (2011). Mental ill health and diversity: Researching human suffering and resilience in a multicultural context (Doctoral thesis). Malmo¨ University, Malmo¨, Sweden. Jacobsson, L. (2011). Psykisk oha¨lsa och sja¨lvmord bland rensko¨tande samer [Mental disorder and suicide among reindeer herding Sami population]. In K. Jonsson, L. Jacobsson, J. Chotai, A. Lehti, R. Adolfsson, A. Norberg, & E. Slander Renberg (Eds.) Depression a¨r vanligare a¨n vi vill tro (pp. 29–43). Umea˚, Sweden: Umea˚ universitet, medicinska fakulteten. Jasinskaja-Lahti, I. (2008). Long-term immigrant adaptation: Eight-year follow-up study among immigrants from Russia and Estonia living in Finland. International Journal of Psychology, 43(1), 6–18. Lehti, V., Niemela¨, S., Hoven, C., Mandell, D., & Sourander, A. (2009). Mental health, substance use and suicidal behaviour among young indigenous people in the Arctic: A systematic review. Social Science & Medicine, 69, 1194–1203.

856

Transcultural Psychiatry 50(6)

Lindencrona, F. (2008). Strategies for a health promoting introduction for newly-arrived refugees and other migrants (Doctoral thesis). Karolinska Institutet, Stockholm, Sweden. Lindencrona, F., Ekblad, S., & Hauff, E. (2008). Mental health of recently resettled refugees from the Middle East in Sweden: The impact of pre-resettlement trauma, resettlement stress and capacity to handle stress. Social Psychiatry and Psychiatric Epidemiology, 43, 121–131. Lustig, S. L., Kia-Keating, M., Knight, W. G., Getman, P., Ellis, H., Kinzie, J. D., . . . Saxe, G. N. (2004). Review of child and adolescent refugee mental health. Journal of the American Academy of Child & Adolescent Psychiatry, 43(1), 24–26. Mucic, D. (2010). Transcultural telepsychiatry and its impact on patient satisfaction. Journal of Telemedicine and Telecare, 16, 237–242. Munch Haagensen, K. (Ed.). (2011). Nordic statistical yearbook 2011. Retrieved from http:// www.norden.org/sv/publikationer/publikationer/2011-001 Munk-Jørgensen, P. (2007). Psychiatric epidemiology: A Scandinavian contribution to international psychiatry. Acta Neuropsychiatrica, 19, 6–10. Nielsen, T. R., Andersen, B. B., Kastrup, M., Phung, T. K. T., & Waldemar, G. (2011). Quality of dementia diagnostic evaluation for ethnic minority patients: A nationwide study. Dementia and Geriatric Cognitive Disorders, 31, 388–396. Nørredam, M., Kastrup, M., & Helweg-Larsen, K. (2011). Register-based studies on migration, ethnicity and health. Scandinavian Journal of Public Health, 39(Suppl. 7): 201–205. Ødegaard, Ø. (1932). Emigration and insanity. A study of mental disease among the Norwegian population of Minnesota. Acta Psychiatrica et Neurologica. (Suppl. 4) Copenhagen, Denmark: Elving & Munksgaard. Oppedal, B., Seglem, K. G., & Jensen, L. (2009). Avhengig og Selvstendig. Enslige mindrea˚rige flyktningers stemmer i tall og tale. Rapport 2009:11 [Dependent and independent. The voices of refugees of minor age. Report 2009:11]. Oslo, Norway: Folkehelseinstituttet. Pakaslahti, A., & Huttunen, M. (Eds.). (2010). Kulttuurit ja la¨a¨ketiede [Culture and medicine]. Helsinki, Finland: Duodecim. Porter, M. (2007). Global evidence for a biopsychosocial understanding of refugee adaptation. Transcultural Psychiatry, 44(3), 418–439. Sa¨a¨va¨la¨, M. (2007–2008). How do locals in Finland identify resident foreigners? Finnish Yearbook of Population Research, 43, 115–130. Scarpinati Rosso, M., & Ba¨a¨rnhielm, S. (2012). Use of cultural formulation in Stockholm: A qualitative study of mental illness experience among immigrants. Transcultural Psychiatry, 49(2), 283–301. Schubert, C. C., & Punama¨ki, R.-L. (2011). Mental health among torture survivors: Cultural background, refugee status and gender. Nordic Journal of Psychiatry, 65(3), 175–182. Sexton, R., & Buljo Stabbursvik, E. A. (2010). Healing in the Sa´mi North. Culture, Medicine and Psychiatry, 34, 571–589. Shahnavaz, S., & Ekblad, S. (2007). Understanding the culturally diverse in psychiatry rather than being culturally competent: A preliminary report of Swedish psychiatric teams’ views on transcultural competence. International Journal of Migration, Health and Social Care, 3, 14–30. Siebens, H. C. (2011). Proposing a practical clinical model. Topics in Stroke Rehabilitation, 18(1), 60–65.

Ekblad and Kastrup

857

Sjo¨lander, P. (2011). What is known about the health and living conditions of the indigenous people of northern Scandinavia, the Sami. Global Health Action, 4, 8457 Retrieved from http://www.globalhealthaction.net/index.php/gha/article/view/8457/12500 Sørlie, T., & Nerga˚rd, J.-I. (2005). Treatment satisfaction and recovery in Saami and Norwegian patients following psychiatric hospital treatment: A comparative study. Transcultural Psychiatry, 42(2), 295–316. Tingho¨g, P., Hemmingsson, T., & Lundberg, I. (2007). To what extent may the association between immigrant status and mental illness be explained by Socioeconomic factors? Social Psychiatry and Psychiatric Epidemiology, 42(12), 990–996. Wesley Lindahl, R. (2010). Reception of refugee children in the Nordic countries: National reports. Retrieved from http://www.dignityinstitute.dk/servicenavigation/news-andactivities/news/2010/12/reception-of-refugee-children-in-the-nordic-countries.aspx World Health Organization (WHO). (2005). Mental health: Facing the challenges, building solutions. Geneva, Switzerland: Author. Retrieved from http://www.euro.who.int/ __data/assets/pdf_file/0008/96452/E87301.pdf World Health Organiztion (WHO). (2006). Working together for health. The world health report. Geneva, Switzerland: Author. Retrieved from http://www.who.int/whr/2006/ whr06_en.pdf World Health Organization (WHO). (2010). Mental health and development: Targeting people with mental health conditions as a vulnerable group. Geneva Switzerland: Author Retrieved from http://whqlibdoc.who.int/publications/2010/9789241563949_eng.pdf.

Solvig Ekblad, licensed psychologist, PhD, is Head of the Unit for Cultural Medicine and Associate Professor in Transcultural Psychology in the Department of Learning, Informatics, Management, and Ethics (LIME) at Karolinska Institutet, Stockholm, Sweden. Dr Ekblad is an adjunct professor at the Massachusetts School of Professional Psychology and Program Co-Director in the Master’s Program “Global Mental Health – Trauma and Recovery” (www.hprt-cambridge.org). Ekblad has over 25 years of research experience in the field of global mental health, as well as in teaching and supervision. She is currently the Principal Investigator of several projects with both national and international cooperation. Her published works focus on intercultural and interpersonal competence among clinical staff and global mental health, as well as conceptual and methodological issues with refugee populations. Her work can be accessed online at www.ki.se. Marianne C. Kastrup, MD, PhD, is a senior consultant at the Competence Centre for Transcultural Psychiatry, Psychiatric Centre Ballerup, Denmark. Dr. Kastrup researches mental health services for minority ethnic populations. Her published works focus on mental health register research and issues related to minority ethnic groups and traumatized refugees as well as gender-related violence.

Copyright of Transcultural Psychiatry is the property of Sage Publications, Ltd. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.