Background and Significance:
Canadians of South Asian (SA) origin, defined as individuals with ancestral ties to India,
Pakistan, Bangladesh, Sri Lanka, Bhutan, Afghanistan, Maldives and Nepal, comprise the
largest racialized group in Canada, amounting to 1.6 million individuals or 5% of the
Canadian population and 32% of the Canadian Asian population. This makes them the largest
visible minority group in Canada, comprising 25.6% of the visible minority population,
followed by East Asian and African-Caribbean Canadians, respectively. The SA Canadians are
disproportionately affected by high rates of anxiety and mood disorders, placing those
immigrating to Canada at age 17 or younger at a significantly higher risk for this condition
compared to immigrants from elsewhere who immigrated at the same age.
The SA Canadians are disproportionately impacted by the social determinants of health,
including unemployment, low income, language barriers, low education, low literacy and
migration stress. These factors can negatively impact mental health and decrease access to
care, thereby increasing mental health inequities. Compared to other ethnocultural groups, SA
Canadians with a major depressive episode reported the highest proportion of unmet mental
health care needs (48%) and the highest percentage of perceived barriers to the availability
of mental health care(33%). Canadians who had a major depressive episode and identified as SA
were 85% less likely to seek treatment than Canadians who had experienced the same illness
but identified as white. The lower use of mental health services by SA Canadians highlights
the inequities in access to appropriate care for these populations.
The Mental Health Commission of Canada (MHCC) recommends improving Canadian mental health
care to serve diverse populations with equitable, timely access to appropriate, effective,
and evidence-based treatments that attend to unique sociocultural needs (Mental Health
Commission of Canada, 2014). The MHCC Case for Diversity report further highlights the
necessity for culturally and linguistically relevant services particularly for immigrant,
refugee, ethnocultural and racialized populations, such as SA Canadians. In light of the new
$5B targeted federal transfer to "improve access to mental health and addiction services and
to structured psychotherapy" (Government of Canada, 2016) there is an opportunity to
complement efforts to expand the access that adequately address the mental health needs of
diverse Canadian populations.
Cognitive Behavioural Therapy in its current form is not suitable for persons from the
non-western cultural background. Culturally-adapted Cognitive Behavioural Therapy (Ca_CBT) is
an evidence-based practice. CaCBT is more effective than standard CBT and can reduce dropouts
from therapy compared with standard CBT. Thus CaCBT can increase access to mental health
services and improve outcomes for immigrant, refugee, ethnocultural and racialized
populations. Adapting CBT for growing SA populations in Canada will ensure equitable access
to effective, culturally-appropriate interventions. Accordingly, this study proposes to
develop and evaluate Ca_CBT for depression and anxiety among SA populations in Canada.
Study Objectives:
The primary objective of the study is to develop culturally adapted CBT for South Asian
persons with depression and anxiety. Secondary objectives include; (a) testing CaCBT against
standard CBT for efficacy and cost-effectiveness, and (b) to test whether training in
culturally adapted CBT can improve therapist's cultural competence.
Methods:
This mixed methods study will be conducted in three phases:
Phase 1: Cultural Adaptation of CBT Cultural adaptation of CBT for SA populations in Canada
experiencing depression and anxiety using stakeholder consultations and qualitative
methodology
Phase 2: Pilot Feasibility Testing of Ca_CBT Pilot test the newly developed Ca_CBT for
feasibility, acceptability and effectiveness via quantitative methodology and a randomized
controlled trial
Phase 3: Implementation & Evaluation of Ca_CBT Trained therapists working with SA populations
to use Ca_CBT with their clients. Evaluate therapist competence in using Ca_CBT as well as
client satisfaction with the newly developed therapy.