The effects of psycho-education and self-help on depressive Surinamese Hindustani

In the Netherlands, there is a large community of Surinamese Hindustani. The
prevalence of depression in this group is approximately just as high as that in
the autochthon population (12.4%). The impact seems however more severe. The
percentage suicides in this group is approximately four times as high as that
in the autochthonal population. Moreover this group is underrepresented in the
regular psychiatric care. Most of the people seek help in their own group or at
the spiritual leader. Given the seriousness of the impact the prevention of
depressive disorders in this group deserves a high priority. Finding the right
access for preventive interventions in this group, forms thereby the most
important challenges.
The assistance is provided at the place where the community mainly looks for
support: the temple (part of the cultural organization).
This study will also take place in the Hindu temples. In about 3 temples, a
semi-structured interview will be taken of the board and structured
questionnaire of the visitors.

In this study we propose the following:
Inventory of the support and willingness of the visitors of the temples to
participate. This study should be beneficiary in the development of a
preventive program, focusing on depression.

Objective
Inventory of the support and willingness of the visitors of the temples to
participate. This study should be beneficiary in the development of a
preventive program, focusing on depression.
The primary outcome of this randomised trial is: depressive symptoms. Secondary
outcomes include: incidence of depression, suicidal ideation, symptoms of
anxiety, use of antidepressants / benzodiazepines, (mental) health care use
(including medication), absence of work and quality of life.

Problem definition
In the Netherlands, approximately 332,500 people of Surinamese origin are
living (CBS, 2006). About 200,000 of them are Hindustani. The Hindustani
community can be considered as a collection of smaller groups, dynasties and
families (Adhin, from 1998; Van Dijk et al. 1999). It is a very closed
community with a we-character, which identify itself as conflict avoiding,
demanding, loyal and progressive. The groups have generally a patriarchal
structure (Van Dijk et al. 1999). During the upbringing much emphasis is laid
on performance, amiability and respect. This even can seems to be very humbly.
Hindustani believe in spirits. Gods can also appear as spirits (Van Dijk et
al.1999; Rambaran & Koeldiep 2004). These spirits gives support, unless they
are evil spirits. They play a role at rituals during birth, sickness and dead,
as well as in traditional (religious or spiritual) healing. People who sees
good spirits are not considered to have a psychiatric disorder. When it is
about evil spirits, a spiritual healing will be done by a Pandit (Hindu priest)
or a spiritual healer.
Within these closed community psychiatry is considered a taboo. It has been
known from the healthcare authorities that this group seeks very minimal aid
through the common way. Most of the Hindustani are a member of a cultural
organisation, which manages the Hindu temples. First they seek for help for
their problems within this organisation or temple, by a religious or spiritual
healing (Gokoel, 2005; Adhin, 1998; Van Dijk, et al., 1999). When they have to
visit a general practitioner (GP), they usually are loyal to the doctor.
However, it is necessary to some extent that they can find themselves in the
explanation (explanatory model) of the doctor (Braakman et al., 2003). It is
important to let the patient and the family tell you what the cultural norms
are. When this does not happen, then a disagreement can arise, with a poor work
relation and therapy non-compliance.
From general population research, it is clear that depression is an important
health problem with a high year prevalence, a great burden on personal level,
but also on population level and with enormous economic costs (Smit et al.,
2005; Cuijpers et al., 2005). As well as from the perspective of the public
health and that of the individual patient, the optimum prevention of a
depression deserves the highest priority.
In the Netherlands there are no study known regarding the incidence and
prevalence of depression in the Hindustani community. In the international
literature estimates are given which varies from 5 to 25% (Fareed Aslam Minas
et al, 2000; Mirza and Jenkins, 2004; Raguram et al, 1996; Khan 2002; Tiwari
2000). Therefore it seems that depression occurs as frequent as in the
autochthon population and possibly even more often. However, the impact seems
to be more severe than in the autochthon population. Research by the GGD in The
Hague shows that suicide ideations and suicide attempts in the Hindustani group
are four times higher than in the autochthons (GGD The Hague, 2000; Burger, et
al. 2005). Research within the Hindustani comunity, who lives in Suriname, has
shown approximately the same remarkably high percentage suicide ideations and
suicide attempts (Graafsma & Mooij, 2006; Graafsma, et al., 2006). This is
confirmed in studies in the Hindustani communities elsewhere in the world, like
in United Kingdom, Maleisia, Singapore, the Fiji islands, Guyana and Trinidad
(Bhugra 2003; Mahy 1993; Maniam 2003). Social deprivation (poverty), social
fragmentation, alcoholism, family problems (especially in women) and
psychiatric disorders are considered in these studies to be important risk
factors.
For this reason, the prevention of depressive disorders in this group deserves
high priority. Finding the precise access for preventive interventions in this
closed community, forms thereby the most important challenges.

Relevance
To reach the participants, existing networks are used as much as possible. The
temple is therefore the most suitable place, because it has a important role in
the Hindustani community and it is the first place where problems are
discussed.
There are no figures known of the under represenation of this target group in
the regular (mental) health care. In the report "Diversiteit in de participatie
in gezondheidsbevordering, een verkennende studie* (diversity in the
participation in health promotion, an exploring study) (Vliet et al., 2006)
this is appointed as a problem: "Allochthones (immigrants) does not know the
rules and possibilities of the health care and prevention and the care workers
experience this as a burden. The knowledge concerning participation of
immigrants has been fragmented and limited, and the conditions for
participation in policy making are not yet present."
There is little information or knowledge available on the specifics of target
group participation of immigrants. Immigrants are underrepresented or not
involved in policy making, researches (studies), knowledge advancement and
care. Target group, community or target group participation (of immigrants) are
no unambiguous concepts. Moreover, these concepts get especially interpreted
from the point of view of the professionals. It is important to give attention,
on by who and how the target group or community is defined, to the diversity
within the target group and the different positions the members of the group
takes at the same time. There is almost never a discussion explicitly about the
different roles of the professionals and the specific competence necessary to
work together with the target group. There is furthermore no health policy
especially form the immigrants, and even less the participation of immigrants
in health care policy making. The assumption is that participation of
immigrants can be significant with a view to improving their health situation
and the degree of care usage. Professionals needs specific skills, which is
necessary to make a collaboration work. There is a tension between the wishes
and interests of the target groups and of the professionals. Intercultural
competency and knowledge of different migrant groups, cultures and backgrounds
must be promoted to the professionals. Cultural differences, such as the
difference in the way health is experienced and the manner of communicating can
play a role. Attention is necessary for `conflict or interest*: there are
inevitably differences in expectations, wishes and perspective. The
professional must have sufficient skills, knowledge and commitment to work with
the target group. It stands out that there is never a explicitly discussion
about the competency of the professional, which is necessary to work well with
the target group, such as skills in intercultural communication. Professionals
also must be able to handle several roles: they should be able to anticipate
on the wishes of the target group, and use their professionalism to work out
and carry out those wishes further (Vliet, et al. 2006).
This is an important reason why the Hindustani, first seeks help in their own
group.
In the Netherlands, approximately fifty percent of the depressive disorders are
not treated and in about half of the cases it leads to a severe major
depression (Spijkers et al., 2002; Bijl et al., 2003). It is proven that
subclinical depressive disorders lead to serious sickness burden (Kruijshaar et
al., 2003; Cuijpers, 2004), associated with high mortality chance (Cuijpers &
Schoevers, 2004) and a risk to develop a major depression (Cuijpers & Smit,
2004).
This makes the necessity for prevention great, also seen the high prevalence of
depression and the severe impact and consequences of this.

Knowledge transfer
This project will produce a description of a preventive intervention form
Surinamese Hindustani with depressive symptoms. The head applicant of this
project is a member of this community and holds a lot of functions in
organisations within the community. He has excellent contacts with the Hindoe
Raad Nederland (Hindu Council the Netherlands (HRN) and MIKADO, with whom he
will work together.
The HRN is a covering body for all the Hindu organisations established in the
Netherlands and is considered by the government as a speaking partner for all
matters concerning the Hindustani community and Hinduism. The HNR is the
advising organ for the government. All Hindu temples are part of the HRN.
MIKADO is the centre for intercultural mental health care.
HRN and MIKADO have offer to support this project and dissemination of the
results will also take place by this existing network, among other existing
networks.
Moreover, the results of this research can be use to reach other allochthone
community in the Netherlands with the same characteristics as the Surinamese
Hindustani. In particular the Moroccan and Turkish community.
These are also closed communities with a clear man/woman role for example. This
means, also in these communities the upbringing of the boys are different
(freely) than that of the girls and that the brothers feel responsible for
their sisters. Problems, in particular psychological or psychiatric, are
considered taboo and is not discussed outside the group. The Moroccan and
Turkish community also uses the mosque to discuss their problems with the Imam,
the elderly or others with an important role in the community (Meekeren, et
al., 2002; Borra, et al., 2002).
Some members of the project group participates in the Netherlands Study of
Depression and Anxiety (NESDA) in which there is a cooperation of a lot of
other institutions, which is responsible for research and policy considering
the treatment of anxiety and depression (University of Groningen, University of
Leiden, WOK (Centre for Quality of Care Research), NIVEL, Trimbos-institute
and a lot of patients' organisations). Also this extended network will be used
to disseminate the results of this project. Without doubt, the outcomes of the
project will be make known by professional and public media, by means of study
days and publications in national and international practically-oriented
magazines.

Study design
Pre - post treatment study
No controle group

Intervention
For this research, about 3 temples are approached and divided into two steps.
Step I
A semi-structured interview will be conducted on the basis of a questionnaire
to the board of the temple. One must think of the Pandiet (Hindu priest),
chairman, secretary, treasurer.
Questions will be asked about:
their co-cooperation
-the co-operation from the visitors
-the prevention of mood disorders, anxiety disorders, suicidality
-is this a problem
-schould the problems adressed and solved by the Hindu community itself or is
external help needed
-what could be the causes for these problems
-the feasibility of a study
-will visitors participate in a prevention study (as proposed: 'lichte dagen,
donkere dagen')

Step II
A structured interview will be taken from the visitors of the temple. In
addition, the CES-D (for depressive symptoms) and suicide risk questionaire
will be presented to the visitors. For visitors with a score> 15 on the CES-D,
a MINI interview will be taken, by telephone, to establish a depressive
disorder. This will give an impression of the prevalence of depressive symptoms
and disorder. Questionnaires will also be taken on suicide ideation, anxiety
symptoms, use of antidepressants / benzodiazepines, use of health care, absence
from work and quality of life.

The degree of participation will help determine the feasibility of a preventive
study.

Recruitment of respondents
All respondents will be recruited at the temples.

Inclusion and exclusion criteria
The inclusion criteria are: all visitors to the Hindu temple, who are 18 years
and older. In general, all visitors speaks the Dutch language. But this is not
crucial for the study, since the principal investigator speaks the Sarnami
Hindi and can explain the study. There are no exclusion criteria.

Measuring
CES-D will be use for the screening of depressive symptoms. During the
telephone interview participants will be diagnosed for depression, using the
MINI International Neuropsychiatric Interview. The MINI is a brief structured
interview to diagnose psychiatric disorders, according to the DSM-IV (Sheenan,
1998).
During the interview, we also measured the following: personality (Mastry
list), suicide ideation (Beck Scale), anxiety (HADS), quality of life (SF36 and
Euroqol), and use of health care (TIC-P).
This choice for these instruments are made, because of their frequent use in
national and international surveys.

Planning
The timeline is divided into 3 phases.

Phase I: duration 6 weeks
A semi-structured interview conducted from the board. And once for a temple.

Phase II: duration 16 weeks
Interview and questionaire from the visitors. This will be repeated 4 times a
temple as much as possible to recruit respondents.

Phase III: duration 12 weeks
Processing the collected data.

Time frame
The necessary time for this research is estimated at 9 months (34 weeks).
Due to unforeseen circumstances the above schedule may be changed or adjusted.

Time investment is required from the participants for the course, ' lichte
dagen, donkere dagen'. The course consists of 12 meetings. Each session lasts
approximately 2 hours. In total the course takes 24 hours. In addition, the
participants have to do some homwork, as part of the course. This is about 1
hours per session (total 12 hours for the course). The total time investment
necessary for the entire course is 36 hours.