Culture, stress and recovery from schizophrenia: lessons from the field for global mental health

"Everyone means well but the one person who's really going to go to bat" - experiences and perspectives of substitute decision makers in caring for their loved ones with serious mental illness

In the era of on-going efforts to empower persons with mental illness to be independent decision makers as informed by the United Nations' Convention on the Rights of Persons with Disability (CRPD), family members acting as substitute decision makers (SDM) for people suffering from disabling serious mental illness (SMI) remain an integral part of the medical-legal system in psychiatric care in many parts of the world, including Canada; yet their experiences and perspectives are rarely studied. This explorative qualitative study examines the lived experiences and reflections of 14 family member SDMs in Toronto, Canada. Five key themes related to being SDM emerged: 1) Varied subjective understanding of the responsibility and authority of the SDM role; 2) Varied role demands and impact on SDMs' lives; 3) Challenges in dealing with the mental health system; 4) Leveraging decision making status to promote patient care; and 5) SDM role impact on family relationships. The need to improve SDM understanding of their role, acknowledging their value and care-taker burden, finding a balance for their involvement, and improving their support in efforts to enhance care for the patients are discussed.

"Mending fractured personalities": A photography-based cultural study of recovery from mental distress in Romania

This study explored the lived experiences and meanings of recovery from mental distress from the perspective of mental health service users in Romania, along with investigating cultural particularities of recovery in this country. Research in this area is essential in the context of Romania's mental health reform marked by a transition from institutionalised mental health services to a recovery-based approach, and profound social and economic changes during the post-communist era. Subscribing to the recovery framework, this study employed a qualitative phenomenological design involving 15 adults with mental health problems purposively recruited from a community day centre in Romania. The phenomenological background was enriched with elements of participatory photography to elicit subjective experiences and meanings of recovery. The outcome of this study was a better understanding of recovery in Romanian adults living with mental distress, as a complex and multi-layered phenomenon. Three key themes were identified through Interpretative Phenomenological Analysis: awakening, healing, and reconstructing life. The findings add to the current recovery models by showing that recovery cannot be fully understood unless situated in a socio-political, cultural, and historical context. Implications for mental health practice in Romania are discussed and directions for future research are recommended.

Experiences of Family Burden in Caring for the Severely Mentally Ill in a Foreign Land: A Qualitative Study of Chinese Immigrant Families in Toronto, Canada

There is a relative dearth of qualitative studies on the actual experiences of families caring for members suffering from serious mental illness, and even less is known about disadvantaged ethnic minority immigrant families. This explorative qualitative study examines the burden experienced by 15 family members of Chinese immigrant background in Toronto, Canada. Six common themes emerged from the study: 1) significant worries about not being able to take care of ill members in the future; 2) on-going strain and changed family life; 3) pervasive social stigma, discrimination and lack of resources; 4) general appreciation of Canadian health and welfare systems and opportunities; 5) cultural factors and beliefs uniquely shape families' support and caring commitment; and 6) families find various ways to cope and help themselves. Opportunities for improved care delivery based on these understandings are discussed.

Recovery From Severe Mental Health Problems: A Systematic Review of Service User and Informal Caregiver Perspectives

Introduction: The recovery approach aims to have users' perspectives at the heart of service development and research; it is a holistic perspective that considers social needs, personal growth and inclusion. In the last decade recovery-oriented research and practice has increased greatly, however, a comprehensive model of recovery considering exclusively the perspectives of people with lived experience has not been devised. Aims: This review aimed to develop a framework and contextualize service users' and informal caregivers' understanding of recovery from severe mental health problems. Methods: We systematically searched 6 databases including key terms related to knowledge, experience and narratives AND mental health AND personal recovery. The search was supplemented with reference sourcing through gray literature, reference tracking and expert consultation. Data analysis consisted of a qualitative meta-synthesis using constant comparative methods. Results: Sixty-two studies were analyzed. A pattern emerged regarding the recovery paradigms that the studies used to frame their findings. The resulting recovery framework included the domains Social recovery; Prosperity (Legal, political, and economic recovery); Individual Recovery; and Clinical Recovery Experience (SPICE). Service users' definitions of recovery tended to prioritize social aspects, particularly being accepted and connecting with others, while caregivers focused instead on clinical definitions of recovery such as symptom remission. Both groups emphasized individual aspects such as becoming self-sufficient and achieving personal goals, which was strongly linked with having economic means for independence. Conclusions: The recovery model provided by this review offers a template for further research in the field and a guide for policy and practice. Predominant definitions of recovery currently reflect understandings of mental health which focus on an individual perspective, while this review found an important emphasis on socio-political aspects. At the same time, only a small number of studies took place in low-income countries, focused on minoritized populations, or included caregivers' perspectives. These are important gaps in the literature that require further attention. Systematic Review Registration: The review protocol was registered on PROSPERO (CRD42017076450); https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=76450.

Assembling Adjustment: Parergasia, Paper Technologies, and the Revision of Recovery

Drawing from research on 'paper technologies' conducted by medical historians Volker Hess and Andrew Mendelsohn, among others, this article explores how Adolf Meyer (1866-1950) and his staff at the Phipps Psychiatric Clinic used customized punch cards to develop an alternative conceptualization of schizophrenia: 'parergasia.' It begins by examining 'dementia praecox,' the conceptual precursor to both schizophrenia and parergasia, to explain how earlier paper technologies used to track patients transferred to asylums generated prognostic assumptions that precluded deinstitutionalization and community-based care. It then describes how Meyer's staff modified these technologies to define parergasia in opposition to dementia praecox and other diagnoses that resulted in prolonged hospitalization, primarily by conducting follow-up studies on discharged patients that correlated outcomes with various social factors. After demonstrating how the standardized forms used in these studies limited the possible metrics of recovery, it concludes by suggesting how Meyer's research influenced leaders of the community mental health movement, and prefigured later trends in psychiatric services.

Exploration of recovery of people living with severe mental illness (SMI) in low/middle-income countries (LMICs): a scoping review

OBJECTIVE

To examine the literature on how recovery of people with severe mental illness (SMI) is conceptualised in low/middle-income countries (LMICs), and in particular what factors are thought to facilitate recovery.

DESIGN

Scoping review.

DATA SOURCES AND ELIGIBILITY

We searched 14 electronic databases, hand searched citations and consulted with experts during the period May-December 2019. Eligible studies were independently screened for inclusion and exclusion by two reviewers. Unresolved discrepancies were referred to a third reviewer.

DATA EXTRACTION AND SYNTHESIS

All bibliographical data and study characteristics were extracted using a data charting form. Selected studies were analysed through a thematic analysis emerging from extracted data.

RESULTS

The Preferred Reporting Items for Systematic Reviews and Meta-Analyses flow diagram offers a summary of the results: 4201 titles, 1530 abstracts and 109 full-text articles were screened. Ten articles were selected for inclusion: two from Turkey, two from India, and one each from China, Swaziland, Indonesia, Egypt, South Africa and Vietnam. Although most studies used qualitative methods, data collection and sampling methods were heterogeneous. One study reported on service provider perspectives while the rest provided perspectives from a combination of service users and caregivers. Three themes emerged from the data analysis. First, studies frame recovery as a personal journey occurring along a continuum. Second, there was an emphasis on social relationships as a facilitator of recovery. Third, spirituality emerged as both a facilitator and an indicator of recovery. These themes were not mutually exclusive and some overlap exists.

CONCLUSION

Although there were commonalities with how high-income countries describe recovery, we also found differences in conceptualisation. These differences in how recovery was understood reflect the importance of framing the personal recovery concept in relation to local needs and contextual issues found in LMICs. This review highlighted the current sparse evidence base and the need to better understand recovery from SMI in LMICs.

Essential Elements That Contribute to the Recovery of Persons With Severe Mental Illness: A Systematic Scoping Study

Introduction: There is an increasing emphasis on recovery-oriented care in the design and delivery of mental health services. Research has demonstrated that recovery-oriented services are understood differently depending on the stakeholders involved. Variations in interpretations of recovery lead to challenges in creating systematically organized environments that deliver a consistent recovery-oriented approach to care. The existing evidence on recovery-oriented practice is scattered and difficult to apply. Through this systematic scoping study, we aim to identify and map the essential elements that contribute to recovery outcomes for persons living with severe mental illness. Methods: We used the Arksey & O'Malley framework as our guiding approach. Seven key databases (MEDLINE, PubMed, CINAHL/EBSCO, EMBASE, ProQuest, PsycINFO, and Google Scholar) were searched using index terms and keywords relating to recovery and severe mental illness. To be included, studies had to be peer-reviewed, published after 1988, had persons with severe mental illness as the focal population, and have used recovery in the context of mental health. The search was conducted in August 2018 and last updated in February 2020. Results: Out of 4,496 sources identified, sixty (n = 60) sources were included that met all of the selection criteria. Three major elements of recovery that emerged from the synthesis (n = 60) include relationships, sense of meaning, and participation. Some sources (n = 20) highlighted specific elements such as hope, resilience, self-efficacy, spirituality, social support, empowerment, race/ethnicity etc. and their association with the processes underpinning recovery. Discussion: The findings of this study enable mental health professionals to incorporate the identified key elements into strategic interventions to facilitate recovery for clients with severe mental illness, and thereby facilitate recovery-oriented practice. The review also documents important gaps in knowledge related to the elements of recovery and identifies a critical need for future studies to address this issue.

Predictors of subjective recovery from recent-onset psychosis in a developing country: a mixed-methods study

PURPOSE

This study was conducted to: (a) investigate the levels and progress of subjective recovery from recent-onset psychosis; (b) examine its predictive factors and; (c) describe perceived challenges and opportunities affecting recovery. The findings were expected to help inform recovery-oriented psychiatric care in low-income, particularly African, countries.

METHODS

This sequential explanatory mixed-methods study involved 263 service users with recent-onset psychosis from Northwestern Ethiopia. For the quantitative part, a 9-month longitudinal study approach was employed with three time point measurements over 9 months. Predictor variables for subjective recovery from recent-onset psychosis were identified by hierarchical multiple linear regression tests. Following the quantitative survey, individual qualitative interviews were conducted with 19 participants. Interview data were transcribed and thematically analysed.

RESULTS

High mean subjective recovery scores were recorded throughout the study (Questionnaire about the Process of Recovery score ranging from 44.17 to 44.65). Quality of life, internalized stigma, disability, hopelessness, satisfaction with social support, and central obesity were significant predictors of subjective recovery across the three time points. Participants' perceived challenges and opportunities affecting their recovery were categorized into four themes.

CONCLUSION

In Ethiopia, a low percentage of individuals with SMIs initiate psychiatric treatment and many discontinue this to attend spiritual healing. In this study, the Ethiopian SMI patients engaged consistently in psychiatric treatment indicated high mean subjective recovery scores. Devising mechanisms to integrate the psychiatric treatment and spiritual healing sectors are suggested. Approaches to improve quality of life, functioning, hope, internalized stigma and provide need-based social support are suggested.

Factors influencing subjective recovery of people with recent-onset psychosis: A cross-sectional study in a low-income sub-Saharan country

People with psychosis were traditionally believed to have a chronic deteriorating condition with no hope of recovery. Recent studies have shown varied levels of recovery across countries. However, evidence from low-income, particularly African countries is scant. This study aimed to investigate levels of subjective recovery of people with recent-onset psychosis and identify its influencing factors. A cross-sectional study was conducted among 263 outpatients with recent-onset psychosis in a low-income country, Ethiopia. Psychiatric outpatients were randomly selected, and assessed by a set of questionnaires measuring their psychosocial, clinical and physical health conditions. Hierarchical multiple regression tests were used to identify factors influencing subjective recovery. The level of subjective recovery was found to be high, with a mean Questionnaire about the Process of Recovery score of 44.17. Individuals with higher quality of life were found to have significantly better subjective recovery level. Hopeless and centrally obese individuals were found to have significantly lower level of subjective recovery. Despite the limitations associated with a cross sectional study design, the results suggest that individuals with recent-onset psychosis in Ethiopia may have a better level of subjective recovery than those in high-income countries and their recovery is influenced by quality of life, hopelessness and central obesity.

Exploration of recovery of people living with severe mental illness (SMI) in low-income and middle-income countries (LMIC): a scoping review protocol

INTRODUCTION

The construct of recovery was conceptualised in high-income countries and its applicability in low-income and middle- income countries is underexplored. A scoping review is proposed to synthesise knowledge, review conceptual overlap and map key elements of recovery from severe mental illness in low-income and middle-income countries. We aim to appraise the literature so as to inform future recovery-oriented services that consider the cultural and contextual influences on recovery from severe mental illness.

METHODS AND ANALYSIS

The following electronic databases: MEDLINE via PubMed, SCOPUS (which included contents of Embase), PsycINFO, CINAHL, Africa-Wide Information, PsycARTICLES, Health source: Nursing/Academic Edition, Academic Search Premier and SocINDEX all via the EBSCOHOST platform, the Latin American and Caribbean Health Sciences Literature, the Cochrane Centre Register of Controlled Trials) and grey literature sources will be searched between May and December 2019. Eligible studies will be independently screened for inclusion and exclusion by two reviewers using a checklist developed for this purpose. Studies published between January 1993 and November 2019 that focus on recovery from severe mental illness in a low-income and middle-income country will be included. Findings will be compared and discrepancies will be discussed. Unresolved discrepancies will be referred to a third reviewer. All bibliographic data and study characteristics will be extracted and thematically analysed using a tool developed through an iterative process by the research team. Indicators will be classified according to a predefined conceptual framework and categorised and described using qualitative content analysis.

ETHICS AND DISSEMINATION

The review aims to synthesise information from available publications, hence it does not require ethical approval. The results will be disseminated through publications, conference presentations and future workshops with stakeholders involved within the recovery paradigm of mental health policy and practice. The scoping review title is registered with the Joanna Briggs Institute.

Treatment Adherence in Youth with First-Episode Psychosis: Impact of Family Support and Telehealth Delivery

Mental health-care delivery to young people with first-episode schizophrenia presents significant challenges especially in underserved areas. This chart review reveals the importance of family support as a predictor for medication and treatment adherence with this vulnerable group. An unexpected disengagement rate of 47% was discovered. It was further discovered that receiving care with telehealth delivery was a significant predictor of lost to follow-up or treatment nonadherence. Recommendations include psychoeducation for families during the initial crisis, initiation of long-acting injectable antipsychotics early in care, a hybrid telehealth intervention with in-home medication delivery, and collaboration with educational, vocational county agencies for employment support. A system of care must be developed to support young people with this severe illness for optimum outcome and protection of long-term cognitive functioning.

The experiences and meanings of recovery for Swazi women living with "schizophrenia"

WHAT IS KNOWN ON THE SUBJECT?: While there is no single definition of the concept of recovery for people with mental illness, hope has been recognized as a guiding principle; the belief that it is possible for a person to regain a meaningful life, despite serious mental illness. Little is known about the recovery process of women diagnosed with schizophrenia per se, with only six studies offering the woman's voice identified and these all having taken place in developed countries. No studies on this topic have been carried out in Sub-Saharan Africa, including Swaziland. WHAT THIS PAPER ADDS TO EXISTING KNOWLEDGE?: This study provides unique insight into what is important to Swazi women, diagnosed with schizophrenia, in their process of their recovery. Because of current trends in migration, the findings of this study may provide mental health professionals with a better understand of the needs of those from this particular Sub-Saharan country. The study discusses a range of issues affecting women including being labelled as mentally ill, stigma and discrimination, the importance of the sociocultural context of illness and positive attributes which promote women's recovery. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: This study provides mental health practitioners with insights and understanding of the lives of women from a Sub-Saharan developing country. This will be helpful for better understanding of the context of mental illness both for practitioners supporting the development of services in such countries and for those working in Western countries with migrant populations.

ABSTRACT

INTRODUCTION: Globally, twenty-four million people live with schizophrenia, 90% living in developing countries. While most Western cultures recognize service user expertise within the recovery process, this is not evident in developing countries. In particular, Swazi women diagnosed with schizophrenia experience stigma from family, community and care providers, thus compromising their recovery process.

AIM

This study aimed to explore the experiences and meanings of recovery for Swazi women living with schizophrenia.

METHODOLOGY

Interpretive phenomenological analysis was used. Fifteen women were recruited from Swaziland National Psychiatric Hospital out-patients' department, and face-to-face interviews were conducted.

FINDINGS

Four super-ordinate themes were identified: (a) The emotionality of "illness of the brain"; (b) Pain! Living with the illness and with others; (c) She is mad just ignore her; and (d) Being better.

DISCUSSION

Discussion focuses on the findings of this study and a number of positive and negative implications emanating from them: labelling, stigma and the roles of family, culture and religious beliefs on the process of recovery.

IMPLICATIONS FOR PRACTICE

This study provides practitioners with insight into the importance of the sociocultural context of the lives of women diagnosed with schizophrenia and how, in understanding this, mental health care could be improved.

Conceptualizations of subjective recovery from recent onset psychosis and its associated factors: A systematic review

AIM

There is no standard definition of "subjective recovery" from psychosis, its nature is currently contested and debated among service-users and professionals. Individual studies have explored conceptualizations of subjective recovery from recent onset psychosis, but there have been no previously published systematic reviews on the topic. The aim of this review was to examine and synthesize quantitative and qualitative studies examining the concept of subjective recovery from recent onset psychosis and identify common factors associated with this recovery process.

METHODS

Relevant electronic databases (Medline, CINAHL, PsychInfo and ProQuest Dissertations and Theses) were searched and hand searches were also carried out. Publications in each database from the inceptions of the databases to April 12, 2017 were included. Data from selected articles were extracted using a piloted extraction form and thematic integrative analysis was performed.

RESULTS

Ten studies with different study designs were included in this review. Subjective recovery was conceptualized into 3 main themes: "recovery as outcome", "recovery as process" and "endeavours during recovery". Factors contributing to subjective recovery were categorized into 4 main themes; "treatment related", "illness related", "individual related" and "social environment" related. Non-linear and subjective nature of the process of recovery were reinforced by the review findings.

CONCLUSIONS

Studies in subjective recovery from recent onset psychosis are limited to developed countries. Acquiring hope and self-confidence, overcoming symptoms and stigma through mobilizing all resources available were accentuated in conceptualizing subjective recovery and related factors. Recovery-oriented health care services should acknowledge individual differences and involve service users in their care decisions.

Factors influencing subjective recovery of people with recent-onset psychosis: A cross-sectional study in a low-income Sub-Saharan country

People with psychosis were traditionally believed to have a chronic deteriorating condition with no hope of recovery. Recent studies have shown varied levels of recovery across countries. However, evidence from low-income, particularly African countries is scant. This study aimed to investigate levels of subjective recovery of people with recent-onset psychosis and identify its influencing factors. A cross-sectional study was conducted among 263 outpatients with recent-onset psychosis in a low-income country, Ethiopia. Psychiatric outpatients were randomly selected, and assessed by a set of questionnaires measuring their psychosocial, clinical and physical health conditions. Hierarchical multiple regression tests were used to identify factors influencing subjective recovery. The level of subjective recovery was found to be high, with a mean Questionnaire about the Process of Recovery score of 44.17. Individuals with higher quality of life were found to have significantly better subjective recovery level. Hopeless and centrally obese individuals were found to have significantly lower level of subjective recovery. Despite the limitations associated with a cross sectional study design, the results suggest that individuals with recent-onset psychosis in Ethiopia may have a better level of subjective recovery than those in high-income countries and their recovery is influenced by quality of life, hopelessness and central obesity.

Measuring Functional and Patient-Reported Outcomes After Treatment of Mutilating Hand Injuries: A Global Health Approach

Understanding the global burden of trauma, particularly upper extremity trauma, is necessary in addressing the need for surgical services. Critical to that mission is to understand, and accurately measure, disability and related disability-adjusted life-years from massive upper extremity trauma. The impact of these injuries is magnified when considering that they frequently occur to young people in prime working years. This article discusses these social and medical system issues and reviews components of a comprehensive approach to measuring outcomes after these injuries. Patient-reported outcomes are highlighted. Methods of optimizing outcomes measurements and studies, disability assessments, and associated research are also discussed.

Does Employment Promote Recovery? Meanings from Work Experience in People Diagnosed with Serious Mental Illness

Employment has been highlighted as a determinant of health and as an essential milestone in the recovery process of people with serious mental illness. Different types of programs and public services have been designed to improve the employability of this population. However, there has not been much interest in the meanings attributed to these experiences and the negative aspects of work experience. In this research, we explored the meanings that participants attributed to their work experience and the impact of work on their recovery process. Research participants lived in Andalusia (Spain), a region in southern Europe with a high unemployment rate. Two versions of a semi-structured interview were designed: one for people who were working, and one for unemployed people. Participants' narratives were categorized according to grounded theory and the analyses were validated in group sessions. Apart from several positive effects for recovery, the analysis of the narratives about work experience outlined certain obstacles to recovery. For example, participants mentioned personal conflicts and stress, job insecurity and meaningless jobs. While valid, the idea that employment is beneficial for recovery must be qualified by the personal meanings attributed to these experiences, and the specific cultural and economic factors of each context.

Recovery stories: An anthropological exploration of moral agency in stories of mental health recovery

Moral agency has been loosely defined as the freedom to aspire to a "good life" that makes possible intimate relationships with others. This article uses ethnographic research to further the discussion of the role of moral agency in mental health recovery. This article attends to the ebb and flow of moral agency in the life stories of three people diagnosed with a serious psychiatric disability at different stages in their individual recoveries to illustrate particular aspects of moral agency relevant for recovery. From these, a more complex notion of moral agency emerges as the freedom not only to aspire to a "good life," but also to achieve a "good" life through having both the intention to aspire and access to resources that help bring one's life plans to fruition. Each storyteller describes an initial Aristotelian peripeteia, or "breach" of life plan, followed by an erosion of moral agency and sense of connection to others. The stories then diverge: some have the resources needed to preserve moral agency, and others attempt to replenish moral agency that has been eroded. In these stories, the resources for preserving and nourishing moral agency include the ability to cultivate the social bases of self-respect, autobiographical power, and peopled opportunities. These stories cumulatively suggest that without such resources one's attempts to preserve or nourish the moral agency needed for recovery after the peripeteia, which is often perpetuated by the onset and experience of serious mental illness, may fall short.

Ethno-Racial Variation in Recovery From Severe Mental Illness: A Qualitative Comparison

OBJECTIVE

Purpose-driven studies examining the relationship between ethnicity, culture, and recovery are absent from the empirical literature. As such, the overall aim of this study was to examine ethno-racial variations in recovery perspectives. Specific objectives consist of comparing and contrasting ethno-racial variations in 1) definitions of recovery, 2) barriers to recovery, and 3) facilitators of recovery.

METHODS

We recruited people with severe mental illness from 2 broad ethno-racial groups (Caribbean-Canadian and Euro-Canadian) to partake in a qualitative interview on recovery (n = 47). Participants were asked to give their own definitions of recovery, as well as self-perceived barriers and facilitators. Interview transcripts were then subjected to thematic analysis. We compared and contrasted the distribution and salience of emerging themes between the Euro-Canadian and Caribbean-Canadian participants.

RESULTS

Recovery was consistently defined as a gradual process involving progress in key life domains including employment, social engagement, and community participation by both groups. This was underpinned by a growing future orientation. Stigma, financial strain, and psychiatric hospitalization were considered major barriers to recovery in both groups. Participants from both groups generally considered stated definitions of recovery to be simultaneous facilitators of recovery-employment and social engagement being the most frequently mentioned. God and religion were key facilitators for the Caribbean-Canadian group but not for Euro-Canadians.

CONCLUSIONS

Definitions, barriers, and facilitators to recovery were generally shared among our sample, regardless of ethno-racial status, with the exception of God and religion.

Recovery outcomes of schizophrenia patients treated with paliperidone palmitate in a community setting: patient and provider perspectives on recovery

OBJECTIVES

This study evaluated the effect of paliperidone palmitate long-acting injectable (LAI) antipsychotic on recovery-oriented mental health outcomes from the perspective of healthcare providers and patients during the treatment of patients with schizophrenia or schizoaffective disorders.

METHODS

Archival data for patients with a primary diagnosis of schizophrenia or schizoaffective disorder receiving ≥6 months of paliperidone palmitate LAI were retrieved from the electronic medical records system at the Mental Health Center of Denver. Mental health recovery was assessed from both a provider's (Recovery Markers Inventory [RMI]) and patient's (Consumer Recovery Measure [CRM]) perspective. A three-level hierarchical linear model (HLM) was utilized to determine changes in CRM and RMI scores by including independent variables in the models: intercept, months from treatment (slope), treatment time period (pretreatment and treatment), age, gender, primary diagnosis, substance abuse diagnosis, concurrent medications, and adherence to paliperidone palmitate LAI.

RESULTS

A total of 219 patients were identified and included in the study. Results of the final three-level HLMs indicated an overall increase in CRM scores (p < 0.05), an overall increase (p < 0.01), and an increased rate of change (p < 0.05) in RMI scores during the paliperidone palmitate LAI treatment period vs the pre-treatment period.

LIMITATIONS

This study contained a retrospective, non-comparative design, and did not adjust for multiplicity Conclusions: The current study demonstrates that changes in recovery-oriented mental health outcomes can be detected following the administration of a specific antipsychotic treatment in persons with schizophrenia or schizoaffective disorders. Furthermore, patients receiving paliperidone palmitate LAI can effectively improve recovery-oriented outcomes, thereby supporting the drug's use as schizophrenia treatment from a recovery-oriented perspective.

Conversations between anthropology and psychiatry: drawing out the best from interdisciplinarity in global mental health

OBJECTIVES

Conversations between anthropologists and psychiatrists have led to new theoretical trajectories, research agendas and clinical practices as social scientists and medical practitioners forged new understandings about the interaction of culture, personhood and illness. However, the demands of global mental health, coupled with health service provision requirements, mean that mental health interventions set up with the best intentions can fail to take into account the knowledge and expertise that social sciences can contribute to a programme's success. In this paper, I reflect on conversations between an anthropologist and mental health professionals in direct reference to data analysis of an AusAID mental health capacity-building programme undertaken in the Pacific region.

CONCLUSIONS

Social and cultural perspectives embedded within programmes can provide richer, more contextualised interventions. In drawing on the combined expertise of anthropology and psychiatry, new taken-for-granted reference points embedding cultural approaches form the basis for delivery of global mental health programmes. These perspectives include: Locating mental health programmes within development critiques. Situating the subjects of development within contextualised settings, acknowledging and respecting local knowledge, understandings and practices. A focus on interdisciplinarity as the basis for future practice in global mental health projects.

Toward a new architecture for global mental health

Current efforts in global mental health (GMH) aim to address the inequities in mental health between low-income and high-income countries, as well as vulnerable populations within wealthy nations (e.g., indigenous peoples, refugees, urban poor). The main strategies promoted by the World Health Organization (WHO) and other allies have been focused on developing, implementing, and evaluating evidence-based practices that can be scaled up through task-shifting and other methods to improve access to services or interventions and reduce the global treatment gap for mental disorders. Recent debates on global mental health have raised questions about the goals and consequences of current approaches. Some of these critiques emphasize the difficulties and potential dangers of applying Western categories, concepts, and interventions given the ways that culture shapes illness experience. The concern is that in the urgency to address disparities in global health, interventions that are not locally relevant and culturally consonant will be exported with negative effects including inappropriate diagnoses and interventions, increased stigma, and poor health outcomes. More fundamentally, exclusive attention to mental disorders identified by psychiatric nosologies may shift attention from social structural determinants of health that are among the root causes of global health disparities. This paper addresses these critiques and suggests how the GMH movement can respond through appropriate modes of community-based practice and ongoing research, while continuing to work for greater equity and social justice in access to effective, socially relevant, culturally safe and appropriate mental health care on a global scale.

Beyond critique: rethinking roles for the anthropology of mental health

The current supremacy of the 'bio-bio-bio' model within the discipline of psychiatry has progressively marginalized social science approaches to mental health. This situation begs the question, what role is there for the anthropology of mental health? In this essay, I contend that there are three essential roles for the anthropology of mental health in an era of biological psychiatry. These roles are to (i) provide a meaningful critique of practices, beliefs, and movements within current psychiatry; (ii) illuminate the socio-cultural, clinical, and familial context of suffering and healing regarding emotional distress/mental illness; and (iii) act as a catalyst for positive change regarding healing, services and provisions for people with emotional distress/mental illness. My argument is unified by my contention that a credible anthropology of mental health intending to make a societal contribution should offer no opposition without proposition. In other words, any critique must be counter-balanced by the detailing of solutions and proposals for change. This will ensure that the anthropology of mental health continues to contribute critical knowledge to the understanding of mental suffering, distress, and healing. Such social and cultural approaches are becoming especially important given the widespread disenchantment with an increasingly dominant biological psychiatry.

"Now he walks and walks, as if he didn't have a home where he could eat": food, healing, and hunger in Quechua narratives of madness

In the Quechua-speaking peasant communities of southern Peru, mental disorder is understood less as individualized pathology and more as a disturbance in family and social relationships. For many Andeans, food and feeding are ontologically fundamental to such relationships. This paper uses data from interviews and participant observation in a rural province of Cuzco to explore the significance of food and hunger in local discussions of madness. Carers' narratives, explanatory models, and theories of healing all draw heavily from idioms of food sharing and consumption in making sense of affliction, and these concepts structure understandings of madness that differ significantly from those assumed by formal mental health services. Greater awareness of the salience of these themes could strengthen the input of psychiatric and psychological care with this population and enhance knowledge of the alternative treatments that they use. Moreover, this case provides lessons for the global mental health movement on the importance of openness to the ways in which indigenous cultures may construct health, madness, and sociality. Such local meanings should be considered by mental health workers delivering services in order to provide care that can adjust to the alternative ontologies of sufferers and carers.

Social defeat in recovery-oriented supported housing: moral experience, stigma, and ideological resistance

Drawing from ethnographic observations and interview data gathered during 6 months working as a home caregiver at the Pinewood Apartments, a recovery-oriented supported housing community in Texas, I demonstrate how stigma and social defeat were moral and social processes that pervaded life for all involved, including service providers. Yet, because of the extreme power differentials that characterized tenant-staff relationships, the assault of stigma and social defeat was much more frequent, existentially intense, and morally and materially consequential for certain tenants, whose attempts at ideological resistance were delegitimized by service providers, including myself, who were backed by the authority of dominant psychiatric and moralistic discourses concerning the inherent irrationality and irresponsibility of people with severe mental illness. Nevertheless, due to the indeterminate and at times inharmonious nature of moral experience, it is not my intention to portray tenants as wholly defeated. Rather, individual tenants often exhibited defeat and resistance simultaneously.

Recovery: conceptual and ethical aspects

PURPOSE OF REVIEW

To examine recent publications on implications of recovery for the provision of mental health services.

RECENT FINDINGS

Predominantly, the concept of recovery, implications for professional mental health services, and the impact of peer workers on the provision of healthcare are discussed.

SUMMARY

Recovery in the context of mental health issues refers to multiple dimensions of the individual's development. According to recent publications, the dimension of an individual journey, measurable through subjective parameters and accounts, is complementary to the traditional objectives of symptom reduction, improvement of functioning, and social inclusion. To foster recovery orientation in mental health services subjective measures should be included in clinical practice, research, and teaching. Moreover, services striving to support recovery need to implement strategies in terms of policy, concepts, structures, and professional attitude. This challenging paradigm shift is claimed to be supported by the integration of peer workers with own lived experience in the provision of mental healthcare. Some exponents of the social recovery movement criticize this recent international development to implement recovery into traditional services, as it would uphold the established structures of power and control. Questions of impaired legal capacity, involuntary admissions and risk assessment related to recovery are rarely discussed.

Everyday life, culture, and recovery: carer experiences in care homes for individuals with severe mental illness

Supported homes or Care Homes (CHs) have become in-services that play a fundamental role in social-health systems, particularly in mental health systems in Europe and the United States. They provide settings where residents' day-to-day routines are supervised by in-house non-clinician professional carers. Ten semi-structured in-depth interviews were conducted by expert professional carers of persons with schizophrenia to explore interactions and activities between carers and users living in special "Care Homes". Analysis focused primarily on the functions of everyday life and daily routines in the recovery process. Social positioning analysis was used to investigate meanings and subjective experiences of professionals. The analysis revealed the importance of personal interactions in daily routines for recovery. We identified two main concerns guiding professionals' interactions with users: "Bring [users] to the here and now" and "give them the initiative to start actions". We suggest that CHs promote the construction of privileged identity in western urban societies, forming part of the process towards recovery and better social integration.

Update: schizophrenia across cultures

The incidence of schizophrenia, as well as the symptoms, course, and outcomes for people so diagnosed seem to vary across some cultural contexts. The mechanisms by which cultural variations may protect one from or increase one's risk of developing schizophrenia remain unclear. Recent findings from transdisciplinary cross-cultural research, indicate ways that we may better understand how socioenvironmental and cultural variables interact with physiologic pathways relating psychosocial stress and psychotic symptoms, epigenetic changes, and people's use of culturally available tools to mitigate stress, in ways that may inform relevant, effective interventions for people diagnosed with psychotic disorders worldwide.