Global mental health and neuroscience: potential synergies

Ethical Considerations in Psychiatric Genomics

The ethics of psychiatric genetics and genomics is an emerging field, distinct from general genetics. Key ethical concerns include the implications for personhood and identity, the dual perception of psychiatric conditions as both afflictions and integral aspects of identity, and the unique vulnerabilities of affected populations regarding informed consent. The multifactorial nature of psychiatric disorders, characterized by complex genetic and environmental interactions, further complicates ethical considerations. This paper explores ethical issues in psychiatric genomic research, clinical applications, and prevention efforts, emphasizing the need for a multidisciplinary approach and the importance of context sensitivity, particularly in low-and-middle-income countries.

Current perspectives on perinatal mental health and neurobehavioral development: focus on regulation, coregulation and self-regulation

PURPOSE OF REVIEW

Perinatal mental health research provides an important perspective on neurobehavioral development. Here, we aim to review the association of maternal perinatal health with offspring neurodevelopment, providing an update on (self-)regulation problems, hypothesized mechanistic pathways, progress and challenges, and implications for mental health.

RECENT FINDINGS

(1) Meta-analyses confirm that maternal perinatal mental distress is associated with (self-)regulation problems which constitute cognitive, behavioral, and affective social-emotional problems, while exposure to positive parental mental health has a positive impact. However, effect sizes are small. (2) Hypothesized mechanistic pathways underlying this association are complex. Interactive and compensatory mechanisms across developmental time are neglected topics. (3) Progress has been made in multiexposure studies. However, challenges remain and these are shared by clinical, translational and public health sciences. (4) From a mental healthcare perspective, a multidisciplinary and system level approach employing developmentally-sensitive measures and timely treatment of (self-)regulation and coregulation problems in a dyadic caregiver-child and family level approach seems needed. The existing evidence-base is sparse.

SUMMARY

During the perinatal period, addressing vulnerable contexts and building resilient systems may promote neurobehavioral development. A pluralistic approach to research, taking a multidisciplinary approach to theoretical models and empirical investigation needs to be fostered.

Physical, psychological, and behavioral problems among children and adolescents in countries with different economic statuses during the COVID-19 pandemic: a systematic review and meta-analysis

Introduction

The COVID-19 pandemic has impacted children and adolescents' physical activity (PA), sleeping patterns, and psychological and behavioral health. Yet, little is known about the differences between those in countries with various economic statuses.

Methods

Articles published from database inception through 16 March 2022 were retrieved using CINAHL Complete, Cochrane Library, EMBASE, Medline, PubMed, and PsycINFO. High-quality studies that reported the number of participants with parameters associated with PA, sleeping patterns, and psychological and behavioral problems in young people aged under 18 years during the pandemic were included. We referenced the Canadian 24-Hour Movement Guidelines for PA and sleep duration to provide the event rate for young people who were not compliant with the guidelines. The event rate of young people who had decreased sleep quality and experienced psychological and behavioral problems were also investigated. A subgroup analysis was conducted to identify the differences in those in countries with diverse economic statuses. Funnel plot analysis and Egger's test were also conducted to identify any risk of publication bias.

Result

A total of 66 studies with 1,371,168 participants aged between 0 and 18 years, involving 27 countries, were included. During the pandemic, we identified that 41% (95% CI: 39%, 43%; I2 = 96.62) and 43% (95% CI: 34%, 52%; I2 = 99.42) of young people did not meet the PA and sleep duration recommendation guidelines. In addition, 31% (95% CI: 28%, 35%; I2 = 99.66) of young people had decreased their sleep quality. Yet, no significant difference was found across countries with different economic statuses. However, the event rates of participants with psychological and behavioral problems were 32% (95% CI: 28%, 36%; I2 = 99.85) and 19% (95% CI: 14%, 25%; I2 = 99.72), respectively. In addition, the rate of psychological problems was more severe in those who live in lower middle-income countries (p < 0.001), while the rate of behavioral problems was more severe in those who live in high-income countries (p = 0.001).

Discussion

During the pandemic, the discouragement of PA, poor sleep quality, and high risk of psychological and behavioral problems are concerning. A large number of young people did not comply with the recommendation guidelines. Timely implementation of recovery plans is critical to address the adverse effects on young people.

Systematic review registration

https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=309209, identifier CRD42022309209.

Psychiatric diagnosis and treatment in the 21st century: paradigm shifts versus incremental integration

Psychiatry has always been characterized by a range of different models of and approaches to mental disorder, which have sometimes brought progress in clinical practice, but have often also been accompanied by critique from within and without the field. Psychiatric nosology has been a particular focus of debate in recent decades; successive editions of the DSM and ICD have strongly influenced both psychiatric practice and research, but have also led to assertions that psychiatry is in crisis, and to advocacy for entirely new paradigms for diagnosis and assessment. When thinking about etiology, many researchers currently refer to a biopsychosocial model, but this approach has received significant critique, being considered by some observers overly eclectic and vague. Despite the development of a range of evidence-based pharmacotherapies and psychotherapies, current evidence points to both a treatment gap and a research-practice gap in mental health. In this paper, after considering current clinical practice, we discuss some proposed novel perspectives that have recently achieved particular prominence and may significantly impact psychiatric practice and research in the future: clinical neuroscience and personalized pharmacotherapy; novel statistical approaches to psychiatric nosology, assessment and research; deinstitutionalization and community mental health care; the scale-up of evidence-based psychotherapy; digital phenotyping and digital therapies; and global mental health and task-sharing approaches. We consider the extent to which proposed transitions from current practices to novel approaches reflect hype or hope. Our review indicates that each of the novel perspectives contributes important insights that allow hope for the future, but also that each provides only a partial view, and that any promise of a paradigm shift for the field is not well grounded. We conclude that there have been crucial advances in psychiatric diagnosis and treatment in recent decades; that, despite this important progress, there is considerable need for further improvements in assessment and intervention; and that such improvements will likely not be achieved by any specific paradigm shifts in psychiatric practice and research, but rather by incremental progress and iterative integration.

Child, adolescent, and caregiver mental health difficulties and associated risk factors early in the COVID-19 pandemic in South Africa

At the onset of the COVID-19 pandemic in early 2020 in South Africa, many safety measures were implemented to protect the lives of the population. Ironically, these same safety measures have negatively impacted on the lives of children and their caregivers resulting in increased mental health problems. This study forms part of the multicountry Co-SPACE (COVID-19: Supporting Parents, Adolescents and Children during Epidemics) study that explores how families are coping during the COVID-19 pandemic, and what caregivers can do to help support their children's mental health. This paper aims to gain a better understanding of the mental health status of families specifically in South Africa in the early onset of the pandemic during restrictive lockdown measures, and identify certain risk factors that might contribute towards deteriorating mental health. Two hundred and fifty-four South African parents and carers of children and adolescents completed an online survey about their child's mental health as well as their own mental health during and post- hard lockdown in South Africa. Data collection took place over the period of the first and second waves of the COVID-19 pandemic in South Africa. Results showed that children experienced significantly higher mental health problems than adolescents (p = 0.016). Younger children were particularly negatively affected by lockdown and had more mental health problems than adolescents (p = 0.023); including emotional problems (p = 0.017), misconduct (p = 0.030), and hyperactivity (p = 0.001). Additionally, the presence of special educational needs/neurodevelopmental disorders (SEN/ND) was associated with more mental health problems (p = 0.001). Surprisingly, single parent households, which is another well-known risk factor showed no differences in mental health problems compared to nuclear families. There was also a reciprocal relationship between parental/carer mental health and child/adolescent mental health, with higher level of endorsement of mental health problems in children by parents/caregivers who themselves associated with higher levels of depression, anxiety and stress (all p's < 0.001). These results highlight the dramatic impact that COVID-19 had on children, adolescents and parents in South Africa early in the pandemic, and emphasises the need for specific support structures to be implemented within the SEN/ND community, as well as for younger children and single parent households.

ENIGMA-anxiety working group: Rationale for and organization of large-scale neuroimaging studies of anxiety disorders

Anxiety disorders are highly prevalent and disabling but seem particularly tractable to investigation with translational neuroscience methodologies. Neuroimaging has informed our understanding of the neurobiology of anxiety disorders, but research has been limited by small sample sizes and low statistical power, as well as heterogenous imaging methodology. The ENIGMA-Anxiety Working Group has brought together researchers from around the world, in a harmonized and coordinated effort to address these challenges and generate more robust and reproducible findings. This paper elaborates on the concepts and methods informing the work of the working group to date, and describes the initial approach of the four subgroups studying generalized anxiety disorder, panic disorder, social anxiety disorder, and specific phobia. At present, the ENIGMA-Anxiety database contains information about more than 100 unique samples, from 16 countries and 59 institutes. Future directions include examining additional imaging modalities, integrating imaging and genetic data, and collaborating with other ENIGMA working groups. The ENIGMA consortium creates synergy at the intersection of global mental health and clinical neuroscience, and the ENIGMA-Anxiety Working Group extends the promise of this approach to neuroimaging research on anxiety disorders.

The prevalence of mental health problems in sub-Saharan adolescents: A systematic review

Background and purpose

Most research regarding child and adolescent mental health prevention and promotion in low-and middle-income countries is undertaken in high-income countries. This systematic review set out to synthesise findings from epidemiological studies, published between 2008 and 2020, documenting the prevalence of mental health problems in adolescents from across sub-Saharan Africa.

Methods

A systematic search of multiple databases (MEDLINE, PsycINFO, Scopus) and Google Scholar was conducted guided by the Joanna Briggs Institute (JBI) Reviewer’s manual for systematic reviews of observational epidemiological studies. Studies included reported prevalence outcomes for adolescents aged 10–19 using either clinical interviews or standardized questionnaires to assess psychopathology. Clinical samples were excluded.

Results

The search yielded 1 549 records of which 316 studies were assessed for eligibility and 51 met the inclusion criteria. We present a qualitative synthesis of 37 of these 51 included articles. The other 14 studies reporting prevalence rates for adolescents living with HIV are published elsewhere. The prevalence of depression, anxiety disorders, emotional and behavioural difficulties, posttraumatic stress and suicidal behaviour in the general adolescent population and selected at-risk groups in 16 sub-Saharan countries (with a total population of 97 616 adolescents) are reported.

Study design and baseline characteristics of Shenzhen ageing-related disorder cohort in China

PURPOSE

The Shenzhen ageing-related disorder cohort was designed to detect the associations of lifestyle, environmental and genetic factors with major ageing-related disorders, especially neurological and mental disorders.

PARTICIPANTS

The cohort was a community-dwelling prospective study of 9411 elderly adults aged 60 to 92 years from 51 community health service centres in Luohu district of Shenzhen, China. The baseline data were collected between 2017 and 2018, including demographics and socioeconomics, lifestyles, medical history, family history of major non-communicable chronic disease, environmental exposures, clinical analysis of blood and urine, clinical imaging measurements, anthropometric measures and neurological function and mental health assessments. Blood and urinary samples were collected at baseline. All participants will be followed for physiological and psychological disorders and updated lifestyle and environmental exposures every 5 years.

FINDINGS TO DATE

The mean age of the participants was 67.73 years at baseline, and 42.74% were males. The prevalences of individuals with unhealthy conditions were as follows: overweight/obesity (54.38%), hypertension (58.24%), diabetes mellitus (22.30%), dyslipidaemia (75.69%), chronic bronchitis (1.45%), myocardial infarction (0.55%), coronary heart disease (5.69%), stroke (1.10%), cancer (2.18%), arthritis (5.04%), Alzheimer's disease (0.18%), Parkinson's disease (0.23%), brain injury (5.75%), cognitive impairment (5.39%) and depression status (3.28%). The mean scores for the Lawton-Brody Activities of Daily Living Scale and the Social Support Rate Scale were 14.15 and 39.54, respectively.

FUTURE PLANS

2000 new entrants from Luohu district will be recruited every year until 2028. The data collection is expected to be ended at the end of 2030. The data will be used to assess the causality of ageing-related disorders, especially neurological and mental disorders through integrating environmental, genetic and lifestyle factors. The data sets generated and/or analysed during the current study are not publicly available at this stage, but are available from the corresponding author on reasonable request.

Toward identifying reproducible brain signatures of obsessive-compulsive profiles: rationale and methods for a new global initiative

BACKGROUND

Obsessive-compulsive disorder (OCD) has a lifetime prevalence of 2-3% and is a leading cause of global disability. Brain circuit abnormalities in individuals with OCD have been identified, but important knowledge gaps remain. The goal of the new global initiative described in this paper is to identify robust and reproducible brain signatures of measurable behaviors and clinical symptoms that are common in individuals with OCD. A global approach was chosen to accelerate discovery, to increase rigor and transparency, and to ensure generalizability of results.

METHODS

We will study 250 medication-free adults with OCD, 100 unaffected adult siblings of individuals with OCD, and 250 healthy control subjects at five expert research sites across five countries (Brazil, India, Netherlands, South Africa, and the U.S.). All participants will receive clinical evaluation, neurocognitive assessment, and magnetic resonance imaging (MRI). The imaging will examine multiple brain circuits hypothesized to underlie OCD behaviors, focusing on morphometry (T1-weighted MRI), structural connectivity (Diffusion Tensor Imaging), and functional connectivity (resting-state fMRI). In addition to analyzing each imaging modality separately, we will also use multi-modal fusion with machine learning statistical methods in an attempt to derive imaging signatures that distinguish individuals with OCD from unaffected siblings and healthy controls (Aim #1). Then we will examine how these imaging signatures link to behavioral performance on neurocognitive tasks that probe these same circuits as well as to clinical profiles (Aim #2). Finally, we will explore how specific environmental features (childhood trauma, socioeconomic status, and religiosity) moderate these brain-behavior associations.

DISCUSSION

Using harmonized methods for data collection and analysis, we will conduct the largest neurocognitive and multimodal-imaging study in medication-free subjects with OCD to date. By recruiting a large, ethno-culturally diverse sample, we will test whether there are robust biosignatures of core OCD features that transcend countries and cultures. If so, future studies can use these brain signatures to reveal trans-diagnostic disease dimensions, chart when these signatures arise during development, and identify treatments that target these circuit abnormalities directly. The long-term goal of this research is to change not only how we conceptualize OCD but also how we diagnose and treat it.

Obsessive-compulsive disorder

Obsessive-compulsive disorder (OCD) is a highly prevalent and chronic condition that is associated with substantial global disability. OCD is the key example of the 'obsessive-compulsive and related disorders', a group of conditions which are now classified together in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, and the International Classification of Diseases, 11th Revision, and which are often underdiagnosed and undertreated. In addition, OCD is an important example of a neuropsychiatric disorder in which rigorous research on phenomenology, psychobiology, pharmacotherapy and psychotherapy has contributed to better recognition, assessment and outcomes. Although OCD is a relatively homogenous disorder with similar symptom dimensions globally, individualized assessment of symptoms, the degree of insight, and the extent of comorbidity is needed. Several neurobiological mechanisms underlying OCD have been identified, including specific brain circuits that underpin OCD. In addition, laboratory models have demonstrated how cellular and molecular dysfunction underpins repetitive stereotyped behaviours, and the genetic architecture of OCD is increasingly understood. Effective treatments for OCD include serotonin reuptake inhibitors and cognitive-behavioural therapy, and neurosurgery for those with intractable symptoms. Integration of global mental health and translational neuroscience approaches could further advance knowledge on OCD and improve clinical outcomes.

Integrating mental health with other non-communicable diseases

Mental disorders often coexist with other non-communicable diseases and they share many risk factors. Dan Stein and colleagues examine the evidence for an integrated approach

Obsessive-compulsive disorder and global mental health

The discipline of global mental health has emphasized the importance of the treatment gap in mental disorders, and of addressing this gap via changes in health policy, an emphasis on human rights, and innovations such as task-shifting. Although global mental health research has focused on both common mental disorders such as depression, and serious mental disorders such as schizophrenia, it has paid relatively little attention to obsessive-compulsive and related disorders (OCRDs). Nevertheless, international collaborations have recently paid a good deal of attention to the nosology and neurobiology of OCRDs, and given the prevalence and morbidity of these conditions, further work along these lines should be encouraged. This article provides a brief overview of recent international collaborations on OCRDs, and outlines future directions for such work.

A Preliminary Exploration of the Barriers to Delivering (and Receiving) Exposure-Based Cognitive Behavioral Therapy for Anxiety Disorders in Adult Community Mental Health Settings

Despite the effectiveness of exposure-based cognitive behavioral therapy (CBT) for anxiety disorders, few individuals in need receive this treatment, particularly in community mental health settings serving low-income adults. The present study took a preliminary step to understand these barriers by conducting a series of key informant interviews and focus groups among patients, providers, clinical administrators, and policy makers. Several themes emerged as barriers to the delivery of exposure-based CBT in these settings, including therapist training and compentency issues, logistical issues, and funding stream issues. Clinical implications and future research that can build from these data are discussed.

Global mental health and the National Institute of Mental Health Research Domain Criteria

BACKGROUND

The National Institute of Mental Health (NIMH) Research Domain Criteria (RDoC) project presents innovative ways of investigating mental illness based on behavioral and neurobiological measures of dimensional processes. Although cultural psychiatrists have critiqued RDoC's implications and limitations for its under-developed focus on context and experience, RDoC presents opportunities for synergies with global mental health. It can capture aspects of clinical or sub-clinical behavior which are less dependent upon Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM-5) and perhaps better elucidate the role of culture in disease expression and resilience. Aim/Results: This article uses the example of migration to describe several starting points for new research: (1) providing components for building an investigable conceptual framework to understand individual's mental health, resilience and adjustment to migration challenges or social adversities in low- and middle-income countries (LMICs) and (2) identifying measurable factors which determine resilience or vulnerability, to guide development and evaluation of targeted prevention, treatment and recovery strategies for mental health in LMICs.

CONCLUSION

In such ways, RDoC frameworks could help put the new cutting edge neurobiological dimensional scientific advances in a position to contribute to addressing mental health problems amid social adversities in LMICs. However, this would require a much-expanded commitment by both RDoC and global mental health researchers to address contextual and experiential dimensions.

Epidemiology of anxiety disorders: from surveys to nosology and back

On the basis of epidemiological survey findings, anxiety disorders are the most prevalent mental disorders around the world and are associated with significant comorbidity and morbidity. Such surveys rely on advances in psychiatric nosology and may also contribute usefully to revisions of the nosology. There are a number of questions at the intersection of psychiatric epidemiology and nosology. This review addresses the following: What is the prevalence of anxiety disorders and how do we best explain cross-national differences in prevalence estimates? What are the optimal diagnostic criteria for anxiety disorders, and how can epidemiological data shed light on this question? What are the comorbidities of anxiety disorders, and how do we best understand the high comorbidities seen in these conditions? What is the current treatment gap for anxiety disorders, and what are the implications of current understandings of psychiatric epidemiology and nosology for policy-making relevant to anxiety disorders? Here, we emphasize that anxiety disorders are the most prevalent of the psychiatric conditions, and that rather than merely contrasting cross-national prevalence in anxiety disorders, it is more productive to delineate cross-national themes that emerge about the epidemiology of these conditions. We discuss that optimizing diagnostic criteria for anxiety disorders is an iterative process to which epidemiological data can make a crucial contribution. Additionally, high comorbidity in anxiety disorders is not merely artefactual; it provides key opportunities to explore pathways to mental disorders and to intervene accordingly. Finally, work on the epidemiology and nosology of anxiety disorders has provided a number of important targets for mental health policy and for future integrative work to move between bench and bedside, as well as between clinic and community.

Thinking globally to meet local needs: autism spectrum disorders in Africa and other low-resource environments

PURPOSE OF REVIEW

Most people with autism spectrum disorders (ASDs) live in low and middle-income countries, yet almost everything we know about ASD comes from high-income countries. Here we review recent research from Africa, with some references to research in other low-resource environments. We examine publications on screening and diagnosis, intervention, clinical presentation of ASD, cultural perspectives, and neuroscience and technology.

RECENT FINDINGS

Open-access screening and diagnostic tools represent a positive, but nontrivial, future goal. Recent efforts at 'low intensity' community-based interventions are encouraging, but many significant scalability challenges remain. Proposals that ASD in Africa is more severe and overrepresented in high socioeconomic families are likely to be attributable to ascertainment biases and the absence of standardized phenotyping tools. Cultural perspectives and innovative use of technology and neuroscience have the potential to generate novel strategies of global relevance, but research priorities have to be determined by local needs.

SUMMARY

To have a real impact on clinical services, training, and research in local communities, clinician-scientists should start by thinking globally. ASD research in Africa and other low-resource environments remains limited and of questionable quality and highlights the need to build high-quality research capacity in these low-resource environments.

Development process of an assessment tool for disruptive behavior problems in cross-cultural settings: the Disruptive Behavior International Scale - Nepal version (DBIS-N)

Systematic processes are needed to develop valid measurement instruments for disruptive behavior disorders (DBDs) in cross-cultural settings. We employed a four-step process in Nepal to identify and select items for a culturally valid assessment instrument: 1) We extracted items from validated scales and local free-list interviews. 2) Parents, teachers, and peers (n=30) rated the perceived relevance and importance of behavior problems. 3) Highly rated items were piloted with children (n=60) in Nepal. 4) We evaluated internal consistency of the final scale. We identified 49 symptoms from 11 scales, and 39 behavior problems from free-list interviews (n=72). After dropping items for low ratings of relevance and severity and for poor item-test correlation, low frequency, and/or poor acceptability in pilot testing, 16 items remained for the Disruptive Behavior International Scale-Nepali version (DBIS-N). The final scale had good internal consistency (α=0.86). A 4-step systematic approach to scale development including local participation yielded an internally consistent scale that included culturally relevant behavior problems.

The cost and impact of compulsivity: A research perspective

Compulsivity is the defining feature of various psychiatric disorders including Obsessive Compulsive Related Disorders (OCRDs), and other compulsive, impulsive, and addictive disorders. These disorders are disabling, chronic conditions with an early onset and high rates of comorbidity, misdiagnoses, and delay in treatment onset. Disorders of compulsivity are responsible for considerable socioeconomic burden to society. We review the costs and impacts of compulsivity. In order to facilitate earlier diagnosis and targeted treatments, we examine the overlapping mechanisms that underlie compulsivity. We reconceptualize psychiatric disorders based on core features of compulsivity, highlight challenges in harmonizing research in children and adults, describe newer research methodologies, and point to future directions that can impact the costs and impact of disorders of compulsivity.

Hot Topics in Research: Preventive Neuroradiology in Brain Aging and Cognitive Decline

Preventive neuroradiology is a new concept supported by growing literature. The main rationale of preventive neuroradiology is the application of multimodal brain imaging toward early and subclinical detection of brain disease and subsequent preventive actions through identification of modifiable risk factors. An insightful example of this is in the area of age-related cognitive decline, mild cognitive impairment, and dementia with potentially modifiable risk factors such as obesity, diet, sleep, hypertension, diabetes, depression, supplementation, smoking, and physical activity. In studying this link between lifestyle and cognitive decline, brain imaging markers may be instrumental as quantitative measures or even indicators of early disease. The purpose of this article is to provide an overview of the major studies reflecting how lifestyle factors affect the brain and cognition aging. In this hot topics review, we will specifically focus on obesity and physical activity.

Global mental health and neuroethics

BACKGROUND

Global mental health is a relatively new field that has focused on disparities in mental health services across different settings, and on innovative ways to provide feasible, acceptable, and effective services in poorly-resourced settings. Neuroethics, too, is a relatively new field, lying at the intersection of bioethics and neuroscience; it has studied the implications of neuroscientific findings for age-old questions in philosophy, as well as questions about the ethics of novel neuroscientific methods and interventions.

DISCUSSION

In this essay, we address a number of issues that lie at the intersection of these two fields: an emphasis on a naturalist and empirical position, a concern with both disease and wellness, the importance of human rights in neuropsychiatric care, and the value of social inclusion and patient empowerment.

SUMMARY

These different disciplines share a number of perspectives, and future dialogue between the two should be encouraged.

Beyond Scientism and Skepticism: An Integrative Approach to Global Mental Health

The global burden of disorders has shifted from infectious disease to non-communicable diseases, including neuropsychiatric disorders. Whereas infectious disease can sometimes be combated by targeting single causal mechanisms, such as prevention of contact-spread illness by handwashing, in the case of mental disorders multiple causal mechanisms are typically relevant. The emergent field of global mental health has emphasized the magnitude of the treatment gap, particularly in the low- and middle-income world and has paid particular attention to upstream causal factors, for example, poverty, inequality, and gender discrimination in the pathogenesis of mental disorders. However, this field has also been criticized for relying erroneously on Western paradigms of mental illness, which may not be relevant or appropriate to the low- and middle-income context. Here, it is important to steer a path between scientism and skepticism. Scientism regards mental disorders as essential categories, and takes a covering law approach to causality; skepticism regards mental disorders as merely social constructions and emphasizes the role of political power in causal relations. We propose an integrative model that emphasizes the contribution of a broad range of causal mechanisms operating at biological and societal levels to mental disorders and the consequent importance of broad spectrum and multipronged approaches to intervention.