Global Mental Health: Interdisciplinary challenges for a field in motion

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.

Research on psychotherapy for refugees in Germany: A systematic review on its transdisciplinary and transregional opening

Recently, an increasing amount of research has focused on adapting psychotherapy concepts for refugees moving to Germany. For a long time, research from disciplines like anthropology and cultural studies has problematized the eurocentrism of psychology's theoretical premises and methodologies. Currently, scholarship around Global Mental Health and decolonization emphasizes how knowledge production from various disciplines and regions relates to this topic and could contribute to improving respective approaches. Consequently, this review aims at evaluating the actual transdisciplinary and transregional opening of studies on psychotherapeutic interventions for refugees in Germany. It provides a theoretically as well as empirically informed basis for looking at disciplinary premises, practices, and boundaries as well as the regional locatedness of respective research. Fourteen relevant studies, published between January 1, 2007 and March 4, 2022, were identified by systematically searching the databases PubPsych and Web of Science. The studies were reviewed regarding study design, choice and characterization of target groups, regional origin and target group specific adaptations of the therapeutic concepts, integration of elements from and connections to other disciplines, and use of references to scholarship from the Global South. The findings show a pronounced focus on the development of trauma therapy approaches and moreover a broad variety of concept adaptations in response to the assumed characteristics, situations, and needs of the target groups. While the findings reveal a complex transregional pattern of development and adaptation of the therapeutic concepts, transdisciplinary opening and reference to the Global South appear scarce.

Depression and Global Mental Health in the Global South: A Critical Analysis of Policy and Discourse

Over the past two decades, depression has become a prominent global public health concern, especially in low- and middle-income countries (LMICs). The World Health Organization (WHO) and the Movement for Global Mental Health have developed international guidelines to improve mental health services globally, prioritizing LMICs. These efforts hold promise for advancing care and treatment for depression and other mental, neurological, and substance abuse disorders in LMICs. The intervention guides, such as the WHO's mhGAP-Intervention Guides, are evidence-based tools and guidelines to help detect, diagnose, and manage the most common mental disorders. Using the Global South as an empirical site, this article draws on Foucauldian critical discourse and document analysis methods to explore how these international intervention guides operate as part of knowledge-power processes that inscribe and materialize in the world in some forms rather than others. It is proposed that these international guidelines shape the global discourse about depression through their (re)production of biopolitical assumptions and impacts, governmentality, and "conditions of possibility." The article uses empirical data to show nuance, complexity, and multi-dimensionality where binary thinking sometimes dominates, and to make links across arguments for and against global mental health. The article concludes by identifying several resistive discourses and suggesting reconceptualizing the treatment gap for common mental disorders.

Thick description and systems thinking: Reiterating the importance of a biopsychosocial approach to mental health

STUDY AIMS

The article aims at reiterating the importance of a biopsychosocial approach to mental health, taking stock of the critiques that have been raised and moving forward throughout a reconsideration of the theoretical background of systems thinking and emphasizing the relevance of the concept of thick description for the promotion of an adequate reflection on methodology and case formulation.

LITERATURE REVIEW

It is our opinion that the biopsychosocial approach is still a powerful framework for making sense of the growing data collected in the different fields related to mental health and for designing proper treatment plans. A crucial challenge for mental health is that of surpassing the dichotomies and ideological disputes that still contaminate the field with detrimental effects on the advancement of knowledge and on the integration and continuity of different kind of interventions.

CONCLUSIONS

The time is ripe for building bridges among neuroscience, humanities and social sciences, and this can only happen within the umbrella of a biopsychosocial perspective reinstated into its systems thinking background.

On Orthorexia Nervosa: A Systematic Review of Reviews

INTRODUCTION

Orthorexia nervosa (ON), characterized by a pathological preoccupation with "extreme dietary purity," is increasingly observed as a mental health condition among young adults and the general population. However, its diagnosis is not formally recognized and has remained contentious.

OBJECTIVE

In this systematic review, we attempt to overview previous reviews on ON, focusing on the methodological and conceptual issues with ON. This would serve both as a summary and a way to highlight gaps in earlier research.

METHODS

This systematic review took reference from the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) reporting guidelines, and using combinations of the search terms ("orthorexia" OR "orthorexia nervosa" OR "ON") AND ("review" OR "systematic review" OR "meta-analysis"), a literature search was performed on EMBASE, Medline and PsycINFO databases from inception up to October 31, 2023. Articles were included if (1) they were written or translated into English and (2) contained information pertaining to the diagnostic stability or validity of ON, or instruments used to measure ON symptoms and behaviors. Only review articles with a systematic literature search approach were included.

RESULTS

A total of 22 reviews were qualitatively reviewed. Several studies have reported variable prevalence of ON and highlighted the lack of thoroughly evaluated measures of ON with clear psychometric properties, with no reliable estimates. ORTO-15 and its variations such as ORTO-11, ORTO-12 are popularly used, although their use is discouraged. Existing instruments lack specificity for pathology and several disagreements on the conceptualization and hence diagnostic criteria of ON exist.

DISCUSSION

Previous reviews have consistently highlighted the highly variable (and contradictory) prevalence rates with different instruments to measure ON, lack of stable factor structure and psychometrics across ON measures, paucity of data on ON in clinical samples, and a need for a modern re-conceptualization of ON. The diagnosis of ON is challenging as it likely spans a spectrum from "normal" to "abnormal," and "functional" to "dysfunctional." "Non-pathological" orthorexia is not related to psychopathological constructs in the same way that ON is.

Global Is Local: Leveraging Global Mental-Health Methods to Promote Equity and Address Disparities in the United States

Structural barriers perpetuate mental health disparities for minoritized US populations; global mental health (GMH) takes an interdisciplinary approach to increasing mental health care access and relevance. Mutual capacity building partnerships between low and middle-income countries and high-income countries are beginning to use GMH strategies to address disparities across contexts. We highlight these partnerships and shared GMH strategies through a case series of said partnerships between Kenya-North Carolina, South Africa-Maryland, and Mozambique-New York. We analyzed case materials and narrative descriptions using document review. Shared strategies across cases included: qualitative formative work and partnership-building; selecting and adapting evidence-based interventions; prioritizing accessible, feasible delivery; task-sharing; tailoring training and supervision; and mixed-method, hybrid designs. Bidirectional learning between partners improved the use of strategies in both settings. Integrating GMH strategies into clinical science-and facilitating learning across settings-can improve efforts to expand care in ways that consider culture, context, and systems in low-resource settings.

Mutuality as a method: advancing a social paradigm for global mental health through mutual learning

PURPOSE

Calls for "mutuality" in global mental health (GMH) aim to produce knowledge more equitably across epistemic and power differences. With funding, convening, and publishing power still concentrated in institutions in the global North, efforts to decolonize GMH emphasize the need for mutual learning instead of unidirectional knowledge transfers. This article reflects on mutuality as a concept and practice that engenders sustainable relations, conceptual innovation, and queries how epistemic power can be shared.

METHODS

We draw on insights from an online mutual learning process over 8 months between 39 community-based and academic collaborators working in 24 countries. They came together to advance the shift towards a social paradigm in GMH.

RESULTS

Our theorization of mutuality emphasizes that the processes and outcomes of knowledge production are inextricable. Mutual learning required an open-ended, iterative, and slower paced process that prioritized trust and remained responsive to all collaborators' needs and critiques. This resulted in a social paradigm that calls for GMH to (1) move from a deficit to a strength-based view of community mental health, (2) include local and experiential knowledge in scaling processes, (3) direct funding to community organizations, and (4) challenge concepts, such as trauma and resilience, through the lens of lived experience of communities in the global South.

CONCLUSION

Under the current institutional arrangements in GMH, mutuality can only be imperfectly achieved. We present key ingredients of our partial success at mutual learning and conclude that challenging existing structural constraints is crucial to prevent a tokenistic use of the concept.

Opening up the 'black-box': what strategies do community mental health workers use to address the social dimensions of mental health?

PURPOSE

Community-based workers promote mental health in communities. Recent literature has called for more attention to the ways they operate and the strategies used. For example, how do they translate biomedical concepts into frameworks that are acceptable and accessible to communities? How do micro-innovations lead to positive mental health outcomes, including social inclusion and recovery? The aim of this study was to examine the types of skills and strategies to address social dimensions of mental health used by community health workers (CHWs) working together with people with psychosocial disability (PPSD) in urban north India.

METHODS

We interviewed CHWs (n = 46) about their registered PPSD who were randomly selected from 1000 people registered with a local non-profit community mental health provider. Notes taken during interviews were cross-checked with audio recordings and coded and analyzed thematically.

RESULTS

CHWs displayed social, cultural, and psychological skills in forming trusting relationships and in-depth knowledge of the context of their client's lives and family dynamics. They used this information to analyze political, social, and economic factors influencing mental health for the client and their family members. The diverse range of analysis and intervention skills of community health workers built on contextual knowledge to implement micro-innovations in a be-spoke way, applying these to the local ecology of people with psychosocial disabilities (PPSD). These approaches contributed to addressing the social and structural determinants that shaped the mental health of PPSD.

CONCLUSION

Community health workers (CHWs) in this study addressed social aspects of mental health, individually, and by engaging with wider structural factors. The micro-innovations of CHWs are dependent on non-linear elements, including local knowledge, time, and relationships. Global mental health requires further attentive qualitative research to consider how these, and other factors shape the work of CHWs in different locales to inform locally appropriate mental health care.

Development of the UPSIDES global mental health training programme for peer support workers: Perspectives from stakeholders in low, middle and high-income countries

BACKGROUND

Peer support in mental health is a low-threshold intervention with increasing evidence for enhancing personal recovery and empowerment of persons living with severe mental health conditions. As peer support spreads globally, there is a growing need for peer support training programmes that work well in different contexts and cultures. This study evaluates the applicability and transferability of implementing a manualised multi-national training programme for mental health peer support workers called UPSIDES from the perspective of different local stakeholders in high-, middle-, and low-income countries.

METHOD

Data from seven focus groups across six study sites in Africa (Tanzania, Uganda), Asia (India, Israel), and Europe (Germany 2 sites) with 44 participants (3 service users, 7 peer support workers, 25 mental health staff members, 6 clinical directors and 3 local community stakeholders) were thematically analysed.

RESULTS

397 codes were identified, which were thematically analysed. Five implementation enablers were identified: (i) Enhancing applicability through better guidance and clarity of training programme management, (ii) provision of sufficient time for training, (iii) addressing negative attitudes towards peer support workers by additional training of organisations and staff, (iv) inclusion of core components in the training manual such as communication skills, and (v) addressing cultural differences of society, mental health services and discrimination of mental health conditions.

DISCUSSION

Participants in all focus groups discussed the implementation of the training and peer support intervention to a greater extent than the content of the training. This is in line with growing literature of difficulties in the implementation of peer support including difficulties in hiring peer support workers, lack of funding, and lack of role clarity. The results of this qualitative study with stakeholders from different mental health settings worldwide emphasises the need to further investigate the successful implementation of peer support training. All results have been incorporated into the manualisation of the UPSIDES peer support training.

Paternal postnatal depression and associated factors: Community-based cross-sectional study

Introduction

Paternal postnatal depression is a type of depression that occurs among male partners after childbirth. Although the problem has a multidimensional impact, there is limited data in low-income countries, including Ethiopia. Therefore, this study aimed to uncover this problem in the study setting.

Objective

To assess paternal postnatal depression and associated factors.

Method and study period

A community-based cross-sectional study was employed from April 1 to 30, 2023, among 423 fathers in Mattu Town, Southwest Ethiopia. A face-to-face interviewer administered a structured questionnaire prepared by the Open Data Kit tool. The study participants were selected by simple random sampling techniques. A binary and multivariable logistic regression analysis was used. Both crude and adjusted odds ratios with a 95% confidence interval were calculated, and a p-value of less than 0.05 was used.

Result

Among 423 fathers, 412 participated, making the response rate 97.40%. The prevalence of paternal postnatal depression was 29.37% (95% confidence interval: 24.95%, 31.25). The poor wealth index (adjusted odds ratio (AOR): 1.67; 95% confidence interval: 1.88, 3.14), loneliness (AOR: 1.81; 95% confidence interval: 1.20, 3.20), poor social support (AOR: 6.08; 95% confidence interval: 2.55, 14.48), feeling of family income stress (AOR: 3.22; 95% confidence interval: 1.89, 5.50), and history of adverse pregnancy outcome (AOR: 3.00; 95% confidence interval: 1.62, 0.59) were significant associated factors at p-value less than 0.05.

Conclusions

The study identified nearly 3 in 10 fathers suffering from paternal postnatal depression. Therefore, the Ministry of Health and other concerned bodies should focus on this population group to alleviate it. In addition, health professionals and extension workers should provide evidence-based care plans based on the identified factors.

The Impact of an Online Post-Graduate Interdisciplinary Mental Health Programme on Graduates' Confidence and Practice

This study aimed to examine the experiences of graduates of online interdisciplinary postgraduate mental health programmes in Australia. The program was delivered in 6-week terms. Seven graduates from diverse backgrounds were interviewed about their experiences with the course and its impact on their practice, confidence, professional identity, views on mental health service users, and their motivation for additional learning. The interviews were recorded and transcribed and underwent thematic content analysis. The graduates reported an increase in confidence and knowledge after completing the course, which led to a change in their views and attitudes towards service users. They appreciated the examination of psychotherapies and motivational interviewing, and applied their newly acquired skills and knowledge in their practice. The course was found to have improved their clinical practice. This study highlights a departure from traditional pedagogical approaches in mental health skill acquisition, as the entire program was delivered online. There is a need for further research to determine who might benefit most from this mode of delivery and to verify the competencies acquired by graduates in real-world situations. Online mental health courses are a feasible option and have been positively received by graduates. To enable graduates to participate in transforming mental health services, systemic change and recognition of their capabilities, particularly those from non-traditional backgrounds, is required. The results of this study suggest the potential for online postgraduate programs to play a significant role in transforming mental health services.

Contingent universality: The epistemic politics of global mental health

The field of global mental health (GMH) has undergone profound changes over the past decade. Outgrowing its earlier agenda it has performed a reflexive turn, broadened towards a social paradigm and developed new modes of knowledge production, all of which reshaped 'mental health' as a global object of knowledge and care, and the epistemic politics of the field. Drawing on long-term ethnographic fieldwork among GMH experts and recent agenda-setting publications, I discuss how GMH advocates and critical observers alike have created conceptual and practical middle-grounds between different forms of mental health knowledge - across culture, epistemic power, lived experience, policy platforms and academic disciplines - framing their dynamic encounters as dialogue, adaptation, participation, co-production or integration. Ultimately, I argue, GMH today is focusing less on establishing mental health as a universal problem than on managing its inherent multiplicity through alignment and integration across different bodies of knowledge. Global knowledge, so conceived, is fluid and malleable and produced in open-ended knowledge practices, governed by what I call 'contingent universality'. It is not new that the concepts and practices of the psy-disciplines are malleable and multiple, internally and externally contested, rapidly changing over time and not easily transferrable across space. What is new is that within the increasingly heterogenous epistemic space of GMH, these features have become assets rather than liabilities. GMH knowledge achieves both global reach and local relevance precisely because 'mental health' can be many things; it can be expressed in a wide range of idioms and concepts, and its problems and solutions align easily with others, at many scales. These fluid and integrative knowledge practices call for renewed empirical, critical and collaborative engagement.

Strategic universality in the making of global guidelines for mental health

Based on interviews with members of the Guideline Development Group (GDG) of the World Health Organization's (WHO) Mental Health Gap Action Programme (mhGAP) Guidelines for Mental, Neurological and Substance Use Disorders, this article adds empirical depth to understanding the contingent and strategic nature of universality in relation to mental health. Differently from debating whether or not mental health is global, the article outlines the people, ideas, and processes involved in making it global. Thematic analysis of interviews carried out with nine (out of 21) members of the original mhGAP GDG identified six intersecting strategies that enable the construction of universality in global mental health (GMH): 1) processes and practices of assembling expertise; 2) decisions on what counts as evidence; 3) framing cultural relativism as nihilistic; 4) the delaying of complexity to prioritize action; 5) the narration of tensions as technical rather than epistemological; and 6) the ascription of messiness to local contexts rather than to processes of standardization. Interviews showed that differently from the public-facing consensus often presented in GMH, GDG members hold contrasting and contingent understandings of the nature of universality in relation to mental health diagnoses and interventions. Thus, the universality of mental health achieved through the mhGAP Guidelines is partial and temporary, requiring continuous (re)iteration. The article uses empirical data to show nuance, complexity, and multi-dimensionality where binary thinking sometimes dominates, and to make links across arguments 'for' and 'against' global mental health.

'All in good faith?' An ethno-historical analysis of local faith actors' involvement in the delivery of mental health interventions in northern Uganda

Faith actors have become increasingly significant in the field of global mental health, through their inclusion in the delivery of psychosocial support in humanitarian settings. This inclusion remains empirically underexplored. We explore historical and contemporary activities of local faith actors in responding to mental disquiet in northern Uganda. Given pre-existing roles, we question what it means when humanitarians draw on faith actors to deliver mental health and psychosocial support (MHPSS) in conflict-affected settings. We argue for a recognition of faith actors as agents operating within a therapeutic marketplace, which on occasion links suffering to social inequality and exclusion. We show, moreover, that the formal inclusion of Christian actors within MHPSS may not equate to the enforcement of rights-based values at the core of international ideas of protection.

Seeking Healing for a Mental Illness: Understanding the Care Experiences of Service Users at a Prayer Camp in Ghana

Human rights abuses in mental health care are a global concern. Addressing the problem requires input from key stakeholders, particularly from people using mental health services. This study explored the experiences of persons with mental illness receiving care in a faith-based setting in Ghana. The study employed a qualitative design, with in-depth interviews (n = 23) and focus groups (n = 18 participants in 3 groups). The constant comparative method of analysis was used to identify themes in participants' descriptions of their experiences. The first three themes identified are consistent with human rights and coercion, and the last two themes related to service users' views on participation in spiritual practices. Themes included: decision-making around care; consent and efficacy of religious healing; experiences with chaining; views around biomedical treatment; participation in religious activities as part of healing and recognition of the need for spiritual healing. It was observed that participants with prior experience of psychiatric treatment were happy about the absence of chaining in psychiatric facilities but strongly disliked the side effects of medications. These findings underscore the need for faith-based institutions to provide care that is consistent with patient preferences, thereby helping to address the resultant human rights abuses.

Stakeholders' perspectives on the development of an Africa-focused postgraduate diploma to address public mental health training needs in Africa: a qualitative study

BACKGROUND

Despite the significant contribution of mental health conditions to the burden of disease, there is insufficient evidence from Africa to inform policy, planning and service delivery. Thus, there is a need for mental health research capacity building, led by African public mental health researchers and practitioners, to drive local research priorities. The aim of African mental health Researchers Inspired and Equipped (ARISE) was to develop a one-year postgraduate diploma (PGDip) in public mental health to address the current gaps in public mental health training.

METHODS

Thirty-six individual interviews were conducted online with three groups of participants: course convenors of related PGDips in South Africa, course convenors of international public mental health degree programmes and stakeholders active in public mental health in Africa. The interviewers elicited information regarding: programme delivery, training needs in African public mental health, and experiences of facilitators, barriers and solutions to successful implementation. The transcribed interviews were analysed by two coders using thematic analysis.

RESULTS

Participants found the Africa-focused PGDip programme acceptable with the potential to address public mental health research and operational capacity gaps in Africa. Participants provided several recommendations for the PGDip, including that: (i) the programme be guided by the principles of human rights, social justice, diversity and inclusivity; (ii) the content reflect African public mental health needs; (iii) PGDip faculty be skilled in teaching and developing material for online courses and (iv) the PGDip be designed as a fully online or blended learning programme in collaboration with learning designers.

CONCLUSIONS

The study findings provided valuable insight into how to communicate key principles and skills suited to the rapidly developing public mental health field while keeping pace with changes in higher education. The information elicited has informed curriculum design, implementation and quality improvement strategies for the new postgraduate public mental health programme.

Reprioritising global mental health: psychoses in sub-Saharan Africa

Arthur Kleinman's 2009 Lancet commentary described global mental health as a "moral failure of humanity", asserting that priorities should be based not on the epidemiological and utilitarian economic arguments that tend to favour common mental health conditions like mild to moderate depression and anxiety, but rather on the human rights of those in the most vulnerable situations and the suffering that they experience. Yet more than a decade later, people with severe mental health conditions like psychoses are still being left behind. Here, we add to Kleinman's appeal a critical review of the literature on psychoses in sub-Saharan Africa, highlighting contradictions between local evidence and global narratives surrounding the burden of disease, the outcomes of schizophrenia, and the economic costs of mental health conditions. We identify numerous instances where the lack of regionally representative data and other methodological shortcomings undermine the conclusions of international research carried out to inform decision-making. Our findings point to the need not only for more research on psychoses in sub-Saharan Africa, but also for more representation and leadership in the conduct of research and in international priority-setting more broadly-especially by people with lived experience from diverse backgrounds. This paper aims to encourage debate about how this chronically under-resourced field, as part of wider conversations in global mental health, can be reprioritised.

Maximising impactful, locally relevant global mental health research conducted in low and middle income country settings: ethical considerations

Background: Achieving ethical and meaningful mental health research in diverse global settings requires approaches to research design, conduct, and dissemination that prioritise a contextualised approach to impact and local relevance. Method: Through three case studies presented at the 2021 Global Forum on Bioethics in Research meeting on the ethical issues arising in research with people with mental health conditions, we consider the nuances to achieving ethical and meaningful mental health research in three diverse settings. The case studies include research with refugees Rwanda and Uganda; a neurodevelopmental cohort study in a low resource setting in India, and research with Syrian refugees displaced across the Middle East. Results: Key considerations highlighted across the case studies include how mental health is understood and experienced in diverse contexts to ensure respectful engagement with communities, and to inform the selection of contextually-appropriate and feasible research methods and tools to achieve meaningful data collection.  Related to this is a need to consider how communities understand and engage with research to avoid therapeutic misconception, exacerbating stigma, or creating undue inducement for research participation, whilst also ensuring meaningful benefit for research participation. Central to achieving these is the meaningful integration of the views and perspectives of local stakeholders to inform research design, conduct, and legacy. The case studies foreground the potential tensions between meeting local community needs through the implementation of an intervention, and attaining standards of scientific rigor in research design and methods; and between adherence to procedural ethical requirements such as ethical review and documenting informed consent, and ethical practice through attention to the needs of the local research team. Conclusions: We conclude that engagement with how to achieve local relevance and social, practice, and academic impact offer productive ways for researchers to promote ethical research that prioritises values of solidarity, inclusion, and mutual respect.

Global Mental Health in South Lebanon: Psychoeducation, Translation, and Culture

In this article I examine the unintended consequences of global mental health reform in postwar South Lebanon. I follow the integration of mental health in primary health care centers. Three key tensions emerge: First, integrating mental health led to separating mental health from socioeconomic conditions. Second, culture was simultaneously conceived as a barrier to therapy and a local context requiring adaptation. Third, the use of personality disorders as psychological interpretations of social life resulted in psychologizing gender and class. The article contributes to growing ethnographic research on global mental health and calls for attention to structural competence in similar settings.SECOND LANGUAGE ABSTRACTفي هذا المقال، أستكشف العواقب غير المقصودة لإصلاحات الصحة النفسية العالمية في جنوب لبنان بعد الحرب. أتابع دمج الصحة النفسية في مراكز الرعاية الصحية الأولية. تظهر هنا ثلاث معضلات رئيسية: أولاً ، أدّى دمج الصحة النفسية إلى فصلها عن الظروف الاجتماعية والاقتصادية المحيطة بها. ثانيًا، تم تصوير مفهوم الثقافة كحاجز أمام العلاج النفسي من جهة وكسياق محلي يتطلب تكيفا وترجمة. ثالثًا، أدى استخدام تشخيصات اضطرابات الشخصية كتفسيرات نفسية للحياة الاجتماعية إلى نفسنة الجنس والطبقة. يساهم المقال الى البحوث الإثنوغرافية المتنامية حول الصحة النفسية العالمية ويدعو إلى الاهتمام بالكفاءة الهيكلية للصحة النفسية في بيئات مماثلة                        .

"I wanted to be a bride, not a wife": Accounts of child marriage in the Bedouin community in Israel

This article presents a qualitative study of the experience of child marriage among Bedouin in Israel. We conducted semi-structured interviews with a convenience sample of 17 young Bedouin women, aged 17-21, who were married between the ages of 12-17. The interviewees' descriptions indicate that child marriage is a powerful cultural practice that has evolved into a "natural" and "obvious" tool for supervising girls and women. All the interviewees reported domestic violence, despair, and reported suicide attempts as a response to their existential suffering in their marriage and as an act of daily resistance to a powerful and oppressive cultural practice. These findings raise challenges in the case of global mental health interventions since these interventions not only require cultural sensitivity to avoid the constraint of Western psychiatric diagnoses and classifications, but also more critical thinking about the interactions between global and local, universalist and culturalist perspectives.

Help-seeking strategies and treatment experiences among individuals diagnosed with Bipolar Spectrum Disorder in Iran: A qualitative study

Social, cultural, and structural factors are associated with delays in seeking help from mental health professionals and poor treatment adherence among patients with mood disorders. This qualitative study examined the perspectives on the services and response to treatments of individuals diagnosed with Bipolar Spectrum Disorder (BSD) in Iran through 37 in-depth semi-structured interviews with patients who had received BSD diagnosis and treatment (excluding Bipolar-I). Interviews explored two broad areas: 1) coping and help-seeking strategies; and 2) barriers to treatment and expectations of outcomes from treatment. Multiple factors influenced the help-seeking strategies and trajectories of patients with BSD diagnoses in Iran, including: structural limitations of the mental healthcare system; modes of practice of biological psychiatry; characteristics of the official psychology and counseling services permitted by Iran's government; popular psychology and consultation (offered through social media from the diaspora) by Iranian psychologists and counsellors in the diaspora; and alternative spiritual and cult-based groups. To improve the quality and accessibility of mental health services, it is essential to have structural changes in the healthcare system that prioritize human rights and individuals' values over the political and ideological values of the state and changes in the professions that promote secular training of mental healthcare providers and an ecosocial model of care.

Maximising impactful and locally relevant mental health research: ethical considerations

Background: Achieving ethical and meaningful mental health research in diverse global settings requires approaches to research design, conduct, and dissemination that prioritise a contextualised approach to impact and local relevance. Method: Through three case studies presented at the 2021 Global Forum on Bioethics in Research meeting on the ethical issues arising in research with people with mental health conditions, we consider the nuances to achieving ethical and meaningful mental health research in three diverse settings. The case studies include research with refugees Rwanda and Uganda; a neurodevelopmental cohort study in a low resource setting in India, and research with Syrian refugees displaced across the Middle East. Results: Key considerations highlighted across the case studies include how mental health is understood and experienced in diverse contexts to ensure respectful engagement with communities, and to inform the selection of contextually-appropriate and feasible research methods and tools to achieve meaningful data collection.  Related to this is a need to consider how communities understand and engage with research to avoid therapeutic misconception, exacerbating stigma, or creating undue inducement for research participation, whilst also ensuring meaningful benefit for research participation. Central to achieving these is the meaningful integration of the views and perspectives of local stakeholders to inform research design, conduct, and legacy. The case studies foreground the potential tensions between meeting local community needs through the implementation of an intervention, and attaining standards of scientific rigor in research design and methods; and between adherence to procedural ethical requirements such as ethical review and documenting informed consent, and ethical practice through attention to the needs of the local research team. Conclusions: We conclude that engagement with how to achieve local relevance and social, practice, and academic impact offer productive ways for researchers to promote ethical research that prioritises values of solidarity, inclusion, and mutual respect.

Psychiatrization of Resistance: The Co-option of Consumer, Survivor, and Ex-patient Movements in the Global South

This article examines contemporary examples of psychiatrization as a tool of disciplinary control and repression, focusing on new research on the co-option of consumer/survivor/ex-patient movements within the Global South. Here, we understand psychiatrization as (1) the process of imposing certain interpretive limits on states of difference and distress and (2) the conceptualization of treatment and recovery through the teleological notion of normalcy. By interpreting difference solely in psychiatric terms, psychiatrization functions as a tool of disciplinary control in both domestic and international contexts by reterritorializing efforts to resist hegemonic norms and political institutions of gendered and racialized oppression, colonialism, and imperialism. After setting out our understanding of psychiatrization as a political process in the sense that it enacts a particular "ontological politics", one that foregrounds psychiatric interpretations of difference and dissent to the exclusion of other possible meanings, we examine the reach and complexity of psychiatrization in the suppression of political and social movements that attempt to resist oppressive norms and institutions. We then present new research within the consumer/survivor/ex-patient and psychosocial disability movements in the Global South to show how psychiatrization can thwart activist's aims of transforming how we view both the end goals of mental health treatment and the political valence of mental distress.

Perspective: Decolonizing postmodernist approaches to mental health discourse toward promoting epistemic justice

Currently, it is possible to observe a slowly (but surely) growing volume of claims seeking to disprove Foucauldian ideas about knowledge and power as overlapping basic theories of epistemic justice. Prompted by these claims, alongside adopting tenets of Critical Race Theory to address injustices inflicted upon people facing mental health challenges, I propose applying decolonizing deconstruction to Foucault's terminology, toward identifying opportunities to enhance epistemic justice, primarily in direct interventions in mental health services.

Engaging culture and context in mhGAP implementation: fostering reflexive deliberation in practice

In 2002, WHO launched the Mental Health Gap Action Programme (mhGAP) as a strategy to help member states scale up services to address the growing burden of mental, neurological and substance use disorders globally, especially in countries with limited resources. Since then, the mhGAP program has been widely implemented but also criticised for insufficient attention to cultural and social context and ethical issues. To address this issue and help overcome related barriers to scale-up, we outline a framework of questions exploring key cultural and ethical dimensions of mhGAP planning, adaptation, training, and implementation. This framework is meant to guide mhGAP activity taking place around the world. Our approach is informed by recent research on cultural formulation and adaptation, and aligned with key components of the WHO implementation research guide (Peters, D. H., Tran, N. T., & Adam, T. (2013). Implementation research in health: a practical guide. Implementation research in health: a practical guide.). The framework covers three broad domains: (1) Concepts of wellness and illness-how to examine cultural norms, knowledge, values and attitudes in relation to the "culture of the mhGAP"; (2) Systems of care-identifying formal and informal systems of care in the cultural context of practice.; and (3) Ethical space: examining issues related to power dynamics, communication, and decision-making. Systematic consideration of these issues can guide integration of cultural knowledge, structural competence, and ethics in implementation efforts.

Identifying challenges and recommendations for advancing global mental health implementation research: A key informant study of the National Institute of Mental Health Scale-Up Hubs

OBJECTIVE

This study explored perspectives of researchers working with the National Institute of Mental Health (NIMH) Scale-Up Hubs, consisting of research partnerships for scaling up mental health interventions in low- and middle-income countries (LMICs), to: 1) identify common barriers to conducting impactful research on the implementation of evidence-based mental health services; and 2) provide recommendations to overcome these implementation challenges.

METHODS

A sequential qualitative approach was employed. First, an open-ended survey was distributed to the 10 Scale-Up Hubs and NIMH program staff asking informants to identify challenges in conducting mental health implementation research in LMICs. Second, survey findings guided an in-person workshop to generate implementation recommendations to inform the field.

RESULTS

In total, 46 respondents completed surveys, and 101 researchers attended the workshop. The workshop produced implementation recommendations for low-resource settings: 1) identifying impact of research on policy and practice; 2) sustaining careers of early researchers in global mental health; 3) engaging policymakers and donors to value mental health research; 4) supporting the workforce for delivering evidence-based treatments for mental disorders; and 5) promoting sustainability of programs.

CONCLUSIONS

These findings can strengthen collaboration between researchers and key stakeholders, and highlight important targets for improving mental health implementation research in LMICs.

"We Need Other Human Beings in Order to be Human": Examining the Indigenous Philosophy of Umunthu and Strengthening Mental Health Interventions

This paper examines how cultural, historical and contemporary perspectives of mental health continue to inform ways of understanding and responding to mental distress even under the biomedical gaze of the Movement for Global Mental Health (MGMH). Based on experiences in Malawi, the authors explore three prominent interventions (practical support, counselling and support groups) employed by village health workers within a mental health task-shifting initiative and reveal how the ancient philosophy of Umunthu with its values of interconnectedness, inclusion and inter-relationships informs and shapes the direction of these interventions. Practical support is marshalled through traditional village structures, counselling provides advice and an encouragement to hope, and support groups provide a place for emotional exchange and a forum for the enactment of values, reflection and reinforcement of Umunthu. What are pronounced as biomedical psychosocial interventions are in fact the delivery of culturally embedded therapeutic approaches. Historical and socio-political evidence is offered to explain the dominance of biomedical perspectives and the HSAs' responses and a call is made for a transformation of MGMH to embrace rich philosophies such as Umunthu and enact respectful, inclusive and democratic values to enlist collaborations between equals to develop relevant and effective knowledge and local responses to mental distress.

[Situating atention deficit and hyperactivity in Portugal: social, historical, and ethical dimensions of an emerging global health issue]

Attention deficit and hyperactivity disorder (ADHD) is considered one of the most frequent behavioral and neurodevelopmental problems in school-age children and adolescents, both in Portugal and worldwide. The diagnostic categorization of ADHD and the prescription of psychostimulants as its first-line treatment have been the object not only of scientific research and clinical validation, but also of controversy and social critique, especially in light of the concept of medicalization. Despite its high profile and salience in such diverse fields as education, pharmaceuticals, mental health, and public policy, a significant gap remains in the characterization of social-historical, ethical, and institutional dimensions of ADHD outside English-speaking countries. Combining historical and ethnographic research with document and media analysis, the article addresses that challenge by tracing the social trajectory of ADHD in Portugal, from the emergence of "hyperactivity" in the 1970s and 1980s to the current public and political debates on psychostimulant treatments and prescribing trends. From this interdisciplinary perspective and based on the Portuguese case study, the aim of this article is to contextualize the definition, validation, and expansion of ADHD as part of a dynamic and socially situated process in which global diagnostic and pharmaceutical systems intersect with institutional and socioeconomic contingencies, as well as local specificities and needs. More broadly, the article discusses how the case study of ADHD contributes to the development of interdisciplinary research that helps rethinking the social scope of mental health across local and global health contexts.

Global health and rehabilitation education in Canada: a qualitative analysis of experiences and perspectives of educators

BACKGROUND

Rehabilitation practice is increasingly tied to global trends. First, healthcare services are increasingly tailored to be patient-centered, requiring knowledge of sociocultural contexts and experiences of a diverse patient population. Second, non-communicable diseases and morbidity stemming from infectious diseases are creating greater needs for rehabilitation services in countries facing this double burden of disease. Third, globalization continues to shape the risk factors for disease and disability and influences the type of services accessible and the financing and management of such services. Given this context, there is a critical need to examine how global health (GH) is approached in rehabilitation curricula. How students learn about these various dynamics will impact their ability to practice in this environment and best meet the needs of the patients and populations they are caring for.

OBJECTIVES

This study explores how university-level Canadian occupational and physical therapy educators understand GH within their academic and clinical practices.

METHODS

The project followed a qualitative design. Semi-structured interviews were conducted with participants (n = 12; randomized purposive sampling was used). A deductive and inductive thematic analysis was performed to describe the participants perspectives on and practices of GH education in rehabilitation education programs.

FINDINGS

There was an overall coherence between the literature and the participant's views of the constituent elements of GH. Participants viewed GH as a framework to broaden the clinical training of students by encouraging a critical "clinical toolbox" via themes of structural competency, cultural sensitivity, and a sense of global citizenship and stewardship. However, GH was also described by participants as being implicitly present in the curriculum due to ambiguities regarding the scope of GH, seen as a key obstacle in the integration of GH education in rehabilitation programs.

INTERPRETATION

Despite the growing interest and relevance of GH, there is a noteworthy absence of GH education guidelines. There is a need to uncover the scope and underpinnings of GH and to outline rehabilitation-oriented GH competencies as per the positive value of GH attributed by the educators to the training of our healthcare workforce.IMPLICATIONS FOR REHABILITATIONGlobal health is seen by a sample of educators to provide rehabilitation students with a critical and holistic "clinical toolkit" by introducing themes of structural competency, cultural sensitivity and awareness, and global stewardship, enabling them to become good global clinicians and global citizens;The increased interest in global health throughout academic curricula presents new challenges for educators and students, specifically relating to understanding the mission and aims of this field. There is a need to clarify the notion and field of global health and how it complements clinical training within rehabilitation programs;There is a need to advance the literature on global health in rehabilitation by exploring what competencies are seen to be relevant to the field and practice of rehabilitation.

Cultural adaptation of Hap-pas-Hapi, an internet and mobile-based intervention for the treatment of psychological distress among Albanian migrants in Switzerland and Germany

BACKGROUND

Internet- and mobile-based mental health interventions have the potential to narrow the treatment gap in ethnic groups. Little evidence exists on the cultural adaptation of such interventions. Cultural adaptation of evidence-based interventions distinguishes between surface and deep structure adaptation. Surface refers to matching materials (e.g., illustrations, language) or methods of treatment delivery to the target population, whereas deep structure adaptation considers cultural concepts of distress (CCD). So far, CCD have only been considered to a limited extent in cultural adaptation of psychological interventions, and there is a lack of well documented adaptation procedures.

AIMS

With a cross-disciplinary and mixed-method approach, following a new conceptual framework for cultural adaptation of scalable psychological interventions, this study aimed to develop both surface and deep structure adaptations of an internet- and mobile-based intervention called Hap-pas-Hapi for the treatment of psychological distress among Albanian migrants in Switzerland and Germany.

METHODS

A qualitative ethnopsychological study was conducted to examine the target group's CCD. Focus group discussions, an online survey, and individual key informant interviews were utilised to evaluate the original intervention, adaptation drafts and the final adapted intervention. A reporting system was developed to support the decision-making process and to report all adaptations in a transparent and replicable way.

RESULTS

The ongoing involvement of target population key informants provided valuable feedback for the development of a more person-centred intervention, which might enhance treatment acceptance, motivation and adherence.

DISCUSSION

This study provides empirical and theory-based considerations and suggestions for future implementation that may foster acceptability and effectiveness of culturally adapted evidence-based interventions.