From categories to contexts: a decade of the 'new cross-cultural psychiatry'

Migrants' mental health recovery in Italian reception facilities

BACKGROUND

Forced migration leaves deep marks on the psychological well-being of migrants, with post-traumatic stress disorder (PTSD) and other psychological conditions being prevalent among them. While research has clarified the extent to which pre-migration trauma is a predictor of mental health outcomes, the role of post-migration stressors in the settlement environment are yet to be fully characterized.

METHODS

We monitored mental health of a cohort of 100 asylum-seekers during their 14-day COVID-19-related quarantine in reception facilities in Rome, Italy, through the administration of six questionnaires (a demographic survey, the WHO-5 well-being index, the Primary Care PTSD Screen for Diagnostic and Statistical Manual of Mental Disorders 5 (DSM-5), the Harvard Trauma Questionnaire, the Trauma and Loss Spectrum-Self Report, and the LiMEs-Italian version). Through the combination of statistical analysis and supervised learning, we studied the impact of the first contact with the reception system on asylum-seekers' mental health and sought for possible risk and shielding factors for PTSD.

RESULTS

We find that sheltering in refugee centers has a positive impact on migrants' mental health; asylum-seekers with PTSD reported more traumatic events and personality characteristics related to loss and trauma; life events are predictors of PTSD in asylum-seekers.

CONCLUSIONS

We identify past traumatic experiences as predictors of PTSD, and establish the positive role the immediate post-migration environment can play on migrants' psychological well-being. We recommend for host countries to implement reception models that provide effective protection and integration of asylum-seekers, similar to those in the Italian system.

Prevalence, correlates and explanatory models of cognitive deficits in patients with schizophrenia-A cross sectional study

Background

Schizophrenia may cause significant impairment in social and economic aspects of a patient's life. Current evidence suggests that cognitive deficits may affect the functioning of a person with schizophrenia more than positive or negative symptoms. There is a lack of literature on explanatory models of cognitive deficits in schizophrenia that can influence help-seeking behavior.

Objectives

This study aimed to estimate the prevalence of cognitive deficits and assess their relationship with socio-demographic and clinical characteristics among patients with schizophrenia. We also planned to explore the explanatory models of cognitive deficits in these patients.

Methods

Consecutive outpatients with schizophrenia who met eligibility criteria were recruited after obtaining informed consent. The Addenbrooke's Cognitive Examination Tamil version (ACE III) and Observable Social Cognition - A Rating Scale (OSCARS) and Positive and Negative Symptom Scale (PANSS) were used to assess cognitive functioning and symptom profile, respectively. Beliefs about illness were recorded using the modified Short Explanatory Model Interview (SEMI). Socio-demographic and treatment-related details were collected with a structured proforma. Statistical analysis was done using SPSS for Windows (version 16.0.1).

Results

One hundred and forty patients participated in the study. The prevalence of cognitive deficits was 75.7% using ACE-III scores, 19.3% on OSCARS, and 40% based on subjective reports. Though the majority (81.4%) of patients reported a medical explanatory model for cognitive impairment, a significant number of them (70.7%) also held non-medical models simultaneously.

Conclusion

Cognitive deficits are prevalent in the majority of patients with schizophrenia. Poor test performance on cognitive testing was observed in those with a significant family history. Multiple contradictory explanatory models for the causation of cognitive deficits were reported.

Explanatory Models of Depression in a Rural Community of Coastal Karnataka, India: A Cross-Sectional Survey

BACKGROUND

Depression is a major public health problem but there is a huge treatment gap in India. Cultural beliefs influence conception of illness, personal meaning, help-seeking behaviors, and adherence to treatment. Research on explanatory models of depression attempt to explore these unique characteristics in an individual and the community. We set out to examine explanatory models of depression in a rural community of coastal Karnataka and explore the association between sociodemographic variables and explanatory models of depression.

METHODS

A cross-sectional household survey in the rural community of Harekala village, Mangaluru taluk, Dakshina Kannada district, Karnataka, was done using Kish tables. A total of 200 individuals were interviewed with an adaptation of the Short Explanatory Model Interview in a local language using a case vignette of depression.

RESULTS

Around 40% of the individuals perceived the problem as tension/stress/excessive worrying and did not perceive it as mental illness. A scant 10% of the participants recognized some mental illness. Around one-fifth of the individuals attributed the problem to evil spirits and black magic; female participants were more likely to endorse consulting a doctor (P = 0.003**) or a psychiatrist (P = 0.012*). In addition, participants belonging to Islam were less likely to consult a doctor (P = 0.028*) and psychiatrist (P = 0.021*). Also, participants belonging to lower social class were less likely to endorse psychiatric consultation (P = 0.018*).

CONCLUSIONS

A vast majority of the study subjects failed to identify depression as an illness or acknowledge biomedical causation. Gender, religion, and socioeconomic class may influence help-seeking behavior.

Ethnoepidemiology and mental health: insights from Latin America

In this essay, I explore methodological as well as theoretical implications of an ethno-epidemiological approach, aiming to integrate research findings in mental health into new conceptual models. With this objective, I first evaluate the roots and uses of the term “ethnoepidemiology” to designate three research strategies for scientific knowledge production: type I (studies of sociocultural risk factors and ethnically defined risk groups); type II (studies of lay models of distribution and occurrence of illness in populations); type III (ethnographic studies of projects and areas of epidemiologic research). As an illustration, selected methodological features of three studies in which I have participated are presented and discussed. I then elaborate upon methodological developments derived from this experience of doing research, generating new models for transcultural transdisciplinary research of mental health practices. Lastly, I comment on some broad implications of studying mental health problems from an integrated ethnographical and epidemiological point of view, in diverse and deeply unequal societies such as those of contemporary Latin America.

Sociocultural and economic aspects of quality of life measurement

Obtaining a level of consensus over the definition, construction and measurement of the concept of quality of life would allow for an improved degree of standardization in the assessment of clinical intervention for people with mental health problems. One of the many benefits of this standardization would be the ability to make valid and reliable comparisons between various interventions and across different groups or settings, which is of particular interest to economists. There are, however, a host of sociocultural issues that present fundamental obstacles to the satisfactory attainment of consensus over definitions and domains of quality of life. This paper considers the arguments pertinent to each of these two alternative perspectives, the economic and the sociocultural (or anthropological), and draws out the lessons that these perspectives — despite the apparent polarity that exists between them — can offer to the improved measurement of quality of life for those with mental health problems.

Cultural adaptation of cognitive behavioural therapy (CBT) for patients with depression and anxiety in Saudi Arabia and Bahrain: a qualitative study exploring views of patients, carers, and mental health professionals

Western values influence cognitive behavioural therapy (CBT) as it was primarily developed and practised in the West. As understanding the cultural context has been linked to better therapy outcomes, it has been suggested that CBT might need modification to non-Western clients’ cultural backgrounds. Previously we developed a cost-effective approach to adapt CBT for clients in China and Pakistan. In this study, we applied the same methodology for local clients suffering from depression and anxiety in the Kingdom of Saudi Arabia and Bahrain. This study aimed to understand the views of patients with depression and anxiety, caregivers and mental health professionals about CBT to develop guidelines for culturally adapting CBT for depression and anxiety. We conducted semi-structured interviews with the patients (n= 42), caregivers (n= 11), and psychiatrists and psychologists (n= 16). The data were analysed using a thematic framework analysis by identifying emerging themes and categories. The themes emerging from the analyses of interviews by each interviewer were compared and contrasted with those of other interviewers. The results highlighted barriers of access to and strengths of CBT while working with these patient groups. Patients and their caregivers in both countries use a bio-psycho-spiritual-social model of illness and seek help from multiple sources. Therapists emphasized the need for using local idioms, culturally appropriate translation and minor adjustments in therapy. There were no thematic differences between the two sites. These findings will be used to culturally adapt a CBT manual, which will be tested in a randomized controlled trial.

Key learning aims

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Identifying heterogeneous health profiles of primary care utilizers and their differential healthcare utilization and mortality - a retrospective cohort study

BACKGROUND

Heterogeneity of population health needs and the resultant difficulty in health care resources planning are challenges faced by primary care systems globally. To address this challenge in population health management, it is critical to have a better understanding of primary care utilizers' heterogeneous health profiles. We aimed to segment a population of primary care utilizers into classes with unique disease patterns, and to report the 1 year follow up healthcare utilizations and all-cause mortality across the classes.

METHODS

Using de-identified administrative data, we included all adult Singapore citizens or permanent residents who utilized Singapore Health Services (SingHealth) primary care services in 2012. Latent class analysis was used to identify patient subgroups having unique disease patterns in the population. The models were assessed by Bayesian Information Criterion and clinical interpretability. We compared healthcare utilizations in 2013 and one-year all-cause mortality across classes and performed regression analysis to assess predictive ability of class membership on healthcare utilizations and mortality.

RESULTS

We included 100,747 patients in total. The best model (k = 6) revealed the following classes of patients: Class 1 "Relatively healthy" (n = 58,213), Class 2 "Stable metabolic disease" (n = 26,309), Class 3 "Metabolic disease with vascular complications" (n = 2964), Class 4 "High respiratory disease burden" (n = 1104), Class 5 "High metabolic disease without complication" (n = 11,122), and Class 6 "Metabolic disease with multi-organ complication" (n = 1035). The six derived classes had different disease patterns in 2012 and 1 year follow up healthcare utilizations and mortality in 2013. "Metabolic disease with multiple organ complications" class had the highest healthcare utilization (e.g. incidence rate ratio = 19.68 for hospital admissions) and highest one-year all-cause mortality (hazard ratio = 27.97).

CONCLUSIONS

Primary care utilizers are heterogeneous and can be segmented by latent class analysis into classes with unique disease patterns, healthcare utilizations and all-cause mortality. This information is critical to population level health resource planning and population health policy formulation.

Generating toxic landscapes: impact on well-being of cotton farmers in Telangana, India

Existing literature demonstrates agro-chemicals result in physical toxicity and damages human health, flora and fauna. However, little is known about how such ‘toxicity’ relates to mental well-being and social suffering. This paper aims to demonstrate how local, national and international vectors are interlinked to shape social distress among cotton farmers in India. Ethnographic interviews and focus group discussions were conducted in a cotton-growing village of the Warangal district, Telangana state, India. The results advance the concept of counter therapeutic spaces and hypothesise that toxic landscapes emerge through a dynamic interaction between dispersed agencies that interact and reconfigure agricultural spaces into socially toxic places. The paper argues that the disciplines of public health and agriculture suffer from a failure of imagination to forge vital interdisciplinary links that could address farmer suffering. Unpacking local ecologies of farmer suffering offer innovative ways for enhancing mental health policy and interventions in India.

Defeat Depression Campaign

The vigorous public profile adopted by the College in the ‘Defeat Depression’ campaign (Psychiatric Bulletin, 1993,17, 573–574) is to be welcomed, but the proposed educational programme is premature. The MORI poll is not an adequate basis for understanding how ‘depression’ is popularly conceived nor how people respond to it. The research report (Royal College of Psychiatrists, 1992) says little about the methods used in the qualitative part of the study: whether the researchers were properly trained in ethnographic field interviewing to elicit illness categorisations, and their ability to elicit the whole complex of ideas and actions, involving nomenclature, causation, agency, recognition and recourse to treatment.

DSM–IV and culture: is the classification internationally valid?

Although relatively neglected in Britain, the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders has been widely adopted in both Western and non-Western countries (Spitzer, Williams & Skrodol, 1983). The descriptive and multiaxial approach used in DSM-III (1980) and in its revised edition DSM-III-R (1987), together with the introduction of specific criteria for allocating each diagnosis, would seem particularly useful when comparing psychopathologies across societies. In addition to Axes I, II and III (Clinical Syndromes, Developmental and Personality Disorders, Physical Disorders and Conditions), the Manual has two more obviously ‘social’ axes – (IV) Severity of Psychosocial Stressors and (V) Global Assessment of Functioning.

How ‘culture bound’ is ‘cultural psychiatry’?

Cultural psychiatry as a clinical specialty sprung mainly from Europe and North America, in order to respond to growing concerns of ethnic minorities in high-income countries. Academic psychiatrists pursuing comparative international studies on mental health, together with medical anthropologists conducting clinical ethnographies, contributed to its theoretical basis (Kleinman, 1987; Littlewood, 1990). What at first appeared to be a marginal specialty is no longer so. For example, the UK alone has witnessed a steady growth of the field, as evidenced by its mandatory inclusion in mental health training curricula, and the existence of several taught masters courses, academic positions in universities and three dedicated journals, as well as, more recently, lead papers in mainstream publications that have debated the cultural position of ‘biology’ itself (Timimi & Taylor, 2004). Additionally, with a proliferation of clinical jobs for ‘ethnic minority’ services in hospital trusts across the country, there is ample scope for employment. The overall evidence indicates that ‘cultural psychiatry’ in the UK is now a specialty in its own right.

Cross-cultural psychiatric research: an anthropologist's view

A need for improved communication between the social sciences and psychiatry is being expressed from many quarters. Interest in social and cultural issues is not, of course, new to psychiatry, but collaboration between the two approaches has not always been easy. Recently one social science in particular has become popular with psychiatry. This is social anthropology, and many psychiatrists consider that the inclusion of anthropological data and methods, particularly in cross-cultural research, can be useful and informative to psychiatry. What then is the relationship between anthropology and psychiatry and what are the problems which professionals face in attempting interdisciplinary research?

Family Life and Social Medicine: Discourses and Discontents Surrounding Puebla's Psychiatric Care

Drawing on clinical data from 15 months of on-site participant observation in the only public psychiatric hospital in the state of Puebla, Mexico, this article advances our understanding of globalization in relation to psychiatry. I challenge the construction of psychiatry as only treating the individual patient and provide grounded doctor-patient-family member interaction in a Mexican psychiatric clinic in order to review what happens when doctors cannot interact with patients as atomized individuals even though in theory they are trained to think of patients that way. Challenged by severe structural constraints and bolstered by lessons from other nations' efforts at deinstitutionalization, psychiatrists in Puebla push to keep patients out of the inpatient wards and in their respective communities. To this end, psychiatrists call upon co-present kin who are identified both as the customer and part of the caretaking system outside the clinic. This modification to the visit structure changes the dynamic and content of clinical visits while doctors seamlessly respond to unspoken beliefs and values that are central to local life, ultimately showing that efforts to define a "global psychiatry" informed by global policy will fail because it cannot exist in a uniform way-interpersonal interaction and personal experience matters.

Hispanic immigrants in the USA: social and mental health perspectives

Hispanic immigration in the USA and its effect on many areas of US society are of great relevance to health care, public health, mental health, and medical and social sciences. In this report, we review and discuss pertinent literature on causes, procedures, and eventual outcomes of Hispanic migration waves throughout the last four decades. Hispanic immigrants do not constitute a monolithic group, despite the clear predominance of Mexican and Mexican-American segments. Common features of Hispanic immigrants include a younger average age, higher presence of married households, and lower educational levels than the overall US population. Differences within the Hispanic immigrant population are present in naturalisation figures, English language fluency, occupational and income status, health insurance coverage, and sense of accomplishment in the host society. We examine most of these aspects in the context of the so-called Hispanic paradox, presented as both a cause and a result of a heavily discussed acculturative process. We investigate prevalence and other data on depression, anxiety, substance abuse, and psychotic syndromes, with emphasis on the need to do further neurobiological, epigenetic, and sociocultural research in the Hispanic population.

Multicultural Assessment:

Current suggestions for assessing clients across cultures fail to adequately aid the average practitioner This failure arises from unresolved issues and problems, interfering with the ability of most counselors and therapists to render sound clinical judgments. In response to these issues and problems, a procedure is described that sensitizes counselors to cultural data in assessment and case conceptualization. Grounded in a guiding philosophy of assessment, the Multicultural Assessment Procedure (MAP) was developed in consideration of a number of relevant critical issues. The procedure entails identifying cultural data through multiple methods of data collection, interpreting cultural data to formulate a working hypothesis, incorporating cultural data with other relevant clinical information to test the working hypothesis, and arriving at a sound (i.e., comprehensive and accurate) assessment decision. A case illustration demonstrates how to use the proposed procedure.

The psychological effects of reporting extreme violence: a study of Kenyan journalists

OBJECTIVE

To assess the psychological health of journalists in Kenya who have reported on, and been exposed to, extreme violence.

DESIGN

Descriptive. Psychological responses were elicited to two stressors, the ethnic violence surrounding the disputed 2007 general election and the Al-Shabab attack on the Westgate Mall in Nairobi.

PARTICIPANTS

A representative sample of 90 Kenyan journalists was enrolled.

SETTING

Newsrooms of two national news organizations in Kenya.

MAIN OUTCOME MEASURES

Symptoms of post-traumatic stress disorder (Impact of Event Scale-revised), depression (Deck Depression inventory-revised) and general psychological wellbeing (General Health Questionnaire).

RESULTS

Of the 90 journalists approached 57 (63.3%) responded. Journalists covering the election violence (n = 23) reported significantly more PTSD type intrusion (p = 0.027) and arousal (p = 0.024) symptoms than their colleagues (n = 34) who had not covered the violence. Reporting the Westgate attack was not associated with increased psychopathology. Being wounded (n = 11) emerged as the most robust independent predictor of emotional distress. Journalists covering the ethnic violence compared to colleagues who did not were not more likely to receive psychological counselling.

CONCLUSIONS

These data, the first of their kind from an African country, replicate findings over a decade old from Western media, namely that journalists asked to cover life-threatening events may develop significant symptoms of emotional difficulties and fail to receive therapy for them. Good journalism, a pillar of civil society, depends on healthy journalists. It is hoped that these data act as a catalyst encouraging news organisations sending journalists into harm's way to look out for their psychological health in doing so.

The Phenomenology of Delusions in a Patient with Disorders of Sex Development

Abnormal development of the external and internal genital organs and male pseudohermaphrodite-type disorders of sex development is one of the conditions that creates problem in determination of gender. In this case report, our aim is to discuss how disorders with psychotic symptoms may affect different cultural life styles, circumstances, experience, delusion contents of identification and acceptance in a patient diagnosed with bipolar affective disorder, and with male-pseudohermaphroditism during adulthood.

A Qualitative Study to Explore Patients', Carers' and Health Professionals' Views to Culturally Adapt CBT for Psychosis (CBTp) in Pakistan

BACKGROUND

Cognitive Behaviour Therapy (CBT) has an established evidence base and is recommended by the national organizations in United Kingdom and the United States. CBT remains under utilized in low and middle income countries. CBT was developed in the west and it has been suggested that it is underpinned by western values. It therefore follows that to make CBT accessible for non western clients, it needs adapting into a given culture.

AIMS

Our aim was to develop guidelines for adapting CBT for psychosis in Pakistan by incorporating the views of the patients, their carers and mental health professionals.

METHOD

We conducted a series of qualitative studies in Pakistan to adapt CBT for psychosis (a total of 92 interviews). The data were analyzed by systematic content and question analysis. Analysis started by identifying emerging themes and categories. Themes emerging from the analyses of interviews by each interviewer were compared and contrasted with others interviewers constantly. Triangulation of themes and concepts was undertaken to further compare and contrast the data from the different participating groups.

RESULTS

The results of these studies highlighted the barriers in therapy as well as strengths while working with this patient group. Patients and their carers in Pakistan use a bio-psycho-spiritual-social model of illness. They seek help from various sources. Therapists make minor adjustments in therapy.

CONCLUSIONS

The findings from this study will help therapists working with this client group using CBT for psychosis in Pakistan. These results need to be tested through controlled trials.

Cross-cultural factorial validation of the Clinical Interview Schedule--Revised (CIS-R); findings from a nationally representative survey (EMPIRIC)

The Clinical Interview Schedule - Revised (CIS-R) has been widely adopted across cultures to assess common mental disorders. We assessed the factorial validity of the CIS-R across ethnic minority groups, using data from a nationally representative survey conducted in England in 2000. The sample comprised White British (n = 837), Irish (n = 733), Black Caribbean (n = 694), Bangladeshi (n = 650), Indian (n = 643) and Pakistani (n = 724) respondents. Ordered logistic regression determined the reporting of CIS-R symptoms. Principal components analysis (PCA) determined the underlying construct of the CIS-R in White British participants. These factor solutions were then assessed for "best fit" using confirmatory factor analyses (CFAs) across all ethnic groups. In ordered logistic regression analyses, there was heterogeneity in the reporting of worries, phobias, panic and somatic symptoms across ethnic minority groups relative to the White British group. "Best" fit solutions confirmed through CFA were models where all symptoms were allowed to vary across ethnic groups, or models where an underlying "depression-anxiety" construct was held invariant while "somatic symptoms" were permitted to vary across groups, although differences between models assessed were slight. In conclusion, there may be benefits in assessing the functioning of certain CIS-R items within specific cultural contexts to ensure adequate face validity of the CIS-R.

A comparison of bipolar disorders in children in Italy and the United States

BACKGROUND

The clinical presentation of bipolar disorders, though clearly recognized in adolescents, remains controversial in younger children and across cultures. The aim of this study was to compare the clinical presentation of bipolar disorders in Italian and American children between ages 5 and 12 years.

METHODS

Sixty-seven children from six outpatient programs were enrolled (Italian sample: n=40; American sample: n=28) between January 2010 and June 2011. Children and their parents were interviewed by experienced clinicians using the Washington University in St. Louis Schedule for Affective Disorders and Schizophrenia for School-Age Children-Present, Lifetime Version (WASH-U K-SADS).

RESULTS

Italian children scored significantly higher on ratings of "elevated mood" (p=0.002), whereas American children scored significantly higher on ratings of "flight of ideas" (p=0.001) and "productivity" (p=0.001). Rates of comorbidity were different between groups.

LIMITATIONS

Data were acquired from several sites in Italy as compared to from a single American site. Medication and educational information were not systematically collected. Furthermore, the sample collected may only reflect characteristics of a less severely ill group of bipolar children.

CONCLUSIONS

Our comparison of Italian and American children with early onset bipolar disorders found that the phenotype of bipolar spectrum disorders is largely shared across cultures, although psychiatric comorbidities differed.

The global prevalence of common mental disorders: a systematic review and meta-analysis 1980-2013

BACKGROUND

Since the introduction of specified diagnostic criteria for mental disorders in the 1970s, there has been a rapid expansion in the number of large-scale mental health surveys providing population estimates of the combined prevalence of common mental disorders (most commonly involving mood, anxiety and substance use disorders). In this study we undertake a systematic review and meta-analysis of this literature.

METHODS

We applied an optimized search strategy across the Medline, PsycINFO, EMBASE and PubMed databases, supplemented by hand searching to identify relevant surveys. We identified 174 surveys across 63 countries providing period prevalence estimates (155 surveys) and lifetime prevalence estimates (85 surveys). Random effects meta-analysis was undertaken on logit-transformed prevalence rates to calculate pooled prevalence estimates, stratified according to methodological and substantive groupings.

RESULTS

Pooling across all studies, approximately 1 in 5 respondents (17.6%, 95% confidence interval:16.3-18.9%) were identified as meeting criteria for a common mental disorder during the 12-months preceding assessment; 29.2% (25.9-32.6%) of respondents were identified as having experienced a common mental disorder at some time during their lifetimes. A consistent gender effect in the prevalence of common mental disorder was evident; women having higher rates of mood (7.3%:4.0%) and anxiety (8.7%:4.3%) disorders during the previous 12 months and men having higher rates of substance use disorders (2.0%:7.5%), with a similar pattern for lifetime prevalence. There was also evidence of consistent regional variation in the prevalence of common mental disorder. Countries within North and South East Asia in particular displayed consistently lower one-year and lifetime prevalence estimates than other regions. One-year prevalence rates were also low among Sub-Saharan-Africa, whereas English speaking counties returned the highest lifetime prevalence estimates.

CONCLUSIONS

Despite a substantial degree of inter-survey heterogeneity in the meta-analysis, the findings confirm that common mental disorders are highly prevalent globally, affecting people across all regions of the world. This research provides an important resource for modelling population needs based on global regional estimates of mental disorder. The reasons for regional variation in mental disorder require further investigation.

At the crossroads of anthropology and epidemiology: current research in cultural psychiatry in the UK

Cultural psychiatry research in the UK comprises a broad range of diverse methodologies, academic disciplines, and subject areas. Methodologies range from epidemiological to anthropological/ethnographic to health services research; mixed methods research is becoming increasingly popular, as are public health and health promotional topics. After briefly outlining the history of cultural psychiatry in the UK we will discuss contemporary research. Prominent themes include: the epidemiology of schizophrenia among Africans/Afro-Caribbeans, migration and mental health, racism and mental health, cultural identity, pathways to care, explanatory models of mental illness, cultural competence, and the subjective experiences of healthcare provision among specific ethnic groups such as Bangladeshis and Pakistanis. Another strand of research that is attracting increasing academic attention focuses upon the relationship between religion, spirituality, and mental health, in particular, the phenomenology of religious experience and its mental health ramifications, as well as recent work examining the complex links between theology and psychiatry. The paper ends by appraising the contributions of British cultural psychiatrists to the discipline of cultural psychiatry and suggesting promising areas for future research.

Ethnicity, detention and early intervention: reducing inequalities and improving outcomes for black and minority ethnic patients: the ENRICH programme, a mixed-methods study

Background

Black and minority ethnic (BME) service users experience adverse pathways into care. Ethnic differences are evident even at first-episode psychosis (FEP); therefore, contributory factors must operate before first presentation to psychiatric services. The ENRICH programme comprised three interlinked studies that aimed to understand ethnic and cultural determinants of help-seeking and pathways to care.

Aims and objectives

Study 1: to understand ethnic differences in pathways to care in FEP by exploring cultural determinants of illness recognition, attribution and help-seeking among different ethnic groups. Study 2: to evaluate the process of detention under the Mental Health Act (MHA) and determine predictors of detention. Study 3: to determine the appropriateness, accessibility and acceptability of generic early intervention services for different ethnic groups.

Methods

Study 1: We recruited a prospective cohort of FEP patients and their carers over a 2-year period and assessed the chronology of symptom emergence, attribution and help-seeking using semistructured tools: the Nottingham Onset Schedule (NOS), the Emerging Psychosis Attribution Schedule and the ENRICH Amended Encounter Form. A stratified subsample of user–carer NOS interviews was subjected to qualitative analyses. Study 2: Clinical and sociodemographic data including reasons for detention were collected for all MHA assessments conducted over 1 year (April 2009–March 2010). Five cases from each major ethnic group were randomly selected for a qualitative exploration of carer perceptions of the MHA assessment process, its outcomes and alternatives to detention. Study 3: Focus groups were conducted with service users, carers, health professionals, key stakeholders from voluntary sector and community groups, commissioners and representatives of spiritual care with regard to the question: ‘How appropriate and accessible are generic early intervention services for the specific ethnic and cultural needs of BME communities in Birmingham?’

Results

There were no ethnic differences in duration of untreated psychosis (DUP) and duration of untreated illness in FEP. DUP was not related to illness attribution; long DUP was associated with patients being young (< 18 years) and living alone. Black patients had a greater risk of MHA detention, more criminal justice involvement and more crisis presentations than white and Asian groups. Asian carers and users were most likely to attribute symptoms to faith-based or supernatural explanations and to seek help from faith organisations. Faith-based help-seeking, although offering comfort and meaning, also risked delaying access to medical care and in some cases also resulted in financial exploitation of this vulnerable group. The BME excess in MHA detentions was not because of ethnicity per se; the main predictors of detention were a diagnosis of mental illness, presence of risk and low level of social support. Early intervention services were perceived to be accessible, supportive, acceptable and culturally appropriate. There was no demand or perceived need for separate services for BME groups or for ethnic matching between users and clinicians.

Conclusions

Statutory health-care organisations need to work closely with community groups to improve pathways to care for BME service users. Rather than universal public education campaigns, researchers need to develop and evaluate public awareness programmes that are specifically focused on BME groups.

Funding

The National Institute for Health Research Programme Grants for Applied Research programme.

Social change and increasing of bipolar disorders: an evolutionary model

INTRODUCTION

The objective of this paper is to see if behaviours defined as pathological and maladjusted in certain contexts may produce adaptive effects in other contexts, especially if they occur in attenuated form. Interactions between environment and behaviour are studied from an evolutionary standpoint in an attempt to understand how new attitudes emerge in an evolving context.

METHODOLOGY

Narrative review. Following an historical examination of how the description of depression in Western society has changed, we examine a series of studies performed in areas where great changes have taken place as well as research on emigration from Sardinia in the 1960s and 70s and immigration to Sardinia in the 1990s.

RESULTS AND CONCLUSIONS

If we postulate that mood disorders are on the increase and that the epidemic began in the 17th century with the "English malady", we must suppose that at least the "light" forms have an adaptive advantage, otherwise the expansion of the disorder would have been self-limiting. "Compulsive hyper-responsabilization", as well as explorative behaviours, may represent a base for adaptation in certain conditions of social change. The social emphasis in individualism and responsibility may have changed not only the frequency, but also the phenomenology of mood disorders particularly the increases in bipolar disorders. From the sociobiological standpoint the conditions that may favour "subthreshold" bipolar or depressive features are to be considered in relation to the contextual role of gender and the different risks of the two disorders in males and females.

Diagnostic and statistical manual-5: Position paper of the Indian Psychiatric Society

The development of the Diagnostic and Statistical Manual-5 (DSM-5) has been an exhaustive and elaborate exercise involving the review of DSM-IV categories, identifying new evidence and ideas, field testing, and revising issues in order that it is based on the best available evidence. This report of the Task Force of the Indian Psychiatric Society examines the current draft of the DSM-5 and discusses the implications from an Indian perspective. It highlights the issues related to the use of universal categories applied across diverse cultures. It reiterates the evidence for mental disorders commonly seen in India. It emphasizes the need for caution when clinical categories useful to specialists are employed in the contexts of primary care and in community settings. While the DSM-5 is essentially for the membership of the American Psychiatric Association, its impact will be felt far beyond the boundaries of psychiatry and that of the United States of America. However, its atheoretical approach, despite its pretensions, pushes a purely biomedical agenda to the exclusion of other approaches to mental health and illness. Nevertheless, the DSM-5 should serve a gate-keeping function, which intends to set minimum standards. It is work in progress and will continue to evolve with the generation of new evidence. For the DSM-5 to be relevant and useful across the cultures and countries, it needs to be broad-based and consider social and cultural contexts, issues, and phenomena. The convergence and compatibility with International Classification of Diseases-11 is a worthy goal. While the phenomenal effort of the DSM-5 revision is commendable, psychiatry should continue to strive for a more holistic understanding of mental health, illness, and disease.

Explanatory models in patients with first episode depression: a study from north India

The purpose of this work was to study the explanatory models of patients with first episode depression presenting to a tertiary care hospital located in North-western India. One hundred sixty four consecutive patients with diagnosis of first episode depression (except severe depression with psychotic symptoms) according to the International Classification of Diseases-10th Revision (ICD-10) and ≥18 years of age were evaluated for their explanatory models using the causal models section of Explanatory Model Interview Catalogue (EMIC). The most common explanations given were categorized into Karma-deed-heredity category (77.4%), followed by psychological explanations (62.2%), weakness (50%) and social causes (40.2%). Among the various specific causes the commonly reported explanations by at least one-fourth of the sample in decreasing order were: will of god (51.2%), fate/chance (40.9%), weakness of nerves (37.8%), general weakness (34.7%), bad deeds (26.2%), evil eye (24.4%) and family problems (21.9%). There was some influence of sociodemographic features on the explanations given by the patients. From the study, it can be concluded that patients with first episode depression have multiple explanatory models for their symptoms of depression which are slightly different than those reported in previous studies done from other parts of India. Understanding the multiple explanatory models for their symptoms of depression can have important treatment implications.

Impact of migration on explanatory models of illness and addiction severity in patients with drug dependence in a Paris suburb

Objectives of this study were to assess explanatory models (considering illness experience and meaning), addiction severity among patients with drug dependence, and the role of migration. Adapted Explanatory Model Interview Catalogue interviews were conducted with 70 outpatients in a Paris suburb. Among them, 42 were either first- or second-generation immigrants, most from North Africa. Explanatory models were analyzed qualitatively and quantitatively according to migration status, assessing potential confounders with multivariate linear models. Explanatory models were heterogeneous. Compared with nonmigrants, migrants reported fewer somatic and violence-related symptoms. They attributed the causes of their addiction more frequently to social and magico-religious factors and less to psychological factors. Conversely, no difference in addiction severity was found between migrants and nonmigrants. Considering local patterns of illness experience and meaning of drug dependence is a critical component of culturally sensitive clinical care.

Global mental health: from science to action

This article charts the historical development of the discipline of global mental health, whose goal is to improve access to mental health care and reduce inequalities in mental health outcomes between and within nations. The article begins with an overview of the contribution of four scientific foundations toward the discipline's core agenda: to scale up services for people with mental disorders and to promote their human rights. Next, the article highlights four recent, key events that are indicative of the actions shaping the discipline: the Mental Health Gap Action Programme to synthesize evidence on what treatments are effective for a range of mental disorders; the evidence on task shifting to nonspecialist health workers to deliver these treatments; the Movement for Global Mental Health's efforts to build a common platform for professionals and civil society to advocate for their shared goal; and the Grand Challenges in Global Mental Health, which has identified the research priorities that, within the next decade, can lead to substantial improvements in the lives of people living with mental disorders. The article ends by examining the major challenges for the field, and the opportunities for addressing them in the future.

The assessment of insight across cultures

The assessment of insight is a part of the routine clinical examination for people with mental illness. Such assessment, by psychiatrists, is based on the current definitions of insight, which rely on western notions of health and illness. This paper discusses the recent findings of illness perspectives of people with a variety of physical diseases and mental disorders from India. Studies on insight in schizophrenia and bipolar disorders also examined explanatory models of illness among patients, relatives, and the general population. The findings argue for the fact that the assessment of insight should be against the local cultural standards rather than universal yardsticks. The assessment of insight should evaluate awareness, attribution, and action. People with psychosis who are able to re-label their psychotic experience, offer non-delusional explanations for changes in themselves, which correspond to beliefs about illness held by the subculture, admit to the need for restitution, and seek locally available help, can be said to possess insight. The results recommend the use of universal conventions to assess insight in people with psychosis rather than the use of uniform criteria.

Perceptions of illness in self and in others among patients with bipolar disorder

AIM

The study aimed to examine the perceptions of illness in self and among others in patients with bipolar disorder in remission. The effect of a structured educational programme on the perceptions of illness was also tested.

METHOD

We examined the perceptions of illness in self and in others (using a vignette) among patients with bipolar disorder in remission attending the Department of Psychiatry, Christian Medical College, Vellore, India. We also examined the effect of a structured educational programme on explanatory models in a randomized controlled trial. Explanatory models were assessed using the Tamil version of the Short Explanatory Model Interview.

RESULTS

Eighty two subjects were recruited for the trial; half of them received structured education while the other half received treatment as usual. There was agreement between perceptions related to the individual's own illness and their opinion of illness in others as assessed using a vignette at baseline and at follow-up. There were no significant differences in explanatory models between patients who received education and those who did not.

CONCLUSIONS

The results of this study show that during periods of remission, patients can clearly see the relationship between their own illness and that described in others, suggesting that insight is state dependent and may be related to psychopathology with good recovery of insight during periods of remission. These findings also argue for the fact that the current multi-dimensional models of insight which focus on biomedical explanations and treatments are not culturally sensitive. The assessment of insight demands universal conventions with comparison to the local cultural standards rather than universal definitions and yardsticks which employ Western and biomedical perspectives.

Transcultural psychiatry: from practice to theory

Psychiatric patients of non-western origin leave treatment against the advice of their clinicians far more often than do their western counterparts. This article presents a theoretical framework for better understanding such clinical cases, developed from examples of psychiatric practice in different cultures. The theory is based on two meanings of the concept of culture, an elaboration of the universality-relativity dichotomy, and a view of the work of mental health care providers as involving three components: (1) building a trusting relationship with the patient; (2) making a diagnosis and treatment plan; and (3) carrying out treatment that is acceptable and meaningful to the patient. The article argues that all psychiatry is transcultural psychiatry, because a cultural gap always exists between the psychiatrist and the patient.

Identidades em crise: imigrantes, emoções e saúde mental em Portugal

Este artigo, baseado em 4 anos de pesquisa de terreno num serviço de saúde mental específico para imigrantes em Portugal, discute criticamente o carácter da experiência migratória enquanto factor de risco e patologia psíquica. As condições particularmente duras da migração contemporânea são consideradas como propícias a um aumento exponencial de psicopatologias. A ideia de que a emigração esteja indissoluvelmente ligada a formas específicas de sofrimento psicológico acabou para promover uma progressiva medicalização da experiência migratória. Esta leitura patologizante da experiência migratória funda as suas conclusões sobre o modelo de "selecção negativa", isto é: seriam os sujeitos fracos, pouco integrados na sociedade de origem, com escassas ligações afectivas e estrutura familiar instável a optar pela emigração, levando a que os seus distúrbios latentes se manifestassem particularmente no país de acolhimento. A representação da vulnerabilidade psicológica como característica intrínseca dos migrantes não toma todavia em conta a relação mais ampla entre sofrimento individual e experiência de exclusão, marginalização social, discriminação e precariedade das condições habitacionais e laborais, entre outros factores. O estereótipo do imigrante como pessoa frágil do ponto de vista mental, com um elevado risco de desenvolvimento de patologias psiquiátricas, permite transformar os problemas sociais, económicos e políticos de grupos desfavorecidos em elementos potencialmente patológicos que podem ser controlados e monitorizados farmacologicamente.

Mental health care and resistance to fascism

Mental health nurses have a critical stake in resisting the right-wing ideology of British fascism. Particularly concerning is the contemporary effort of the British National Party (BNP) to gain credibility and electoral support by the strategic re-packaging of a racist and divisive political manifesto. Evidence that some public sector workers are affiliated with the BNP has relevance for nursing at a series of levels, not least the incompatibility of party membership with a requirement of the Professional Code to avoid discrimination. Progressive advances, though, need to account for deep rooted institutionalized racism in the discourse and practice of healthcare services. The anomalous treatment of black people within mental health services, alongside racial abuse experienced by ethnic minority staff, is discussed in relation to the concept of race as a powerful social category and construction. The murder of the mentally ill and learning disabled in Nazi Germany, as an adjunct of racial genocide, is presented as an extreme example where professional ethics was undermined by dominant political ideology. Finally, the complicity of medical and nursing staff in the state sanctioned, bureaucratic, killing that characterized the Holocaust is revisited in the context of ethical repositioning for contemporary practice and praxis.