Abstracts: Psychiatry and Society: Global Mental Health
Challenges of Creating Synergy Between Global Mental Health and Cultural Psychiatry
This article addresses four major challenges for efforts to create synergy between the global mental health movement and cultural psychiatry. First, although they appear to share domains of mutual interest, the worlds of global mental health and cultural psychiatry have distinct lineages. Expanding their horizons by learning from adjacent disciplines would be mutually beneficial. A second challenge concerns the conceptualization of a new classification system for mental health problems. Adopting a classification system that integrates new insights from socio-neurobiology and from a networks perspective could bring cultural psychiatry and global mental health closer and change the way each field addresses the mental health gap, which constitutes the third challenge. I summarize attempts to achieve comprehensive mental health coverage around the globe and question whether the strategies employed to achieve these goals have been successful, both in high- (HIC) and low- and middle-income countries (LMIC). In LMIC, the dominant strategy needs to be complemented by mobilization of other community resources including local practitioners. A fourth challenge is the lack of mathematical models to guide action and research and solve major preoccupations such as access to care or multilevel analyses in complex ecological or health systems.
Reprinted from Transcult Psychiatry 2014; 51:806–828 with permission from Sage Publications.
An Ethical Framework for Global Psychiatry
Existing literature addresses the ethical considerations of global health work and how medical school curricula can help prepare students for them, but little has been written regarding an ethical approach to global psychiatry. In this paper we summarize prominent ethical issues that arise in global health psychiatry in order to provide a foundation for a framework in global health psychiatry. These issues include obtaining informed consent in the face of language barriers, diagnosing and treating for mental illnesses while navigating communities where such conditions are heavily stigmatized, and justifying the cessation of proving care to current patients for the sake of providing care to new patients abroad. To help prepare psychiatrists and students for work that engages these issues, we propose a multistep process to assist the practicing global psychiatrist in recognizing ethical dilemmas and evaluating potential courses of action based on their respective ethical merits.
Reprinted from Ann Glob Health 2014; 80:146–15 with permission from Elsevier Inc.
Using the Cultural Formulation to Resolve Uncertainty in Diagnoses of Psychosis Among Ethnoculturally Diverse Patients
OBJECTIVE: The aim of the study was to assess the impact of systematic use of the DSM-IV-TR cultural formulation on diagnoses of psychotic disorders among patients of ethnic minority and immigrant backgrounds referred to a cultural consultation service (CCS) in Canada. METHODS: The study entailed a review of medical records and case conference transcripts of 323 patients seen in a ten-year period at the CCS to determine factors associated with change in the diagnosis of psychotic disorders by the CCS. Logistic regression analysis was used to identify variables associated with changes in diagnosis. RESULTS: A total of 34 (49%) of the 70 cases with an intake (referral) diagnosis of a psychotic disorder were rediagnosed as nonpsychotic disorders, whereas only 12 (5%) of the 253 cases with an intake diagnosis of a nonpsychotic disorder were rediagnosed as a psychotic disorder (p<0.001). Major depression, posttraumatic stress disorder (PTSD), adjustment disorder, and bipolar affective disorder were the common disorders diagnosed with use of the cultural formulation. Rediagnosis of a psychotic disorder as a nonpsychotic disorder was significantly associated with being a recent arrival in Canada (odds ratio [OR]=6.05, 95% confidence interval [CI]=1.56–23.46, p=0.009), being nonblack (OR=3.72, CI=1.03–13.41, p=0.045), and being referred to the CCS by nonmedical routes (such as social work or occupational therapy) (OR=3.23, CI=1.03–10.13, p=0.044). CONCLUSIONS: Misdiagnosis of psychotic disorders occurred with patients of all ethnocultural backgrounds. PTSD and adjustment disorder were misidentified as psychosis among immigrants and refugees from South Asia. Studies are needed that compare clinical outcomes of use of cultural consultation with outcomes from use of other cultural competence models.
Reprinted from Psychiatr Serv 2012; 63:147–153 with permission from American Psychiatric Association Publishing
Economic Grand Rounds: Income Inequality and Depression Prevalence Across the United States: An Ecological Study
Research has shown a relationship between income inequality and poor health. This column reports findings from a state-level study of the relationship between income inequality and the prevalence of depression. Estimates of depression prevalence by state, obtained from the Behavioral Risk Factor Surveillance System, were linked with Gini coefficients for U.S. household income, obtained from the Census Bureau. The current prevalence of depression was significantly associated with income inequality–the more unequal, the higher the depression prevalence. The association persisted after adjustment for income per capita, percentage of the population with a college degree, and percentage over age 65 years.
Reprinted from Psychiatr Serv 2011; 62:710–712 with permission from American Psychiatric Association Publishing
No Health Without Mental Health
About 14% of the global burden of disease has been attributed to neuropsychiatric disorders, mostly due to the chronically disabling nature of depression and other common mental disorders, alcohol-use and substance-use disorders, and psychoses. Such estimates have drawn attention to the importance of mental disorders for public health. However, because they stress the separate contributions of mental and physical disorders to disability and mortality, they might have entrenched the alienation of mental health from mainstream efforts to improve health and reduce poverty. The burden of mental disorders is likely to have been underestimated because of inadequate appreciation of the connectedness between mental illness and other health conditions. Because these interactions are protean, there can be no health without mental health. Mental disorders increase risk for communicable and noncommunicable diseases, and contribute to unintentional and intentional injury. Conversely, many health conditions increase the risk for mental disorder, and comorbidity complicates help-seeking, diagnosis, and treatment, and influences prognosis. Health services are not provided equitably to people with mental disorders, and the quality of care for both mental and physical health conditions for these people could be improved. We need to develop and evaluate psychosocial interventions that can be integrated into management of communicable and noncommunicable diseases. Health-care systems should be strengthened to improve delivery of mental health care, by focusing on existing programs and activities, such as those which address the prevention and treatment of HIV, tuberculosis, and malaria; gender-based violence; antenatal care; integrated management of childhood illnesses and child nutrition; and innovative management of chronic disease. An explicit mental health budget might need to be allocated for such activities. Mental health affects progress toward the achievement of several Millennium Development Goals, such as promotion of gender equality and empowerment of women, reduction of child mortality, improvement of maternal health, and reversal of the spread of HIV/AIDS. Mental health awareness needs to be integrated into all aspects of health and social policy, health-system planning, and delivery of primary and secondary general health care.
Reprinted from Lancet 2007; 370:859–877 with permission from Elsevier, Inc.
