Cultural concepts of distress and psychiatric disorders: literature review and research recommendations for global mental health epidemiology

Folk Classification and Factor Rotations: Whales, Sharks, and the Problems With the Hierarchical Taxonomy of Psychopathology (HiTOP)

The Hierarchical Taxonomy of Psychopathology (HiTOP) uses factor analysis to group people with similar self-reported symptoms (i.e., like-goes-with-like). It is hailed as a significant improvement over other diagnostic taxonomies. However, the purported advantages and fundamental assumptions of HiTOP have received little, if any scientific scrutiny. We critically evaluated five fundamental claims about HiTOP. We conclude that HiTOP does not demonstrate a high degree of verisimilitude and has the potential to hinder progress on understanding the etiology of psychopathology. It does not lend itself to theory-building or taxonomic evolution, and it cannot account for multifinality, equifinality, or developmental and etiological processes. In its current form, HiTOP is not ready to use in clinical settings and may result in algorithmic bias against underrepresented groups. We recommend a bifurcation strategy moving forward in which the DSM is used in clinical settings while researchers focus on developing a falsifiable theory-based classification system.

Exploring Mental Health Presentations in Remote Aboriginal Community Controlled Health Services in the Kimberley Region of Western Australia Using an Audit and File Reviews

The study aims to explore the role of mental health care in remote Aboriginal health services in the Kimberley region of Western Australia and provide a more nuanced understanding of the patients presenting for care, their needs, and the clinical response. Little is currently known about primary health care presentations for mental health, suicide, and self-harm for remote dwelling Aboriginal residents of the Kimberley region, despite high rates of psychological distress, self-harm, and suicide across the area. This study was progressed through a retrospective, cross-sectional audit of the electronic medical records system used by three remote clinics to explore the interactions recorded by the clinics about a patient's mental health. In addition, an in-depth file review was conducted on a stratified purposive sample of 30 patients identified through the audit. Mental ill-health and psychological distress were found to be prominent within clinical presentations. Psychosocial factors were frequently identified in relation to a patient's mental health presentation. Optimizing patients' recovery and wellness through service improvements, including an enhanced mental health model of care, is an important next step.

Risk and protective factors for comorbidity of PTSD, depression, and anxiety among Somali refugees in Kenya

Background:

Comorbid common mental disorders (CMDs) are pervasive in refugee populations. However, limited research has explored psychosocial factors for mental disorder comorbidity in Somali refugee samples.

Aims:

This study aims to explore potential risk and protective factors for comorbid depression-anxiety and comorbid depression-PTSD by examining associations between trauma exposure, psychosocial factors, and mental health symptoms among a sample of Somali refugees displaced in urban Kenya.

Methods:

We used snowball sampling to recruit Somali youth aged 15 to 35years( N = 250, n = 143 female, n = 88 male, n = 19 unknown gender). We measured 16 common types of trauma exposure and three psychosocial factors (endorsing violence, willingness to share problems, and symptom awareness) and used the HSCL-25 and PCL-C to capture individual and comorbid CMD symptoms, using guided cutoff points and/or algorithms. We then ran a series of logistic regression analyses to examine relationships between trauma exposure, psychosocial factors, and individual and comorbid CMD symptoms.

Results:

Findings showed that increased trauma exposure predicted symptoms of individual and comorbid CMDs. Increased symptom awareness and endorsement of violence predicted comorbid depression-PTSD and comorbid anxiety-depression symptoms, respectively. Willingness to share problems buffered depressive symptoms but did not predict comorbidity.

Conclusions:

These findings revealed the high CMD comorbidity prevalence with differential effects of trauma and psychosocial factors on individual or comorbid mental disorders. This study suggests a need for transdiagnostic approaches that cut across Western diagnostic boundaries and consider culturally responsive and relevant items for mental health measures.

Risk and protective factors for comorbidity of PTSD, depression, and anxiety among Somali refugees in Kenya

BACKGROUND

Comorbid common mental disorders (CMDs) are pervasive in refugee populations. However, limited research has explored psychosocial factors for mental disorder comorbidity in Somali refugee samples.

AIMS

This study aims to explore potential risk and protective factors for comorbid depression-anxiety and comorbid depression-PTSD by examining associations between trauma exposure, psychosocial factors, and mental health symptoms among a sample of Somali refugees displaced in urban Kenya.

METHODS

We used snowball sampling to recruit Somali youth aged 15 to 35years(N = 250,n = 143 female, n = 88 male, n = 19 unknown gender). We measured 16 common types of trauma exposure and three psychosocial factors (endorsing violence, willingness to share problems, and symptom awareness) and used the HSCL-25 and PCL-C to capture individual and comorbid CMD symptoms, using guided cutoff points and/or algorithms. We then ran a series of logistic regression analyses to examine relationships between trauma exposure, psychosocial factors, and individual and comorbid CMD symptoms.

RESULTS

Findings showed that increased trauma exposure predicted symptoms of individual and comorbid CMDs. Increased symptom awareness and endorsement of violence predicted comorbid depression-PTSD and comorbid anxiety-depression symptoms, respectively. Willingness to share problems buffered depressive symptoms but did not predict comorbidity.

CONCLUSIONS

These findings revealed the high CMD comorbidity prevalence with differential effects of trauma and psychosocial factors on individual or comorbid mental disorders. This study suggests a need for transdiagnostic approaches that cut across Western diagnostic boundaries and consider culturally responsive and relevant items for mental health measures.

A pilot study adapting and validating the Harvard Trauma Questionnaire (HTQ) and PTSD checklist-5 (PCL-5) with Indian women from slums reporting gender-based violence

Background

Despite high rates of gender-based violence (GBV) in India, culturally sensitive measures that examine universal and culturally relevant trauma reactions are lacking. Although the Harvard Trauma Questionnaire (HTQ) has been used in India, no study has adapted the measure in full for use with this population. Similarly, the  PTSD checklist-5 (PCL-5) has not yet been validated in India. This study describes the adaptation, validation, and results from the adapted HTQ, and embedded PCL-5, for Indian women from slums reporting GBV.

Method

This study used the adaptation framework proposed by the HTQ measure developers. The adapted HTQ contained a (1) trauma screen relevant for stressors faced by Indian women from slums, (2) description of the index trauma, (3) description of any ongoing stressors, (4) universal trauma reactions (i.e., PTSD measured by the PCL-5), and culturally relevant trauma reactions (i.e., idioms of distress measured by a scale developed for the study). This measure was piloted on 111 women from Indian slums in face-to-face interviews. Trauma characteristics, types of ongoing stressors, and psychometric properties of the PCL-5 and idioms of distress scale were explored. These scales were validated against measures of depression (PHQ-9), anxiety (GAD-7), and somatic complaints (PHQ-15).

Results

The majority of participants (77%) reported physical beatings, 18% reported unwanted sexual touch, and 28.8% reported infidelity as the primary emotional abuse. Further, 96.7% of GBV was perpetrated by partner or family member and over half reported ongoing stressors (e.g., poverty-related strain). The PCL-5 embedded in the HTQ yielded good internal consistency (Cronbach’s alpha = .88) as did the idioms of distress scale with deletion of one item (Cronbach’s alpha = .80). Both scales were externally valid, yielding large correlations with depression, anxiety, and somatic complaints (rs between .54 and .80, ps < .05).

Discussion

This is the first study to develop a comprehensive measure of trauma exposure with universal and culturally relevant trauma reactions in India. This study also enhances HTQ usage in India by delineating all the steps in the adaptation process. Results can inform the development of trauma-focused interventions for Indian women from slums.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12905-022-01595-3.

Stigma against mental health disorders in Nepal conceptualised with a 'what matters most' framework: a scoping review

AIMS

Stigma related to mental disorders is a barrier to quality mental healthcare. This scoping review aimed to synthesise literature on stigma related to mental disorders in Nepal to understand stigma processes. The anthropological concept of 'what matters most' to understand culture and stigma was used to frame the literature on explanatory models, manifestations, consequences, structural facilitators and mitigators, and interventions.

METHODS

We conducted a scoping review with screening guided by the Preferred Reporting Items for Systematic Review and Meta-analysis Extension for Scoping Reviews (PRISMA-ScR). A structured search was done using three international databases (PsycINFO, Medline and Web of Science), one Nepali database (NepJol) and cross-referencing for publications from 1 January 2000 through 24 June 2020. The search was repeated to include structural stigma-related terms. Quality of quantitative studies was assessed using the Systematic Assessment of Quality in Observational Research (SAQOR) tool. The review was registered through the Open Science Framework (OSF) (osf.io/u8jhn).

RESULTS

The searches yielded 57 studies over a 20-year period: 19 quantitative, 19 qualitative, nine mixed methods, five review articles, two ethnographies and three other types of studies. The review identified nine stigma measures used in Nepal, one stigma intervention, and no studies focused on adolescent and child mental health stigma. The findings suggest that 'what matters most' in Nepali culture for service users, caregivers, community members and health workers include prestige, productivity, privacy, acceptance, marriage and resources. Cultural values related to 'what matters most' are reflected in structural barriers and facilitators including lack of policies, programme planning and resources. Most studies using quantitative tools to assess stigma did not describe cultural adaptation or validation processes, and 15 out of the 18 quantitative studies were 'low-quality' on the SAQOR quality rating. The review revealed clear gaps in implementation and evaluation of stigma interventions in Nepal with only one intervention reported, and most stigma measures not culturally adapted for use.

CONCLUSION

As stigma processes are complex and interlinked in their influence on 'what matters most' and structural barriers and facilitators, more studies are required to understand this complexity and establish effective interventions targeting multiple domains. We suggest that stigma researchers should clarify conceptual models to inform study design and interpretations. There is a need to develop procedures for the systematic cultural adaptation of stigma assessment tools. Research should be conducted to understand the forms and drivers of structural stigma and to expand intervention research to evaluate strategies for stigma reduction.

Tension and Other Idioms of Distress Among Slum Dwelling Young Men: A Qualitative Study of Depression in Urban Bangladesh

In low- and middle-income countries (LMIC) it is vital to understand acceptable, comprehensive, and culturally appropriate ways of communicating about mental distress. Diagnostic terminology is rarely used, may be stigmatizing, and is subject to misinterpretation. Local terms, such as idioms of distress, can improve mental health literacy and service delivery. Our objective was to examine lived experience and coping connected to distress and depression in an under-researched population: young men from LMIC urban slums. We conducted 60 qualitative interviews with men (ages 18-29) in Bhashantek slum, Bangladesh. Themes were generated using thematic analysis and grounded theory techniques. The heart-mind (mon), mentality (manoshikota), mood (mejaj), head (matha or "brain"), and body (shorir) comprised the self-concept, and were related to sadness, hopelessness, anger, worry, and mental illness. The English word "tension" was the central idiom of distress. "Tension" existed on a continuum, from mild distress or motivational anxiety, to moderate distress including rumination and somatic complaints, to severe psychopathology including anhedonia and suicidality. Respondents connected "tension" to burnout experiences and mental illness which was summarized in an ethnopsychological model. These findings can inform culturally sensitive measurement tools and interventions that are acceptable to the community, potentially increasing engagement and enhancing therapeutic outcomes.

A mixed-methods, population-based study of a syndemic in Soweto, South Africa

A syndemic has been theorized as a cluster of epidemics driven by harmful social and structural conditions wherein the interaction between the constitutive epidemics drive excess morbidity and mortality. We conducted a mixed-methods study to investigate a syndemic in Soweto, South Africa, consisting of a population-based quantitative survey (N=783) and in-depth, qualitative interviews (N=88). We used ethnographic methods to design a locally relevant measure of stress. Here we show that multimorbidity and stress interacted with each other to reduce quality of life. The paired qualitative analysis further explored how the quality of life impacts of multimorbidity were conditioned by study participants’ illness experiences. Together these findings underscore the importance of recognizing the social and structural drivers of stress and how they affect the experience of chronic illness and well-being.

Feeling unsafe as a source of psychological distress in early adolescence

RATIONALE

Symptoms of psychological distress at an early age have proved to undermine adolescents' academic achievements, as well as their personal and social well-being. The literature acknowledges a wide range of risk factors that cause psychological distress, while at the same time emphasizing the role of social support as a protective factor. On the other hand, feelings of unsafety as a possible source of psychological distress have been so far largely overlooked in the literature.

OBJECTIVE

The present study explores the consequences of a specific stressor (feeling unsafe) and asks whether social support can act as a moderator in the association between subjective unsafety and psychological distress.

METHODS

A multi-group structural equation model was run with a sample of 2876 young adolescents aged 10-12 enrolled in educational centers in the city of Barcelona, Spain.

RESULTS

The results show that direct exposure to sibling violence at home and bullying at school are significant predictors of psychological distress, regardless of biological sex. The hypothesis of a negative correlation of subjective perceptions of unsafety on psychological distress is also supported, although neighborhood-based risk factors emerge as a greater source of distress for females than for males. The involvement of supportive adults is associated with lower levels of perceptions of unsafety and distress in both groups, but girls seem capable of drawing more effectively on alternative sources of support, specifically their peers, to enhance their safety at school and in the neighborhood.

CONCLUSION

Overall, gender differences in our model overlap with socio-environmental inequalities (low income, exposure to violence and conflictual public spaces), thus suggesting that an intervention into the root causes of these inequalities could contribute to lowering psychological distress in early adolescence.

Addressing Mental Health Stigma in Low-Income and Middle-Income Countries: A New Frontier for Digital Mental Health

BACKGROUND

Mental health stigma is a major barrier to seeking help, and leads to poor quality of life and social withdrawal for individuals living with mental illness. These concerns are especially severe in low-income and middle-income countries (LMICs) that face a disproportionate share of the global burden of mental illnesses. With growing access to digital technologies in LMICs, there may be new opportunities to address mental health stigma. This review considers the potential for emerging digital technologies to advance efforts to challenge mental health stigma in LMICs.

METHODS

Promising digital strategies to reduce mental health stigma were identified through searching the peer-reviewed literature. Drawing from the Mental Illness Stigma Framework, these studies of digital strategies were grouped into three categories: 1) protest; 2) education, and 3) contact.

RESULTS

These three categories align with established stigma reduction programs. Digital strategies could expand the reach of or complement existing efforts. There are challenges with digital stigma reduction strategies, including the need for cultural adaptation of these programs to diverse contexts and settings, consideration of reliable measurement of mental health related stigma, and risks that digital media could perpetuate the spread of misinformation and exacerbate concerns pertaining to mental health stigma.

CONCLUSION

This review highlights the promise of technology for addressing mental health stigma in LMICs. This is imperative in the face of growing demand for mental health services owing to the economic and social impacts of the COVID-19 pandemic, and the increasing reliance on digital platforms among individuals in most countries.

"Thinking Too Much": A Systematic Review of the Idiom of Distress in Sub-Saharan Africa

Idioms of distress have been employed in psychological anthropology and global mental health to solicit localized understandings of suffering. The idiom "thinking too much" is employed in cultural settings worldwide to express feelings of emotional and cognitive disquiet with psychological, physical, and social consequences on people's well-being and daily functioning. This systematic review investigates how, where, and among whom the idiom "thinking too much" within varied Sub-Saharan African contexts was investigated. We reviewed eight databases and identified 60 articles, chapters, and books discussing "thinking too much" across Sub-Saharan Africa. Across 18 Sub-Saharan African countries, literature on "thinking too much" focused on particular sub-populations, including clinical populations, including people living with HIV or non-communicable diseases, and women experiencing perinatal or postnatal depression; health workers and caregivers; and non-clinical populations, including refugees and conflict-affected communities, as well as community samples with and without depression. "Thinking too much" reflected a broad range of personal, familial, and professional concerns that lead someone to be consumed with "too many thoughts." This research demonstrates that "thinking too much" is a useful idiom for understanding rumination and psychiatric distress while providing unique insights within cultural contexts that should not be overlooked when applied in clinical settings.

Reporting Cultural Adaptation in Psychological Trials - The RECAPT criteria

Background

There is a lack of empirical evidence on the level of cultural adaptation required for psychological interventions developed in Western, Educated, Industrialized, Rich, and Democratic (WEIRD) societies to be effective for the treatment of common mental disorders among culturally and ethnically diverse groups. This lack of evidence is partly due to insufficient documentation of cultural adaptation in psychological trials. Standardised documentation is needed in order to enhance empirical and meta-analytic evidence.

Process

A "Task force for cultural adaptation of mental health interventions for refugees" was established to harmonise and document the cultural adaptation process across several randomised controlled trials testing psychological interventions for mental health among refugee populations in Germany. Based on the collected experiences, a sub-group of the task force developed the reporting criteria presented in this paper. Thereafter, an online survey with international experts in cultural adaptation of psychological interventions was conducted, including two rounds of feedback.

Results

The consolidation process resulted in eleven reporting criteria to guide and document the process of cultural adaptation of psychological interventions in clinical trials. A template for documenting this process is provided. The eleven criteria are structured along A) Set-up; B) Formative research methods; C) Intervention adaptation; D) Measuring outcomes and implementation.

Conclusions

Reporting on cultural adaptation more consistently in future psychological trials will hopefully improve the quality of evidence and contribute to examining the effect of cultural adaptation on treatment efficacy, feasibility, and acceptability.

Standardised Research Methods and Documentation in Cultural Adaptation: The Need, the Potential and Future Steps

Background

Refugees and asylum seekers in Europe are affected by high prevalence of common mental disorders. Under the call 'mental health of refugee populations', the German Federal Ministry of Education and Research (FMER) funded a series of research projects to test evidence-based psychological interventions among refugee populations in Germany. In addition, the "Task force for cultural adaptation of mental health interventions for refugees" was established to develop a structured procedure for harmonising and documenting cultural adaptations across the FMER-funded research projects.

Method

A template for documenting cultural adaptations in a standardised manner was developed and completed by researchers in their respective projects. Documentation contained original data from formative research, as well as references and other sources that had been used during the adaptation process. All submitted templates and additional materials were analysed using qualitative content analysis.

Results

Research projects under the FMER call include minors, adults, and families from different origins with common mental disorders. Two studies used and adapted existing manuals for the treatment of PTSD. Four studies adapted existing transdiagnostic manuals, three of which had already been developed with a culture-sensitive focus. Four other studies developed new intervention manuals using evidence-based treatment components. The levels of cultural adaptation varied across studies, ranging from surface adaptations of existing manuals to the development of new, culture-sensitive interventions for refugees.

Conclusions

Cultural adaptation is often an iterative process of piloting, feedback, and further adaptation. Having a documentation system in place from start helps structuring this process and increases transparency.

Towards a better understanding of attitudes and beliefs held by traditional healers and recipients of traditional medicine concerning mental health conditions in post-conflict Liberia: a qualitative investigation

Background

A better understanding of attitudes and beliefs held by traditional healers and utilizers of traditional medicine concerning mental health conditions in Liberia is important as Liberia seeks to improve its delivery of mental healthcare in the context of scarce resources and recovery from civil war.

Methods

A qualitative research design was used to collect data from 24 Liberian traditional healers, and 11 utilizers of Liberian traditional medicine. Participants were queried about mental health problems in Liberia, treatments, and attitudes towards modern healthcare. Qualitative data were probed and aggregated using content analysis.

Results

Mental health problems described by study participants included: Open Mole, African Science, Epilepsy, Depression and Mental Illness (trauma/substance use). Mental health problems were often associated with socioeconomic distress, and participants described their attitudes and beliefs concerning mental healthcare, traditional medicine, and modern healthcare.

Conclusion

Traditional medicine is an important part of mental healthcare in Africa. Mental illness, social factors, and healthcare access were important problems in Liberia. Mental health problems blended local cultural beliefs with Westernized nosology and social factors. Traditional healer's attitudes towards Western medicine reflected ambivalence. There is a desire for collaboration with ‘modern’ health care providers, but this will require reciprocal trust-building.

Self-stigma in Serious Mental Illness: A Systematic Review of Frequency, Correlates, and Consequences

Self-stigma is associated with poor clinical and functional outcomes in Serious Mental Illness (SMI). There has been no review of self-stigma frequency and correlates in different cultural and geographic areas and SMI. The objectives of the present study were: (1) to review the frequency, correlates, and consequences of self-stigma in individuals with SMI; (2) to compare self-stigma in different geographical areas and to review its potential association with cultural factors; (3) to evaluate the strengths and limitations of the current body of evidence to guide future research. A systematic electronic database search (PubMed, Web of Science, PsycINFO, Scopus, and Ovid SP Cumulative Index to Nursing and Allied Health Literature [CINAHL]) following PRISMA guidelines, was conducted on the frequency, correlates, and consequences of self-stigma in SMI. Out of 272 articles, 80 (29.4%) reported on the frequency of self-stigma (n = 25 458), 241 (88.6%) on cross-sectional correlates of self-stigma and 41 (15.0%) on the longitudinal correlates and consequences of self-stigma. On average, 31.3% of SMI patients reported high self-stigma. The highest frequency was in South-East Asia (39.7%) and the Middle East (39%). Sociodemographic and illness-related predictors yielded mixed results. Perceived and experienced stigma-including from mental health providers-predicted self-stigma, which supports the need to develop anti-stigma campaigns and recovery-oriented practices. Increased transition to psychosis and poor clinical and functional outcomes are both associated with self-stigma. Psychiatric rehabilitation and recovery-oriented early interventions could reduce self-stigma and should be better integrated into public policy.

Is There an Association Between Psychiatric Disorders and Adolescent Idiopathic Scoliosis? A Large-database Study

BACKGROUND

Children with adolescent idiopathic scoliosis (AIS) have reduced quality of life related to poor self-image, perhaps because of cosmetic concerns. However, there has not been a large-database epidemiologic study on the association between psychiatric disorders and scoliosis.

QUESTIONS/PURPOSES

Using the Korean National Health Insurance database, we asked: (1) How common are psychiatric disorders among children with AIS? (2) After controlling for gender, age, insurance type, and residential district, are psychiatric disorders more common among children with AIS than among age-matched controls?

METHODS

A retrospective analysis was conducted using sample datasets from the Health Insurance Review and Assessment Service from 2012 to 2016, which is a 10% randomly extracted sample of total inpatients and outpatients each year. The mean number of total patients in each dataset was 1,047,603 ± 34,534. The mean number of children with AIS was 7409 ± 158 for each year. The age criteria was 10 to 19 years for the matching. Mood disorders, anxiety disorders, and behavioral disorders were selected as disorders possibly associated with AIS. We identified children with AIS who had any of the disorders above, and we obtained the prevalence of these disorders based on diagnostic codes. As an exploratory analysis, clinically meaningful variables were selected among the available codes in the dataset, and a univariable logistic regression test was performed for each variable. A multivariable logistic regression test with advanced variables was performed to identify the adjusted odds ratios of psychiatric disorders in children with AIS.

RESULTS

The median (range) prevalence of psychiatric disorders in children with AIS from 2012 to 2016 was 7% (6% to 7%). Compared with children who did not have AIS, and after controlling for gender, age, insurance type, and residential district, children with AIS were more likely to have psychiatric disorders in all 5 years. The adjusted ORs of psychiatric disorders in children with AIS compared with children who did not have AIS ranged from 1.47 to 1.74 (2012: OR 1.60 [95% CI 1.46 to 1.75]; p < 0.001; 2013: OR 1.73 [95% CI 1.58 to 1.89]; p < 0.001; 2014: OR 1.74 [95% CI 1.59 to 1.91]; p < 0.001; 2015: OR 1.71 [95% CI 1.56 to 1.88]; p < 0.001; 2016: OR 1.47 [95% CI 1.33 to 1.62]; p < 0.001).

CONCLUSION

Considering the higher prevalence of psychiatric disorders in children with AIS compared with children who did not have AIS, children with AIS and their parents should be counseled about the increased risk of deteriorating mental health of the patients, and surgeons should provide early referral to pediatric psychiatrists. Further studies should investigate the effect of the factors related to AIS, such as curve type, Cobb angle, and treatment modality.

LEVEL OF EVIDENCE

Level III, prognostic study.

Inclusiveness of the Concept of Mental Disorder and Differences in Help-Seeking Between Asian and White Americans

Ethnic and racial group differences in help-seeking are a barrier to the effective and equitable delivery of mental health services. Asian American populations demonstrate relatively low levels of help-seeking. Explanations for this effect typically point to elevated levels of stigma in these populations. An alternative explanation is that low help-seeking might also reflect holding a relatively circumscribed concept of mental disorder. Individuals and groups with less inclusive concepts of disorder may be less likely to identify problems as appropriate for mental health treatment. This study aimed to test whether group differences in the breadth of the mental disorder concept account for group differences in help-seeking attitudes. A sample of 212 American participants (102 Asian Americans and 110 White Americans) were assessed on personal stigma, help-seeking attitudes, and mental disorder concept breadth. Mediation analyses examined whether stigma and concept breadth mediated group differences in attitudes. Compared to White Americans, Asian Americans reported higher levels of stigma and narrower concepts of mental disorder, both of which were associated with less positive help-seeking attitudes. Stigma and concept breadth both partially mediated the group difference in attitudes. Theoretical and practical implications for mental health promotion and culturally sensitive clinical practices are explored.

Effectiveness of Group Problem Management Plus, a brief psychological intervention for adults affected by humanitarian disasters in Nepal: A cluster randomized controlled trial

BACKGROUND

Globally, 235 million people are impacted by humanitarian emergencies worldwide, presenting increased risk of experiencing a mental disorder. Our objective was to test the effectiveness of a brief group psychological treatment delivered by trained facilitators without prior professional mental health training in a disaster-prone setting.

METHODS AND FINDINGS

We conducted a cluster randomized controlled trial (cRCT) from November 25, 2018 through September 30, 2019. Participants in both arms were assessed at baseline, midline (7 weeks post-baseline, which was approximately 1 week after treatment in the experimental arm), and endline (20 weeks post-baseline, which was approximately 3 months posttreatment). The intervention was Group Problem Management Plus (PM+), a psychological treatment of 5 weekly sessions, which was compared with enhanced usual care (EUC) consisting of a family psychoeducation meeting with a referral option to primary care providers trained in mental healthcare. The setting was 72 wards (geographic unit of clustering) in eastern Nepal, with 1 PM+ group per ward in the treatment arm. Wards were eligible if they were in disaster-prone regions and residents spoke Nepali. Wards were assigned to study arms based on covariate constrained randomization. Eligible participants were adult women and men 18 years of age and older who met screening criteria for psychological distress and functional impairment. Outcomes were measured at the participant level, with assessors blinded to group assignment. The primary outcome was psychological distress assessed with the General Health Questionnaire (GHQ-12). Secondary outcomes included depression symptoms, posttraumatic stress disorder (PTSD) symptoms, "heart-mind" problems, social support, somatic symptoms, and functional impairment. The hypothesized mediator was skill use aligned with the treatment's mechanisms of action. A total of 324 participants were enrolled in the control arm (36 wards) and 319 in the Group PM+ arm (36 wards). The overall sample (N = 611) had a median age of 45 years (range 18-91 years), 82% of participants were female, 50% had recently experienced a natural disaster, and 31% had a chronic physical illness. Endline assessments were completed by 302 participants in the control arm (36 wards) and 303 participants in the Group PM+ arm (36 wards). At the midline assessment (immediately after Group PM+ in the experimental arm), mean GHQ-12 total score was 2.7 units lower in Group PM+ compared to control (95% CI: 1.7, 3.7, p < 0.001), with standardized mean difference (SMD) of -0.4 (95% CI: -0.5, -0.2). At 3 months posttreatment (primary endpoint), mean GHQ-12 total score was 1.4 units lower in Group PM+ compared to control (95% CI: 0.3, 2.5, p = 0.014), with SMD of -0.2 (95% CI: -0.4, 0.0). Among the secondary outcomes, Group PM+ was associated with endline with a larger proportion attaining more than 50% reduction in depression symptoms (29.9% of Group PM+ arm versus 17.3% of control arm, risk ratio = 1.7, 95% CI: 1.2, 2.4, p = 0.002). Fewer participants in the Group PM+ arm continued to have "heart-mind" problems at endline (58.8%) compared to the control arm (69.4%), risk ratio = 0.8 (95% CI, 0.7, 1.0, p = 0.042). Group PM+ was not associated with lower PTSD symptoms or functional impairment. Use of psychosocial skills at midline was estimated to explain 31% of the PM+ effect on endline GHQ-12 scores. Adverse events in the control arm included 1 suicide death and 1 reportable incidence of domestic violence; in the Group PM+ arm, there was 1 death due to physical illness. Study limitations include lack of power to evaluate gender-specific effects, lack of long-term outcomes (e.g., 12 months posttreatment), and lack of cost-effectiveness information.

CONCLUSIONS

In this study, we found that a 5-session group psychological treatment delivered by nonspecialists modestly reduced psychological distress and depression symptoms in a setting prone to humanitarian emergencies. Benefits were partly explained by the degree of psychosocial skill use in daily life. To improve the treatment benefit, future implementation should focus on approaches to enhance skill use by PM+ participants.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03747055.

Beyond the DSM-5 Diagnoses: A Cross-Cultural Approach to Assessing Trauma Reactions

Although trauma exposure is a global phenomenon, trauma reactions vary considerably across cultures. Western psychiatric diagnoses, such as posttraumatic stress disorder (PTSD), may be limited in capturing the breadth of trauma reactions in cross-cultural contexts. Instead, cross-cultural instruments should examine locally relevant reactions, such as idioms of distress and explanatory models of illness, and account for ongoing stress and adversity. This article explains the need for complementing traditional trauma assessment approaches, how to create culturally sensitive instruments, the style and stance of practicing cultural humility when administering instruments, how to account for ongoing trauma and adversity, and ways to incorporate findings into treatment. These steps can improve culturally sensitive and comprehensive trauma assessment to capture universal and culturally relevant trauma reactions.

Critical qualitative research on 'madness': knowledge making and activism among those designated 'mad'

This paper charts the background to a project which aimed to map the knowledge being generated across the world by people silenced for centuries - the 'mad': a term with derogatory historical resonances but which is now being reclaimed. The idea that those designated 'mad' can produce knowledge is novel: 'mad' people are imagined as lacking rationality, and incapable of producing knowledge; they are subject to epistemic injustice. Patient engagement in research has grown in the last 20 years but we lack methodological frameworks through which such knowledge can be surfaced. One goal of the project is to let the mad speak their knowledge, often practical knowledge. To do this we had to innovate methodology. Centrally, we refuse the distinction between theory and method for these are constantly intertwined in all research. Thus, what typically comes under 'Method' in background papers is infused with implicit conceptualisation. We carried out 48 interviews in North America, England, Australia, New Zealand, and Eastern and Western Europe. We argue all aspects of these interviews are radically different than is usual for exploratory research in this area. Psychiatry is not central here - it is present only when present in the words of our participants; situated in material and symbolic spaces. We also seek to move away from the individualising therapies of medicines and psychological treatment because they strip participants from their situated realities. Psychiatry enters also because of what it does not do - engage with the life world of its patients. We call then for 'recontextualisation' of madness at all levels. The project was user-led and all researchers had experienced distress and responses to it. Future papers will develop and demonstrate this approach.

Combat stress in a small-scale society suggests divergent evolutionary roots for posttraumatic stress disorder symptoms

Military personnel in industrialized societies often develop posttraumatic stress disorder (PTSD) during combat. It is unclear whether combat-related PTSD is a universal evolutionary response to danger or a culture-specific syndrome of industrialized societies. We interviewed 218 Turkana pastoralist warriors in Kenya, who engage in lethal cattle raids, about their combat experiences and PTSD symptoms. Turkana in our sample had a high prevalence of PTSD symptoms, but Turkana with high symptom severity had lower prevalence of depression-like symptoms than American service members with high symptom severity. Symptoms that facilitate responding to danger were better predicted by combat exposure, whereas depressive symptoms were better predicted by exposure to combat-related moral violations. The findings suggest that some PTSD symptoms stem from an evolved response to danger, while depressive PTSD symptoms may be caused by culturally specific moral norm violations.

Cultural psychiatry: beyond DSM-5

BACKGROUND

Cultural psychiatry evaluates manifestations, symptoms of emotional distress and mental disorders in diverse cultural contexts; it also addresses social problems such as poverty, violence, inequalities between groups or social classes.

OBJECTIVE

To present a narrative review of the most relevant cultural aspects in the context of clinical practice in psychiatry and to suggest some alternatives to improve the cultural competence of health care professionals.

METHOD

A narrative review was carried out of the most relevant articles in the area.

RESULTS

Usually, the cultural argument is used to explain differences in observed prevalences in some mental disorders according to gender and geographical location. Cultural differences modify the expression of emotional distress and this can reduce the accuracy and affect the reliability and validity of the current diagnostic classification used in psychiatry. The American Psychiatric Association, in the most recent classification, revised cultural syndromes but only included a limited number of situations. Consequently, medical education and psychiatry must respond to diverse populations and provide quality care through the development of trans-cultural competence in the curriculum.

CONCLUSIONS

It should be considered that cultural differences modify the expression of distress and thereby undermine the validity and reliability for diagnoses in distinct cultural contexts. In an increasingly globalised world, future classifications may completely omit 'cultural syndromes'.

Depressive Symptoms Differentially Predict Neurocognition in Latinx and Non-Hispanic White People Living with HIV

OBJECTIVES

Depression is common in people living with HIV (PLWH) and can contribute to neurocognitive dysfunction. Depressive symptoms in PLWH are often measured by assessing only cognitive/affective symptoms. Latinx adults, however, often express depressive symptoms in a somatic/functional manner, which is not typically captured in assessments of depression among PLWH. Given the disproportionate burden of HIV that Latinx adults face, examining whether variations in expressed depressive symptoms differentially predict neurocognitive outcomes between Latinx and non-Hispanic white PLWH is essential.

METHODS

This cross-sectional study included 140 PLWH (71% Latinx; 72% male; mean (M) age = 47.1 ± 8.5 years; M education = 12.6 ± 2.9 years) who completed a comprehensive neurocognitive battery, Wechsler Test of Adult Reading (WTAR), and Beck Depression Inventory-II (BDI-II). Neurocognitive performance was measured using demographically adjusted T-scores. BDI-II domain scores were computed for the Fast-Screen (cognitive/affective items) score (BDI-FS) and non-FS score (BDI-NFS; somatic/functional items).

RESULTS

Linear regressions revealed that the BDI-NFS significantly predicted global neurocognitive function and processing speed in the Latinx group (p < .05), such that higher physical/functional symptoms predicted worse performance. In the non-Hispanic white group, the cognitive/affective symptoms significantly predicted processing speed (p = .02), with more symptoms predicting better performance. Interaction terms of ethnicity and each BDI sub-score indicated that Latinx participants with higher cognitive/affective symptoms performed worse on executive functioning.

CONCLUSIONS

Depressive symptoms differentially predict neurocognitive performance in Latinx and non-Hispanic white PLWH. These differences should be considered when conducting research and intervention among the increasingly culturally and ethnically diverse population of PLWH.

Neuropathic pain in Mali: The current situation, comprehensive hypothesis, which therapeutic strategy for Africa?

INTRODUCTION

According to the taxonomy of the International Association for the Study of Pain (IASP 2011), neuropathic pain (NeuP) is defined as "pain caused by a lesion or disease of the somatosensory nervous system". NeuP is currently well-defined clinically, despite a high degree of etiological variation, and it has become a significant public health problem. This work aimed to study the situation regarding NeuP in current practice in Mali, as well as to analyze the therapeutic environment of the patients.

METHODOLOGY

This was a retrospective and cross-sectional study, carried out in two phases: (1) compilation of the files of patients according to the ICD-11, over a period of 24 months (2) a second prospective phase regarding the Knowledge, Attitudes, and Practices (KAP) of general practitioners and neurologists in regard to NeuP. The focus of the first phase of the study was the files of the patients who had undergone a consultation at the Gabriel Touré UHC. The second phase of the study focused on the general practitioners (Community Health Centers (comHC) of Bamako) and neurologists (Malian or not).

RESULTS

Over the period of the study, 7840 patients were seen in consultation in the Department of Neurology, of whom 903 for NeuP, thus amounting to a NeuP frequency of 11.5%. Women accounted for 58.9% (532/903), with a sex ratio of 1.4. Using a comparative normal law, the difference in frequency was statistically significant between males and females (p < 10-7) and between two age groups (p 〈10-3). The 49-58 years of age group was represented the most. Diabetic NeuP (21%), lumbar radiculopathies (14%), HIV/AIDS NeuP (13%), and post-stroke NeuP (11%) were the most represented. The survey among the carers revealed: a need for training, a low level of compliance with the therapeutic guidelines, and the use of traditional medicine by the patients.

DISCUSSION/CONCLUSION

This work confirms that NeuP is encountered frequently in current practice, and its optimal management will involve specific training of carers and improvement of access to the medications recommended in this indication. In light of this issue, we revisit the debate regarding the concept of essential medications and the relevance of taking into account effective medications for the treatment of NeuP.

Barriers and drivers to service delivery in global mental health projects

BACKGROUND

Research in global mental health (GMH) has previously documented how contextual factors like political instability, poverty and poorly-funded health infrastructure continue to compromise effective and equitable mental health service delivery. There is a need to develop more feasible and evidence-based solutions through implementation research. This paper, one in a series pertaining to implementation in GMH projects worldwide, focuses on implementation factors influencing mental health service delivery.

METHODS

This is a qualitative study carried out as part of a Theory of Change-driven evaluation of Grand Challenges Canada's (GCC's) Global Mental Health portfolio. Purposive sampling was used to recruit twenty-nine GCC grantees for interviews. A semi-structured interview schedule was used to guide the interviews which were recorded and subsequently transcribed. Transcripts were double-coded and analyzed in NVivo 11 using framework analysis. This paper reports results related to detection and treatment of mental illness, mental health promotion and prevention of mental illness.

RESULTS

Key barriers included: lack of appropriate human resources and expertise for service delivery; lack of culturally appropriate screening tools and interventions; and difficulties integrating services with the existing mental health system. Formative research was a key driver facilitating the cultural adaptation of mental health detection, treatment, promotion and preventative approaches. Recruiting local providers and utilizing mHealth for improving screening, monitoring and data management were also found to be successful approaches in reducing workforce burden, improving sustainability, mental health literacy, participant engagement and uptake.

CONCLUSIONS

The study identifies a number of key barriers to and drivers of successful service delivery from the perspective of grantees implementing GMH projects. Findings highlight several opportunities to mitigate common challenges, providing recommendations for strengthening systems- and project-level approaches for delivering mental health services. Further, more inclusive research is required to inform guidance around service delivery for successful implementation, better utilization of funding and improving mental health outcomes among vulnerable populations in low-resource settings.

Social vulnerability, parity and food insecurity in urban South African young women: the healthy life trajectories initiative (HeLTI) study

Social vulnerability indices (SVI) can predict communities' vulnerability and resilience to public health threats such as drought, food insecurity or infectious diseases. Parity has yet to be investigated as an indicator of social vulnerability in young women. We adapted an SVI score, previously used by the US Centre for Disease Control (CDC), and calculated SVI for young urban South African women (n = 1584; median age 21.6, IQR 3.6 years). Social vulnerability was more frequently observed in women with children and increased as parity increased. Furthermore, young women classified as socially vulnerable were 2.84 times (95% CI 2.10-3.70; p < 0.001) more likely to report household food insecurity. We collected this information in 2018-2019, prior to the current global COVID-19 pandemic. With South Africa having declared a National State of Disaster in March 2020, early indicators suggest that this group of women have indeed been disproportionally affected, supporting the utility of such measures to inform disaster relief efforts.

Ethnographic Insights into the Quality of Life and Experiences of People Living with Schizophrenia in Harare, Zimbabwe

Schizophrenia is a complex and severe mental disorder affecting more than 20 million people worldwide. This study used focused ethnography to explore the everyday lives of 18 people living with schizophrenia in Zimbabwe and its impact on their quality of life (QOL). Data were collected using semi-structured interviews, observational fieldwork, and the short form of the World Health Organization QOL-BREF questionnaire. Those aged 20-40 years experienced poorer QOL than older people. Family dislocation, living with stigma and discrimination, cost of medications and limited and variable access to treatment and support disrupted participants' ability to enjoy life and function socially.

Artificial Intelligence in mental health and the biases of language based models

BACKGROUND

The rapid integration of Artificial Intelligence (AI) into the healthcare field has occurred with little communication between computer scientists and doctors. The impact of AI on health outcomes and inequalities calls for health professionals and data scientists to make a collaborative effort to ensure historic health disparities are not encoded into the future. We present a study that evaluates bias in existing Natural Language Processing (NLP) models used in psychiatry and discuss how these biases may widen health inequalities. Our approach systematically evaluates each stage of model development to explore how biases arise from a clinical, data science and linguistic perspective.

DESIGN/METHODS

A literature review of the uses of NLP in mental health was carried out across multiple disciplinary databases with defined Mesh terms and keywords. Our primary analysis evaluated biases within 'GloVe' and 'Word2Vec' word embeddings. Euclidean distances were measured to assess relationships between psychiatric terms and demographic labels, and vector similarity functions were used to solve analogy questions relating to mental health.

RESULTS

Our primary analysis of mental health terminology in GloVe and Word2Vec embeddings demonstrated significant biases with respect to religion, race, gender, nationality, sexuality and age. Our literature review returned 52 papers, of which none addressed all the areas of possible bias that we identify in model development. In addition, only one article existed on more than one research database, demonstrating the isolation of research within disciplinary silos and inhibiting cross-disciplinary collaboration or communication.

CONCLUSION

Our findings are relevant to professionals who wish to minimize the health inequalities that may arise as a result of AI and data-driven algorithms. We offer primary research identifying biases within these technologies and provide recommendations for avoiding these harms in the future.

Dimensionality and differential item endorsement of depressive symptoms among aging Black populations in South Africa: Findings from the HAALSI study

BACKGROUND

The Center for Epidemiologic Studies-Depression (CES-D) scale is a widely used measure of depressive symptoms, but its construct validity has not been adequately assessed in sub-Saharan Africa. This study validates the CES-D among an aging Shangaan-speaking and predominantly Black African sample in rural South Africa, with a special emphasis on gender differences.

METHODS

An 8-item CES-D scale was administered in Shangaan to 5059 respondents, aged 40+ years, residing in Agincourt, South Africa. We used Cronbach's alpha and exploratory and confirmatory factor analysis to examine and confirm dimensionality of the CES-D scale. Differential endorsement of CES-D items by gender were assessed using the Mantel-Haenszel (MH) odds ratio test.

RESULTS

Reliability of the CES-D scale differed by gender with women reporting higher internal consistency on items than men. A two-factor solution was retained and confirmed representing two latent factors: (1) Negative Affect (six items) and (2) Diminished Positive Affect (two items). MH results showed that men exhibited significantly higher odds of putting an effort in everything that they did (OR: 1.33, 95% CI: 1.15-1.54) and lower odds of feeling depressed (OR: 0.71, 95% CI: 0.56-0.89) and having restless sleep (OR: 0.67, 95% CI:0.58-0.77) than women.

LIMITATIONS

Analyses were limited to a dichotomous, short form of the CES-D, a self-reported population-based measure.

CONCLUSION

Aging Black Africans differ in endorsing affective and somatic items on the CES-D scale by gender, which may lead to skewed population-level estimates of depression in key subpopulations. These findings highlight the importance of continued research disentangling cross-cultural and gendered nuances of depression measurements.

A cross-national study of depression in preclinical dementia: A COSMIC collaboration study

INTRODUCTION

Depression commonly accompanies Alzheimer's disease, but the nature of this association remains uncertain.

METHODS

Longitudinal data from the COSMIC consortium were harmonized for eight population-based cohorts from four continents. Incident dementia was diagnosed in 646 participants, with a median follow-up time of 5.6 years to diagnosis. The association between years to dementia diagnosis and successive depressive states was assessed using a mixed effect logistic regression model. A generic inverse variance method was used to group study results, construct forest plots, and generate heterogeneity statistics.

RESULTS

A common trajectory was observed showing an increase in the incidence of depression as the time to dementia diagnosis decreased despite cross-national variability in depression rates.

DISCUSSION

The results support the hypothesis that depression occurring in the preclinical phases of dementia is more likely to be attributable to dementia-related brain changes than environment or reverse causality.

A randomised test of the effect of medical v. lay idiom on assessment of perceived mental health condition in the USA

AIMS

To test the impact of using different idioms in epidemiological interviews on the prevalence and correlates of poor mental health and mental health service use.

METHODS

We conducted a randomised methodological experiment in a nationally representative sample of the US adult population, comparing a lay idiom, which asked about 'problems with your emotions or nerves' with a more medical idiom, which asked about 'problems with your mental health'. Differences across study arms in the associations of endorsement of problems with the Kessler-6 (a validated assessment of psychological distress), demographic characteristics, self-rated health and mental health service use were examined.

RESULTS

Respondents were about half as likely to endorse a problem when asked with the more medical idiom (18.1%) than when asked with the lay idiom (35.1%). The medical idiom had a significantly larger area under the ROC curve when compared against a validated measure of psychological distress than the lay idiom (0.91 v. 0.87, p = 0.012). The proportion of the population who endorsed a problem but did not receive treatment in the past year was less than half as large for the medical idiom (7.90%) than for the lay idiom (20.94%). Endorsement of problems differed in its associations with age, sex, race/ethnicity and self-rated health depending on the question idiom. For instance, the odds of endorsing problems were threefold higher in the youngest than the oldest age group when the medical idiom was used (OR = 3.07; 95% CI 1.47-6.41) but did not differ across age groups when the lay idiom was used (OR = 0.76; 95% CI 0.43-1.36).

CONCLUSION

Choice of idiom in epidemiological questionnaires can affect the apparent correlates of poor mental health and service use. Cultural change within populations over time may require changes in instrument wording to maintain consistency in epidemiological measurement of psychiatric conditions.

Metaphors For Trauma: A Cross-Cultural Qualitative Comparison in Brazil, India, Poland, and Switzerland

The concept of psychological trauma implies that people experiencing traumatic stress are wounded, thus relating to the metaphor of a physical injury. Although this notion is widely accepted by clinicians and researchers in mental health, there is evidence of a broad range of metaphorical idioms for extremely aversive experiences or catastrophic events across different cultures. In this ethnopsychological study, we aimed to investigate and contrast culturally shared metaphors for trauma among four distinct cultural groups: two indigenous communities (Pitaguary from Brazil, Adivasis from India) and two rural communities (mountain villagers of Gondo, Switzerland; the Lemko ethnic minority in Poland). The communities in Brazil and in Poland were marked by historical trauma, and the communities in India and Switzerland each suffered from a natural disaster. Semistructured interviews that focused on metaphors shared within each community were conducted with key informants and laypersons (Brazil: N = 14, India: N = 28, Poland, N = 13, Switzerland: N = 9). We conducted separate metaphor analyses, then cross-culturally contrasted the findings from the four samples. Across the four cultural groups, we found similar metaphorical concepts of trauma related to bodily processes, such as shock, burden, and wound.

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.

"We need more big trees as well as the grass roots": going beyond research capacity building to develop sustainable careers in mental health research in African countries

BACKGROUND

There are substantial gaps in our knowledge regarding the aetiology of mental, neurological and substance use disorders in sub-Saharan Africa, and the cost-effectiveness and scalability of interventions to reduce the burden of these conditions on the continent. To address these gaps, international investment has focussed on building research capacity, including funding doctoral students in African countries, to support development of high quality, contextually relevant interventions. Absent, however, is an understanding of how capacity building feeds into research careers.

METHODS

Within a broader mental health research capacity-building initiative (African Mental Health Research Initiative), we conducted 52 qualitative interviews with early-career researchers, policymakers, academics, and service users from four African countries (Ethiopia, Malawi, South Africa, and Zimbabwe) and with international funders of mental health research. The interview guide focused on the research context, planning, and priorities and how respondents perceive research careers and funding. Thematic analysis was applied to the transcribed interviews.

RESULTS

Five components of a research career emerged: (i) research positions; (ii) research skills; (iii) funding; (iv) research commitment from African countries; and (v) advocacy. All stakeholders wanted more high-impact African researchers, but few saw a clear, replicable track for developing their careers within universities or their Ministries of Health in their African countries. This stemmed, in part, from the lack of support for infrastructure that enables high-quality research: grants administration, mentorship, university leadership, research culture, and open communication between policymakers and researchers.

CONCLUSIONS

This study highlights the importance of developing research infrastructure alongside capacity-building efforts. International funders should invest in grant management at African universities which would place them at the centre of research initiatives. African universities should prioritise the creation of a research culture by developing and promoting well-defined research tracks for both clinicians and academics, investing in grant management, and raising the profile of research within their institutions.

Fractures in the framework: limitations of classification systems in psychiatry

This article examines the limitations of existing classification systems from the historical, cultural, political, and legal perspectives. It covers the evolution of classification systems with particular emphasis on the DSM and ICD systems. While pointing out the inherent Western bias in these systems, it highlights the potential of misuse of these systems to subserve other agendas. It raises concerns about the reliability, validity, comorbidity, and heterogeneity within diagnostic categories of contemporary classification systems. Finally, it postulates future directions in alternative methods of diagnosis and classification factoring in advances in artificial intelligence, machine learning, genetic testing, and brain imaging. In conclusion, it emphasizes the need to go beyond the limitations inherent in classifications systems to provide more relevant diagnoses and effective treatments.


Factors predicting symptoms of somatization, depression, anxiety, post-traumatic stress disorder, self-rated mental and physical health among recently arrived refugees in Germany

BACKGROUND

There is a large body of research indicating increased prevalence rates of mental disorders among refugees. However, the vast majority of the evidence available on risk factors for mental disorders among refugees focuses on post-migration stressors and was collected in surveys that were conducted months and sometimes years after the participants had resettled.

OBJECTIVE

In the present study, we analyze socio-demographic and flight-related characteristics as predictors for symptoms of somatization, depression, anxiety, and post-traumatic stress disorder as well as self-rated mental and physical health in recently arrived refugees (up to 4 weeks after arrival) in Germany.

METHODS

The study was conducted in a reception facility for asylum-seekers in Leipzig, Germany. A total of 1316 adult individuals arrived at the facility during the survey period; 502 took part in the study. The questionnaire (self-administrated) included socio-demographic and flight-related questions as well as standardized instruments for assessing PTSD (PCL-5), depression (PHQ-9), anxiety (HSCL-10) and somatization (SSS-8). Linear regression models were conducted to predict symptoms of different mental disorders as well as self-rated mental and physical health.

RESULTS

Lack of information about family members and subjective need for health care were found to be significantly associated with symptoms of depression, somatization, anxiety, and PTSD. Better self-rated mental health was significantly associated with partnership, childlessness, lower number of traumatic events, and having information about family left behind. No associations were found between flight-related factors and symptom burden.

CONCLUSIONS

The results provide initial methodologically robust insights for research and health care services, which should aid in better identifying newly arrived refugees in need of psychosocial care. Furthermore, the results might help answering the question of how to provide health care for highly vulnerable groups within refugee populations regardless their residential status.

Effect of herbal medicine (Huanglian-jie-du granule) for somatic symptoms and insomnia in patients with Hwa-byung: A randomized controlled trial

Background

Huanglian-jie-du (HJD) granule, which is composed of representative “heat-clearing” herbs has been used for Hwa-byung. Hwa-byung is a culture-bound syndrome in Korea, characterized by distinct somatic symptoms such as chest congestion and heat sensation resulting from suppressed anger. We investigated the effect of HJD in patients with Hwa-byung.

Methods

Forty-four patients with Hwa-byung were recruited, and HJD or placebo granules were administered orally three times daily for seven days. The two primary outcomes were somatic symptoms, which were measured by Patient Health Questionnaire of physical symptoms (PHQ-15), and insomnia, which was measured by Insomnia Severity Index (ISI) at post-treatment.

Results

Between July 10 and October 31, 2017, 44 patients with Hwa-byung (mean age 36.68 years; and 38 female) were randomly assigned to HJD (n = 22) or placebo (n = 22) group. After administration of HJD or placebo granule for seven days, ISI score was lower in the HJD group compared to placebo group at post-treatment (adjusted mean difference -2.56 [95% CI -4.72 to -0.39], p = 0.0208). Meanwhile, there was no difference in PHQ-15 score between HJD group and placebo group at post-treatment (adjusted mean difference -0.50 [95% CI: -3.02–4.02], p = 0.7812).

Conclusions

Our results suggest that the administration of HJD granule has a potential to improve insomnia in Hwa-byung patients. Effect of HJD granule for general somatic symptoms in Hwa-byung patients is unclear, and further researches are needed.

Trial registration

Clinical Research Information Service, KCT0002379.

Health care needs among recently arrived refugees in Germany: a cross-sectional, epidemiological study

Objectives

The purpose of the present study is to investigate current needs for physical and/or mental health treatment in recently arrived refugees’ by considering socio-demographic, flight, and mental health-related characteristics as well as different social care needs based on epidemiological data.

Methods

The study was conducted in a reception facility for asylum-seekers in Leipzig, where 569 newly arrived adult residents participated. The questionnaire included socio-demographic and flight-related questions as well as standardized instruments for assessing mental health symptoms. Logistic regression models were conducted to predict current needs for treatment of self-rated physical and mental health status.

Results

Greater numbers of traumatic events, positive screening results for at least one mental disorder, and a current need for assistance navigating the health care system were found to be significant predictors for current mental and physical health treatment needs. In addition, males are more likely to report current treatment needs for mental health symptoms.

Conclusions

Health-related characteristics do predict newly arrived refugees’ treatment needs, and socio-demographic and flight-related characteristics do not. The results provide both academia and policy makers with first implications for improving health care for refugees in need as quickly as possible.

National and regional prevalence of posttraumatic stress disorder in sub-Saharan Africa: A systematic review and meta-analysis

BACKGROUND

People living in sub-Saharan Africa (SSA) are disproportionately exposed to trauma and may be at increased risk for posttraumatic stress disorder (PTSD). However, a dearth of population-level representative data from SSA is a barrier to assessing PTSD. This manuscript sought to calculate pooled PTSD prevalence estimates from nationally and regionally representative surveys in SSA.

METHODS AND FINDINGS

The search was conducted in PubMed, Embase, PsycINFO, and PTSDpubs and was last run between October 18, 2019, and November 11, 2019. We included studies that were published in peer-reviewed journals; used probabilistic sampling methods and systematic PTSD assessments; and included ≥ 450 participants who were current residents of an SSA country, at least 50% of whom were aged between 15 and 65 years. The primary outcomes were point prevalence estimates of PTSD across all studies, and then within subgroups. The protocol was registered with the International Prospective Register of Systematic Reviews (PROSPERO) (registration number CRD42016029441). Out of 2,825 unique articles reviewed, 25 studies including a total of 58,887 eligible participants (54% female) in 10 out of the 48 countries in SSA were identified. Most studies enrolled any adult aged 18 years or older. However, some studies only enrolled specific age brackets or persons as young as 15 years old. Six studies were national surveys, and 19 were regional. There were 4 key findings in the meta-analysis: (1) the overall pooled prevalence of probable PTSD was 22% (95% CI 13%-32%), while the current prevalence-defined as 1 week to 1 month-was 25% (95% CI 16%-36%); (2) prevalence estimates were highly variable, ranging from 0% (95% CI 0%-0%) to 74% (95% CI 72%-76%); (3) conflict-unexposed regions had a pooled prevalence of probable PTSD of 8% (95% CI 3%-15%), while conflict-exposed regions had a pooled prevalence of probable PTSD of 30% (95% CI 21%-40%; p < 0.001); and (4) there was no significant difference in the pooled prevalence of PTSD for men and women. The primary limitations of our methodology are our exclusion of the following study types: those published in languages other than English, French, and Portuguese; smaller studies; those that focused on key populations; those that reported only on continuous measures of PTSD symptoms; and unpublished or non-peer-reviewed studies.

CONCLUSIONS

In this study, PTSD symptoms consistent with a probable diagnosis were found to be common in SSA, especially in regions exposed to armed conflict. However, these studies only represent data from 10 of the 48 SSA countries, and only 6 studies provided national-level data. Given the enormous heterogeneity expected across the continent, and also within countries and regions, this review cannot speak to rates of PTSD in any regions not included in this review. Thus, substantial gaps in our knowledge of PTSD prevalence in SSA remain. More research on population-level prevalence is needed to determine the burden of trauma symptoms and PTSD in SSA and to identify acceptable and feasible approaches to address this burden given limited mental healthcare resources.

Metaphors and cultural narratives on adaptive responses to severe adversity: A field study among the Indigenous Pitaguary community in Brazil

The expressions resilience and posttraumatic growth represent metaphorical concepts that are typically found in Euro-American contexts. Metaphors of severe adversity or trauma and the expressions of overcoming it vary across cultures-a lacuna, which has not been given much attention in the literature so far. This study aimed to explore the metaphorical concepts that the Indigenous Pitaguary community in Brazil uses to talk about adaptive and positive responses to severe adversity and to relate them to their socio-cultural context. We carried out 14 semi-structured interviews during field research over a one-month period of fieldwork. The data were explored with systematic metaphor analysis. The core metaphors included images of battle, unity, spirituality, journeys, balance, time, sight, transformation, and development. These metaphors were related to context-specific cultural narratives that underlie the Pitaguary ontological perspective on collectivity, nature, and cosmology. The results suggest that metaphors and cultural narratives can reveal important aspects of a culture's collective mindset. To have a contextualized understanding of expressive nuances is an essential asset to adapt interventions to specific cultures and promote culture-specific healing and recovery processes.

Effectiveness of a School-Based Intervention on the Students' Mental Health After Exposure to War-Related Trauma

BACKGROUND

After the war, which was conducted against Palestinian civilians in the Gaza Strip, the prevalence of posttraumatic stress disorder (PTSD) among children and adolescents has increased. The counselling department at the Ministry of Education in the Gaza Strip applied a counselling program in schools in order to alleviate the effect of exposure to war. The aim of the study is to investigate the effectiveness of the counselling program after exposure to war-traumatic events among Palestinian children and adolescents in the Gaza Strip.

METHODS

The sample consists of 572 students aged 12-18 years old. Of them, 331 (57.9%) were female and 241 (42.1%) were male. Traumatic events were measured by War-Traumatic Events Checklist (W-TECh). PTSD was measured by the Post-Traumatic Stress Disorders Symptoms Scale (PTSDSS). Anxiety symptoms were adapted from The Anxiety Symptoms Scale, and depression symptoms were measured by Child Depression Inventory. Repeated measures design was employed as the counselling program was applied in all the schools at the same time. Specifically, the data were collected from the participants before the application of the counselling program and 2 months later.

RESULTS

After applying the school-based counselling program, the prevalence of PTSD (according to DSM-V) decreased from 57.5% to 45.6% among the children and adolescents who were exposed to war-traumatic events. In addition, PTSD symptoms, and emotional, somatic and cognitive functional impairment symptoms has decreased after the implementation of the counselling program especially amongst girls.

CONCLUSIONS

The school-based counselling program was effective in decreasing the PTSD symptoms among children and adolescents after the exposure to war-traumatic events.

A Point in the Heart: Concepts of Emotional Distress Among Albanian-Speaking Immigrants in Switzerland

Cultural variability regarding concepts of distress for common mental disorders (CMD) has been reported extensively in cultural clinical psychology across the globe. However, little is known about illness narratives in social communities from Southeast Europe. The purpose of this paper is to identify cultural concepts of distress (CCDs) among Albanian-speaking immigrants in Switzerland and to integrate the findings into literature from other parts of the world. Twenty semi-structured qualitative interviews were conducted using the Barts Explanatory Model Inventory (BEMI). A set of concepts was described through content analysis and semantic network analysis. The results show complex expressions of distress, which are mainly associated with post-migration living difficulties. Social problems and life-changing events mark the onset of the most common symptoms. Self-management and social support were described as the most important coping behaviors. Participants expressed trust in physical health care but little belief in psychotherapy. There is indication that mental illnesses are stigmatized in this population. It is therefore important to use non-stigmatizing terms in health communication. Moreover, individuals from this community consider suffering to be part of life, and they assume that this suffering must be endured with patience. It is vital to address these beliefs in psychological interventions.

Challenges and lessons learned in re-filming the WHO mhGAP training videos for Sri Lankan context - a qualitative study

BACKGROUND

Understanding and addressing the unmet mental health needs burden in the Northern Province of Sri Lanka is the subject of the COMGAP-S two-phase study. Phase Two involves the implementation of the World Health Organization's mental health Gap Action Programme (mhGAP) in primary healthcare settings. As part of the contextual adaptation of mhGAP, eleven of the videos provided in the mhGAP training package have been re-filmed by a local team. We investigated the challenges, barriers and good practices of this adaptation effort from the point of view of team participants.

METHODS

Twelve persons from the adaptation team, including students of medicine and drama, doctors, drama lecturers and professionals, consented to in-depth individual interviews following an open-ended topic guide with a member of the COMGAP-S study team. Interviews were recorded, transcribed, translated as necessary, and subjected to thematic analysis.

RESULTS

The majority of participants perceived the process positively and had pride in their involvement. Expectations, opportunities, and exposure were discussed as stemming from the video production. The main challenges derived from the analysis were lack of discussion around budgeting, logistical difficulties, struggles with team cooperation, and creative differences. Issues around exact translation into the local Tamil dialect and modelling around mental health were emphasised by the majority of participants. Potential uses for the videos were identified beyond the current study and recommendations included setting out clear guidance around available funding and role allocation, and increasing the flexibility in adapting the material.

CONCLUSIONS

This study illustrated details of the adaptation of existing video materials to facilitate locally-based training for non-specialists on mhGAP curricula. With this, we have added to the knowledge base on conducting cultural and language adaptations and our findings indicate participants felt adapting the mhGAP films to local context was vital to ensuring training materials were culturally appropriate and valid.

TRIAL REGISTRATION

This project was nested within the larger COMGAP-S clinical trial. Ethics approval was granted from the Ethics Review Committee, Faculty of Medicine, University of Jaffna (J/ERC/17/81/NDR/0170) and the Faculty Research Ethics Panel, Faculty of Medical Science, Anglia Ruskin University (SC/jc/FMSFREP/16/17076). The project is registered with the Sri Lankan Clinical Trial Registry (SLCTR/2018/008) and listed on the ISRCTN registry (trial ID ISRCTN62598070).

Pharmacotherapeutic interventions for bipolar disorder type II: addressing multiple symptoms and approaches with a particular emphasis on strategies in lower and middle-income countries

Introduction: Appropriately managing mental disorders is a growing priority across countries in view of the impact on morbidity and mortality. This includes patients with bipolar disorders (BD). Management of BD is a concern as this is a complex disease with often misdiagnosis, which is a major issue in lower and middle-income countries (LMICs) with typically a limited number of trained personnel and resources. This needs to be addressed.Areas covered: Medicines are the cornerstone of managing patients with Bipolar II across countries including LMICs. The choice of medicines, especially antipsychotics, is important in LMICs with high rates of diabetes and HIV. However, care is currently compromised in LMICs by issues such as the stigma, cultural beliefs, a limited number of trained professionals and high patient co-payments.Expert opinion: Encouragingly, some LMICs have introduced guidelines for patients with BD; however, this is very variable. Strategies for the future include addressing the lack of national guidelines for patients with BD, improving resources for mental disorders including personnel, improving medicine availability and patients' rights, and monitoring prescribing against agreed guidelines. A number of strategies have been identified to improve the treatment of patients with Bipolar II in LMICs, and will be followed up.

Social Factors of Health-Seeking Behavior: On Medical Treatment for Elders With Dementia in Oaxaca, Mexico

This article presents data on family caregiving for elders with dementia in Oaxaca, Mexico. Drawing on a year of ethnographic research, this article explores how caregivers engage in health-seeking behaviors and how they choose between biomedical and traditional medical alternatives. While caregivers are primarily concerned to maintain elders’ health, decisions about which medical providers to (not) consult invoke broader social factors that go beyond their relationships with elders, and concern socioeconomic realms of power, as well as broader ideals concerning local tradition and its maintenance in the contemporary world.