Bianca in the neighborhood: moving beyond the ‘reach paradigm’ in public mental health

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

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

Advancing socioecological mental health promotion intervention: A mixed methods exploration of Phase 1 Agenda Gap findings

Introduction

Protecting and promoting the mental health of youth under 30 years of age is a priority, globally. Yet investment in mental health promotion, which seeks to strengthen the determinants of positive mental health and wellbeing, remains limited relative to prevention, treatment, and recovery. The aim of this paper is to contribute empirical evidence to guide innovation in youth mental health promotion, detailing the early outcomes of Agenda Gap, an intervention centering youth-led policy advocacy to influence positive mental health for individuals, families, communities and society.

Methods

Leveraging a convergent mixed methods design, this study draws on data from n = 18 youth (ages 15 to 17) in British Columbia, Canada, who contributed to pre- and post-intervention surveys and post-intervention qualitative interviews following their participation in Agenda Gap from 2020-2021. These data are supplemented by qualitative interviews with n = 4 policy and other adult allies. Quantitative and qualitative data were analyzed in parallel, using descriptive statistics and reflexive thematic analysis, and then merged for interpretation.

Results

Quantitative findings suggest Agenda Gap contributes to improvements in mental health promotion literacy as well as several core positive mental health constructs, such as peer and adult attachment and critical consciousness. However, these findings also point to the need for further scale development, as many of the available measures lack sensitivity to change and are unable to distinguish between higher and lower levels of the underlying construct. Qualitative findings provided nuanced insights into the shifts that resulted from Agenda Gap at the individual, family, and community level, including reconceptualization of mental health, expanded social awareness and agency, and increased capacity for influencing systems change to promote positive mental health and wellbeing.

Discussion

Together, these findings illustrate the promise and utility of mental health promotion for generating positive mental health impacts across socioecological domains. Using Agenda Gap as an exemplar, this study underscores that mental health promotion programming can contribute to gains in positive mental health for individual intervention participants whilst also enhancing collective capacity to advance mental health and equity, particularly through policy advocacy and responsive action on the social and structural determinants of mental health.

Moderation by socioeconomic status of the relationship between familiarity with mental illness and stigma outcomes

Purpose

Multiple studies suggest response to mental health treatment is worse for people of lower socioeconomic status, a group who also express more mental illness stigma. Worse response to treatment may lead to greater therapeutic pessimism, an important component of stigma. However, familiarity with mental illness is associated with lower levels of stigma. This study therefore examines whether, among the general public, socioeconomic status moderates the relationships between familiarity and stigma related outcomes: knowledge; attitudes; and desire for social distance.

Methods

We carried out secondary analysis of data from the Attitudes to Mental Illness survey, collected annually from different general population samples from 2009-17, and every two years from 2017-19. Three separate multiple linear regression models examined factors associated with each outcome, with interaction tests between socioeconomic status and familiarity. Stigma related knowledge was measured using the Mental Health Knowledge Schedule (MAKS), which includes items on treatment effectiveness and recovery, thus addressing aspects of therapeutic pessimism. Attitudes were measured using the Community Attitudes towards the Mentally Ill Scale; and desire for social distance using the Reported and Intended Behaviour scale.

Results

In lower socioeconomic groups, personal experience was more frequent, while familiarity with someone else was less frequent. Interaction tests were significant for stigma related knowledge (p<0.0001) and desire for social distance (p=0.0118), but not for attitudes (p=0.057). The direction of the interaction differed between knowledge and the other outcomes. In lower socioeconomic groups the positive effect of familiarity on knowledge was weaker, as hypothesised, but for attitudes and desire for social distance, its effect was stronger.

Conclusions

Our results support the promotion of familiarity through encouraging discussion of mental health problems within social networks. However, lower stigma related knowledge among people with personal experience in lower socioeconomic groups suggests different responses to mental illness among these groups are needed.

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Familiarity with mental illness is associated with lower levels of stigma.

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Different experiences of familiarity may lead to moderation by socioeconomic group.

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The effect of familiarity on knowledge is weaker in lower socioeconomic groups.

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The results suggest more therapeutic pessimism in lower socioeconomic groups.

Experiences of pregnancy in adolescence of internally displaced women in Bogotá: an ethnographic approach

Background

Pregnancy in adolescence is higher among internally displaced women in Colombia than non-displaced women. It is defined as a problem with significant negative outcomes by both biomedical and epidemiological approaches. However, little is known about pregnancy during adolescence from the perspective of women who experienced this in the specific context of armed conflict and displacement.

Aim

This article focuses on how internally displaced women understand their experiences of pregnancy in adolescence in the context of armed conflict through an ethnographic approach in a receptor community of internally displaced women in Bogotá, Colombia.

Methods

Based on 10 years of experience in the community, we conducted 1 year of fieldwork, using an ethnographic approach. We collected life stories of 20 internally displaced women through in-depth interviews and ran 8 workshops with them and other women from the community. We used thematic analysis to analyse the responses of internally-displaced women and understand how they made meaning around their experiences of adolescent pregnancy in the context of displacement.

Results

The main themes that emerged from participants’ experiences include rural violence, early family life (characterized by violence and mistreatment at home), meanings of pregnancy at an early age (including being challenged and feelings of love), and reactions to their pregnancies during adolescence (such as stigmatization) from their families and partners.

Conclusion

Our analysis of the in-depth interviews and the workshops suggests that adolescent pregnancy among women who are internally displaced has complex dynamics, characterized by the violent context of the rural areas, but primarily by the violence experienced during their childhood. The experience of pregnancy during adolescence brings feelings of ownership and also challenges, together with the forced displacement. This understanding will provide insights for policy makers and healthcare providers on how to work with this specific population who have experienced pregnancy in adolescence.

Utilising community engagement approaches to influence public mental health policy in a rural setting

Purpose

Drawing on the notion of “mental health policy participation”, the purpose of this paper is to describe and reflect on a regional case study of a community engagement approach that explored community perspectives on mental health and the factors that influence it. It established three expectations, that: the development of the Dumfries and Galloway Public Mental Health Strategy is informed by project outputs; services and innovations are based on what people want; active involvement of local people in decision making around mental health services and strategy is achieved.

Design/methodology/approach

A “participatory appraisal” approach was used to engage with communities. A three-day “Training of Trainers” exercise was undertaken. These individuals then accessed a number of community groups. Data collection was based on five key questions. A total of 443 were engaged in the process. Insights were reviewed by 20 stakeholders from a range of services to identify key actions. This led to the development of the mental health forum and, in turn, a Public Mental Health Strategy for Dumfries and Galloway. Community members were further included in processes through feedback mechanisms.

Findings

Factors of resilience, support of families and friends, social inclusion, access to social and leisure opportunities were most important. This was followed by structural issues like fear of judgement, lack of transport, discrimination and financial support. Finally, individual factors (sleep, meaningful hobbies and health) were highlighted.

Originality/value

This approach sought to go beyond a traditional focus to explore broader community perspectives on mental health and the factors that influence it.