How scientifically valid is the knowledge base of global mental health?

Cognitive interviewing to assess and adapt three measures of mental health symptoms among people living with HIV in Rakai, Uganda: the Thinking a Lot Questionnaire, the Patient Health Questionnaire 9 (PHQ-9), and the Hopkins Symptoms Checklist (HSCL)

Mental health is conceptualized differently across cultures, making cross-cultural validation of screening tools critical. In Uganda, we used cognitive interviewing to assess and adapt three scales for measuring psychological distress: the Thinking a Lot Questionnaire, the Patient Health Questionnaire 9 (PHQ-9), and the Hopkins Symptoms Checklist (HSCL). We recruited 12 people living with HIV from the Rakai Community Cohort Study (RCCS) and interviewed seven potential users of the scales (four RCCS survey interviewers and three local health workers). Data were analyzed systematically using a team-based matrix approach. The HSCL was generally well understood, with minor clarifications needed. The Thinking a Lot Questionnaire was also well understood, though differences between "how much" and "how often" required specificity. Both included local idioms of distress from prior adaptations. The PHQ-9 performed less well, with many questions interpreted variably or showing unclear local applicability, especially among people living with HIV. For example, questions about trouble concentrating were misunderstood, focusing on examples like newspapers rather than the broader issue of concentration. Future research should explore the validity and utility of commonly used instruments as mental health research expands in Africa.

Okweraliikirira and Okwenyamira: Idioms of Psychological Distress Among People Living with HIV in Rakai, Uganda

Introduction

Health and illness experiences are positioned within social and cultural contexts. Understanding the mental health and psychological distress of people living with HIV in highly affected communities is critical to addressing their needs and to ensure programming and interventions are targeted and appropriate.

Methods

Grounded in the ethnomedical theoretical perspective, we conducted qualitative interviews to understand the experience and expression of psychological distress by people living with HIV in Rakai, Uganda. Participants included adults living with HIV (n=20), health workers (counselors, peer health workers, nurses, n=10), and key informants (n=12). Interviews were audio recorded, transcribed/translated, coded, and analyzed using thematic analysis.

Results

Two idioms of distress, okweraliikirira (worry/apprehension) and okwenyamira (deep/manythoughts/lots of thoughts) were described as impacting people living with HIV. Both idioms were said to be alleviated by social support or counseling, but if left unaddressed could lead to more severe mental health problems and poor ART adherence.

Conclusion

People living with HIV understand their psychological distress through culturally specific idioms; such distress can have deleterious impacts on well-being. Incorporating idioms of distress into screening and treatment for people living with HIV may improve identification of individuals in need and overall health services to address this need.

The 'diagnostic gap' and 'economic burden' of depression: Global mental health in neoliberal Poland (2010s-2020s)

While critical sociologists and anthropologists of health have questioned Global Mental Health policies as postcolonial, developmental agendas, little is known on how this critique applies within the central and eastern European countries. As this article shows with the case of Poland, since the advent of capitalism and liberal democracy, the psychiatric conceptualization of depression has steadily aligned with global mental health (GMH) frameworks, amplifying pre-existing trends towards biomedical dominance in Polish psychiatry and the economic framing of mental health in policy-making. These trends are evidenced by the study of Polish Psychiatry, an official journal issued by Polish Psychiatric Association and health policy documents published since the 2010s, including statements by the Ministry of Health. Two findings are presented: first, the logic of 'closing the gap' between Poland and the West has shaped how depression prevalence data is produced and interpreted by state medical institutions and in expert psychiatric discourse; second, the reconceptualization of mental illness through its supposed economic cost has become a dominant approach to depression in Polish psychiatry and public health. Thus, in showing how the Global Mental Health agenda has permeated the specific context of Poland, promoting more individual and biomedical conceptions of mental illness, this case study enables advancing the postcolonial critique of mental health.

The Challenge of Indigenous Healing for Global Mental Health

Psychiatry and anthropology have a long relationship, and it is worth examining aspects of how that relation is carried over into the developing field of Global Mental Health (GMH). One place at which the two disciplines overlap significantly is in addressing religious phenomena and ritual performance in relation to mental health, and one of the greatest challenges for GMH is how productively to take into account forms of indigenous healing based on religion and ritual. In this paper I compare recent texts in GMH written from the standpoint of psychiatry and anthropology, observing that the psychiatric texts emphasize evidence-based determination of treatment efficacy, while the anthropological texts emphasize ethnographic understanding of treatment experience. Reconciling these two emphases constitutes a challenge to the field, attending to contextual variations in treatment events, illness episodes, phenomenological factors both endogenous and intersubjective, and sociopolitical factors both interpersonal and structural. In addressing this challenge, I propose an approach to therapeutic process that on the empirical level can facilitate comparison across the diversity of healing forms, and on the conceptual level can constitute a bridge between efficacy and experience. This approach is predicated on a rhetorical model of therapeutic process including components of disposition, experience of the sacred, elaboration of alternatives, and actualization of change that highlights experiential specificity and incremental change. Deploying this model can help meet the challenge of understanding efficacy and experience in indigenous healing, and prepare the ground for the further challenge of how practitioners of GMH relate to and interact with such forms of healing.

The risks of adverse events with venlafaxine and mirtazapine versus 'active placebo', placebo, or no intervention for adults with major depressive disorder: a protocol for two separate systematic reviews with meta-analysis and Trial Sequential Analysis

BACKGROUND

Major depressive disorder causes a great burden on patients and societies. Venlafaxine and mirtazapine are commonly prescribed as second-line treatment for patients with major depressive disorder worldwide. Previous systematic reviews have concluded that venlafaxine and mirtazapine reduce depressive symptoms, but the effects seem small and may not be important to the average patient. Moreover, previous reviews have not systematically assessed the occurrence of adverse events. Therefore, we aim to investigate the risks of adverse events with venlafaxine or mirtazapine versus 'active placebo', placebo, or no intervention for adults with major depressive disorder in two separate systematic reviews.

METHODS

This is a protocol for two systematic reviews with meta-analysis and Trial Sequential Analysis. The assessments of the effects of venlafaxine or mirtazapine will be reported in two separate reviews. The protocol is reported as recommended by Preferred Reporting Items for Systematic Reviews and Meta-Analysis Protocols, risk of bias will be assessed with the Cochrane risk-of-bias tool version 2, clinical significance will be assessed using our eight-step procedure, and the certainty of the evidence will be assessed with the Grading of Recommendations Assessment, Development and Evaluation approach. We will search for published and unpublished trials in major medical databases and trial registers. Two review authors will independently screen the results from the literature searches, extract data, and assess risk of bias. We will include published or unpublished randomised clinical trial comparing venlafaxine or mirtazapine with 'active placebo', placebo, or no intervention for adults with major depressive disorder. The primary outcomes will be suicides or suicide attempts, serious adverse events, and non-serious adverse events. Exploratory outcomes will include depressive symptoms, quality of life, and individual adverse events. If feasible, we will assess the intervention effects using random-effects and fixed-effect meta-analyses.

DISCUSSION

Venlafaxine and mirtazapine are frequently used as second-line treatment of major depressive disorder worldwide. There is a need for a thorough systematic review to provide the necessary background for weighing the benefits against the harms. This review will ultimately inform best practice in the treatment of major depressive disorder.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42022315395.

Mental Health Gap Action Programme intervention Guide (mhGAP-IG) for Child and Adolescent Mental Health in Low- and Middle-Income Countries (LMIC): A Systematic Review

BACKGROUND

The Mental Health Gap Action Programme (mhGAP) supports engagement of non-specialists in mental health services in Low- and Middle-Income countries. Given this aim, assessment of the effectiveness of approaches under its remit is warranted.

AIMS

We evaluated mhGAP approaches relating to child and adolescent mental health, focusing on provider / child outcomes, and barriers / facilitators of implementation.

METHODS

Thirteen databases were searched for reviews and primary research on mhGAP roll out for child and adolescent mental health.

RESULTS

Twelve studies were reviewed. Provider-level outcomes were restricted to knowledge gains, with limited evidence of other effects. Child-level outcomes included improved access to care, enhanced functioning and socio-emotional well-being. Organisational factors, clients and providers? attitudes and expectations, and transcultural considerations were barriers.

CONCLUSIONS

Further attention to the practical and methodological aspects of implementation of evaluation may improve the quality of evidence of the effectiveness of approaches under its remit.

Knowledge translation in rehabilitation settings in low, lower-middle and upper-middle-income countries: a scoping review

PURPOSE

This review aims to identify the barriers and facilitators to knowledge use and Knowledge Translation (KT) strategies in rehabilitation in low, lower-middle, and upper-middle-income countries (LMICs).

MATERIALS AND METHODS

A scoping review of studies of KT in rehabilitation in LMICs contexts using the Arksey and O'Malley Framework was conducted. A comprehensive search of MEDLINE and 10 other databases was undertaken to identify studies conducted primarily in LMICs.

RESULTS

From the initial 15.606 titles identified; 27 articles were included for final analysis. Our analysis identified the following themes: Professional culture and context; KT interventions; and the conceptualization and application of KT and Evidence Based Practice (EBP). Individual-level barriers to KT included lack of skills, knowledge about EBP and English language, lack of motivation, and decision-making power. Facilitators to KT included positive attitudes and motivation. Organization-level barriers included lack of time, lack of financial resources, limited access to scientific journals, and applicability of research to rural settings. Facilitators included adequate financial and physical resources, a supportive management environment, and the existence of training and continuing education programs.

CONCLUSION

This review identified common and unique barriers and facilitators to KT in LMICs when compared to KT studies conducted in high-income settings.IMPLICATIONS FOR REHABILITATIONKnowledge Translation from academic institutions to rehabilitation clinical practice in low and upper-middle-income countries is important to support evidence-based practice and patient outcomes.Barriers at the individual level include professionals' ability to understand English and knowledge of the evidence-based practice.Organization-level barriers included lack of time to access and implement new practices, lack of financial and personal resources, limited access to scientific journals, and applicability of research to rural settings.Training and continuing education programs are needed to support rehabilitation professionals' efforts to achieve the application of evidence-based practice in clinical practice.

Communalistic use of psychoactive plants as a bridge between traditional healing practices and Western medicine: A new path for the Global Mental Health movement

The Global Mental Health (GMH) movement aims to provide urgently needed treatment to those with mental illness, especially in low- and middle-income countries. Due to the complexity of providing mental health services to people from various cultures, there is much debate among GMH advocates regarding the best way to proceed. While biomedical interventions offer some degree of help, complementary approaches should focus on the social/community aspects. Many cultures conduct traditional rituals involving the communal use of psychoactive plants. We propose that these practices should be respected, protected, and promoted as valuable tools with regard to mental health care at the community level. The traditional use of psychoactive plants promotes community engagement and participation, and they are relatively affordable. Furthermore, the worldviews and meaning-making systems of local population are respected. The medical systems surrounding the use of psychoactive plants can be explained in biomedical terms, and many recently published clinical trials have demonstrated their therapeutic potential. Psychoactive plants and associated rituals offer potential benefits as complementary aspects of mental health services. They should be considered as such by international practitioners and advocates of the GMH movement.

Establishing political priority for global mental health: a qualitative policy analysis

Mental disorders represent the leading cause of disability worldwide, yet they remain a low global health priority. This paper uses a case study methodology and different data sources (35 interviews and documents) to analyse factors that have shaped the generation of political priority for global mental health over the past three decades (1990-2020) and their changes over time. The Shiffman and Smith framework on determinants of political priority for global health issues is used to organize data into themes: actor power, ideas, political context and issue characteristics. Global mental health has gained political attention, especially over the past decade, yet support remains limited. Findings reveal that actor power is undermined by a fragmented policy community, the absence of one guiding institution or coordination mechanism and little civil society mobilization. Public portrayal of the issue is divided, hampered by the absence of a common understanding by the community and by stigma. Some policy windows have been missed and a strong global governance structure is lacking. Credible indicators and evidence on simple cost-effective solutions, especially in low- and middle-income countries, are scarce. However, opportunities are arising, including an increasing number of leaders and grassroots organizations, multiple arguments for action and integrated solutions resonating with broader audiences, widening political support at the national level, an emerging global governance structure and an expanding evidence base on the scale of the problem and available solutions. The results point to three technical and four political challenges that advocates need to address to increase political support over the next decade.

Trauma and resettlement: lessons learned from a mental health screening and treatment programme for Syrian refugees in the UK

Resettlement schemes can offer refugees an opportunity to rebuild their lives and to heal from loss and trauma. Mental health services in host countries may have an important role to play in aiding refugees in this journey to recovery. However, facilitating the process of healing for refugees raises challenges for mental health services working within Western medicalised settings. Recovery and wellbeing for resettled refugees also depends upon an interaction of variables at a wider systemic level, that go beyond the direct remit of mental health services. Based on the experience of delivering a mental health screening and treatment programme for resettled Syrian refugees in the UK over a 5-year period, this paper reflects on these challenges and suggests that future resettlement schemes in the UK be designed in accordance with the principles of trauma-informed care. This means putting safety, trust, choice, collaboration, empowerment and respect for inclusion and diversity at the core of the services provided for resettled refugees.

Which Symptoms of Depression and Anxiety Matter Most? An Investigation of Subjective Importance Ratings With College Students in India

One goal of clinical psychological science is to help people with problems that matter to them. However, little is known about which kinds of symptoms are viewed as most important, particularly among individuals in non-western settings. We examined the extent to which young adults in India rated individual symptoms of depression and anxiety as important, concerning, and undesirable. Participants were college students at Indian Universities (n = 283). They received a measure of depressive symptoms (Patient Health Questionnaire-9) and anxiety symptoms (Generalized Anxiety Disorder Screener-7). For each of the 16 symptoms, they provided three judgments relating to the extent to which they found the symptom important, harmful, and undesirable. These judgments were averaged to form a "subjective importance rating" (SIR) for each symptom. Anxiety symptoms were viewed as more important than depressive symptoms (d = 0.34), and nonsomatic symptoms were viewed as more important than somatic symptoms (d = 0.83). Females rated symptoms as more important than males (d = 0.32), and individuals with higher self-reported symptoms rated symptoms as more important. Sad mood, suicidal ideation, and controlling worries were rated as the most important symptoms, whereas concentration problems, appetite problems, and psychomotor problems were rated as the least important. Overall, some symptoms are viewed as more important and concerning than others. We discuss how this understanding can affect our conceptualization, assessment, and treatment of mental disorders around the world.

In Their Own Words: Using Open-Ended Assessment to Identify Culturally Relevant Concerns among Kenyan Adolescents

Standardized assessment tools developed in western contexts may systematically miss certain problems that are considered important in non-western cultures. In this mixed-methods study, we used an open-ended assessment tool (the Top Problem Assessment; TPA) to identify culturally relevant concerns among low-income Kenyan youth. We then (a) applied thematic analysis to identify the most frequently reported problems and (b) examined the extent to which these problems were reflected in standardized mental health measures. Using the TPA, we identified common social, academic, and economic problems facing Kenyan youths. Specifically, 61% of the sample reported a social problem, 38% an academic problem, and 35% an economic problem. By contrast, the standardized assessments revealed that worrying and difficulty concentrating were the most commonly reported symptoms. However, the emotional and behavioral problems assessed via the standardized measures were only reported as top problems by 17% of the sample. Overall, our findings are consistent with the idea that standardized measures can miss certain culturally-salient concerns that can be acquired through open-ended assessments. We discuss how brief open-ended assessment tools could complement standardized measures, inform the development of culturally relevant standardized measures, and offer rich data about the experiences of people in understudied cultural contexts.

Visceral Visions: Rethinking Embodiment and Desire in Global Mental Health

The globalization of biomedicine poses the problem of finding cross-culturally valid criteria for mental health. Undue pathologization is a major risk for global health, especially when diagnoses rely exclusively on Western nosology. This article focuses on the clinical conflation between involuntary mass possession and conversion disorder. Originally, the diagnosis of "conversion disorder" evolved from the notion of hysteria. Even though the category of hysteria disappeared from psychiatry many decades ago, some of its undergirding assumptions have survived under the new label of conversion. Namely, the assumption that hysteria/conversion is caused by repressed sexual desire is still implicit in widespread explanatory models for mass possession worldwide. Drawing upon an ethnography of demonic possession (grisi siknis) among the Afro-Indigenous Miskitos of Nicaragua, I argue that (1) the label of conversion is eurocentric and inappropriate for mass possession; and (2) emic perspectives on mass possession offer a critical counterpoint to rethink Euro-American and globalized understandings of embodiment and desire.

Psychologists' Perspectives on the Psychological Suffering of Refugee Patients in Brazil

Worldwide there are 79.5 million displaced people, many of which face war, violence, tragic flights and struggles in host countries. Research shows augmented prevalence rates of mental disorders among refugees internationally, but little is known about refugee mental health in Latin American countries. Furthermore, only a few studies have taken into consideration the knowledge of clinical psychologists who treat refugee patients. The present study examines the experiences of 32 psychologists in Brazil regarding their refugee patients' psychological suffering and mental disorders. Semi-structured interviews were conducted in various locations in Brazil and analysed following a consensual qualitative research approach. Four clusters of refugee patients' suffering were synthesised: post-migration stressors, traumatic experiences, flight as life rupture, and the current situation in the country of origin. The most frequently described conditions in patients were anxiety and depression. However, the results also show that the use of manuals for the classification of mental disorders is contested among psychologists in Brazil. Most psychologists stressed patients' socio-political suffering and saw patients' symptoms as normal reactions to their experiences. There is a need to acknowledge the socio-political suffering of refugees in Brazil and foster their mental health by tackling current post-migration stressors such as discrimination.

How can we mainstream mental health in research engaging the range of Sustainable Development Goals? A theory of change

Mental health is a leading cause of ill-health worldwide, disproportionately affects low-and-middle-income countries and, increasingly, is considered relevant across the Sustainable Development Goals (SDGs). Hence, we ask: How can we mainstream mental health in research engaging the range of SDGs? We use the UK Research and Innovation Global Challenges Research Fund (GCRF) as a case study. In a previous scoping review, we purposefully sampled non-mental health focused GCRF grants for diversity from 2015 until May-end 2020 (N = 36). In the present study, the principal investigator of each grant in this sample was invited to interview (11 accepting). Snowballing, our networks, and returning to the funding archive secured a further 15 interviews sampled for diversity (Final sample: 13 UK researchers and 13 of their overseas collaborators). A thematic analysis of this data organised key information into a trajectory from the challenges of incorporating mental health impact, to how these challenges might be overcome and, finally, to support needs. This analysis was then organised into a Theory of Change designed to promote the mainstreaming of mental health in global challenges research. We outline the implications for global challenges researchers, mental health practitioners, and global challenge research funders. One important implication is that we provide evidence to encourage funders to engage with the desire of researchers to contribute more broadly to the wellbeing of the communities with whom they work.

"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.

Psychotherapy in a resource-constrained setting: Understanding context for adapting and integrating a brief psychological intervention into primary care

Low- and middle-income countries have few mental health professionals, and efforts to increase access to treatment are a global priority. A key gap is the lack of integration of psychotherapy interventions as a part of accessible evidence-based care. Current recommendations suggest that the integration of mental health treatments, including psychotherapy, into existing primary care pathways may serve as a means to address this disparity. Understanding the cultural and contextual factors that affect this process is a critical step in identifying necessary adaptations. The aim of this qualitative study was to identify contextual factors associated with integrating psychotherapy in primary care in a predominantly rural district in south-central Ethiopia. Purposive sampling was used to recruit 48 mental health service users, caregivers, health care providers, and community leaders. Semistructured interviews were conducted, recorded, and transcribed in Amharic and translated into English. Although challenges (e.g., stigma, job strain, lack of belief in formal treatments) are present, other existing strengths (e.g., openness to seeking treatment, increasing knowledge about mental health treatment, familiarity with practices similar to therapy) support subsequent psychotherapy adaptation and implementation. These findings suggest possible mechanisms to improve delivery and adaptation in the effort to lower the existing global treatment gap. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Decolonising the medical curriculum: psychiatry faces particular challenges

Colonial thinking runs deep in psychiatry. Recent anti-racist statements from the APA and RCPsych are to be welcomed. However, we argue that if it is to really tackle deep-seated racism and decolonise its curriculum, the discipline will need to critically interrogate the origins of some of its fundamental assumptions, values and priorities. This will not be an easy task. By its very nature, the quest to decolonise is fraught with contradictions and difficulties. However, we make the case that this moment presents an opportunity for psychiatry to engage positively with other forms of critical reflection on structures of power/knowledge in the field of mental health. We propose a number of paths along which progress might be made.

Understanding global mental health: a conceptual review

Background

Mental health disorders are viewed as a global concern requiring globally led approaches to address them. Since the publication of the 2007 Lancet series on global mental health (GMH), the term has become widespread. Over the last two decades, GMH has become increasingly affiliated with policy reform, academic courses, funding bodies and research. However, it is not always obvious how those working in the field of GMH are using the term, resulting in a lack of clarity. Therefore, work is needed to synthesise the current understanding(s) of GMH to help characterise its meaning.

Aim

To synthesise the literature and identify the different ways GMH is understood.

Method

A conceptual review, using a systematic search and a content analysis, was conducted to develop a conceptual framework of the different conceptual understandings of GMH.

Results

We developed a conceptual framework of four understandings of GMH. These understandings of GMH are as follows: an area of research generating findings to establish a GMH evidence-base; implementation of research into practice; improving the mental health environment; learning from and supporting low-and-middle-income countries (LMICs).

Conclusion

Our review proposes a simple framework, clarifying the key characteristics of the GMH landscape. The findings highlight the diversity of usage of the term in the literature, as well as present the wide scope that comprises the field of GMH. Referring to this framework may help those engaged with GMH to be more specific with which aspect of the field they are concerned with.

Social epigenomics: are we at an impasse?

Aim: Social scientists have placed particularly high expectations on the study of epigenomics to explain how exposure to adverse social factors like poverty, child maltreatment and racism - particularly early in childhood - might contribute to complex diseases. However, progress has stalled, reflecting many of the same challenges faced in genomics, including overhype, lack of diversity in samples, limited replication and difficulty interpreting significance of findings. Materials & methods: This review focuses on the future of social epigenomics by discussing progress made, ongoing methodological and analytical challenges and suggestions for improvement. Results & conclusion: Recommendations include more diverse sample types, cross-cultural, longitudinal and multi-generational studies. True integration of social and epigenomic data will require increased access to both data types in publicly available databases, enhanced data integration frameworks, and more collaborative efforts between social scientists and geneticists.

Adaptive coping during protracted political conflict, war and military blockade in Gaza

Identifying culturally-relevant concepts and coping mechanisms can help protect civilian wellbeing. This study explores how seven professional Palestinian university graduates in the Gaza Strip (occupied Palestinian territories) cope with war, military occupation, military blockade and the challenges of living in a conflict-affected area. Participants were interviewed to determine whether culturally specific modes of coping were used. Thematic analysis was applied. The use of resistance and more specifically sumud, ¹ being steadfast and persevering, were identified alongside the motivation to persevere and other adaptive responses to living conditions. Coping strategies identified in this study include adapting, problem-solving, accepting reality, exercising patience, utilising social support, and faith in God (iman) and religion. The implications of this study and the relevance of the findings to mental health and disaster relief are considered.

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.

The ASHA (Hope) Project: Testing an Integrated Depression Treatment and Economic Strengthening Intervention in Rural Bangladesh: A Pilot Randomized Controlled Trial

Depression, a debilitating disorder, is highly prevalent among low-income women in low- and middle-income countries. Standard psychotherapeutic approaches may be helpful, but low treatment uptake, low retention, and transient treatment effects reduce the benefit of therapy. This pilot randomized controlled trial examined the effectiveness and feasibility of an integrated depression treatment/economic strengthening intervention. The study took place in two villages in the Sirajganj district in rural Bangladesh. Forty-eight low-income women with depressive symptoms (Patient Health Questionnaire (PHQ-9) score ≥ 10) were recruited and randomized to intervention or control arms. The intervention included a six-month group-based, fortnightly depression management and financial literacy intervention, which was followed by a cash-transfer of $186 (equivalent to the cost of two goats) at 12 months' follow-up. The cash transfer could be used to purchase a productive asset (e.g., agricultural animals). The control arm received no intervention. Findings showed significant reduction in depression scores in the intervention group. The mean PHQ-9 score decreased from 14.5 to 5.5 (B ± SE, -9.2 ± 0.8 95% CI -10.9, -7.5, p < 0.01) compared to no change in the control group. Most other psycho-social outcomes, including tension, self-esteem, hope, social-support, and participation in household economic decision-making, also improved with intervention. An integrated depression treatment and financial empowerment intervention was found to be highly effective among rural low-income women with depression. Next steps involve formal testing of the model in a larger trial.

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

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

Transcultural transferability of transient therapeutic communities: the living-learning experience workshops

Purpose

This paper aims to describe a method of training for practitioners in democratic Therapeutic Communities (TCs) which has been used in several settings across the world over the past 25 years: the “Living-Learning Experience” (LLE) workshop. It goes on to consider the cross-cultural implications of the work.

Design/methodology/approach

Drawing on the experience of running exactly the same programme in different countries and cultures, the paper examines the cross-cultural adaptability and describes necessary adaptations for local circumstances. It also contains original ethnographic research in UK and Italy; further study is planned for other countries.

Findings

The workshops are readily transferable to different cultures and are appreciated for their democratic and relational way of working.

Research limitations/implications

The ethnographic study examines the workshops in some depth, in UK and Italy, and could usefully be replicated in other countries. No quantitative, outcome or follow-up studies have yet been done, and this paper could contribute to the design of useful quantitative studies.

Practical implications

The paper demonstrates that the LLE is a useful experiential learning tool in widely different settings. It could be developed in different ways, such as for developing relational practice or establishing therapeutic environments in different settings.

Social implications

The workshops' acceptance in widely different cultures indicates that the open and non-didactic format addresses essential and fundamental qualities required for therapeutic engagement and human relatedness.

Originality/value

This is the first description of the principles of democratic TCs being applied across different international settings. Its value extends beyond the TC field, to the use of democratic and relational principles' applicability in therapeutic pedagogy and training.

Post-traumatic stress, social, and physical health: A mediation and moderation analysis of Syrian refugees and Jordanians in a border community

OBJECTIVES

This study examined the mediating or moderating relationship of social health on physical health and post-traumatic stress symptoms among displaced Syrians and Jordanians at high risk for physical and mental health ailments. Frequency of mental health symptoms stratified by demographic factors was also explored. We hypothesized social health would mediate and/or moderate the relationship between physical and post-traumatic stress symptoms (PTSS).

METHODS

This cross-sectional study includes 598 adults between 18 and 75 years old recruited from three health centers in the city of Irbid, Jordan, 20 km away from the Syrian border. Post-traumatic stress symptoms (PTSS) were measured through the primary care post-traumatic stress disorder checklist. Physical and social health were assessed through the Duke Health Profile. One-way ANOVA and independent samples T-tests examined mean scores of social health, PTSS, physical health stratified by age, gender, nationality, education level, and trauma exposure. Bivariate correlations explored the relationship between social health, PTSS, and physical health. PROCESS macro tested social health as a moderator and mediator on the association of the physical health and PTSS.

RESULTS

Social health moderated and mediated the relationship between physical health and PTSS. Males reported (t = 2.53, p < .05) better physical health scores than females. Those who had less than a high school education reported lower social health (F = 13.83, p < .001); higher PTSS (F = 5.83, p < .001); and lower physical health (F = 5.76, p < .01) than more educated individuals. Syrians reported significantly higher PTSS (F = 4.13, p < .05) than Jordanians, however, there was no significant differences between nationality for physical or social health. Social health was positively associated with better physical health (r = 0.10, p < .01) and negatively with PTSS (r = -.293, p < .01).

CONCLUSIONS

Our results support our primary hypothesis suggesting social health mediates and moderates PTSS and physical health. Secondary findings illustrate gender, educational, and income differences in physical health and PTSS.

CLINICAL TRIALS REGISTRY

NCT03721848.

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

BACKGROUND

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

OBJECTIVES

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

METHODS

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

FINDINGS

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

INTERPRETATION

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

Hegemony versus pluralism: Ayurveda and the Movement for Global Mental Health

Under the aegis of the World Health Organization, the Movement for Global Mental Health and an Indian Supreme Court ruling, biomedical psychiatric interventions have expanded in India augmenting biomedical hegemony in a place that is known for its variety of healing modalities. This occurs despite the fact that studies by the WHO show better outcomes in India for people suffering from schizophrenia and related diagnoses when compared to people in developed countries with greater access to biomedical psychiatry. Practitioners of ayurvedic medicine in Kerala have been mounting a claim for a significant role in public mental health in the face of this growing hegemony.This study examines efforts by ayurvedic practitioners to expand access to ayurvedic mental health services in Kerala, and profiles a rehabilitation center which combines biomedical and ayurvedic therapies and has been a key player in efforts to expand the use of Ayurveda for mental health. The paper argues for maintaining a pluralistic healing environment for treating mental illness rather than displacing other healing modalities in favor of a biomedical psychiatric approach.

What kind of in-patient psychiatry for Africa? Report from Zimbabwe

The expanding global mental health field has paid little attention to evaluating the culture of psychiatry prevailing in in-patient settings across Africa. For example, in Zimbabwe in-patient psychiatry has been heavily pathologising, with over-reliance on the diagnosis of schizophrenia and on antipsychotic polypharmacy. It is not helpful that the next generation of African doctors are learning unmediated Western psychiatry, with little credence given to background cultural factors and mentalities shaping presentations. Some of the psychiatric and social consequences of this for patients in Zimbabwe are discussed.

Syndemics theory must take local context seriously: An example of measures for poverty, mental health, and food insecurity

Syndemics theory has provided insight into the ways that disease states and social adversity interact in marginalized populations to further disempower these groups. Yet, until recently, scholars have not identified how we might actually recognize and measure a syndemic, as opposed to a situation where there are multiple but non-interacting diseases present in a population. As researchers like those included in this special issue develop new methods for assessing syndemic interactions in diverse global populations, this short communication argues for the value of locally relevant measures. Poverty, mental health, food insecurity, and type 2 diabetes are used to illustrate the assessment of a potential syndemic from a locally grounded perspective. The discussion emphasizes the insights locally adapted measures can add and what information would be lost without their use.

Towards a translational medical humanities: introducing the cultural crossings of care

In this introductory essay, we will present a translational medical humanities approach where the humanities are not only an auxiliary to medical science and practice, but also an interdisciplinary space where both medicine and the humanities mutually challenge and inform each other. First, we explore how medicine's attempt to tackle the nature-culture divide is emblematically expressed in the concept and practice of knowledge translation (hereinafter KT). Second, we compare and contrast KT as an epistemic ideology and a socio-medical practice, with concepts and practices of translation developed in the human sciences. In particular, we emphasise Derrida's understanding of translation as inherent in all meaning making, as a fundamentally textual process and as a process necessarily creating difference rather than semantic equivalence. Finally, we analyse a case from clinical medicine showing how a more refined notion of translation can enlighten the interaction between biomedical and cultural factors. Such a translational medical humanities approach also requires a rethinking of the concept of evidence in medicine.

Harnessing single-session interventions to improve adolescent mental health and well-being in India: Development, adaptation, and pilot testing of online single-session interventions in Indian secondary schools

BACKGROUND

Many evidence-based prevention and intervention approaches for youth mental health exist, but most are time-consuming and expensive to deliver. Innovative approaches are needed to develop and disseminate scalable mental health interventions, especially for youth in low- and middle-income countries. Computerized single-session interventions (SSIs) may be able to overcome many of these implementation barriers, especially if deployed in school settings.

METHODS

Guided by this logic, we designed three computerized SSIs (based on behavioral activation, gratitude, and growth mindset exercises) for delivery in Indian high schools. Then, we conducted focus groups with Indian adolescents and school officials to inform adaptations of the interventions. Finally, we designed a Hybrid Type 1 effectiveness-implementation study to evaluate the interventions.

RESULTS

In this paper, we present the rationale for selecting the interventions, the results of the focus groups, and the design of a Hybrid Type 1 effectiveness-implementation study. Our initial focus group data showed that the interventions were considered acceptable, feasible, and appropriate by both educators and students. We also describe feedback on the interventions which we incorporated to refine the interventions prior to our randomized controlled trial.

DISCUSSION

Computerized SSIs may offer innovative, scalable ways to disseminate evidence-based interventions. By identifying which interventions are most acceptable and effective in this highly scalable format, we may understand which SSIs are best suited for continued development, testing, and, ultimately, widespread dissemination.

Investigating global mental health: Contributions from political science

This article outlines an agenda for political science engagement with global mental health. Other social sciences have tackled the topic, investigating such questions as the link between poverty and mental health disorders. Political science is noticeably absent from these explorations. This is striking because mental health disorders affect one billion people globally, governments spend only about 2% of their health budgets on these disorders, and most people lack access to treatment. With its focus on power, political science could deepen knowledge on vulnerabilities to mental illness and explain weak policy responses. By illustrating how various forms of power pertaining to governance, knowledge, and moral authority work through the concepts of issue framing, collective action, and institutions, the article shows that political science can deepen knowledge on this global health issue. Political science can analyse how incomplete knowledge leads to contentious framing, thus hobbling advocacy. It can explain why states shirk their obligations in mental health, and it can question how incentives drive mental health mobilisation. The discipline can uncover how power undergirds institutional responses to global mental health at the international, national, and community levels. Political science should collaborate with other social sciences in research networks to improve policy outcomes.

Global Mental Health: Interdisciplinary challenges for a field in motion

In recent years, efforts in Global Mental Health (GMH) have evolved alongside critical engagement with the field's claims and interventions. GMH has shifted its agenda and epistemological underpinnings, increased its evidence base, and joined other global policy platforms such as the Sustainable Development Goals. This editorial introduction to a thematic issue traces the recent shifts in the GMH agenda and discusses the changing construct of "mental health" as GMH moves away from a categorical biomedical model toward dimensional and transdiagnostic approaches and embraces digital technologies. We highlight persistent and emerging lines of inquiry and advocate for meaningful interdisciplinary engagement. Taken together, the articles in this special issue of Transcultural Psychiatry provide a snapshot of current interdisciplinary work in GMH that considers the socio-cultural and historical dimensions of mental health important and proposes reflexive development of interventions and implementation strategies.

Genealogies and Anthropologies of Global Mental Health

Within the proliferation of studies identified with global mental health, anthropologists rarely take global mental health itself as their object of inquiry. The papers in this special issue were selected specifically to problematize global mental health. To contextualize them, this introduction critically weighs three possible genealogies through which the emergence of global health can be explored: (1) as a divergent thread in the qualitative turn of global health away from earlier international health and development; (2) as the product of networks and social movements; and (3) as a diagnostically- and metrics-driven psychiatric imperialism, reinforced by pharmaceutical markets. Each paper tackles a different component of the assemblage of global mental health: knowledge production and circulation, global mental health principles enacted in situ, and subaltern modalities of healing through which global mental health can be questioned. Pluralizing anthropology, the articles include research sites in meeting rooms, universities, research laboratories, clinics, healers and health screening camps, households, and the public spaces of everyday life, in India, Ghana, Brazil, Senegal, South Africa, Kosovo and Palestine, as well as in US and European institutions that constitute nodes in the global network through which scientific knowledge and certain models of mental health circulate.

Four reflections on the new global mental health priorities

The discussion of the achievements and limitations of the strategies prioritised in global mental health that has taken place in recent years contributed to a unified vision for action that addresses the gaps still existing on prevention, treatment, quality of care and human rights protection. This editorial presents four reflections on the impact of this vision on the definition of future priorities, particularly in the areas of policy implementation, services reconfiguration and organisation, human rights and research. It concludes that further debate is needed to redefine the balance between priorities and strategies that can better promote an effective response to the needs of low and middle income countries, and to ensure an efficient coordination of efforts in the future.

An ethnopsychology of idioms of distress in urban Kenya

Idioms of distress have become a central construct of anthropologists who aspire to understand the languages that individuals of certain sociocultural groups use to express suffering, pain, or illness. Yet, such idioms are never removed from global flows of ideas within biomedicine that influence how cultural idioms are conceived, understood, and expressed. This article proposes a preliminary model of ethnopsychology described by urban Kenyans, which incorporates local (traditional) and global (biomedical) idioms of distress that are both distinct and overlapping in symptomology and experience. This ethnopsychology was generated from analyzing 100 life history narrative interviews among patients seeking care in a public hospital in Nairobi, Kenya, which explicitly probed into how people experienced and expressed the Kiswahili idioms huzuni (roughly translated as sadness or grief) and dhiki (stress or agony) and English terms stress and depression. Kufikiria sana, or "thinking too much", emerged organically as a powerful cultural idiom and as a symptom or sign of other forms of psychological distress. We propose a preliminary model of ethnopsychology that: 1) highlights social and political factors in driving people to express and experience idioms of distress; 2) reveals how the English terms "stress" and "depression" have been adopted into Kiswahili discourse and potentially have taken on new meaning; 3) suggests that the role of rumination in how people express distress, with increasing severity, is closely linked to the concept of "thinking too much", and; 4) emphasizes how somatization is central to how people think about psychological suffering.

Do remittances alleviate negative impacts of disaster on mental health? A case of the 2015 Nepal earthquake

This paper contributes to two strands of literature: disaster literature on post-disaster mental health and economics literature on migration. Remittances are a sizable source of income in many developing countries. Evidence suggests, however, that when adults migrate in order to support their families via remittances, family members left behind often experience poorer physical and mental health. We study the effects of remittances on the mental health of victims of a disaster, the earthquake (EQ) that hit Nepal in 2015. We used three waves of data from 335 individuals in 6 villages in Western Nepal in which emigration is prevalent. The first wave of the survey was conducted one year before the 2015 EQ. In the third wave, which was conducted one year after the EQ, the respondents aged 15 and older were assessed for post-traumatic stress disorder (PTSD) and depressive symptoms. PTSD symptoms were evaluated by the 17-item Checklist Civilian (PCL-C), and depressive symptoms were measured by the 20-question Epidemiologic Studies Depression Scales (CESD) questionnaire. In order to avoid capturing the impacts of remittances for daily expenses and reduce possible endogeneity in the remittance variables, we measured the change in remittances following the EQ. After controlling for pre-disaster body-mass index and asset holdings, we found that the increase in remittances sent to HHs reduced psychological distress measured by the PTSD and depression severity scores. The remittance variables, however, did not alleviate mental disorder as defined by the international-standard cutoff points of PCL-C and CES-D.

How to Fail a Scale: Reflections on a Failed Attempt to Assess Resilience

How we interpret concepts from suffering to survival has been historically debated in the field of anthropology, transcultural psychiatry, and global mental health. These debates have centered on the notion that such concepts are cross-culturally reproducible, although scholars who work the boundaries of culture, medicine, and psychiatry often triangulate methods from internationally standardized scales to various interpretive methods from participant observation to narrative. This article considers resilience, as opposed to suffering, as the subject of a reproducible entity by discussing the failure of an attempt to capture resilience via an internationally reputed scale called the "Resilience Scale for Adults" among cancer patients in urban South Africa. Our effort to utilize the internationally validated scale, and our attempt to draw on ethnographic and interview work to translate this scale to a locally relevant entity failed due to linguistic, cultural, and practical issues. In brief, the attempt failed because our resilience scale was too long, syntactically ambiguous, and culturally inappropriate. We write this article to spur a larger conversation about evaluating resilience from scale to ethnography, and how the concept and measurement of resilience might figure into fields of anthropology and medicine.